Self-administration of misoprostol prior to intrauterine device insertion among nulliparous women: a randomized controlled trial

Background

Barriers to intrauterine device (IUD) use in nulliparous women include fear of pain with insertion and provider perception of difficulty with insertion. The goal of this study was to evaluate whether misoprostol prior to IUD insertion in nulliparous women eased insertion and decreased pain.

Study Design

This was a double-blinded, randomized, controlled trial. Nulliparous women requesting an IUD were randomized to buccal placement of 400-mcg misoprostol or placebo. Provider ease of insertion and patient-reported pain were measured using a 100-mm visual analogue scale.

Results

Seventy-three subjects completed the study. Baseline characteristics were similar between groups. Provider perception of ease of insertion was not different between study and control groups (28.97 mm, 22.33 mm, p=.18). Pain immediately prior to IUD insertion (10.84 vs. 2.11; p=.003) and after IUD insertion (46.50 vs. 35.14; p=.040) was higher for those in the study group compared to the control group.

Conclusion

This study demonstrates that it is not helpful to provide misoprostol for cervical ripening prior to insertion of IUDs as it does not improve ease of insertion for provider or decrease reported pain for the woman, and it may increase women's pain experience with insertion.

Implication Statement

Our study demonstrates that providers do not perceive nulliparous IUD insertion as difficult; women do experience pain with insertion but find the experience acceptable. The addition of misoprostol for cervical ripening prior to insertion does not ease insertion for providers and increases the pain level experienced by women.     

Intracervical lidocaine gel for intrauterine device insertion: a randomized controlled trial

BackgroundPain during intrauterine device (IUD) insertion can be a barrier to initiation. Clinical trials have found misoprostol and nonsteroidal drugs to be ineffective (Am J Obstet Gynecol 2006;195:1272–1277, Hum Reprod 2011;26:323–329, Hum Reprod 2007;22:2647–2652). One study suggested that 2% lidocaine gel decreased pain; however, study design problems limit its validity (Brit J Fam Plann 1996;22:177–180). We tested whether intracervical 2% lidocaine gel decreased insertion pain compared to placebo.Study DesignWe planned a randomized, double-blinded clinical trial of 200 women. We placed 2% lidocaine gel or placebo in the cervix prior to uterine sounding. Participants rated pain by marking a 100-mm visual analogue scale at four time points.ResultsWe randomized 200 participants and placed 197 IUDs. Pain was greatest at uterine sounding and similar between groups: placebo group mean 51.6 mm (SD 25), lidocaine group mean 55.5 mm (SD 30, p=.33). Stratified analyses accounting for parity showed no treatment effect. Multivariable analyses identified longer time since last pregnancy, lower parity and higher anticipated pain as predictors of pain during sounding, and dysmenorrhea and the levonorgestrel IUD as additional predictors during IUD insertion.ConclusionsIntracervical 2% lidocaine gel does not decrease IUD insertion pain. Understanding predictors of increased pain may help providers with preprocedure counseling.     

A survey of provider experience with misoprostol to facilitate intrauterine device insertion in nulliparous women

Background

There is a significant need for research on treatments that provide pain relief during intrauterine device (IUD) insertion. Misoprostol is frequently used before IUD insertion but is not always necessary and its use may increase pain and side effects. This survey evaluated how providers who perform IUD insertion in nulliparous women report using misoprostol to facilitate the procedure.

Study Design

An anonymous Internet-based survey was distributed to members of three professional organizations with family planning providers.

Results

Of 2211 survey respondents, 1905 (86%) reported providing IUDs to nulliparous women. Of those providing IUDs to nulliparous women, 947/1905 (49.7%) reported using misoprostol, and 380 (40%) of 947 of misoprostol users reported using the treatment empirically with all nulliparous IUD insertions. There was wide variation reported in dose, route and timing of misoprostol administration. Providers most commonly reported learning of misoprostol use for IUD insertion by word of mouth rather than through the literature.

Conclusions

Despite conflicting published data, nearly half of survey respondents use misoprostol before IUD insertion. Considerable variation in the timing of misoprostol use may explain differences in perception of its effectiveness. Evidence-based information about misoprostol for IUD insertion in nulliparous women, including pharmacokinetics, efficacy and optimal dosing, is needed.     

Do Knowledge and Attitudes Regarding Intrauterine Devices Predict Interest in Their Use?

BackgroundIncreasing use of intrauterine devices (IUDs) is seen as a promising strategy to prevent unintended pregnancies, particularly among young women. In this study, we examined correlates of young women's interest in using an IUD, including sources of information about, knowledge of, and attitudes toward IUDs.MethodsWe conducted a national Web survey of young adults (ages 18–29) in 2012. Using a subset of data from 382 sexually experienced young women who had never used an IUD, we employed multinominal logit regression models to examine differences in IUD interest.FindingsTwenty percent of women in the sample were interested in using an IUD in the future, 32% were not, and 48% were unsure. Women who thought IUDs were unattractive owing to the devices being inside their bodies, the need for provider insertion and removal, or the potential for pain during insertion were less likely to be interested in ever using an IUD. Those who found IUDs attractive owing to the ease of use, the ability to have sex without interruption or a barrier method, the option of a nonhormonal method, the potential length of use, the internal nature of the method, or the high level of effectiveness were more likely to be interested.ConclusionsThese data suggest that young women's attitudes toward IUDs are strongly linked to their interest—or lack thereof—in using an IUD. Health care providers attuned to women's contraceptive preferences are well-poised to help their patients match with methods that best accommodate these preferences.     

Prophylactic vaginal dinoprostone administration six hours prior to copper-T380A intrauterine device insertion in nulliparous women: A randomized controlled trial

ObjectiveTo determine the effectiveness of 3 mg vaginal dinoprostone administered six hours prior to copper intrauterine device (IUD) insertion compared to placebo in increasing ease of insertion and reducing insertion pain among nulliparous women. Study design. This was a single-center double-blinded randomized controlled trial (RCT). We randomly divided the two hundred nulliparous women requesting a copper T380A IUD to receive 3 mg vaginal dinoprostone or placebo six hours before IUD insertion. The primary outcome was provider ease of insertion. Patients reported their perceived insertion pain using a 10 cm visual analog scale (VAS). We also reported number of failed IUD insertions.ResultsBaseline characteristics were similar between groups. Ease of insertion score was lower in dinoprostone group than placebo group (3.6 ± 2.5 vs. 5.4 ± 2.8; p < 0.01) denoting easier insertion for clinicians in dinoprostone group. Mean pain score during copper IUD insertion was lower in dinoprostone group (3.7 ± 2.3 vs. 5.0 ± 2.8; p < 0.01). Failed IUD insertion occurred in two cases of dinoprostone group (2%) versus four cases in control group (4%) (p-value; 0.68).ConclusionsAlthough vaginal dinoprostone administration six hours prior to copper IUD insertion in nulliparous women leads to an easy IUD insertion, we do not routinely advise it as the reduction in IUD insertion pain scores with vaginal dinoprostone lacked clinical significance.ImplicationsIn settings where it is feasible to provide dinoprostone vaginally six hours before copper IUD insertion, clinicians will find insertion easier, and nulliparous women may experience somewhat less pain during the procedure. Where waiting six hours is practical, this may prove to be useful.     

A missed opportunity for care: two-visit IUD insertion protocols inhibit placement

BackgroundThe intrauterine device (IUD) is a safe, long-acting, highly effective method of birth control. Two-visit protocols for IUD insertion may represent a barrier to IUD uptake.Study DesignThis study is a retrospective database review. We identified Medicaid-insured women who requested IUDs in our urban university-based clinic, which employed a two-visit protocol for IUD insertion. The number of women who returned for IUD insertion was determined. To compare women who underwent insertion to those who did not, bivariate and multivariable analyses were used.ResultsOf the 708 women who requested IUDs at the initial visit, only 385 had an IUD inserted (54.4%). Single women were less likely to return for IUD placement compared to women who had ever been married (52.4% vs. 70.3%; p<.01). Patients who ordered IUDs at gynecologic visits were more likely to return as opposed to those who had them ordered at obstetrics-related visits (60.5% vs. 50.2%; p<.01). Women who lived > 10 miles away from the clinic were less likely to return for IUD insertion than women who lived < 10 miles away from the clinic (45.3% vs. 56.2%; p=.03). Race, age and type of IUD ordered were not significantly associated with probability of insertion.ConclusionsAlmost half of women who ordered IUDs did not return for insertion, suggesting that two-visit protocols hinder a woman's ability to have an IUD placed. We must eliminate barriers to IUD insertion.     

Effects of prophylactic misoprostol administration prior to intrauterine device insertion in nulliparous women

Background

This study was conducted to examine the effects of prophylactic misoprostol prior to intrauterine device (IUD) placement in nulliparous women.

Study Design

Nulliparous, reproductive-aged women desiring an IUD for contraception were randomized to receive 400 mcg of buccal misoprostol or placebo 90 min prior to IUD insertion. Subjects completed a series of 100-mm visual analogue scales (VAS, anchors: 0=none, 100 mm=worst imaginable) to measure their perceived pain at several times points (anticipated pain, leg positioning, speculum placement, tenaculum placement, IUD insertion, equipment removal and 5 min postinsertion). Secondary outcomes included provider “ease of placement” (100-mm VAS, anchors: 0=easy, 100 mm=extremely difficult), side effects and retention of the IUD after 1 month (self-report or clinic visit). The study had 80% power (α=0.05, one-sided) to detect a reduction with treatment of 20 mm in VAS scores with a combined sample size of 34.

Results

A total of 40 subjects were randomized to receive either misoprostol or placebo, and 35 completed the study. Five subjects withdrew (four prior to receiving study medication and one declined IUD). Baseline characteristics were similar between groups. There were no significant differences in patient-reported pain with IUD placement [misoprostol 65 mm (SD 21), placebo 55 mm (SD 21), p=.83] or at any other time point. Moreover, the misoprostol group reported significantly more preinsertion nausea (29% vs. 5%, p=.05) and cramping (47% vs. 16%, p=.04) than the placebo group. While provider-reported ease of insertion was not significantly different between groups, three placebo patients required additional dilation vs. none in the misoprostol group. All 35 subjects underwent follow-up at least 1 month postinsertion, and no expulsions were reported.

Conclusion

Prophylactic misoprostol prior to IUD placement in nulliparous women did not reduce patient perceived pain, but it did appear to increase preinsertion side effects.     

Six-month and 1-year continuation rates following postpartum insertion of implants and intrauterine devices

ObjectiveStudies show immediate postpartum (PP) insertion increases use of contraceptive implants and intrauterine devices (IUDs). Our objective was to compare the satisfaction and continuation rates of the two types of devices at 6 months and 1 year following PP insertion.Study DesignWe enrolled 133 women in a prospective cohort study following immediate PP insertion of an implant or IUD at two academic hospitals during 8 months of 2011. Subjects completed an enrollment survey during hospital admission and a follow-up phone survey 6 months and 1 year PP.ResultsAt 6 months PP, 72% of subjects provided follow-up information. Implant users were more likely to be using the originally-placed device (40/41, 98% vs. 45/55, 82%, p=0.02); nine women reported IUD expulsions. When accounting for replacement of expelled IUDs, IUD continuation at 6 months was 89% yielding similar continuation rates between groups (p=0.12). At 1 year PP, 51% provided follow-up. Of those, 82% still had a LARC method in place with similar continuation by device type (84% for implants, 81% for IUDs, p=0.96). Overall, satisfaction was similarly high in both groups.ConclusionDue to IUD expulsion, implants had a higher continuation rate than IUDs six months following immediate PP insertion. After replacement of expelled IUDs, continuation and satisfaction were similar for both devices at 6 months and 1 year.ImplicationsPlacement of implants and IUDs immediately PP can lead to high satisfaction. Despite early IUD expulsions, continuation rates were similar to those placed outside of the immediate PP period.     

Intrauterine Device Training,Attitudes, and Practices Among U.S. Health Care Providers: Findings from a Nationwide Survey

BackgroundProvider training in intrauterine device (IUD) procedures is a key strategy for improving evidence-based IUD care. We examined the influence of IUD training on IUD attitudes and practices among U.S. family planning providers.MethodsIn 2019, we conducted a cross-sectional survey of U.S. family planning providers. We performed logistic regression to examine associations between training in routine IUD placement and specific IUD safety attitudes, confidence performing IUD procedures, and specific IUD practices.ResultsAmong 1,063 physicians and advanced practice clinicians, 85.1% reported training in routine IUD placement. Overall, IUD training was associated with accurately stating IUDs are safe for queried groups, including patients immediately postpartum (prevalence ratio [PR] 4.22; 95% confidence interval [CI] 1.29–13.85). Trained providers reported higher confidence in routine IUD placement for parous (PR 7.71; 95% CI 1.31–45.3) and nulliparous (PR 7.12; 95% CI 1.17–43.5) women and in IUD removal (PR 2.06; 95% CI 1.12–3.81). Among providers with IUDs available onsite, IUD training was associated with frequent same-day IUD provision for adults (PR 7.32; 95% CI 2.16–24.79) and adolescents (PR 7.63; 95% CI 2.22–26.24). Trained providers were also less likely to routinely use misoprostol before IUD placement for nulliparous (PR 0.19; 95% CI 0.11–0.33) and parous women (PR 0.07; 95% CI 0.03–0.16).ConclusionTraining in routine IUD placement was associated with evidence-based IUD safety attitudes, confidence in performing IUD procedures, and clinical practices aligned with Centers for Disease Control and Prevention contraception guidance. Expanding IUD training might increase evidence-based care and patient access to the full range of contraception, including IUDs.     

Immediate Postabortion Intrauterine Device Insertion: Continuation and Satisfaction

BackgroundThe provision of intrauterine devices (IUDs) immediately postabortion has the potential to decrease unintended pregnancy in the United States. Studies have demonstrated safety and efficacy; however, there are limited data about continuation, satisfaction, and bleeding patterns among women receiving immediate postabortion IUDs.Study DesignWe performed a retrospective cohort study of women undergoing immediate postabortion IUD insertion. Demographics and clinical data were collected from intake forms and procedure notes. We attempted to contact women by telephone to administer a short questionnaire to assess continuation, satisfaction, and bleeding patterns.ResultsWe were able to contact 77 of 225 (34%). Women lost to follow-up were more likely to have higher parity or a pregnancy of greater gestational age at the time of abortion compared with women who were successfully contacted. Continuation and satisfaction rates were high (80.5% and 80.6%, respectively). Reported bleeding patterns with IUD use were similar to previously reported patterns.ConclusionFollow-up of women undergoing immediate postabortion IUD insertion is challenging. However, we found that women choosing immediate postabortion IUD had high rates of continuation and satisfaction.     

Does using tampons or menstrual cups increase early IUD expulsion rates?

BackgroundMany intrauterine device (IUD) users utilize intravaginal menstrual cups or tampons during menses, but no studies have investigated the impact this practice may have on IUD expulsions.Study DesignRetrospective chart survey.ResultsOf the 930 women having IUDs placed and reporting menstrual protection, 10.3% (96) used menstrual cups, 74.2% (690) used tampons, and 43.2% (402) used pads (many women reported using more than one method). In the 743 women with adequate follow-up information, there was a full or partial expulsion (i.e., part of the IUD in the cervical canal) rate of 2.5% (27) during the first 6 weeks after insertion. There was no difference in the women using cups, tampons or pads (confidence intervals overlap).ConclusionsFrom this study, there is no evidence that women who report using menstrual cups or tampons for menstrual protection had higher rates of early IUD expulsion.     

Higher dose cervical 2% lidocaine gel for IUD insertion: a randomized controlled trial

ObjectiveTo determine the effectiveness of 6 mL of 2% lidocaine cervical gel for pain during intrauterine device (IUD) insertion.Study DesignThis is a randomized double-blind placebo controlled trial of 6 mL of 2% lidocaine gel for IUD insertion pain among first-time IUD users. No other analgesia other than the study intervention was provided. The study was conducted at a university-based obstetrics and gynecology clinic. The primary outcome, pain during IUD insertion on a 0 to 100-mm visual analog scale, was analyzed using the t test.ResultsSeventy-three women received placebo gel, and 72 women received 2% lidocaine gel. The groups had similar sociodemographic and clinical characteristics. Baseline pain scores with speculum insertion were no different between the two groups. The lidocaine group reported a mean pain score with tenaculum placement of 37.5 (median: 39) compared to the placebo group of 41.6 (median: 37) (p=.4). Similarly, pain with IUD insertion was no different with a mean pain score of 35.2 (median: 34) in the lidocaine group and 36.7 (median 36) in the placebo group (p=.8).ConclusionsTwo percent lidocaine gel placed on the anterior lip of the cervix and at the internal os did not reduce pain with tenaculum placement and IUD insertion compared to placebo gel.ImplicationsAmong first-time IUD users, including both nulliparous and multiparous women, 6 mL of 2% lidocaine gel placed on the anterior lip of the cervix and at the internal os for 3 min did not reduce pain with tenaculum placement and IUD insertion compared to placebo gel.     

Evaluation of an intervention designed to improve the management of difficult IUD insertions by advanced practice clinicians

ObjectivesTo assess whether clinical skills training in cervical dilation and paracervical anesthesia, as well as the introduction of a clinical protocol for difficult insertions, increased intrauterine device (IUD) insertion success rates among advanced practice clinicians (APCs) including women's health and family practice nurse practitioners, physician assistants and certified nurse midwives.Study designThis prospective study assessed an intervention to improve IUD insertions among APCs at six family planning clinics in Utah. We collected data on IUD insertions performed by participating clinicians during two observation phases: preintervention (Phase 1) and postintervention (Phase 2). Using electronic medical records, we tracked patient characteristics, IUD insertion success, difficulties and failures. We constructed a mixed-effects logistic regression model to control for provider and patient demographics influencing insertion success rates.ResultsNine clinicians participated in both preintervention and postintervention phases. The analysis included 428 IUD insertion procedures (242 preintervention and 186 postintervention). During Phase 1, 31/242 (12.8%) insertions failed. Insertion rates in Phase 2 improved with only 8/186 (4.3%) failures. Using mixed-effects logistic regression, the odds of a successful insertion postintervention was 4.8 times greater than preintervention (aOR = 4.8.95% CI 1.8–12.7) when controlling for provider and patient characteristics. Increased risk of insertion failure was associated with nulliparity and younger age during Phase 1, but not during Phase 2.ConclusionsA brief training for APCs and the use of a clinical protocol for difficult insertions may be able to improve IUD insertion rates.ImplicationsClinics with high rates of IUD insertion failure can improve care with a simple intervention, which may yield significant benefits in IUD service delivery.     

Wider opportunities for IUD insertion

The timing of IUD insertion has important implications for those who insert the devices as well as the users. In 1978 the US Food and Drug Administration recommended insertion during menstruation but acknowledged that it is also "necessary and proper" to insert IUDs at other times in the cycle. A 1977 study found that 30% of European and North American obstetricians limited insertion to the time of menstruation. Nearly half those in Africa and the Middle East and 13% of those in Asia followed this practice. Consequently, many women are required to make more than 1 visit to a clinic, meaning inconvenience for both the user and provider and some unintended pregnancies. In developing countries women may depend on mobile clinics or infrequent visits by trained personnel and many seek help without an appointment. 1 reason for insertion at or just after menstruation is to ensure that the woman is not pregnant when the IUD is inserted. 2 recent articles attempt to assess the best time for IUD insertion with regard to IUD performance. White et al. found that women whose Copper T IUDs were inserted on days 1-5 of the menstrual cycle had a lower continuation rate in the 1st few months than did those whose IUDs were inserted at a later time in the cycle. Edelman et al. found that Copper T and Copper 7 IUDs could be inserted at any time during the menstrual cycle without any increased risk of subsequent pregnancy, removal for medical reasons or expulsion during the 1st 12 months after insertion. Pooled International Fertility Research Program (IFRP) data indicate that there is no consistent pattern with regard to the time in the cycle that the IUD is inserted and its later performance. In no case is there a distinct advantage for the 1st 5 days of the menstrual cycle. It is much simpler to offer a woman an IUD when she is first seen, provided she is reasonably sure she is not pregnant. New practices are evolving in relation to recently pregnant women. The postabortal use of IUDs has been extensively researched and is a useful option, using a variety of currently available devices. In regard to the postpartum use of IUDs, some programs have reported a high expulsion rate. Provided proper insertion technique is used, IUDs can be inserted immediately postpartum with a high degree of retention. Another use for copper containing IUDs is insertion within 5 days of unprotected sexual intercourse. In sum, women can be provided with IUDs upon request at any time during the menstrual cycle.     

Pregnancy outcomes with an IUD in situ: a systematic review

BackgroundWhile intrauterine devices (IUDs) provide highly effective contraception, pregnancies among IUD users do rarely occur. The objective of this systematic review is to assess the evidence about risks for adverse pregnancy outcomes among women who conceive with an IUD in situ.MethodsWe searched MEDLINE, POPLINE, EMBASE and LILACS databases from inception through April 2011 for peer-reviewed articles containing evidence related to pregnancy outcomes among women who conceived while using copper (Cu) and levonorgestrel-releasing (LNG) IUDs.ResultsNine articles met our inclusion criteria. Women with retained IUDs were at the greatest risk of adverse pregnancy outcomes, including spontaneous abortion, preterm delivery, septic abortion and chorioamnionitis. Cu-IUD removal decreased risks but not to the baseline risk of pregnancies without an IUD. One case series examined the LNG-IUD; when left in situ, 8 in 10 ended in spontaneous abortions.ConclusionPregnancies complicated by a remaining IUD in situ were at greater risk of adverse pregnancy outcomes. Early IUD removal appeared to improve outcomes but did not entirely eliminate risks.     

Effect of shared contraceptive experiences on IUD use at an urban abortion clinic

BackgroundWe studied the effect of contraceptive social networking on postabortion intrauterine device (IUD) uptake. This study explores whether women who have heard personal stories of IUD use are more likely to use an IUD for postabortion contraception.Study DesignWe surveyed 299 women undergoing induced abortion at San Francisco General Hospital's Women's Options Center before and after contraceptive counseling. Both English- and Spanish-speaking women, aged 15 years and older, were surveyed.ResultsFifty percent of women surveyed chose to use an IUD for postabortion contraception. Women choosing IUDs were more likely than women choosing other contraceptives or no contraceptives to be multiparous, Latina and interested in IUDs prior to contraceptive counseling. Disclosure of personal IUD use by a clinic staff member was independently associated with the decision to use an IUD (odds ratio 8.1, 95% confidence interval 3.8–17.2).ConclusionsWomen undergoing abortion in an urban clinic have knowledge and high acceptance of IUDs, and sharing of contraceptive experiences is common among women of all demographics. Controlling for demographics and prior knowledge of IUDs, sharing of personal IUD experiences by providers is significantly associated with IUD use.     

Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review

Concerns exist as to whether the insertion of copper and levonorgestrel-releasing intrauterine devices (IUDs) increases the risk of pelvic inflammatory disease (PID) among women with sexually transmitted infection (STI). We searched the MEDLINE database for all articles published between January 1966 and March 2005 that included evidence relevant to IUDs and STIs and PID. None of the studies that examined women with STIs compared the risk of PID between those with insertion or use of an IUD and those who had not received an IUD. We reviewed indirect evidence from six prospective studies that examined women with insertion of a copper IUD and compared risk of PID between those with STIs at the time of insertion with those with no STIs. These studies suggested that women with chlamydial infection or gonorrhea at the time of IUD insertion were at an increased risk of PID relative to women without infection. The absolute risk of PID was low for both groups (0-5% for those with STIs and 0-2% for those without).     

Can ultrasound predict IUD expulsion after medical abortion?

Objectives

Our randomized trial compared early and delayed intrauterine device (IUD) insertion following medical abortion. In this planned substudy, we explore if endometrial thickness and initial IUD position were associated with IUD expulsion. We also describe IUD movement within the uterus during the 6 months after insertion.

Study design

We recruited women undergoing medical abortion and choosing the copper IUD for contraception (n = 156). Participants were randomly assigned to early insertion 1 week after mifepristone or delayed insertion 4–6 weeks later. We measured endometrial thickness by transvaginal sonogram 1 week after abortion and IUD distance from the fundal aspect of the endometrial cavity three times: at insertion, 6–8 weeks later and at 6 months.

Results

We analyzed endometrial thickness in 113 women, baseline IUD position in 114 women and IUD movement in 65 women. Women who expelled IUDs (n = 15) had slightly thicker endometria (p = .007) and slightly lower baseline IUD positions (p = .03) than those who retained IUDs, but no clear cutoffs emerged in the receiver operating characteristic curve analysis. Retained IUDs commonly moved up and down throughout the 6 months (from 14 mm towards the fundus to 32 mm towards the cervix). Overall, retained IUDs moved a median of 2 mm towards the cervix between insertion and exit (p < .0001).

Conclusions

After medical abortion, the risk of IUD expulsion increases with thicker endometria and lower baseline position. Since no clear cutoffs emerged in the analysis and expulsion remained uncommon even with thicker endometria, we do not recommend restricting IUD insertion based on ultrasound data.

Implication

Copper T IUDs often move within the uterus without expelling. Expulsion is uncommon, and we do not recommend restricting IUD insertion based on ultrasound data.     

Effect of an atraumatic vulsellum versus a single-tooth tenaculum on pain perception during intrauterine device insertion: a randomized controlled trial

IntroductionIntrauterine devices (IUDs) are used by only 5.6% of contraceptive users in the United States. One barrier to IUD uptake is fear of pain during insertion, particularly among nulliparous women. Many interventions to reduce pain during IUD insertion have proven unsuccessful. Comparisons of different tenaculae have not been previously reported.MethodsThis was a single-blinded, randomized control trial of 80 women randomized to the use of a vulsellum or a single-tooth tenaculum during IUD insertion. The primary outcome was reported pain on a 100-mm visual analog scale at the time of vulsellum placement. Secondary outcomes included pain at other intervals during IUD insertion and bleeding from the tenaculum site. Pain scores were analyzed with a Mann–Whitney test because they were not normally distributed.ResultsPain scores at the time of single-tooth tenaculum (33.3 mm) and vulsellum (35.0 mm) placement were the same in both groups (p=0.58). It took longer to control bleeding in the single-tooth tenaculum versus the vulsellum group (1.1 vs. 0.4 min, p=0.001), although there was no statistically significant difference in the number of maneuvers required to control bleeding at the tenaculum site between the two groups. Preprocedure anxiety appeared to correlate with more pain during IUD insertion.ConclusionThis is the first randomized trial comparing tenaculae. There was no difference in reported pain, but the vulsellum may be associated with less bleeding than a single-tooth tenaculum. Women with higher preprocedure anxiety may experience more pain during IUD insertion. Future research could investigate an anxiolytic's effect on pain during IUD insertion.     

(药)铜165宫内节育器系统评估

目的:评价(药)铜165宫内节育器的有效性、副反应和可接受性,试图发现其与新型宫内节 育器使用效果的差别。方法:见本刊“我国常用口服避孕药和宫内节育器系统评估方法概述”(2005 年1期17页)。结果:与新型宫内节育器药铜γIUD、TCu220CIUD和MLCu375IUD相比,药铜165 IUD确实存在较高的脱落率和妊娠率;其续用率显著低于药铜γ和TCu220CIUD;其因症取出率高于 药铜γIUD,略低于TCu220CIUD。结论:新使用者不宜选用药铜165IUD,现用者不需取出药铜165 IUD,可继续使用。