More evidence on postpregnancy IUD placement
Bednarek PH, Creinin MD, Reeves MF, Cwiak C, Espey E, Jensen JT; Post-Aspiration IUD Randomization (PAIR) Study Trial Group. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med. 2011;364(23):2208–2217.
Cremer M, Bullard KA, Mosley RM, et al. Immediate vs. delayed post-abortal copper T 380A IUD insertion in cases over 12 weeks of gestation. Contraception. 2011;83(6):522–527.
Hohmann HL, Reeves MF, Chen BA, Perriera LK, Hayes JL, Creinin MD. Immediate versus delayed insertion of the levonorgestrel-releasing intrauterine device following dilation and evacuation: a randomized controlled trial. Contraception. 2012;85(3):240–245.
Shimoni N, Davis A, Ramos ME, Rosario L, Westhoff C. Timing of copper intrauterine device insertion after medical abortion: a randomized controlled trial. Obstet Gynecol. 2011;118(3):623–628.
Betstadt SJ, Turok DK, Kapp N, Feng KT, Borgatta L. Intrauterine device insertion after medical abortion. Contraception. 2011;83(6):517–521.
Celen S, Sucak A, Yildiz Y, Danisman N. Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section. Contraception. 2011;84(3):240–243.
Intrauterine devices have received a great deal of attention in recent years. Indeed, the utilization rate has increased significantly, with 5.5% of contraceptive users—2.1 million women—now using an IUD.4 Although most women who use an IUD obtain it at an outpatient office, remote from pregnancy and where the safety profile and risk of expulsion are well documented, many women who desire effective contraception like an IUD may not be seen by a provider until they are pregnant.
A significant body of data has been published recently on the role of postpregnancy IUD placement, adding important information to the existing body of literature.
Multicenter randomized trial. A study in the United States by Bednarek and co-workers demonstrated that immediate post-aspiration placement of an IUD resulted in a higher rate (>90%) of IUD utilization at 6 months than did insertion 6 to 8 weeks postpartum (just above 75%). Furthermore, five pregnancies were documented in the group with delayed IUD insertion; none were seen in the immediate-insertion group.
Independent randomized trials. Two studies (by Cremer and colleagues and Hohmann and colleagues) showed that immediate post-dilation and evacuation placement of an IUD also yielded a significantly higher rate of continued usage at 6 months than did delayed placement. (The terms “postaspiration” and “post–dilation and evacuation” are important as they encompass elective termination procedures for miscarriage management and fetal demise among women who may have undesired fertility.) For women having such procedures who do not want another pregnancy in the near future, immediate provision of highly effective contraception can best be performed at the time of the procedure.
New data: Use of IUD after medical abortion. A randomized trial conducted by Shimoni and colleagues showed 1) no significant difference in expulsion after immediate versus delayed placement and 2) several pregnancies in the delayed group. Regrettably, the investigators did not clearly define “immediate placement.”
In another prospective cohort study, Betstadt and coworkers reported a low rate of expulsion (4.1%) when an IUD was placed within 14 days after confirmed medical abortion. The findings of that study were also limited because the researchers followed women for only 3 months after the IUD was placed.
These new studies shed important light on the safety and tolerability of immediate IUD insertion. More questions remain, however, about ideal timing of placement after medical abortion. Postpartum IUDs have also been promoted as an important method of effective contraception despite higher expulsion rates than interval insertion, which must be compared to the high rate of loss to follow-up.5
Prospective cohort study. A well-designed study recently addressed outcomes of post-placental IUD placement during cesarean delivery. Celen and colleagues followed 245 women for longer than 1 year after postplacental copper-T IUD placement and reported a 17% cumulative expulsion rate and an overall continuation rate of 62%. These rates are not significantly lower than the cumulative expulsion rate and overall continuation rate associated with postplacental insertion after vaginal delivery. The investigators also reported no increased risk of serious complications, infection, or perforation with postplacental IUD placement after cesarean delivery.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
The necessity of coming to clinic in the months right after the end of a pregnancy to obtain highly effective contraception is, for women who are in this position, a well-established barrier to ensuring that they receive the protection they want. We now have important data showing that IUD placement after suction aspiration, dilation and evacuation, cesarean delivery, and vaginal delivery6 is effective and causes minimal side effects.
Better data are needed before we can make a universal recommendation about inserting an IUD shortly after medical abortion.
Overall, you should consider that the reversibility and known safety profile of an IUD continue to make this device an ideal contraceptive for many women.