Intrauterine Device Insertion Failure After Misoprostol Administration: A Systematic Review.

OBJECTIVE: To examine rates of intrauterine device (IUD) insertion failure with and without prior misoprostol administration. Additional outcomes included difficulty of insertion, subjective pain, expulsion, and complications.

DATA SOURCES: Systematic searches were performed in PubMed MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Cumulative Index to Nursing and Allied Health Literature for articles with the following keywords: "misoprostol," "intrauterine devices," and "IUDs."

METHODS OF STUDY SELECTION: A total of 161 unique results were retrieved. Titles, abstracts, and full-text articles were independently screened twice by two reviewers for content and relevance. Quality assessment was performed using previously established criteria. After screening and quality assessment, nine randomized controlled trials (RCTs) were obtained for inclusion. Six articles were designated high quality and three were designated low quality.

TABULATION, INTEGRATION, AND RESULTS: Six of six RCTs examining IUD insertion failure with misoprostol revealed no difference in this measure. Of nine RCTs examining difficulty of IUD insertion with misoprostol, seven revealed no difference in this measure and two revealed decreased difficulty of insertion with misoprostol administration. Of nine RCTs examining pain with IUD insertion, seven revealed no difference in pain measurement scores, one revealed increased pain with misoprostol administration, and one revealed decreased pain with misoprostol administration. Five studies examining rates of expulsion and two studies examining complications of IUD insertion revealed no difference in this measure.

CONCLUSION: No data support routine administration of misoprostol before IUD insertion. Success of insertion is high even among nulliparous women, and good-quality data do not demonstrate that misoprostol use increases success. These data similarly reveal no differences in difficulty of insertion, pain with insertion, or expulsion with prior administration of misoprostol. However, data for several outcomes are limited by lack of power.