IUD insertion safe and effective for teens

When deciding which type of birth control to recommend to a patient, a healthcare provider wants to maximize her patient's satisfaction and the effectiveness and feasibility of the contraceptive method. There are so many choices, but few are as effective, long-lasting, and easy to use as IUDs.

So why don't more teens choose IUDs for contraception? Because there are several barriers to getting an IUD. Many providers worry about ease of inserting IUDs in young women, especially those who have never been pregnant. (When inserting an IUD, the provider threads the device through the cervix, the opening to the uterus. The cervix is usually more open after a woman has a baby, so it is easier to insert the IUD.) What if the provider needs to take extra steps to insert the IUD, like using local anesthesia or dilating the cervix open, and they don't have the tools necessary? What if patients faint or have extreme pain? Providers also worry about who will insert the IUD- can a nurse practitioner or physician assistant do it? Or does it have to be the doctor? There are far more "Advanced Practice Clinicians" (APCs)- nurse practitioners, certified nurse-midwives, and physician's assistants- than doctors. In fact, at Title X clinics, there are on average 4.2 full time APCs for every full time physician. 

A set of researchers at the Title X clinic at the Children's Hospital Colorado, led by Dr. Teal, decided to set the record straight. They collected medical records from all the women aged 13 to 24 who visited their birth control clinic from April 2009 to December 2011. During that time, 1,177 women had an attempted IUD placement. A whopping 96.2% of insertions were successful on the first attempt. For the 45 women who did not have a successful first attempt, 40% came back for a second attempt with a doctor, and 78% of these were successful. That makes for a total success rate of >97%.

Does age matter? Does whether or not the patient had a baby in the past matter? The researchers compared the success for patients aged 13-17 with those aged 18-24. They also compared patients who had given birth with those who hadn't. There was no difference in success rate. IUD insertion was very successful for all the women, regardless of age or whether they had given birth in the past. The success rate was 95.5% in 13-17 year-olds and 96.3% for 18-24 year-olds.  The success rate was 95.8% for women who hadn't given birth and 96.7% for those who had.

Does what type of provider performed the insertion matter? The vast majority of insertions were performed by APCs at this clinic. The authors report that there were 8 APCs who performed 86% of insertions. These APCs varied in level of experience and years of practice. There were 7 physicians who performed 14% of insertions. The authors emphasize the importance of this finding and conclude that APCs can insert IUDs with a high success rate. Training APCs to insert IUDs should increase the availability of IUDs from community clinics, where APCs make up a large percentage of the work force.

What about complications or the need for extra measures to ensure success? It turns out, very few! 0.6% of patients had excess pain with insertion, and 0.4% fainted. Providers needed to take extra measures like dilating the cervix and using local anesthesia (a paracervical block) only 1.8% of the time. In the 6 months following insertion, none of the IUDs made a tear through the wall of the uterus (perforation). The IUD came out for only 3% of patients in the 6 months following insertion. The authors found that whether the IUD came out after insertion was not related to age, whether or not a women had a baby in the past, and type of IUD.

Overall, this medical record review has some very reassuring results. The findings support the argument that adolescents and young adults can have access to safe and effective birth control via the IUD whether or not they are over the age of 18, have access to a physician, or have had a baby in the past. APCs like nurse practitioners can successfully insert IUDs for teens, even if they don't have access to local anesthesia or dilators because so few women will even need this extra measure. All around, very good news for birth control clinics everywhere.