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.   

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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.  

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Questions for both Dr. Amico and Diana Green Foster

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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.