Removal of copper IUD improves, but does not eliminate, poor pregnancy outcomes
Karakus and colleagues conducted a retrospective cohort study of 233 patients in Turkey with pregnancies that occurred during copper 380-mm2 IUD use from 2011 to 2021. The authors reported that, at the time of first contact with the health system and diagnosis of retained IUD, 18.9% of the pregnancies were ectopic, 13.2% were first trimester losses, and 67.5% were ongoing pregnancies.
The authors assessed outcomes in patients with ongoing pregnancies based on whether or not the IUD was removed or retained. Outcomes included gestational age at delivery and adverse pregnancy outcomes, assessed as a composite of preterm delivery, PPROM, chorioamnionitis, placental abruption, and postpartum hemorrhage.
Of those with ongoing pregnancies, 13.3% chose to have an abortion, leaving 137 (86.7%) with continuing pregnancy. The IUD was able to be removed in 39.4% of the sample, with an average gestational age of 7 weeks at the time of removal.
Compared with those with a retained IUD, patients in the removal group had a lower rate of pregnancy loss (33.3% vs 61.4%; P<.001) and a lower rate of the composite adverse pregnancy outcomes (53.1% vs 27.8%; P=.03). TABLE 2 shows the approximate rate of ongoing pregnancy by gestational age in patients with retained and removed copper 380-mm2 IUDs. Notably, the largest change occurred periviably, with the proportion of patients with an ongoing pregnancy after 26 weeks reducing to about half for patients with a retained IUD as compared with patients with a removed IUD; this proportion of ongoing pregnancies held through the remainder of gestation.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
These studies confirm that a retained IUD is a rare outcome, occurring in about 1 in 8,000 pregnancies. Previous US national data from 2010 reported a similar incidence of 1 in 6,203 pregnancies (0.02%).10 Management and counseling depend on the patient’s desire to continue the pregnancy, gestational age, intrauterine IUD location, and ability to see the IUD strings. Contemporary data support management practices created from limited and outdated data, which include device removal (if able) and counseling those who desire to continue pregnancy about high-risk pregnancy complications. Those with a retained IUD should be counseled about increased risk of preterm or previable delivery, IUFD, and placental abnormalities (including accreta spectrum and retained placenta). Specifically, these contemporary data highlight that, beyond approximately 26 weeks’ gestation, the pregnancy loss rate is not different for those with a retained or removed IUD. Obstetric care providers should feel confident in using this more nuanced risk of extreme preterm delivery when counseling future patients. Implications for antepartum care and delivery timing with a retained IUD have not yet been defined.
These studies confirm that a retained IUD is a rare outcome, occurring in about 1 in 8,000 pregnancies. Previous US national data from 2010 reported a similar incidence of 1 in 6,203 pregnancies (0.02%).10 Management and counseling depend on the patient’s desire to continue the pregnancy, gestational age, intrauterine IUD location, and ability to see the IUD strings. Contemporary data support management practices created from limited and outdated data, which include device removal (if able) and counseling those who desire to continue pregnancy about high-risk pregnancy complications. Those with a retained IUD should be counseled about increased risk of preterm or previable delivery, IUFD, and placental abnormalities (including accreta spectrum and retained placenta). Specifically, these contemporary data highlight that, beyond approximately 26 weeks’ gestation, the pregnancy loss rate is not different for those with a retained or removed IUD. Obstetric care providers should feel confident in using this more nuanced risk of extreme preterm delivery when counseling future patients. Implications for antepartum care and delivery timing with a retained IUD have not yet been defined.
Do national data reveal more breakage reports for copper 380-mm2 or LNG IUDs?
Latack KR, Nguyen BT. Trends in copper versus hormonal intrauterine device breakage reporting within the United States’ Food and Drug Administration Adverse Event Reporting System. Contraception. 2023;118:109909. doi:10.1016/j.contraception.2022.10.011
Latack and Nguyen reviewed postmarket surveillance data of IUD adverse events in the US Food and Drug Administration’s (FDA) Adverse Event Reporting System (FAERS) from 1998 to 2022. The FAERS is a voluntary, or passive, reporting system.
Study findings
Of the approximately 170,000 IUD-related adverse events reported to the agency during the 24-year timeframe, 25.4% were for copper IUDs and 74.6% were for hormonal IUDs. Slightly more than 4,000 reports were specific for device breakage, which the authors grouped into copper (copper 380-mm2)and hormonal (LNG 52 mg, 19.5 mg, and 13.5 mg) IUDs.
The copper 380-mm2 IUD was 6.19 times more likely to have a breakage report than hormonal IUDs (9.6% vs 1.7%; 95% CI, 5.87–6.53).
WHAT THIS EVIDENCE MEANS FOR PRACTICE
The overall proportion of IUD-related adverse events reported to the FDA was about 25% for copper and 75% for hormonal IUDs; this proportion is similar to sales figures, which show that about 15% of IUDs sold in the United States are copper and 85% are hormonal.11 However, the proportion of breakage events reported to the FDA is the inverse, with about 6 times more breakage reports with copper than with hormonal IUDs. Because these data come from a passive reporting system, the true incidence of IUD breakage cannot be assessed. However, these findings should remind clinicians to inform patients about this rare occurrence during counseling at the time of placement and, especially, when preparing for copper IUD removal. As the absolute number of IUD users increases, clinicians may be more likely to encounter this relatively rare event.
Management of IUD breakage is based on expert opinion, and recommendations are varied, ranging from observation to removal using an IUD hook, alligator forceps, manual vacuum aspiration, or hysteroscopy.7,10 Importantly, each individual patient situation will vary depending on the presence or absence of other symptoms and whether or not future pregnancy is desired.
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