There has been concern about the efficacy of implants in overweight women because the original trials of subdermal implants excluded women >130% of ideal body weight. However, according to the Contraceptive CHOICE Project, overweight and obese women enrolled in its program did not experience reduced contraceptive efficacy when using the implant when compared with normal-weight women.18
When can LARC devices be inserted?
LARC device insertion is possible at any time during the menstrual cycle. An algorithm to guide initiation of LARC is available through the Reproductive Health Access Project’s Web site at http://www.reproductiveaccess.org/wp-content/uploads/2014/12/quickstart_algorithm.pdf.
Rule out pregnancy before placing any LARC device. The copper IUD can be inserted at any time during the menstrual cycle without the need for back-up contraception.11,19 In contrast, for LNG-IUDs, back-up contraception is recommended for 7 days unless the insertion is done during the first 7 days of the menstrual cycle.12-14,19
For the implant, recommendations about when to insert are based on a woman’s previous method of contraception (TABLE 2).15 If insertion is done at a time other than when recommended, advise patients to use barrier protection for 7 days after insertion.4,15,19
Other issues often arise and cause concern about whether and when a LARC device can be inserted, including the possibility of undiagnosed STI, time elapsed since delivery, and advisability of use when breastfeeding.
Sexually transmitted infections and IUDs
Whether or not a woman chooses to receive an IUD, follow routine CDC guidelines in determining if a patient is a candidate for STI screening.20 If a woman wants an IUD and routine screening is recommended, you can perform screening on the day of IUD insertion.4,19 For women with an IUD already in place who are diagnosed with an STI, treat the infection while leaving the IUD in place.19 For women with a known or suspected STI who do not have an IUD already, treat the STI before inserting the IUD. The American Congress of Obstetricians and Gynecologists (ACOG) advises postponing insertion of an IUD until a negative STI test result is obtained 3 to 4 weeks after treatment completion.4
Breastfeeding concerns and timing of insertion postpartum
The US MEC classifies insertion of the copper IUD as category 1 for all postpartum women, regardless of breastfeeding status, if placed >4 weeks postpartum or immediately postpartum (defined as within 10 minutes of the delivery of the placenta). IUD placement is category 2 (recommended with the caution that advantages usually outweigh risks) if placed ≥10 minutes after placental delivery (until 4 weeks postpartum) because of an increased risk of expulsion.3
The US MEC also considers use of the implant and LNG-IUDs in breastfeeding women as category 1 if the device is placed at ≥4 weeks postpartum. Insertion at <4 weeks postpartum is considered category 2 because of concerns for decreased breast milk supply.3 However, studies on whether progestin-containing LARC devices affect breastfeeding have yielded varying results. In one randomized controlled trial (RCT) of 69 breastfeeding women using the implant, breastfeeding duration and milk production were not dependent on the timing of insertion after delivery.21 Another RCT of 96 women using LNG-IUDs showed fewer women continued to breastfeed at 6 months when their LNG-IUD was inserted immediately postpartum, compared with waiting 6 weeks.22
In addition to a concern about breast milk supply, breastfeeding women have a higher risk for uterine perforation from IUDs, especially during the first 36 weeks after delivery.23
Several studies have shown that there is a lower repeat pregnancy rate among women who receive immediate postpartum LARC placement.24 However, even if IUD insertion is performed immediately postpartum, there is a higher expulsion rate than when the IUD is inserted ≥4 weeks postpartum. The expulsion rates for insertion <10 minutes after vaginal delivery range from 9.5% to 15% for the copper IUD to as high as 24% for the LNG-IUDs. Expulsion rates for all IUDs are slightly lower for cesarean delivery.4,25,26 ACOG supports immediate post-placental placement for women with barriers to postpartum care or limited access to contraception.4
How can I help my patients make an informed choice?
Provide counseling on efficacy, common adverse effects, risks, and complications.
Efficacy is high
The failure rate of LARC is equal to, or lower than, that of female sterilization and is significantly lower than that of oral contraceptives (TABLE 1).4-6 Not only are LARC devices extremely effective, they have a higher rate of satisfaction than any other reversible contraceptive (TABLE 1).7,8