Expulsion

ACOG supports immediate postpartum LARC insertion as a best practice, recognizing its role in preventing rapid repeat and unintended pregnancy.

Despite the higher expulsion rate of immediate postpartum IUD placement over interval placement, evidence from clinical trials and from cost-benefit analyses strongly suggest the superiority of immediate placement in reduction of unintended pregnancy, especially for those at greatest risk of not having recommended postpartum follow-up visit.

Expulsion rates for immediate postpartum IUD insertions are higher than for interval or postabortion insertions, vary by study, and may be as high as 10–27% (73-90% of women retain the device).

Differences in expulsion rates are similar with manual insertion versus use of ring forceps, but may differ depending on the experience of the inserter.

Optimally, women should be counseled prenatally about the option of immediate postpartum LARC. Counseling should include advantages, risk of IUD expulsion, contraindications, and alternatives to allow for informed decision making.

Many women experience barriers to interval LARC placement, such that the advantages of immediate placement outweigh the disadvantages.

As many as 40% of women do not return for a postpartum visit because of:

  • Childcare obligations
  • Unable to get off work
  • Unstable housing
  • Lack of transportation
  • Communication or language barrier
  • Lack of insurance coverage or potential expiration of Medicaid eligibility

Replacement cost may vary by insurance plan, and a woman who experiences or suspects expulsion should contact her health care provider and use a back-up contraceptive method.

Learn more about immediate postpartum IUD expulsion