A randomised clinical trial to assess satisfaction with the levonorgestrel‐ releasing intrauterine system inserted at caesarean section compared to postpartum placement

Abstract

BackgroundInsertion of levonorgestrel‐releasing intrauterine system (LNG‐IUS) at caesarean section (CS) provides contraception prior to resumption of ovulation or sexual activity. Patient satisfaction with insertion at CS has not previously been studied.AimsThe aim of this study was to compare patient satisfaction with LNG‐IUS inserted at the time of lower uterine segment CS to six weeks postpartum.Materials and MethodsOpen‐label randomised controlled trial. Women booked for elective CS were randomised to LNG‐IUS insertion either at the time of CS (study group) or at six weeks postpartum (control group). The primary outcome measure was patient satisfaction. Outcomes were measured at six weeks, three months and six months postpartum.ResultsForty‐eight women were randomised into two treatment groups. Twenty‐five women were randomised to have LNG‐IUS inserted at the time of CS, 23 of whom had the planned intervention and two had the LNG‐IUS inserted postpartum. Twenty‐three women were randomised to the control group, four of whom withdrew prior to treatment. The 44 remaining women contributed to data analysis. Patient satisfaction was high and similar in both groups. At six months postpartum, 90.5% of the study group were very satisfied or somewhat satisfied compared with 88.2% of the control group.ConclusionsPatient satisfaction is high with LNG‐IUS insertion at CS and not different to that with delayed insertion. LNG‐IUS insertion may be an option for women who find postpartum contraception difficult to access.

Insertion of intrauterine devices after cesarean section: a systematic review update

“…If the threads of the TCu380A are left at the incision length, then follow-up visibility is around 30%–40%. The same is true for the LNG IUD, where string visibility of 30%–60% was reported in two studies 13,15. The elongated strings require trimming at follow-up.…”

“…This RCT is the first three-way study that attempts to evaluate which type of IUD is superior, and not assume they behave generically in this situation unless they are tethered to the uterine fundus 20. There were four RCTs of PPIUDCS insertion versus interval insertion (at 4–8 weeks) 12,13,15,17. All had small numbers and limited follow-up.…”

“…They all showed that those allocated to the delayed insertion group very often failed to present for their later insertion. This was true in both developed countries like Australia,13 and GS countries like Uganda 12. One study described a new technique to anchor the IUD to the fundus (hang up) to prevent expulsion,20 while one examined elongating threads to help prevent the problem of missing threads 14.…”

“…One study described a new technique to anchor the IUD to the fundus (hang up) to prevent expulsion,20 while one examined elongating threads to help prevent the problem of missing threads 14. Expulsion rates were very variable, with no expulsions in studies with very small numbers13,17 and where the device was sutured into the uterus,20 while in other studies it varied between 10% and 15%. There were no reports of perforations.…”

“…In more recent studies this distinction may have become slightly blurred since the newer studies have subjects in both groups ie, post-partum and very early interval, as they are controlled and compare post-placental insertion with 6- to 8-week post-partum insertion as a control group 12,13. The control group thus “straddles” the boundary of post-partum and interval6 insertion.…”