IUD Insertion Research Articles

52. Levonorgestrel Intrauterine Device Insertion for Menstrual Suppression in Adolescents with Gender Dysphoria: A Case Series

Menstruation can be a source of significant distress for adolescents with gender dysphoria. While pubertal blockers are not recommended for adolescents who present with gender dysphoria after menarche, menstrual suppression represents an important aspect of their medical care. Levonorgestrel intrauterine devices (LNG IUDs) are associated with less uterine bleeding than any other reversible method of menstrual suppression and are well tolerated by adolescents. However, many adolescents with gender dysphoria have not had vaginal sex and are distressed by their female genitalia, potentially exacerbating pain and anxiety during the intravaginal LNG IUD insertion. We present our experience with 6 cases of LNG IUD use in such adolescents.

RETRACTED: Effect of topical glyceryl trinitrate cream on pain perception during intrauterine device insertion in multiparous women: A randomized double-blinded placebo-controlled study

ObjectiveIntrauterine contraceptive device (IUD) insertion-related pain presents a push beyond the decline of women to use IUD for family planning. We aimed to investigate the analgesic effect of glyceryl trinitrate cream (GTN) in reducing pain during IUD insertion. Materials and methodsWe conducted a randomized double-blinded placebo-controlled study (NCT02708251, clinicaltrials.gov) in a tertiary University hospital. Reproductive-aged women requesting Copper IUD for contraception were considered. Eligible women for IUD insertion were randomized (1:1) to glyceryl trinitrate cream (GTN arm) or Placebo. Three minutes before IUD insertion, 1 ml of GTN cream or placebo was applied to the cervical lip at the planned tenaculum site, followed by 1 ml placed in the cervical canal up to the level of the internal os using a Q-tip applicator. Our outcomes were the participant’s self-rated pain perception utilizing a 10-cm Visual Analogue Scale (VAS) during cervical tenaculum placement, uterine sound and IUD insertion, then 15 min post-procedure. Results100 women were enrolled and randomized to GTN arm (n = 50) or placebo (n = 50). Women in the GTN arm reported lower VAS scores during tenaculum placement, sound and IUD insertion (median: 2 vs. 4, p < 0.0001; 2.5 vs. 4.5, p < 0.001;3 vs. 5.5, p < 0.0001, respectively). Higher ease of insertion score was also determined among GTN arm (mean ± SD: 6.9 ± 1.15 vs. 4.7 ± 1.38, p < 0.0001). Additionally, women in the GTN arm were more satisfied by the end of the insertion (92% vs. 74%, p = 0.003). ConclusionApplication of cervical GTN cream before IUD insertion seems to reduce the induced pain with subsequent easy insertion.

EVALUASI KOMPETENSI BIDAN DALAM PEMASANGAN ALAT KONTRASEPSI DALAM RAHIM COPPER T 380A BERDASARKAN UMUR, PENDIDIKAN, PENGALAMAN PEMASANGAN DAN LAMA PRAKTIK DI KOTA PADANG

Midwives are health providers influential in helping families to choose appropriate contraception for patients. Midwives must have competence in providing midwifery services in particular IUD insertion. This study’s aim was to evaluate the competency of midwives in the insertion of an intrauterine device Copper T 380A based on their age, education, experience of insertion and duration of practice in Padang City. This study was done in puskesmas and private midwivery practice in Padang from September to December 2014 using cross-sectional method on 24 samples who met the inclusion criteria and not exclusion criteria. We conducted interviews and observed how the respondents perform IUD insertion by using a check- list. From this study, there was no significant association between age (p: 0.540, p&gt; 0.05), education (p: 0.439, p&gt; 0.05), experience of insertion (p: 0.472, p&gt; 0.05) and duration of practice (p: 0.505, p&gt; 0.05) with competency of IUD insertion. Most respondents have a good competence in IUD insertion. Part of the checklist the respondents frequently missed out were conseling to the patients and prevention of infection.Keywords: Midwives Competency, IUD insertion, Copper T-380a

Huge Intravaginal Pedunculated Fibroid Embolization and Resectoscopy—A Case Report and Review of Literature

Background: Submucosal fibroids account for approximately 15 - 20 percent of total fibroids. Rarely, they prolapse. Common size is 2 - 6 cm, because larger fibroids are unlikely to fit through the cervix. Larger fibroids are associated with significant bleeding and pose a surgical challenge. Case Presentation: We present a 38-year-old woman nulliparous with an intravaginal pedunculated fibroid, 12 cm in diameter. She presented with metrorrhagia and an intense malodorous vaginal discharge, irresponsive to oral therapy. The patient had a history of resectoscopic fibroid enucleation, 7 months earlier, followed by insertion of an (intra-uterine device) IUD. There was no uterine prolapse. Management involved bilateral uterine artery embolization, followed by hysteroscopic excision with rigid resectoscope. The fibroid was “delivered” transvaginally intact. The uterus was preserved. The IUD was partly buried within the mass. Blood loss was negligible. Patient recovery was quick and uneventful. At 6-months follow up, pelvic anatomy has been restored. Conclusion: Large pedunculated fibroids are very rare. Embolization of uterine arteries has proven a valuable tool in challenging gynecologic operations. In our case, not only it prevented massive bleeding during excision, but also allowed a fertility-sparing minimally invasive management.

Feasibility and Safety of IUD Insertion by Mid-Level Providers in Sub-Saharan Africa.

The copper IUD is safe and effective, but underutilized in Sub-Saharan Africa, in part because of a lack of trained providers. The World Health Organization recommends training mid-level providers-including nurses and midwives-to insert IUDs; however, the safety of such task shifting has not been evaluated in Sub-Saharan Africa. Data were drawn from baseline surveys and study charts of 535 sexually active women aged 18-45 who used a copper IUD while participating in an HIV-prevention clinical trial conducted from August 2012 through June 2015 in Malawi, South Africa, Uganda and Zimbabwe. IUDs were inserted by study physicians, nurses and midwives trained as part of the trial, and by local nonstudy providers. Chi-square and Fisher's exact tests were used to compare women's experiences of adverse events-such as irregular bleeding, pelvic pain or device expulsion-by provider type. Half (54%) of women reported experiencing an adverse event; the most common were irregular bleeding and pelvic pain (45% and 25%, respectively). Compared with women who had received an IUD from a study physician or study nurse, greater proportions of women who had received one from a nonstudy provider reported any adverse event (76% vs. 49% and 51%, respectively), irregular bleeding (57% vs. 41% and 45%) and pelvic pain (35% vs. 15% and 32%); the difference between study physicians and nurses was significant only for pelvic pain. Expulsion rates were comparable for study nurses and nonstudy providers (12.3 and 11.9 per 100 woman-years, respectively), but lower for study physicians (7.3 per 100 woman-years). The findings support task shifting of IUD insertion to mid-level providers to improve IUD access in Sub-Saharan Africa.

Does sublingual misoprostol reduce pain and facilitate IUD insertion in women with no previous vaginal delivery? Methodological and statistical concerns

Does sublingual misoprostol reduce pain and facilitate IUD insertion in women with no previous vaginal delivery? Methodological and statistical concerns

Bleeding, cramping, and satisfaction among new copper IUD users: A prospective study

ObjectiveWe assess change in bleeding, cramping, and IUD satisfaction among new copper (Cu) IUD users during the first six months of use, and evaluate the impact of bleeding and cramping on method satisfaction.MethodsWe recruited 77 women ages 18–45 for this prospective longitudinal observational cohort study. Eligible women reported regular menses, had no exposure to hormonal contraception in the last three months, and desired a Cu IUD for contraception. We collected data prospectively for 180 days following IUD insertion. Monthly, participants reported bleeding scores using the validated pictorial blood loss assessment chart (PBAC), IUD satisfaction using a five-point Likert scale, and cramping using a six-level ordinal scale. We used multiple imputation to address nonrandom attrition. Structural equation models for count and ordered outcomes were used to model bleeding, cramping, and IUD satisfaction growth curves over the six monthly repeated assessments.ResultsBleeding significantly decreased (approximately 23%) over the course of the study from an estimated PBAC = 195 at one month post-insertion to PBAC = 151 at six months (t = -2.38, p<0.05). Additionally, IUD satisfaction improved over time (t = 2.65, p<0.01), increasing from between “Neutral” and “Satisfied” to “Satisfied” over the six month study. Cramping decreased notably over the six month study from between biweekly and weekly, to once or twice a month (t = -4.38, p<0.001). Finally, bleeding, but not cramping, was associated with IUD satisfaction across the study (t = -2.31, p<0.05) and at study end (t = -2.81, p<0.01).ConclusionsNew Cu IUD users reported decreasing bleeding and cramping, and increasing IUD satisfaction, over the first six months. Method satisfaction was negatively associated with bleeding.

The Association Between Multiple Abortions Within 1 Year and Previous Postabortal Desired Contraception at an Urban, Public Hospital.

Objectives: To determine the proportion of women undergoing multiple abortions within 1 year at an urban, public hospital and the association with desired contraception after the index abortion. Materials and Methods: We conducted a retrospective analysis of all women undergoing abortion up to 13 weeks and 6 days gestation at Stroger Hospital from June 1, 2012 to May 31, 2014. We examined the proportion of women with additional abortions up to 1 year after the index abortion and contraception desired at the index abortion. We also collected data about Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) infection in surgical abortion patients, to assess suitability for intrauterine device insertion immediately postabortion. Results: Of the 5,104 women with an abortion in the study period, 720 (14.1%) had at least one additional abortion within 1 year. Among women with multiple abortions, 153 (21.3%) selected Tier 1 contraception, 359 (49.8%) Tier 2, 103 (14.3%) Tier 3, and 105 (14.6%) were undecided or desired no method. The contraception desired at the index abortion did not differ significantly between women with and without subsequent abortions (p = 0.107). CT/GC coinfection and CT infection alone were associated with having multiple abortions over the 1-year period (p = 0.020 and p = 0.006). Conclusions: Among women presenting for abortion at an urban, public hospital, desired contraception did not differ significantly between women with multiple abortions versus one abortion within 1 year, but prevalence of CT/GC did. Women at high risk for multiple abortions may benefit from immediate postabortion IUD insertion to avoid unintended pregnancy, provided risk of infection is carefully evaluated.

Assessment of knowledge and attitude regarding intrauterine devices among auxiliary nurse midwife in two districts of North Bengal

Background: Despite being one of the most easily available and reversible methods of family planning, IUD utilization continue to remain low, as evident in the nationwide surveys. One of the reasons was poor knowledge and skills on IUD provision among health care providers. This study examined factors related to providers, by examining their IUD-related knowledge, and their attitudes toward recommending or inserting the IUD.Methods: A descriptive cross sectional study was conducted among 503 ANMs from Uttar Dinajpur and Darjeeling Districts using a semi-structured questionnaire exploring the service providers’ knowledge, current practices and experience with IUD insertion. Attitudes regarding IUDs were assessed by asking how much they agreed with a number of hypothetical statements about the IUD.Results: The proportion of good knowledge and favourable attitude was 57.5% and 60% respectively. The knowledge was found to be significantly higher among ANMs aged less than 30 years and who had graduate education than their counterparts. Better knowledge and favourable attitude was found among the ANMs posted in Darjeeling and had service experience of more than 5 years.Conclusions: The knowledge and attitude of the ANMs were found to be less than satisfactory. Addressing IUDs and other newer contraceptives in pre-service curriculum, within job training and peer group education in both public and private areas may help the situation.

Helping Postpartum Women in Mali Achieve Their Fertility Intentions: Perspectives From Introduction of the Dedicated Postpartum IUD Inserter.

Mali has one of the highest maternal mortality ratios in the world coupled with one of the lowest modern contraceptive use rates. Nearly a quarter of the country's 750,000 annual births occur within 24 months of a previous birth, increasing the risks for mothers and babies. Nearly 70% of postpartum women have an unmet need for family planning. In 2016, Population Services International Mali (PSI-Mali) introduced a dedicated postpartum intrauterine device (PPIUD) inserter to replace the technique of using forceps for PPIUD insertion, with the aim of helping to address this substantial family planning gap. A mixed-methods approach was used to assess program results and the experiences of PSI-trained providers using the dedicated PPIUD inserter in 5 health facilities in Bamako. We conducted 10 key informant interviews with providers and 4 key informant interviews with operational and clinical staff involved in training and supporting providers. Further data were collected from district health surveys and facility registers. Secondary data encompassed documentation from 2011 through 2017, with the service delivery figures of PPIUD using the dedicated inserter focused on the pilot period of March 2016 through December 2017. Primary data were collected in Mali in July 2017. Between March 2016 and December 2017, PSI-Mali trained 134 providers on the dedicated PPIUD inserter and provided more than 3,500 voluntary PPIUDs. Of the 1,840 voluntary PPIUDs provided in 2017 alone, 67% were provided by facilities trained to use the dedicated PPIUD inserter. Providers stated a preference for the inserter (compared with the use of forceps) due to its ease, speed, and perceived lower associated risks of infection. Service data from the 5 facilities visited showed an overall average PPIUD uptake of 7.3% of deliveries in 2017. Although private facilities had considerably fewer deliveries than public facilities (600-900 compared with 20-30, respectively), a much higher proportion of women delivering in the private facilities chose a PPIUD. The acceptance of the dedicated PPIUD inserter by providers may help reduce some of the supply-side barriers that inhibit women's access to postpartum family planning methods. With continued support to providers, coupled with ongoing efforts to address differences in service trends between sectors and demand-side barriers to the PPIUD and family planning more broadly, the dedicated PPIUD inserter could play an important role in responding to the high unmet need among postpartum women in Mali.

Utility of the Comfort, Assurance, Language Model (CALM) as a nonpharmacological intervention for pain relief during IUD insertion

Objectives: IUDs are among the most effective methods of contraception and are increasingly popular, but fear of insertion pain may be a barrier to use. Few interventions to reduce pain with IUD insertion exist. Our study implemented and evaluated a new nonpharmacological method to reduce patients’ anticipated and experienced pain.

Age, race, parity and access to same-day IUD insertion at obstetrician-gynecology practices in Ohio: a mystery client study

Age, race, parity and access to same-day IUD insertion at obstetrician-gynecology practices in Ohio: a mystery client study

Discontinuation Rates among Copper Intrauterine Device Users in Primary Healthcare Unit and University Clinic. Is There a Difference?

Background: in Egypt, despite the high percentage of women using IUD according to Demographic and Health Surveys (DHS) 2014 (52.9%) of total women using contraceptive methods, the discontinuation rates among Cu-IUD users (within 12 months of use) reaches 14.3% in 2014. Aim of the Work: the aim of the study was to compare between primary health care unit and university family planning clinic in discontinuation rate among copper IUD users. Patients and Method: study design: prospective analytical observational study. Study setting: This study was conducted at Family planning Outpatient clinic of Ain Shams Maternity Hospital and El-Zahraa primary health care unit for a year. This study included 260 women whom attending family planning clinic for Cu- IUD insertion. Total 100 subjects was enrolled from each clinic. Rest of subjects was lost on follow up either after 6 months or 12 months. Some others refused to participate or gave wrong personal contacts. Results: preliminary results of the study revealed that there is no statistically significant difference between discontinuation rate among Copper IUD users in university clinic and primary healthcare clinic (p-value = 0.095). Conclusion: in our Study, analysis of data revealed that age, parity and previous usage of IUD may affect discontinuation rate after 12 months of IUD use. The mean cause of IUD discontinuation was bleeding and Anemia was present in 66.6% of patients complaining from bleeding.

The organizational attributes of HIV care delivery models in Canada: A cross-sectional study.

HIV treatment in Canada has rapidly progressed with the advent of new drug therapies and approaches to care. With this evolution, there is increasing interest in Canada in understanding the current delivery of HIV care, specifically where care is delivered, how, and by whom, to inform the design of care models required to meet the evolving needs of the population. We conducted a cross-sectional survey of Canadian care settings identified as delivering HIV care between June 2015 and January 2016. Given known potential differences in delivery approaches, we stratified settings as primary care or specialist settings, and described their structure, geographic location, populations served, health human resources, technological resources, and available clinical services. We received responses from 22 of 43 contacted care settings located in seven Canadian provinces (51.2% response rate). The total number of patients and HIV patients served by the participating settings was 38,060 and 17,678, respectively (mean number of HIV patients in primary care settings = 1,005, mean number of HIV patients in specialist care settings = 562). Settings were urban for 20 of the 22 (90.9%) clinics and 14 (63.6%) were entirely HIV focused. Primary care settings were more likely to offer preventative services (e.g., cervical smear, needle exchange, IUD insertion, chronic disease self-management program) than specialist settings. The study illustrates diversity in Canadian HIV care settings. All settings were team based, but primary care settings offered a broader range of preventative services and comprehensive access to mental health services, including addictions and peer support.

In women desiring postpartum contraception with an IUD, does immediate IUD insertion after delivery increase continued IUD use at 6 months compared with delayed IUD insertion?

In women desiring postpartum contraception with an IUD, does immediate IUD insertion after delivery increase continued IUD use at 6 months compared with delayed IUD insertion?

Comparative safety and efficacy of a dedicated postpartum IUD inserter versus forceps for immediate postpartum IUD insertion: a randomized trial

ObjectiveTo compare postpartum intrauterine device (PPIUD) insertion using a newly developed dedicated PPIUD inserter (inserter) to insertion with modified Kelly placental forceps (forceps). Study designWe randomized 500 women at five Indian academic centers to PPIUD insertion of a Copper T380A with either the inserter or forceps. The primary outcomes were fundal placement (assessed by postinsertion ultrasound), ease of insertion on a 5-point Likert scale and safety (infection/perforation). Secondary outcomes included IUD status at 6–8 weeks postpartum, assessed by string check, ultrasound or x-ray. ResultsBetween September 2015 and July 2016, 241 women in the inserter group and 239 women in the forceps group completed the study, with 20 women excluded due to consent withdrawal (n=4), lost to follow-up (n=10) and protocol deviation (n=6). Median distance from the fundus was similar (p=.36): 5.2 mm (0–130) and 5.8 mm (0–120) in the inserter and forceps groups, respectively. Most providers reported insertion to be easy or very easy with inserter (n=195, 81%) and forceps (n=206, 86%; p=.51). There were no perforations or insertion-related infections. Complete expulsion occurred in 19 (7.9%) in the inserter and 13 (5.4%) forceps groups (p=.28). The inserter group had more partial expulsions (n=26, 10.8% versus n=12, 5.0%,) and self-removals (n=4, 1.7% versus n=0); however, most retained their IUD [174 (72.2%) and 200 (83.7%), respectively] (p=.01). Strings were not visible at follow-up in 23 (13.1%) participants in the inserter group and 45 (22.4%) in the forceps group (p=.04). ConclusionsHigh fundal placement was similar between groups, with strings subsequently seen more frequently in the inserter group. The inserter's increased partial expulsions and self-removals are likely associated with the longer string. ImplicationsThe easily performed technique of Cu-T380A PPIUD insertion with the inserter may make immediate PPIUD insertions more convenient for patients and providers. The technique, involving less IUD manipulation and reduced dependence on extra instruments, could combine to make PPIUD a more popular option. Since this study has a short follow-up period, further study is needed to better understand comparative outcomes with longer follow-up. Additional research on string management for IUDs inserted with the inserter could help explain the increased number of partial expulsions.

Can a Telephone Encounter Replace in Person Follow-up after IUD Insertion? [14G

INTRODUCTION: Limited research informs the recommendation for a 4 - 6 week follow-up surveillance visit after IUD insertion. We explored whether surveillance could occur over the phone instead of in-person without affecting continuation rates or adverse events. METHODS: Subjects were offered in-person or telephone follow-up 4 - 6 weeks after IUD insertion. All subjects were called at 6 months to assess if and why they had discontinued IUD use, or if they had any adverse events including expulsion, pregnancy, or pelvic infection. Subjects were also asked about string check attempts and success and their preferred method for IUD surveillance. Group demographics and outcome measures were compared using Chi-square, Fisher’s exact, T-test and Wilcoxon tests as appropriate. RESULTS: 47 and 131 patients enrolled respectively in the in-person and telephone follow-up groups. Demographics and medical history were not significantly different between the groups. The majority of subjects were white, college educated, privately insured, and nulliparous. Of all subjects who completed the 6-month assessment, 138 (94%) reported still having their IUD in place, 8 had discontinued, and 1 had an expulsion. Subjects in the two groups had similar IUD continuation rates at 6 months (p=0.70). Unscheduled visits and ability to feel strings were similar between the groups. CONCLUSION: We observed similar 6-month continuation rates, no evidence of increased unscheduled visits, expulsions or adverse events in the telephone group compared to the in-person group. More subjects chose phone follow-up. The 4 - 6 week telephone follow-up was comparable to in-person IUD follow-up in our population.

Immediate Postpartum LARC Reimbursement Increases Uptake of Effective Contraception After Pregnancy [22G

INTRODUCTION: Over one third of women have unfulfilled contraceptive needs during their first year postpartum, and women without health insurance are 30% less likely to use contraception. As states have begun to reimburse for immediate postpartum LARC placement (immediate post-placental IUD insertion and implant insertion before discharge), the objective of this study was to determine if LARC uptake increased in the Medicaid population after immediate postpartum reimbursement was instated. METHODS: Women receiving Medicaid were prospectively recruited from a postpartum service of a large, urban hospital before and after immediate postpartum reimbursement. They completed a survey regarding their contraceptive choices, and additional information was gathered from the medical record. A binary logistic regression was performed to determine if women receiving Medicaid were more likely to choose LARC as a contraceptive method after the policy took effect, adjusting for race, mode of delivery, and primiparity. RESULTS: 178 women were included in the analysis (70 before reimbursement, 108 after reimbursement). Women were 2.5 times more likely to use LARC as postpartum birth control after immediate postpartum reimbursement was instated (95% CI: 1.26-4.79). Of the 49 women who chose LARC after immediate postpartum reimbursement, 42 (86%) received their method before hospital discharge. CONCLUSION: Immediate postpartum reimbursement resulted in women being more than twice as likely to choose LARC as their postpartum contraceptive method. Removing this barrier to cost and access is particularly important in a population vulnerable to unintended pregnancy and loss of healthcare coverage.

Study on Quality of IUD Services Provided by Trained Professionals at Teaching Institutes.

Access the completeness in IUD services provided by trained professionals and find out the weak links. Study was conducted on 100 IUD trained professionals of tertiary care hospital and nursing teaching institute. All were given questionnaire that was duly filled by them. Data obtained were analysed. Protocols of case selection, pre-insertion counselling, insertion process and follow-up were assessed. All the four criteria were assessed on score of ten. Study group could not get ten points under any of the set criteria. Average of 53% case selection, 31.4% pre-insertion counselling, 42.5% insertion protocols and 46.1% follow-up counselling criteria were observed by study group. Highest compliance of protocols was seen among postgraduate students. Although IUD training is given to all medical professionals and IUD facility is available up to subcentres but the study shows that completeness in services is still lacking. Ensuring ideal place for IUD insertion, proper case selection, use of specific instruments for insertion and observance of insertion protocols are very vital for the success of IUD.

Structured integration of family planning curriculum: comparative assessment of knowledge and skills among new medical graduates in Ethiopia

ObjectiveThe objective was to assess if structured integration of a comprehensive family planning (FP) training into a medical school curriculum improves FP knowledge and skill scores of medical interns. Study designWe compared mean contraception knowledge scores of interns in a medical school with the integrated FP curriculum [intervention school] (n=56) to interns at four conventional medical curriculum schools without structured reinforcement of FP content [control schools] (n=161) in Ethiopia. A survey with 19 multiple choice contraception questions was administered. We also compared the mean contraception skills scores of the two groups at four Objective Structured Clinical Examination stations. The survey included self-reported number of contraception procedures and self-assessed competencies on a Likert scale. ResultsA total of 217 interns who have completed an Obstetrics and Gynecology rotation participated in the study. Interns from the intervention school reported performing substantially higher numbers of contraception procedures and rated themselves as being competent/highly competent across all procedures compared to the control schools (p<.001 for both). The mean knowledge score was significantly higher in the intervention school [13.1 vs. 8.7, difference 4.5, 95% CI: (3.7–5.2), p<.001]. The mean contraceptive implant insertion skill score was twofold higher for interns in the intervention school [22 points vs. 11, difference 10.7, 95% CI: (8.6–12.8), p<.001 out of a maximum possible point of 30]. Statistically significant differences in skill scores were also observed for intrauterine device IUD insertion [15 vs. 12, p<.01] and implant removal [11 vs. 9, p=.01]. ConclusionA structured integration of family planning curriculum was associated with higher scores in knowledge, clinical skills and self-assessed competencies. ImplicationsIntegrating comprehensive family planning training in medical curriculum can lead to graduating physicians who are more competent to offer the full range of FP options.