IMMEDIATE POSTPARTUM LEVONORGESTREL (LNG) IUD INSERTION: ANALYSIS OF INSERTION TECHNIQUE AND EXPULSION RATES

Objectives

Prior studies report expulsion rates for immediate postpartum (IPP) IUDs as high as 27%. It is unclear whether modifiable insertion techniques affect the expulsion rate. We examined whether the technique of IPP LNG IUD insertion after vaginal delivery (manual vs device applicator vs ring forceps) was associated with IUD expulsion or other complications by six months postpartum.

Methods

We conducted a retrospective cohort study of all patients who delivered vaginally and received an IPP LNG IUD (Mirena®) in a multihospital healthcare system from 2019-2022. We identified eligible patients using ICD-10 codes and MAR administration. We manually extracted outcomes and confounding variables: expulsion, IUD complications, use of ultrasound, and obstetrical characteristics. Statistical analysis was performed using chi square tests.

Results

We included 647 IPP LNG IUD insertions; 48% (311) were inserted manually, 14% (90) via ring forceps, and 38% (246) via device applicator. The overall expulsion rate was 14.4%. We found no difference in the rate of expulsion between manual, ring forceps, or device applicator insertion (14.8%, 10.0%, and 15.4% respectively; p=0.43), nor was there a difference in the rate of composite IUD complications (13.2%, 10.0%, and 16.7%, respectively; p=0.25). Providers were more likely to use ultrasound with ring forceps (24.4%) and device applicator (22.0%) compared to manual insertion (11.3%; p <0.001).

Conclusions

Real world data suggest an LNG IUD expulsion rate of 14% after vaginal delivery. Our study found no difference in rates of IUD expulsion or complication based on insertion technique. These findings should inform pre-delivery long-acting reversible contraception (LARC) counseling and intrapartum practice patterns.