Immediate postpartum IUDs increase use but raise expulsion risk

Immediate postpartum IUDs increase use but raise expulsion risk | Image Credit: © New Africa - © New Africa- stock.adobe.com.

A study published in the American Journal of Obstetrics & Gynecology evaluated outcomes of immediate versus delayed postpartum intrauterine device (IUD) insertion, finding that immediate placement increased long-term adherence but was associated with higher expulsion rates.¹

According to the authors, postpartum IUD placement offers a reliable contraceptive option at a time when women are highly motivated to prevent pregnancy, yet access to interval placement can be limited by postpartum follow-up challenges.² The investigators noted that immediate postpartum placement is convenient and may increase uptake, but prior evidence regarding long-term continuation, expulsion, and safety has been inconsistent.¹

Researchers conducted a systematic review and meta-analysis of randomized controlled trials comparing immediate and delayed postpartum IUD insertion. The analysis included 16 studies and 2762 participants, of whom 1389 received immediate placement and 1373 received delayed placement.

The primary outcomes were IUD use at 6 and 12 months and device expulsion at 6 and 12 months. Secondary outcomes included removal rates, pregnancy, infection, uterine perforation, and missing strings.

Adherence and expulsion risk

At 6 months, pooled data from 6 trials demonstrated higher adherence among participants with immediate placement compared with delayed placement, with a relative risk (RR) of 1.27. By 12 months, the RR was 1.14, indicating immediate placement was still associated with greater adherence.

However, immediate placement was also linked with significantly higher expulsion risk. At 6 months, pooled analysis of 11 trials reported an expulsion rate of 10.0% for immediate placement versus 1.9% for delayed placement, with an RR of 4.89;. At 12 months, pooled data from 4 trials showed expulsion rates of 9.2% for immediate insertion versus 1.8% for delayed insertion, indicating an RR of 4.55.

The investigators noted that despite the increased expulsion risk, long-term use was higher in the immediate placement group. “Overall, women randomized to immediate postpartum placement of an IUD were more likely to be using an IUD at 6 months and 12 months postpartum than those randomized to delayed placement,” the authors wrote.

Analysis of delivery mode

Other outcomes showed no statistically significant differences. Removals at 12 months were similar between groups, and pregnancy rates were low in both cohorts. Across studies, no cases of uterine perforation were reported. Rates of pelvic infection did not differ significantly between immediate and delayed placement.

The analysis also examined outcomes by delivery mode. In cesarean deliveries, immediate IUD placement was associated with lower expulsion risk compared with vaginal deliveries.

Expulsion rates after cesarean section were 3.8% at 6 months for immediate placement compared with 0.6% for delayed placement, indicating an RR of 6.01. In contrast, after vaginal delivery, immediate insertion was linked with higher expulsion rates. Rates 15.4% at 6 months for immediate placement vs 2.1% for delayed placement, and the RR was 7.63.

Implications

The study adds to growing evidence supporting immediate postpartum contraceptive options. While expulsion remains a consideration, the findings suggest that immediate placement may facilitate higher rates of long-term IUD use in clinical practice.

The authors emphasized the clinical relevance of balancing convenience and adherence with expulsion risk. “Immediate postpartum IUD placement leads to greater IUD use at 6 and 12 months postpartum but also higher risk of expulsion,” they concluded.

References

1. Friedland BA, Sales JM, Atrio J, et al. Preference, adherence, and acceptability of 3 nonmedicated intravaginal rings of differing external diameters: a randomized, crossover trial. Am J Obstet Gynecol 2025;233:188.e1-10. doi:10.1016/j.ajog.2025.03.001
2. Boyd P, Merkatz R, Variano B, Malcolm RK. The ins and outs of drug-releasing vaginal rings: a literature review of expulsions and removals. Expert Opin Drug Deliv. 2020;17(11):1519-1540. doi:10.1080/17425247.2020.1798927