EXECUTIVE SUMMARY

Just-published research indicates that postpartum insertion of a hormonal intrauterine device does not affect a woman’s ability to lactate and breastfeed.

  • There have been theoretical concerns that exogenous progesterone, such as the progestin in hormonal IUDs or implants, could prevent onset of milk production, since progesterone withdrawal after delivery of the placenta is thought to trigger the onset of lactogenesis.
  • Results of the new study suggest no difference in breastfeeding continuation and lactogenesis between women who received an IUD immediately after delivery and those who received a hormone IUD at six weeks postpartum.

Just-published research indicates that postpartum insertion of a hormonal intrauterine device (IUD) does not affect a woman’s ability to lactate and breastfeed.1

There have been theoretical concerns that exogenous progesterone, such as the progestin in hormonal IUDs or implants, could prevent onset of milk production, since progesterone withdrawal after delivery of the placenta is thought to trigger the onset of lactogenesis (start of lactation).2 However, there have been limited long-term data. Results from observational studies of progestin-only contraceptives suggest they have no effect on successful initiation and continuation of breastfeeding or on infant growth and development.3

Results of the new study suggest no difference in breastfeeding continuation and lactogenesis between women who received an IUD immediately after delivery and those who received a hormone IUD at six weeks postpartum, says Eve Espey, MD, MPH, professor and chair of the department of obstetrics and gynecology at the University of New Mexico in Albuquerque and a co-author of the current paper. The paper serves as an important contribution to the literature on the safety of breastfeeding with use of progestin-only contraceptives because of its strong study design and the clinically important outcomes of breastfeeding continuation and lactogenesis, she notes.

“Many women are interested in initiating highly effective contraception as soon as possible after a delivery,” says Espey. “This research should reassure women who desire to start a hormone IUD immediately after delivery that placement will not interfere with their ability to breastfeed.”

Review the Results

To conduct the randomized, controlled trial, researchers at the University of Utah and the University of New Mexico Health Sciences Centers enrolled participants from February 2014 through March 2016. Eligible women were pregnant and planned to breastfeed, spoke English or Spanish, were ages 18-40 years, and wanted a levonorgestrel intrauterine device. Study participants randomized 1:1 to immediate postpartum insertion or delayed insertion at 4-12 weeks postpartum.

Prespecified exclusion criteria included delivery of less than 37.0 weeks’ gestational age, chorioamnionitis, postpartum hemorrhage, contraindications to levonorgestrel intrauterine device insertion, and medical complications of pregnancy that could affect breastfeeding.

The study was powered for the primary outcome: breastfeeding continuation at eight weeks. Time to lactogenesis, defined as the secondary study outcome, was analyzed by survival analysis and log-rank test. Participants were followed for ongoing data collection for six months.

Researchers reached the enrollment target of 319 participants, but lost 34 prior to randomization. An additional 26 were excluded for medical complications prior to delivery. These changes led to 132 women in the immediate group and 127 in the delayed group for the final analytic sample.

What did the analysis find? Report of any breastfeeding at eight weeks in the immediate group (79%; 95% confidence interval [CI], 70-86%) was noninferior to that of the delayed group (84%; 95% CI, 76-91%). The 5% difference in breastfeeding continuation at eight weeks between the groups fell within the noninferiority margin (95% CI, -5.6 to 15%). Time to lactogenesis (mean ± SD) in the immediate group, 65.3 ± 25.7 hours, was noninferior to that of the delayed group, 63.6 ± 21.6 hours. The mean difference between groups was 1.7 hours (95% CI, -4.8 to 8.2 hours), noninferior by log-rank test. A total of 24 intrauterine device expulsions occurred in the immediate group compared to two in the delayed group (19% vs. 2%, P < 0.001), consistent with the known higher expulsion rate with immediate vs. delayed postpartum intrauterine device insertion. No intrauterine device perforations were reported in either group, figures indicate.1

“Bottom line, early placement of a hormonal IUD is a safe, long-term birth control method that doesn’t negatively affect women who want to breastfeed their baby,” said first author David Turok, MD, MPH, associate professor in the department of obstetrics and gynecology at the University of Utah, in a statement accompanying the paper’s release.

Prenatal Talk for Preparation

During prenatal care is an ideal time for healthcare providers to speak to women about long-term birth control in the immediate postpartum period. Counseling should include advantages, risks of IUD expulsion, contraindications, and alternatives to allow for informed decision-making.4

Use of long-acting reversible contraception (LARC) in the postpartum period is safe. The U.S. Medical Eligibility Criteria for Contraceptive Use classifies immediate postpartum initiation of IUDs and implants as Category 1 (no restriction for use) or Category 2 (advantages generally outweigh theoretical or proven risks).5

Talk with women about the increased risk for device expulsion, as well as signs and symptoms of expulsion. Explain that expulsion rates for immediate postpartum IUD insertions are higher than for interval or postabortion insertions, vary by study, and may be as high as 10-27%.6-9 According to Contraceptive Technology, symptoms of IUD expulsion include unusual vaginal discharge, cramping or pain, intermenstrual spotting, postcoital spotting, dyspareunia, absence or lengthening of the IUD string, and presence of the hard plastic of the IUD at the cervical os or in the vagina. If a woman’s menstrual period is delayed, she should check for IUD strings. A missed period may be the first indication of a “silent” expulsion.10

According to a committee opinion from the American College of Obstetricians and Gynecologists, despite the higher expulsion rate of immediate postpartum IUD placement over interval placement, evidence from clinical trials and from cost-benefit analyses indicates the increased benefits of immediate placement in reduction of unintended pregnancy, especially for those at greatest risk of not having recommended postpartum follow-up.4

“New mothers have to juggle the competing priorities of a new or growing family, and it is difficult to schedule postpartum appointments,” said co-author Jessica Sanders, PhD, research assistant professor in obstetrics and gynecology at the University of Utah. “Women are already at the hospital for the delivery, and receiving the IUD at this time is more convenient.” 

REFERENCES

  1. Turok DK, Leeman L, Sanders JN, et al. Immediate postpartum levonorgestrel intrauterine device insertion and breast-feeding outcomes: A noninferiority randomized controlled trial. Am J Obstet Gynecol 2017; doi: 10.1016/j.ajog.2017.08.003.
  2. Stuebe AM, Horton BJ, Chetwynd E, et al. Prevalence and risk factors for early, undesired weaning attributed to lactation dysfunction. J Womens Health (Larchmt) 2014;23:404-412.
  3. Kapp N, Curtis K, Nanda K. Progestogen-only contraceptive use among breastfeeding women: A systematic review. Contraception 2010;82:17-37.
  4. Committee Opinion No. 670: Immediate postpartum long-acting reversible contraception. Obstet Gynecol 2016;128:e32-37.
  5. Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR Morb Mortal Wkly Rep 2010;59(RR04):1-86.
  6. Dahlke JD, Terpstra ER, Ramseyer AM, et al. Postpartum insertion of levonorgestrel–intrauterine system at three time periods: A pro-spective randomized pilot study. Contraception 2011;84:244-248.
  7. Chen BA, Reeves MF, Hayes JL, et al. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: A randomized controlled trial. Obstet Gynecol 2010;116:1079-1087.
  8. Hayes JL, Cwiak C, Goedken P, Zieman M. A pilot clinical trial of ultrasound-guided postplacental insertion of a levonorgestrel intrauterine device. Contraception 2007;76:292-296.
  9. Celen S, Sucak A, Yildiz Y, Danisman N. Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section. Contraception 2011;84:240-243.
  10. Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.