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  • Title: Postpartum insertion of modified intrauterine devices.
    Author: Cole LP, Edelman DA, Potts DM, Wheeler RG, Laufe LE.
    Journal: J Reprod Med; 1984 Sep; 29(9):677-82. PubMed ID: 6387112.
    Abstract:
    The immediate postpartum insertion of standard intrauterine devices (IUDs) and those specially modified for postpartum use was evaluated in a multicenter clinical trial. The immediate postpartum insertion of IUDs was not associated with any increased risk of perforation or infection, although expulsion rates were higher than with interval insertions. The expulsion rate varied widely between centers using similar devices, suggesting that training in insertion is essential. Postpartum IUD insertions can be a practical contraceptive option for patients and providers of medical services. The postpartum insertion of IUDs, especially in the case of institutional deliveries, has a number of advantages, including ease of insertion, availability of skilled personnel, appropriate facilities, and convenience for the mother. Immediate postpartum insertion of IUDs is not associated with increased risk of perforation or pelvic inflammatory disease (PID), although expulsion rates are higher than with interval insertions. In studies by Family Health International (FHI), expulsion rates varied widely between centers using similar devices. Expulsion rates ranged from 6-37/100 women at 6 months after insertion. This finding suggests that insertion may be as important a factor in influencing expulsion as the configuration of the device. FHI has developed modified IUDs with added suture material to project into the endometrium and reduce expulsion. After insertion the suture projections become soft and pliable and biodegrade completely within 6 weeks. Standard IUDs used for modification were the TCu and Lippes Loop. Adequate training and supervision of delivery room staff in insertion of IUDs is necessary. Midwives can betrained to insert the IUD after parturition through demonstrations and followup monitoring. Timing of IUD insertion is very important; FHI data show a significantly higher (p0.05) expulsion rate associated with insertions performed within the period of 10 minutes to 36 hours as compared to the immediate postpartum period (within 10 minutes). The use of postpartum IUDs raises questions of how much overlap there will be with the natural suppression of ovulation, especially in breastfeeding women, and whether the altered physiology of the reproductive tract interacts with the method. The inability to predict for individual women when ovulation will return, particularly among those who are breastfeeding, combined with inconvenience and sometimes impossibility of returning to a medical facility for insertion make the compromise of immediate postpartum insertion demographically effective and reasonable in many circumstances.
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