The challenge to solve the expulsion problem of immediate postplacental insertion of IUD.

We have read with interest the article by Cohen et al. entitled “Twelve-month contraceptive continuation and repeat pregnancy among young mothers choosing post-delivery contraceptive implants or postplacental intrauterine devices” [1]. What strikes us time and time again in articles published on postplacental/postpartum insertion of IUDs is the unacceptable high total expulsion as well as the high displacement rates reported [2]. As expressed by the authors, immediate postpartum intrauterine device (IUD) insertion deserves great attention as it can provide immediate contraception and prevents repeat unintended pregnancies. Immediate post placental insertion (within 10 min of delivery of the placenta) of copper-bearing or hormone-releasing IUDs is safe and acceptable. When compared with interval insertion, it however carries a significantly higher risk of full and/or partial expulsions, thus affecting effectiveness and overall patient acceptance. To address this important challenge, an anchoring technique for use in the immediate postplacental period was developed in Belgium in the 1980s and has been the subject of extensive clinical research since 1985 at the University in Ghent and in internationally conducted clinical trials [3]. The results of these trials indicated that the anchoring technology was a valid concept and can use copper or LNG as the contraceptive agent. Since that time, the technology has passed through several phases of redesign and improvement. Recently, the technique was optimized to allow for suspension of the frameless IUD for intraoperative cesarean implantation of the anchor. A historical review was published by Wildemeersch et al. [4]. The technique consists of the precise placement of the non-biodegradable anchoring knot immediately below the serosa of the uterus, followed by fixing the knot in place with an absorbable suture. This adaptation of the frameless anchoring technology has shown to be easy, quick and safe in pilot trials with no expulsions at 12 months. It was readily apparent that the technique could