Immediate Post-Partum Insertion of Intrauterine Devices

A Cochrane review [Abstract] 3 included 10 studies. Immediate insertion of IUDs improved the initiation rate compared with delayed insertion (RR 1.27, 95% CI 1.07 to 1.51; 10 studies, n=1894; I²=98%; moderate-certainty evidence). However, the expulsion rate was higher in immediate postpartum IUD insertion at six months after delivery (RR 4.55, 95% CI 2.52 to 8.19; 8 studies, n=1206; I²=31%) compared with a delayed postpartum insertion.There was no clear difference between the two groups in the utilization of IUDs at six months after insertion (RR 1.02, 95% CI 0.65 to 1.62; 6 studies, n=971 participants; I² = 96%; very low-certainty evidence).Immediate IUDs insertion reduced unintended pregnancy at 12 months (RR 0.26, 95% CI 0.17 to 0.41; 1 study, n=1000 ; low-ertainty evidence).

Another Cochrane review[Abstract] 1 included 15 studies; of 4 with full reports, 3 were small trials. Newer trials compared immediate postplacental insertion versus early (10 minutes to 48 hours) or standard insertion (during the postpartum visit). A study (n=102) compared immediate (within 10 minutes of passing the placenta) and delayed (6 to 8 weeks post-partum) insertion of levonorgestrel-releasing intrauterine system (IUS); expulsion by 6 months was more likely for the immediate group than the delayed insertion group (23.5% vs 4.4%, OR 6.77, 95% CI 1.43 to 32.14). Insertion rates did not differ significantly between study arms. In the meta-analysis, IUD use at 6 months was more likely with immediate insertion than with standard insertion (OR 2.04, 95% CI 1.01 to 4.09; 4 trials, n=243), though expulsion by 6 months was more likely for the immediate group, but the confidence interval was wide (OR 4.89, 95% CI 1.47 to 16.32; 4 trials, n= 210). Study arms did not differ in use at 3 or 12 months in individual small trials.

A meta-analysis 2 including 48 trials estimated expulsion rates among women with postpartum IUD insertion (copper- IUD or LNG-IUS). Pooled rates of expulsion varied by timing of IUD placement, ranging from 1.9% with interval placements (4 weeks postpartum or greater), 10.0% for immediate placements (10 minutes or less after placental delivery), and 29.7% for early placements (greater than 10 minutes to less than 4 weeks postpartum). Immediate and early postpartum placements were associated with increased risk of expulsion compared with interval placement. Postpartum placement less than 4 weeks after vaginal delivery was associated with an increased risk of expulsion compared with cesarean delivery. Analysis of expulsion rates at less than 4 weeks postpartum also indicated that the lLNG-IUS was associated with a higher risk of expulsion (adjusted RR 1.91, 95% CI 1.50-2.43) compared with CuT380A.

A retrospective cohort study 4 including 24 959 women evaluated uterine perforation and expulsion rates with IUD insertion at 4-8 weeks postpartum vs 9-36 weeks postpartum. 157 uterine perforations and 273 IUD expulsions were identified. Perforation rates were significantly higher with placement at 4-8 weeks than at 9-36 weeks (0.78% vs 0.46%; P=.001), also adjusted odds ratio was higher (aOR 1.92, 95% CI 1.28 to 2.89). The Kaplan-Meier survival curve showed that the risk of uterine perforation remained elevated until approximately 22-23 weeks postpartum. Expulsion rates were similar between the 2 groups (1.02 vs 1.17; P=.52).

The Association of Perforation and Expulsion of Intrauterine Devices (APEX-IUD) cohort study 5 evaluated the association of postpartum timing of IUD insertion and breastfeeding status with incidence and risk of IUD expulsion. The full cohort included 326 658 women, 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% to 12.61%) and lowest for insertions more than 6 weeks to 14 or fewer weeks post partum (3.18%; 95% CI 2.95% to 3.42%). In the subcohort, 5-year cumulative incidence was 3.49% (95% CI 3.25% to 3.73%) for breastfeeding women and 4.57% (95% CI 4.22% to 4.95%) for nonbreastfeeding women; the adjusted HR for breastfeeding vs not breastfeeding was 0.71 (95% CI 0.64 to 0.78).

The quality of evidence is downgraded by study quality (unclear allocation concealment).

References

• Lopez LM, Bernholc A, Hubacher D et al. Immediate postpartum insertion of intrauterine device for contraception. Cochrane Database Syst Rev 2015;(6):CD003036. [PubMed]
• Jatlaoui TC, Whiteman MK, Jeng G et al. Intrauterine Device Expulsion After Postpartum Placement: A Systematic Review and Meta-analysis. Obstet Gynecol 2018;132(4):895-905. [PubMed]
• Sothornwit J, Kaewrudee S, Lumbiganon P, et al. Immediate versus delayed postpartum insertion of contraceptive implant and IUD for contraception. Cochrane Database Syst Rev 2022;10(10):CD011913 [PubMed]
• Ramos-Rivera M, Averbach S, Selvaduray P, et al. Complications after interval postpartum intrauterine device insertion. Am J Obstet Gynecol 2022;226(1):95.e1-95.e8 [PubMed]
• Armstrong MA, Raine-Bennett T, Reed SD, et al. Association of the Timing of Postpartum Intrauterine Device Insertion and Breastfeeding With Risks of Intrauterine Device Expulsion. JAMA Netw Open 2022;5(2):e2148474 [PubMed]