Exploring Control in Contraceptive Use: Perspectives on IUD Self-Removal

As a nonprofit pharmaceutical organization specializing in women’s health, Medicines360 works to democratize access to medicines and health care products for women. We are guided by our values – one of which is to support health equity for women regardless of geographic location or economic status.[1] We developed and brought our anchor product to market – a hormonal intrauterine device (IUD) branded as Liletta® in the US and Avibela™ in low- and middle-income countries – to help accelerate the timeline from innovation to affordable access for women. We’ve documented our journey to promoting equitable access in a case study, which you can read here.

One barrier that may prevent women from choosing the hormonal IUD as their contraceptive is the need for a trained provider to both insert and remove the device at a clinic or provider’s office. While much effort has concentrated on identifying and removing barriers to accessing IUDs, less research has focused on reducing barriers for women when they want their IUD removed, which has critical implications for reproductive autonomy.[2]

When a woman wants to have her IUD removed, she must have access to a provider who can do the removal and, if it is prior to the expiration of the IUD, she may also be asked to explain her rationale for desiring removal. In some cases, providers may be hesitant to honor IUD removal requests prior to the expiration because of their own feelings that it is not in the woman’s best interest.[3] Most women using IUDs are advised to return to a clinician for removal when desired, though some women have removed or attempted self-removal of their own IUDs. In one study of internet forums discussing IUD self-removal experiences, women IUD users commonly reported turning to self-removal when unable to access removal by a provider: when successful, individuals reported that their IUD self-removal experiences were positive.[4]

During the recent COVID-19 pandemic when clinics were overwhelmed and women were hesitant to seek care, some women explored self-removal of their IUDs, subsequently sharing their learnings on social media platforms like TikTok.[5]

Providers have a diverse range of thoughts and attitudes about the idea of IUD self-removal, including personal feelings about the advisability of early removal, logistical questions, and safety concerns, but little has been known about their current practices and counseling around the concept of IUD self-removal. In 2022, the Society of Family Planning issued guidance about contraception provision during the pandemic, which included IUD self-removal; prior to that, no professional society had provided guidance about IUD self-removal counseling by providers.[6]

What if women were empowered to self-remove their IUD, wherever, whenever? With support from Arnold Ventures, Medicines360 explored the concept of IUD self-removal in more depth through research from both the user and provider perspective, including the desirability of a device for self-removal. Our aim was to be inclusive in our approach to conducting this research – from beginning to end. The two qualitative research arms, one with users and one with providers, sought input from a diversity of people and used deliberate sampling methodologies to amplify the voices and feedback from women of color – who can be underrepresented in consumer and product research. Camber Collective helped manage and analyze the research findings.

User Insights on IUD Self-Removal

Dr. Jennet Arcara, PhD, MPH, MPP, of Santa Clara University, and Dominique Pierre, MPH, led the research with users to better understand women’s interest in IUD self-removal, including in the context of a potential removal device. Here is the full research report.

The User Insights research was comprised of 30 in-depth individual interviews and 12 focus group discussions with 48 participants utilizing a semi-structured interview guide and some creative qualitative research techniques. Of the total 78 participants, over two-thirds were people of color, with ages ranging from 19-49, and approximately half reported never using an IUD.

Key findings from User Insights interviews and focus group discussions:

  • Acceptability surrounding the concept of IUD self-removal, and the possibility of having a device to facilitate self-removal, tended to increase over the course of individual interviews and focus group discussions as users become more comfortable with the concept.  
  • Study participants recognized the benefit of IUD self-removal for autonomy and accessibility and thought that a device to facilitate removal should be available.
  • Participants had a general lack of knowledge around IUDs, which can contribute to medical misinformation and skepticism of self-removal.
  • Participants desired more information on a variety of contraceptive methods and more research on IUD self-removal, particularly on its safety.

Provider Perspectives on IUD Self-Removal

Dr. Jennifer Amico, MD, MPH, an Associate Professor at the Rutgers Robert Wood Johnson Medical School, led the research to investigate provider perspectives on IUD self-removal. Here is the full research report.

Dr. Amico’s Provider Perspectives research was an observational study using mixed methods and based on semi-structured interviews of 38 provider participants, followed by a nationwide survey of 279 providers. Dr. Amico engaged a range of family planning providers in both phases to better understand provider perspectives and practices around IUD self-removal, including opinions about its safety, and the role of a potential device to facilitate removal.

Overall, providers were supportive of IUD self-removal, although varied in practices regarding how they incorporate counseling about IUD self-removal.  

Key findings from the Provider Perspectives interviews and survey responses:

  • More than 95% of survey participants somewhat or strongly agreed that IUD self-removal is safe.
  • Despite support for IUD self-removal, providers believe that most patients would prefer their provider to remove their IUD.
  • Providers speculate that lack of awareness about IUD self-removal is the largest barrier.
  • Providers varied in whether they believed a device was necessary or unnecessary for some patients seeking to self-remove their IUDs.

Across both User Insights and Provider Perspectives, this research provides important new findings on the knowledge and acceptability of IUD self-removal and desirability and feasibility of a removal device. Most Users believed IUD self-removal should be an available option to increase reproductive autonomy, even if they were not interested in IUD self-removal for themselves (with or without an IUD removal device). The Providers sampled were overwhelmingly supportive of IUD self-removal and believe it is safe, which had been previously underexplored.

Research Partners:

  • Jennifer Amico, MD, MPH, Associate Professor of Family Medicine, Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School
  • Jennet Arcara, PhD, MPH, MPP, Santa Clara University
  • Dominique Pierre, MPH

For more information, please contact Allison Knox, Director of Project Management, Medicines360, aknox@medicines360.org.

[1] Medicines360 has five company values that guide our work: equity, compassion, integrity, collaboration, and transparency.

[2] Trussell J, Henry N, Hassan F, Prezioso A, Law A, Filonenko A. Burden of unintended pregnancy in the United States: potential savings with increased use of long-acting reversible contraception. Contraception. 2013;87(2):154-61; ACOG Committee Opinion no. 450: Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol. 2009;114(6):1434-8; Dehlendorf C, Levy K, Ruskin R, Steinauer J. Health care providers’ knowledge about contraceptive evidence: a barrier to quality family planning care? Contraception. 2010;81(4):292-8.

[3] Amico JR, Bennett AH, Karasz A, Gold M. “I Wish They Could Hold on a Little Longer”: Physicians’ Experiences with Requests for Early IUD Removal. Contraception. 2017 Aug. PMID: 28578147.

[4] Stimmel S, Hudson SV, Gold M, Amico JR. Exploring the experience of IUD self-removal in the United States through posts on internet forums. Contraception. 2022;106:34-8; Amico JR, Stimmel S, Hudson S, Gold M. “$231 … to pull a string!!!” American IUD users’ reasons for IUD self-removal: An analysis of internet forums. Contraception. 2020;101(6):393-8; Broussard K, Becker A. Self-removal of long-acting reversible contraception: A content analysis of YouTube videos. Contraception. 2021;104(6):654-8.

[5] Woman goes viral on TikTok for filming her ‘DIY’ IUD removal (cosmopolitan.com).

[6] Stifani BM, Madden T, Micks E, Moayedi G, Tarleton J, Benson LS. Society of Family Planning Clinical Recommendations: Contraceptive Care in the Context of Pandemic Response. Contraception. 2022;113:1-12.

About Medicines360

Located in San Francisco, California, Medicines360 is a global nonprofit pharmaceutical organization with a mission to accelerate the timeline from health innovation to access for all women. Medicines360 is committed to working with healthcare providers, advocacy groups, and patients to deliver innovative and meaningful treatments that help women around the world have greater access to the medicines they need. For more information, visit www.medicines360.org.

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AVIBELA can be made available in the following 88 countries

  1. Algeria
  2. Angola
  3. Bangladesh
  4. Belize
  5. Benin
  6. Bhutan
  7. Botswana
  8. Burkina Faso
  9. Burundi
  10. Cambodia
  11. Cameroon
  12. Cape Verde
  13. Central African Republic
  14. Chad
  15. Comoros
  16. Costa Rica
  17. Cuba
  18. Democratic Republic of the Congo
  19. Djibouti
  20. Dominica
  21. Dominican Republic
  22. Egypt
  23. El Salvador
  24. Equatorial Guinea
  25. Eritrea
  26. Ethiopia
  27. Gabon
  28. Ghana
  29. Grenada
  30. Guatemala
  31. Guinea
  32. Guinea-Bissau
  33. Haiti
  34. Honduras
  35. India
  36. Indonesia
  37. Ivory Coast
  38. Jamaica
  39. Kenya
  40. Lao PDR
  41. Lesotho
  42. Liberia
  43. Libya
  44. Madagascar
  45. Malawi
  46. Malaysia
  47. Maldives
  48. Mali
  49. Mauritania
  50. Mauritius
  51. Mayotte
  52. Morocco
  53. Mozambique
  54. Myanmar
  55. Namibia
  56. Nepal
  57. Nicaragua
  58. Niger
  59. Nigeria
  60. Pakistan
  61. Panama
  62. Papua New Guinea
  63. Philippines
  64. Republic of the Congo
  65. Rwanda
  66. Sao Tome and Principe
  67. Senegal
  68. Seychelles
  69. Sierra Leone
  70. Somalia
  71. South Africa
  72. South Sudan
  73. Sri Lanka
  74. Kitts and Nevis
  75. Lucia
  76. Vincent & the Grenadines
  77. Sudan
  78. Swaziland
  79. Tanzania
  80. Thailand
  81. The Gambia
  82. Timor-Leste
  83. Togo
  84. Tunisia
  85. Uganda
  86. Vietnam
  87. Zambia
  88. Sri Lanka

Tina Raine-Bennett, MD, MPH, FACOG

Chief Executive Officer

Tina Raine-Bennett, MD, MPH, is CEO of Medicines360. Previously, she served as a senior research scientist at the Kaiser Permanente Northern California Division of Research and the research director of the Women’s Health Research Institute. She is a Board-Certified Obstetrician Gynecologist who received her medical training at the University of California, San Diego, and post-graduate residency training and MPH at the University of Washington in Seattle, where she also completed a Robert Wood Johnson Clinical Scholars Fellowship. She was also senior staff physician at Kaiser Permanente and has a special interest in family planning and adolescent reproductive health.

As the director of the Women’s Health Research Institute, Dr. Raine-Bennett focused on expanding research on women’s health within the Division and translating women’s health research into clinical practice and policy within the Ob/Gyn departments in Northern California. She also promoted the involvement of clinicians in research designed to improve the health outcomes and healthcare experiences of women at Kaiser Permanente and women in general.

Prior to Kaiser Permanente, Dr. Raine-Bennett was a professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at University of California, San Francisco (UCSF). She was based at San Francisco General Hospital where she was also the medical director of the New Generation Health Center, a UCSF affiliate site that provides community-based reproductive health services. Dr. Raine-Bennett’s research has focused on contraceptive methods and on elucidating factors that influence contraceptive choice and continuation, and she was principal investigator on NIH grants to assess hormonal contraceptive use predictors and develop interventions to improve contraceptive access.

Her past and current research on emergency contraception has focused on the safety of making emergency contraception more accessible and she conducted a pivotal clinical trial to make emergency contraception available to teens without a prescription. She served on the editorial board of Obstetrics and Gynecology and has over 100 peer-reviewed publications. She was the Treasurer of the Board of Directors for the Society of Family Planning and Society of Family Planning Research Fund. She has also served as an examiner for the American Board of Obstetrics and Gynecology, and on national committees for the American College of Obstetrics and Gynecology and the National Medical Board of Planned Parenthood Federation of America.