Systematic Reviews ajog.

org

Expulsion of intrauterine devices after postpartum

placement by timing of placement, delivery type,
and intrauterine device type: a systematic review
and meta-analysis
Sarah H. Averbach, MD, MAS; Yokabed Ermias, MPH; Gary Jeng, PhD;
Kathryn M. Curtis, PhD; Maura K. Whiteman, PhD; Erin Berry-Bibee, MD, MPH;
Denise J. Jamieson, MD, MPH; Polly A. Marchbanks, PhD; Naomi K. Tepper, MD, MPH;
Tara C. Jatlaoui, MD, MPH

Introduction
Intrauterine devices (IUDs) provide OBJECTIVES: To provide updated and more detailed pooled intrauterine device expulsion
highly effective contraception and are rates and expulsion risk estimates among women with postpartum intrauterine device
commonly placed at an interval post- placement by timing of insertion, delivery type, and intrauterine device type to inform
partum visit typically 4
6 weeks after current intrauterine device insertion practices in the United States.
delivery for women who desire intra- DATA SOURCES: We searched PubMed, Cochrane Library, and ClinicalTrials.gov through
uterine contraception. However, the June 2019.
timing of providing postpartum STUDY ELIGIBILITY CRITERIA: We included all studies, of any study design, that
contraception around 6 weeks after de- examined postpartum placement of Copper T380A (copper) or levonorgestrel-containing
livery is based on historical precedent, intrauterine devices that reported counts of expulsion.
not evidence.1 By 6 weeks postpartum, STUDY APPRAISAL AND SYNTHESIS METHODS: We evaluated intrauterine device
more than half of women have resumed expulsion among women receiving postpartum intrauterine devices in the “immediate”
(within 10 minutes), “early inpatient” (>10 minutes to <72 hours), “early outpatient” (72
hours to <4 weeks), and interval (4 weeks) time periods after delivery. We assessed
From the Department of Obstetrics, study quality using the US Preventive Services Task Force evidence grading system. We
Gynecology, and Reproductive Sciences (Dr calculated pooled absolute rates of partial and complete intrauterine device expulsion
Averbach), School of Medicine, University of separately and estimated adjusted relative risks by the timing of postpartum placement,
California San Diego, San Diego, CA; School of
delivery type, and intrauterine device type using log-binomial multivariable regression.
Medicine (Ms Ermias), University of California
San Diego, San Diego, CA; Division of RESULTS: We identified 48 level I to II-3 studies of poor to good quality that reported a total of 7661
Reproductive Health (Drs Jeng, Curtis, intrauterine device placements. Complete intrauterine device expulsion rates varied by timing of
Whiteman, Berry-Bibee, Marchbanks, Tepper, placement as follows: 10.2% (range, 0.0
26.7) for immediate; 13.2% (3.5
46.7) for early
and Jatlaoui), Centers for Disease Control and inpatient; 0% for early outpatient; and 1.8% (0.0
4.8) for interval placements. Complete intra-
Prevention, Atlanta, GA; Department of
uterine device expulsion rates also varied by delivery type: 14.8% (range, 4.8
43.1) for vaginal
Gynecology and Obstetrics (Dr Jamieson),
Emory University School of Medicine, Atlanta, and 3.8% (0.0
21.1) for cesarean deliveries. Among immediate postpartum vaginal placements,
GA. the expulsion rate for levonorgetrel intrauterine devices was 27.4% (range, 18.8
45.2) and
Received Nov. 12, 2019; revised Feb. 13, 2020; 12.4% (4.8
43.1) for copper intrauterine devices. Compared with interval placement, immediate
accepted Feb. 24, 2020. and early postpartum placements (inpatient and outpatient combined) were associated with greater
The authors report no conflict of interest. risk of complete expulsion (adjusted risk ratio, 8.33; 95% confidence interval, 4.32
16.08, and
Dr. Averbach is supported by the National adjusted risk ratio, 5.27; 95% confidence interval, 2.56e10.85, respectively). Among immediate
Institutes of Health Eunice Kennedy Shriver postpartum placements, risk of expulsion was greater for placement after vaginal compared with
National Institute of Child Health & Human cesarean deliveries (adjusted risk ratio, 4.57; 95% confidence interval, 3.49
5.99). Among
Development (NICHD) physician scientist career immediate placements at the time of vaginal delivery, levonorgestrel intrauterine devices were
development award (K12 HD001259).
associated with a greater risk of expulsion compared with copper intrauterine devices (adjusted risk
The findings and conclusions in this report are
ratio, 1.90; 95% confidence interval, 1.36
2.65).
those of the authors and do not necessarily
represent the official position of the Centers for CONCLUSION: Although intrauterine device expulsion rates vary by timing of placement,
Disease Control and Prevention or the National type, and mode of delivery, intrauterine device insertion can take place at any time.
Institutes of Health. Understanding the risk of intrauterine device expulsion at each time period will enable
Corresponding author: Sarah Averbach, MD, women to make an informed choice about when to initiate use of an intrauterine device in
MAS. [email protected] the postpartum period based on their own goals and preferences.
0002-9378/$36.00
ª 2020 Elsevier Inc. All rights reserved. Key words: contraception, copper, delivery, early, expulsion, immediate, interval, IUD,
https://doi.org/10.1016/j.ajog.2020.02.045 levonorgestrel, postpartum

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 Systematic Reviews ajog.org

expanded state Medicaid payment stra-

AJOG at a Glance tegies that improve reimbursement for
Why was this study conducted? inpatient devices.9e11 However,
This review was conducted to provide more detailed estimates of expulsion risk expanding the timeframe when IUDs are
among women with intrauterine device (IUD) placement in the postpartum placed in the postpartum period beyond
period than previously published, further describing pooled rates and risk esti- the immediate and interval time periods
mates by timing of insertion, IUD type, and delivery type to better inform current may allow for increased access to highly
IUD practices in the United States. effective contraception among post-
partum women. The early postpartum
Key findings period, from 10 minutes to 4 weeks after
delivery, provides additional convenient
 This analysis is consistent with previous findings that the risk of IUD expulsion times for women to receive contracep-
is greater when IUDs are placed in the immediate and early postpartum periods tion, including IUDs. An IUD can be
compared with placement at an interval postpartum visit (4 weeks or more). placed any time before a woman leaves
 Novel analyses demonstrate that the risk of IUD expulsion after early inpatient the hospital after delivery or at a post-
postpartum placements is similar to that for immediate postpartum place- partum visit within the first few weeks
ments and greater than for early outpatient or interval placements. after delivery. The US Medical Eligibility
 Three studies of early outpatient postpartum placements between 13 and 24 Criteria for Contraceptive Use supports
days postpartum demonstrated no expulsions after 136 placements with 6 the safety of IUD placement during this
months of follow-up. early time period.12 Providing IUDs
 New analyses comparing IUD types highlight that the risk of expulsion is during the early postpartum period,
greater when initiating levonorgestrel (LNG)
containing IUDs compared rather than waiting for an interval post-
with copper IUDs in the early inpatient postpartum period, and in the im- partum placement at more than 4 weeks,
mediate postpartum period with vaginal delivery. THe IUD type was not may offer additional benefits, including
associated with an increased risk of expulsion at the time of cesarean delivery the following: (1) it is unlikely that
for any time period. women are pregnant at this time; (2) a
visit can be co-located with other health
What does this add to what is known? visits, such as well-baby visits13; and (3)
the timing may offer opportunities to
 This review provides new pooled rates of IUD expulsion after postpartum screen women for postpartum depres-
placement by timing of placement, delivery type, and IUD type, with a focus on sion or to evaluate cesarean delivery in-
IUDs that are currently available in the United States, to better inform patient- cisions. Finally, recent recommendations
centered counseling in the United States. from the ACOG support contact be-
 This review provides new pooled rates of IUD expulsion and expulsion risk tween women and a maternal health
estimates when IUDs are placed in the early inpatient postpartum time period provider within the first 3 weeks after
between 10 minutes and 72 hours after delivery and in the early outpatient time delivery, so women may increasingly be
period (from 72 hours to less than 4 weeks). seen for routine early postpartum visits
in the United States.14
A previous meta-analysis of 48 studies
suggested that the risk of expulsion may
intercourse.2e4 Non-breastfeeding hospital and lack of standardized pro- be greater among women receiving early
women may ovulate as early as 25 days vider training on the technique for de- postpartum IUDs between 10 minutes
postpartum, and at least 30% will have vice placement.7 In addition, there are and 4 weeks postpartum compared with
ovulated by 8 weeks.5 Therefore, delay- gaps in knowledge about the risks of immediate postplacental placement
ing access to postpartum contraception expulsion for immediate postpartum (within 10 minutes), and both were
until 6 weeks postpartum may increase IUD placement. For example, the risk of significantly greater than interval place-
the risk of rapid repeat pregnancy. expulsion is greater among women ment (4 weeks after delivery); it also
Immediate postpartum IUD place- receiving immediate IUDs compared provided pooled rates of expulsion by
ment, within 10 minutes of delivery, is with interval placement,8 but it is un- placement timing, delivery method, and
safe and effective as well as convenient clear whether the risk of expulsion varies IUD type.8 Given the new ACOG rec-
for providers and patients.6 Despite the by IUD type.9 ommendations and interest in more
benefits of immediate IUD insertion, Efforts are currently in place to in- detailed analyses,15 we aimed to update
there are significant barriers to wide- crease access to immediate postpartum the previous analysis by calculating
spread implementation, including bar- IUDs, including practice guidance from pooled absolute rates of expulsion for
riers to receiving insurance the American College of Obstetricians immediate placements by IUD type and
reimbursement for devices placed in the and Gynecologists (ACOG) and delivery type, and for early placements,

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 ajog.org Systematic Reviews

divided into more clinically relevant including “ Postpartum AND IUD.” No follow-up, number of women enrolled
time periods, and assessed by IUD type. methodological filters were used. We or randomized, number of IUDs initially
In addition, we focused on IUD types hand-searched relevant articles and re- placed, number of women with any
currently used in the United States to views for additional references. Interim follow-up, and counts of expulsion
better inform patient-centered coun- results were not included; only trials (overall, complete, and partial).
seling in the United States. with full data were included. We used the
Preferred Reporting Items for Systematic Assessment of risk of bias
Objective Reviews and Meta-Analyses (PRISMA) Newly identified studies were indepen-
The purpose of this updated review and guidelines for reporting.16 dently assessed for quality separately by 2
secondary analysis was to calculate more co-authors (SHA and TCJ) according to
detailed pooled absolute expulsion rates Study selection the US Preventive Services Task Force
among women with postpartum IUD Our population of interest was women system17 as previously described.8 To
placement and to estimate relative risk who received a postpartum IUD after a assess study quality, 2 coauthors inde-
for expulsion in further detail. We vaginal or cesarean delivery. IUD place- pendently reviewed each study to eval-
sought to calculate updated pooled ment data were stratified by “immedi- uate study design and risk of bias, such as
expulsion rates for immediate post- ate” (within 10 minutes), “early potential for selection bias (eg, groups
partum placements (<10 minutes) and inpatient” (>10 minutes to <72 hours), not comparable at baseline for ran-
to provide new pooled expulsion rates “early outpatient’ (72 hours to <4 domized controlled trials), misclassifi-
for immediate postpartum placements weeks), and interval (4 weeks). Our cation (eg, outcome of expulsion
by delivery type and IUD type. We also primary outcome of interest was com- diagnosed inconsistently by nonblinded
sought to calculate pooled expulsion plete expulsion of the IUD. We included healthcare provider), and confounding
rates for early placements, further pre- all primary research studies with any (eg, parity and breastfeeding status not
sented as early inpatient (>10 minutes to study design, in any language, that re- collected or adjusted for). Studies were
<72 hours) and early outpatient (72 ported counts of IUD expulsion after classified as “good,” “fair,” or “poor”
hours to <4 weeks) placements, and postpartum IUD placement that clearly based on the risk of bias assessment. Any
additionally categorized by IUD type. defined the timing of IUD placement by discrepancies between authors for se-
Finally, we aimed to focus our analysis hours, days, or weeks from delivery. lection, abstraction, or risk of bias
on IUD types currently available in the Studies that straddled the early and in- assessment were resolved through
United States. terval timing categories of interest were discussion.
excluded. We included studies with any
Methods length and rate of follow-up. Data synthesis
Information sources We included only those studies that We calculated pooled expulsion rates by
We updated the previous search8 in reported expulsion rates for IUD types dividing the total pooled number of ex-
PubMed, Cochrane Library, and currently available in the United States, pulsions by the total pooled number of
ClinicalTrials.gov, published from May including copper (CuT380A) and levo- IUD placements within each strata
2018 through June 2019, that examined norgestrel (LNG) IUDs, to focus ana- weighted by study sample size. For our
placement of IUDs in the postpartum lyses on current practice in the United primary analysis, we assumed that ex-
period. States. We excluded studies that evalu- pulsions were “complete” if not other-
ated IUDs that were modified from their wise defined. We additionally collected
Search strategy standard structure. We included studies counts of partial expulsion when re-
We searched using the search strategy evaluating IUD placement after vaginal ported by study authors or when counts
previously published8:((((“ Intrauterine and/or cesarean delivery. were provided for IUDs visualized in the
Devices” [Mesh] OR “ Intrauterine De- cervix by speculum or ultrasound ex-
vices, Copper” [Mesh] OR “ Intrauterine Data extraction amination to calculate pooled partial
Devices, Medicated” [Mesh] OR ((in- Results from the initial search of the expulsion rates.
trauterine OR intrauterine) AND (de- previous publication and the new search We calculated pooled expulsion rates
vice OR system OR contracept*)) OR were reviewed by 2 co-authors (SHA and for IUDs placed in each of the following
IUD OR IUC OR IUCD OR IUS OR YE), including titles, abstracts, and full- time periods: immediate, early inpatient,
mirena OR Skyla OR liletta OR paragard text articles when necessary, to deter- early outpatient, early inpatient and early
OR “ Copper T380” OR CuT380 OR “ mine whether the studies met inclusion outpatient combined, mixed (immedi-
Copper T380a” OR “ Cu T380a” ) AND criteria. Two co-authors (SHA and TCJ) ate, early inpatient, and early outpatient
(postpartum OR Puerperium*) NOT independently reviewed newly identified combined), or interval placement, and
(“Animals” [Mesh] NOT “ Humans” studies and extracted the following: by delivery type (cesarean, vaginal, or
[Mesh])))). We searched Cochrane Li- author, year of publication, country, either cesarean or vaginal [mixed]). We
brary and ClinicalTrials.gov for any study design, IUD type, timing of IUD reported the rate of IUD expulsion over
published reviews or additional studies placement, delivery type, length of study each time period and the range of

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 Systematic Reviews ajog.org

expulsion rates reported. We stratified by additional articles. We excluded 6 that among 9 studies. Six studies contributed
IUD type when possible (copper, LNG did not meet inclusion criteria because to the early inpatient pooled complete
IUD, or either copper or LNG IUD they did not specify IUD type or timing expulsion rate of 13.2% (range,
[mixed]), and by length of study follow- of IUD placement, or did not provide 3.5
46.7%, n ¼ 273). Three studies
up. individual counts for expulsion. We including 216 copper IUD placements
We used a log-binomial regression included an additional 5 new contributed to a pooled complete
model to estimate adjusted risk ratios studies24e28 in this analysis for a total of expulsion rate of 6.9% (range,
(aRRs) of IUD expulsion (for complete 48 studies (Figure 1). 3.5
24.2%). Three studies including 57
and partial expulsions separately) with LNG IUD placements contributed to a
associated 95% confidence intervals. Study characteristics pooled complete expulsion rate of 36.8%
For IUDs placed in the immediate time Studies included were published be- (range, 26.7
46.7%).
period, we reported aRRs by delivery tween 1999 and 2019. The level of evi- For IUDs placed during the early
type and IUD type, and adjusted for the dence ranged from I to II-3. Five studies outpatient period, more than 72 hours
following covariates: World Health Or- were rated as good quality24,26,29e31 and but less than 4 weeks postpartum, there
ganization study region,18 study quality, the remainder were fair or poor quality. were no complete IUD expulsions
and length of study follow-up. We The majority of studies examined IUDs among 136 woman in 3 studies. All early
adjusted for study region because of placed in the immediate time period, outpatient IUD placements occurred
potential differences in regional prac- whereas 6 examined early inpatient28,32e36 between 13 days and 28 days
tice in which type of clinicians provide and 3 examined early outpatient postpartum.
IUDs and the technique that they use to placements.37e39 In all, 13 studies included
place them, as well as differences in IUD IUDs placed in the interval time period as a Interval. For IUDs placed during the in-
prevalence in different regions. For comparison group,30-35,37,38,40e44 A total terval time period, the risk of complete
IUDs placed in the early inpatient time of 24 studies included only copper expulsion was 1.8% (range, 0.0
4.8%,
period, we reported aRRs by IUD type, IUDs,24,26,28,29,32,34,41,45e61 14 studies n ¼ 502) among 13 studies.
adjusting for the same 3 covariates as included only LNG The pooled rate of complete IUD
immediate placements as well as for IUDs,25,30,33,35,36,39,40,42-44,62e65 and 10 expulsion varied by type of IUD when
delivery type. Analyses were completed studies included data on both types of placed after vaginal delivery.
using SAS 9.4 software (SAS Institute IUDs.27,31,37,38,66e71 A total of 16 studies Among women with IUDs placed
Inc, Cary NC). included only IUDs placed at cesarean immediately after vaginal deliveries, the
delivery,29,31,40e42,45,48,52,54e56,60,62,63,65,69 pooled complete expulsion rates varied
Results 14 studies included only IUDs placed at between women using LNG IUDs
Study selection vaginal delivery,24,26,30,32e36,43,57,59,64,68,70 (27.4%; range, 18.8
45.2%, n ¼ 299)
The previous meta-analysis included and 18 studies included data on both among 8 studies, and 13 studies
data from 48 studies. For this analysis, types of delivery.25,27,28,37e39,44, including women using copper IUDs
we excluded 4 studies from the pre- 46,47,49e51,53,58,61,66,67,71
Follow up ranged (12.4%; range, 4.8
37.5%, n ¼ 1586).
viously published meta-analysis that from 4 weeks to 5 years, and study sample However, among women with IUDs
described IUDs not currently available size ranged from 7 to 2733 women. All placed at the time of cesarean delivery,
or in use in the United States studies included are listed in Table 1. the expulsion rates were generally lower
(CuT200, Cu7)19-22 and 1 study that than after vaginal deliveries and were
included early postpartum placements Complete IUD expulsion similar between women using LNG
but did not report expulsions by our The pooled rate of complete IUD IUDs and copper IUDs (2.3%; range,
pre-identified timing categories: im- expulsion varied by timing of placement. 0.0
21.1%, n ¼ 261, 7 studies; and
mediate, early inpatient, early outpa- 3.8%; range, 0.0
15.0%, n ¼ 1320, 17
tient, or interval.23 Therefore, we Immediate expulsion. For IUDs placed studies), respectively.
included 43 studies from the original during the immediate period, within 10 The adjusted relative risk of complete
meta-analysis. minutes of the placenta, the pooled rate IUD expulsion varied by the timing of
We identified an additional 98 studies of complete IUD expulsion was 10.2% postpartum placement, delivery type,
in PubMed published between May 1, (range, 0.0
26.7%, n ¼ 4460) among 39 and IUD type.
2018, and June 1, 2019. There were no studies (Table 2).
new studies identified with published Timing of delivery. Compared with in-
data from ClinicalTrials.gov or Early expulsion. For IUDs placed during terval placement, immediate and early
Cochrane reviews. We removed 3 the early postpartum period (combined postpartum (combined inpatient and
duplicate studies and screened the titles inpatient and outpatient), from more outpatient) placements were associated
and abstracts of 95 records. We than 10 minutes to less than 4 weeks, the with increased risk of complete expul-
excluded 84 articles not relevant to our pooled complete expulsion rate was sion (aRR, 8.33; 95% CI, 4.32e16.08;
search. We read the full texts of 11 8.8% (range, 0.0
46.7%, n ¼ 409) and aRR, 5.27; 95% CI, 2.56e10.85,

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2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 ajog.org Systematic Reviews

respectively) (Table 3). The risk of

FIGURE 1
expulsion among early inpatient place-
ments compared with interval place-
Flow diagram of publication selection for inclusion in the review. The
ments did not reach statistical
search from a previous systematic review7 was used to identify all
significance (aRR, 9.51; 95% CI,
relevant studies published prior to May 1, 2018
0.63
19.52).

Delivery type. Among immediate post-

partum placements, risk of expulsion
was greater for placement after vaginal
compared with cesarean deliveries (aRR,
4.57; 95% CI, 3.49-5.99).

IUD type. Among women initiating use

of IUDs in the immediate postpartum
time period at the time of vaginal de-
livery, women using LNG IUDs had a
greater risk of expulsion compared with
those using copper IUDs (aRR, 1.90;
95% CI, 1.36e2.65). No statistically
significant difference in risk of IUD
expulsion between IUD types placed
during cesarean delivery was demon-
strated (aRR, 0.52; 95% CI, 0.22
1.22)
(Table 4).

Partial expulsion
When assessing partial IUD expulsions,
for IUDs placed during the immediate,
early (combined inpatient and outpa-
tient), and interval time periods, the
pooled partial expulsion rates were 6.3%
(range, 0.0
37.3%, n ¼ 2111; 21
studies), 13.8% (range, 0.0
66.7%; n ¼
196; 6 studies), and 1.9% (range, Averbach. Intrauterine device expulsion after placement in the postpartum period. Am J Obstet Gynecol 2020.
0.0
5.6%, n ¼ 319; 8 studies) respec-
tively (data not shown). When early
placement was further categorized into expulsion (aRR, 4.56; 95% CI, The previous meta-analysis grouped
the early inpatient period and outpatient 1.98e10.94, and aRR, 13.34; 95% CI, all IUDs occurring between immediate
postpartum time periods, the pooled 5.82e30.57, respectively) (data not and interval insertions as early post-
partial expulsion rates were 26.4% shown). partum IUD insertions, from more than
(range, 0.0
66.7%, n ¼ 87) among 4 10 minutes to less than 4 weeks after
studies and 3.7% (range, 3.0
4.7%, n ¼ Comment delivery, based on timing categories in
109) between 2 studies, respectively. This systematic review provides upda- the US Medical Eligibility Criteria for
Expulsion rates after early inpatient ted estimates of expulsion rates among Contraceptive Use.8 In this analysis, we
placement varied by IUD type, with women with postpartum IUD place- further estimated the risk of early
pooled partial expulsion rates of 48.9% ment by timing of insertion, further expulsion specifically in the time before
(range, 0.0
66.7%, n ¼ 45) between 2 described by delivery type, and/or IUD a woman typically leaves the hospital
studies of women receiving copper type when IUDs are placed within the (early inpatient) or at a follow-up visit
IUDs, and 2.4% (range, 0.0
3.7%, n ¼ immediate (<10 minutes), “early within 4 weeks of delivery (early
109) between 2 studies of women inpatient” (>10 minutes to <72 outpatient). In addition, we included
receiving LNG- IUDs. Compared with hours), and “early outpatient” (72 only IUDs currently available in the
interval placement, immediate and early hours to <4 weeks) postpartum time United States. We provided new pooled
postpartum IUD placements were asso- periods compared with interval place- rates of IUD expulsion when IUDs are
ciated with increased risks of partial ments (>4 weeks). placed in the immediate postpartum

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Systematic Reviews
182 American

TABLE 1
Characteristics of included studies reporting counts of expulsions among postpartum women
for Fakultas

No. of women No. of women with

First author, year, Level of Study Placement Length of No. enrolled or with IUDs IUDs placed with
reference Regiona evidenceb qualityc IUD typed timinge Delivery typef follow-up randomized placed follow-up (%)
Journal

Agarwal, 201745
Kedokteran

SE Asia II-3 Fair CuT380A Immediate Cesarean 3 mo 50 50 50 (100)

of Obstetrics

37
Baldwin, 2016 N America I Fair Mixed Mixed Mixed 6 mo 201 139 Unknown (66g)
2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

24
Blumenthal, 2018 SE Asia II-3 Good CuT380A Mixed Vaginal 6 wk 500 496 480 (97)
Universitas

40
Braniff, 2015 W. Pacific I Fair LNG IUD Mixed Cesarean 6 mo 48 42 Unknown (84g)
& Gynecology

Bryant, 201332 Africa I Poor CuT380A Mixed Vaginal 12 wk 49 28 28 (100)

Sam Ratulangi

29
Celen, 2011 E. Mediterranean II-3 Good CuT380A Immediate Cesarean 12 mo 245 245 245 (100)
30
Chen, 2010 N America I Good LNG IUD Mixed Vaginal 6 mo 124 96 84 (88)
AUGUST

Chen, 201738 N America II-2 Poor Mixed Mixed Mixed 6 mo 74 74 59 (80)

([email protected])

66
Cohen, 2016 N America II-3 Poor Mixed Immediate Mixed 12 mo 82 82 67 (82)
2020

25
Cole, 2019 N America II-3 Poor LNG IUD Immediate Mixed 6 mo 116 116 87 (75)
46
Colwill, 2018 N America II-2 Fair CuT380A Immediate Mixed 6 wk 210 210 169 (80)
33
Dahlke , 2011 N America I Poor LNG IUD Mixed Vaginal 6 mo 53 46 45 (98)
Dias, 201547 SE Asia II-2 Poor CuT380A Immediate Mixed 6 wk 91 91 91 (100)
67
Eggebroten, 2017 N America II-2 Poor Mixed Immediate Mixed 6 mo 211 211 186 (88)
62
Elsedeek, 2012 E. Mediterranean II-3 Fair LNG IUD Immediate Cesarean 2y 65 65 62 (95)
at Sam Ratulangi University from ClinicalKey.com by Elsevier on August 22,

63
Elsedeek, 2015 E. Mediterranean II-3 Fair LNG IUD Immediate Cesarean 5y 80 80 80 (100)
34
Eroglu, 2006 E. Mediterranean II-2 Fair CuT380A Mixed Vaginal 12 mo 268 268 257 (96)
Goldthwaite, 201768 N America II-2 Fair Mixed Immediate Vaginal 12 wk 123 123 96 (78)
48
Gueye , 2013 Africa II-3 Fair CuT380A Immediate Cesarean 6 mo 46 46 39 (85)
61
Gupta, 2014 SE Asia II-3 Fair CuT380A Immediate Mixed 6 mo 100 100 92 (92)
26
Gurney, 2018 N America II-3 Good CuT380A Immediate Vaginal 6 mo 200 195 162 (83)
64
Hayes, 2007 N America II-3 Fair LNG IUD Immediate Vaginal 10 wk 20 20 16 (80)
Heller, 201669 Europe II-3 Fair Mixed Immediate Cesarean 12 mo 120 114 99 (87)
27
Hinz, 2019 N America II-3 Fair Mixed Immediate Mixed 6 mo 118 118 114 (97)
49
Hooda, 2016 SE Asia II-2 Poor CuT380A Immediate Mixed 6 wk 593 593 171 (29)
70
Jatlaoui, 2014 N America II-3 Fair Mixed Immediate Vaginal 6 mo 99 99 88 (89)

ajog.org
28
Kumar, 2019 SE Asia II-3 Poor CuT380A Mixed Mixed 12 mo 1200 1200 844 (70)
Averbach. Intrauterine device expulsion after placement in the postpartum period. Am J Obstet Gynecol 2020. (continued)
Downloaded for Fakultas Kedokteran Universitas Sam Ratulangi ([email protected]) AUGUST

ajog.org
TABLE 1
Characteristics of included studies reporting counts of expulsions among postpartum women (continued)
No. of women No. of women with
First author, year, Level of Study Placement Length of No. enrolled or with IUDs IUDs placed with
reference Regiona evidenceb qualityc IUD typed timinge Delivery typef follow-up randomized placed follow-up (%)
Kumar, 201450 SE Asia II-3 Poor CuT380A Mixed Mixed 6 wk 2733 2733 1730 (63)
41
Lester, 2015 Africa I Poor CuT380A Mixed Cesarean 6 mo 68 52 Unknown (90g)
2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

Letti Müller, 200551 S America II-2 Fair CuT380A Immediate Mixed 1 mo 38 38 37 (97)
52
Levi, 2012 N America II-3 Fair CuT380A Immediate Cesarean 6 mo 90 90 42 (47)
Levi, 201531 N America I Good Mixed Mixed Cesarean 6 mo 112 87 Unknown (88g)
Mishra, 201453 SE Asia II-3 Poor CuT380A Immediate Mixed 4
6 wk 564 564 434 (77)
54
Nelson, 2009 N America II-3 Fair CuT380A Immediate Cesarean 6 wk 7 7 7 (100)
65
Puzey, 2005 Africa II-3 Poor LNG IUD Immediate Cesarean 6 mo 33 33 20 (61)
55
Ragab, 2015 E Mediterranean II-3 Fair CuT380A Immediate Cesarean 12 mo 40 40 40 (100)
Singal, 201454 SE Asia II-3 Fair CuT380A Immediate Cesarean 12 mo 300 300 300 (100)
57
Singh, 2016 SE Asia II-3 Fair CuT380A Mixed Vaginal 8 wk 80 80 80 (100)
43
Soon, 2018 N America I Poor LNG IUD Mixed Vaginal 6 mo 11 8 7 (88)
36
Stuart, 2012 N America II-3 Fair LNG IUD Early Vaginal 6 mo 40 29 27 (93)
35
Stuart, 2015 N America I Poor LNG IUD Mixed Vaginal 6 mo 35 31 Unknown (80g)
58
Sucak, 2015 E Mediterranean II-2 Fair CuT380A Immediate Mixed 12 mo 160 160 153 (96)
at Sam Ratulangi

44
Turok, 2017 N America I Poor LNG IUD Mixed Mixed 8 wk 285 228 214 (94)
60
Unal, 2018 E Mediterranean II-3 Fair CuT380A Immediate Cesarean 3 mo 70 70 68 (97)
2020 American

42
Whitaker, 2014 N America I Poor LNG IUD Mixed Cesarean 12 mo 42 37 Unknown (81g)
UniversityJournal

Woo, 201571 N America II-3 Poor Mixed Immediate Mixed 12 mo 76 76 43 (57)

Xu, 199959 W Pacific II-3 Fair CuT380A Immediate Vaginal 36 mo 384 384 381 (99)
from ClinicalKey.com

39

Systematic Reviews
Zerden, 2017 N America II-3 Fair LNG IUD Delayed Mixed 6 mo 50 50 43 (86)
Cu, copper; E, East; IUD, intrauterine device; LNG, levonorgestrel; N, North; S, South; SE, Southeast; W, West.
of Obstetrics by

a
Based on World Health Organization (WHO) Regions, 18 with Region of the Americas separated into North and South American regions; b Level of evidence: I, a randomized, controlled trial; II-2, a cohort or case-controlled study that includes a comparison group; II-3,
an uncontrolled descriptive study including case series; c Defined by US Preventive Services Task Force17; d Mixed refers to CuT380A and LNG IUD combined; e Immediate refers to 10 min of placental delivery; early, >10 min to <4 wk postpartum; Mixed,
immediate and early placements; or immediate or early placements and interval placements (4 wk postpartum); f Mixed refers to vaginal or cesarean delivery; g Number of women with IUDs placed with follow-up not reported; therefore percentage represents
number of women with IUD placements among all women randomized.
& Elsevier

Averbach. Intrauterine device expulsion after placement in the postpartum period. Am J Obstet Gynecol 2020.
Gynecology
on August
18322,
Downloaded

Systematic Reviews
184 American

TABLE 2
Pooled complete expulsion rates by study follow-up length
for Fakultas

All studies Study follow-up: >6 mo Study follow-up: 3L6 mo Study follow-up: <3 mo
Journal

Complete Complete Complete Complete

Kedokteran

No. of women expulsion rate No. of women expulsion rate No. of women expulsion rate Number of expulsion rate
of Obstetrics

Placement timing, with IUDs (% range with IUDs (% range with IUDs (% range women with (% range
2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

delivery type, and No. of placed with among No. of placed with among No. of placed with among No. of IUDs placed among
studiesa follow-up studies)b studiesa studies)b studiesa studies)b studiesa studies)b
Universitas

IUD type follow-up follow-up with follow-up

Total 48 7661 7.8 (0.0e37.0) 13 2539 8.7 (0.0e25.4) 22 1569 10.3 (0.0e37.0) 13 3553 6.1 (0.0e19.8)
& Gynecology

c
Interval timing 13 502 1.8 (0.0e4.8) 2 122 4.1 (0.0e4.8) 9 262 0.8 (0.0e2.9) 2 118 1.7 (0.0e2.0)
Sam Ratulangi

c,d
Mixed timing 3 2290 4.4 (3.6e7.5) 0 N/A N/A 0 N/A N/A 3 2290 4.4 (3.6e7.5)
Early timingc 9 409 8.8 (0.0e46.7) 2 204 6.9 (3.5e24.2) 6 193 10.9 (0.0e46.7) 1 12 8.3
AUGUST

Inpatient 6 273 13.2 (3.5e46.7) 2 204 6.9 (3.5e24.2) 3 57 36.8 (26.7 1 12 8.3
([email protected])

e46.7)
2020

Copper IUD 3 216 6.9 (3.5e24.2) 2 204 6.9 (3.5e24.2) 0 N/A N/A 1 12 8.3
LNG IUD 3 57 36.8 (26.7 0 N/A N/A 3 57 36.8 (26,7 0 N/A N/A
e46.7) e46.7)
Outpatient 3 136 0.0 0 N/A N/A 3 136 0.0 0 N/A N/A
c
Immediate timing 39 4460 10.2 (0.0e26.7) 13 2213 9.1 (0.0e25.4) 17 1114 12.4 (0.0e26.7) 9 1133 10.1 (0.0e21.4)
Vaginal deliveries 18 1885 14.8 (4.8e43.1) 4 1026 13.0 (4.8e23.5) 8 479 20.3 (8.0e43.1) 6 380 12.6 (7.8e22.2)
Copper IUD 13 1586 12.4 (4.8e37.5) 4 1026 13.0 (4.8e23.5) 4 251 13.2 (8.0e37.5) 5 309 9.7 (7.8e22.2)
at Sam Ratulangi University from ClinicalKey.com by Elsevier on August 22,

LNG IUD 8 299 27.4 (18.8 0 N/A N/A 6 228 28.1 (19.4 2 71 25.4 (18.8
e45.2) e45.2) e27.3)
Cesarean 25 1733 3.8 (0.0e21.1) 9 1077 3.9 (0.0e21.1) 11 449 4.5 (0.0 e11.8) 5 207 1.5 (0.0e3.2)
deliveries
Copper IUD 17 1320 3.8 (0.0e15.0) 5 817 4.0 (2.0e15.0) 7 296 4.7 (0.0e11.8) 5 207 1.5 (0.0e3.2)
LNG IUD 7 261 2.3 (0.0e21.1) 3 161 2.5 (0.0e21.1) 4 100 2.0 (0.0e4.2) 0 N/A N/A
Copper or LNG 2 152 5.9 (5.1e7.6) 1 99 5.1 1 53 7.6 0 N/A N/A
Vaginal or 5 842 13.1 (9.0e25.4) 2 110 23.6 (20.9 1 186 11.3 2 546 11.5 (9.0e21.4)
cesareane e25.4)
IUD, intrauterine device; LNG, levonorgestrel; N/A, not applicable.
a
Some studies included and reported more than 1 category; b Among women with IUDs placed with any follow-up; c Immediate refers to 10 min of placental delivery; Early, >10 minutes to <4 wk postpartum; Mixed, immediate and early combined; Interval, 4
wk postpartum; d Two studies did not classify IUD placements between early and immediate timing; e Seven studies did not specify delivery types.
Averbach. Intrauterine device expulsion after placement in the postpartum period. Am J Obstet Gynecol 2020.

ajog.org
 ajog.org Systematic Reviews

time period, stratified by both IUD and

delivery type, and when placed in the TABLE 3
early inpatient and early outpatient time Adjusted risk ratioa (95% CI) for IUD expulsion among postpartum
periods, stratified by IUD type. women by placement timing
Similar to a previous analysis, we
found that the risks of expulsion after Placement timing Complete expulsions aRRa (95% CI)b
immediate and early postpartum IUD Interval timingc 1.00 (Ref)
insertions were greater than those for Early or immediate timing d
4.49 (2.22e9.09)
interval insertion. The benefits of im- c
Early timing 5.27 (2.56e10.85)
mediate and early IUD insertion, how-
ever, may outweigh the increased risk of Early inpatient 9.51 (0.63e19.52)
expulsion if uptake, continuation, or Early outpatient N/A
satisfaction are improved with earlier Immediate timing c
8.33 (4.32e16.08)
insertion. In addition, we found no
aRR, adjusted risk ratio; CI, confidence interval; IUD, intrauterine device; N/A, not applicable; Ref, reference.
complete expulsions among women a
Among women with IUDs placed with any follow-up from 48 studies; b Adjusted for IUD type, delivery type, placement timing,
with IUDs placed in the early outpatient study region, study quality, and length of follow-up; c Immediate refers to within 10 min of placental delivery; Early, <10 min
time period between 2 and 4 weeks to <4 wk postpartum; Interval, 4 wk postpartum; d Studies did not classify IUD placements between early and immediate
timing.
postpartum, and the pooled rate of par-
Averbach. Intrauterine device expulsion after placement in the postpartum period. Am J Obstet Gynecol 2020.
tial expulsion was low (3.7%). The pre-
cision of our pooled rates of IUD
expulsion after early postpartum place-
ment was limited by a small number of after early outpatient IUD placement, we addition, we were unable to calculate the
studies with sample sizes ranging from were unable to compare the risk of IUD pooled rates of IUD expulsion by de-
12 to 171. These data suggest that the risk expulsion with interval placement or livery type when IUDs were placed in the
of IUD expulsion may be lower in the with early inpatient placement. In early postpartum period, because these
early outpatient time period compared
with the early inpatient time period, and
that IUD placement during the early TABLE 4
outpatient postpartum period warrants Adjusted risk ratioa (95% CI) for IUD expulsion among postpartum
further study. women by placement timing, delivery type, and IUD type
This analysis has many strengths. In
pooling the counts of IUD expulsion, we Placement timing, delivery type, and IUD type Complete expulsionsb aRRa (95% CI)
are able to include IUD placements from Early timing c

more than 7500 postpartum women in IUD type (inpatient only)

the analysis, with more than 400 women
Copper 1.00 (Ref)
having early postpartum IUD place-
ments using currently available IUDs. In LNG 1.91 (0.96e3.78)
addition, we were able to adjust for Immediate timingc
length of follow up and study quality. Delivery type
Another strength of this analysis is that
we were able to stratify the analysis of Cesarean 1.00 (Ref)
early postpartum IUD insertion to esti- Vaginal 4.57 (3.49e5.99)
mate the risk of expulsion specifically in Cesarean or vaginal 4.03 (2.76e5.86)
the time shortly after birth before a IUD type (vaginal deliveries)
woman leaves the hospital (early inpa-
tient) or at a follow-up visit within 4 Copper 1.00 (Ref)
weeks of delivery (early outpatient). In LNG 1.90 (1.36e2.65)
addition, we were able to estimate the IUD type (cesarean deliveries)
risk of IUD expulsion after immediate Copper 1.00 (Ref)
postpartum placement by IUD and de-
LNG 0.52 (0.22e1.22)
livery type.
This analysis has several limitations. aRR, adjusted risk ratio; CI, confidence interval; IUD, intrauterine device; LNG, levonorgestrel; Ref, reference.
a
We were limited by the small number of Adjusted for IUD type, delivery type, placement timing, study region, study quality, and length of follow-up; b Among women
with IUDs placed with any follow-up from 48 studies; c Immediate, within 10 minutes of placental delivery; Early, more than 10
studies reporting IUD expulsion after minutes to <4 wk postpartum; Interval, 4 wk postpartum.
placement in the early postpartum Averbach. Intrauterine device expulsion after placement in the postpartum period. Am J Obstet Gynecol 2020.
period. With no expulsions reported

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 Systematic Reviews ajog.org

studies generally did not report expul- the postpartum period can help women www.medicaid.gov/federal-policy-guidance/
sions by delivery type. Although we to achieve their reproductive goals and to downloads/cib040816.pdf. Accessed
October 14, 2019.
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