larc removal as an essential service

In light of the current COVID-19 pandemic, routine preventive outpatient services have been broadly suspended or switched to telemedicine across the health care system. On March 15, 2020, the Massachusetts Executive Office of Health and Human Services (EOHHS) issued a memorandum to health care providers instructing them that some medical procedures should be deferred during the pandemic. PICCK believes that clinicians should proceed with the insertion of contraceptive devices according to their individual clinical judgment and institutional policies. However, we believe that removal of contraceptive devices should not be delayed. Declining to schedule removals is potentially unethical as it could compel individuals to continue using a medical device against their will. Individuals may desire removal for a variety of reasons, including a desired return to normal fertility.

The March 15 memorandum from EOHHS states in part:

“to focus health care personnel resources on responding to this outbreak and conserve the critical shortage of personal protective equipment, all hospitals and ambulatory surgical centers are directed to postpone or cancel any nonessential, elective invasive procedures…[The Massachusetts Department of Public Health] recommends that providers at each hospital or ambulatory surgical center use their clinical judgment on a case by case basis regarding any invasive procedures that must be done to preserve the patient’s life and health. This does not apply to the cancelation or delay of life sustaining care. DPH defines nonessential, elective invasive procedures as procedures that are scheduled in advance because the procedure does not involve a medical emergency; provided, however, that terminating a pregnancy is not considered a nonessential, elective invasive procedure for the purpose of this guidance. However, the ultimate decision is based on clinical judgement by the caring physician.”

PICCK encourages providers to prioritize the prompt removal of contraceptive devices such as intrauterine devices and subdermal implants upon patient request, according to the following principles:

• Patients considering contraceptive device removal for the purposes of achieving pregnancy should be made aware that the effects of COVID-19 on pregnancy are currently unknown.
• Patients seeking device removal due to unacceptable side effects or other reasons unrelated to fertility must weigh their desire for removal against the increased risk of presenting for care in a setting where they may be at increased risk of viral infection due to the potential presence of asymptomatic individuals with COVID-19 illness.
• Patients should be advised to engage in social distancing when transporting themselves to a device removal appointment and as much as possible within medical facilities.
• Pre-removal counseling on risks and alternatives may be effectively achieved via telemedicine, minimizing time in the clinic.