Does Copay Amount or Insurance Type Impact
the Duration of Levonorgestrel IUD Retention?
Lauren E Vestal1, Mistie P Mills2 and Erma Z Drobnis3*
1Department of Obstetrics, Gynecology and Women’s Health, University of Missouri-Kansas City School of Medicine, USA
2Department of Obstetrics, Gynecology and Women’s Health, University of Missouri-Columbia School of Medicine, USA
3Department of Ob/Gyn & Women’s Health, University of Missouri, USA
Submission: February 09, 2019;Published: February 21, 2019
*Corresponding author: Erma Z Drobnis, Department of Ob/Gyn & Women’s Health, University of Missouri, USA
How to cite this article: Lauren E V, Mistie P M, Erma Z D. Does Copay Amount or Insurance Type Impact the Duration of Levonorgestrel IUD Retention?. J Gynecol Women’s Health 2019: 14(2): 555884. DOI: 10.19080/JGWH.2019.14.555884
Objective: To determine whether co-payment amount or insurance status at the time of levonorgestrel-releasing intrauterine device (Mirena IUD) insertion affects duration of device retention.
Study design: Insertions and removals of levonorgestrel-releasing IUDs performed at an academic Obstetrics and Gynecology practice from October 2004 to October 2009. Data collection was performed, via procedure codes and chart review, yielding 199 IUD insertions for 160 patients, with 161 cases of individual IUD insertion-removals and 38 re-insertions with the IUD retained at study completion. The median (interquartile range) retention duration was10 (4.4-20) months, copay amount $3.5 ($0-25), patient age 26 (23-32) years, number of prior pregnancies 2 (1-3), number of prior abortions 0 (0-1) and number of living children 2 (1-2). The primary outcome was IUD retention duration in relation to copay amount at insertion. Data analysis for 161 IUD insertions with removals was performed using Mann-Whitney rank sum analysis and Spearman correlation, and for the entire study cohort of 199 IUD insertions, Kaplan-Meier log-rank and multivariable Cox hazard analyses, right-censored for IUDs retained at study completion.
Results: Retention time was not related to patient cost at time of insertion nor to privately-funded insurance. Factors that independently decreased IUD retention time were insertion for reason other than contraception (duration of 3 vs. 11 months; risk ratio 2.9; 95% confidence interval 1.5-5.4) and removal after second IUD insertion during study interval (10 vs. 11 months; 3.3; 1.7-6.1).
Conclusion: Copay amount and insurance type may not relate to duration of levonorgestrel-releasing IUD retention.
With the number of unintended pregnancies in the United States reaching almost three million in 2011  and with the escalating debate over controlling health care costs, aiding patients in choosing cost-effective and reliable contraception is paramount. Currently, 45% of pregnancies in the United States annually are unintended, and approximately 5% of reproductive-age women have an unintended pregnancy each year [1,2]. By age 45 years, over half of women in the United States have had an unintended pregnancy and 3 in 10 will have had an abortion. These numbers remain significantly higher than those in numerous other developed countries.
As conversation and legislative discussions continue regarding federal funding of contraception and of pregnancy care, it is essential to note that the total public expenses of unintended pregnancies nationwide were estimated at $21 billion in 2010 . Of that, $14.6 billion were federal expenditures and $6.4 billion were state expenditures. With appropriate counseling and contraceptive guidance, it may be possible to decrease these costs.
The women at greatest risk of unintended pregnancy are those that use contraception inconsistently or incorrectly and those that do not practice any form of contraception. They account for 41% and 54%, respectively, of all unintended pregnancies in the United States . If these women receive counseling and highly effective contraception , the numbers of unintended pregnancy will decline, as shown in the Contraceptive CHOICE study .
The 52mg levonorgestrel-releasing intrauterine device (Mirena IUD) has been FDA-approved for contraception since 2000, and is approved for usage up to five years. This progestin-releasing IUD (pIUD) is one of the most effective contraceptive agents [5-10]. In addition, recent research into cost-effectiveness of contraception in the US has revealed that the pIUD is also one of the most cost-effective methods currently available [7-12]. The cost-effectiveness of the pIUD has been well-documented if
the device is retained for the full five years [7-10]. Importantly,
the cost-effectiveness can be drastically affected if not retained
for its intended duration. Considerable data exist investigating
contraceptive choice as it relates to race, age, socioeconomic
status, parity and marital status ; however, no research
addresses the use of the pIUD specifically as it relates to
insurance provider or copay and its relation to retention. If a
difference in retention duration is found to be related to these
factors, counseling could maximize pIUD usage which may
decrease healthcare financial strain.
With recent changes in government coverage of contraceptive
care , more women have access to contraception. It is
therefore important to investigate whether the woman’s payer
status relates to her retention of highly effective contraception.
This retrospective chart review was approved by the University
of Missouri Health Sciences Institutional Review Board.
Using American Medical Association Current Procedural Terminology
(CPT) procedure codes, records of all insertions and
removals of Mirena pIUDs performed at the University of Missouri-
based Obstetrics and Gynecology practice were collected
during the period of October 2004 to October 2009. Data collection
was performed by direct chart review by one reviewer
(LV). Data were matched for those patients with insertion and
removal for this time frame. For these patients, data collected
included type of insurance provider, insurance company, copay
requirements and length of pIUD retention. Some patients had a
pIUD removed followed by re-insertion of a new pIUD, and these
second pIUD insertions were included in right-censored analyses.
Inclusion criteria were as follows: At least one levonorgestrelreleasing
IUD placed and removed during the study period by the
University-based Obstetrics and Gynecology practice. Exclusion
criteria were as follows: lack of documentation, inaccurate
The primary outcome variable was the retention time for
pIUD in relation to up front patient cost at the insertion visit.
Patient cost was categorized into 4 groups: $0 for no copay; < $50
and $50 - $100 for insured patients with a copay; and $15,000,
which was the cost of the pIUD for patients with no insurance
coverage. Secondary outcome variables were age, number of
prior pregnancies, number of term pregnancies, number of prior
abortions, number of living children, delivery within the past 12
months, whether the patient had a second pIUD insertion within
the study period, contraception as the indication for insertion,
and whether the pIUD was removed for desire to become
Because retention time was not normally distributed, Mann-
Whitney rank sum analyses and Kruskal-Wallis ANOVA were used
to compare pIUD retention for categorical factors, and Spearman
rank sum correlation for numerical outcomes when pIUD
insertion was followed by removal during the study period. In
analyses of all pIUD insertions, including those retained at study
completion, Kaplan-Meier analyses were used for univariable
analyses while multivariable, Cox regression analyses were used
to determine how the “risk” of pIUD removal over time for the
factors studied. Hazard analyses were right-censored to account
for women retaining an pIUD at the end of the study.
Data collection yielded 1,830 pIUD insertion and removal
events during the study period. After sorting for individual
patients with at least 1 insertion and 1 removal event, 205 pIUD
insertions remained. Exclusions were 3 for inaccurate coding
and 3 due to inability to obtain data from the electronic medical
record or paper chart. This yielded 199 pIUD insertions in 160
patients. The patient demographics and descriptive statistics for
the pIUD insertions are shown in Table 1. Of the pIUD insertions
studied, 161 individual pIUDs were inserted then removed
during the study period. Thirty-eight pIUDs were not removed,
28 were second pIUDs placed in patients with a prior insertion/ removal and 10 were placed when the first pIUD was removed
due to expiration of its 5 year effective lifespan. We assumed that
these pIUDs were in place at the end of the study.
*p values from univariable Mann-Whitney rank sum tests
*p values from Spearman rank sum correlation
*p values from multivariable Cox log-rank regression analysis
First, we looked at the 161 pIUD insertions that were followed
by removal during the study period. pIUD retention time was
not related to copay category ($0, <$100, $1500), or to payer
category (private insurance, government payer, or self-pay),
by univariable analysis of these factors (Table 2). Multivariable
risk analysis of the entire population also found no difference in
duration of pIUD retention for copay or payer categories when
controlling for the other factors analyzed (Table 3&4).
Univariable analysis (Tables 1&2) found that pIUD retention
duration was longer if the pIUD was inserted for contraception,
if the patient had delivered within 12 months before pIUD
insertion, if the pIUD was removed in order to attempt pregnancy,
or if the patient was younger at the time of pIUD insertion.
Factors not associated to retention duration were whether the
pIUD insertion was the second for the same patient, if the patient
had one or more abortions prior to pIUD insertion, the number
of pregnancies or term pregnancies prior to pIUD insertion, or
the number of living children at the time of insertion. When
controlling for other factors in a multivariable model, whether
the pIUD insertion was the second for the same patient became a
significant factor and if the pIUD was inserted for contraception
remained significant, while all other factors were not related to
pIUD retention duration. The 15 pIUD insertions not performed
for contraception were 13 for menorrhagia, 1 for endometriosis
and 1 for endometrial hyperplasia.
In this unique study, we have demonstrated that retention
of pIUDs are not affected by financial motivators. Neither cost to
patient nor payer categories affected duration of pIUD retention
in our study. Retention duration was shorter for second pIUD
insertions during the study period, which is not unexpected.
Longer retention duration was also found if the pIUD was
inserted for contraception, compared with those placed for other
As discussed, very few analyses have investigated these
variables specifically related to retention of pIUDs, thus this
study is novel. Several studies have investigated the likelihood
of women to use medically prescribed contraception depending
on their personal cost. In a large, recent study, Carlin et al. 
compared contraceptive choice in a cohort of women with
employer-sponsored coverage, before and after the Affordable
Care Act (ACA)-mandated decrease in cost-sharing (i.e. lower
cost to patient). There was an increase in women’s use of
prescribed contraception after ACA compliance compared with
before. These authors also noted a 2.3% increase over the 30%
of women who selected long term contraception methods. This
suggests that women with insurance through work are more
likely to use prescribed contraception methods if their outof-
pocket cost is low. Consistent with this finding, two earlier
studies [15,16] found that IUD initiation rates were less for
those women with employer-sponsored or private insurance
plans requiring higher cost sharing than those who had less out of-pocket cost. Limitations to these studies were they did not
address the factors effecting retention or continuation of long
Considering the current political climate, with fluctuating
legislation affecting contraception and women’s health care, it
is very important to know what motivates patients’ long term
decisions. This study showed that the up-front cost of reliable,
long-acting reversible contraception did not significantly affect
a woman’s decision regarding length of usage in our population.
This information is valuable when counseling women on their
reproductive plans. As cost does not appear to relate to patients’
contraceptive length of use, physicians can be confident in
recommending long-acting reversible contraceptives such as the
pIUD to all patient populations. Furthermore, legislators should
be assured that by reducing fees and increasing access, they will
not hamper the retention of long-acting reversible contraceptives
like the pIUD. Appropriate counseling, together with legislation
to increase access, can decrease health care expenditures by
decreasing the rate of unplanned pregnancy.
Our study was limited in that it may have been underpowered
to detect differences. The possibility of the latter is less likely due
to the risk ratio of pIUD removal by up-front cost was essentially
1.0 with tight 95% confidence interval. Other limitations of this
study include its retrospective nature as well as the timeframe
occurring prior to the implementation of the ACA. Furthermore,
whether this data is generalizable is uncertain, as this was a
A strength of the study is that the data were collected by a
single reviewer, thus limiting errors and imprecision. Additionally,
to our knowledge this is the first study of its kind, investigating
financial motivators as related to pIUD retention. Even though
this study was conducted prior to the implementation of the
ACA, it may be more useful, as the data is unaffected by those
changes. Opportunities for more research exist. They include the
analysis of other data points from this study, how the ACA has
affected retention time, whether retention is dependent on type
of IUD and investigating these data points at multiple sites for
This is the first study of its kind in the US to investigate
IUD retention duration as related to patient cost/insurance
type at the time of insertion. This can have major implications
for counseling and access to IUDs given the current legislative
All pIUD insertions that resulted in removal during a 5
year study period at a single university-based Obstetrics and
Gynecology practice were included (n=161). A. pIUD retention
duration, categorized by patient cost at the time of insertion,
is shown using Tukey box plots with filled triangles indicating
outliers + 3.0 times the interquartile range from the median.
B. Kaplan-Meier curves from right-censored survival analysis
(pIUD retention duration) of all pIUD insertions during the
study period (n=199) categorized by copay category detected no
difference between copay groups (p=0.90 by log-rank analysis).
All patients who had a pIUD inserted and removed within the
5 year study period at a single university-based Obstetrics and
Gynecology practice were included (n=167). A. Box plots showing
data for patients with and without private insurance. Horizontal
lines on the box plots enclose 90% of the data. B. Kaplan-Meier
curves from right-censored survival analysis (pIUD retention
duration) of all pIUD insertions during the study period (n=199)
categorized by payer category detected no difference between
copay groups (p=0.26 by log-rank analysis).