Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis

Averbach, Sarah; Ermias, Yokabed; Jeng, Gary; Curtis, Kathryn M.; Whiteman, Maura K.; Berry-Bibee, Erin; Jamieson, Denise J.; Marchbanks, Polly A.; Tepper, Naomi K.; Jatlaoui, Tara C.

doi:10.1016/j.ajog.2020.02.045

Cited by 65 publications

(107 citation statements)

References 61 publications

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“…14 On the other hand, half of the women included in this study had a cesarean delivery, which is associated with lower expulsion rates than vaginal delivery in post-placental insertion. [8][9][10] Our finding that the expulsion rate was significantly higher among the TCu380A IUD users than among the LNG IUS users differs from previous reports. [7][8][9][15][16][17][18][19] In a systematic review 8 Two systematic reviews showed a 1.9 times higher risk of LNG IUS expulsion than TCU380A IUD expulsion following postpartum placement after vaginal birth.…”

Section: Discussioncontrasting

confidence: 99%

“…Our finding that the expulsion rate was significantly higher among the TCu380A IUD users than among the LNG IUS users differs from previous reports 7‐9,15‐19 . In a systematic review 8 with 48 studies of 7661 IUD placements, the IUD expulsion rates differed according to the timing of placement. In the main reported finding for 13 studies with a follow up longer than 6 months, IUD expulsion after post‐placental insertion was 9.1% (range 0.0‐25.4).…”

Section: Discussioncontrasting

confidence: 90%

“…The sample size was calculated based on the assumption of expulsion rates of 5%-7% and 15%-25% for the TCu380A IUD and LNG IUS, respectively. [8][9][10] We established a 0.05 two-sided alpha and power equal to 80%. Consequently, we needed at least 114 women to accept both IUDs for the final analysis.…”

Section: Statistical Analysesmentioning

confidence: 99%

“…8 Three systematic reviews evaluated IUD expulsion when inserted at different postpartum periods (from post-placental delivery to 72 hours to <4 weeks after delivery) or at intervals (>4 weeks after childbirth), and concluded that the risk of expulsion is higher in an early and immediate postpartum period than for an interval time. [8][9][10] Furthermore, two other systematic reviews included the analysis according to IUD type and showed that the risk of expulsion of the LNG IUS was almost twice that of TCu380A IUD. 9 However, no significant differences in expulsions was reported when LNG IUS was compared with a copper (Cu) IUD inserted at cesarean delivery.…”

Section: Introductionmentioning

confidence: 99%

“…9 However, no significant differences in expulsions was reported when LNG IUS was compared with a copper (Cu) IUD inserted at cesarean delivery. 8 The systematic reviews included studies with short follow up, and the authors did not randomize women by IUD type. Given the above situation, our hypothesis was that both the LNG and Cu-IUD will have high continuity rates 1 year after device placement with, however, a higher expulsion rate after vaginal delivery.…”

Section: Introductionmentioning

confidence: 99%

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One‐year follow up on post‐placental IUD insertion: A randomized clinical trial

Marangoni

Laporte

Surita

et al. 2021

Acta Obstet Gynecol Scand

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Introduction Our objectives were to compare the 1‐year follow‐up clinical performance of the TCu380A intrauterine device (TCu380A‐IUD) and levonorgestrel (LNG) 52‐mg intrauterine system (IUS) inserted at post‐placental period. Material and methods We conducted an open‐label, parallel‐group, randomized clinical trial, 1:1 with pregnant women admitted for childbirth independently of the mode of birth. Our primary outcome was expulsion up to 1 year after device placement by type of IUD and mode of delivery. During the follow up (42, 90 and 365 days (±7 days) after device placement), an ultrasound was performed to evaluate the device position. Kaplan–Meier with log‐rank test was used to compare the survival curves of the TCu380A IUD and the LNG IUS. Couple‐Years of Protection after insertion of both devices was calculated. Results One hundred and forty women were randomized to the TCu380A IUD (n = 70) or the LNG IUS (n = 70). By the end of the first year after device placement, 38 women experienced device expulsion (27.1%), most of them (33/38; 86.8%) within the first 42 days after delivery. The expulsions were significantly higher among users of TCu380A IUD (39.4%) than among users of the LNG IUS (22.2%; P = .039), and among those with vaginal delivery (43.8%) than among women with cesarean delivery (15%; P = .003). The 1‐year cumulative continuation rate was 64.2%, significantly higher for LNG IUS (73.1%) than for TCu380A IUD (54.4%; P = .03), and among women with cesarean delivery (77.6%) than for vaginal delivery (52%; P = .00). The post‐placental IUD insertion provided 356.4 Couple‐Years of Protection. Conclusions Two‐thirds of women who accepted a post‐placental IUD placement still used the device 1 year after childbirth. However, expulsion was the most prevalent reason for discontinuation, mainly within 42 days after device placement. The expulsion rate was significantly higher among TCu380A IUD users and among women with vaginal delivery.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussioncontrasting

confidence: 90%

Section: Statistical Analysesmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

One‐year follow up on post‐placental IUD insertion: A randomized clinical trial

Marangoni

Laporte

Surita

et al. 2021

Acta Obstet Gynecol Scand

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Long-Acting Reversible Contraception With Contraceptive Implants and Intrauterine Devices

Averbach

Hofler

2022

JAMA

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Early vs Interval Postpartum Intrauterine Device Placement

Averbach

Kully

Hinz

et al. 2023

JAMA

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ImportanceThe early postpartum period, 2 to 4 weeks after birth, may be a convenient time for intrauterine device (IUD) placement; the placement could then coincide with early postpartum or well-baby visits.ObjectiveTo determine expulsion rates for IUDs placed early postpartum compared with those placed at the standard interval 6-week visit.Design, Setting, and ParticipantsIn this randomized noninferiority trial, people who had a vaginal or cesarean birth were randomly assigned to undergo early (14-28 days) or interval (42-56 days) postpartum IUD placement. Clinicians blinded to participant study group used transvaginal ultrasonography to confirm IUD presence and position at the 6-month postpartum follow-up. The study assessed 642 postpartum people from 4 US medical centers, enrolled a consecutive sample of 404 participants from March 2018 to July 2021, and followed up each participant for 6 months postpartum.InterventionsEarly postpartum IUD placement, at 2 to 4 weeks postpartum, vs standard interval placement 6 to 8 weeks postpartum.Main Outcomes and MeasuresThe primary outcome was complete IUD expulsion by 6 months postpartum; the prespecified noninferiority margin was 6%. Secondary outcomes were partial IUD expulsion, IUD removal, pelvic infection, patient satisfaction, uterine perforation, pregnancy, and IUD use at 6 months postpartum. IUD malposition was an exploratory outcome.ResultsAmong 404 enrolled participants, 203 participants were randomly assigned to undergo early IUD placement and 201 to undergo interval IUD placement (mean [SD] age, 29.9 [5.4] years; 46 [11.4%] were Black, 228 [56.4%] were White, and 175 [43.3%] were Hispanic). By 6 months postpartum, 53 participants (13%) never had an IUD placed and 57 (14%) were lost to follow-up. Among the 294 participants (73%) who received an IUD and completed 6-month follow-up, complete expulsion rates were 3 of 149 (2.0% [95% CI, 0.4%-5.8%]) in the early placement group and 0 of 145 (0% [95% CI, 0.0%-2.5%]) in the interval placement group (between-group difference, 2.0 [95% CI, −0.5 to 5.7] percentage points). Partial expulsion occurred in 14 (9.4% [95% CI, 5.2%-15.3%]) participants in the early placement group and 11 (7.6% [95% CI, 3.9%-13.2%]) participants in the interval placement group (between-group difference, 1.8 [95% CI, −4.8 to 8.6] percentage points). IUD use at 6 months was similar between the groups: 141 (69.5% [95% CI, 62.6%-75.7%]) participants in the early group vs 139 (67.2% [95% CI, 60.2%-73.6%]) in the interval group.Conclusions and RelevanceEarly IUD placement at 2 to 4 weeks postpartum compared with 6 to 8 weeks postpartum was noninferior for complete expulsion, but not partial expulsion. Understanding the risk of expulsion at these time points may help patients and clinicians make informed choices about the timing of IUD placement.Trial RegistrationClinicalTrials.gov Identifier: NCT03462758

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Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis

Cited by 65 publications

References 61 publications

One‐year follow up on post‐placental IUD insertion: A randomized clinical trial

One‐year follow up on post‐placental IUD insertion: A randomized clinical trial

Long-Acting Reversible Contraception With Contraceptive Implants and Intrauterine Devices

Early vs Interval Postpartum Intrauterine Device Placement

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