What is the expulsion rate of a postpartum Intrauterine Device (IUD)?

Expulsion Rates of Postpartum Intrauterine Devices (IUDs)

Postpartum IUD expulsion rates vary based on timing of insertion, with immediate postplacental insertion having approximately 10% expulsion rate at 6 months, while expulsion rates can be as high as 24% when compared to interval insertion (2%). 1

Timing of Insertion and Associated Expulsion Rates

• Immediate postplacental insertion (within 10 minutes of placental delivery) has expulsion rates of approximately 10% 1
• Insertion between 10 minutes and 48 hours postpartum has similar expulsion rates, with one study showing 5% for immediate vs 3.7% for early insertion (not statistically significant) 2
• Postplacental placement at cesarean section has lower expulsion rates than vaginal postplacental insertions 1
• Interval insertion (≥4 weeks postpartum) has significantly lower expulsion rates of approximately 2% 1

Factors Affecting Expulsion Rates

• Insertion technique significantly impacts expulsion rates 3:

  • Digital insertion has lower expulsion rates (19.5%) compared to surgical forceps insertion (39.6%) 3
  • Experience of the provider performing the insertion affects expulsion rates, with higher rates for inexperienced inserters 3
  • High fundal placement of the IUD decreases expulsion rates 1, 4

• Type of IUD:

  • Copper IUDs have been more extensively studied in the immediate postpartum period 1
  • Modern copper IUDs inserted postplacentally have unplanned pregnancy rates of 2.0-2.8 per 100 users at 24 months 4

Continuation Rates Despite Higher Expulsion

• Despite higher expulsion rates with immediate postpartum insertion, 6-month continuation rates are higher in immediate placement groups (80%) compared to interval insertion groups (50%) 1
• In low- and middle-income countries, immediate postpartum copper IUDs have a six-month continuation rate of 87% 5
• After accounting for IUD replacement following expulsion, continuation rates at 1 year are similar between implants (84%) and IUDs (81%) 1

Clinical Implications and Recommendations

• Immediate postpartum IUD insertion is considered safe with low rates of infection, bleeding problems, and uterine perforation 4
• Women should be counseled about the higher expulsion risk with immediate postpartum insertion 1
• Patients should be taught how to detect expulsions and instructed to return for reinsertion or alternative contraception if expulsion occurs 4
• Ultrasound guidance may be useful to ensure fundal placement after vaginal delivery 1
• Follow-up examination is recommended to check for partial expulsion or malposition 2

Special Considerations

• For cesarean deliveries, IUD placement in the uterine fundus can be done manually, with ring forceps, or with the manufacturer's inserter before hysterotomy closure 1
• Higher age, higher parity, lack of satisfaction, and motivation to continue are predictors of expulsion 2
• Despite higher expulsion rates, the benefits of immediate postpartum IUD insertion generally outweigh the drawbacks due to higher continuation rates and reduced unintended pregnancies 1