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Intrauterine Device Expulsion After Postpartum Placement: A Systematic Review and Meta-analysis

Jatlaoui, Tara C., MD, MPH; Whiteman, Maura K., PhD; Jeng, Gary, PhD; Tepper, Naomi K., MD, MPH; Berry-Bibee, Erin, MD, MPH; Jamieson, Denise J., MD, MPH; Marchbanks, Polly A., PhD; Curtis, Kathryn M., PhD

doi: 10.1097/AOG.0000000000002822
Contraception: Review: PDF Only

OBJECTIVE: To estimate expulsion rates among women with postpartum intrauterine device (IUD) placement by timing of insertion, IUD type, and delivery method.

DATA SOURCES: We searched PubMed, Cochrane Library, and ClinicalTrials.gov from 1974 to May 2018.

METHODS OF STUDY SELECTION: We searched databases for any published studies that examined postpartum placement of a copper IUD or levonorgestrel intrauterine system and reported counts of expulsions. We assessed study quality using the U.S. Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of IUD expulsion and estimated adjusted relative risks (RRs) for timing of postpartum placement, delivery method, and IUD type using log-binomial multivariable regression model.

TABULATION, INTEGRATION, AND RESULTS: We identified 48 level I to II-3 studies of poor to good quality. 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 (adjusted RR 7.63, 95% CI 4.31–13.51; adjusted RR 6.17, 95% CI 3.19–11.93, respectively). Postpartum placement less than 4 weeks after vaginal delivery was associated with an increased risk of expulsion compared with cesarean delivery (adjusted RR 5.19, 95% CI 3.85–6.99). Analysis of expulsion rates at less than 4 weeks postpartum also indicated that the levonorgestrel intrauterine system was associated with a higher risk of expulsion (adjusted RR 1.91, 95% CI 1.50–2.43) compared with CuT380A.

CONCLUSION: Postpartum IUD expulsion rates vary by timing of placement, delivery method, and IUD type. These results can aid in counseling women to make an informed choice about when to initiate their IUD and to help institutions implement postpartum contraception programs.

Postpartum intrauterine device expulsion rates vary by timing of placement, delivery method, and intrauterine device type.

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia; the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and Emory University School of Medicine, Atlanta, Georgia.

Corresponding author: Tara C. Jatlaoui, MD, MPH, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop F-74, Chamblee, GA 30341-3717; email: tjatlaoui@cdc.gov.

Financial Disclosure The authors did not report any potential conflicts of interest.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Each author has indicated that he or she has met the journal's requirements for authorship.

Received March 20, 2018

Received in revised form June 14, 2018

Accepted June 21, 2018

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.