LONG ACTING REVERSIBLE CONTRACEPTIVES ADVANCED Troubleshooting in difficult

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 don’t use contraception have ~85% chance of experiencing pregnancy over the course of a year

Nearly half (45%) of pregnancies in the US are unintended Unintended – Mistimed 27% Intended 55% Unintended- Unwanted 18%

Unintended pregnancy by consistency of contraception use Consistent use 5% Nonuse 54% Inconsistent use 41%

One year failure rates Effectiveness Contraceptive Typical-use pregnancy rate Perfect-use pregnancy rate Ineffective Chance 85% Less effective Condoms 14% 3% More effective Pill/patch/Ring 8% 1 -3% Highly effective IUDs 0. 8 – 2% Injectable 0. 1 – 0. 3% Implant 0. 1 – 0. 3% Sterilization (male and female) 0. 1 – 0. 3%

Pill F Sterilization M Condoms IUD M Sterilization Withdrawal Injectable Vaginal Ring Fertility Awareness Implant Patch EC Other None 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

There’s an APP for that: - Can be downloaded on i. OS and Android operating systems (https: //www. cdc. gov/mobileapp. html)

Another helpful APP… • Contraceptive Point-of-Care App

Non-coercive Counseling • 10 minute counseling video: https: //www. youtube. com/watch? v=OP 9 kl. E 0 JLLU

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) • Mc. Robert’s 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

CONTRACEPTIVE IMPLANT

Implant Insertion • Proper positioning • Proper placement • Lidocaine with epi • Anticipatory guidance re: bruising • Insensitivity to Lidocaine

Removal: Pop Out Technique http: //www. screenr. com/MS 7 N

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

Resources: Videos • “Pop out” Implant removal technique: http: //www. screenr. com/MS 7 N • Liletta insertion video (this link doesn’t 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=Fu. PFbg. Sm 0 QQ ARHP Mirena IUS insertion video https: //www. youtube. com/watch? v=hlf. V 8 t. Kgw 6 E Implant insertion video: https: //www. youtube. com/watch? v=1 KPilt. HQZ 9 w (I may substitute out something better for this one, if something better is produced in the next few months) LARC training resources at get. LARC. org http: //getlarc. org/training/

Resources: Patient Ed • • Patient education on choosing between IUDs: http: //www. reproductiveaccess. org/resource/iudfacts/ 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/wpcontent/uploads/2014/12/Quickstart. Algorithm. pdf Medical eligibility by the CDC for LARC and other methods: https: //www. cdc. gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibilitycriteria_508 tagged. pdf