ACOG & SMFM Guidance on the Use of IUDs and Contraceptive Implants

SUMMARY:  

IUDs and etonogestrel single-rod contraceptive implants are categorized as Long-Acting Reversible Contraception (LARC).  ACOG and other professional and public health entities are calling for reduced barriers and improved access to LARC.  The latest ACOG practice bulletin reviews various LARC options, including clinical considerations such as use in the postpartum period and management in the setting of pelvic infections.  ACOG has also released an updated ‘Quick Coding Guide’ for LARC that can be found in ‘Learn More – Primary Sources’ section.

Available LARCs

Copper Intrauterine Device (T380A) 

  • FDA approval for 10 years  

Levonorgestrel-Releasing Intrauterine Devices (LNG-IUD) 

  • Total of 52 mg of levonorgestrel 
    • 20 micrograms released per day (Mirena) 
      • FDA approved for 8 years 
    • 18.6 micrograms released per day (Liletta)  
      • FDA approved for 6 years  
  • Total of 19.5 mg of levonorgestrel (Kyleena) 
    • 17.5 micrograms released per day  
      • FDA approved for 5 years 
  • Total of 13.5 mg of levonorgestrel (Skyla)   
    • 14 micrograms released per day
    • FDA approved for 3 years 

Contraceptive Implant

  • Subdermal implant with a core containing 68 mg of etonogestrel 
  • FDA approved for 3 years

Clinical Considerations

Nulliparous and Adolescents

  • LARCs should be offered routinely as safe and effective contraceptive options for nulliparous women and adolescents
  • Use of LARCs in adolescents supported by the AAP  
  • IUD  
    • MEC category 2 (advantages outweigh risks)
    • Risk of infection is low 
      • No evidence of association with infertility or tubal occlusion   
    • High satisfaction rate based on continuation rates  
    • Expulsion rates may be higher in adolescents vs older women and multiparous vs nulliparous  
    • Like the general population, nulliparous women and adolescents prefer LNG-IUD  
  • Implant 
    • MEC category 1 (no restrictions)  
    • Continuation rates higher in adolescents compared to OCPs  

SMFM Guidance on Women at High Risk for Medical Complications (2019)

  • Use of LARC is encouraged for women at highest risk for adverse health events as a result of a future pregnancy (GRADE 1B)
  • SMFM recommends discussion take place in the prenatal period regarding availability of immediate postpartum LARC and MEC guidelines should be used to determine best method for particular medical conditions (GRADE 1C)
  • Counseling should include discussion around expulsion rates but appear to be outweighed by benefit of higher continuation rates (GRADE 1C)
  • Providers who intend to utilize immediate postpartum LARC should obtain appropriate training (Best Practice)
  • SMFM recommends that for women who are eligible and desire LARC, following a high-risk pregnancy, immediate postpartum LARC should be used vs delayed placement due to overall superior efficacy and cost-effectiveness (GRADE 1B)
  • Encourage breastfeeding following immediate postpartum LARC based on current evidence (GRADE 1B)
  • SMFM suggests that if a women wishes and is eligible for LARC, but immediate postpartum is not feasible, consider early postpartum placement (GRADE 2C)
  • Contraceptive counseling should be (Best Practice)
    • Patient-centered
    • Within a shared decision-making framework 

Timing of Insertion  

  • Interval insertion 
    • Insertion may be performed at any time during menstrual cycle if patient is not pregnant  
    • No benefit to inserting during menses 
  •  Postabortion LARC Insertion  
    • Routinely offer immediate insertion following first trimester and second trimester abortion (induced or spontaneous)  
  • Postpartum LARC Insertion 
    • Offer immediate LARC insertion (IUD and implant) prior to hospital discharge 
    • Higher IUD expulsion rates (10-27%), but cost-benefit supports immediate insertion  
      • Considered ACOG ‘best practice’  
      • Waiting 4-6 weeks may result in barrier to access  
    • Contraindications to IUD placement include chorioamnionitis, endometritis, or puerperal sepsis or ongoing postpartum hemorrhage 

Effect on Breastfeeding  

  • Copper IUD: No hormonal concerns  
  • LNG-IUD and implant: Studies do not demonstrate a deleterious effect on breast feeding including milk volume/composition, newborn weight or exclusive breastfeeding rates  
  • ACOG recommends shared decision making regarding concerns  
    • Patients should be counseled regarding
      • Theoretical risk of reduced duration of breastfeeding
      • Lack of data supporting a negative association

Infection Risk and IUD  

  • Asymptomatic women who are at low risk of STDs and have undergone routine screening  
    • No additional screening required at the time of IUD insertion  
  • Women who have not been screened for STDs or at increased risk for STDs  
    • Requires CDC-recommended STD screening at the time of a single visit for IUD insertion 
    • Do not delay IUD placement while waiting on results  
    • Treat a positive test without removing the IUD  
  • Purulent cervicitis is a contraindication to IUD placement
  • If known chlamydia or gonorrhea infection, delay IUD insertion following infection treatment until  
    • Antibiotic course is complete 
    • Symptoms resolved 
    • Pelvic/cervical exam normal 
    • Repeat testing at 3 months for gonorrhea or chlamydia to rule out reinfection  
  • Routine antibiotic prophylaxis is not recommended prior to IUD insertion 
  • Actinomyces on cytology is an incidental finding 
    • No treatment or IUD removal required if patient is asymptomatic  

Pregnancy with IUD in situ 

  • Determine location of pregnancy to rule out ectopic pregnancy  
  • Remove IUD if strings visible as benefits outweigh risks  
  • If patient opts to retain IUD, counsel regarding risks (which are not totally eliminated by IUD removal) 
    • Abruption, placenta previa, preterm delivery, cesarean delivery, low-birth-weight infants, and chorioamnionitis  
    • Theoretical concerns regarding hormonal exposure with LNG-IUD  
  • If a patient opts for termination, remove at that time  

Ectopic pregnancy and IUDs 

  • IUDs do not increase the risk and therefore can be offered to women with history of ectopic pregnancy 
  • If pregnancy does occur with IUD in place, there is a small increased risk of ectopic pregnancy  

IUD Removal and Menopause 

  • Copper IUD: Wait for a year of amenorrhea before removal  
  • LNG-IUD: Continue until 50-55 years of age  (as amenorrhea may be related to LNG component)
    • Non-contraceptive benefit of protecting uterus in women using estrogen therapy 
  • IUDs do not need to be removed in menopausal women prior to expiration date 

Gyn Procedures with IUD in Place 

  • Endometrial biopsy, colposcopy, cervical ablation or excision, and endocervical sampling may all be performed with an IUD in place 

Backup Contraceptive Method  

  • Copper IUD 
    • No backup method required  
  • LNG-IUD & implant  
    • Backup required (e.g. condoms) for 7 days after insertion unless 
      • Immediately following surgical abortion  
      • 21 days from childbirth 
      • Transition from other reliable method 
      • Within 7 days of LMP for LNG-IUD 
      • Within 5 days of LMP for implant   

KEY POINTS:  

Underlying Mechanism

  • LARC devices do not disrupt pregnancy but rather disrupt fertilization  
  • Copper IUD 
    • Inhibits sperm migration/viability  
  • LNG-IUD 
    • Increased cervical mucus viscosity that prevents sperm entry  
  • Implant  
    • Suppresses ovulation 
    • Increased cervical mucus thickening  
    • Alters endometrial lining  

Adverse Events and Side Effects

IUDs 

  • Overall complications are uncommon and include expulsion (2 to 10%), method failure and rarely perforation (see ‘Related ObG Topics’ below)  
  • Copper IUDs 
    • Heavy Menses and pain  
      • LNG-IUD offers benefit of reduced menses, despite continued ovulation in majority of women  
  • LNG-IUD  
    • Minimal hormone released systemically 
    • Hormone related effects include headaches, nausea, breast tenderness, mood changes, acne and ovarian cyst formation  
    • No difference in weight gain compared to copper IUD  

Implants 

  • Amenorrhea or menstrual irregularity 
  • GI symptoms 
  • Hormonal effects: Headaches, breast pain and worsening acne (10-14%)  
  • Weight gain (reported in 12% of users) 
    • Literature shows no difference in weight gain at 1 year, after adjusting for confounders, between implant and IUD users 
  • Complications related to insertion (1%)  
    • Pain, bleeding, hematoma or incorrect insertion 
  • Complications related to removal (1.7%)  
    • Breakage or inability to palpate/locate the implant because of overly deep insertion 
    • Imaging techniques to identify location include high-frequency ultrasonography, MRI, X-ray, CT, or fluoroscopy 

Failure Rates (typical use)

  • Copper IUD  
    • 0.8 % (1 year)  
    • 10-year failure rate comparable with that of female sterilization (1.9 per 100 women) 
  • LNG-IUD  
    • 20 microgram release:  0.2% (1 year) 
  • Implant 
    • 0.05% (1 year)

Learn More – Primary Sources:

ACOG Practice Bulletin 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices

SMFM Consult Series #48: Immediate postpartum long-acting reversible contraception for women at high-risk for medical complications

ACOG: Coding for the Contraceptive Implant and IUDs

Teenagers and Medical Care – When Is Parental Consent Not Required?

Adolescents are concerned about confidentiality and sometimes do not seek health care for this reason.  Myriad federal and state laws affect confidentiality of medical records in general.  However, it is the state that determines the statutes on the rights of minors to consent to healthcare services. Parents must generally consent before medical care is provided to their minor children; however, many states make important exceptions when it comes to sensitive services for which a parental consent requirement might deter an adolescent from obtaining needed care in a timely way. For example, all 50 states and the District of Columbia allow minors age 12 and older to access health care without parental consent for the treatment of STIs. Likewise, certain states and the District of Columbia allow minors to receive contraceptive services without notifying parents.  The access to these services helps reduce the transmission of STIs and prevent unplanned pregnancies. In most states, minors themselves may consent for substance abuse treatment, and in about half of the states, they are specifically authorized to consent to outpatient mental healthcare.

Furthermore, minors who may give consent can be divided into to two groups: mature minors and emancipated minors.

  • A mature minor is an adolescent younger than the age of majority. Such a minor can consent or refuse to consent to medical treatment if it is established that the minor is sufficiently mature to understand, discern and appreciate the benefits and risks of the proposed medical treatment. The age, ability, experience, education, training, and degree of maturity or judgment of the minor, as well as the conduct and demeanor of the minor at the time of the incident involved, all play a role.
  • To contrast, an emancipated minor is one who is legally free of parental control. A court ruling, marriage or enlistment in the U.S military for active duty are the most common scenarios. A minor who becomes a parent becomes the decision maker for the child.

Care of mature and emancipated minors is provided without parental consent or notification, although the physician will frequently work with the adolescent to involve parents in decision making, risk reduction, and ongoing health care. Of note, both mature and emancipated minors must still follow state laws on age-restricted activities such as voting and purchasing alcohol.

Health care providers should therefore be familiar with the regulations in their state of practice as minor consent laws vary between states. Institutions should be well-versed in state law to determine the degree of disclosure to parents/guardians that is permitted and/or required. If state law is not explicit, then institutions or individual providers should establish firm policies regarding the degree of confidentiality.

It is vital (and parents or guardians and adolescents should be informed, both separately and together) that the information each of them shares with the health care provider will be treated as confidential, and of any restrictions to the confidential nature of the relationship. Lastly, electronic health record systems need to be reviewed and possibly customized to accommodate the confidentiality needs related to minor adolescents and comply with the requirements of state and federal laws.

You can find a table with the state-by-state overview, broken down by contraceptive, STI, prenatal, adoption and abortion services at the Guttmacher Institute link below in ‘Learn More – Primary Sources’.

Learn More – Primary References:

ACOG Committee Opinion 803: Adolescent Confidentiality and Electronic Health Records

Guttmacher Institute: An Overview of Minors’ Consent Law

Confidentiality in Pediatric and Adolescent Gynecology: When We Can, When We Can’t, and When We’re Challenged

Adolescent and Caregiver use of a Tethered Personal Health Record System

LGBTQ Youth’s Perceptions of Primary Care

IUDs and Implants: How to Manage Potential LARC Complications

Use of long-acting reversible contraceptive (LARC) methods, both intrauterine devices and subdermal contraceptive implants, has increased dramatically in the past ten years.  Although the risk of complications is low, as use increases the absolute number of complications will increase.

CLINICAL ACTIONS:

Intrauterine device:

  • Pain
    • Lidocaine paracervical block reduces pain scores on insertion
    • Misoprostol does not improve pain scores and may be associated with nausea and vomiting
  • Strings not visualized
    • Rule out pregnancy and expulsion
    • Recommend backup contraception until IUD position can be verified
    • Recommend emergency oral contraceptives (if appropriate)
    • Ultrasound and X-ray of abdomen and pelvis can be used for localization
  • Possible expulsion
    • IUDs seen in the cervix are partially expelled and should be removed
      • Replacement or use of another method are both acceptable options
    • Low-lying IUDs (lower uterine segment) can be expectantly managed
  • Risk factors for expulsion include
    • Young age
    • Heavy menstrual bleeding and dysmenorrhea
    • Placement postpartum or post second trimester abortion
    • Presence of anatomic distortion of the uterine cavity
  • Uterine perforation
    • Is rare and generally asymptomatic
    • Usually occurs at the time of insertion
      • Do not use misoprostol routinely prior to insertion in nulliparous women but may be considered with difficult insertions
    • Rule out pregnancy and remove surgically unless the surgical risks of removal outweigh the benefits
  • PID
    • Can be treated with the IUD left in situ
    • Consider removal if no clinical improvement after 48-72 hours of antibiotics
  • Pregnancy with an IUD in place
    • Remove the IUD if the strings are visible or IUD within the cervix
    • IUD can be removed at time of procedure if patient elects termination
    • Evaluate for ectopic pregnancy

Implant:

  • Infection prevention
    • Use antiseptic technique and cover the insertion/removal site
    • Skin flora are the most common cause of infection
    • Remove implant if infection does not resolve
  • Bruising
    • Is common
    • Ice and anti-inflammatory medication can help
  • Nonpalpable implant
    • Locate with high frequency (>/= 10 MHz) ultrasound probe, two dimensional X-ray, or CT scan/fluoroscopy
    • Obtain a serum etonogestrel level if all studies are negative/equivocal
    • Refer to a surgeon with knowledge of the anatomy of the arm if implant is within muscle or neurovascular bundle
  • Pregnancy
    • Is rare
    • Remove the implant if the pregnancy is to be continued
    • Rule out ectopic pregnancy

SYNOPSIS:

LARCs are highly effective contraceptives with a low risk of complications.  Those mentioned above should be discussed with patients as part of informed consent.

KEY POINTS:

  • Recognition and prompt diagnosis/treatment of the untoward outcomes described above are important aspects of care
  • Overall, complication rates are low and LARCs remain a very effective mode of birth control

ICD-10 codes:

  • Z30.49 check/reinsertion/removal of implant
  • Z30.430 insertion of IUD
  • Z30.432 removal of IUD
  • Z30.433 removal and reinsertion of IUD

Learn More – Primary Sources:

ACOG Committee Opinion 672: Clinical challenges of long-acting reversible contraceptive methods

Emergency Contraception: What, When and How?

Emergency contraception interventions are intended to prevent an unplanned pregnancy after unprotected or inadequately protected intercourse. Contraceptive failure or failure to use contraception are common indications for use.

CLINICAL ACTIONS:

  • Offer emergency contraception (EC) to all women who have had unprotected or inadequately protected intercourse and who do not desire pregnancy
    • There are no exclusionary health conditions –women who have contraindications to oral contraceptives can be given EC
  • Offer EC to all reproductive-aged women who have sustained sexual assault
  • No clinical examination or pregnancy testing is necessary
  • Treatment should be initiated as soon as possible, and should be made available up to 5 days after unprotected or inadequately protected intercourse
  • If menses are delayed by a week or more, a woman who has received EC should have a pregnancy test and clinical evaluation
  • EC may be used more than once even in the same menstrual cycle
  • Regular contraception should be started immediately after EC and women should abstain or use barrier contraception for 14 days or until onset of next menses
    • Those receiving uripristal acetate should delay starting hormonal contraception until 5 days after use

SYNOPSIS:

All of the methods below are effective only before a pregnancy is established. Hormonal EC does not pose a risk to an established pregnancy and is not associated with embryonal developmental abnormalities. Adverse effects for all of the oral methods include nausea and headache as well as irregular bleeding. Adverse effects for the copper IUD include perforation, changes in menses or dysmenorrhea. Pregnancy rates after EC range from 0-2.2%, and may be impacted by body weight.

KEY POINTS:

  • Uripristal acetate, a selective progesterone receptor modulator, is given as a single 30 mg dose
    • Requires a prescription
    • Efficacy may be reduced in women with BMI ≥30
    • Effective up to 5 days after unprotected intercourse
    • FDA approved for EC
  • Progestin only EC, either 1 tablet Levonorgestrel in a single dose (1.5 mg) or as a split dose (1 dose of 0.75 mg of levonorgestrel followed by a second dose of 0.75 mg of levonorgestrel 12 hours later)
    • May be less effective in women with BMI ≥25
    • 1 tablet formulation available over the counter without age restriction
    • 2 tablet formulation available over the counter to women ≥17 years with photo ID
    • Effective for up to 3 days after unprotected intercourse
    • FDA approved for EC
  • Copper IUD insertion
    • Requires office visit and insertion by a clinician
    • Efficacy not impacted by body weight
    • Effective up to 5 days after unprotected intercourse
    • Safe and effective but not FDA labeled for use as EC
    • LNG-IUDs “are currently being investigated” (ACOG PB) | Recent RCT suggests LNG-IUD is not inferior to copper IUD (see ‘Learn More – Primary Sources’)
  • Combined progestin-estrogen pills
    • Can use a variety of formulations (see ‘Learn More – Primary Sources’ below for a list of appropriate formulations)
    • Two doses every 12 hours
    • All aim for 100-120 micrograms of ethinyl estradiol and 0.5-0.6 milligrams of levonorgestrel per dose
    • Requires a prescription
    • Effective up to 5 days after unprotected intercourse
    • Safe and effective but not FDA labeled for use as EC

Learn More – Primary Sources:

Practice Bulletin No. 152: Emergency Contraception

CDC Contraceptive Guidance for Health Care Providers

CDC: U.S. Selected Practice Recommendations for Contraceptive Use, 2016 – Recommendations and Reports