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Postpartum IUD placement at 2 to 4 weeks is noninferior to placement at 6 to 8 weeks, with caveats
Clinical Question
Is intrauterine device placement at 2 to 4 weeks postpartum noninferior to placement at 6 to 8 weeks?
Bottom line
The rate of complete expulsion of IUDs placed at 2 to 4 weeks postpartum was noninferior (within 6%) to placement at 6 to 8 weeks. IUD continuation at 6 months postpartum did not differ. However, the rate of partial expulsion after early placement was inferior, and other outcomes, such as malposition, trended to favor placement at 6 to 8 weeks. In individual decision-making, the small differences in favor of later placement should be balanced with a potential risk of pregnancy due to delay in placement, which was not observed in this study. There were no perforations in either group. 1b
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Government
Setting: Outpatient (primary care)
Synopsis
The purpose of this randomized controlled trial was to assess whether the risks of intrauterine device (IUD) placement in the early postpartum period (2-4 weeks) are noninferior to the risks of placement in the usual time frame of 6 to 8 weeks postpartum (interval placement). People were excluded if they had conditions precluding IUD placement, intrauterine infection, fourth-degree perineal laceration, another long-term contraceptive method, or if they desired pregnancy within 6 months. Both hormonal and copper IUDs were permitted (the majority were hormonal). Outcome assessment was masked. Among the 404 enrolled participants, 13% had no IUD placement and 14% were lost to follow-up and not included in the analysis. Patients in the early placement group had the procedure outside of the prescribed window (30/140 [20%] vs 10/145 [7%]). At 6 months postpartum, there was no difference in IUD use (141 [69.5%] vs 139 [67.2%]; NS). The principal outcome was expulsion rate, with a not-more-than 6% difference considered noninferior. By that metric, the complete expulsion rate was noninferior (3/149 [2%]; 95% CI 0.4 - 5.8% vs 0/145 [0%]; 0% - 2.5%; between group difference 2.0; -0.5 to 5.7). However, partial expulsion was higher in the early group (14/149 [9.4%]; 5.2% - 15.3% vs 11/145 [7.6%] 3.9% - 13.2%; between group difference 1.8; -4.8 to 8.6%). Secondary outcomes included malposition, removal, and pelvic infection, which all had nonsignificant trends that favored interval placement, though the sample size was not based on an assessment of these outcomes. There was no difference in pregnancy rate, and no perforations in either group.
Reviewer
Linda Speer, MD
Professor and Chair, Department of Family Medicine
University of Toledo
Toledo, OH
Comments
Assessment
Excellent
Post partum IUDs
Very useful information but depends on the willingness of FP clinics to undertake IUD insertion so early postpartum.