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.
