Intrauterine contraception after cesarean section and during lactation: a systematic review

Figures & data

Table 1 Interval IUD insertion after cesarean section

Type of IUD	Number of subjects	Time of insertion	Significant event rate	Comments	Study
$\begin{array}{l}\text{Antigon I}-45\hfill \\ \text{Antigon III}-17\hfill \\ \text{Antigon IV}-29\hfill \\ \text{Antigon F}-33\hfill \end{array}\}$	121	6–8 weeks	Expulsion 28.3*,e Controls expulsion 11.8%	Prospective, cumulative per 100 woman yearsa	Wiese^Citation5
$\begin{array}{l}\text{Lippes loop}\hfill \\ \text{Cu-T}\hfill \\ \text{Multiload}\hfill \\ \text{Cu-T} 200\hfill \end{array}\}$	318	6 weeks+	Nil	Retrospective pooled Controlledb	Chi and Balogh^Citation6
Cu-T 200	107	6 weeks	Expulsion 6.5%* Removals 8.4%*	Prospective controlled %, not life tablec	Gupta et al^Citation7
$\begin{array}{l}\text{Dalkon shield} 2\hfill \\ \text{MLCu} 250 168\hfill \\ {\text{Copper 7}}^{\text{®}} 22\hfill \\ \text{Lippes loop} 7\hfill \\ {\text{Copper-T}}^{\text{®}} 2\hfill \\ \text{Not stated} 14\hfill \end{array}\}$	215	6 weeks+	Expulsion 19e	Retrospective cumulative rate, non-controlledd	Holloway et al^Citation8
Szontagh IUD	288	Interval	Expulsion elevated (rate not specified)a	Controlled prospective cumulative rates not expressed	Chi et al^Citation9
$\begin{array}{l}\text{VCu} 200\hfill \\ \text{TCu} 380\text{A}\hfill \end{array}\}$	400	Interval	Pregnancy□ Removal⋄ Expulsion• VCu 200 0% TCu 380A 3.1%a	Prospective controlled VCu vs TCu 380A Event rates for both devices within accepted limits Not cumulative	Tang and Feng^Citation10
Cu-T 200	45	Interval	Expulsion 8.8%a	Not life-table1 perforation not controlled	Parikh and Gandhi^Citation11

Notes:

* P<0.05 for study group versus control group;

□ P<0.05 for VCu (1.02%) versus TCu 380A (4.64%);

⋄ P<0.05 for VCu (1.02%) versus TCu 380A (4.13%);

• P<0.05 for VCu (0%) versus TCu 380A (3.1%);

a 12 month follow up;

b 6 month follow up;

c 24 month follow up;

d 48 month follow up;

e per 100 women years of use. Antigon (Svend Schroeder Co., Copenhagen, Denmark); Lippes Loop (Ortho Pharmaceutical, Raritan, NJ, USA); Dalkon shield (AH Robbins, Richmond, VA, USA); MLCu (Prosan S.A. Arnham, the Netherlands); Copper 7® (G.D.Searle and Co., High Wycombe, England, UK); Copper-T® (Ortho Pharmaceutical); Szontagh IUD (Semmelweiss University, Budapest, Hungary); VCu (Dr Y. Wu, Shanghai, People’s Republic of China); TCu 380A (Teva Pharmaceutical Industries Ltd., Petach Tikva, Israel); Copper T 200 originally marketed by Ortho Pharmaceuticals, now replaced by TCU 380A of Teva Pharmaceutical Industries Ltd.

Abbreviation: IUD, intrauterine device; vs, versus.

Table 2 Post-placental IUD insertions after cesarean section

Event rate per 100 woman years (range)
Type of IUD	Studies	Subjects followed	Expulsion	Medical removal	Pregnancy	Comments and references
Mirena®	1	33	0	0	0	12 month follow up^Citation13
MLCu 250	1	154	2.6%	7.8%	0	12 month percentage rate^Citation14
TCu 220	3	714	(1.78–10.9)	Not stated	0–1.1	12 month cumulative rate^Citation15^–^Citation17
TCu 380	5	314	(0–17.6)	(0–10.6)	0	One study had 6 month follow up only^Citation18^–^Citation22
$\begin{array}{l}\text{Delta T}\hfill \\ \text{Delta loop}\hfill \\ \text{Delta Beijing}\hfill \end{array}\}$	2	135	(4.1–9.6)	7.2	2.4	aOne reported 6 month cumulative, the other 24 month percentage rates^Citation23,Citation24
Metal ring ± catgut knots	7	3131	(1.2–9.6)	(0.8 – 7.2)	(0–7.5)	aCumulative rate from 6–24 months^Citation24,Citation25

Notes:

a Reference 24 reported 9 Chinese studies also reported in 23 and 25. The data was only used once. Mirena® (Bayer, Wuppertal, Germany); MLCu 250 (Prosan S.A. Arnham, the Netherlands); TCu 380 (Teva Pharmaceutical Industries Ltd., Petach Tikva, Israel); Delta T, Delta loop, Delta Beijing, Metal ring (Chinese government, Beijing, People’s Republic of China).

Abbreviation: IUD, intrauterine device.

Table 3 Comparison of IUD expulsion rate after post-placental insertion following cesarean or vaginal delivery

Type of IUD	Subjects	Expulsion rate		Comments and reference
		PPCS	PPV
TCu 220	554	10.9	16.4a	3 month cumulative^Citation15
TCu 380A	19	0	50b	Ultrasound detection cumulative at 12 months^Citation20
Delta T	52	4.1	20.5b	6 month cumulative^Citation23,Citation24
Delta loop
Delta T 24	83	3.9	7.5	Catgut strings on IUDs cumulative at 12 months^Citation24
Delta loop 26
Delta Beijing 33
Metal ring ± 3 catgut knots	906	5.5	23.5	Cumulative at 12 months^Citation24

Notes:

a P<0.05

b P<0.001. TCu 380 (Teva Pharmaceutical Industries Ltd., Petach Tikva, Israel); Delta T, Delta loop, Delta T 24, Delta Beijing, Metal ring (Chinese Government, Beijing, People’s Republic of China).

Abbreviations: IUD, intrauterine device; PPCS, post-placental insertion after cesarean section; PPV, post-placental insertion after vaginal delivery.

Table 4 Prolactin levels in IUD users

Type of IUD	Subjects	Prolactin levels	Comments and reference
Lippes loop	6	Increase after insertion	Normalized next cycle^Citation34
Lippes loop C	2	Increase after insertion	Galactorrhea reversed after removal^Citation26
$\begin{array}{l}\text{Copper} 7^{\circledR }\hfill \\ {\text{Copper-T}}^{\text{®}}\hfill \\ \text{Soonawalla YCu}\hfill \end{array}\}$	40	Increase compared to control (P<0.05)	^Citation28
$\begin{array}{l}\text{Copper} (\text{unspecified}) 25\hfill \\ \text{Inert} (\text{unspecified}) 25\hfill \end{array}\}$	50	No increase	Controlled^Citation29
Progestasert	26	No increase	^Citation27
$\begin{array}{l}\text{Copper} 7 25\hfill \\ \text{Lippes loop} 17\hfill \end{array}\}$	42	No increase	Controlled^Citation30
$\begin{array}{l}\text{Progestasert} 14\hfill \\ \text{Copper-T} 21\hfill \end{array}\}$	35	No increase	Controlled-lactating^Citation33

Notes: Lippes Loop (Ortho Pharmaceutical, Raritan, NJ, USA); Copper 7® (G.D.Searle and Co., High Wycombe, England, UK); Copper-T® (Ortho Pharmaceutical); Soonawalla YCu (Prof RP Soonawala, Indian Council of Medical Research, Mumbai, India); Progestasert (Alza Corporation, Palo Alto, CA, USA). Copper T 200 originally marketed by Ortho Pharmaceuticals, now replaced by TCU 380A of Teva Pharmaceutical Industries Ltd.

Abbreviation: IUD, intrauterine device.

Table 5 The effect of the IUD on lactation

Type of IUD	Studies	Subjects	Observations and results	Comments and references
Lippes loop D	1	185	No change in duration of lactation and amenorrhea versus controls	PPV insertion^Citation35
Progestasert	2	100	Quantity and quality of milk significantly higher versus controls	PPV insertion^Citation37,Citation38
TCu 380A TCu 200B	$\begin{array}{l}\hfill 1 33\\ \hfill 29\end{array}\}$	62	No increased copper in milk	^Citation33
Mirena®	1	163	No changes in lactation or infant development versus TCu 380A	157 in TCu 380A group insertion 6–8 weeks post-partum^Citation46
TCu 380A	2	831	No change in lactation versus progesterone vaginal ring	^Citation42,Citation43
LNG – IUD	2	90	Milk production and infant development same as controls LNG in breast milk 0.1% of daily serum level	10 ug and 30 ug releasing IUDs inserted 6 weeks post-partum^Citation39,Citation47
Cu – IUD	1	38	No change in volume and composition of breast milk versus Implanon	Insertion 6 weeks post-partum. IUD type not specified^Citation48
Cu – IUD	1	68	No alteration of duration of lactation or LAM	Interval insertion DMPA and POP controls^Citation36
MLCu 250	3	169	No change in milk quality and quantity and infant development	Interval insertion comparison with POP and DMPA^Citation38,Citation40,Citation41
MLCu 375	1	41	No change in milk quality and infant development	Interval insertion comparison with POP^Citation45

Notes: Lippes Loop (Ortho Pharmaceutical, Raritan, NJ, USA); Progestasert (Alza Corporation, Palo Alto, CA, USA); TCu 380 (Teva Pharmaceutical Industries Ltd., Petach Tikva, Israel); Mirena® (Bayer, Wuppertal, Germany); MLCu (Prosan S.A., Arnham, the Netherlands).

Abbreviations: IUD, intrauterine device; DMPA, depo-medroxyprogesterone acetate; PPV, post-placental vaginal; LAM, lactational amenorrhea; LNG, levonorgestrel; POP, progestogen only pills.

Table 6 IUD event rates in breastfeeding women

Type of IUD	Subjects	Expulsion	Event rates per 100 woman years
			Medical removal	Pregnancy	Comments and references
$\begin{array}{l}\text{Lippes loop D}\hfill \\ {\text{Copper-T}}^{\text{®}}\hfill \end{array}\}$	173	3.4a	0.6a	0.0a	3 month rate interval insertion^Citation49
	109	2.1a	0.0a	0.0a	3 month rate interval insertion^Citation49
TCu 380A	590	13a	0.9b	1a	No distinction between interval and PPV insertions 6 month rate^Citation50
TCu 380A	1032	3.9a	2.9 b	0.3a	12 month rate all interval insertions^Citation51

Notes:

a Not significant versus non breastfeeding

b P<0.05 versus non breastfeeding (significantly lower than non-breastfeeders). Lippes Loop (Ortho Pharmaceutical, Raritan, NJ, USA); Copper 7® (G.D.Searle and Co., High Wycombe, England, UK); TCu 380 (Teva Pharmaceutical Industries Ltd., Petach Tikva, Israel).

Abbreviations: IUD, intrauterine device; PPV, post-partum vaginal insertion.

WieseJA study of four Antigon models and factors in use-effectiveness of the IUDContraception19761466877011017203

 PubMed Web of Science ®Google Scholar

ChiICBaloghSInterval insertion of intrauterine device in women with previous cesarean sectionContraception19843032092146509977

 PubMed Web of Science ®Google Scholar

GuptaIMahajanULataPGuptaANCopper intrauterine contraceptive device insertion 6 weeks after caesarean sectionIndian J Med Res1985822142163908303

 PubMed Web of Science ®Google Scholar

HollowayGAGoldstuckNDBowenDInterval insertion of an intrauterine contraceptive device following cesarean sectionInt J Gynecol Obstet1989293243248

 Web of Science ®Google Scholar

ChiICZhouSWBaloghSNgKIUD insertions following cesarean deliveries examined1983111th Annual Meeting of the American Public Health Association

 Google Scholar

TangYHFengZJComparative study of clininical effects of VCu IUD and TCu 380A IUD were used on women who once been done caesarean sectionZhonghua Yi Xue Za Zhi2012921712091211 Chinese22883013

 PubMedGoogle Scholar

ParikhVGandhiASSafety of copper-T as contraceptive after caesarean sectionJ Indian Med Assoc19898751131152600433

 PubMedGoogle Scholar

PuzeyMMirena at caesarean sectionEur J Contracept Reprod Health Care200510316416716318963

 PubMed Web of Science ®Google Scholar

Ruiz – VelascoVGarciaCCastroHCesarean section IUD insertionContracept Deliv Syst198231212412264124

 PubMedGoogle Scholar

LaraRSanchezRAAznarR[Application of intrauterine device through the incision of the cesarean section]. Aplicacion del dispositivo intrauterino a traves de la incision de la cesareaGinecol Obstet Mex1989572327 Spanish2486853

 PubMedGoogle Scholar

Van KetsHThieryMVan der PasHIUD insertion during cesarean sectionAdv Contracept1985143373393842224

 PubMedGoogle Scholar

CelenSSucakAYildezYDanismanNImmediate postplacental insertion of an intrauterine contraceptive device during cesarean sectionContraception201184324024321843687

 PubMed Web of Science ®Google Scholar

CelenSMoroyPSucakAAktulayADanismanNClinical outcomes of early postplacental insertion of intrauterine contraceptive devicesContraception200469927928215033401

 PubMed Web of Science ®Google Scholar

ChiICSu-WenZBaloghSNgKPost-cesarean section insertion of intrauterine devicesAm J Pub Health19847411128112826496826

 PubMed Web of Science ®Google Scholar

ChiICGaoJISiemensAJWaszakCSIUD insertion at cesarean section – the Chinese experienceAdv Contracept198621451453535432

 PubMedGoogle Scholar

LiuBHZhangLYZhangBRIntrauterine contraceptive device insertion with suture fixation at cesarean sectionChin Med J19839621411446406171

 PubMed Web of Science ®Google Scholar

Letti MüllerALLopes RamosJGMartins-CostaSHTransvaginal ultrasonographic assessment of the expulsion rate of intrauterine devices inserted in the immediate postpartum period: a pilot studyContraception200572319219516102554

 PubMed Web of Science ®Google Scholar

FortunyAPajol–AmatPCalafJMackinnonPCBRobynCPlasma levels of LH, FSH and prolactin in women during and after insertion of an intrauterine deviceJ Reprod Fert197335628629

 Google Scholar

HornHFinkelsteinMBen-DavidMPossible effect of intrauterine device on galactorrhoea in womenContraception19751244194241238229

 PubMed Web of Science ®Google Scholar

MehtaSPawarVJoshiJSerum prolactin levels in women using copper IUDsContraception1977153327334560285

 PubMed Web of Science ®Google Scholar

RansomWTMChapmanRSHullMGRSerum prolactin concentrations related to copper or inert intrauterine devices (IUDs) in womenContraception1979205441446527340

 PubMed Web of Science ®Google Scholar

SpellacyWNBuhiWCA prospective study of plasma prolactin levels in women using the progesterone releasing intrauterine device (P-IUD)Contraception19791919194428227

 PubMed Web of Science ®Google Scholar

WenofMAubertJMReyniakJVSerum prolactin levels in short-term and long-term use of inert plastic and copper intrauterine devicesContraception19791912127428221

 PubMed Web of Science ®Google Scholar

Rodrigues da CunhaACDorenJGCantuariaAAIntrauterine device and maternal copper metabolism during lactationContraception2001631373911257247

 PubMed Web of Science ®Google Scholar

HingoraniVUma BaiGRLactation and lactational amenorrhoea with post-partum IUCD insertionsJ Reprod Fert197023513515

 Google Scholar

BadraouiMHAskalaniHMahronsHSerourGHefnawiFLactation pattern in Egyptian women using the Progestasert systemContracept Deliv Syst198231536012264128

 PubMedGoogle Scholar

BadraouiMHHefnawiFBahgatRContraception during lactationReproduccion198269186180940

 PubMedGoogle Scholar

ShaamashAHSagenGHHusseinMHShaabanMMA comparative study of the levonorgestrel – releasing intrauterine system Mirena versus the Copper T 380A intrauterine device during lactation: breastfeeding performance, infant growth and infant developmentContraception200572534635116246660

 PubMed Web of Science ®Google Scholar

ChenJHWuSCShaoWQThe comparative trial of TCu 380A IUD and progesterone releasing vaginal ring used by lactating womenContraception19985763713799693396

 PubMed Web of Science ®Google Scholar

SivinIDíazSCroxattoHBContraceptives for lactating women: a comparative trial of a progesterone-releasing vaginal ring and the copper T 380A IUDContraception19975542252329179454

 PubMed Web of Science ®Google Scholar

HeikkilaMHaukkamaaMLuukainenTLevonorgestrel in milk and plasma of breastfeeding women with a levonorgestrel-releasing IUDContraception198225141496800691

 PubMed Web of Science ®Google Scholar

HeikkilaMLuukainenTDuration of breastfeeding and development of children after insertion of a levonorgestrel-releasing intrauterine contraception deviceContraception19822532792926804164

 PubMed Web of Science ®Google Scholar

TaneepanichskulSReinprayoonDThaithumyanonPPraisuwanaPTosukhowongPDiebenTEffects of the etonogestrel – releasing implant Implanon and a non-medicated intrauterine device on the growth of breast-fed infantsContraception200673436837116531169

 PubMed Web of Science ®Google Scholar

PremaKDuration of lactation and return of menstruation in lactating women using hormonal contraception and IUDsContracept Deliv Syst198231394612264126

 PubMedGoogle Scholar

Delgado BetancourtJSandovalJCSanchezFVallesteros De CanoPDe La Luz BantistaMJimenezFInfluence of Exluton (progestogen-only OC) and the Multiload Cu 250 IUD on lactationContracept Deliv Syst198451919512266200

 PubMedGoogle Scholar

SinchaiWSethavanichSAsavapiriyanontSEffects of a progestogen-only pill (Exluton) and an intrauterine device (Multiload Cu250) on breastfeedingAdv Contracept19951121431557491855

 PubMedGoogle Scholar

BjarnadottirRIGottfredsdottirHSigurdardottirKGeirssonRTDiebenTOComparative study of the effects of a progestogen-only pill containing desogestrel and an intrauterine contraceptive device in lactating womenBJOG20011081174118011762658

 PubMed Web of Science ®Google Scholar

ColeLPMcCannMHigginsJEWaszakCSEffects of breastfeeding on IUD performanceAm J Pub Health19837343843886829821

 PubMed Web of Science ®Google Scholar

ChiICPottsMWilkensLRChampionCBPerformance of the Copper T-380A intrauterine device in breastfeeding womenContraception19893966036182666018

 PubMed Web of Science ®Google Scholar

FarrGRiveraRInteractions between intrauterine contraceptive device and breast-feeding status at time of intrauterine contraceptive device insertion: analysis of TCu 380A acceptors in developing countriesAm J Obstet Gynecol199216711441511442918

 PubMed Web of Science ®Google Scholar