Executive Summary

A recent webinar hosted by the American Congress of Obstetricians & Gynecologists’ LARC Program focuses on the use of a long-acting reversible contraceptive - the IUD- for emergency contraception.

  • The copper IUD represents an excellent choice for emergency contraception since it is the most effective at preventing pregnancy after unprotected sex.
  • Although the copper IUD is the only device approved for emergency contraception, the levonorgestrel IUD is currently under investigation for this purpose.

What do you need to know about emergency contraception (EC) methods and new clinical recommendations, as well as ways to improve access to LARC at the time of EC visits?

The Washington, DC-based American Congress of Obstetricians & Gynecologists’ LARC Program recently hosted a free webinar, “LARC and Emergency Contraception,” to help clinicians get up to speed on the subject. (Access the archived webinar at http://bit.ly/2e4dN81.)

According to David Turok, MD, MPH, associate professor in the Department of Obstetrics and Gynecology at the University of Utah in Salt Lake City and the webinar presenter, a systematic review of the emergency contraceptive efficiency of the copper IUD indicated a pregnancy rate of 0.09% – less than a 1/1000 risk of pregnancy.1 The review looked at results from 42 studies conducted in six countries, looking at eight types of copper IUDs used by 7,034 women.

Compared to EC users who choose oral levonorgestrel, those who select the copper IUD have lower rates of pregnancy in the next year, results of a 2014 study indicate.2 The prospective study followed women for one year after choosing the copper T380 IUD or oral levonorgestrel for EC. The study was powered to detect a 6% difference in pregnancy rates within the year after presenting for emergency contraception.

Of the 542 women who presented for emergency contraception, agreed to participate in the trial, and met the inclusion criteria, 215 (40%) chose the copper IUD and 327 (60%) chose oral levonorgestrel. In the IUD group, 127 (59%) were nulligravid. IUD insertion failed in 42 women (19%). The one-year follow-up rate was 443/542 (82%); 64% of IUD users contacted at one year still had their IUDs in place.

The one-year cumulative pregnancy rate in women choosing the IUD was 6.5% vs. 12.2% in those choosing oral LNG [hazard ratio (HR) 0.53, 95% confidence interval (CI): 0.29-0.97, P=.041]. By type of EC method actually received, corresponding values were 5.2% for copper IUD users vs. 12.3% for EC pill users (HR 0.42, 95% CI: 0.20-0.85, P=.017). A multivariable logistic regression model controlling for demographic variables indicates that women who chose the IUD for EC had fewer pregnancies in the following year than those who chose oral LNG (HR 0.50, 95% CI: 0.26-0.96, P=.037). Greater use of the copper IUD for EC might lower rates of unintended pregnancy in high-risk women, researchers conclude.2

In a 2016 study, researchers offered women who presented for emergency contraception either the copper IUD or oral emergency contraception plus the levonorgestrel 52 mg IUD. Two weeks after IUD insertion, participants reported the results of a self-administered home urine pregnancy test. The primary outcome, EC failure, was defined as pregnancies resulting from intercourse occurring within five days prior to IUD insertion.3

One hundred eighty-eight women enrolled and provided information regarding their current menstrual cycle and recent unprotected intercourse.

Sixty-seven (36%) chose the copper IUD and 121 (64%) chose oral levonorgestrel plus the levonorgestrel IUD. The probability of pregnancy two weeks after oral EC plus the LNG IUD was 0.9% (95% CI 0.0-5.1%). The only positive pregnancy test after treatment occurred in a woman who received oral EC plus the levonorgestrel IUD and who had reported multiple episodes of unprotected intercourse including an episode more than five days prior to treatment.3

Turok says a new trial will look at women who are interested in an IUD for emergency contraception. The women will be randomly assigned to copper or levonorgestrel IUD use. The primary outcome will be non-inferiority pregnancy at four weeks, with the secondary outcome defined as IUD continuation.

Why LARC is Best

Why do LARC methods – specifically the IUD – represent a good choice for emergency contraception?

The copper IUD (ParaGard, Teva Women’s Health, Sellersville, PA) represents an excellent choice for emergency contraception since it is the most effective at preventing pregnancy after unprotected sex, says Eve Espey, MD, MPH, chair of the Department of Obstetrics and Gynecology and professor in the faculty of the Department of Obstetrics and Gynecology, Division of Family Planning at the University of New Mexico. The copper IUD is more effective than either of the two emergency contraceptive pills (levonorgestrel, multiple marketers, and ulipristal acetate, marketed as ella, Afaxys, Charleston). Additionally, the copper IUD is effective for up to five days after unprotected sex and can be used for ongoing long-term contraception.

“Although the copper IUD is the only device approved for emergency contraception, the levonorgestrel IUD (Mirena, Bayer HealthCare Pharmaceuticals, Whippany, NJ) is currently under investigation for this purpose,” says Espey, who serves as chair of the College’s LARC Working Group.

Clinicians need to remember the “five-day rule” when it comes to using contraception after EC, says Anita Nelson, MD, professor and chair of the obstetrics and gynecology department at Western University of Health Sciences in Pomona, CA.

Compared to LNG EC, ulipristal acetate is more effective and more effective for a longer period of time after unprotected sex, especially in women with greater body mass index. However, if progestin from a contraceptive is added before all the sperm from the accidental exposure are dead, ulipristal acetate’s efficacy can be compromised, states Nelson.

“Therefore, women should wait for five days after intercourse to start any hormonal method,” says Nelson. “And they need to use another method for every act of intercourse until the new method is effective.”

REFERENCES

  1. Cleland K, Zhu H, Goldstuck N, et al. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod 2012; 27(7):1,994-2,000.
  2. Turok DK, Jacobson JC, Dermish AI, et al. Emergency contraception with a copper IUD or oral levonorgestrel: an observational study of 1-year pregnancy rates. Contraception 2014; 89(3):222-228.
  3. Turok DK, Sanders JN, Thompson IS, et al. Preference for and efficacy of oral levonorgestrel for emergency contraception with concomitant placement of a levonorgestrel IUD: a prospective cohort study. Contraception 2016; 93(6):526-532.