Research eyes safety of same-day IUD insertion
Executive Summary
Concerns about asymptomatic sexually transmitted infections in women at high risk for disease might deter clinicians from same-day placement of intrauterine devices (IUDs). However, results from two studies presented at a national meeting indicate such delays are unnecessary.
• Findings from a study of women who were offered same-day insertion of intrauterine contraception indicate rates of pelvic inflammatory disease within three months were similar in those who opted for and against same-day insertion.
• In a study to identify the incidence of gonorrhea and chlamydia in women presenting for intrauterine device insertion in a clinic with a "two-visit" insertion policy, statistics show just 69.74% of patients returned for the second visit for IUD placement.
Concerns about asymptomatic sexually transmitted infections (STIs) in women at high risk for disease might deter clinicians from same-day placement of intrauterine contraception. However, results from two recent studies indicate such delays are unnecessary.1,2 Both studies were presented at the 2014 annual clinical meeting of the American College of Obstetricians and Gynecologists (ACOG).
In the first study, researchers at a Title X Pittsburgh clinic offered same-day testing for STIs and intrauterine device (IUD) placement from September 2011 to May 2013 to all women seeking emergency contraception or pregnancy testing who had no cervicitis on examination and wanted to avoid pregnancy for six or more months. Participants in the study completed surveys on the day of their clinic visit and three months later regarding contraceptive use and STI testing, diagnosis, and treatment.
Of 947 eligible women, 366 (39%) completed surveys. Of those who completed surveys, 28 women had chosen same-day intrauterine contraceptive insertion. Rates of pelvic inflammatory disease within three months of visiting the study clinic were similar with same-day IUD placement (3.6%, 95% confidence interval [CI] 0-10.4%) or without same-day intrauterine contraceptive placement (5.3%, 95% CI 3.0-8.5%, P = .82). Most women (82%) who opted for same-day intrauterine contraceptive placement reported still using the IUD three months later. Pregnancy within three months of visiting the study clinic was reported by 3.6% (95% CI 0-19.2%) of women who opted for same-day intrauterine contraceptive placement compared with 10.7% (95% CI 7.4-15.3%) of others.1
"The women in our study were seeking either emergency contraception or pregnancy testing. When they saw that [same-day IUD insertion] was offered, they chose it," said Eleanor Bimla Schwarz, MD, MS, director of the women’s health services research unit at the Center for Research on Health Care in the Pitt School of Medicine in Pittsburgh. "Same-day insertion increases the convenience of the method."
In the second study, researchers at the Baylor College of Medicine in Houston sought to identify the incidence of gonorrhea and chlamydia in women presenting for intrauterine device insertion in People’s Community Health Center, a Houston academic community clinic, to evaluate the current "two-visit" practice for IUD insertion. The scientists performed a retrospective chart review from 2009 to 2010. They identified study participants from a list of all patients who had gonorrhea and chlamydia testing as those who presented for IUD insertion. Subsequent encounters were reviewed to identify participants who presented for IUD placement, were lost to follow-up, or presented with a pregnancy.
A total of 720 patients met inclusion criteria. The average age was 30.3 years, with average gravidity at 2.89 and parity at 2.5 (SD 1.2-3.8). The incidence of gonorrhea was 0.56%, and the incidence of chlamydia was 2.5%.
Just 69.74% of patients returned for the second visit for IUD placement, according to a chart review. Those who tested positive for gonorrhea or chlamydia were less likely to return (odds ratio, 4.68), and the rate of pregnancy was significantly higher in those who did not return (32.4% vs. 1.9%).
"Like previously reported studies in other populations, the incidence of gonorrhea and chlamydia in our patients is low; however, rates of failure to return and pregnancy are high," the researchers conclude. "Current two-visit’ protocols should be amended to allow for immediate placement of IUDs in similar populations to prevent delay in contraceptive services and unintended pregnancy."
Why the hesitation?
Clinicians have in hand guidance asserting the safety of same-day insertion of intrauterine contraception.
In 2009, ACOG issued a recommendation to adopt same-day insertion protocols for the IUD and the contraceptive implant, both of which are methods of long-acting reversible contraception (LARC).3 ACOG’s clinical recommendations specifically state that LARCs can be inserted at any time during the menstrual cycle as long as pregnancy is reasonably excluded and that routine STI screening is not required unless the client is at high risk of STIs. If this situation is the case, screening and insertion can occur on the same day or when the test results are available.3
Previous research also backs this practice. According to a 2012 joint study of nearly 60,000 women by researchers at the University of California, San Francisco and Kaiser Permanente Northern California in Oakland, the risk of developing pelvic inflammatory disease following insertion of an IUD is very low, whether or not women have been screened for gonorrhea and chlamydia.4
(Contraceptive Technology Update reported on the research. See "Put myths to bed: Study shows IUD insertions don’t cause PID in women," February 2013, p. 13.)
To understand clinicians’ attitudes about LARC same-day insertions, researchers surveyed staff members at family planning agencies in Colorado and Iowa regarding their LARC provision practices and their attitudes. Just 18% of agencies typically offered an IUD, and 36% typically offered an implant, in one visit.5
Barriers must be overcome for more women to receive IUDs without the extra burden of multiple visits. Often, the option of delivering same-day placement of IUDs is out of the clinician’s hands; there are often issues regarding payment authorization, says Susan Wysocki, WHNP-BC, FAANP, president & chief executive officer of iWomansHealth in Washington, DC, which focuses on information on women’s health issues for clinicians and consumers. Also, some clinics might not have IUDs in stock due to cost considerations, she notes.
"When possible, offering IUDs the same day of an appointment can mean that the woman’s next visit isn’t for a pregnancy test," says Wysocki. "It’s important to recognize any time lag for providing an effective method of contraception can make a difference for preventing an unintended pregnancy."
- Wang NA, Papic M, Parisi SM, et al. Same-day placement of intrauterine contraception for high-risk women. Obstet Gynecol 2014; doi: 10.1097/01.AOG.0000447266.38459.4d.
- Markham MR, Maggio L, Shah UR, et al. Effects of routine screening for gonorrhea and Chlamydia before intrauterine device insertion. Obstet Gynecol 2014; doi:10.1097/01.AOG.0000447257.48749.a4.
- American College of Obstetricians and Gynecologists, Gynecologists Committee on Gynecologic Practice, Long-Acting Reversible Contraception Working Group. ACOG Committee Opinion no. 450: Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2009; 114(6):1,434-1,438.
- Sufrin CB, Postlethwaite D, Armstrong MA, et al. Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease. Obstet Gynecol 2012; 120(6):1,314-1,321.
- Biggs MA, Arons A, Turner R, et al. Same-day LARC insertion attitudes and practices. Contraception 2013; 88(5):629-635.
