Intrauterine devices, or IUDs, are suitable for nearly all women, including those who have just delivered a baby, have had an abortion or miscarriage, or who have a history of ectopic pregnancy, the American College of Obstetricians and Gynecologists now says.
The ACOG’s practice bulletin covers the three long-acting reversible contraceptives currently approved by the Food and Drug Administration: the copper T380A IUD, the levonorgestrel intrauterine system, and subdermal etonogestrel implants.
The copper IUD is recommended as an effective method of emergency contraception when inserted 5 days after unprotected intercourse, ACOG now says, citing a documented pregnancy rate of 0.23% from one study investigating the method in nearly 2,000 women (BJOG 2010;117:1205-10).
Another key recommendation is that prophylaxis with antibiotics to prevent pelvic infection is not necessary before inserting an IUD. This is supported by a meta-analysis of four randomized, controlled trials of women with a low prevalence of sexually transmitted infections, which found that antibiotic prophylaxis at the time of IUD insertion did not decrease the risk of pelvic inflammatory disease or the likelihood of removal within 3 months (Cochrane Database of Systematic Reviews 2007 [doi:10.1002/14651858.CD001327]).
The ACOG bulletin is the first full update in 6 years of its recommendations on IUDs, which have gained more widespread use in the interim – from 1.3% of contraceptive use in the United States in 2002 to 5.5% in 2008. The organization’s bulletins on IUDs – which in the 1990s were marked by restrictive and cautionary language – have become progressively more positive in the past decade, as safety findings accumulate and the consensus on patient eligibility has broadened.
A bulletin from the early 1990s describes IUDs as suited for older, parous, monogamous women who are not ready for sterilization, have no history of pelvic inflammatory disease or ectopic pregnancy, and who could not take oral contraceptives (Int. J. Gynaecol. Obstet. 1993;41:189-93).
But by 2005, the last time it issued a full practice bulletin concerning IUDs (Obstet. Gynecol. 2005;105:223-32), ACOG’s tone had changed dramatically, calling the devices "safe, effective, long-term contraception [that] should be considered for all women who seek a reliable, reversible contraception that is effective before coitus." The same year, the package insert of the copper IUD was changed to include its use in women who have not had any children, and in 2007, ACOG published a committee opinion saying that IUDs could be considered appropriate for use in adolescents (Obstet. Gynecol. 2007;110:1493-5).
The current bulletin, which replaces the 2005 guidance, not only includes the postcoital, emergency contraceptive use of the copper IUD, but explicitly promotes IUDs and implants, saying that the methods "may help lower U.S. unintended pregnancy rates because gaps in use and discontinuation of shorter acting methods are associated with unintended pregnancy rates in high-risk women."
The ACOG separated its updated recommendations into three levels based on the type and quality of evidence supporting them (Practice Bulletin 121; Obstet. Gynecol. 2011;118:184-96).
The recommendations that routine antibiotic prophylaxis is unnecessary before IUD insertion and that the copper IUD may be inserted up to 5 days after intercourse to prevent unwanted pregnancy, are classified as level A, which means that they are supported by good and consistent scientific evidence, ACOG said.
Insertion of an IUD immediately after childbirth is safe, the ACOG says, although it classifies this as a level B recommendation, one based on inconsistent evidence. The risk of an IUD inserted immediately after childbirth being expelled may be as high as 24%, ACOG noted, and insertion is contraindicated immediately after childbirth for women with peripartum chorioamnionitis, endometritis, or puerperal sepsis.
Other level B recommendations now include offering IUDs to women with previous ectopic pregnancy and to women who have just miscarried or had an abortion.
The safety evidence for insertion immediately after a first trimester abortion is stronger than that for a second-trimester procedure, according to the recommendations. Evidence suggests that women who have an IUD inserted immediately after abortion have higher rates of use and lower rates of repeat abortion, compared with women who received appointments for insertion later (Contraception 2011;83:34-40). However, the recommendations state that women who have had septic abortions should not receive an IUD until at least 3 months afterward.
Women who have had an ectopic pregnancy need not be excluded from receiving IUDs as they have not been shown to increase the absolute risk of ectopic pregnancy.
Subdermal implants may be offered to non-breastfeeding women any time after childbirth.
Expert opinion supports the recommendation that implants not be offered to breastfeeding women until 4 weeks after childbirth, because of theoretical concerns about contraceptive hormones affecting infant development.