Requests for intrauterine device self-removal guidance from clinics during COVID-19

Patients can face obstacles if they wish to remove their IUDs, including cost, scheduling, and even resistance from clinicians.1 During the Covid-19 pandemic, patients faced issues with access to healthcare as another barrier. Some patients want to remove their own IUDs, and this may be an important choice for reproductive autonomy.¹ How often were IUD users removing their own IUDs before the pandemic? What about after?Kathryn E Fay, MD, of the department of obstetrics, gynecology, and reproductive biology at Harvard Medical School in Boston, Massachusetts and colleagues conducted a study to find out.

Researchers analyzed secondary data from research previously performed between April and October 2020 by the Society of Family Planning (SFP) Abortion Clinical Research Network on clinic sites throughout the United States. SFP’s longitudinal survey recruited family planning clinics online through Qualtrics. Researchers said community-based and academic clinics were equally represented in the sample, and noted greater participation in the West and Northeast. “Approximately half of clinics provided 26 to 250 unique contraceptive encounters per month at baseline and a remaining quarter provided 251 to 1000 encounters,” researchers reported.1 Providers were asked about contraception and abortion clinical practices before and during the pandemic for survey 1 (66 sites), while surveys 2 and 3 concentrated on the ways clinics adapted to Covid-19 in these areas. Researchers said 53 sites participated in all 3 surveys.

Fay and colleagues used data from 63 of the respondents. They reported three clinics were excluded because they only provided abortion services. Of those that provided contraceptive services, 7.9% (5) said they provided information on the self-removal of IUDS before Covid-19.1 By the end of the study, which was 8 months into the pandemic, 25.4% (16) gave guidance to patients about IUD removal.¹ “Self-removal counseling was associated with being an academic center and reporting a median lower number of monthly contraceptive encounters,” researchers said.1 Fay and colleagues noted that the increase was 3 times higher than before the pandemic.

Researchers reported that a “qualitative study that examined clinician opinion of self-removal highlighted that…clinicians were not concerned about the safety of self-removal and may plan to remove their own IUDs.”1,2 However, they also noted that the study found that clinicians prefer to be involved in the decision to remove IUDs.^1,2

Generally, women who have selected IUD for contraception are urged to have removal performed by a professional. However, researchers said that, “self-removal guidance may be an important practice for patient autonomy, and, during a pandemic, a means of reducing exposure risk. In the context of public health demand to innovate remote contraceptive care delivery, family planning clinics demonstrated increasing endorsement of IUD self-removal.”¹

Fay and colleagues noted that contraception care is changing to include patients getting services outside of traditional healthcare settings. They said that this trend may increase, “particularly now that SFP's pandemic-responsive clinical recommendations endorse IUD self-removal counseling.”¹

Study limitations included small sample size and wording of certain questions that may not have captured the full the full picture of how many patients requested guidance for self-removal. Of particular concern was the reference specifically to the pandemic, when patients may have removed their IUDs for other reasons, researchers noted.

Fay and colleagues said the study results are a launch point for more studies to examine the future of IUD self-removal, regular contraception recommendations, and implementation. “These findings suggest clinician support for patient autonomy in contraceptive self-management and limited concern for safety issues with self-removal during a public health emergency,” Fay and colleagues concluded.

References

1. Fay KE, Traore F, Amico JR. Intrauterine device self-removal practices during the COVID-19 pandemic among family planning clinics [published online ahead of print, 2022 Oct 12]. Contraception. 2022;S0010-7824(22)00391-2. doi:10.1016/j.contraception.2022.09.127
2. Amico JR, Bennett AH, Karasz A, Gold M. Taking the provider "out of the loop: "Patients' and physicians' perspectives about IUD self-removal. Contraception. 2018; 98: 288-291