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Research roundup: June 2024 edition

Factors that increase risk for deep or nonpalpable implant, 12-hour vs. 24-hour mifepristone-misoprostol interval, and two studies reinforcing the safety and efficacy of no-test medication abortion.

by Colleen Denny, MD and Emma Gilmore, MD

published 06/30/24

1. Ease of removal of malpositioned IUDs: a retrospective cohort study

IUDs can provide long-acting, highly effective contraception, and are becoming more popular among the US population. Accordingly, they are also being assessed more frequently via pelvic ultrasound, and it is not clear whether an abnormal appearance of an IUD on ultrasound will be associated with increased difficulty removing the IUD. In this retrospective cohort study, the authors identified 1,759 pelvic ultrasounds performed with an IUD in place, of which 436 (25%) were read as malpositioned in some way; 150 were described as embedded and 16 were described as partially perforated. The authors noted that the time to removal of an IUD reported as malpositioned was shorter (median of 17 days) than those not reported as malpositioned (median of 236 days). However, the majority of malpositioned IUDs were removed on the first attempt (85%), similar to nonmalpositioned IUDs (82%). Even most IUDs reported as embedded or partially perforated were successfully removed on the first attempt, at 84% and 91% respectively; the majority of these removals were performed using ring forceps. This data suggests that removal of malpositioned IUDs is not necessarily more complicated than removal of nonmalpositioned IUDs and can be successfully managed with standard removal techniques the majority of the time.

2. A retrospective analysis of factors associated with deep contraceptive implant removals compared to superficial removals

The subdermal contraceptive implant is the most effective reversible form of birth control available in the US, and is particularly popular among younger groups of patients. However, slightly less than 1% of all implants are found to be deep or nonpalpable at time of removal attempts, complicating or delaying removal and potentially requiring specialist consultation. In this retrospective cohort study, the authors sought to identify which factors among implant users were associated with the need for a deep implant removal as compared to a more typical superficial removal. Among 747 patients undergoing implant removal at the authors’ institution, 162 (21%) required techniques for a deep implant removal. The authors identified three independent factors associated with higher likelihood of requiring a deep implant removal: low BMI at time of placement, weight gain during implant use, and longer duration of implant use. The authors stress the importance of correct implant placement technique, especially among patients at risk of deep insertion, and encourage timely referral for patients with nonpalpable implants to Centers of Experience, clinicians with the training and expertise in deep implant removal.

3. Mepivacaine instillation for pain reduction during intrauterine device placement in nulliparous women: a double-blinded randomized trial

While IUDs can be safely and effectively used by both nulliparous and multiparous patients, fear of pain during IUD placement may be a barrier to patients who would otherwise be interested in using this form of contraception. Accordingly, interventions to decrease pain during IUD placement are particularly valuable to patients. In this randomized placebo controlled trial, the authors enrolled 151 nulliparous patients seeking IUD placement and randomized them to intrauterine instillation of either mepivicaine or normal saline two minutes before IUD placement. The authors found that patients in the mepivicaine group reported significantly lower pain scores overall, and were more likely to report that pain during IUD placement was tolerable. The authors suggest that offering mepivicaine before IUD placement is a clinically relevant pain reduction strategy and could potentially improve contraception access for patients interested in IUDs.

4. Placement of an intrauterine device within 48 hours after second trimester medical abortion: a randomized controlled trial

Intrauterine devices (IUDs) are effective, safe methods of contraception that should be available to patients seeking abortion. Data clearly supports IUD placement as soon as a first-trimester medication abortion is deemed complete, but there is less available evidence regarding IUD placement after second-trimester abortion. Close-interval birth control availability has been demonstrated to result in improved uptake, as patients may be lost to follow up with longer delays in care. This study examined IUD placement within 48 hours for patients undergoing second-trimester medication abortion, and compared it to IUD placement after 2-4 weeks. 179 participants were recruited out of 8 Swedish clinics, and randomized to either the intervention (IUD placement before discharge, or within 48 hours after abortion) or the control group (who were scheduled for later IUD placement). Attendance at the 48-hour placement visit was higher than that at the delayed visit. However, study enrollment was halted after participants undergoing 48-hour placement exceeded an IUD expulsion rate of 20%. Because a minority of patients chose to reinsert the IUD, the intervention did not lead to greater uptake in IUDs after second-trimester abortion. Overall, the authors found that 48-hour placement was not superior to delayed placement, and resulted in a significantly higher expulsion rate. If patients choose this option for IUD placement, they should be appropriately counseled regarding the lack of large-scale data and concern for higher expulsion risk.

5. 24-Hour Compared With 12-Hour Mifepristone-Misoprostol Interval for Second-Trimester Abortion: A Randomized Controlled Trial

Patients seeking abortion or who have fetal demises in the second trimester may opt for medication management. The combination of mifepristone followed by sequential doses of misoprostol is considered the most effective regimen for second trimester medication abortion, but the optimal timing of these medications has varied in the research literature. In this prospective randomized controlled trial of 80 patients undergoing medication abortion between 12 and 28 weeks of gestation, the authors allocated patients to either a 12-hour or 24-hour interval between mifepristone administration and the beginning of misoprostol administration. In their analysis, the authors found that the induction time, defined in this trial as the time from first misoprostol administration to delivery, was shorter by three hours in the 24-hour interval group (9.5 hours vs 12.5 hours); however, the abortion time, defined in this trial as the time from mifepristone administration to expulsion of the fetus and placenta, was 8.5 hours shorter in the 12-hour interval group (24.5 hours vs 33 hours). Pain scores, need for surgical intervention, side effects, and satisfaction levels were not different between the two groups. The authors suggest that this data can help with shared decision-making with patients when trying to choose the optimal dosing of mifepristone before second-trimester medication abortion.

6. Comparison of No-Test Telehealth and In-Person Medication Abortion &

7. Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening

Medication abortion with mifepristone and misoprostol is highly effective and is now the most common form of abortion obtained in the US, comprising more than 60% of all abortions. Many studies have already demonstrated low rates of complications and high efficacy rates achieved with medication abortion. As legislative battles over abortion access continue around the US, it becomes increasingly important to have data on methods of virtual abortion delivery. To this end, these studies examine different outcomes for a variety of hybrid or virtual medication abortion care models. For this study, the authors conducted a prospective, observational cohort study to compare the efficacy of no-test assessment (with mailed medications) and office assessment with ultrasound. Participants were recruited from six states over the course of two years, and the final cohort included 585 abortion seekers. There were low rates of adverse events overall, and no-test medication abortion was deemed non-inferior to medication abortion with in-person ultrasound. The next study examines outcomes of medication abortion when provided over two phases: in-person screening, including ultrasonography, followed by delivery of medications via mail-order pharmacy. This was a prospective cohort study conducted across 11 clinics in 7 US states, enrolling a total of 540 participants. The authors used survey and medical record data to assess effectiveness, acceptability and feasibility of this model of medication abortion care delivery. They found that in-person assessment followed by medication delivery resulted in effective, acceptable, and feasible medication abortions for participants, with very low rates of adverse events. These findings reinforce pre-existing evidence to support no-test medication abortion, with the hopes of improving access for patients around the United States. Ongoing efforts are needed to make virtual medication abortion, with the potential for mail-order medication delivery, more accessible for patients.

8. Assessing Contraceptive Switching and Discontinuation Over 3 Years in the HER Salt Lake Study

The HER Salt Lake Study, conducted with the University of Utah, took place at four clinics in Salt Lake County between March 2016 and March 2020, with the fundamental goal of providing no-cost contraception services to patients. Method continuation has historically been viewed as a sign of patient acceptability, but the actual significance of continuation is poorly understood. For this publication, the authors specifically analyzed the factors associated with switching, discontinuing, or continuing contraception over time, and how these choices are affected by previously used contraception. More than 4,000 participants in the study filled out numerous surveys during their enrollment, and these results were used to conduct the analysis. The authors found that 50.8% of participants reported switching or discontinuing a method of contraception during the study, and about half of these individuals chose not to start a new method of birth control. Furthermore, individuals who knew from the outset of the study that they would have access to no-cost contraception, even if switching methods, were more likely to make changes. The results seemed to indicate that cost does affect patient choices, though efficacy and contraception type may have less of an effect than previously assumed. More study is needed to understand the factors that influence individual decisions about birth control continuation and discontinuation.

Colleen Denny, MD, is an attending ObGyn at Bellevue Hospital in New York City, where she is the Medical Director of the Women's Clinic, and a clinical assistant professor with the NYU School of Medicine. She enjoys providing care for patients in all phases of life and is especially interested in issues related to contraception access and public health. Outside of work, she’s a runner, a dancer, and a bit of a crossword puzzle nerd.
Emma Gilmore is a fellow in Complex Family Planning at the University of Pennsylvania. She completed her residency in Obstetrics and Gynecology at New York University. She's passionate about reproductive rights, medical education, and combating health care disparities, particularly in sexual and reproductive health. In her free time, she can be found taking her dog on walks around the beautiful parks in and around Philadelphia.
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