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Immediate IUD Insertion Better Than Delayed


 

From the New England Journal of Medicine

IUD insertion immediately after first-trimester induced or spontaneous abortion rather than at a later visit decreases the likelihood of unintended pregnancy 6 months later, without raising the risk of complications such as IUD expulsion, pelvic infection, or uterine perforation, according to a recent report.

“Mathematical modeling suggests that a switch from delayed IUD insertion to immediate insertion could prevent more than 70,000 unintended pregnancies annually in the United States. However, the availability of immediate IUD insertion is restricted by federal funding for contraceptive use … because the provision of contraceptive services on the day of an abortion in the same facility is prohibited.

“Such policies that require health care providers to separate contraception provision from abortion provision reduce the likelihood that women will obtain the contraception needed to prevent unintended pregnancy,” said Dr. Paula H. Bednarek of Oregon Health and Science University, Portland, and her associates.

The investigators compared outcomes between immediate and delayed IUD insertion following first-trimester uterine aspiration in a study of 575 women who were treated at four academic medical centers across the United States. All the women requested an IUD, and selected either a levonorgestrel-releasing IUD (Mirena) or a copper device (ParaGard T380A) before undergoing uterine aspiration for induced or spontaneous abortion at 5–12 weeks' gestation.

Before the procedure commenced, the study subjects were randomly assigned to either immediate IUD insertion (258 women) within 15 minutes after completion of the procedure, or delayed insertion (317 women) at a separate visit 2–6 weeks later. Women were excluded from the study “in cases of failure to confirm completion of the aspiration, hemorrhage, perforation, or any other condition that, in the opinion of the surgeon, precluded safe IUD insertion,” the researchers noted.

All the study subjects maintained daily diaries of bleeding; cramping or pain; and medication use from the day of the aspiration until 1 month after IUD insertion. They were followed at 1, 3, and 6 months after the procedure with review of the diary; completion of a questionnaire; physical examination; ultrasound verification of the location of the IUD; and assessment for infection, pain, bleeding, pregnancy, and other medical concerns.

IUDs were inserted in 100% of the immediate-insertion group, compared with only 71% of the delayed-insertion group. This was because 29% of the women in the delayed-insertion group never returned for their scheduled insertion visit.

“Our results confirm previously published data showing that 25%–68% of women who make an appointment for an IUD placement after an abortion do not return,” Dr. Bednarek and her colleagues said.

After 6 months, the rate of IUD use was significantly higher in the immediate-insertion group (92%) than in the delayed-insertion group (77%). Women in the delayed-insertion group who never received an IUD frequently reported that they were instead using much-less-effective forms of contraception such as condoms (32%), or no method at all (25%).

During follow-up, no pregnancies occurred in the immediate-insertion group, while five pregnancies occurred in the delayed-insertion group. All five occurred in women who were not using IUDs. “Although this difference was not statistically significant, our study was not powered for this outcome and involved only 6 months of follow-up. A greater cumulative effect would be expected over a longer period,” they noted (N. Engl. J. Med. 2011;364:2208–17).

Rates of IUD expulsions were low in both groups and not significantly different between the two groups, with a 5% rate in the immediate-insertion group and a 2.7% rate in the delayed-insertion group. Thus, immediate IUD insertion carried a slightly higher but statistically noninferior rate of expulsion than delayed IUD insertion.

Rates of other adverse events also were no different between the two groups. Rates of incomplete abortion requiring a repeat uterine aspiration were 0.8% with immediate insertion and 0.9% with delayed insertion. Rates of pelvic infection were 1.9% and 1.6%, respectively, and there were no cases of uterine perforation.

Pelvic infections were uncommon, even among women with a history of pelvic inflammatory disease and women who tested positive for chlamydia at the time of the procedure. “These findings support the expansion of access to IUDs after first-trimester uterine aspiration, including elimination of an additional visit to test for sexually transmitted infection when no infection is clinically evident.

“In addition, these data add to the growing body of evidence supporting the safety and effectiveness of IUD use among a wider range of women who previously may not have been considered good candidates for an IUD,” Dr. Bednarek and her associates said.

This study was limited in that there was substantial loss to follow-up in both groups of patients, with 27% of women in the immediate-insertion group and 25% of those in the delayed-insertion group dropping out of the study. “Ongoing contact with women who have undergone an abortion is difficult,” as many of them “have to travel a great distance to obtain an abortion and many wish to maintain their privacy,” they said.

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