Association of the Timing of Postpartum Intrauterine Device Insertion and Breastfeeding With Risks of Intrauterine Device Expulsion

Abstract

IMPORTANCE Intrauterine device (IUD) expulsion increases the risk of unintended pregnancy; how timing of postpartum IUD insertion and breastfeeding are associated with risk of expulsion is relevant to the benefit-risk profile. OBJECTIVE To evaluate the association of postpartum timing of IUD insertion and breastfeeding status with incidence and risk of IUD expulsion. DESIGN, SETTING, AND PARTICIPANTS The Association of Perforation and Expulsion ofIntrauterine Devices (APEX-IUD) cohort study included women aged 50 years or younger with an IUD insertion between 2001 and 2018. The breastfeeding analysis focused on a subcohort of women at 52 or fewer weeks post partum with known breastfeeding status. The study was conducted using data from electronic health records (EHRs) at 4 research sites with access to EHR: 3 Kaiser Permanente sites (Northern California, Southern California, Washington) and the Regenstrief Institute (Indiana). Data analysis was conducted from June to November 2019. EXPOSURES Timing of IUD insertion post partum was categorized into discrete time periods: 0 to 3 days, 4 days to 6 or fewer weeks, more than 6 weeks to 14 or fewer weeks, more than 14 weeks to 52 or fewer weeks, and non-post partum (>52 weeks or no evidence of delivery). Breastfeeding status at the time of insertion was determined from clinical records, diagnostic codes, or questionnaires from well-baby visits. MAIN OUTCOMES AND MEASURESIncidence rates and adjusted hazard ratios (aHRs) were estimated using propensity scores to adjust for confounding. RESULTSThe full cohort included 326 658 women (mean [SD] age, 32.0 [8.3] years; 38 911 [11.9%] Asian or Pacific Islander; 696 [0.2%] Hispanic Black; 56 180 [17.2%] Hispanic other; 42 501 [13.0%] Hispanic White; 28 323 [8.7%] non-Hispanic Black; 137 102 [42.0%] non-Hispanic White), and the subcohort included 94 817 women. Most IUDs were levonorgestrel-releasing (259 234 [79. 4%]).There were 8943 expulsions. The 5-year cumulative incidence of IUD expulsion was highest for insertions 0 to 3 days post partum (10.73%; 95% CI, 9.12%-12.61%) and lowest for insertions more than 6 weeks to 14 or fewer weeks post partum (3.18%; 95% CI, 2.95%-3.42%). Adjusted HRs using women with non-post partum IUD insertion as the referent were 5.34 (95% CI, 4.47-6.39) for those with postpartum insertion at 0 to 3 days; 1.22 (95% CI, 1.05-1.41) for those with postpartum insertion at 4 days to 6 or fewer weeks; 1.06 (95% CI, 0.95-1.18) for those with postpartum insertion at more than 6 to 14 or fewer weeks; and 1.43 (95% CI, 1.29-1.60) for those with postpartum insertion at more than 14 to 52 or fewer weeks. In the subcohort, 5-year cumulative incidence was 3.49% (95% CI, (continued) Key Points Question Are timing of intrauterine device (IUD) insertion post partum and breastfeeding associated with the risk of IUD expulsion? Findings In this cohort study of 326 658 women, 5-year cumulative incidence of IUD expulsion was highest among women with postpartum IUD insertions at 0 to 3 days and lowest for those with insert...

Demographic, Reproductive, and Medical Risk Factors for Intrauterine Device Expulsion

“…1,3,4,[6][7][8][9][10][11] The APEX-IUD (Association of Perforation and EXpulsion of Intra-Uterine Devices) study was an observational cohort study of 326,658 individuals designed to assess the association of breastfeeding and timing of postpartum IUD insertion with IUD expulsion and IUD-related uterine perforation among individuals in the United States. 12,13 The study also evaluated risks of IUD expulsion and uterine perforation in individuals with heavy menstrual bleeding and by IUD type (copper IUDs vs levonorgestrel-releasing intrauterine systems [LNG-IUDs]). 14,15 Although APEX-IUD was conducted to address a postmarketing requirement from the U.S. Food and Drug Administration, data from the study were also used to address questions raised by the European Medicines Agency about specific demographic, reproductive, and medical risk factors associated with IUD expulsion.…”

“…The APEX-IUD study population included individuals aged 50 years or younger at the time of IUD insertion and in the health care system for 12 months or longer before IUD insertion; only the first IUD insertion in the study period was included. To reduce the effects of confounding by breastfeeding or early postpartum timing at IUD insertion, 4 , 12 , 16 , 18 and the effect of pregnancy on BMI measurement, these analyses excluded individuals with a delivery 52 weeks or less before IUD insertion. Individuals were followed from IUD insertion until IUD expulsion, uterine perforation, removal, reinsertion, or expiration (ie, end of the approved duration of use); pregnancy; hysterectomy or other sterilization procedure; death; disenrollment from the health care system; or end of the study period (June 30, 2018).…”

“… 1 , 3 , 4 , 6 – 11 The APEX-IUD (Association of Perforation and EXpulsion of IntraUterine Devices) study was an observational cohort study of 326,658 individuals designed to assess the association of breastfeeding and timing of postpartum IUD insertion with IUD expulsion and IUD-related uterine perforation among individuals in the United States. 12 , 13 The study also evaluated risks of IUD expulsion and uterine perforation in individuals with heavy menstrual bleeding and by IUD type (copper IUDs vs levonorgestrel-releasing intrauterine systems [LNG-IUDs]). 14 , 15 …”

Early vs Interval Postpartum Intrauterine Device Placement

“…This study suggests that IUD placement between 2 to 4 weeks postpartum is associated with lower rates of expulsion than historical expulsion rates for immediate postpartum placement. Similarly, a retrospective cohort study demonstrated the highest expulsion rates among IUDs placed immediately postpartum (46.5/1000 person-years) and lower rates for IUDs placed between 4 days and 6 weeks postpartum (10.9/1000 person-years) and 6 to 14 weeks postpartum (9.3/1000 person-years) …”

Long-Acting Reversible Contraception With Contraceptive Implants and Intrauterine Devices

“…7 Breastfeeding is associated with lower IUD expulsion risk. 8 Nulliparous and Adolescent Patients. LARC can be safely used in nulliparous and adolescent patients.…”