Checking IUD position by Transvaginal ultrasound not necessary if no history of pain or bleeding

NETHERLANDS: According to a research that was recently published in AJOG Global Reports, transvaginal ultrasonography (TVUS) may not be required for positioning follow-ups beyond six weeks following the proper installation of an intrauterine device (IUD) in women.

The T-shaped contraceptive device known as the levonorgestrel intrauterine system (IUD) contains 52 mg of levonorgestrel. A clinical examination by speculum to measure the length of the threads six weeks after insertion appears to be a suitable test for evaluation as full expulsion or perforation may be ruled out by looking for threads. This will confirm the LNG-intrauterine IUD's location.

"Other types of malposition, such as the embedding of the stem in the myometrium, might go unnoticed, though, because this position has no effect on how far the threads extend from the ostium. Transvaginal ultrasonography can be used to identify this type of malposition. The therapeutic effects of these malpositions, aside from a full expulsion and perforation, are up for debate," asserted the authors.

The objective of the study was to determine how frequently malposition occurred on two-dimensional transvaginal ultrasonography (TVUS) during regular examination six weeks following implantation. The researchers also looked into the connection between pelvic pain and/or poor bleeding patterns and the positioning of the levonorgestrel 52 mg intrauterine device (LNG-IUD).

The researchers carried out a large prospective cohort study. Patients who needed an LNG-IUD were eligible to participate. The LNG-IUD was checked for position using TVUS both immediately following insertion and six weeks later. Six weeks following insertion, patients completed questionnaires concerning their bleed patterns and pelvic pain. There were 500 patients registered in total between March 2015 and December 2016. 448 patients had TVUS assessments six weeks after insertion, and 363 patients (72.6%) had complete data (TVUS plus questionnaire).

Conclusive points of the study:

• 6.3% of the patients (28/448) experienced malposition.
• In comparison to 3/165 individuals (1.8%) with a good bleeding pattern and no pelvic pain, malposition was observed in 15/198 patients (7.6%) with unfavorable bleeding and/or pelvic pain (p=0.03).
• In contrast to 4/177 individuals (2.3%) with favorable bleeding patterns, malposition was observed in 14/186 patients (7.5%) with an unfavorable bleeding pattern (p=0.008).
• In comparison to 13/313 individuals (4.2%) without pelvic pain, malposition was observed in 5/50 patients (10%) with pelvic pain (p=0.08).

The study speculated that a higher percentage of patients could request a TVUS to check for malposition because of the increased prevalence of adverse hemorrhage within six weeks of insertion. " We were unable to identify a particular bleeding pattern that showed malposition on TVUS", they said.

The clinical significance of an IUD that is positioned incorrectly and adjustments to levonorgestrel IUD positions are the authors' two main recommendations for future research in this field. They emphasized that a cost-benefit analysis in patients with symptoms would be beneficial.

REFERENCE

P.A.H.H. van der Heijden, P.M.A.J. Geomini, I. Ketel, S. Veersema, M.Y. Bongers, Is two-dimensional transvaginal ultrasonography necessary six weeks after insertion of levonorgestrel 52 mg intrauterine device?, AJOG Global Reports, 2022,100104,ISSN 2666-5778, https://doi.org/10.1016/j.xagr.2022.100104