Event 1: May 28, 2020
On May 28, 2020 at 12:00pm Eastern, we held a short live-stream event about access to IUD removal and IUD protocols during COVID-19. There were two objectives for this event: 1) address issues arising in IUD care during the early days of the COVID pandemic where little was known about the disease and much of the world was still on lockdown. 2) To speak to constituents about the Committee's plans for the Symposium going forward and to get information about the priorities and concerns of attendees as decisions were made about whether to reschedule an in-person event or whether (and how) to roll out an online event instead.
Speakers included David Hubacher, PhD MPH, Carolyn Westhoff, MD MSc, Jennifer Amico, MD MPH, Diana Greene Foster, PhD, Gathari Ndirangu Gichuhi, MD, Gillian Dean, MD, and Michael Policar, MD.
The videos of the event are viewable below or on our YouTube playlist.
Michael Policar shared the following resources at the end of his video:
FPNTC COVID-19 Resources
•COVID-19 and Family Planning Services FAQ
•What Family Planning Providers Can Do to Meet Client Needs During COVID-19
•Prioritization of In-Person and Virtual Visits During COVID-19: A Decision-Making Guide
•COVID-19 Social Media Toolkit for Family Planning Providers
•Help Staff Reduce Stress During COVID-19
Family Planning COVID-19 Resources
•UCSF Beyond the Pill: Contraception During COVID-19: Best Practices and Resources
•RHAP: Contraception in the Time of COVID-19
•KFF: A Look at Online Platforms for Contraceptive and STI Services during the COVID-19 Pandemic
•Upstream USA: Ensuring contraceptive access during the COVID-19 pandemic
CDC COVID-19 Out-patient Clinic Guidelines
Interim CDC Guidance on Handling Non-COVID-19 Public Health Activities that Require Face-to-Face Interaction with Clients in the Clinic and Field in the Current COVID-19 Pandemic
•CDC Guidance for Healthcare Facilities
CDC Information for Healthcare Professionals
ACOG COVID-19 Resources
•COVID-19 FAQs for Obstetrician–Gynecologists, Gynecology
•ACOG/SMFM Outpatient Management of Pregnant Women
•ACOG Managing clients Remotely: Billing for Digital and Telehealth Services
AAFP and AMA Telehealth Resources
•AAFP Checklist to Prepare Physician Offices for COVID-19
•AAFP Using Telehealth to Care for Patients During the COVID-19 Pandemic
–Contains helpful list of telemedicine vendors
•AMA quick guide to telemedicine in practice
More Telehealth Resources
•Essential Access Health Telehealth Essentials Resource Hub
•DHHS: FAQs on Telehealth and HIPAA during the COVID-19 nationwide public health emergency
•The National Telehealth Policy Resource Center
•CMS: General Provider Telemedicine Toolkit
•Medicare Telemedicine Health Care Provider Fact Sheet
•Medical Economics: Telehealth primer: How to set up a program quickly
Q&A: David Hubacher, PhD, MPH
Event Host
Note: Dr. Hubacher spoke on the history of the IUD Symposia, but his presentation is not available on video.
Q: Is that data on IUD use in the US over time available broken down by Cu-IUD and Hormonal IUD?
A: No it is not. In 2014, about 26% of IUD use was copper and the remaining (74%) was hormonal. See : Hubacher D, Kavanaugh M. Historical record-setting trends in IUD use in the United States. Contraception. 2018;98:467-70.
Q&A: Diana Green Foster, PhD
Desire for control over IUD removal
Q: In the 2014 paper, only 59% willing to try self-removal and then 19% successful is low. How do you see self-removal fitting into wider removal services?
A: Not all women will be interested in removing their own IUDs. The clinician placing the IUD has to ask the woman if she might be interested in self-removing the device later. If she does not like the idea or if she has concerns about a partner removing her IUD against her will, then the provider can trim the strings short. If she is interested in self-removal, the clinician can trim the strings 2 inches (5cm) or longer from the external os.
Q: If IUD strings are left long (5-7 cm), is there higher incidence of accidental removal or partial expulsions, from tampon use or perhaps sex?
A: There aren’t hard data on this but it seems reasonable to assume that there is a higher risk of accidental removal with longer strings. This may be a trade off the woman is willing to make in order to have control over removal. Women who want to use a menstrual cup, who don’t trust their partner not to remove it, or who are sure that they want to use the method for a long time may prefer to have shorter strings. Women who want control over discontinuation may want longer strings.
Q: How long does the string need to be to be successfully removed?
A: More work should be done on this. Based on our data, 2 inches (5 cm) from the external os may be long enough for successful removal.
Q: Why was the third position, with a person standing with one leg up on a step, less successful for self-removal?
A: I don’t know why one foot up was less successful. Note that the trial occurred inside a clinic. At home, a woman could try a variety of positions until she finds one where her ability to grasp the string is greatest.
Q: For patients whose strings are left longer, has any qualitative data been collected rated to “bothersome strings” (reported by patient or partner)?
A: I am not familiar with the complete literature on IUD complaints. Anecdotally, I know that both long strings and short strings can be bothersome. One can feel long strings but short strings can poke. Short strings also can retreat into the cervix and require a more painful removal process. Only the woman would know which she prefers.
Q: What were the characteristics of self removal failure? Were most partially removed, trapped in cervical canal? If partially removed this could potentially decrease efficacy of the method until the pt is able to obtain an appointment for removal or transition to another method.
A: In our trial, nobody partially removed their IUD. (This was not a concern in Dr. Amico’s data either.) All the failures to self-removal involved women who were not able to grasp the string and therefore could not pull on it.
Questions for both Dr. Foster and Jennifer Amico
Q: Do you have any concerns about self-removal, especially in the LMIC context or areas where STI and other vaginal infections may be high. In addition, is there any concern that the removal appointment is an important opportunity for provider contact and self-removal would remove that opportunity for healthcare provisions for other issues
A: Amico: I do not have any concerns about uterine infection resulting in self-removal attempts. This was not mentioned in the data as an outcome. Also, since self-removal (and provider-removal) does not require instrumentation into the cervix at all, this clinically would not be a concern.
A: Amico and Foster: We need to keep in mind that people can discontinue most other reversible contraceptives without seeing a clinician first. Self-removal simply makes IUD discontinuation as accessible as discontinuation of short acting methods. Requiring a visit for IUD discontinuation is like requiring a pap for an oral contraceptives prescription or an IUD insertion: while ideally people will have cervical cancer screening and access to information about effective contraception, it does not make sense to hold one service hostage in order to access another.
Q&A: Jennifer R. Amico, MD, MPH
IUD Removal Access and Obstacles
Q: Can you talk more about why patients felt that self-removal would be a risk for coercion?
A: In our study, both patients and providers were concerned that someone else in an IUD user’s life, such as their partner, would remove the IUD without their consent.
Q: In your qualitative study, did you find providers who were okay with removing IUDs on request? You only presented providers who expressed concerns. Was that the totality of the sample?
A: Thank you for this question. In our sample of 16 patients, 9 had reported that their providers gave them the option to keep or remove the IUD, while the other 7 only reported that their provider encouraged continuation. Of those 9 who offered either option, only 3 were perceived by the patient as being neutral about it, with the other 6 clearly preferring IUD continuation.
In our sample of 12 providers, no one reported that they removed IUDs on request without giving a recommendation to keep it, everyone spoke about being conflicted and favoring continuation when possible.
Of course, please keep in mind that this breakdown is not meant to be evidence of a quantitative outcome, but only to give context to the data.
Q: Are there any regulatory or other risks to providers for supporting self-removal of IUDs?
A: This is a great question and one that is worth thinking about. I think it is fair to tell people what we know about self-removal as well as the limitations of what we know, without medical-legal trouble.
Q: Would you recommend self-removal during menses?
A: While the people in our data set recommended self-removal during menses, many people removed not during menses. We don’t have quantitative data to say that attempting removal during menses is more effective or more comfortable. Given what we know about IUD insertion (that insertion during menses might be helpful or more comfortable, but not required), giving that same recommendation regarding timing is probably fair.
Q: Any Information on IUD type in the position/data collected in your study with Dr. Stimmel?
A: We did not extract the data about which IUD (when that was offered) to look at any differences with respect to positions or outcomes of self-removal attempts.
Q: Can you go into the risk of expulsion during the use of menstrual cups?
A: There have certainly been reports of IUD expulsion caused by removal of menstrual cups. In a study looking at expulsion rates among people using different menstrual products (pads, tampons, menstrual cups) there was no statistical difference in expulsion between users of these products (Wiebe and Trouton, Contraception, 2012).
Because the suction created by menstrual cups, a colleague suggested to me that menstrual cups could be recommended for self-removal, but this has not yet been explored as far as I know.
A: (from David Hubacher) Some research suggests there may be an association. See recent ACOG abstract: https://journals.lww.com/greenjournal/Abstract/2020/05001/Menstrual_Cup_Use_and_Intrauterine_Device.3.aspx
Q: Is there any pushback from providers to counsel patients about self-removal since they would lose a billable visit for IUD removal?
A: The providers in our study were residency faculty practicing at an FQHC in the Bronx, and this was not a common concern with them. However, I can imagine this being more of a concern with providers in different settings.
Questions for both Dr. Amico and Diana Green Foster
Q: Do you have any concerns about self-removal, especially in the LMIC context or areas where STI and other vaginal infections may be high. In addition, is there any concern that the removal appointment is an important opportunity for provider contact and self-removal would remove that opportunity for healthcare provisions for other issues ?
A: Amico: I do not have any concerns about uterine infection resulting in self-removal attempts. This was not mentioned in the data as an outcome. Also, since self-removal (and provider-removal) does not require instrumentation into the cervix at all, this clinically would not be a concern.
A: Amico and Foster: We need to keep in mind that people can discontinue most other reversible contraceptives without seeing a clinician first. Self-removal simply makes IUD discontinuation as accessible as discontinuation of short acting methods. Requiring a visit for IUD discontinuation is like requiring a pap for an oral contraceptives prescription or an IUD insertion: while ideally people will have cervical cancer screening and access to information about effective contraception, it does not make sense to hold one service hostage in order to access another.
Q&A: Gillian Dean, MD, MPH
IUD Care During COVID-19: A United States Case Study
Q: Could you share the current availability of IUDs immediately post abortion at PP sites during COVID? Is it universal or does it vary by site/provider? During COVID it seems that offering contraception at the time of an abortion, delivery or other non contraceptive visit is one way to reduce COVID risk by combining visits.
A: Planned Parenthood (PP) is a federated organization made up of 49 affiliates, each of which oversees a number of health centers in their region. Each of the 49 PP affiliates follows PPFA Medical Standards and Guidelines; however, some clinical practices vary from affiliate to affiliate based on state laws and regulations and other local factors. Most PP affiliates provide immediate post-abortion IUDs. However, a small number of affiliates do not for the following reasons: some providers are not privileged; issues with payment/insurance on the day of abortion; some have separate corporations for abortion and other family planning services.
Q: Who participates in the discussion with the patient regarding whether to schedule a telemedicine or in-person visit? Does the patient speak with a clinician or administrative staff?
A: Whom the patient speaks with initially varies by affiliate; each affiliate has their own staffing model and workflows related to triaging patients to in-person or telehealth care. PPFA created sample workflows and scripts for affiliates to help with this process; however, affiliates are able to customize these tools. At some affiliates, the initial screening for telehealth versus in-person care is by a trained layperson or medical assistant; the call is transferred to a clinician as needed. At some affiliates, clinicians speak with the patient to discuss options for care.
Q: Why is the cost of removal so high? What do PP Clinics typically charge?
A: The cost of IUD removal varies by affiliate and generally falls between $60-150, with the average somewhere in the lower to middle of that range (i.e. <$100). Many affiliates have grants or state programs that allow them to provide removals (and placements) at no charge for eligible patients. Some affiliates offer sliding scales for removal based on a patient’s income.
Q&A: Michael S. Policar, MD, MPH
Changes in LARC Visits During the COVID-19 Public Health Emergency
Q: Can DepoSubQ be used safely and effectively up to 15 weeks?
A: The patient package insert for Depo-SubQ Provera 104 states that the recommended injection interval is every 12-14 weeks. In the United States, national family planning guidelines, including the CDC Selected Practice Recommendations (SPR), have no specific recommendation about extending the DMPA-SQ interval to 15 weeks. However, a number of studies done in Africa with DMPA-SQ that show that its efficacy is equivalent to DMPA-IM, including use with a 15 week injection interval.
Q: For safe LARC insertion or removal – would you recommend a full gear or the minimum of face shield, surgical mask and gloves?
A: Full PPE gear is not recommended for GYN office procedures, assuming that the patient has a negative COVID-19 screening at intake. The clinician doing the IUD or implant placement or removal should use a surgical (or n95) face mask, eye protection, and gloves (for IUD procedures, non-sterile exam gloves can be used as long as “no-touch” technique is used). Any staff members in the room should wear a surgical mask and gloves as necessary when cleaning countertops and other surfaces after the procedure. The patient should wear a surgical mask, or if not available, a cloth face mask or n95 face mask that is brought to the office.
Q: When telehealth is not feasible, what are your thoughts on the safest way to provide counseling to ensure safety and giving the patient the best counseling for an informed choice?
A: Whether a provider has telehealth capability or not, a telehealth visit may not be possible because the patient doesn’t have access to a computer or smartphone, there is poor quality or no internet access, or the patient is concerned about the cost to their mobile phone data plan for an extended smartphone conversation.
When a telemedicine visit with an audio-visual platform is not available, contraceptive counseling, shared decision making, and consent for a procedure can be done telephonically. During the public health emergency, the federal Title X Program, many commercial health plans, and some state Medicaid programs that cover “telehealth visits” (billed with an Evaluation and Management code with a -95 modifier) permit the use of a telephone-only conversation in lieu of the previously required audio/video interaction. Other payers, including certain state Medicaid programs and state family planning programs, do not permit billing for telephone-only visits, in which case counseling can be performed telephonically but not billed.
Be sure to check the telemedicine policies of each of your payers to determine whether telephonic-only visits can be billed and be aware that these policies may be time-limited and will change when the public health emergency is over.
Q: Are there any new IUDs in the pipeline?
A: Yes. A copper IUD called VeraCept is in phase III clinical trials in the U.S. and a similar-framed levonorgestrel IUD (LevoCept) is nearing Phase III trials. Another copper IU&D called the Mona Lisa NT Cu380 Mini is being compared to the Paragard in a U.S. clinical trial
A: (by David Hubacher) The Mona Lisa NT Mini is T-shaped copper device, shaped like a Mirena, but a bit smaller. Too early to know if/when the Mona Lisa NT Mini and the Veracept will be available in the US. Both products are in the final phase of study.
Q: To what extent are patients expressing a desire to delay pregnancy due to the pandemic?
A: To my knowledge, there are no studies yet on this topic