LONG ACTING REVERSIBLE CONTRACEPTIVES ADVANCED: Troubleshooting in difficult insertions and removals Objectives Anticipate difficulties with LARC insertion and removals
List instruments and techniques needed to address these difficulties with step by step strategies Describe non-coercive counseling approach when a patient requests a premature removal Contraceptive users in the US
61 million US women in childbearing years ~43 million of them (70%) are at risk of unintended pregnancy 62% of women of reproductive age currently using some form of contraception
Couples who dont use contraception have ~85% chance of experiencing pregnancy over the course of a year Nearly half (45%) of pregnancies in the US are unintended 27.00%
55.00% 18.00% Unintended pregnancy by consistency of contraception use
5.00% 41.00% 54.00% One year failure rates Effectiveness
0.1 0.3% 0.1 0.3% Contraceptive Methods in the U.S. 25.00% 20.00% % of women
at risk of unintended pregnancy* 15.00% 10.00% 5.00% 0.00% Increase in LARC use
THE MEC US Medical Eligibility Criteria (MEC) CDC recommendations for specific contraceptive methods with certain medical conditions MEC Categories of Safety
Theres an APP for that: - Can be downloaded on iOS and Android operating systems (https://www.cdc.gov/mobile/mobileapp.html) Another helpful APP Contraceptive Point-of-Care App Non-coercive Counseling
10 minute counseling video: https://www.youtube.com/watch?v=OP9klE0JLLU Easy Set Up Challenges with IUD insertions Discomfort/difficulty with speculum placement
Visualizing the cervix Extreme uterine position/uterine distortion Prior c-sections Tight cervical os Vasovagal reaction Perforation Positions of the Uterus
Tips Use as short a speculum as possible Give lidocaine 2-3 cc prior to tenaculum placement Put traction on the tenaculum to straighten out the uterus Very gently advance the sound, letting it follow the
smooth surface of the canal Cannot find cervix Relaxation techniques Position patient move further down on the exam table,
with their hips off the edge Remove redundant labial tissue from sides of speculum Speculum handle close to perineum Lateral wall traction (glove, condom, instrument) Switch speculum size (length and width)
McRoberts maneuver Post C-section uterus Position of cervix can be very challenging as lower uterine segment often scarred to anterior abdominal wall Uterus often seems initially anteverted and then fundus
curves downwards midline to almost retroverted position Sound vs Sound with dilation Graduated os finders More tips Have smelling salts available (for vasovagal reactions)
If perforation is suspected suspend procedure perform ultrasound Monitor vitals x 1 hour Re-try insertion in 2 weeks with ultrasound guidance and more experienced provider Use caution with:
Recently post partum and breastfeeding Uterus is softer, higher risk of perforation Prior c-section Fibroids Challenges: Removal Malpositioned IUD Missing Strings
Embedded IUD Ultrasound To confirm if IUD in place if patient returns with concerns The Low-down on Low-down IUDs: Malposition and IUD Failure IUDs in the Cervix:
- Copper IUD - Odds ratio for pregnancy with intracervical insertion 13.93 (95%CI 4.13 48.96) - Absolute risk increase of 1-2% - LNG IUD - Intracervical versus fundal placement found no difference in
failure between groups Malposition stats and risk factors 10% of IUD are malpositioned Risk factors: Adenomyosis (OR 3.04 (1.08-8.52)) Related to change in contractility of uterus?
NOT associated with post-abortion or 6-9 week postpartum insertion Protective factors: Prior vaginal delivery (OR 0.53 (0.32 0.87)) Private Insurance (OR 0.38 (0.24 0.59))
IUDs move IUDs move up/down uterus after insertion Most commonly, IUDs shift towards fundus after insertion Particularly true in women with lower parity Most malpositioned IUDs will move into proper position within 3 months without any intervention Watchful waiting is a reasonable option
Removal with missing strings Cytobrush Ultrasound to confirm in uterus Thread retriever IUD hook Alligator forceps MVA aspirator with #5 or # 6 cannula
Embedded IUD May only become apparent when removal efforts unsuccessful, feels stuck or strings break off Ultrasound confirmation is the next step Usually needs to be removed hysteroscopically
Insensitivity to Lidocaine Removal: Pop Out Technique http://www.screenr.com/MS7N Removal challenges Broken device
Deep insertion If distal end more palpable, can remove from that end. US guidance helpful. Implant and shadow Removal of Deep Implant
Removal of Deep Implant Removal of Deep Implant Resources: Videos Pop out Implant removal technique: http://www.screenr.com/MS7N Liletta insertion video (this link doesnt always work, you may have to google Liletta insertion
video https://www.lilettahcp.com/resources/placement ARHP Copper IUD insertion video https://www.youtube.com/watch?v=FuPFbgSm0QQ ARHP Mirena IUS insertion video https://www.youtube.com/watch?v=hlfV8tKgw6E Implant insertion video: https://www.youtube.com/watch?v=1KPiltHQZ9w (I may substitute out something better for this one, if something better is produced in the next few months) LARC training resources at getLARC.org http://getlarc.org/training/
Resources: Patient Ed Patient education on choosing between IUDs: http://www.reproductiveaccess.org/resource/iud-facts/ Patient education on implants: http://www.reproductiveaccess.org/resource/progestin-implant/ Take home information sheet after progestin IUD is placed: http://www.reproductiveaccess.org/resource/progestin-iud-user-guide/
Take home information sheet after copper IUD is placed: http://www.reproductiveaccess.org/resource/copper-iud-user-guide/ Take home information sheet after implant is placed: http://www.reproductiveaccess.org/resource/progestin-implant-user-guide/ Web site for patients, especially teens, on contraception: https://www.bedsider.org/
Resources for Clinicians How to switch methods and prevent gaps in contraceptive coverage: http://www.reproductiveaccess.org/wp-content/uploads/2014/12/switching_bc.pdf CDC US Medical Eligibility Criteria long version: https://www.cdc.gov/reproductivehealth/contraception/usmec.htm Quick start algorithm:
http://www.reproductiveaccess.org/wp-content/uploads/2014/12/QuickstartAlgorithm.pd f Medical eligibility by the CDC for LARC and other methods: https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-el igibility-criteria_508tagged.pdf
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