Expulsion Rates of Postpartum Intrauterine Devices (IUDs)

Timing of Insertion and Associated Expulsion Rates

• Immediate postplacental insertion (within 10 minutes of placental delivery) has expulsion rates of approximately 10% 1
• Interval insertion (≥4 weeks postpartum) has significantly lower expulsion rates of approximately 2% 1
• Postplacental placement at cesarean section has lower expulsion rates than vaginal postplacental insertions 2, 3

Factors Affecting Expulsion Rates

• High fundal placement of the IUD decreases expulsion rates 4
• Copper IUDs have been more extensively studied in the immediate postpartum period 5

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
• After accounting for IUD replacement following expulsion, continuation rates at 1 year are similar between implants (84%) and IUDs (81%) 5

Clinical Implications and Recommendations

• Women should be counseled about the higher expulsion risk with immediate postpartum insertion 1
• Ultrasound guidance may be useful to ensure fundal placement after vaginal delivery 4

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 6
• 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