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Trends in use of and complications from intrauterine contraceptive devices and tubal ligation or occlusion

  • Brandon Howard1Email author,
  • ElizaBeth Grubb2,
  • Maureen J. Lage3 and
  • Boxiong Tang4
Reproductive Health201714:70

https://doi.org/10.1186/s12978-017-0334-1

Received: 24 August 2016

Accepted: 30 May 2017

Published: 8 June 2017

Abstract

Background

Long-acting reversible contraceptives such as intrauterine devices (IUDs) are highly effective in preventing pregnancy, cost effective, and increasing in popularity. It is unclear whether changes in IUD use are associated with changes in rates of irreversible tubal sterilization. In this analysis, we evaluate changes in rates of tubal sterilization, insertion of copper or levonorgestrel (LNG) IUDs, and related complications over time.

Methods

Data were obtained from a retrospective claims database (OptumTM ClinformaticsTM Data Mart) of women aged 15 to 45 years who underwent insertion of copper or LNG IUD or tubal sterilization between 1/1/2006 and 12/31/2011. Outcomes of interest included annual rates of insertion or sterilization and annual rates of potential complications and side effects.

Results

The number of women included in the analysis each year ranged from 1,870,675 to 2,016,916. Between 2006 and 2011, copper IUD insertion claim rates increased from 0.18 to 0.25% and LNG IUD insertion claim rates increased from 0.63 to 1.15%, while sterilization claims decreased from 0.78 to 0.66% (P < 0.0001 for all comparisons). Increases in IUD insertion were apparent in all age groups; decreases in tubal sterilization occurred in women aged 20 to 34 years. The most common side effects and complications were amenorrhea (7.36–11.59%), heavy menstrual bleeding (4.85–15.69%), and pelvic pain (11.12–14.27%). Significant increases in claims of certain complications associated with IUD insertion or sterilization were also observed.

Conclusion

Between 2006 and 2011, a decrease in sterilization rates accompanied an increase in IUD insertion rates, suggesting that increasing numbers of women opted for reversible methods of long-term contraception over permanent sterilization.

Keywords

Copper IUD Levonorgestrel IUD Tubal sterilization

Plain English summary

Long-acting reversible contraceptives such as intrauterine devices (IUDs) are among the most effective options for preventing pregnancy, and their popularity is increasing. However, whether changes in IUD use are associated with changes in rates of tubal sterilization, a largely irreversible and permanent contraceptive option, is unclear. In this study, we evaluated changes in rates of tubal sterilization, insertion of two different types of IUDs (copper or levonorgestrel [LNG] IUDs) and side effects associated with these devices over time. Data were obtained from an insurance claims database that included women aged 15 to 45 years who underwent insertion of copper or LNG IUD insertion or tubal sterilization between 1/1/2006 and 12/31/2011. Approximately 2 million women were included in the database each year. Between 2006 and 2011, copper IUD insertion rates increased from 0.18 to 0.25% and LNG IUD insertion rates increased from 0.63 to 1.15%, while sterilization claims decreased from 0.78 to 0.66%. Increases in IUD insertion were apparent in all age groups; decreases in tubal sterilization occurred in women aged 20 to 34 years. Results from our study suggest that increasing numbers of women are opting for copper and LNG IUDs over permanent sterilization.

Background

Intrauterine devices (IUDs) are the most common method of reversible contraception [1, 2], used by approximately 14.3% of reproductive-aged women worldwide [3]. However, they are used only by 6.4% of American women using contraception [4]. Two commonly used IUDs in the US include the copper T380A IUD (copper IUD) and the levonorgestrel 20-mcg-releasing intrauterine device (LNG IUD). Both IUDs have been shown to be cost effective, have few contraindications, and are well tolerated [59].

Although the use of both IUDs is low in the US compared with the rest of the world, data suggest that use has substantially increased in recent years [10, 11]. Factors that may affect IUD use, including changes in rates of tubal sterilization, complications, or side effects have not been investigated.

In this report, we compare the use and complications associated with the copper IUD, LNG IUD, and tubal sterilization using data obtained from the Optum™ Clinformatics™ Data Mart database.

Methods

The Optum™ Clinformatics™ Data Mart database is a large database of medical claims, pharmacy claims, lab results, and administrative data that contains information on patient characteristics, inpatient and outpatient encounters, and outpatient prescription drug coverage throughout the US. The database includes approximately 13 million unique individuals each year. Most individuals included in the database are commercially insured. The database is fully compliant with the Health Insurance Portability and Accountability Act.

This study evaluated claims from January 1, 2006, to December 31, 2011, among women aged 15–45 years as of the index date, defined as the insertion date of copper IUD (Healthcare Common Procedure Coding System [HCPCS] code J7300) or LNG IUD (HCPCS code J7302), or date of sterilization by tubal ligation/tubal occlusion, based on receipt of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 66.2 or 66.3 or Current Procedure Terminology codes 58600, 58605, 58611, 58615, 56870, or 56871.

Outcomes of interest included the rate of copper IUD insertion, LNG IUD insertion, and tubal sterilization by year (2006–2011) and by age group (ages 15–19, 20–24, 25–34, and 35–45), and changes in rate of potential complications and side effects over time. Complications and side effects were assessed based on receipt of ICD-9-CM codes for the following conditions: uterine perforation, pelvic inflammatory disease, post-insertion infection, dysmenorrhea, heavy menstrual bleeding (HMB), menorrhagia, anemia, ovarian cyst, pelvic pain, and amenorrhea.

All analyses were conducted using SAS®, version 9.3 (SAS Institute Inc., Cary, NC, USA). Chi square analyses were used to analyze categorical variables; analyses of variance were used to evaluate continuous variables. Findings with associated P values <0.05 were considered statistically significant.

Results

The number of women included in the analysis each year ranged from 1,870,675 to 2,016,916. Rates of tubal sterilization decreased and rates of insertion of both copper and LNG IUDs increased between 2006 and 2011 (Table 1, Fig. 1). The percentage of women who underwent tubal ligation/tubal occlusion decreased from 0.78% (14,887/1,907,748) in 2006 to 0.66% (12,560/1,909,316) in 2011 (P < 0.0001), while rates of copper IUD insertion increased from 0.18% (3,454/1,907,748) to 0.25% (4,682/1,909,316) (P < 0.0001) and rates of LNG IUD insertion increased from 0.63% (12,028/1,907,748) to 1.15% (22,035/1,909,316) (P < 0.0001) from 2006 to 2011, respectively.
Table 1

Rate of IUD insertion and tubal sterilization over time

  

Copper IUD

LNG IUD

Tubal Sterilization

Year

Total N

n (%)

n (%)

n (%)

2006

1,907,748

3454 (0.18)

12,028 (0.63)

14,887 (0.78)

 Age 15 to 19 y

293,354

52 (0.02)

216 (0.07)

38 (0.01)

 Age 20 to 24 y

220,950

330 (0.15)

1257 (0.57)

451 (0.20)

 Age 25 to 34 y

566,152

1735 (0.31)

6230 (1.10)

6642 (1.17)

 Age 35 to 45 y

827,292

1337 (0.16)

4325 (0.52)

7756 (0.94)

2007

1,940,301

3803 (0.20)

16,789 (0.87)

14,769 (0.76)

 Age 15 to 19 y

299,599

79 (0.03)

416 (0.14)

42 (0.01)

 Age 20 to 24 y

224,324

403 (0.18)

1813 (0.81)

444 (0.20)

 Age 25 to 34 y

583,955

1964 (0.34)

8533 (1.46)

6471 (1.11)

 Age 35 to 45 y

832,423

1357 (0.16)

6027 (0.72)

7812 (0.94)

2008

2,001,739

4474 (0.22)

24,276 (1.21)

14,667 (0.73)

 Age 15 to 19 y

308,311

102 (0.03)

690 (0.22)

21 (0.01)

 Age 20 to 24 y

237,192

455 (0.19)

2845 (1.2)

410 (0.17)

 Age 25 to 34 y

615,537

2368 (0.38)

12,545 (2.04)

6473 (1.05)

 Age 35 to 45 y

840,699

1549 (0.18)

8196 (0.97)

7763 (0.92)

2009

2,016,916

4868 (0.24)

24,811 (1.23)

14,881 (0.74)

 Age 15 to 19 y

312,431

93 (0.03)

777 (0.25)

37 (0.01)

 Age 20 to 24 y

237,723

460 (0.19)

2920 (1.23)

394 (0.17)

 Age 25 to 34 y

625,323

2578 (0.41)

12,614 (2.02)

6232 (1.00)

 Age 35 to 45 y

841,439

1737 (0.21)

8500 (1.01)

8218 (0.98)

2010

1,870,675

5246 (0.28)

20,639 (1.10)

13,313 (0.71)

 Age 15 to 19 y

289,736

142 (0.05)

677 (0.23)

37 (0.010

 Age 20 to 24 y

222,812

551 (0.25)

2101 (0.94)

243 (0.11)

 Age 25 to 34 y

574,702

2782 (0.48)

10,316 (1.8)

5485 (0.95)

 Age 35 to 45 y

783,425

1771 (0.23)

7545 (0.96)

7548 (0.96)

2011

1,909,316

4682 (0.25)

22,035 (1.15)

12,560 (0.66)

 Age 15 to 19 y

295,377

116 (0.04)

762 (0.26)

24 (0.01)

 Age 20 to 24 y

265,891

601 (0.23)

2648 (1.00)

280 (0.11)

 Age 25 to 34 y

575,729

2451 (0.43)

10,694 (1.86)

5102 (0.89)

 Age 35 to 45 y

772,319

1514 (0.20)

7931 (1.03)

7154 (0.93)

P Value for Trend Over Time in the Overall Population

 

<0.0001

<0.0001

<0.0001

Fig. 1

Rate of claims related to copper IUD insertion, LNG IUD insertion, and tubal sterilization by year of insertion/sterilization

Increases in IUD insertion and decreases in tubal sterilization rates were apparent in most age groups (Table 1, Fig. 2). The greatest decreases in rates of sterilization occurred in women ages 25–34. Although insertion of either IUD in adolescents ages 15–19 was rare, the copper IUD insertion rate doubled and the LNG IUD insertion rate more than tripled in this age group between 2006 and 2011.
Fig. 2

Rate of claims related to copper IUD insertion, LNG IUD insertion, and tubal sterilization by year of insertion or sterilization in women aged 15 to 19 years (a), 20 to 24 years (b), 25 to 34 years (c), and 35 to 45 years (d)

Rates of complications or side effects were low and are shown in Table 2. The most common side effects and complications were amenorrhea (7.36–11.59%), HMB (4.85–15.69%), and pelvic pain (11.12–14.27%). Significant increases over time were observed in rates of perforation of the uterine wall in all groups, HMB and menorrhagia with LNG IUD and tubal sterilization, dysmenorrhea and anemia with sterilization, and ovarian cysts with LNG IUD. A significant decrease in pelvic inflammatory disease was observed over time among women who underwent sterilization.
Table 2

Complications and side effects associated with IUD insertion and tubal sterilization over time

 

Copper IUD

LNG IUD

Tubal Sterilization

Complications/Side Effect

n (%)

n (%)

n (%)

Amenorrhea (ICD-9 626.0)

 Total (2006–2011)

2385 (8.99)ab

9077 (7.53)ac

7050 (11.67)bc

 2006

308 (8.92)

941 (7.82)

1638 (11.00)

 2007

381 (10.02)

1278 (7.61)

1614 (10.93)

 2008

412 (9.21)

1873 (7.72)

1700 (11.59)

 2009

448 (9.20)

1845 (7.44)

1658 (11.14)

 2010

452 (8.62)

1518 (7.36)

1429 (10.73)

 2011

384 (8.20)

1622 (7.36)

1371 (10.92)

P Value

0.0775

0.4191

0.2768

Anemia (ICD-9 280.xx)

 Total (2006–2011)

595 (2.24)b

2832 (2.35)c

2003 (3.32)bc

 2006

67 (1.94)

279 (2.32)

435 (2.92)

 2007

78 (2.05)

386 (2.30)

433 (2.93)

 2008

106 (2.37)

538 (2.22)

492 (3.35)

 2009

119 (2.44)

600 (2.42)

513 (3.45)

 2010

135 (2.57)

512 (2.48)

481 (3.61)

 2011

90 (1.92)

517 (2.35)

469 (3.73)

P Value

0.1496

0.5243

0.0001

Dysmenorrhea (ICD-9 625.3)

 Total (2006–2011)

733 (2.76)ab

3909 (3.24)ac

2491 (4.12)bc

 2006

90 (2.61)

378 (3.14)

587 (3.94)

 2007

85 (2.50)

566 (3.37)

591 (4.00)

 2008

132 (2.95)

723 (2.98)

598 (4.08)

 2009

139 (2.86)

807 (3.25)

647 (4.35)

 2010

137 (2.61)

692 (3.35)

649 (4.87)

 2011

140 (2.99)

743 (3.37)

606 (4.82)

P Value

0.6388

0.1234

<0.0001

Heavy Menstrual Bleeding (ICD-9 626.2)

 Total (2006–2011)

1370 (5.16)ab

10 204 (8.46)ac

7328 (12.13)bc

 2006

204 (5.91)

1048 (8.71)

1687 (11.33)

 2007

198 (5.21)

1406 (8.37)

1750 (11.85)

 2008

224 (5.01)

1846 (7.60)

1922 (13.10)

 2009

256 (5.26)

1992 (8.03)

2045 (13.74)

 2010

261 (4.98)

1881 (9.11)

2006 (15.07)

 2011

227 (4.85)

2031 (9.22)

1971 (15.69)

P Value

0.3527

<0.0001

<0.0001

Infection (ICD-9 998.5x)

 Total (2006–2011)

15 (0.06)

88 (0.07)c

18 (0.03)c

 2006

4 (0.12)

12 (0.10)

2 (0.01)

 2007

1(0.03)

14 (0.08)

2 (0.01)

 2008

6 (0.13)

15 (0.06)

7 (0.05)

 2009

2 (0.04)

25 (0.10)

4 (0.03)

 2010

0 (0.00)

14 (0.07)

4 (0.03)

 2011

2 (0.04)

8 (0.04)

5 (0.04)

P Value

0.0543

0.1255

0.4301

Menorrhagia (ICD-9 627.0)

 Total (2006–2011)

53 (0.20)ab

528 (0.44)ac

410 (0.68)bc

 2006

12 (0.35)

48 (0.40)

88 (0.59)

 2007

6 (0.16)

58 (0.35)

94 (0.64)

 2008

11 (0.25)

84 (0.35)

92 (0.63)

 2009

12 (0.25)

89 (0.36)

119 (0.80)

 2010

8 (0.15)

121 (0.59)

121 (0.91)

 2011

4 (0.09)

128 (0.58)

126 (1.00)

P Value

0.1181

<0.0001

<0.0001

Ovarian Cyst (ICD-9 620.2)

 Total (2006–2011)

1157 (4.36)ab

6340 (5.26)ac

4324 (7.16)bc

 2006

140 (4.05)

539 (4.48)

1045 (7.02)

 2007

155 (4.08)

786 (4.68)

990 (6.70)

 2008

211 (4.72)

1268 (5.22)

1076 (7.34)

 2009

209 (4.29)

1400 (5.64)

1039 (6.98)

 2010

223 (4.25)

1142 (5.53)

1003 (7.53)

 2011

219 (4.68)

1205 (5.47)

910 (7.25)

P Value

0.5197

<0.0001

0.0975

Pelvic Inflammatory Disease (ICD-9 614.xx–616.xx)

 Total (2006–2011)

5053 (19.05)ab

19 063 (15.81)ac

11 162 (18.48)bc

 2006

13 (0.38)

40 (0.33)

64 (0.43)

 2007

12 (0.32)

53 (0.32)

66 (0.45)

 2008

23 (0.51)

74 (0.30)

69 (0.47)

 2009

15 (0.31)

60 (0.24)

54 (0.37)

 2010

12 (0.23)

49 (0.24)

41 (0.31)

 2011

18 (0.38)

58 (0.26)

25 (0.20)

P Value

0.282

0.3727

0.02

Pelvic Pain (ICD-9 625.9, 789.00)

 Total (2006–2011)

3222 (12.15)ab

13 891 (11.52)ac

8323 (13.78)bc

 2006

384 (11.12)

1395 (11.60)

1987 (13.35)

 2007

466 (12.25)

1915 (11.41)

1997 (13.52)

 2008

519 (11.60)

2729 (11.24)

1976 (13.47)

 2009

627 (12.88)

2897 (11.68)

2117 (14.23)

 2010

661 (12.60)

2419 (11.72)

1881 (14.13)

 2011

565 (12.07)

2536 (11.51)

1792 (14.27)

P Value

0.1449

0.617

0.0593

Perforation of Uterine Wall (ICD-9 621.8, 665.3)

 Total (2006–2011)

412 (1.55)ab

1558 (1.29)ac

387 (0.64)bc

 2006

40 (1.16)

142 (1.18)

57 (0.38)

 2007

51 (1.34)

176 (1.05)

76 (0.51)

 2008

48 (1.07)

301 (1.24)

91 (0.62)

 2009

88 (1.81)

319 (1.29)

119 (0.80)

 2010

98 (1.87)

307 (1.49)

103 (0.77)

 2011

87 (1.86)

313 (1.42)

109 (0.87)

P Value

0.0014

0.0023

<0.0001

abcChi square pairwise comparisons between groups with the same superscript, P < 0.05. The pairwise comparisons were done for the total for each complication/side effect across years 2006–2011 and not for the individual years

Discussion

Results indicate that tubal sterilization rates decreased and IUD insertion rates increased between 2006 and 2011. These findings were noted across all age groups, with the exception of sterilization in women ages 35–45, the rates of which were constant. By 2008, insertion rates of LNG IUD exceeded rates of sterilization in every age group, including women ages 35–45. Importantly, substantial increases in insertion rates for both the copper and LNG IUDs were seen in younger women, including adolescents.

Results suggesting an increase in IUD use are consistent with data from the National Survey of Family Growth, which showed that from 2002 to 2013, the prevalence of IUD use increased from 2.0 to 10.3% among female contraceptive users aged 15–44 years [12]. The prevalence of female sterilization in the same population decreased from 27.0 to 25.1% over the same time period. In a separate analysis of sexually active women aged 15–24 years, IUD use increased from 0.2 to 2.5% in teens ages 15–19 and from 2.0 to 5.4% in women aged 20–24 years, although the increase was primarily observed in parous women [11]. Another retrospective cohort study found that IUD insertion rates increased nearly 7-fold between 2002 and 2009 [6].

Importantly, women experienced few complications with either IUD. Differences in complication rates between IUDs were of minimal clinical significance. The most frequent complications in both IUD groups were menstrual disorders and pelvic pain; however, patients who underwent tubal sterilization reported these adverse effects more frequently than IUD users. The most serious complications associated with IUD use, such as uterine perforation and pelvic inflammatory disease, were reported in fewer than 2% of women.

Limitations of the study included its observational, retrospective nature, lack of representation of women without health insurance, and nature of claims databases. Despite these limitations, our findings confirm recent data suggesting a shift toward long-acting reversible contraceptive methods and away from permanent methods. Copper IUD and LNG IUD insertion and tubal sterilization were associated with a low rate of complications.

Conclusions

Our analysis of a retrospective claims database supported an increase in women selecting reversible methods of long-term contraception over permanent tubal sterilization, as shown by an increase in copper IUD and LNG IUD insertion rates and decreased sterilization rates between 2006 and 2011. Younger women showed substantial increases in IUD insertion rates. Among all women, rates of complications or side effects were low.

Abbreviations

HCPCS: 

Healthcare Common Procedure Coding System

HMB: 

Heavy menstrual bleeding

ICD-9-CM: 

International Classification of Diseases, Ninth Revision, Clinical Modification

IUD: 

Intrauterine device

LNG: 

Levonorgestrel

Declarations

Acknowledgement

The authors thank Nicole Cooper of MedVal Scientific Information Services, LLC, for providing medical writing and editorial assistance. This manuscript was prepared according to the International Society for Medical Publication Professionals’ ‘Good Publication Practice for Communicating Company-Sponsored Medical Research: the GPP2 Guidelines’ and the International Committee of Medical Journal Editors’ ‘Uniform Requirements for Manuscripts Submitted to Biomedical Journals.’

Funding

This analysis was sponsored by Teva Branded Pharmaceutical Products R&D, Inc. Medical writing assistance was provided by MedVal Scientific Information Services, LLC (Skillman, NJ), and was funded by Teva Branded Pharmaceutical Products R&D, Inc. (Frazer, PA). Teva provided a full review of the article.

Availability of data and materials

The datasets generated during and/or analyzed during the current study are available in the Optum™ Clinformatics™ Data Mart database.

Authors’ contributions

Study concept and design: BH, EG, ML, BT. Acquisition, analysis, or interpretation of data: All authors. Drafting of manuscript: All authors. Critical revisions of manuscript for important intellectual content: All authors. Statistical analysis: ML. Final approval of manuscript: All authors.

Competing interests

Brandon Howard was an employee of Teva Global Medical Affairs at the time this work was conducted; ElizaBeth Grubb was an employee of Teva Global Health Economics & Outcomes Research at the time this work was conducted; Maureen J. Lage is the managing member of HealthMetrics Outcomes Research and was compensated by Teva Branded Pharmaceutical Products, R&D, Inc. for her work on this project. Boxiong Tang is an employee of Teva Global Health Economics & Outcomes Research.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Not applicable.

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Authors’ Affiliations

(1)
Teva Global Medical Affairs
(2)
Teva Global Health Economics & Outcomes Research
(3)
HealthMetrics Outcomes Research
(4)
Teva Global Health Economics & Outcomes Research

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Copyright

© The Author(s). 2017

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