Associate Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI

Dr. Allen reports she is a Nexplanon trainer for Merck.

SYNOPSIS: Two-thirds of women complied with the recommendation for a six-week follow-up visit after intrauterine device (IUD) insertion. Among these women, 19.8% had their IUD removed in the first year compared to 12.6% among women who did not attend the follow-up visit. The majority of removals occurred outside the six-week follow-up period.

SOURCE: Bernard A, Satterwhite CL, Reddy M. Frequency of 6-week follow-up appointment scheduling after intrauterine device insertion. BMJ Sex Reprod Health 2017. [Epub ahead of print].

This is a single-institution, retrospective cohort study from the University of Kansas from January to June 2015. Women who underwent intrauterine device (IUD) insertion were identified, and subsequent follow-up visits and outcomes in the first year of placement were described. The primary outcome was the proportion of women who attended a six-week follow-up visit for IUD string check. Data on demographics, parity, IUD type, and IUD removals in the first year were collected.

A total of 380 women underwent IUD insertion during the six-month period. Mean age was 29.3 years (standard deviation, 6.4). One-third of women (35.2%) were nulliparous. For IUD types, 88.4% of women chose the 52 mg levonorgestrel device, 2.1% chose the 13.5 mg levonorgestrel device, and 9.5% chose the copper IUD. In the majority of cases (91.3%), the provider recommended a six-week follow-up visit, and 253 women (66.6%) complied. At the follow up-visit, bleeding concerns were documented in 26.9% of visits and string concerns in 9.1% of visits. Sixteen ultrasounds to document IUD location were ordered, presumably because strings were not visualized. Two ultrasounds showed malposition and one showed a small perforation. At the six-week visit, three IUDs were noted to have been expelled (one was replaced) and 11 IUDs were removed (four for malpositioning [two replaced], one because of the presence of a septate uterus, and the remaining for various complaints such as pelvic pain or desire for pregnancy). Of the 380 women who had an IUD placed, 66 (17.4%) had their IUD removed within one year. Type of IUD was not associated with removal rates. Among women who attended the six-week visit, 19.8% had their IUD removed compared to 12.6% who did not attend a six-week follow-up visit (P = 0.08). When removals at the six-week visit were excluded from the analysis, visit attendance was not associated with subsequent IUD removal rates within the first year (36/239 removals vs. 16/127 removals, P = 0.52).

COMMENTARY

Long-acting reversible contraceptives (LARC), including IUDs and implants, are highly effective and have continuation rates as high as 70% at three years of use.¹ The use of LARCs in the United States has increased dramatically in the past decade, with the most recent data reporting 11.6% of contracepting U.S. women opting for LARC in 2012.² IUDs are placed in the office setting and, traditionally, a six-week visit to check the IUD strings and ensure proper placement of the IUD has been recommended. The rationale for this interval was that the patient would have had a menstrual period during this time and also would have resumed sexual intercourse if sexually active. The follow-up visit also then would be an opportunity to discuss any patient complaints or questions regarding the IUD. Furthermore, although rare, if the patient had developed pelvic inflammatory disease from the insertion process, this could be detected. This recommendation is present on the manufacturers’ prescribing information for Mirena, Liletta, Skyla, Kyleena, and Paragard.

Nevertheless, this clinical recommendation does not have a strong evidence base. Unfortunately, the existing studies are limited and of poor quality. In a review, Steenland et al found two studies addressing this question and were unable to determine whether a specific follow-up visit after insertion improved continuation rates.³ Based on this review, the Centers for Disease Control and Prevention’s U.S. Selected Practice Recommendations for Contraceptive Use (USSPR) does not recommend a mandatory six-week follow-up visit. However, the USSPR does add a caveat that the recommendations refer to general situations and might vary for different users and different situations, such as adolescents or persons with certain medical conditions or characteristics.⁴

The authors of this study concluded that their data support the fact that the six-week IUD check is unnecessary given that removal rates did not differ significantly between those who attended the visit and those who did not. They felt that the complaints addressed at the six-week visit (bleeding and string-related) could have been handled over the phone. One critique of this study is the lack of documentation regarding provider experience at the time of insertion (resident vs. attending) and whether any of those women who did not attend the visit were lost to follow-up in terms of tracking outcomes at one year. This is also a single institution study, which decreases generalizability.

The interpretation of this study depends on what one considers the goal of the six-week visit. If the goal of the visit is to increase IUD continuation rates, then I agree that this study demonstrates the six-week visit does not seem to make a difference. However, if the goal of the visit is to detect complications with the IUD, it seems that this was accomplished. After all, three expulsions and four malpositioned IUDs were discovered, and 16 ultrasounds were ordered to confirm IUD placement because the strings were not visualized. These women could have had silent expulsions, and one perforation actually was found. The authors reported that nulliparous women (P = 0.015) and women receiving their first IUD (P = 0.004) were more likely to attend the follow-up visit. Therefore, certain women actually may seek the reassurance of a follow-up visit if they are uncomfortable checking for the strings themselves.

As IUDs become more and more popular, we owe it to our patients to ensure that they have a good experience with the IUD and catch any issues if they arise. I have no problem offering women a six-week follow-up visit if they desire it; however, I also would not make it mandatory if the patient found it inconvenient to attend and was able to check for strings herself and call for any issues. That being said, I work in an ob/gyn resident continuity clinic, and most of the IUDs are inserted by residents. For their patients, we do mandate six-week follow-up visits because these providers are less experienced. The bottom line is that, as with any guidelines, providers should practice medicine in a way with which they are comfortable when treating individual patients. The absence of evidence supporting six-week IUD checks does not prove that they are useless; it only proves that proper studies have not yet been carried out.

REFERENCES

1. Diedrich JT, Zhao Q, Madden T, et al. Three-year continuation of reversible contraception. Am J Obstet Gynecol 2015;213:662.e1-8.
2. Kavanaugh ML, Jerman J, Finer LB. Changes in use of long-acting reversible contraceptive methods among U.S. women, 2009-2012. Obstet Gynecol 2015;126:917-927.
3. Steenland MW, Zapata LB, Brahmi D, et al. The effect of follow-up visits or contacts after contraceptive initiation on method continuation and correct use. Contraception 2013;87:625-630.
4. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65:1-66.