USA: Immediate postabortal insertion of intrauterine devices

From the Cochrane Database of Systematic Reviews.

The authors note that insertion of an intrauterine device (IUD) immediately after an abortion has several advantages. The woman is known not to be pregnant. Many clinicians refuse to insert an IUD in a woman who is not menstruating. After induced abortion, a woman’s motivation to use contraception may be high. However, insertion of an IUD immediately after a pregnancy ends carries risks, such as spontaneous expulsion due to recent cervical dilation.

The study’s objectives were to assess the safety and efficacy of IUD insertion immediately after spontaneous or induced abortion. The authors searched MEDLINE, CENTRAL, POPLINE, EMBASE, ClinicalTrials.gov, and ICTRP. They also contacted investigators to identify other trials.

The authors sought all randomised controlled trials with at least one treatment arm that involved IUD insertion immediately after an induced abortion or after curettage for spontaneous abortion, and identified 11 trials which described random assignment. The authors evaluated the methodological quality of each report and abstracted the data. We focused on discontinuation rates for accidental pregnancy, perforation, expulsion, and pelvic inflammatory disease. They computed the weighted average of the rate ratios, and computed relative risks (RR) with 95% Confidence Intervals (CI).

The main results found three trials randomised to immediate or delayed insertion. One showed no significant differences. Meta-analysis of two showed use of levonorgestrel-releasing intrauterine system or CuT380A was more likely for immediate versus delayed insertion (RR 1.18; 95% CI 1.08 to 1.28). Another trial randomised to the levonorgestrel IUD or Nova T; discontinuation rates due to pregnancy were 0.8 and 9.5, respectively. Sub-analysis showed higher expulsion rates for postabortal than interval insertions (levonorgestrel: 2.8 versus 6.8; Nova T: 3.0 versus 8.3).

Seven trials examined immediate insertion. From meta-analysis of two multicenter trials, pregnancy was less likely for the TCu 220C versus the Lippes Loop (RR 0.38; 95% CI 0.20 to 0.72) as was expulsion (RR 0.51; 95% CI 0.30 to 0.88). Estimates for the TCu 220 versus the Copper 7 were 0.52 (95% CI 0.36 to 0.77) and 0.58 (95% CI 0.39 to 0.87), respectively. In other work, adding copper sleeves to the Lippes Loop improved efficacy (RR 3.82; 95% CI 1.41 to 10.36) and reduced expulsion (RR 3.37; 95% CI 1.65 to 6.90).

The authors concluded that insertion of an IUD immediately after abortion is safe and practical. IUD expulsion rates appear higher than after interval insertions. However, IUD use is higher at six months with immediate than with interval insertion.

Behavioral and Biomedical Research, Family Health International, P.O. Box 13950, Research Triangle Park, North Carolina, USA, 27709.

Immediate postabortal insertion of intrauterine devices. Grimes DA, Lopez LM, Schulz KF, Stanwood NL. Cochrane Database of Systematic Reviews. 2010 Jun 16;6:CD001777.