Perception about Intrauterine Devices, Prior to and After Placement—Prospective Survey

Clin. Exp. Obs e . Gynecol. 2022; 49(4): 92 h ps://doi.o g/10.31083/j.ceog4904092 Copy igh : © 2022 The Au ho (s). Published by IMR P ess. This is an open access a icle unde he CC BY 4.0 license. Publishe ’s No e: IMR P ess s ays neu al wi h ega d o ju isdic ional claims in published maps and ins i u ional a ilia ions. O iginal Resea ch Pe cep ion abou In au e ine De ices, P io o and A e Placemen —P ospec i e Su ey And eia de Vasconcelos Gaspa 1,*, Isabel San os Sil a1, Ma ia do Céu Almeida1 1Bissaya Ba e o Ma e ni y - Obs e ics Se ice B, Coimb a Hospi al and Uni e si y Cen e , 3004-561 Coimb a, Po ugal *Co espondence: [email p o ec ed] (And eia de Vasconcelos Gaspa ) Academic Edi o : Michael H. Dahan Submi ed: 6 Janua y 2022 Re ised: 23 Feb ua y 2022 Accep ed: 24 Feb ua y 2022 Published: 15 Ap il 2022 Abs ac Backg ound: In au e ine de ices a e e ec i e long-las ing con acep i e me hods wi h a high a e o sa is ac ion among use s. This s udy aimed a de e mining women’s pe cep ion o in au e ine con acep ion, be o e and a e i s placemen , and assessing he impac o con acep i e counseling on ha pe cep ion. Me hods: Desc ip i e p ospec i e s udy, ca ied ou h ough a ques ionnai e, ega ding women who unde wen a Family Planning (FP) consul a ion in a Te ia y Hospi al Cen e , om Sep embe 1, 2020 o Augus 31, 2021. Resul s: 108 women we e included in his s udy. Con acep i e me hods used p io o he consul a ion we e mainly ho monal (62%) and ba ie (30%). The main eason o choosing he in au e ine de ice was he ad ice gi en by he physician o o he heal h p o essional (87%). The g ea es conce n o women ega ding his me hod was he placemen p ocess (27%), especially wi h ega d o pain associa ed wi h he p ocedu e (50%). 79% o women conside ed ha hey we e ully cla i ied p io o de ice placemen . A e placemen , mean pain in ensi y was 3.94 (SD = 2.273; Visual Analogue Scale), and i was ound o be lowe han women’s pe cep ion p io o placemen . 73% hough he p ocess was simple han expec ed and 88% would ad ise he me hod o o he women. All use s epo ed ha ing been in o med abou possible complica ions o ad e se e ec s associa ed wi h his con acep i e me hod. Conclusions: Resul s indica e ha he choice o long-ac ing con acep ion is mainly associa ed wi h co ec medical ad ice. Mos o he women we e clea a e amily planning consul a ion, which made he in au e ine de ice placemen easie and less pain ul han expec ed. Keywo ds: con acep i e me hods; amily planning; in au e ine de ices 1. In oduc ion I is es ima ed ha a ound 30% o p egnancies a e unplanned. Long-ac ing e e sible con acep i es (LARC) a e me hods ha allow e ec i e con acep ion o a long pe iod o ime, wi hou he need o use collabo a ion. Acco ding o he ACOG guidelines, hey consis o me h- ods adminis e ed wi h a pe iodici y o mo e han 12 weeks [1]. LARCs, namely in au e ine de ices, may play a b oade ole in con acep ion, and hei inc eased use may help educe unwan ed p egnancies [2,3]. In au e ine de- ices (IUD) include he coppe -con aining IUD and he le ono ges el- eleasing in au e ine de ice (LNG-IUD). The e a e h ee ypes o LNG-IUD: one wi h 52 mg le - ono ges el (Mi ena®/Le ose ®), which eleases 20 mi- c og ams/day o LNG; one wi h 19.5 mg le ono ges el (Kyleena®), which eleases 17.5 mic og ams/day; and he IUD wi h 13.5 mg le ono ges el (Jaydess®), eleasing 14 mic og ams/day o le ono ges el [4–7]. The coppe de ice ac s mainly as a o eign body, while he LNG-IUD wo ks by eleasing ho mone locally. The coppe de ice’s mech- anism o ac ion consis s o : cy o oxic in lamma o y eac- ion in he endome ium, by biochemical and mo pholog- ical al e a ions induced by coppe , spe m and oocy e ox- ici y and al e a ions in ubal mo ili y [8]. The LNG-IUD wo ks h ough he ollowing mechanisms: ce ical mucus hickening, inhibi ion o e iliza ion by inc eased p oduc- ion o glycodelin A, glandula a ophy and pa ial inhibi- ion o ollicula de elopmen and o ula ion [8,9]. They a e one o he mos e ec i e o ms o long- las ing e e sible con acep ion, wi h ailu e a es o less han 1%, o bo h pe ec and ypical use [10]. IUDs ha e high accep abili y and con inua ion a es, which a e a ound 70% [11]. ACOG conside s he IUD o be a i s -line con- acep ion, e en in adolescence and in nullipa ous women [1,12]. Da a on women’s pe cep ion o he IUD and i s place- men a e limi ed. This s udy’s main goal is o de e mine he pe cep ion o women abou in au e ine de ices, be o e and a e hei placemen . I s second goal is o e i y he impac o con- acep i e counseling in his pe cep ion abou in au e ine de ices. 2. Ma e ials and Me hods Desc ip i e p ospec i e s udy, ca ied ou h ough a ques ionnai e, wi h women who unde wen a Family Plan- ning (FP) consul a ion a a e ia y hospi al, om Sep embe 1, 2020 o Augus 31, 2021. The inclusion c i e ia o he s udy consis ed o he desi e o ha e an in au e ine sys em (IUS) and being able o ead Po uguese. The exclusion c i e ion was no mee - ing he eligibili y c i e ia o placemen o he me hod, ac- co ding o USA Cen e s o Disease Con ol (CDC) guide- lines: p egnancy (diagnosed o suspec ed); u e ine mal o - ma ions; u e ine abno mali ies wi h dis o ion o he ca - i y; ac i e Pel ic In lamma o y Disease (PID) (and up o 3 mon hs a e cu e); u e ine bleeding o unclea e iology; ophoblas malignan disease; Wilson’s disease o coppe alle gy; b eas cance wi h posi i e p oges in ecep o s (up o 5 yea s) [13]. Women we e e e ed om o he ma e ni y consul a- ions o sen om p ima y ca e. FP consul a ion and IUD placemen we e ee. IUDs we e placed by a physician. Those in e es ed in IUD placemen we e in o med abou he a ailable ypes and placemen p ocedu e, and he e i ica ion o eligibili y c i e ia was ca ied ou . Con a- cep i e counseling p o ided by se e al medical p o ession- als was iden ical. Inse ion o de ices ollowed he manu- ac u e ’s speci ica ions. Local analgesia was no adminis- e ed du ing he p ocedu e. Two pape ques ionnai es we e comple ed on he day o he consul a ion: p io o and a e de ice placemen . Since he e a e no s anda dized ques ionnai es a ailable o de e mine women’s pe cep ion o he IUD, speci ic ques- ionnai es we e de eloped o his s udy. Demog aphic da a we e ob ained h ough he com- pu e sys em. The cons i u ion and manipula ion o he da abase, as well as he s a is ical analysis, we e pe o med using he SPSS p og am e sion 23 (IBM Co p., A monk, NY, USA). A desc ip i e analysis o he dis ibu ion o pa ien s was ca ied ou , conside ing a ious sociodemog aphic a i- ables. Ca ego ical a iables a e p esen ed as equencies and pe cen ages and con inuous a iables as means and s anda d de ia ions o medians and in e qua ile anges. The es o no mal da a dis ibu ion was pe o med using he Shapi o–Wilk es o by analyzing he alues o skew- ness and ku osis. Pai ed compa isons we e pe o med wi h he use o a pai ed S uden ’s - es o pai ed-sample es o con inuous a iables. Ca ego ical a iables we e compa ed wi h he use o Fishe ’s exac es o he chi-squa e es , as app op ia e. All epo ed p alues a e wo- ailed, wi h a p alue o 0.05 indica ing s a is ical signi icance. 3. Resul s A o al o 108 women who ag eed o answe he ques- ionnai es, we e included in his s udy. O hese, none was excluded, as all o hem me he eligibili y c i e ia o IUD placemen . 46 LNG-52 (42.6%), 18 LNG-19.5 (16.7%), 37 LNG- 13.5 (34.3%) and 7 coppe IUDs (6.5%) we e placed. Wi h ega d o women’s age, he class wi h he high- es numbe o consul a ions was 30–34 yea s (21.3%). The dis ibu ion by age g oups can be seen in Fig. 1. The demog aphic cha ac e iza ion o he sample in- cluded in he s udy can be seen in Table 1. Fig. 1. Dis ibu ion o women included in he s udy by age g oups. 93% o he women we e Po uguese. Mos women we e single a he ime o he amily planning consul a ion. Wi h ega d o he le el o educa ion, 41% o women com- ple ed seconda y educa ion and 35% comple ed highe ed- uca ion. Unskilled emale wo ke s, s uden s and adminis- a i e s a a e he main ca ego ies o use his consul a ion o IUD placemen . The a e age pa i y o his sample was 1.22 (SD 1.113), he majo i y being mul ipa ous (65.7%) and 12% ha ing h ee o mo e child en. The main con acep i e me hods used p io o consul- a ion we e ho monal (62%) and ba ie (29.6%)—Fig. 2. 5% did no use con acep ion and 3.8% used na u al me h- ods (wi hd awal o calenda me hod). Fig. 2. Con acep ion used p io o FP consul a ion. The i s ques ionnai e was ca ied ou p io o IUD placemen . Women esponded ha he main eason o choosing he in au e ine de ice was he ad ice gi en by he physician o o he heal h p o essional (87%). In 8.3% o cases, i was due o pe sonal esea ch and in 4.6% o amily o iends’ ad ice. Women’s main conce n ega d- ing his me hod was he placemen p ocess (26.9%). O h- e s epo ed ea o complica ions (23.1%), becoming p eg- nan (18.5%), gaining weigh (9.3%) o no adap ing o he me hod (15.7%). 15% o women did no ha e any conce ns 2 Table 1. Sociodemog aphic cha ac e iza ion. Demog aphy No. (%) Na ionali y Po uguese 100 (92.6) B azilian 4 (3.7) Angolan 1 (0.9) Cape-Ve dean 1 (0.9) Venezuelan 1 (0.9) Chinese 1 (0.9) Li e as a couple Yes 67 (62.0) Ma i al s a us Single 61 (56.5) Ma ied 40 (37.0) Di o ced 7 (6.5) Le el o educa ion Basic Educa ion – 1s Cycle 2 (1.9) Basic Educa ion – 2nd Cycle 4 (3.8) Basic Educa ion – 3 d Cycle 19 (18.3) Seconda y Educa ion 43 (41.3) Highe Educa ion 36 (34.6) P o ession Senio Manage s o Public Adminis a ion, Manage s and Senio Manage s o Companies 1 (1.0) Specialis s in In ellec ual and Scien i ic Jobs 11 (10.7) In e media e Le el Technicians and Wo ke s 10 (9.7) Adminis a i e S a , Se ices and simila 17 (16.5) Fa me s, Wo ke s, C a smen and o he Skilled Wo ke s 13 (12.6) Mili a y and Police Fo ces 1 (1.0) Unskilled wo ke s 20 (19.4) Unpaid housewo k 2 (1.9) S uden 17 (16.5) Unemployed 11 (10.7) Pa i y 0 37 (34.3) 1 26 (24.1) 2 32 (29.6) 3 11 (10.2) 4 1 (0.9) 5 1 (0.9) abou his con acep i e me hod. Rega ding he placemen p ocess, hey mainly men ioned ea o pain associa ed wi h he p ocedu e (50%) o o he associa ed symp oms, such as nausea o lipo hymia (1.9%). 29% we e a aid o complica- ions du ing placemen , such as bleeding o in ec ion. 27% had no conce ns abou he placemen p ocess. They hough ha he mean deg ee o pain associa ed wi h he p ocedu e would be 5 (SD 2.187), assessed using a isual analogue scale (VAS). Du ing he consul a ion, he e we e no complica ions associa ed wi h he placemen o he de ice, namely u e ine pe o a ion. The second ques ionnai e was ca ied ou a e IUD placemen . A e placemen , mean pain in ensi y was 3.94 (SD = 2.273; VAS), and i was ound o be lowe han he pe cep ion o women be o e placemen (p= 0.002) (Fig. 3). 99% o use s epo ed ha he e was enough in o - ma ion abou he inse ed IUD and ad e se e ec s associ- a ed wi h his con acep i e me hod. 79% o women con- side ed ha hey we e ully cla i ied p io o de ice inse - ion, ega ding he placemen me hod and associa ed com- plica ions. 19.5% hough hey we e no comple ely cla i- ied. 73.1% conside ed ha he p ocess was simple han expec ed, and 17.6% said ha i co esponded o wha was 3 Fig. 3. Pain p io o and a e IUS placemen . expec ed a e counseling. Only 8% o he sample consid- e ed ha he whole p ocedu e was wo se han hey had ex- pec ed. 88% would ad ise he me hod o o he women. The pe cep ion o co ec con acep i e counseling was associa ed wi h a lowe isk o pain (≤5 on VAS) when placing he in au e ine de ice (p= 0.043, OR 2.720 [1.405–5.265]). The expec a ion o high pain (>5 on VAS) be o e he p ocedu e was associa ed wi h highe pain a de ice place- men (≥5 VAS) (p= 0.006; OR 2.431 [1.295–4.566]. 4. Discussion The IUD is one o he p e e ed LARCs, being used by a ound 14% o women o ep oduc i e age in Eu ope [14]. In Po ugal, i has a simila a e o use, being used by 12% o women who eso o con acep i e me hods [15]. 93.5% op ed o LNG-IUD e sus 6.5% coppe IUD. This choice may be associa ed wi h he non-con acep i e bene i s o le ono ges el, especially LNG-52: ea men o abno mal u e ine bleeding; indica ed o women ea ed wi h an icoagulan s o hemo hagic dias asis (inc eases hemoglobin le els and quali y o li e); dysmeno hea ea - men ; ea men /p ophylaxis o simple endome ial hype - plasia; ea men o symp oms associa ed wi h Endome io- sis/Adenomyosis; endome ial p o ec ion du ing es ogen o amoxi en he apy; i seems o dec ease he isk o en- dome ial, o a ian and colo ec al cance s [16,17]. The IUD was chosen mainly by women be ween 30 and 34 yea s old. These da a do no co espond o he age p esen ed in he las s udy on con acep i e p ac ices in Po - uguese women, which s a es ha he IUD is mainly chosen in he age g oup be ween 40 and 49 yea s old [15]. This may e eal a end owa ds an ea lie use o his me hod. Mos o he women included in he s udy we e ed- uca ed, ha ing comple ed seconda y o highe educa ion. These da a a e compa ible wi h o he s udies ca ied ou [15,18]. The IUD con inues o be used mo e o en in mul i- pa ous women. This ac is o en ela ed o medical ad- ice. A s udy ca ied ou e ealed ha only 66% o mem- be s o he Ame ican College o Obs e icians and Gyne- cologis s conside he IUD o be an adequa e con acep- ion in nullipa ous women [19]. The main ba ie s men- ioned by doc o s ega ding i s use in nullipa ous women a e: ea o pel ic in lamma o y disease, di icul y in inse - ion and/o conce n wi h e ili y [20]. Howe e , a ecen e iew ound ha inse ions a e well- ole a ed and success- ul in his g oup o women [21]. The la es in e na ional guidelines s a e ha he IUD is an app op ia e me hod and can be used as a i s line in his g oup o women [1]. Despi e all he in o ma ion a ailable, 5% did no use con acep ion p io o consul a ion. Al hough su p ising, his ac is in line wi h he a ailable li e a u e. 3.8% o women used na u al me hods (wi hd awal o calenda me hod). This pe cen age is ela i ely highe han ha e- po ed in he las s udy ca ied ou in he coun y (0.7%) [7]. Cu en ly, he e a e no s udies on his opic, bu se e al p ess a icles ha e e e ed o his end in he millennial gene a ion. In his s udy, he p ima y eason o choosing he IUD was he ad ice gi en by he physician o o he heal h p o es- sional. Co ec counseling and high-quali y in e pe sonal communica ion seem o be associa ed wi h be e accep- ance, sa is ac ion, and IUD con inua ion [22]. The as majo i y o use s conside ed ha he e was no lack o in o ma ion abou he inse ed IUD, ad e se e ec s, 4 placemen me hod and associa ed complica ions. Ac i ely in o ming women abou he bene i s, isks, and equen ad- e se e ec s o IUDs appea s o imp o e conside a ion and accep ance o he me hod [23]. The p ocess was simple o co esponded o wha was expec ed in 91% o cases. This is an impo an ou come o be men ioned, as we did no ind hese indings in o he s udies. The main conce n o women ega ding his me hod was he placemen p ocess, especially wi h ega d o he pain associa ed wi h he p ocedu e. Pain was signi ican ly less han expec ed by use s. The pe cep ion o co ec con- acep i e counseling was associa ed wi h a lowe isk o pain when placing he in au e ine de ice. De ailed medical ad ice ega ding con acep i e me hods appea s o dec ease pain in ensi y upon IUD placemen [24]. The pe cep ion o pain is in luenced by he pa ien ’s ela ionship wi h he physician [25–27]. One o he isk ac o s associa ed wi h inc eased pain in ensi y wi h gynecological p ocedu es is he p edic ion a high le el o pain p io o he p ocedu e [28,29]. The e is s ill no explana ion o his inding in he li e a u e. Ou IUD placemen p o ocol does no include he ad- minis a ion o analgesics. Howe e , he la es Coch ane e iew demons a ed modes bene i in educing pain wi h opical lidocaine, amadol, o nap oxen pe os. Ibup o- en, diclo enac and ke o olac did no demons a e signi - ican pain educ ion [30,31]. Al hough he pe cep ion o use s abou he placemen o an in au e ine de ice was gen- e ally qui e a o able, he analgesics men ioned abo e can be a use ul app oach in imp o ing he esul s. The s eng h o his s udy is ha i is p ospec i e. This educes possible bias as he da a was collec ed in eal ime. The esul s can be conside ed eliable and ep esen a i e o ou popula ion, p o iding an oppo uni y o lea n abou and imp o e amily planning and inc ease he use o LARCs. I s limi a ion is ha all pa ien s a e om he cen al egion o he coun y and his popula ion may no be gene - alizable o he es o he coun y. 5. Conclusions This s udy adds in o ma ion ega ding he pe cep ion o women abou he in au e ine de ice, p io o and a e i s placemen . To da e, as a as we a e conce ned, he e is no simila p ospec i e s udy. The choice o an in au e ine de ice as a con acep i e me hod is mainly associa ed wi h co ec medical ad ice. The majo i y o women demons a ed o be clea a e he amily planning appoin men . This ac made he p ocedu e less pain ul han expec ed. The p ocess o placing he in au e ine de ice is sim- ple han women hink be o e consul a ion. Con acep i e counseling plays a majo ole in accep- ance and good ole ance when placing he in au e ine de- ice. Au ho Con ibu ions Concep ualiza ion—AVG, ISS and MCA; me hodology—AVG and ISS; so wa e—AVG; alida ion—AVG ISS and MCA; o mal analysis— AVG and ISS; in es iga ion—AVG; esou ces—AVG; da a cu a ion—AVG; w i ing—o iginal d a p epa a ion— AVG, ISS and MCA; w i ing— e iew and edi ing—AVG, ISS and MCA; isualiza ion—AVG, ISS and MCA; supe ision—ISS. All au ho s ha e ead and ag eed o he published e sion o he manusc ip . E hics App o al and Consen o Pa icipa e The au ho s decla e ha he p ocedu es we e ollowed acco ding o he egula ions es ablished by he Clinical Re- sea ch and E hics Commi ee and o he 2013 Helsinki Dec- la a ion o he Wo ld Medical Associa ion(app o al num- be : No 270/CES). The au ho s decla e ha ing ollowed he p o ocols in use a hei wo king cen e ega ding pa ien s’ da a publica ion. In o med consen was ob ained om all subjec s in ol ed in he s udy. Acknowledgmen We a e g a e ul o he nu sing eam ha helped ca y ou he su eys. Funding This esea ch ecei ed no ex e nal unding. Con lic o In e es The au ho s decla e no con lic o in e es . Re e ences [1] Commi ee on P ac ice Bulle ins-Gynecology, Long-Ac ing Re- e sible Con acep ion Wo k G oup. P ac ice Bulle in no. 186: Long-Ac ing Re e sible Con acep ion: Implan s and In au e - ine De ices. Obs e ics and Gynecology. 2017; 130: e251–e269. [2] Na ional Ins i u e o Heal h and Ca e Excellence. NICE Clinical Guideline 30: Long-ac ing e e sible con acep ion. July, 2019. [3] Ha pe CC, Rocca CH, Thompson KM, Mo esis J, Goodman S, Da ney PD, e al. Reduc ions in p egnancy a es in he USA wi h long-ac ing e e sible con acep ion: a clus e andomised ial. Lance . 2015; 386: 562–568. [4] Mi ena® (le ono ges el- eleasing in au e ine sys em). High- ligh s o p esc ibing in o ma ion. Whippany (NJ): Baye Heal h- Ca e Pha maceu icals Inc. 2021. A ailable a : h ps://labeling.b aye heal hca e.com/h ml/p oduc s/pi/Mi ena_PI.pd (Accessed: 31 Oc obe 2021). [5] Kyleena®. Highligh s o p esc ibing in o ma ion. Whippany (NJ): Baye Heal hCa e Pha maceu icals Inc. 2021. A ailable a : h ps://www.kyleena-us.com/pi#isi (Accessed: 31 Oc obe 2021). [6] Jaydess®. Resumo das ca ac e ís icas do medicamen o. Whip- pany (NJ): Baye Heal hCa e Pha maceu icals Inc. 2021. A ail- able a : h ps://www.pi.baye .com/si es/g/ iles/ xlpx33726/ ile s/2021-10/PT-Jaydess_SPC_10_2021.pd (Accessed: 31 Oc o- be 2021). [7] Le ose ®. Resumo das ca ac e ís icas do medicamen o. IN- FARMED. A ailable a : h ps://e-academia.gedeon ich e .p /w 5 p-con en /uploads/2018/05/Le ose -RCM.pd (Accessed: 31 Oc obe 2021). [8] O iz ME, C oxa o HB. Coppe -T in au e ine de ice and le - ono ges el in au e ine sys em: biological bases o hei mech- anism o ac ion. Con acep ion. 2007; 75: S16–S30. [9] Lewis RA, Taylo D, Na a io MF, Melamed A, Felix J, Mishell D. E ec s o he le ono ges el- eleasing in au e ine sys em on ce ical mucus quali y and spe m pene abili y. Con acep ion. 2010; 82: 491–496. [10] T ussell J. Con acep i e ailu e in he Uni ed S a es. Con acep- ion. 2011; 83: 397–404. [11] Sande s JN, Tu ok DK, Gaw on LM, Law A, Wen L, Lynen R. Two-yea con inua ion o in au e ine de ices and con acep i e implan s in a mixed-paye se ing: a e ospec i e e iew. Ame - ican Jou nal o Obs e ics and Gynecology. 2017; 216: 590.e1– 590.e8. [12] Ame ican College o Obs e icians and Gynecologis s. In au e - ine de ice and adolescen s. ACOG Commi ee Opinion No. 392. Obs e ics and Gynecology. 2007; 110: 1493–1495. [13] Cu is KM, Teppe NK, Ja laoui TC, Be y-Bibee E, Ho on LG, Zapa a LB, e al. U.S. Medical Eligibili y C i e ia o Con acep- i e Use, 2016. Mo bidi y and Mo ali y Weekly Repo . 2016; 65: 1–103. [14] Buhling KJ, Zi e NB, Lo ke P, Black K. Wo ldwide use o in- au e ine con acep ion: a e iew. Con acep ion. 2014; 89: 162–173. [15] Águas F, Bombas T, Pe ei a da Sil a D. E alua ion on po - uguese women con acep i e p ac ice. Ac a Obs e icia e Gy- necologica Scandina ica. 2016; 10: 184–192. [16] Chi C, Huq FY, Kadi RA. Le ono ges el- eleasing in au e - ine sys em o he managemen o hea y mens ual bleeding in women wi h inhe i ed bleeding diso de s: long- e m ollow-up. Con acep ion. 2011; 83: 242–247. [17] Ame ican College o Obs e icians and Gynecologis s Commi - ee on Gynecologic P ac ice. ACOG commi ee opinion. No. 337: Noncon acep i e uses o he le ono ges el in au e ine sys em. Obs e ics and Gynecology. 2006; 107: 1479–1482. [18] Ka anaugh ML, Je man J, Fine LB. Changes in Use o Long- Ac ing Re e sible Con acep i e Me hods among U.S. Women, 2009–2012. Obs e ics and Gynecology. 2015; 126: 917–927. [19] Luchowski AT, Ande son BL, Powe ML, Raglan GB, Espey E, Schulkin J. Obs e ician-gynecologis s and con acep ion: p ac- ice and opinions abou he use o IUDs in nullipa ous women, adolescen s and o he pa ien popula ions. Con acep ion. 2014; 89: 572–577. [20] Black KI, Lo ke P, Li a J, Pee s T, Zi e NB. Global su ey o heal hca e p ac i ione s’ belie s and p ac ices a ound in au e - ine con acep i e me hod use in nullipa ous women. Con acep- ion. 2013; 88: 650–656. [21] Loh PA, Lyus R, P age S. Use o in au e ine de ices in nulli- pa ous women. Con acep ion. 2017; 95: 529–537. [22] Dehlendo C, Hende son JT, Vi ingho E, G umbach K, Le y K, Schmi diel J, e al. Associa ion o he quali y o in e pe - sonal ca e du ing amily planning counseling wi h con acep i e use. Ame ican Jou nal o Obs e ics and Gynecology. 2016; 215: 78.e1–78.e9. [23] A owsmi h ME, Aicken CR, Saxena S, Majeed A.S a egies o imp o ing he accep abili y and accep ance o he coppe in au e ine de ice. Coch ane Da abase o Sys ema ic Re iews. 2012; CD008896. [24] New on JR, Reading AE. The e ec s o psychological p epa- a ion on pain a in au e ine de ice inse ion. Con acep ion. 1977; 16: 523–532. [25] Dina B, Peipe LJ, Zhao Q, Peipe JF. An icipa ed pain as a p e- dic o o discom o wi h in au e ine de ice placemen . Ame i- can Jou nal o Obs e ics and Gynecology. 2018; 218: 236.e1– 236.e9. [26] I eland LD, Allen RH. Pain Managemen o Gynecologic P o- cedu es in he O ice. Obs e ical & Gynecological Su ey. 2016; 71: 89–98. [27] Gemzell-Danielsson K, Mansou D, Fiala C, Kauni z AM, Baha- mondes L. Managemen o pain associa ed wi h he inse ion o in au e ine con acep i es. Human Rep oduc ion Upda e. 2013; 19: 419–427. [28] Akin omide H, B ima N, Sewell RDE, S ephenson JM. Pa- ien s’ expe iences and p o ide s’ obse a ions on pain du ing in au e ine de ice inse ion. The Eu opean Jou nal o Con a- cep ion & Rep oduc i e Heal h Ca e. 2015; 20: 319–326. [29] Akdemi Y, Ka adeniz M. The ela ionship be ween pain a IUD inse ion and nega i e pe cep ions, anxie y and p e ious mode o deli e y. The Eu opean Jou nal o Con acep ion & Rep o- duc i e Heal h Ca e. 2019; 24: 240–245. [30] Lopez LM, Be nholc A, Zeng Y, Allen RH, Ba z D, O’B ien PA, e al. In e en ions o pain wi h in au e ine de ice in- se ion. The Coch ane Da abase o Sys ema ic Re iews. 2015; CD007373. [31] Nguyen L, Lama che L, Lennox R, Ramdyal A, Pa el T, Black M, e al. S a egies o Mi iga e Anxie y and Pain in In au e ine De ice Inse ion: a Sys ema ic Re iew. Jou nal o Obs e ics and Gynaecology Canada. 2020; 42: 1138–1146.e2. 6