Intrauterine contraception in nulligravid vs parous women

Intrauterine Contraception Continuation in Adolescents and Young Women: A Systematic Review

STUDY OBJECTIVE

Adolescents are at high risk for unintended pregnancies. Although intrauterine devices (IUDs), long-acting reversible contraceptives (LARCs), are known to be highly effective in preventing pregnancy, little is known about IUD adherence in adolescents. In this systematic review (SR) we examined IUD continuation rates compared with other forms of contraception in young women aged 25 years and younger. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A systematic search of Ovid Medline, Cochrane Library, and Embase was conducted for the years 1946-2015. Included studies examined IUD use in women 25 years of age and younger, compared IUD use with another form of contraception, and measured continuation rates at 12 months. The quality of each study was appraised using the Downs and Black criteria, and 12-month continuation rates among studies were pooled and analyzed according to contraceptive type.

RESULTS

Of 3597 articles retrieved, 9 studies met criteria for SR. Synthesized across studies, 12-month continuation was significantly higher for IUD users (86.5%, 12,761/14,747) compared with oral contraceptives (39.6%, 1931/4873), Depo-Provera (Pfizer Inc, New York, NY) hormonal injection (39.8%, 510/1282), vaginal ring (48.9%, 196/401), and transdermal patch (39.8%, 37/93; all P values < .001). There was no statistically significant difference in 12-month continuation between the IUD and another LARC method, the subdermal etonogestrel implant (85.3%, 4671/5474).

CONCLUSION

Findings of this SR suggest that continuation rates for IUDs are generally higher compared with other contraceptive methods for women aged 25 years and younger. In a population with high rates of unintended pregnancies, generally low adherence, and imperfect use with other non-LARCs, IUD use should be encouraged.

Association of age and parity with intrauterine device expulsion

OBJECTIVE

To investigate whether age 14 to 19 years and nulliparity are associated with expulsion of levonorgestrel and copper intrauterine devices (IUDs).

METHODS

This was a planned secondary analysis of the Contraceptive CHOICE Project. We used Kaplan-Meier survival analysis to estimate expulsion rates for the first levonorgestrel or copper IUD received during study participation. Cox proportional hazards regression models were used to investigate baseline characteristics associated with expulsion.

RESULTS

A total of 5,403 females were included; 4,219 (78%) used the levonorgestrel IUD and 1,184 (22%) used the copper IUD. There were 432 initial expulsions reported. The 36-month cumulative expulsion rate was 10.2 per 100 IUD users and did not vary by IUD type (levonorgestrel IUD 10.1 compared with copper IUD 10.7, P=.99). In the bivariate analysis, multiple characteristics including age, nulliparity, immediate postabortion insertion, and heavy menses were associated with expulsion. The cumulative rate of expulsion was lower in nulliparous women compared with parous women (8.4 compared with 11.4; P<.001) and higher in females aged 14 to 19 compared with older women (18.8 compared with 9.3; P<.001). After adjusting for confounders and stratifying by IUD type, the hazard ratio of expulsion for females aged 14 to 19 years was 2.26 (95% confidence interval [CI] 1.68-3.06) for the levonorgestrel IUD and 3.06 (95% CI 1.75-5.33) for the copper IUD. Compared to parous levonorgestrel IUD users, expulsion was lower for nulliparous levonorgestrel IUD users (adjusted hazard ratio 0.59, 95% CI 0.44-0.78).

CONCLUSION

IUD expulsions were not increased in nulliparous females. More expulsions were observed in females aged 14 to 19 compared with older women regardless of parity or IUD type.

LEVEL OF EVIDENCE

: II.

Pain at insertion of the levonorgestrel-releasing intrauterine system in nulligravida and parous women with and without cesarean section

BACKGROUND

Despite the high contraceptive effectiveness and noncontraceptive benefits of the levonorgestrel-releasing intrauterine system (LNG-IUS) in nulligravidas, there are still concerns related to the use of this device. Pain at insertion is one of the limitations to the increased use of intrauterine contraceptives. The aim of the study was to evaluate the ease of insertion and occurrence of pain at insertion of the LNG-IUS in nulligravidas (women who never became pregnant) compared to parous women with and without cesarean section (c-section). We also assessed the difficulty at insertion in each group.

METHODS

Three groups of new acceptors of the LNG-IUS were studied: one with 23 nulligravida women, one with 28 parous women who had undergone at least one c-section and one with 23 parous women who had no previous c-section. Pain at insertion was evaluated by using a pain visual analogue score (VAS). The ease of insertion was defined as easy or difficult by health care providers (HCPs) and classified according to the cause of difficulty: tight cervix, anatomically distorted uterus or pain.

RESULTS

Almost all women reported pain at insertion, regardless of parity and form of delivery. The mean VAS was 6.6 for nulligravida women, 5.2 for parous women with c-section and 5.9 for parous women with no c-section. Although 93% of the women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS again if needed. The most common difficulties were a tight cervix in nulligravidas, an anatomically distorted uterus in parous women with c-section and pain in parous women without c-section. There was no failure of insertion in any group. HCPs reported that it was easier to perform insertion in parous women who had undergone only vaginal deliveries than nulligravid women or parous women with a prior c-section.

CONCLUSIONS

Although almost all women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS if needed. This attitude reflects high satisfaction with the LNG-IUS. The type of difficulty at insertion was related to parity and type of delivery. The LNG-IUS was able to be inserted in all women; however, it was easier to do in parous women without c-section than nulligravid women or those with a prior C-section.

Failed IUD insertions in community practice: an under-recognized problem?

BACKGROUND

The data analysis was conducted to describe the rate of unsuccessful copper T380A intrauterine device (IUD) insertions among women using the IUD for emergency contraception (EC) at community family planning clinics in Utah.

METHODS

These data were obtained from a prospective observational trial of women choosing the copper T380A IUD for EC. Insertions were performed by nurse practitioners at two family planning clinics in order to generalize findings to the type of service setting most likely to employ this intervention. Adjuvant measures to facilitate difficult IUD insertions (cervical anesthesia, dilation, pain medication, and use of ultrasound guidance) were not utilized. The effect of parity on IUD insertion success was determined using exact logistic regression models adjusted for individual practitioner failure rates.

RESULTS

Six providers performed 197 IUD insertion attempts. These providers had a mean of 14.1 years of experience (range 1-27, S.D. ±12.5). Among nulliparous women, 27 of 138 (19.6%) IUD insertions were unsuccessful. In parous women, 8 of 59 IUD insertions were unsuccessful (13.6%). The adjusted odds ratio (aOR) showed that IUD insertion failure was more likely in nulliparous women compared to parous women (aOR=2.31, 95% CI 0.90-6.52, p=.09).

CONCLUSION

The high rate of unsuccessful IUD insertions reported here, particularly for nulliparous women, suggests that the true insertion failure rate of providers who are not employing additional tools for difficult insertions may be much higher than reported in clinical trials. Further investigation is necessary to determine if this is a common problem and, if so, to assess if the use of adjuvant measures will reduce the number of unsuccessful IUD insertions.

Adolescent contraception: review and guidance for pediatric clinicians

The objectives of this article are to review current contraceptive methods available to adolescents and to provide information, guidance, and encouragement to pediatric clinicians to enable them to engage in informed up-to-date interactions with their sexually active adolescent patients. Pregnancy prevention is a complex and dynamic process, and young people benefit from having a reliable authoritative source for information, counseling, and support. Clinicians who provide services for adolescents have a responsibility to develop their skills and knowledge base so that they can serve as that source. This review begins with a discussion about adolescent sexuality and pregnancy in the context of the adolescent developmental stages. We discuss approaches to introduce the topic of contraception during the clinic visit and contraceptive counseling techniques to assist with the discussion around this topic. In addition, information is included regarding confidential services, support of parental involvement, and the importance of male involvement in contraception. The specific contraceptive methods are reviewed in detail with the adolescent patient in mind. For each method, we discuss the mechanism of action, efficacy, contraindications, benefits and risks from the medical perspective, advantages and disadvantages from the patient's perspective, side effects, patient adherence, patient counseling, and any medication interactions. Furthermore, we have included a section that focuses on the contraceptive management for the adolescent patient with a disability and/or chronic illness. The article concludes with an approach to frequently asked or difficult questions. This section largely summarizes subsections on specific contraceptive methods and can be used as a quick reference on particularly challenging topics. Finally, a list of useful contraceptive management resources is provided for both clinicians and patients.

Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion

BACKGROUND

Of the 1.3 million abortions performed annually in the United States, approximately half are repeat procedures. Immediate postabortal intrauterine device (IUD) insertion is a safe, effective, practical and underutilized intervention that we hypothesize will significantly decrease repeat unintended pregnancy and abortion.

STUDY DESIGN

All women receiving immediate postabortal IUD insertion in eight clinics of a Northern California Planned Parenthood agency during a 3-year period comprise the IUD cohort. We selected a cohort of controls receiving abortions but choosing other, non-IUD contraception on the day of the abortion visit in a 2:1 ratio matched by date of abortion. We obtained follow-up data on repeat abortions within the agency for both cohorts through 14 months after the 3-year period. We evaluated differences in repeat abortion between cohorts. All analyses were intent-to-treat.

RESULTS

Women who received an immediate postabortal IUD had a lower rate of repeat abortions than controls (p<.001). Women who received a postabortal IUD had 34.6 abortions per 1000 woman-years of follow-up compared to 91.3 for the control group. The hazard ratio for repeat abortion was 0.38 [95% confidence interval (CI), 0.27-0.53] for women receiving a postabortal IUD compared to controls. When adjusted for age, race/ethnicity, marital status, and family size, the hazard ratio was 0.37 (95% CI, 0.26-0.52).

CONCLUSION

Immediate postabortal intrauterine contraception has the potential to significantly reduce repeat abortion.

The levonorgestrel intrauterine system in nulliparous women

The levonorgestrel intrauterine system (LNG-IUS) has been used internationally for over 15 years by 7 million women. Concern about providing the LNG-IUS to nulliparous women still exists, despite growing evidence of its safety and efficacy in this population. Expulsion rates do not vary by parity and, although evidence in nulliparas is scant, perforation rates are low in all women. Efficacy of the LNG-IUS is excellent regardless of parity, with less than 1 pregnancy per 100 woman-years of use. Efficacy with immediate post-abortal insertion is also excellent and unvaried by parity. The presence of an LNG-IUS does not increase the risk of PID or infertility in either parous or nulliparous women and the LNG may be protective against infection. Acceptability is high in nulliparous women when compared either to parous LNG-IUS users or to nulliparous users of combined oral contraceptive pills. In conclusion, LNG-IUS is both safe and extremely efficacious for use in nulliparous women.

Intrauterine contraception: evaluation of clinician practice patterns in Kaiser Permanente Northern California

BACKGROUND

Despite the medical evidence, few women of reproductive age in the United States use intrauterine contraception (IUC) in comparison with women worldwide. To reduce cost as a barrier, Kaiser Permanente removed the cost to the patient for IUC throughout California in 2002. The goal of this study was to evaluate whether providing evidence-based information about IUC would result in changes in the knowledge, attitudes and practice patterns of clinicians and in greater IUC utilization as compared with removing cost alone.

STUDY DESIGN

A comprehensive education intervention was conducted in half of Kaiser Permanente Northern California ob-gyn departments. To make comparisons between the intervention and comparison sites, we surveyed clinicians in both groups before and after the intervention about their IUC knowledge, attitudes as well as practice patterns and collected utilization data for 27 months.

RESULTS

Statistically significant changes in attitudes and practice patterns were reported by the intervention group as compared with the usual care comparison group. By the end of the study, change in IUC utilization was significantly greater in the intervention group (utilization rate=9.57/1000) as compared with the comparison group (utilization rate=7.35/1000) (p=.02).

CONCLUSION

A multifaceted approach to providing evidence-based clinician and patient education resulted in statistically significant reported changes in attitudes and practice patterns and in greater IUC utilization as compared with usual practice.

Barriers to contraceptive use in product labeling and practice guidelines

Many contraceptives are encumbered with potentially unnecessary restrictions on their use. Indeed, fear of side effects, fostered by alarmist labeling, is a leading reason that women do not use contraceptives. In the United States, hormonal methods currently require a prescription, although research suggests that women can adequately screen themselves for contraindications, manage side effects, and determine an appropriate initiation date, leaving little need for routine direct physician involvement. Sizing, spermicidal use, and length-of-wear limits burden users of cervical barriers and may be unnecessary. Despite recent changes in the labeling of intrauterine devices, clinicians commonly restrict use of this method and in some countries may limit the types of providers authorized to insert them. Although in some cases additional research is necessary, existing data indicate that evidence-based demedicalization of contraceptive provision could reduce costs and improve access.

A pilot study on the acceptability of levonorgestrel-releasing intrauterine device by young, single, nulliparous Chinese females following surgical abortion

This study investigated the acceptability of the levonorgestrel-releasing intrauterine device (LNG-IUS) as contraception among young, single women after termination of pregnancy. Twenty subjects, with a median age of 21 years, had LNG-IUS inserted immediately after suction termination of first-trimester pregnancy. The subjects were followed-up at 6 weeks, 3 months, 6 months and 12 months. Fifteen subjects (75%) had other pregnancies terminated in the past. There were no serious complications or pregnancies. The acceptability of the LNG-IUS was generally above 86% during each follow-up visit. A total of seven (35%) subjects were lost to follow-up at different periods of the study. Overall, four subjects (22%) had the LNG-IUS removed. Nine subjects were seen at the end of the 1-year study period and all continued with the LNG-IUS for contraception. Side effects were commonly observed and irregular vaginal bleeding was the most common. We conclude that the LNG-IUS may be an acceptable method among selective young, single, nulliparous clients after termination of pregnancy and could be offered as an option of contraception to them. However, the small sample size and the high lost-to-follow-up rate are the major limitations of this study.

Uterine factors and risk of pregnancy in IUD users: a nested case-control study

Scarce data are available on the relation between the effectiveness of intrauterine device (IUD) and the gynecologic features of a woman. A nested case-control study was conducted to determine whether the uterine position and hysterometry affect the pregnancy rate of copper IUD. Seventy-one cases (pregnant women with IUD) and 284 matched controls (1:4) were included. Matching criteria were date of IUD insertion and duration of use. Data were analyzed by conditional logistic regression modeling that considered age, parity and copper surface of IUD as potential confounders. When cases were compared to nonpregnant controls with IUD, the results showed that uterine position and hysterometry were not associated with an increased risk of pregnancy. The findings suggest that the gynecological characteristics of the woman analyzed should not be a criterion for the selection of potential IUD users.

Experience with GyneFIX insertions in Spain: favorable acceptance of the intrauterine contraceptive implant with some limitations

This study evaluates the incidents associated with GyneFIX insertion and first-year expulsion and continuity rates within the usual intrauterine contraceptive practice of a working group of Spanish professionals (GESEG), formed specifically with this aim. It is a prospective, multicenter, observational study of GyneFIX insertion in 1684 women. Data were prospectively collected on a structured form and processed centrally. Interest was focused on difficulties encountered during the insertion procedure and symptoms experienced during insertion. All terms were defined by consensus. Among the total, 18.6% of the women were nulliparous. GyneFIX insertion was rated easy in 92%, with more difficulty in nulliparous women, who showed significantly more symptoms during insertion of the device. First-year expulsion and continuity rates were 5.6 and 88 per 100 women, respectively. The pregnancy rate was 0.3 per 100 women/years. The GyneFIX system is an interesting alternative to standard IUDs for intrauterine contraception with copper, particularly in women who have experienced expulsion of other types of IUDs. Experienced professionals in IUD insertion quickly acquire familiarity with the GyneFIX insertion system, but proper implantation does not completely eliminate the risk of expulsion. Thus, the insertion system should be further modified to achieve a simpler, safer technique.

Expulsions following 1000 GyneFix insertions

CONTEXT

The GyneFix intra-uterine device has been used in our family planning service since 1997. One of the perceived advantages is its low expulsion rate, as reported by clinical trials.

OBJECTIVE

To calculate expulsion rates in routine clinical use and to look at possible reasons for expulsion.

DESIGN

Retrospective casenote analysis and opportunistic client consultation.

SETTING

A city centre family planning clinic.

PARTICIPANTS

The first 1000 GyneFix insertions.

MAIN OUTCOME MEASURES

Parity of client, experience of clinician carrying out insertion, time from device insertion to expulsion.

RESULTS

Overall expulsion rate was 7.6%. There was no significant difference in parity of clients experiencing expulsion. Most (4.7%) expulsions were early, occurring within 3 months of insertion. There was considerable variation in early expulsion rate from one clinician to another. Later expulsions also occurred, up to 28 months after insertion. Increasing experience of the inserting clinician led to lower rates of late expulsion. Unnoticed expulsion led to four unplanned pregnancies.

CONCLUSIONS

The GyneFix expulsion rate in our service is higher than quoted in clinical trials. Early expulsions may be related to insertion technique, representing insufficient implantation of the anchoring knot into the fundal myometrium. Late expulsions also occur, often many months after insertion; the reason for these is unclear. Users should be taught to check for the presence of the thread after each menstrual period and unnoticed expulsion should be confirmed by ultrasound and abdomino-pelvic plain X-ray.

Use of the intrauterine device: efficacy and safety

OBJECTIVES

To characterize the family planning center population that used an intrauterine device (IUD), to compare the reasons for its removal and types of incidents encountered by nulliparous women and women with children, and to evaluate the efficacy and safety of this method by the use of life tables.

METHOD

This was an observational, descriptive, prospective study of 774 women, recruited over a 5-year period, who used an IUD by informed choice, presented no absolute contraindications and were assessed throughout the whole follow-up period.

RESULTS

The mean age (standard deviation) of IUD use was 32.8 (5.9) years for non-nulliparous women and 27.4 (5.3) years for nulliparous women (p < 0.001). Follow-up was completed at the family planning center for 80.1% of women. No differences were observed between nulliparous and non-nulliparous women with respect to accidental pregnancy, suspected pelvic inflammatory disease or expulsion. Non-nulliparous women experienced more major bleeding incidents and anemia (p = 0.010). All pregnancies occurred with low-load devices. Nulliparous women discontinued IUD use more often due to a desire to become pregnant (p = 0.009) and suffered more vulvovaginal infections (p = 0.044).

CONCLUSIONS

The IUD is a safe contraceptive option regardless of parity, provided that women are carefully selected.

The intrauterine contraceptive device: an often-forgotten and maligned method of contraception

Although 90% of women at risk for unintended pregnancy in the United States use contraception, <1% of these women use the intrauterine contraceptive device. The mechanism of action of intrauterine contraceptive devices has been controversial, but several studies suggest that interference with sperm migration or function and with fertilization may be the most likely mechanisms. More important, there is lack of compelling evidence that the intrauterine contraceptive device acts as an abortifacient. The risk for pelvic inflammatory disease among users now appears to be extremely low, primarily as a result of better selection of candidates. A levonorgestrel-releasing intrauterine contraceptive device may offer some new therapeutic approaches for the treatment of certain gynecologic disorders. Although women who are not at risk for pelvic inflammatory disease or sexually transmitted diseases are appropriate candidates for the intrauterine contraceptive device, it appears that use can be expanded to selected nulliparous women and women with certain medical conditions.

Use of intrauterine contraceptive devices in nulliparous women: personal experience over a 12-year period

OBJECTIVE

To evaluate the use of intrauterine contraceptive devices (IUDs) in nulliparous women compared to their use in parous women.

METHODS

A comparative cross-sectional study was carried out to determine the reasons for removal of IUDs inserted between 1985 and 1996 in a sample of 227 nulliparous women and 2080 parous women. The statistical analysis was performed using the chi 2 test; the differences were considered to be significant when p < 0.05.

RESULTS

The reasons for removal of IUDs in the two groups were: expiry, 49.1% in the nulliparous group vs. 48.2% in the parous group; planned pregnancy, 21.7% vs. 15.4%; accidental pregnancy, 4.8% vs. 6.3%; expulsion, 1.6% vs. 5.1%; pelvic inflammatory disease, 1.6% vs. 1.1%; pain and/or bleeding, 14.5% vs. 10.2%; other, 6.4% vs. 6.3%; vasectomy or tubal sterilization, 0% vs. 7%.

CONCLUSION

Our data suggest that nulliparity is not a contraindication for the use of an IUD, and that the use of an IUD in nulliparous women is as safe and effective as in parous women.