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OBJECTIVES: The objective was to describe the ease and difficulty of removing intrauterine devices (IUDs). METHODS: We conducted a prospective study at the University of Campinas (UNICAMP), Faculty of Medical Sciences, UNICAMP. We included women who requested IUD removal. We excluded women with partial IUD expulsion in which the IUD was protruded at the external os. We identified difficult IUD removal when the removal was challenging, including the inability to visualize IUD strings extending from the cervical os. RESULTS: A total of 869 women participated. Women were aged 29.4 ± 8.0 years (mean ± SD; range 14-51) and the duration of IUD use at the time of removal was 4.3 ± 4.2 years. We found that 702 (80.8%) women had visible strings at the external os and the removals were performed at the first attempt without difficulty in 692 (79.6%) participants. The pain was more intense (>4) in cases of difficult removals. After multivariate logistic analysis, difficult removals were associated with users of IUD ≥3 years (3 times higher risk); for each previous cesarean delivery, the risk increased by 1.5 times. CONCLUSIONS: Our study showed that IUD removal is an easy and safe procedure, with only a small proportion of women reporting significant pain with IUD removal.

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OBJECTIVE: To compare the performance of the abdominal handheld point-of-care ultrasonography (POCUS) Butterfly-iQ to gold standard transvaginal ultrasonography (US) in identifying the position of intrauterine devices (IUDs) in the hands of a medical doctor specialised in ultrasonography. METHODS: In this diagnostic accuracy study, a single operator conducted abdominal POCUS followed by conventional transvaginal US. Seventy patients utilising copper or hormonal IUDs were assessed between June 2021 and October 2022. IUDs were categorised as entirely within the uterine cavity or malpositioned. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for detecting malpositioned IUDs, with conventional US results serving as the reference standard. Concordance rate and Kappa coefficient were computed to assess the agreement between the two ultrasound modalities. RESULTS: Among the 70 patients, 46 (65.7%) used copper IUDs, and 24 (34.3%) used hormonal IUDs. Conventional transvaginal US showed IUDs entirely within the uterine cavity in 56 (80%) patients and 14 (20%) IUDs were malpositioned. Of the 14 malpositioned IUDs seen by conventional US, POCUS identified 13 demonstrating a sensitivity of 92.9% (66.1-99.8). Of the 56 IUDs entirely within the uterine cavity shown by conventional US, only two cases were considered malpositioned by POCUS demonstrating a specificity of 96.4% (87.7-99.6). The concordance rate was 95.7%, and the Kappa value was 0.87 in differentiating between IUDs entirely within the uterine cavity and those that were malpositioned. CONCLUSION: Abdominal POCUS using Butterfly-iQ, when administered by an imaging specialist, exhibited excellent performance in confirming IUDs entirely within the uterine cavity.

Through a smartphone-based handheld point-of-care ultrasonography it was possible to correctly evaluate the position of intrauterine devices (IUDs) in a sample of 70 patients (46 using copper and 24 using hormonal IUDs).

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Los dispositivos intrauterinos de cobre son utilizados como métodos anticoncepcionales y es uno de los métodos más utilizados por su seguridad, reversibilidad y eficacia en la prevención de embarazos, que es superior al 97 %. Se presenta un caso de falla en la anticoncepción con dispositivos intrauterinos de cobre después de 5 años de uso en gestante de 26 años, que acudió al área de emergencias cursando con embarazo de 38 semanas y 4 días en periodo expulsivo; se obtuvo recién nacido a término sano. El periodo de alumbramiento patológico (prolongado) por presencia de dispositivo intrauterino de cobre en membranas ovulares(AU)

Copper intrauterine devices are used as contraceptive methods and are one of the most used methods due to their safety, reversibility and effectiveness in preventing pregnancy, which is greater than 97%. A case of failure in contraception with a copper intrauterine devices is presented after 5 years of use in a 26-year-old pregnant woman, who went to the emergency room with a pregnancy of 38 weeks and 4 days in the expulsive period; a healthy term newborn was obtained.The pathological (prolonged) delivery period due to the presence of copper intrauterine devices in ovular membranes(AU)

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OBJECTIVES: This study aimed to compare the uptake, reasons for discontinuation, continuation, and satisfaction of long-acting contraceptive methods (LARC) when offered at no cost in Campinas, Brazil. STUDY DESIGN: This was a prospective cohort study conducted at University of Campinas, Campinas, São Paulo, Brazil, including women aged 18 to 48 years, who adopted one of three methods. Participants underwent telephone follow-up every 3 months for up to 24 months after insertion. Satisfaction was assessed at the end of 2 years of use through the Likert scale. RESULTS: We invited 1222 women, and among the 971 women who volunteered to participate in follow-up, 414 (42.6%) chose the levonorgestrel 52-mg intrauterine device (IUD), 358 (36.9%) chose the etonogestrel (ENG) implant, and 199 (20.5%) chose the TCu380A IUD. Discontinuation due to bothersome bleeding was higher among users of the ENG implant (10/358; 2.4%) and the TCu380A IUD (32/199; 8.9%), and expulsion was higher for the TCu380A IUD (30/199; 15.1%). Women continued at 24 months were 340/414 (82.1%), 270/358 (75.4%), and 119/199 (59.8%) among users of the levonorgestrel 52-mg IUD, ENG implant, and TCu380A IUD, respectively. The users of the levonorgestrel 52-mg IUD (301/339, 88.8%), the ENG-implant (222/270, 82.2%), and the TCu380A IUD (105/119, 88.2%) were satisfied or very satisfied by 24 months of follow-up. CONCLUSIONS: The three LARC methods had great uptake, high continuation, and discontinuation due to bothersome bleeding was higher among users of the ENG implant and the TCu380A IUD, and expulsion was higher for the TCu380A IUD compared to the 52-mg levonorgestrel IUD. Most of the participants reported being very satisfied. IMPLICATIONS: When the LARC methods were offered at no cost in a Brazilian public clinic the uptake, satisfaction and continuation were high by 24 months after device placement, and high level of satisfaction was reported by most of the participants.

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STUDY OBJECTIVE: To assess clinical performance, bleeding pattern, dysmenorrhea, and satisfaction up to 1 year after placement of 3 types of intrauterine devices (IUDs) (TCu380A, levonorgestrel 52 mg, and levonorgestrel 19.5 mg) in adolescents METHODS: The study was a randomized trial with 318 adolescents allocated to the 3 IUDs. We assessed reasons for removal, continuation, menstrual patterns, dysmenorrhea, and satisfaction. RESULTS: Participants aged (mean ± SD) 17.9 ± 1.4 years, with 80.8% being nulligravidae. After 1 year, 265 (83.3%) continued using the IUD; however, the continuation rate of TCu380A (75.4 ± 4.2) was lower than that of both the levonorgestrel 52-mg (88.6 ± 3.1) and 19.5-mg IUDs (86.8 ± 3.3), and bleeding/pain and expulsion were the main reasons for removal of the TCu380A IUD. The duration of menstruation was longer among the TCu380A IUD users (6.0 ± 2.0 days) than those using the levonorgestrel 52 mg (2.5 ± 3.9) and 19.5 mg (3.2 ± 3.2) devices, P < .001. Amenorrhea was reported by 49.5% and 37.8% users of the levonorgestrel 52-mg and 19.5-mg devices, respectively, P < .001. Dysmenorrhea was reported in 68.5% of all participants at the baseline; this was 67.9% of the TCu380A group and 33.3% and 36.0% of the levonorgestrel 52-mg and 19.5-mg IUD groups, respectively, P < .001. Satisfaction ranged from 80.7% in the TCu380A group to 97.8% in the levonorgestrel 52-mg group (P = .03). CONCLUSION: The 3 IUDs are suitable for adolescents, with high contraceptive efficacies and rates of continuation within 1 year of use and high degrees of satisfaction. Users of the hormonal IUDs reported lower expulsion rates, more favorable menstrual patterns, and less dysmenorrhea compared with the TCu380A IUD.

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OBJECTIVE: To compare the continuation rates, expulsion, and other reasons for discontinuation of the hormonal intrauterine device with 52 mg of levonorgestrel (52 mg LNG-IUD) in adolescents and adult women. METHODS: We conducted a retrospective cohort study that included 393 women in whom we placed a 52 mg LNG-IUD and followed up to 5 years. We created two retrospective cohorts, one with 131 adolescents (aged between 12 and 19 years) and the other with 262 women aged ≥20 years. Each adolescent was paired with two adult women who had the same parity and who had a 52 mg LNG-IUD inserted on the same day. We used the Mann-Whitney test to compare numerical variables in both groups, the Kaplan-Meier method, and the log-rank test to compare the continuation, expulsion and other reasons for IUD discontinuation of the two groups. RESULTS: Age of the adolescents and adult women were mean ± SD 18.1 (±1.1) and 31 (±6.8) years, respectively (p = 0.015). Continuation rates by the fifth year of use were 55.6/100 women-years (W-Y) and 70.3/100 W-Y among adolescents and adult women (p = 0.106); and expulsion rates were 8.4/100 and 6.0/100 W-Y, respectively (p = 0.463). Adolescents had a lower continuation rate during 3 to 5 years of follow-up (p = 0.011) and a high rate of removals due to bleeding/pain (18.5 ± 5.7/100 W-Y vs 6.4/100 ± 2.1 W-Y, p = 0.039). CONCLUSION: Adolescents who used the 52 mg LNG-IUD showed a lower continuation rate 3-5 years after device placement than adult women. The expulsion rates were similar in both groups.

Adolescents who used the 52 mg LNG-IUD showed expulsion rates similar than adult women. Despite the good continuation rate, adolescents had a lower continuation rate within 3­5 years of follow-up and high rate of removals due to bleeding/pain than adult users.

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OBJECTIVES: To assess perimenopausal users of 52 mg levonorgestrel intrauterine devices (LNG-IUD) regarding the IUD impact after menopause. MATERIAL AND METHODS: a cross-sectional study with users aged 40 and 49 years old, without cognitive impairment that answered a questionnaire regarding worries and benefits after the menopause due to LNG-IUD use. RESULTS: Almost half of 221 users (52.9%) have concerns that LNG-IUD use could influence aspects after menopause, 111 (50.3%) that the post-menopause symptoms get worse and 92 (41.6%) that interfere with recognition of menopausal symptoms. CONCLUSION: Half of perimenopausal LNG-IUD users expressed concerns about how device use could affect post-menopause symptoms.

The 52 mg hormonal-IUD who were at menopausal transition reported worries that the use of the IUD can affect menopausal symptoms. It is important that health professionals can routinely guide these women.

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OBJECTIVES: To compare pain and ease of insertion of the copper 380 mm2, levonorgestrel 52 mg, and levonorgestrel 19.5-mg intrauterine devices (IUDs) in Brazilian adolescents. STUDY DESIGN: We conducted a participant-blinded randomized trial at two clinics in Brazil. We enrolled 318 adolescents<19 years old in a 1:1:1 ratio from November 2021 to February 2022. We informed the adolescents about the IUD type inserted after they evaluated the pain associated with the IUD insertion using a Visual Analogue Scale and immediately after that the healthcare provider who placed the IUD evaluated the ease of the procedure. RESULTS: The VAS pain level was significantly higher after the levonorgestrel 52-mg IUD placement, median and [interquartile range, IQ] 8.0 [4.0] than the copper 380-mm2 IUD 7.0 [4.0], and the levonorgestrel 19.5-mg IUD 7.0 [6.0] (p = 0.001). The placement was easier after the copper 380-mm2 IUD (87/106, 82.1%) and the levonorgestrel 19.5-mg IUD (91/106, 85.8%) when compared with the levonorgestrel 52-mg IUD (75/105, 70.7%). After multiple logistic regression analyses, the higher VAS pain scores were associated with the levonorgestrel 52-mg IUD (OR = 2.90), low number of pregnancies (OR -0.48), and with a history of dysmenorrhea (OR = 2.67). CONCLUSIONS: The placement of the copper 380-mm2 IUD and the levonorgestrel 19.5-mg IUD was associated with lower pain according to the adolescent and was easier according to the provider when compared with the levonorgestrel 52-mg IUD. However, the small observed differences may not be clinically relevant. IMPLICATIONS: We found that the three types of IUDs were generally easy to place; however, mean pain scores were high during insertions. Our findings of high pain scores reinforce the need for interventions to reduce pain for adolescent IUD insertion.

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OBJECTIVE: To describe the feasibility of an ultrasound-guided repositioning technique for partially expelled intrauterine devices (IUDs) without use of sedation. METHODS: This was a descriptive feasibility study of patients with a partially expelled IUD managed in our outpatient clinic from January 2016 to February 2020. The partially expelled IUDs (vertical arm extending partially or entirely through the cervical canal) were repositioned at the uterine fundus using Hartmann alligator forceps under ultrasound guidance. Paracervical or intracervical anesthesia and prophylactic antibiotics were not used. Data related to the procedure and 6-month follow-up were extracted from patient medical records. The primary outcome was the success rate of the repositioning procedure, defined as ultrasound confirmation of the entire IUD located above the internal os. Secondary outcomes included the retention and expulsion rates of the repositioned IUD at 6 months after the procedure and description of complications. RESULTS: We included data from 55 women with a partially expelled IUD (35 levonorgestrel IUDs and 20 copper IUDs) referred for repositioning. Ultrasound-guided repositioning of the IUD was successful in 51 (92.7%) cases, while the procedure was not completed in four patients due to pain. Of the 55 procedures, 48 (87.3%) were performed by obstetrics and gynecology trainees under the supervision of a senior specialist. Among the 51 successfully repositioned IUDs, nine (17.6%) were expelled within 6 months after the procedure and six patients were lost to follow-up. No uterine perforation or infection-related complications occurred within 6 months of the procedure. CONCLUSION: The ultrasound-guided repositioning technique appears to be a safe and feasible approach for partially expelled IUDs. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

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OBJECTIVES: To assess the occurrence of pregnancy in a cohort of women who received a copper intrauterine device (IUD), hormonal IUDs or an etonogestrel (ENG) contraceptive implant at a single-visit practice. METHODS: Prospective study conducted at the University of Campinas, Campinas, São Paulo, Brazil. We obtained data from four ongoing studies including both the date of the device placement, the first day of the last menstrual period, and the occurrence of pregnancy up to 3 months after device placement. RESULTS: We included 2479 device placements (413 TCu380A IUDs, 1476 hormonal IUD and 590 ENG implants). Almost half of the device placements (1113/2479; 44.9%) were performed within the first 5 days of the menstrual cycle. We observed three pregnancies: one in an ENG implant user who received the implant within days 1-5 of the menstrual cycle; one in a woman who received a hormonal IUD during days 6-10 of the menstrual cycle; and one in a copper IUD user with placement during days 21-25 of menstrual cycle. CONCLUSIONS: Single-visit long-acting reversible contraception placements are a good strategy with overall very low pregnancy rates. This strategy has a potential to reduce unintended pregnancies and to reduce costs and barriers to both women and the healthcare system.

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