Immediate post-partum insertion of intrauterine devices

Insertion of an intrauterine device (IUD) immediately after delivery is appealing for several reasons. The woman is known not to be pregnant, her motivation for contraception may be high, and the setting may be convenient for both the woman and her provider. However, the risk of spontaneous expulsion may be unacceptably high.

To assess the efficacy and feasibility of IUD insertion immediately after expulsion of the placenta. Our a priori hypothesis was that this practice is safe but associated with higher expulsion rates than interval IUD insertion.

We searched MEDLINE, CENTRAL, POPLINE, EMBASE, ClinicalTrials.gov, and ICTRP. We also contacted investigators to identify other trials.

We sought all randomized controlled trials (RCTs) with at least one treatment arm that involved immediate post-partum (within 10 minutes of placental expulsion) insertion of an IUD. Comparisons could include different IUDs, different insertion techniques, immediate versus delayed post-partum insertion, or immediate versus interval insertion (unrelated to pregnancy). Studies could include either vaginal or cesarean deliveries.

We evaluated the methodological quality of each report and sought to identify duplicate reporting of data from multicenter trials. Two authors abstracted the data. Principal outcome measures were pregnancy, expulsion, and continuation rates. Because the trials did not have uniform interventions, we were unable to aggregate them in a meta-analysis.

We found nine RCTs; one directly compared immediate post-partum insertion with delayed insertion. Expulsion by six months was more likely for the immediate group than the delayed insertion group (OR 6.77; 95% CI 1.43 to 32.14). In trials of immediate insertion alone, modifications of existing devices, such as adding absorbable sutures or additional appendages, did not appear beneficial. Most studies showed no important differences between insertions done by hand or by instruments. Lippes Loop and Progestasert devices did not perform as well as did copper devices.

Immediate post-partum insertion of IUDs appeared safe and effective, though direct comparisons with other insertion times were limited. Expulsion rates appear to be higher than with interval insertion. Advantages of immediate post-partum insertion include high motivation, assurance that the woman is not pregnant, and convenience. The popularity of immediate post-partum IUD insertion in countries as diverse as China, Mexico, and Egypt support the feasibility of this approach. Early follow up may be important in identifying spontaneous IUD expulsions.