European Journal of Cardiovascular Medicine

The Levonorgestrel Intrauterine Device (LNG-IUD) contains 52 mg levonorgestrel, which is slowly released into the uterine cavity over a period of several years.

It can be used as contraception and has a high rate of contraceptive efficacy (greater than 99%), and it can be used for up to 3-7 years, depending on the brand and specific formulation.

In addition to its contraceptive effect, the LNG-IUD is also effective in managing several gynecological conditions, such as heavy menstrual bleeding, dysmenorrhea, and endometriosis-related pain.

It is also associated with a reduction in the risk of endometrial cancer.

LNG IUD is a effective alternative for patients before surgical management and can prevent morbidity to a great extent.

As the use of LNG IUD have increased to great extent and are proving to be a alternative for hysterectomy the expulsion rates when used for non-contraceptive conditions and any associated factors for a greater rate of expulsion has to be studied further. 

Objective 

To determine the rate of spontaneous expulsion of levonorgestrel IUD in patients for management of gynecological conditions at a tertiary care center. 

To identify factors contributing to increased rate of expulsion of LNG IUD.

Study design

A prospective observational study conducted at Kempe Gowda institute of medical science and research center; Bengaluru was done from January 2023 to April 2024.

Study population

Inclusion criteria

1. Patient with age group more than 25 and less than 55 yrs.
2. All cases of AUB according to PALMCOEIN classification.
3. Spontaneous expulsion of LNG IUD.

Exclusion criteria

1. Voluntary removal of IUD.
2. IUD insertion for contraceptive purpose.
3. Fibroids more than 5 cm and submucosal fibroids.
4. Distorted uterine cavity.

Sample size

levonorgestrel 52 mg IUD was inserted in a total of 56 patients, during the study period out of which 9 patients had spontaneous IUD expulsion within 6 months and 5 patients had IUD removed voluntarily.

A prospective observational study was conducted among patients of all ages with a levonorgestrel 52 mg IUD inserted for abnormal uterine bleeding, on day 8 to day 14 of menstrual cycle based on LMP given by patient.

Patients were also further classified based on uterine pathology if imaging studies identified these pathologies. 

Other variable factors like demographic factors, socioeconomic status, parity, gynecological condition for insertion, comorbidities and symptomatic benefits were recorded.

The criteria for levonorgestrel IUD expulsion were either complete or partial expulsion.

 Expulsion was determined   based on palpation of part of IUD through external os or on lack of visualization of strings.

Confirmed by pelvic ultrasound i.e presence of device in cervical canal or absence of the IUD in the uterus.

Consent was taken from all patients included in study.

Total of 56 patients had IUD inserted during the study period out of which 9 patients had spontaneous IUD expulsion within 6 months and 5 patients had IUD removed voluntarily which accounts to 17.6% IUD expulsion rate.

Comparison based on Age of patient

Majority of patients belonged to 36-45 age group accounting for 47.05 % but there was no significant difference between the expulsion rate in different age groups.

According to study conducted by madden et al expulsion rates were higher in younger age women.

Comparison of IUD expulsion based on socioeconomic status

Majority of patients belonged to upper lower class i.e 33.3 % among them 4 patients had IUD expulsion accounting for 44.4 % of total expulsions was slightly higher but not significant. 

Comparison based on BMI

41.1% of patients belonged to normal BMI with 3 IUD expulsion i.e 33.3%, slightly higher rate of expulsion was seen in obese patients with 13.7% insertion rate and 22.2 % expulsion.

Sara Harris et al 2020, expulsion rates were higher in obese patients

Comparison based on parity

Majority i.e 78.4% of patients were multiparous accounting for 77.7 % expulsion with no significant difference in expulsion rates of primi or multiparous patients

Madden et al – no significant difference in expulsion rates based on parity.

Comparison based on uterine pathology

Majority of cases of IUD insertion was for adenomyosis and fibroids but expulsion rates were significantly high in IUD inserted for fibroids i.e 55% of total expulsion.

Sarah harris et al – higher rate of expulsion in cases of fibroids.

Endometrial biopsy findings

Period of expulsion

66.6 % of expulsions took place within 1 month of IUD placement and rest 33.3 % took place within 2 months. No expulsions happened after 2 months in patients under study

Total of 56 patients had IUD inserted during the study period out of which 9 patients had spontaneous IUD expulsion within 6 months and 5 patients had IUD removed voluntarily.

In the study conducted overall rate of expulsion was 17.6% within 6 months of insertion

The expelled group was compared with the group in various aspects. There was no significant difference in age or socioeconomic status and parity and comorbidities between the two groups.

When BMI was compared obese patients had slightly higher rate of expulsion. Similar results were seen in study conducted by Sarah Harris et al 2020.

When uterine pathologies were compared between the groups there was higher rate of expulsion in patients when inserted for fibroids and was statistically significant. Backed by study done by Sarah Harris et al.

In the study conducted overall rate of expulsion was 17.6% within 6 months of insertion. The levonorgestrel IUD is an effective treatment for various gynaecologic conditions, however, expulsion was higher when inserted for fibroids and in obese women. These findings support previous studies. Future research in this area would help to clarify these results. We should counsel women considering levonorgestrel IUD placement for gynaecological condition as an effective alternate to hysterectomy.

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