Clinical Challenges of Long Acting Reversible Contraception (LARC)

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Read along with CO 672: Clinical Challenges of Long-Acting Reversible Contraceptive Methods 

Increased LARC Use 

  • There has been an increase in LARC use over the last few decades 

    • As high as 13.1% in women 20-29 and 11.7% in women 30-39 years of age in 2018 

    • This is compared to 2.4% of all women in 2002 

    • While overall complication of IUDs and implants are low (<1%), the absolute number of these complications will increase as more patients use them.

Complications with IUDs

  • Pain with IUD insertion 

    • IUD insertion can be painful, especially for nulliparous women 

    • Unfortunately, a 2015 Cochrane Review concluded that lidocaine 2% gel, NSAIDs, and misoprostol for cervical ripening were not effective for reducing pain associated with insertion

    • A word on misoprostol use

      • Can cause nausea and abdominal cramping per some trials 

      • Does also require a delay - can be a barrier to access  

    • Paracervical block 

      • Has demonstrated effectiveness in other office transcervical procedures 

      • Studies have shown reduced pain with tenaculum placement after local injection of anesthetic at the tenaculum site 

      • However, other studies have shown no difference in pain with treatment vs. no treatment 

      • Meta-analysis of various analgesic measures did conclude that lidocaine paracervical block reduces pain scores associated with tenaculum placement and IUD insertion 

    • Recommendation: 

      • Routine misoprostol use before IUD insertion in nulliparous women is not recommended, but can be considered with difficult insertions 

      • Pain with IUD insertion needs to be addressed, and one possible way is via a parcervical block as well as injection of lidocaine at the tenaculum site  

    • One last note: patients’ pain should be believed, and discussion for pain relief should be individualized.

      • Some patients may require nothing other than oral medications, but if appropriate and after discussion, some patients may require anesthesia and an OR procedure 

  • Nonvisualized strings 

    • The most common reason for nonvisualized IUD strings is string retraction into the cervical canal or uterine cavity 

      • First step: use a cytobrush to sweep the canal and see if strings are retrievable 

    • However, nonvisualized strings can also indicate other complications such as pregnancy, expulsion, or uterine perforation 

    • If strings cannot be visualized after cytobrush, then rule out pregnancy

      • Can also offer emergency contraception if indicated 

      • Next step is to obtain a pelvic ultrasound 

      • If IUD is not visualized with the pelvic ultrasound, then obtain Xray of the abdomen and pelvis - if not visualized, then IUD is likely expelled 

      • If the IUD is visualized, then this may require laparoscopic removal if there is true perforation and migration 

ACOG CO 672

  • Difficult removal of IUD 

    • If IUD removal is requested, and strings cannot be visualized, alligator forceps can be used to remove the IUD 

    • However, before instrumenting, should confirm that IUD is truly in the uterus 

    • IF strings cannot be visualized, follow above procedure 

  • Malposition/nonfundal position of IUD 

    • If an IUD is in the cervix, this is considered a partial expulsion 

      • Recommendation is to remove the IUD and replace it if it is desired 

    • If an IUD is in the lower uterine segment or low-lying, the ideal management is less clear 

      • Shared decision making - if patient is asymptomatic and IUD is above the internal os, it can be retained and will be effective

        1. However, more studies need to be done to see if failure rates of IUDs are higher when the IUD is located in the lower uterine segment 

        2. Also, many IUDs that are non fundal shortly after insertion move to a fundal position after 3 months 

  • Expulsion/Uterine Perforation 

    • Expulsion can happen in 2-10% of users and varies by IUD type and when the IUD is placed 

      • Risk factors include age <20, heavy bleeding, dysmenorrhea, placement immediately postpartum, and anatomic distortion of the uterine cavity 

      • Recommendation: if IUD is found to be expelled, rule out pregnancy and then counsel regarding contraceptive choices 

    • Perforation into the peritoneal cavity is rare and occurs <1/1000 insertions 

      • Recommendation: rule out pregnancy and then surgical removal 

      • Laparoscopy is preferred 

      • However, depending on location of IUD, it may be possible that it should be left in place if surgical risks associated with removal and considered too great 

      • Replacement of another IUD under laparoscopic guidance can be done if patient desires 

  • Infection 

    • IUDs should not placed if there is active infection 

    • Infection after IUD insertion is rare, and while the risk of PID developing is increased in the first 20 days after IUD insertion, the risk drops to baseline population risk after 

    • In patients with PID who have an IUD, the IUD can be left in-situ unless there is no clinical improvement 

      • IUD removal can be considered after this 

  • Pregnancy with IUD in place 

    • The risk of pregnancy with IUD in place is 2% after 10 years, similar to tubal sterilization procedures 

    • Ectopic pregnancy must be ruled out - first obtain pelvic ultrasound 

      • If ectopic pregnancy is present, then this needs to be managed medically or surgically. The IUD can be retained if desired  

    • If there is an intrauterine pregnancy

      • If undesired, then IUD can be removed at time of surgical abortion or before medical abortion 

      • If desired, then IUD can be removed if strings are visible 

        1. If strings are not visualized, then ultrasound should be done 

          1. If the IUD is in the cervix, then removal can be attempted 

          2. If IUD is above the cervix, then IUD should not be removed; instead, discussion should be had with patient about increased risk of obstetric complication in setting of pregnancy with IUD

            1. These include increased risk of SAB, infection, and preterm delivery 

          3. If no IUD is seen, then Xray should be done of the abdomen/pelvis after pregnancy  

Complications with Implants 

  • Nonpalpable Implant and Deep Insertion 

    • If an implant is not palpable, first thing is to rule out pregnancy 

    • Do not attempt removal unless implant location is determined

    • Obtain imaging to locate the implant 

      • As there is barium in the implant, X-ray, CT, and fluoroscopy can all be used 

      • Ultrasound and MRI can also be used if needed 

    • If there is a deep insertion that cannot be removed in office: 

      • Consult with family planning specialist or general surgery for removal 

      • If implant is not deeply located within muscle or near neurovascular bundle, then outpatient removal can be attempted with local anesthesia and ultrasound 

      • If the implant is deeply embedded into muscle or nearby neurovascular bundle, then attempt should only be made in the operating room with specialist or surgeon 

    • If imaging is not able to locate the implant, then an etonogestrel serum assay can be done – if itis negative, then there is no implant in the person’s body 

  • Pregnancy with Implants 

    • Risk overall is <1%, but if pregnancy is confirmed, there is a higher risk of ectopic pregnancy 

    • An ectopic pregnancy should be managed medically or surgically per guidelines 

    • If patient desires termination of pregnancy, the implant can be retained 

    • If the pregnancy is desired, then the implant should be removed 

      • Etonogestrel is not teratogenic 

Menstrual Suppression

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Read the new ACOG Clinical Consensus! – General Approaches to Medical Management of Menstrual Suppression

Why menstrual suppression?

  • As an OB/GYN that might sound like a silly question – but for our patients, this is a serious concern!

    • A holdover of understanding (even with the design of OCPs) that a “natural cycle” is necessary for health – it’s not. 

  • Goal overall is to:

    • Reduce menstrual flow, by amount and total days while

    • Find a strategy based on patients preferences and goals, balancing any risk factors.

Which method is best?

  • Combined Hormonal Contraception

    • Can achieve menstrual suppression by skipping the placebo week.

      • Some packs designed for this - 84/7 regimens, 24/4 regimens.

      • This can be done indefinitely!

        • Studies have found these extended cycle and continuous use regimens to be safe and effective

    • Patients should be counseled that over time, breakthrough bleeding is more likely to occur. In a recent RCT comparing OCPs to an LNG-IUD for menstrual suppression, folks in the OCP group had BTB:

      • 50% at pill pack 3;

      • 69% at pill pack 7;

      • 79% at pill pack 13.

    • Bleeding overall tends to decrease with successive cycles.

    • Breakthrough happens less with higher doses of estrogen (i.e., more bleeding on a 20mcg pill than a 30mcg pill).

    • BTB will decrease with each successive cycle – so it’s not unreasonable to consider monthly cycles for 3-6 months, then transition to more extended cycles. 

      • Intermittent estrogen can also be used to help prevent BTB.

    • The patch and vaginal ring can also be used for menstrual suppression, and have advantage of not requiring daily medication.

      • Patch has no difference in frequency of BTB compared to pills.

      • Ring is well tolerated for extended cycles and seems to be effective in reducing/minimizing bleeding.

  • Progestin-Only Methods

    • These can be of particular importance to patients where estrogen is contraindicated (cardiovascular disease, migraine with aura, hypertension, hypercoagulability) or undesired (trans-men, patient preference).

  • POPs

    • The mini-pill (norethindrone 0.35mg) has to be taken in a tight window, and has low rates of amenorrhea, so is generally not a great choice for menstrual suppression.

    • Norethindrone acetate 5mg can be used for menstrual suppression with better success compared to the minipill, with amenorrhea rates of up to 76% at 2 years of use.

      • However, this formulation is not approved as a contraceptive so can’t be used for this.

    • Drosperinone 4mg is a new progestin only pill on the market; data is limited, but it is likely more promising than the minipill for menstrual suppression and also has contraceptive effect. 

      • That said, likely not a first line choice for this indication specifically.

  • DMPA (depot medroxyprogesterone acetate)

    • The DMPA shot is given roughly every 3 months.

    • Amenorrhea rates are good, especially with more prolonged use – 68-71% at 2 years.

      • However, unscheduled bleeding is a common side effect.

      • Loss of bone mineral density and weight gain are other common concerns; the loss of BMD is reversible with discontinuation. 

  • LNG-IUD

    • Excellent at amenorrhea - 50% at 1 year, 60% at 5 years; highest with the 52mg varieties.

    • BTB can be managed by offering a trial of NSAIDs, POPs/OCPs, or doxycycline before discontinuing the IUD.

    • Not a good choice for patients where ovulation suppression is also desired (ie, PCOS) – the IUD has unclear/unpredictable effects on ovulation suppression.

  • Etonogestrel implant (nexplanon)

    • Can be continued up to 5 years for contraception, FDA approved for 3 years.

    • For menstrual suppression, use past 3 years may not be effective. 

    • 22% achieve amenorrhea, but breakthrough bleeding and spotting are common, especially shortly after insertion.

      • BTB can be managed with OCPs or norethindrone.

  • The ACOG document contains a very helpful but large table on the different types of hormonal contraception and their relative success, advantages, and disadvantages with menstrual suppression. Definitely worth keeping a bookmark on or a snapshot on your phone!

How do I go about selecting a method?

  • Counsel your patient with shared-decision making in mind:

    • Be aware of inequities in provision of menstrual suppression methods and your own biases

    • Share with patients realistic expectations of what each method might offer in the way of menstrual suppression

      • No method can guarantee amenorrhea

    • Take into account patient’s preferences and values

    • Be aware of medical history / medical eligibility criteria that might contraindicate certain methods

By patient population:

  • Adolescents:

    • Hormone therapies are safe for adolescents

    • Initiation of menstrual suppression is safe anytime after menarche!

      • Need to have at least one menstrual period to be certain of normal pubertal development.

    • Pelvic exam is not needed for routine prescription of contraception, unless needed for the actual insertion (i.e., IUD)

      • IUD insertion has been shown to not be any more difficult in adolescents compared to older individuals, nor more difficult in nulliparas compared to parous patients.

    • Other tenets of adolescent reproductive healthcare counseling should be applied:

      • Discuss concerns about any side effects that are common / common concerns - fertility, weight, development, bone health, STIs

      • Use the opportunity to establish healthy alignment with adolescent at the OB/GYN office to establish as a safe place for current & future care

  • Transgender / Gender Diverse Patients

    • Menstrual suppression can help reduce feelings of gender dysphoria associated with menstruation

    • Testosterone use for gender-affirming care is associated with amenorrhea, often within a few months of starting therapy.

    • GnRH is also capable of pubertal blockade and suppression of menses for gender-affirming therapy, with amenorrhea rates nearing 100%.

      • Testosterone and GnRH are not contraceptives, though - so if they are at risk of pregnancy, contraception should be discussed

      • GnRH also cannot be used long term given concerns for bone density effects.

  • Patients with physical or cognitive disabilities, or both

    • Particularly for patients with cognitive disability, menstruation is a significant source of anxiety for caregivers and is a common reason for visit for pediatric gynecology clinics, even among premenarchal patients

    • Adolescents and adults with disabilities are also often assumed (erroneously) to be asexual and do not receive sexuality and contraceptive counseling on par with their peers

      • These individuals are also at increased risk of sexual abuse and unintended pregnancy

    • Assist families with developmentally-appropriate education and family assistance with hygiene concerns, contraception, STIs, and abuse prevention

    • Menstrual suppression methods can follow the patient’s needs, preferences, and values. 

      • Consider in these patients their mobility and presence of contractures; swallowing ability for pills; and presence of other interacting drugs (i.e., antiepileptics).

      • If plan for LARC and anesthesia required, it can be considered to “bundle” together services like dental work to minimize patient exposures to anesthetics

    • If patient doesn’t have capacity to make independent decision, menstrual suppression discussions should be made with the caregiver in patient’s best insterest.

      • Ethical and prudent choice is reversible and low-risk options.

  • Populations with challenges affecting hygiene/privacy

    • Military deployment

    • Incarceration

    • Houselessness

    • Patients in war zones or difficulty with care access

    • Athletes

      • Obviously hard to think about all of the potentials here, but consider patient access to medical services, sanitary products, restrooms or private areas, in making shared-decision making on menstrual suppression

How do I manage breakthrough bleeding?

  • One of the most common challenges in menstrual suppression

  • Anticipatory counseling that this is common is helpful in reducing method discontinuation rates and improving method satisfaction, as well as reassuring that BTB is benign and common.

    • Reassure that with some methods BTB decreases or ceases after some time period of initial use

The Contraceptive CHOICE Project

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Background 

  • Title: The Contraceptive CHOICE Project: Reducing Barriers to Long-Acting Reversible Contraception 

  • Publishing Info:

    • Done by a group at the department of Ob/Gyn at Washington St. Louis School of Medicine (first author was a PhD!) 

    • Published in AJOG in 2010 (first 2500 patients) 

    • Follow up was published in Clinical Ob/Gyn 2014 - 9256 women 

  • Who funded this study 

    • Funded by an anonymous foundation + also Midcareer Investigator Award in women’s Health Research, Clinical Translational Science Award, and NCRR 

  • Why was this study done? 

    • About half of the pregnancies that occur in the US are unintended 

    • A lot of pregnancies results from incorrect or inconsistent use of birth control methods 

    • At the time, LARC use was low, <3% of women in the US used a LARC 

    • CHOICE was done to promote use of LARCs in the St. Louis region 

  • Goal: 

    • Objective: provide no-cost contraception to a large number of women in that region 

      • Secondary: reduce unintended pregnancy at the population level 

    • In order to accomplish, had to overcome two barriers: 

      • Financial obstacles 

      • Lack of patient awareness of LARC method safety and efficacy 

Methods 

  • Type of study

    • Prospective cohort study of 10,000 women in St. Louis region

  • Intervention

    • Provided each participant with the contraceptive of her choice at no cost for three years  

  • Subject recruitment

    • Convenience sample - meaning no randomization, etc. Just chose women at specific clinic locations and via general awareness of CHOICE through medical providers 

      • Clinics were university-affiliated clinics, two facilities providing abortion services, community clinics, etc. 

    • Eligibility: 

      • Age 14-45

      • Reside in or seek clinical services at recruitment sites in St. Louis region 

      • Sexually active with male partner in last 6 months or anticipate sexual activity with male partner in next 6 months 

      • No tubal or hysterectomy 

      • Does not desire pregnancy in next year 

      • Not currently using contraceptive method or interested in starting a new reversible contraceptive method 

    • Recruitment and screening was done by person on site or by telephone 

      • Person was trained with scripted intro to LARC methods if LNG-IUD, copper IUD, and subdermal implant

      • Enrollment occurs in 1.5-2 hr in person process

        • Rule out pregnancy

        • Due to staff constraints, not everyone got the same counseling - so at the community sites, patients received routine family planning counseling 

      • Informed consent 

    • LARC method

      • If they wanted a LARC method, then they had insertion by trained professional 

      • Emergency contraception was provided if needed  

    • Follow up: phone follow up at 3, 6, 12, 18, 24, 30, 36 months post enrollment 

      • Given $10 for each completed survey 

      • Also screened for gonorrhea and chlamydia at 12, 24, and 36 month contacts 

      • Huge undertaking to follow people for 3 years! 

      • Collected info on baseline demographics, OB and gyn history, etc. 

Results 

  • Findings for first 2500 women (2010 study) 

    • Population

      • Between August 2007 - December 2008, screened 4107 women, 3522 met eligibility criteria, 2500 enrolled 

      • 74% (1845/2500) of enrollments occurred at university-based recruitment site  

      • Average age: 25 (range 14-45), majority were 25 or younger (only 36.9% >25)  

      • 49% white, 44% black 

      • 42% no insurance, more than half reported difficulty paying for transportation food, housing, or medications 

      • 63.7% single or never married

      • 41% nulliparous, 54% of parous women reported having 2 or more children 

      • 67.1% chose a LARC, and 32.9% chose other methods 

        • Of those that chose LARCs: 46.8% LNG-IUD, 9.3% Copper IUD, 11.0% subdermal implant 

        • LARC users more likely to be recruited at an abnortion clinic (RR 1.2, 95% CI 1.1-1.2), report greater parity, or history of abrotion 

        • Those who reported black or other race, single or never married, one or no lifetime partners were less likely to choose LARC 

  • Findings for all the patients 

    • Demographics were overall pretty similar 

    • At the end of the study:

      • LARC users were more likely than non-LARC users to continue at the 12 and 24 months with method (86% vs. 55% at 12 months, 77% vs 41% at 24 months)  

      • At 12 months, the IUDs had highest continuation rates (88% for LNG-IUD, 84% for copper iUD), same at 24 months (79% for LNG-IUD and 77% copper) 

  • Some people voiced concern that with increased LARC use, there may be increase in high risk sexual behavior — no evidence to suggest that there was increased sexual risk-taking 

    • 71% reported no change in their number of sexual partners at 6 and 12 months; only 16% report increase, and of those, 80% experienced a change from 0 to 1 partners 

    • Percent of women reporting multiple partners at baseline was significantly reduced at 6 and 12 months (5.2%, 3.5%, 3.3% respectively) 

  • Reduction of unintended pregnancies! 

    • Failure rates for pill, patch, and ring = 4.8%, 7.8%, 9.4% at 1, 2, and 3 years 

    • Failure rate for LARC users remained <1% throughout the 3 year follow up (cumulative was 0.3%, 0.6%, and 0.9% at each year respectively) 

    • Non-LARC users were 22x as likely to experience an unintended pregnancy compared to LARC counterparts 

    • Adolescent users of pill, patch, or ring were twice as likely as older women to experience unintended pregnancies 

Very cool: super decreased rates of pregnancy, birth and abortion among teens! 

National for each: 158/1000, 94/1000, 41/1000

CHOICE: 34/1000, 19.4/1000, 9.7/1000 - Greater than 75% reduction! 

  • Contraception in the overweight and obese populations 

    • BMI was not found to be significant factor associated with increased risk of method failure for pill, patch, or vaginal ring (there were a total of 334 unintended pregnancies, 128 were determined to be contraceptive failure)

    • Weight gain

      • Those who perceived weight gain were more likely to be implant or DMPA users 

      • Objective weight gain on average was 10.3 lbs 

      • Adjusted models only identified black race as having significant association with weight gain in 12 months 

  •  STIs: Prevalence of GC, CT, and trich were higher in the CHOICE cohort than the national average at baseline 

    • 7.9% had one or more 

Conclusions 

  • Huge # of women seeking reversible contraception 

    • When barriers of cost, access, and knowledge are removed, women choose the most effective and least-user dependent methods more often 

      • In general population, LARC use was 3% 

      • In this population, 46% chose LNG IUD, 11.9% chose Copper IUD, and 16.9% chose implant 

    • Continue to use them 

    • Also found they were highly satisfied 

    • Also decrease risk of unintended pregnancies, teen pregnancies 

What do we do now? 

  • Some pretty cool follow up: 

    • Colorado Family Planning Initiative - provides access to long-acting reversible contraception 

    • Teen birth rates cut in half, abortion rates cut in half 

    • Average rate of first birth increased by 1.2 years among all women 

    • Cost avoided: $66.1-69.6 million

  • Per CDC we have definitely increased LARC use now! 

    • 2015-2017: LARC use was up to 10.3% 

    • LARC was highest among women 20-29 (13.1%)

Postpartum IUD Placement, with Dr. Sarah Prager

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This week we are joined by Dr. Sarah Prager, a professor at the University of Washington in OB/GYN and Complex Family Planning. She shares with us some particular expertise in an ever-more common procedure - the postpartum IUD placement. There’s definitely a few pearls in the podcast that are worth listening for!

Definitions: 

  • Immediate postplacental insertion: within 10 minutes of placental extraction

  • Immediate postpartum insertion: 10 minutes to 48 hours after delivery

  • Delayed postpartum insertion: 48 hours to 6-8 weeks after delivery

  • Interval placement: IUD placement not related to recent delivery

  • Trans-cesarean insertion: IUD placed through the hysterotomy at the time of cesarean delivery

Exclusion criteria:

  • Chorioamnionitis/uterine infection

  • Prolonged rupture of membranes (18-24 hours)

  • Excessive postpartum bleeding that is unresolved

  • Extensive genital trauma that would be negatively impacted by IUD placement

Expulsion rates: 

  • 10% if placed in the first 10 minutes

  • Up to 25-30% if placed after 48 hours

  • Limited data on 10 minutes to 48 hours

    • Pilot study in Zambia showed 4% expulsion with “morning after delivery” IUD placement

  • Provider experience matters!

    • Study from 1985 showed providers cut their expulsion rates almost in half comparing the beginning to the end of the study

  • Take home message: don’t get discouraged! Your expulsion rate will decrease with experience!

Copper vs. LNG-IUD

  • Most older data is with various copper IUDs (primarily the Copper T 380A – ParaGard)

  • Some limited data with specifically Mirena brand LNG-IUD.

  • Recent data often pooled LNG-IUD, without separating different IUDs

  • Limited comparative data

    • Possibly higher expulsion rates with LNG-IUD than Copper IUD

    • Could be due to method used for insertion – inserter vs. no inserter

    • LNG-IUD inserters are long enough to reach the fundus of a PP uterus, ParaGard IUD inserters are not

    • There is a dedicated PP inserter for Copper IUD (longer, stiffer, but not available in USA at this time); unclear if it changes outcomes

  • Recent study out of Kaiser showed slightly lower expulsion rates for breastfeeding vs. non-breastfeeding people.

    • Largest study to date with mostly LNG-IUD

    • Expulsion rates:

      • 10.7% expulsion by 5 years with placement 0-3 days

      • 3.9% for 3 days to 6 weeks

      • 3.2%for 6-14 weeks postpartum

      • 4.9% for interval placement

Medical Eligibility Criteria:

  • CDC: category 1 or 2 at any time, regardless of type of IUD or breastfeeding status.

    • Of course, category 4 if uterus is infected

  • WHO: category more nuanced depending on type of IUD and timing of placement

Method of placement:

  • With the inserter

    • Need a long enough inserter

    • Often can use the LNG-IUD inserters

    • Also need the inserter to be stiff enough – sometimes doesn’t work with LNG-IUD inserters

    • Dedicated copper IUD inserter both longer and stiffer

  • With an instrument

    • Can use a ring forceps

    • Can use a Kelly placenta forceps (longer)

  • With your hand

    • No difference in expulsion seen compared with instrument

    • Personal bias – WAY more painful! No-one likes a hand in their uterus

      • Not reported in the early studies that compared this to using a ring

Clinical tips and tricks for successful insertion with an instrument:

  • Place a ring on the anterior lip of the cervix

  • Hold the IUD gently in a ring forceps (don’t click down if LNG-IUD – don’t want to disrupt the LNG delivery system!)

  • Know the orientation of the IUD with respect to the orientation of the ring handles to make sure you place IUD with the proper orientation in the uterus!!!

  • Once the IUD is in the lower uterine segment, gently let go of the ring on the cervix and place the non-dominant hand on the uterine fundus

  • Drop your wrist! Drop your shoulder! Aim for the fundal hand

    • Angle different from interval insertions – basically aim for the umiblicus

    • Will not go wrong if you aim for the fundus! Feel it with your fundal hand!

  • Let go of the IUD and gently remove the ring without pulling on the IUD or strings

  • If strings are visible, cut at the os

    • Can also pre-cut the strings of LNG-IUDs so they are about 10 cm

    • Cutting strings can sometimes pull the IUD lower or out

  • Can use ultrasound if you want!

If using an inserter: 

  • Pre-deploy the IUD – you do not need the narrow profile with an open cervix!

  • Personal bias – don’t use the inserter

If using your hand:

  • Change your gloves

  • Precut the strings

  • Hold between the index and middle fingers with the strings laying across your palm

  • Make sure you don’t pull it out when you remove your hand!

If trans-cesarean placement:

  • Close 1/3 – ½ the hysterotomy then place

  • Precut the strings shorter before directing down into the cervix

  • Personal bias again toward instrument placement, but usually hand and inserter also work fine

Follow-up care:

  • See patients at 1-2 weeks postpartum and trim strings as needed.

    • May need to do this again at 6-week visit

  • If strings not visible at follow-up, do an ultrasound to verify presence of IUD in the uterus

    • If IUD there, NO NEED FOR ROUTINE ULTRASOUND TO CHECK CONTINUED PRESENCE OF THE IUD

    • Counsel patient that efficacy unchanged, but removal may be more complicated if strings don’t emerge from the cervix

      • This should have been a counseling point during consent!

Permanent Sterilization with Dr. Aparna Sridhar

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Here’s the RoshReview Question of the Week:

​​A 38-year-old woman presents to your office seeking counseling. She has four children, and she would like to have a tubal sterilization procedure. You explain to your patient the risks and benefits of bilateral salpingectomy compared to tubal ligation. Which of the following is this patient at risk for if she undergoes this procedure?

Check out the correct answer by following the links above!

Today we welcome back Dr. Aparna Sridhar, associate professor at UCLA Health, to talk about permanent sterilization counseling. You may remember her from our previous episode about combined hormonal contraceptives.

Dr. Sridhar gives us an awesome overview of all forms of permanent sterilization, including male permanent sterilization (vasectomy).