Intrauterine device insertion during the postpartum period: a systematic review

doi:10.1016/j.contraception.2009.03.024

Contraception

Volume 80, Issue 4, October 2009, Pages 327-336

https://doi.org/10.1016/j.contraception.2009.03.024 Get rights and content

Abstract

Background

Insertion of an intrauterine device (IUD) at different times or by different routes during the postpartum period may increase the risk of complications.

Methods

We searched Medline, Lilacs and Cochrane Collaboration databases for articles in any language, between database inception until December 2008, which compared outcomes of postpartum IUD insertion time intervals. Search terms included postpartum, puerperium, postcesarean delivery, cesarean section, IUD(s), IUCD(s), intrauterine device(s) and insertion.

Results

From 297 articles, we identified 15 for inclusion in this review: all studies examined the outcomes from copper IUD insertions within the postpartum time period compared to other time intervals or compared routes (vaginal or via hysterotomy) of postpartum insertion. No studies of levonorgestrel IUDs were identified.

Immediate IUD insertion (within 10 min of placental delivery) was safe when compared with later postpartum time periods and interval insertion. Immediate postpartum IUD insertion demonstrated lower expulsion rates when compared with delayed postpartum insertion but with higher rates than interval insertion. Immediate insertion following cesarean delivery demonstrated lower expulsion rates than immediate insertion following vaginal delivery.

Conclusion

Poor to fair quality evidence from 15 articles demonstrated no increase in risk of complications among women who had an IUD inserted during the postpartum period; however, some increase in expulsion rates occurred with delayed postpartum insertion when compared to immediate insertion and with immediate insertion when compared to interval insertion. Postplacental placements during cesarean delivery are associated with lower expulsion rates than postplacental vaginal insertions, without increasing rates of postoperative complications.

Introduction

During the postpartum time period, women are often highly motivated to initiate contraceptive use. Intrauterine device (IUD) insertion during this time period is an ideal method for some women, as it does not interfere with breastfeeding, is convenient for both women and their health care providers, is associated with less discomfort and fewer side effects than interval insertions and allows women to obtain safe, long-acting, highly effective contraception while already within the medical system.

Postpartum IUD insertion, however, may increase the risk of adverse events affecting safety (e.g., perforation, pain, bleeding) as well as effectiveness (i.e., expulsion). Whether postpartum IUD insertion increases the risk of expulsion or perforation has been of particular concern to researchers and clinicians. Concerns about local effects of levonorgestrel IUDs on uterine involution and about the theoretical risks of exposing breastfeeding infants to hormones released by these IUDs during the first 6 weeks postpartum have inhibited research into the consequences of their insertion during the postpartum period.

We conducted this review in preparation for an expert working group meeting of international family planning experts convened by the World Health Organization (WHO) on April 2008 to revise the medical eligibility criteria for contraceptive use. This review reports the evidence available concerning whether women who have insertion of an IUD within 48 h postpartum are at higher risk for complications, such as perforation, infection, pain and bleeding, or for IUD expulsion than women who have interval insertion or insertion of an IUD later in the postpartum period. We also provide the recommendations by the expert working group, which were derived from evidence from all but one [1] of the studies summarized in this review.

Section snippets

Materials and methods

We searched Medline, Lilacs and Cochrane Collaboration databases for all articles published between their inception and December 2008 using the following search terms: (postpartum OR puerperium OR postcesarean OR delivery OR cesarean section) AND (IUD(s) OR IUCD(s) OR intrauterine devices OR intrauterine device) AND insertion(s). We did not restrict articles based on language. Reference lists of identified articles and relevant review articles were hand searched for additional citations. We did

Comparisons of insertion timing within the postpartum period

Six studies compared the safety and effectiveness of immediate postpartum insertion (within 10 min of placental delivery) with the safety and effectiveness of later postpartum IUD insertion [1], [4], [5], [6], [7], [14]. A prospective cohort study in Turkey compared outcomes among women where insertion of a CuT380A IUD took place within 10 min (n=84) with outcomes among those with later insertions (>10 min <72 h, n=46) or with interval insertions (>6 weeks, n=138) [14]. After 1 year, the IUD

Discussion

Fifteen studies from poor to fair methodological quality found differing expulsion rates by timing or route of IUD insertion; immediate postplacental insertion of an IUD (less than 10 min after placental delivery) appears to have the lowest risk for expulsion when compared to other postpartum time intervals, but the risk remains higher than that of interval insertion. Additionally, postplacental placement during cesarean section is associated with lower expulsion rates when compared to

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Cited by (165)

Placement of an intrauterine device within 48 hours after early medical abortion—a randomized controlled trial
2023, American Journal of Obstetrics and Gynecology
Intrauterine devices are safe, well-tolerated, and known to reduce the risk of unwanted pregnancies. At medical abortion, intrauterine devices are placed at a follow-up visit. Patients who miss this visit risk being left without contraception.
This study aimed to investigate if placement of an intrauterine device within 48 hours of completed medical abortion at up to 63 days’ gestation leads to higher user rates at 6 months after the abortion compared with placement at 2 to 4 weeks after abortion. Furthermore, we aimed to compare continued use of intrauterine devices, safety, and patient satisfaction between groups.
We performed an open-label, randomized, controlled, multicenter, superiority trial (phase 3). A total of 240 patients requesting medical abortion at up to 63 days’ gestation and opting for an intrauterine device were allocated to placement within 48 hours of complete medical abortion (intervention group) or at 2 to 4 weeks after abortion (control group). We defined the abortion as complete after bleeding with clots and cessation of heavy bleeding following the use of misoprostol. Patients answered questionnaires at 3, 6, and 12 months. The primary outcome was use of intrauterine device at 6 months postabortion. Secondary outcomes included expulsion rate, pain at placement, adverse events and complications from the abortion, acceptability, and pregnancies and their outcomes. Differences in nonparametric continuous variables were analyzed with the Mann–Whitney U test and differences in dichotomous variables with the chi square or Fisher exact tests. A P value of <.05 was considered statistically significant.
In the intervention group, 91 of 111 (82%) participants used an intrauterine device at 6 months after the abortion vs 87 of 112 (77.7%) in the control group, with a difference in proportion of 4.3% (95% confidence interval, −0.062 to 0.148; P=.51). Attendance rate and rate of successful intrauterine device placement were similar between the groups. Patients in the intervention group had lower pain scores at placement of the intrauterine device (mean pain score [visual analogue scale], 32.3; standard deviation, 29) compared with the control group (mean pain score [visual analogue scale], 43.4; standard deviation, 27.9; P=.002). Patients preferred their allocated time of placement significantly more often in the intervention group (83/111, 74.8%) than in the control group (70/114, 61.4%; P=.03). Use of ultrasound at intrauterine device placement (because of doubts concerning complete abortion) was more common in the intervention group (43/108, 39.8%) than in the control group (15/101, 14.9%; P<.001), and in one patient in the control group a retained gestational sac was found. Three patients in the intervention group and 2 in the control group had a vacuum aspiration. No difference was found in intrauterine device expulsion rates between the groups. Expulsion during the first 6 months after abortion was experienced by 9 of 97 (9.3%) patients in the intervention group and 4 of 89 (4.5%; P=.25) in the control group. There were no perforations or infections requiring antibiotic treatment.
Placement of an intrauterine device within 48 hours after medical abortion at ≤63 days’ gestation does not lead to higher user rates at 6 months after the abortion compared with intrauterine device placement at 2 to 4 weeks after abortion. When compared with placement at a follow-up visit after 2 to 4 weeks, intrauterine device placement within 48 hours after early medical abortion seems safe, is preferred by patients, and is associated with lower pain scores.
Efficacy and safety of intrauterine device placement during a planned cesarean section
2022, Heliyon
Citation Excerpt :
Similarly, in the present study, most of the participants stated that they would opt to have the same procedure performed during future cesareans. The expulsion rate after intra-cesarean IUD placement is typically between 0% and 20% [7, 9], and ours was low (2%) and occurred more than one year after insertion. This low rate is most likely related to the nature of the operation, i.e., solely a planned cesarean.
Approximately 79% of pregnancies conceived within the first year after delivery are unintended and 50% of the couples report having unprotected intercourse before the first routine postpartum appointment. Unintended pregnancies are associated with unsafe abortions and other poor outcomes. We aimed to determine the efficacy and safety of intrauterine device (IUD) placement during a planned cesarean section (CS) at one year after insertion.
A survey-based retrospective cohort study conducted at a university teaching hospital. The study cohort included term pregnant women delivered by a planned CS between December 2016 and July 2020, and data collection and questionnaires were completed in July 2021. In the study group, copper or Levonorgestrel IUDs were placed through the uterine incision after delivery of the fetus and placenta, while women in the control group did not receive an IUD. Other perioperative managements were similar. The primary outcome was unintended pregnancy rate during the first year after delivery.
The study comprised a total of 150 women, with 50 and 100 in the study and control groups, respectively. None of the women in the study group became pregnant, compared with nine (9%) in the controls (p = 0.03), of them eight (88.9%) were unplanned. Perioperative outcome was comparable between groups. The rate of contraceptive use one year after delivery was significantly higher in the study group compared to the control group (86.0% vs. 35.0%, respectively, p < 0.001).
IUD placement during CS is effective in preventing unintended pregnancies within the first year after delivery, with operative outcomes unaffected.
Intrauterine device (IUD) placement during a planned cesarean section prevented unintended pregnancies within one year after birth. Additionally, the rate of contraceptive use at one year was significantly higher compared to women who elected not to have an IUD inserted during the cesarean. IUD placement did not affect perioperative outcomes.
Study on the use practices and knowledges of French practitioners about the use of intra-uterine devices in early post-partum contraception in France
2022, Journal of Gynecology Obstetrics and Human Reproduction
Intra-Uterine Device (IUD) insertion is possible in early postpartum. Although this contraception method is recognized and used in lots of country, it seems infrequent and poorly known in France. Our study aims to assess the barriers to the application of this method in France.
A questionnaire was sent to obstetricians-gynaecologist professionals and midwives in France, through the affiliation to CNGOF (French National College of Obstetricians and Gynecologists) and to CNSF (French National College of Midwives). Questions were focused on the practices and knowledge about the insertion of IUD in early postpartum.
four hundred eight practitioners responded. Amongst them, 63% knew about the possibility to use IUDs after a vaginal delivery and 31% knew it could be inserted during cesarean section. Ten percent of them used this method. Most of these practitioners (80% of them) would like to discuss the insertion of an IUD in early postpartum with their patients and 71% would like to perform the insertion themselves after training. Besides, this study shows that contraception is rarely addressed by physicians during the follow-up of pregnancies. Less than 15% of respondents report discussing the topic systematically with the patient during the pregnancy follow during pregnancy follow.
insertion of IUDs in early postpartum is uncommon in France. The main limitation seems to be a lack of knowledge, but practitioners seem to be interested in this practice. Training courses could be created in order to rase up the adoption of this practice.
A trifunctional contraceptive gel enhances the safety and quality of sexual intercourse
2021, Bioactive Materials
Current contraceptive methods come with a number of drawbacks, including low efficacy, in the case of commercial contraceptive gels, and a reduction in the quality of sexual intercourse, in the case of condoms. Adding pharmacologically-active agents to contraceptive gels holds the potential to improve sexual experience, and hardbor safety and hygiene. In this study, we fabricated a carbomer-based contraceptive gel consisting of three agents: tenofovir, gossypol acetate, and nitroglycerin (TGN), with pH adjusted to 4.5 (to be compatible with the vagina). In vitro, the gossypol component of the contraceptive gel proved to be an effective spermicide. When the concentration of gossypol acetate was 10 mg/ml, the spermicidal ability reached 100% after 30 s. In addition, tenofovir in the gel significantly inhibited lentiviral transfection efficiency in cell-containing media. In 6 pairs of rats, the gel successfully prevented all females from conceiving after successful mating. Moreover, increased sexual frequency and enhanced erection, which were promoted by the nitroglycerin in the components, were observed in male rats that had the gel applied to their penises. This novel TGN contraceptive gel yielded a higher contraceptive success rate than that of the commercial contraceptive gel (Contragel®). In addition, it has the added benefits to prevent sexually transmitted diseases and improve male libido and erectile function during sexual intercourse. Combining three FDA-approved and marketed agents together, our trifunctional TGN gel has a great potential for further translation and commercialization.
Long-acting reversible contraceptive (LARCs) methods
2020, Best Practice and Research: Clinical Obstetrics and Gynaecology
Unplanned pregnancy (UP) is a public health problem, which affects millions of women worldwide. Providing long-acting reversible contraceptive (LARC) methods is an excellent strategy to avoid or at least reduce UP, because the effectiveness of these methods is higher than other methods, and is indeed comparable to that of permanent contraception. As the initial introduction of the inert plastic intrauterine device (IUD) and of the six-rod implant, pharmaceutical companies have introduced a copper IUD (Cu-IUD), different models of levonorgestrel-releasing intrauterine system (LNG IUS), and one and two-rod implants, which certainly improved women's LARC options. The main characteristic of LARCs is that they provide high contraceptive effectiveness with a single intervention, and that they can be used for a long time. Emerging evidence from the last few years has demonstrated that it is possible to extend the use of the 52 mg LNG IUS and of the etonogestrel-implant beyond five- and three years, respectively, which adds new value to these LARCs.
Postplacental intra-abdominal placement of levonorgestrel 52 mg intrauterine system: A case report
2020, Contraception

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^☆: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the World Health Organization or Centers for Disease Control and Prevention.

^☆☆: This review was supported by resources from the Department of Reproductive Health and Research at the World Health Organization, the Centers for Disease Control and Prevention, the US Agency for International Development and the National Institute of Child Health and Human Development, USA.

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Review articleIntrauterine device insertion during the postpartum period: a systematic review☆,☆☆

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Comparisons of insertion timing within the postpartum period

Discussion

Contraception

Contraception

Int J Gynaecol Obstet

Contraception

Contraception

Contraception

Am J Obstet Gynecol

Am J Prev Med

Random comparative study between intrauterine device multiload Cu375 and TCu 380A inserted in the postpartum period

Ginecol Obstet Mex

Review article
Intrauterine device insertion during the postpartum period: a systematic review☆,☆☆