61. J Obstet Gynaecol Can. 2010 Jul;32(7):673-8.
Natural family planning: physicians’ knowledge, attitudes, and practice.
Choi J, Chan S, Wiebe E.

SOURCE:
Department of Family Practice, University of British Columbia, Vancouver, BC.

Abstract
OBJECTIVE:
To assess physicians’ knowledge, attitudes, and practice with respect to four evidence-based natural family planning (NFP) methods: Standard Days, cervical mucus, basal body temperature, and the lactational amenorrhea method.

METHODS:
We undertook a cross-sectional survey of a random sample of family physicians and all gynaecologists in British Columbia (n = 460) who have women of reproductive age in their practice, as well as all affiliated residents (n = 239). Main outcome measures were (1) physicians’ attitudes towards NFP and their perceptions of its effectiveness; (2) the relationship between physicians’ demographic factors, their personal experience or beliefs, and their attitudes and knowledge; and (3) how these factors affect the counselling physicians offer their patients.

RESULTS:
The survey response rate was 44%. Only 3% to 6% of physicians had correct knowledge of the effectiveness in perfect use of the NFP methods cited in this study. Fifty percent of physicians who responded mention NFP to their patients as an option for contraception, and 77% of physicians mention NFP as an option to couples trying to conceive. Family physicians and residents were much more likely than gynaecologists or gynaecology residents to mention NFP during counselling. Older physicians were more likely to mention NFP than younger physicians and also had more personal experience with NFP.

CONCLUSION:
Most physicians in our study underestimated the effectiveness of NFP methods, and only a small proportion of physicians provide information about NFP during contraceptive counselling. Physicians need better understanding of modern methods of NFP to provide evidence-based contraceptive counselling to selected highly motivated patients who prefer NFP as a contraceptive choice.

62. Wiebe Ellen R, Najafi Roya, Sohail Naghma, Kamani Alya. Muslim women having abortions in Canada: Attitudes, beliefs and experiences. (2011) Can Fam Phys 57:e134-e138.

Abstract
:
OBJECTIVE:
To improve understanding of the attitudes, beliefs, and experiences of Muslim patients presenting for
abortion. 
Design Exploratory study in which participants completed questionnaires about their attitudes, beliefs, and
experiences.

Setting:
Two urban, free-standing abortion clinics.

Participants:
Fifty-three self-identified Muslim patients presenting for abortion.
 Main outcome measures Women’s background, beliefs, and attitudes 
toward their religion and toward abortion; levels of anxiety, depression,
 and guilt, scored on a scale of 0 to 10; and degree of pro-choice or anti-choice
 attitude toward abortion, assessed by having respondents identify
 under which circumstances a woman should be able to have an abortion.

Results:
The 53 women in this study were a diverse group, aged 17 to 47
 years, born in 17 different countries, with a range of beliefs and attitudes
toward abortion. As found in previous studies, women who were less
 pro-choice (identified fewer acceptable reasons to have an abortion) had
 higher anxiety and guilt scores than more pro-choice women did: 6.9
 versus 4.9 (P = .01) and 6.9 versus 3.6 (P = .004), respectively. Women who
 said they strongly agreed that abortion was against Islamic principles also
 had higher anxiety and guilt scores: 9.3 versus 5.9 (P = .03) and 9.5 versus
 5.3 (P = .03), respectively.

Conclusion:
Canadian Muslim women presenting for abortion come from
many countries and schools of Islam. The group of Muslim women that
we surveyed was so diverse that no generalizations can be made about
them. Their attitudes toward abortion ranged from being completely prochoice
to believing abortion is wrong unless it is done to save a woman’s
life. Many said they found their religion to be a source of comfort as
well as a source of guilt, turning to prayer and meditation to cope with
their feelings about the abortion. It is important that physicians caring
for Muslim women understand that their patients come from a variety
of backgrounds and can have widely differing beliefs. It might be helpful
to be aware that patients who hold more anti-choice beliefs are likely
to experience more anxiety and guilt related to their abortion than prochoice
patients do.

63. Wiebe ER, Trouton KJ  “Does using tampons or menstrual cups increase early IUD expulsion rates?” J Obstet Gynaecol Can 2011;33:S44
Background:
Many IUD users utilize intravaginal menstrual cups or tampons during menses, but no studies have investigated the impact of this practice may have on IUD explosions.
Study Design: retrospective chart survey.
Results: Of the 930 women having IUDs placed and reporting menstrual protection, 10.3% (96) used menstrual cups, 74.2% (690) used tampons and 43.2% (402) used pads (many women reported using more than one method). In the 743 women with adequate follow-up information, there was full or partial expulsion (i.e. part of the IUD in the cervical canal) rate of 2.5% (27) during the first 6 weeks after insertion.  There was no difference in the women using cups, tampons or pads (confidence intervals overlap).
Conclusions: From this study, there is no evidence that women who report using menstrual cups or tampons for menstrual protection had higher rates of early IUD expulsion.

64. Wiebe E  Barriers to access and use of contraception in immigrant women presenting for abortion. J Obstet Gynaecol Can 2011;33:S45

Objective:  The purpose of this study was to compare experiences, attitudes and beliefs of immigrants and non-immigrants presenting for abortion with regard to contraception, and to identify difficulties involved in accessing contraception in Canada.
Design: This was a questionnaire survey of immigrant and non-immigrant women and asked about women’s experiences of and attitudes towards contraceptives and any barriers to contraceptive access they have encountered. Demographic data including ethnicity, country of origin and length of residence in Canada was collected.
Setting: Two urban abortion clinics.
Participants: Women presenting for first trimester abortion
Main outcome measures: Type of contraception used when the unwanted pregnancy was conceived, attitudes to contraceptives and barriers to access of contraceptives
Results: There were 999 women who completed questionnaires during the study period (76% response rate) and 466 (46.6%) had been born in Canada. Immigrant women presenting for abortion were less likely to be using hormonal contraception when they got pregnant (12.5% vs 23.5%, p<.001) and had more negative attitudes towards hormonal contraception (62.7% vs 51.6%, p=.002).  They said they had more difficulties accessing contraception prior to the abortion (24.8% vs 15.3%, p<.001) than non-immigrant women. About half of all the women expressed fear about intrauterine contraceptive device (IUD) use. The longer immigrant women had lived in Canada, the more likely they were to respond like Canadian-born women.
Conclusion: The information provided by this study may be valuable for family doctors and other clinicians to improve contraceptive information resources for immigrants to address existing knowledge gaps as well as other culturally relevant concerns. Since about half of all women presenting for abortion expressed negative attitudes to the more effective methods of contraception, it is important that family doctors educate all women at risk for unintended pregnancies.

65. Wiebe E, Hamidizadeh R. Should we be offering follow-up phone-calls for women having abortions? Contraception 2011;84(3):309.
Objective: to determine the feasibility, costs and results of phone follow-up of abortions by a counsellor
Method: A chart review of patients at an abortion clinic was done to assess the follow-up program which consisted of an optional follow-up phone call by a counsellor 2-4 weeks post-abortion. Data collected included demographics, follow-up call requests, actual calls, referrals and patients’ satisfaction. The costs of the program were calculated.
Results: During the study period May-Oct 2009, the clinic saw 936 women for abortions. 161 requested follow-up phone calls (17.3%). Women who requested the calls had higher anxiety and were less likely to be white/Caucasian than women who did not request calls. There were 112 follow-up phone calls recorded (69.7% of requests, 12.0% of total). The counsellor spent an average of 7.7 minutes on each call with a range of 1-20 minutes. She made an average of 2.5 calls to each woman with a range of 1-6 calls. Four women reported serious emotional difficulties, one reported physical problems and nine received a specific referral for a problem. Most (97%) of the women said they found the phone call helpful. The program was feasible, because it required no change other than the regular counsellor asking each woman if she wanted a follow-up call. The counsellor spent about 10 hours per month doing the calls and this cost the clinic $1.06 per patient.
Conclusion: It is feasible and inexpensive to offer every woman having an abortion a follow-up call by a counsellor. Women who accessed this service found it helpful, even though few had serious problems.

66. Wiebe ER, Byzcko B, Johnson M. Benefits of manual vacuum aspiration for abortion 2011 Int J Gynecol Obstet;114:155-6

Manual vacuum aspiration (MVA) was designed for low-resource settings and has been found to reduce costs compared to electric vacuum aspiration (EVA) for abortion. [1]  For MVA, a plastic re-usable syringe such as Ipas is used. [2] A systematic review of ten trials comparing MVA to EVA found no statistically significant differences in complete abortion rate or participants’ satisfaction; less blood loss and less severe pain were reported during the MVA procedures. [3] These findings have led to an increase in MVA use in high resource settings; a survey of National Abortion Federation clinics in the US and Canada found that 49% of abortion providers selectively utilize MVA. [4]
Most licensing bodies require that the tubing used for EVA is discarded after each use. This is based on international standards, such as those by the Center for Disease Control (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, which states that “A reused single-use device will have to comply with the same regulatory requirements of the device when it was originally manufactured.” [5]

Our free-standing urban abortion clinic started using MVA for all procedures under 10 weeks gestation (69 days) in 2008. Each set of tubing for EVA weighs 293 g. In 2009, we did 2255 MVA procedures under 10 weeks gestation resulting in 660kg less plastic tubing discarded. Our Ipas syringes are re-processed using accelerated hydrogen peroxide, so the by-products are only water and oxygen. Each syringe weighs 108 gms. We have 15 syringes which last approximately 3 years each, resulting in about 0.5 kg of plastic syringes discarded each year.

The cost of the tubing we would have discarded for these 2255 cases was $14,094 ($6.25 x 2255). The cost of the discarded syringes was about $250 (5 x $50). The cost of the reprocessing solution was $510 ($10/week x 51 weeks). The cost for staff time to reprocess each syringe for each case by taking the pieces apart, rinsing, placing it in the solution for 5 minutes, drying and reassembling the unit was $4510 ($25/hr x 5 min x 2255). The cost savings for using MVA instead of EVA for one year was $8,824 ($14,094 – $4510 – $250 – $510).

MVA is equally effective compared to EVA in early gestations and has women-centered benefits related to pain and bleeding. It is also less expensive and causes less damage to the environment. MVA should be recommended in early gestations for abortion and completion of miscarriage.

67. Wiebe ER, Kaczorowski J, MacKay J.  Why are response rates in surveys of clinicians declining? Can Fam Phys 2012 vol. 58 no. 4 e225-e228

68. Wiebe ER. Who uses anal sex for birth control? Int J Gynaecol Obstet. 2012 May;117(2):185-6.
Discussion of anal sex in medical literature is usually related to risk-taking for sexually transmitted infections (STI). In a population of university students, 23% of subjects had anal sex in the past year. Anal sex was associated with more sexual risk-taking but not related to ethnicity [1]. Older women were more likely to have experienced anal sex (51%) than teens (31%) [2]. The majority valued anal intercourse as a negative experience. Women who reported that their partners made the decisions about sex and contraception had increased probability of having had anal sex [3].
Anal sex used for contraception is rarely mentioned in medical literature. A study of adolescent sexual behavior reported that teens involved in a casual relationships were more likely to use anal intercourse as a form of contraception (41.2% vs. 8.5%, P = 0.0022).[4]
The purpose of our study was to determine the rate, characteristics and experience of women who said they had used anal sex as a method of contraception.
This was a questionnaire survey of women presenting for abortion at an urban abortion clinic asking about women’s usage and experiences of natural family planning methods including anal sex. This project was approved by the University of British Columbia Behavioural Research Ethics Board H10-00260.
There were 999 completed questionnaires (response rate 76%). They had been born in 75 different countries with 466 (46.6%) born in Canada; 415 (41.5%) self-identified their ethnicity as white/Caucasian, 256 (25.6%) as East Asian, 183 (18.3%) as South Asian and the rest as “other”. There were 888 women (67.5%) who answered the questions about anal sex and 54 (6.1%) said they had used anal sex for birth control. Of these 54 women, 41 (75.9%) had been born in Canada and 36 and only five had lived in Canada less than 5 years. They were younger and had had more previous abortions than the other women (Table 1). Eleven of the 54 (20.8%) said they disliked anal sex.
Although all women are asked about previous use of contraception when they present to our clinic for abortion, until we asked this specific question, none of the staff were aware of patients who said they had used anal sex as birth control. Our impression that this was a traditional practice used by certain immigrant groups was not confirmed since it was mostly younger, non-immigrants who said they used anal sex for birth control. It is possible they are more comfortable revealing this on a questionnaire.

69. Wiebe ER. (Invited commentary) Adolescent girls undergoing medical abortion have lower risk of haemorrhage, incomplete evacuation or surgical evacuation than women above 18 years old. Evid Based Med. 2012 Feb;17(1):30-1.

70. Wiebe ER, Brotto L, MacKay J. Characteristics of women who complain of mood and sexual side effects from hormonal contraception. J Obstet Gynaecol Can 2011:33;1234-40
Background:
Sexual and mood side effects have been shown to be among the most common reasons for changing or quitting hormonal contraception and yet are either not listed in many drug reference sources or listed with a prevalence of less than 1%.
Study Design:
This was a retrospective questionnaire survey of women presenting for primary care or to a reproductive health clinic. The women were asked if they had specific side effects related to desire, arousability, irritability, etc on any previous hormonal contraceptives used.
Results:
Of the 1243 women recruited (mean age 28 years), 77% (954) had previously used hormonal contraception. Of these women, 51% (482) said they had at least one mood side effect and 38% (358) said they had at least one sexual side effect.
Conclusions:
A large proportion of these women reported sexual and mood side effects from hormonal contraception. It is important that physicians help women choose contraception which is not only effective, but also does not complicate their emotional and sexual lives.

71. Wiebe ER, Trouton KJ. Does using tampons or menstrual cups increase early IUD expulsion rates? Contraception. 2012 Aug;86(2):119-21
Background:
Many intrauterine device (IUD) users utilize intravaginal menstrual cups or tampons during menses, but no studies have investigated the impact this practice may have on IUD expulsions.
Study Design:
Retrospective chart survey.
Results:
Of the 930 women having IUDs placed and reporting menstrual protection, 10.3% (96) used menstrual cups, 74.2% (690) used tampons, and 43.2% (402) used pads (many women reported using more than one method). In the 743 women with adequate follow-up information, there was a full or partial expulsion (i.e., part of the IUD in the cervical canal) rate of 2.5% (27) during the first 6 weeks after insertion. There was no difference in the women using cups, tampons or pads (confidence intervals overlap).
Conclusions:
From this study, there is no evidence that women who report using menstrual cups or tampons for menstrual protection had higher rates of early IUD expulsion.

72. Wiebe ER, Kaczorowski J, MacKay J. Mood and sexual side effects of hormonal contraception: Physicians’ and residents’ knowledge, attitudes, and practices. Can Fam Phys 2012;58:e677-83.

73. Wiebe ER, Yager H, Chalmers A. Delayed motherhood: Understanding the experiences of women over age 33 who are having abortions, but plan to become mothers later. Can Fam Phys 2012 58: e588-e595
Objective:
To examine women who are delaying motherhood by having abortions.
It is important to understand the trend to have children later in life, because there are many implications, including increased rates of C-section, pregnancy-induced hypertension, pre-term birth, low-birth-weight and infertility.
Methods:
We used a mixed methods design including a chart survey, questionnaires and in-depth interviews. The questionnaire asked the reasons for the abortion, plans for future pregnancies, factors used when deciding to have children as well as demographics. Interviews with women over 35 explored in depth the reasons for delaying motherhood.
Results:
In the 1118 completed questionnaires, 30% (334) were over 33 and 26% (87) of these had no children. Of these, 54% (47) planned children in the future and 28% (24) were unsure. The most common reason for having an abortion was that they were “just not ready” (59%). The most important factor in deciding to have children was their relationship. The most striking themes in the interviews were the women’s uncertainty about childbearing and their focus on the quality of their relationships.
Conclusions:
This study contributes additional insight into the uncertainty older nulliparous women experience around childbearing and their primary focus on relationships rather than children.

74. Wiebe ER, Kaczorowski J, Byczko B. Can we safely avoid pre-procedure fasting for abortions with low-dose moderate sedation? A retrospective cohort chart review of anesthesia-related complications in 47,748 abortions. Contraception 2013;87:51-54.
Background:
Some licensing authorities require fasting before abortions under intravenous sedation, to avoid aspiration of gastric contents.
Objective:
To estimate the incidence of anesthesia-related complications in women undergoing abortions without pre-procedure fasting.
Study Design:
Retrospective cohort chart review of patients having abortions with both fentanyl and midazolam at two urban free-standing abortion clinics with routine policy of advising women to eat a light meal before the procedure.
Results:
There were no reports of anesthesia-related complications in the 47,748 charts reviewed from 1998-2010. Applying Hanley’s formula for rare events that have not occurred, the upper 95% confidence interval for the true incidence of anesthesia-related complications for women having abortion under low dose procedural sedation without fasting was estimated to be 0.00006%.
Conclusions:
This large retrospective cohort chart review identified no complications related to low dose proceduralsedation in over 47,000 consecutive non-fasting patients having abortions through 18 weeks’

75. Wiebe ER. Contraceptive practices and attitudes in immigrant and non-immigrant women in Canada. Can Fam Phys 2013;59(10):e451-5.
Objective: 
The purpose of this study was to compare experiences, attitudes and beliefs of immigrants and non-immigrants presenting for abortion with regard to contraception, and to identify difficulties involved in accessing contraception in Canada
Design:
This was a questionnaire survey of immigrant and non-immigrant women and asked about women’s experiences of and attitudes towards contraceptives and any barriers to contraceptive access they have encountered. Demographic data including ethnicity, country of origin and length of residence in Canada was collected.
Setting:
Two urban abortion clinics.
Participants:
Women presenting for first trimester abortion
Main outcome measures: Type of contraception used when the unwanted pregnancy was conceived, attitudes to contraceptives and barriers to access of contraceptives
Results:
There were 999 women who completed questionnaires during the study period (76% response rate) and 466 (46.6%) had been born in Canada. Immigrant women presenting for abortion were less likely to be using hormonal contraception when they got pregnant (12.5% vs 23.5%, p<.001) and had more negative attitudes towards hormonal contraception (62.7% vs 51.6%, p=.002).  They said they had more difficulties accessing contraception prior to the abortion (24.8% vs 15.3%, p<.001) than non-immigrant women. About half of all the women expressed fear about intrauterine contraceptive device (IUD) use. The longer immigrant women had lived in Canada, the more likely they were to respond like Canadian-born women.
Conclusion:
The information provided by this study may be valuable for family doctors and other clinicians to improve contraceptive information resources for immigrants to address existing knowledge gaps as well as other culturally relevant concerns. Since about half of all women presenting for abortion expressed negative attitudes to the more effective methods of contraception, it is important that family doctors educate all women at risk for unintended pregnancies.

76. Wiebe E, Littman L. Misconceptions about abortion risks in pro-choice and anti-choice women having abortions. Contraception 2012;86:303.

77. Wiebe E, Yousefi R, Ramji F, Isbister A, Trouton K. How can we best train primary care providers to insert IUDs? Contraception 2012;86:321-2.

78. Wiebe E, Trouton K. Women’s perceptions of viewing ultrasound before abortion: comparing first and second trimester. Contraception 2012;86:321.

79. Wiebe ER. Broken IUD. J Obstet Gynaecol Can. 2012 Dec;34(12):1121.

80. Wiebe ER. Invited Commentary: How can we reconcile the findings of this study “Hormonal contraception use is associated with reduced depressive symptoms: A national study of sexually active women in the US” with the experience of our patients in clinical practice? American Journal Of Epidemiology 2013 doi: 10.1093/aje/kwt186.
Although the accompanying study by Keyes et al. (Am J Epidemiol. 2013;178(9):1378–1388) shows us that women currently using hormonal contraception (HC) have better scores on the Center for Epidemiologic Studies Depression Scale and report fewer suicide attempts, it does not show us that HC protects women from mood disorders or that HC is free of the mood-related side effects which cause high rates of discontinuation. The groups compared in the Keyes et al. study were different in many ways; the women using HC were younger, were more likely to engage in positive  health behaviors, and had lower depression scores at each prior interview. Women with mood disorders are more likely to avoid or discontinue HC and more likely to experience worsening mood while on HC. The negative mood-related side effects experienced by women using HC (irritability and lability) are not captured by a screening tool for clinical depression, such as the depression scale used in this study. The database used in this study was longitudinal and multiwave, so the authors could have compared changes in depressive symptoms among women who switched from hormonal to nonhormonal contraceptive methods (and vice versa) across different waves. Only if the same women experienced greater levels of depressive symptoms after discontinuing HC and fewer symptoms when they restarted HC could we conclude that HC may protect women from mood disorders.

81. Wiebe ER. Use of telemedicine for providing medical abortion. Int J Gynaecol Obstet 2013;07:038
Telemedicine has been used to provide abortion in several ways. The website “Women on Web” uses e-mail support to facilitate the provision of medical abortion to women in situations in which safe abortion is not available. Some US clinics offer medical abortions in which the patients see a counselor in the clinic but see the doctor via videoconferencing. Routine ultrasound is usually used to date the pregnancy and determine abortion success in North America but serial quantitative human chorionic gonadotropin (hCG) values can also be used. Because mifepristone is not available in Canada, the usual regimen is methotrexate (50 mg/m2) followed by misoprostol (800 μg vaginally) repeated twice 4–12 hours later. This regimen has a similar success rate to that of mifepristone plus misoprostol.
We conducted a retrospective chart review of women who underwent medical abortion via telemedicine between May 1, 2012, and May 1, 2013, at Willow Women’s Clinic, Vancouver, Canada. The study was approved by the Research Ethics Board at the University of British Columbia, Vancouver, Canada. To be eligible for a telemedicine abortion at the study clinic, women must live in British Columbia (where the clinic physicians are licensed); have access to a laboratory for timely serum quantitative hCG estimations; and be able to travel to the clinic or to another community facility for surgical completion, if necessary. They see a physician and counselor via Skype (Microsoft Skype Division, Luxembourg City, Luxembourg) videoconferencing for screening, information, and consent. The women go to a local laboratory for hCG tests at initial screening, on the day of the medication, and 1 week later (3 tests). If their hCG level is above 5000 mIU/mL, an ultrasound is arranged. Rhesus-negative women are offered anti-D; this is arranged through a local facility. The medications are couriered or a prescription is faxed to a local pharmacy. Women have a follow-up videoconferencing appointment to discuss their blood test results and any reactions to the medications. If their hCG level has fallen by 80% in 1 week, women are informed that the abortion is complete and that they require no further follow-up. If additional medication, surgery, or further blood tests are required, they are arranged by the clinic.
Between May 2012 and May 2013, 11 women underwent medical abortion via telemedicine at the study clinic. One woman experienced spontaneous abortion with no medication, 1 woman required surgical completion, and 1 woman was lost to follow-up; the other women experienced uneventful medical abortion. During the study period, a further 29 women were seen in-clinic for their first visit and ultrasound, with scheduled videoconferencing for follow-up; in addition, 1858 women made regular in-clinic visits.
The main innovation with regard to this program is that we see patients in their own homes using their own technology (a computer or smart phone), yet provide the same physician and counseling services as we do in the clinic. This method of providing abortion via telemedicine is feasible in the present setting and may improve access to abortion.

82. Wiebe ER, Littman L, Kaczorowski J, Moshier E. Misperceptions about the risks of abortion in women presenting for abortions: Comparing women who believe abortions should be restricted to women who do not. J Obstet Gynaecol Can 2014, 36, 3, 223-230.
Objective:
Misinformation that exaggerates the risks and sequelae of abortion is common. The purpose of this study was to examine whether women having abortions who believe that there should be restrictions to abortion (i.e. that some other women should not be allowed to have abortions) also believe this misinformation about the health risks associated with abortion.

Methods:
A cross-sectional survey of consecutive women presenting for abortions at an urban abortion clinic in Vancouver BC (Canada) between February and September 2012.

Results:
Of 1008 women presenting for abortion, 978 completed questionnaires (97% response rate) and 333 (34%) favored abortion restrictions. More women who favored restrictions believed that an abortion had the same or more health risk than birth (84.2% vs 65.6%, p=<0.0001), that abortion caused mental health problems (39.1% vs 28.3%, p=0.0007) and that abortion caused infertility (41.7% vs 21.9%, p=<0.0001). Using multivariate logistic regression analyses, believing abortion should not be restricted was found to be a significantly correlated with correct answers about health risks, mental health problems and infertility.
Conclusions:
Beliefs about exaggerated risks of abortion are common among women having abortions. Women presenting for abortions who favored restrictions to abortion have more misperceptions about abortion risks than women who favor no restrictions.

83. Wiebe ER. Pain of IUD insertion: A comparison of different IUDs. Euro J Contracept Reprod Health Care, 2014; 19 Supplement 1: S92–S239

84. Wiebe ER IUD strings: A comparison of male partners’ reactions to different IUDs. Euro J Contracept Reprod Health Care, 2014; 19 Supplement 1: S92–S239 85. Wiebe ER Post-abortion insertion of frameless copper IUDs: A comparison of early expulsion rates of IUDs inserted immediately post-abortion or at unrelated times Euro J Contracept Reprod Health Care, 2014; 19 Supplement 1: S92–S239
BACKGROUND:
Other studies with other IUDs have found inconsistently higher early expulsion rates with immediate insertion, but fewer unintended pregnancies in the following year compared with women who planned later insertions (1). Since the frameless IUD is anchored within the myometrium, it may be less likely to be expelled with uterine contractions typical after an abortion (2).
OBJECTIVES:
The purpose of this study was to compare the early expulsion rates and other complications in frameless copper IUDs (GyneFix Viz) inserted immediately after first trimester surgical abortions to those inserted into women unrelated to pregnancy.
METHODS:
This was a prospective chart review of women who had IUDs inserted by five experienced physicians in two clinics between February and December of 2013. The gestational age limits for abortions at the clinics were 10 and 14 weeks. At a follow-up visit 6-8 weeks post-insertion, ultrasound and pelvic examinations were performed. Women who did not come in for the follow-up visit were contacted by phone or email. We compared rates of expulsion, infection, perforation, pregnancy and removal.
RESULTS:
There were 153 women who had the IUDs inserted post-abortion with follow-up data on 122 (79.7%) and 493 who had insertions unrelated to abortion with follow-up data on 423 (85.8%). The two groups were similar with respect to mean age (28.3 vs 29.1 years) and history of dysmenorrhea (worst period pain score 5.2/10 vs 5.1/10). The women in the post abortion group were more likely to have had births (41.3% vs 17.9%). There were no significant differences with respect to expulsion rates or other complications. The post abortion group had 5 expulsions (4.1%), 4 removals (3.3%) and one perforation (0.8%). The unrelated group had 6 expulsions (1.4%), six removals (1.4%), four perforations (0.9%) and one infection (0.8%). One removal was in a woman who wanted to get pregnant, one because she didn’t like the idea of a foreign body in her uterus and the others for pain and bleeding. The women who had perforations had the IUDs removed with a laparoscope and had no further complications.
DISCUSSION: Complications rates are so low after IUD insertion that over 1100 subjects in each group would be required to compare rates of expulsion of 2% difference with a power of .80 and α of .05. This study with only 152 women in the post-abortion group and 493 in the unrelated group can only show differences of greater than 6%. The rate of perforation is close to 1% and higher than we would expect with experienced providers. This may be related to the different insertion technique compared to traditional IUDs.
CONCLUSIONS: This study gives us some reassurance that frameless copper IUDs can be a good choice for insertions immediately post abortion. 86. Wiebe ER, A comparison of the insertion pain associated with three different types of intrauterine device, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.11.004 SYNOPSIS: A chart review comparing the pain scores of insertion of three types of IUDs, LNG-IUS, copper T IUDS and frameless IUDs, found no important differences   Pain control for IUD insertion is important because fear of that pain may prevent some women from getting highly effective long-acting reversible contraception. A review of IUD insertion pain management stated “No interventions that have been properly evaluated reduce pain during or after IUD insertion.”[1] Topical lidocaine may help for tenaculum placement, NSAIDs may reduce pain during the 2 hours after insertion and misoprostol may make the insertion easier from the providers’ viewpoint. A review of local anesthesia in cervical dilation and uterine intervention found mixed results. [2].The risk factors for increased pain include nulliparity (or no vaginal births) age<20 years. [3] The purpose of this study was to compare the pain scores of insertion of three types of IUDs, LNG-IUS, copper T IUDS and frameless IUDs This was a retrospective chart review of women who had IUDs inserted in one clinic between February and September 2013 and included women in a clinical trial of frameless copper IUDs. We compared the pain of insertion of LNG-IUS (Mirena, Bayer Inc), copper T (Liberté TT 380 and UT 380, 7 Med) and frameless copper (GyneFix Viz 200) IUDs. The women rated the pain of insertion on a scale of 0-10 with 0 being no pain and 10 being the worst possible pain. Data was entered into SPSS (IBM SPSS 22) and the three groups were compared using chi-squares, with a p-value <.05 being considered significant. Logistic regression was used to assess significant predictors of severe pain. UBC Research Ethics Board approval was received. Pain scores were recorded for 199 LNG-IUS, 154 copper T and 317 frameless IUD insertions, representing 89.5%, 84.8% and 95.5% IUDs inserted during the study period. For pain control, 99.7% of the women took ibuprofen 400-800 mg, 1.1% took misoprostol 400 mcg pv 3 hours prior, 1.9% took 5-10 mg oxycodone, 1.9% took 1-4 mg lorazepam and 99.7% had local anesthesia (5-10cc lidocaine 0.5-1%). There were no significant differences in pains scores between the three different IUDs. Using logistic regression, no vaginal births and dysmenorrhea remained significant predictors of severe pain (8-10), but the three different IUDs and age were not significant. The odds ratio for severe pain (8-10) with no vaginal birth compared to any vaginal birth was 5.2 and the odds ratio of having severe pain if there was a history of dysmenorrhea (8-10) was 3.0. In conclusion, there were no important differences in the pain scores of inserting different IUDs. No previous vaginal births and dysmenorrhea were the best predictors of severe pain. The author has no conflict of interest to declare. [1] Allen RH, Bartz D, Grimes DA, Hubacher D, O’Brien P. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD007373. doi(3):CD007373. [2] Tangsiriwatthana T, Sangkomkamhang US, Lumbiganon P, Laopaiboon M. Paracervical local anaesthesia for cervical dilatation and uterine intervention. Cochrane Database Syst Rev. 2013 Sep 30;9:CD005056. [3] Hubacher D, Reyes V, Lillo S, Zepeda A, Chen PL, Croxatto H. Pain from copper intrauterine device insertion: Randomized trial of prophylactic ibuprofen. Am J Obstet Gynecol. 2006 Nov;195(5):1272-7. 87. Wiebe ER, A comparison of male partners’ reactions to different intrauterine device strings, Int J Gynecol Obstet (2014),http://dx.doi.org/10.1016/j.ijgo.2014.09.020 SYNOPSIS: A survey of 873 women found that 6.7% with LNG-IUS, 2.3% with copper Ts and 18.2% with frameless IUDs reported partners bothered by the strings.
The purpose of this study was to compare male partners’ reactions to the IUD strings of three types of IUDs. Usually partners reactions to strings are not mentioned as side effects of IUDs, but one study found that 3% of women discontinued IUDs due to “partner dissatisfaction” [1] and another found that 9% of women reported that “partners felt strings” [2]. This was a retrospective chart review of women who had IUDs inserted in one clinic and included women in a clinical trial of frameless copper IUDs plus other women that had IUDs inserted during the same timeframe of April to December of 2013. At a follow-up visit 6-8 weeks post-insertion, women were asked if their partners noticed or were bothered by the IUD strings. We compared the answers for the three different types of IUDs (LNG-IUS, Mirena by Bayer, copper T, Liberte UT380 and TT380 by 7-Med, frameless, GyneFix Viz by Contrel). This study was approved by UBC REB. There were 1266 women who had follow-up visits 6-8 weeks after IUD insertion, of which 951 (75.1%) answered the question about strings. We excluded the 78 women who had not had sex since the insertion, leaving 873 charts for analysis. Of these, 180 had LNG-IUS, 128 had copper T IUDs, and 565 had frameless copper IUDs. There were 118 women (13.5%) who said their partners were bothered by the strings and 113 women (13.4%) who said their partners noticed the strings but were not bothered. There was a significant difference between the three types of IUDs; male partners had not noticed the strings in 154 (85.6%) women with LNG-IUS, 119 (93.0%) women with copper T IUDs and 369 (65.3%) women with frameless copper IUDs (p<.001). The five doctors in our clinic managed these string complaints with reassurance that it would improve with time in 40 (34.2%) women, shortening the string in 33 (28.2%) women, tucking the string up inside the cervix in 34 (29.1%) women or both shortening and tucking in 10 (8.5%) women. In this sample, 13.5% of the women reported that their partners said the IUD strings bothered them during sex. This was more likely with frameless copper IUDs than with LNG-IUS or copper T IUDs. It is likely that the stiffer string of the frameless copper IUD is causing this problem. Clinicians must be aware of how to manage the strings, including tucking them into the cervix.
References:
1. Aoun J, Dines VA, Stovall DW, Mete M, Nelson CB, Gomez-Lobo V. Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol. 2014 Mar;123(3):585-92. 2. Lara-Torre E, Spotswood L, Correia N, Weiss PM. Intrauterine contraception in adolescents and young women: A descriptive study of use, side effects, and compliance. J Pediatr Adolesc Gynecol. 2011 Feb;24(1):39-41.  

88. Wiebe E. The feasibility of offering medical abortions by telemedicine: 20 months of experience. Contraception 2014;90:s300.

89. Wiebe E. A comparison of early complication rates in three IUDs — LNG-IUS, copper T and frameless copper. Contraception 2014;90:s312. 90. Wiebe E. Serosal-anchor measurements immediately and 6–8 weeks postinsertion of frameless copper intrauterine devices: are these related to early complications? Contraception 2014;90:s312.
OBJECTIVES:
The purpose of this study was to determine if the position of the anchor of the frameless IUD (GyneFix-Viz) on ultrasound post insertion was related to early complications.
METHODS:
This was a prospective observational study of serosal-anchor (SA) measurements done by endovaginal ultrasound immediately post-insertion. At follow-up 6-8 weeks later, ultrasound examinations were performed.
RESULTS:
There were follow-up data available on 724 of 828 women (87.4 %). There were 37 early complications including 15 expulsions (2.1%), 9 perforations (1.2%), 11 removals (1.5%), one minor infection requiring oral antibiotics (0.1%) and one pregnancy (0.1%). There was a positive relationship between SA distance and the odds of expulsion (OR = 1.29, 95%CI = 1.06 -1.53, p = 0.01); every increase in 1mm of SA distance corresponded to an increase of 29% in the odds of expulsion.
CONCLUSIONS:
Measuring the SA distance with ultrasound was feasible with the GyneFix Viz, and was predictive of expulsion.