EXECUTIVE SUMMARY

In a new study, a collaboration between the University of Utah Department of Obstetrics and Gynecology’s Family Planning Program and the Planned Parenthood Association of Utah, of 176 women receiving either a levonorgestrel or copper T intrauterine device (IUD) for emergency contraception (EC), 147 (67%) were using the method at one year.

  • Women participating in the study selected either the copper T380A IUD or a combination of the 52 mg levonorgestrel IUD and 1.5 mg oral levonorgestrel for emergency contraception.
  • While levonorgestrel emergency contraception pills are more accessible in many clinics, they do not represent the most effective method of EC. On the other hand, the copper T IUD is the most effective form of emergency contraception.

While placement of an intrauterine device (IUD) is the most effective form of emergency contraception (EC), how many women continue to use their IUD on a long-term basis? In a new study, a collaboration between the University of Utah Department of Obstetrics and Gynecology’s Family Planning Program and the Planned Parenthood Association of Utah, of 176 women receiving either a levonorgestrel or copper T IUD for EC, 147 (67%) were using the method at one year.1 Women participating in the study selected either the copper T380A IUD or a combination of 52 mg levonorgestrel IUD and 1.5 mg oral levonorgestrel for emergency contraception.

The study found that three of the women receiving IUDs became pregnant in the course of the first year.1 The three unintended pregnancies occurred in women receiving the levonorgestrel IUD, for a 12-month pregnancy rate of 1.7% (95% confidence interval [CI], 0.3%-4.9%). The first unintended pregnancy was classified as a luteal phase pregnancy that occurred in the index EC cycle, while the second unintended pregnancy was a result of an unrecognized IUD expulsion at 10 weeks post-insertion. The third unintended pregnancy occurred with an IUD in place at seven months post-insertion.1 The rate of unintended pregnancy in the IUD users in the current study is lower than in earlier studies of oral EC users initiating routine contraceptive care, which ranges up to 12%.2,3

There is little published data regarding one-year continuation rates when an IUD is initiated at the time of emergency contraception, the researchers note.1 Rates range from 64% in a small U.S. study to 94% in a large Chinese sample.4,5

Check the Data

To perform the current study, researchers enrolled 188 women who presented for emergency contraception at a single family planning clinic in Utah between June 2013 and September 2014. Women participating in the study selected either the copper T380A IUD or a combination of the 52 mg levonorgestrel IUD and 1.5 mg oral levonorgestrel for emergency contraception. Research personnel followed participants by phone, text, or email for 12 months, or until discontinuation occurred.

Why offer oral EC along with the IUD? In an earlier paper, the same researchers reported that study participants seeking EC who desired an IUD preferentially chose the pills along with the levonorgestrel IUD over the copper IUD. Neither group had EC treatment failures. Including the option of pills with concomitant insertion of the levonorgestrel IUD in EC counseling may increase the number of emergency contraception users who opt to initiate long-acting reversible contraception, researchers note.6

The analysis in the current study indicates 176 women received IUDs; 66 (37%) chose the copper IUD, while 110 (63%) chose the levonorgestrel IUD plus oral EC. At one year, of 147 (84%) participants, 33 (22%) had requested removal, 13 (9%) had an expulsion and declined reinsertion, three (2%) had a pregnancy with their IUD in place, and 98 (67%) still were using their device. Two-thirds of women who chose IUD placement when they came to the clinic requesting emergency contraception services were continuing to use their device, data indicate. Women initiating either the copper IUD or the levonorgestrel IUD had similar one-year continuation rates: 60% of copper IUD users and 70% of levonorgestrel IUD plus levonorgestrel EC users still were using their device at 12 months (adjusted hazard ratio 0.72, 95% CI, 0.40-1.3).1

Is the IUD Available for EC at Your Clinic?

While levonorgestrel emergency contraception pills are more accessible in many clinics, they do not represent the most effective method of EC. On the other hand, the copper T IUD is the most effective form of emergency contraception.

Where does your clinic stand when it comes to emergency contraceptive placement of IUDs? In a survey of 199 primary care, family planning, and obstetrician/gynecology clinics in nine U.S. cities, using a “mystery caller” assuming the role of a patient seeking the copper IUD for EC, less than half of family planning clinics offered an IUD as emergency contraceptive, compared to 13.8% of obstetrician/gynecology offices and 3.2% of primary care sites.7 On the other hand, in the same survey, researchers found that 87% of family planning clinics, all obstetrician/gynecology offices, and two-thirds (68%) of primary care clinics offered the copper IUD as a contraceptive.

When presenting the options for emergency contraception, clinicians may wish to use a patient education tool based on the tiered effectiveness approach developed by the University of California, San Francisco Bixby Center for Global Reproductive Health and the Bedsider Internet reproductive health resource. (See this chart at http://bit.ly/2uOaWps. Also, look at another example of a tiered chart produced by Planned Parenthood at http://bit.ly/2u9XCtH.)

Each night, close to 800,000 to 1 million women who do not want to become pregnant have completely unprotected sex, notes Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta. In the United States, 45% of all pregnancies are unintended, and 42% of those pregnancies are terminated by an abortion, he says. “If one of your goals is to increase the use of long-acting reversible methods, then the single intervention most likely to accomplish this would be the ready availability of copper IUDs and levonorgestrel IUDs as emergency contraceptives,” says Hatcher. 

REFERENCES

  1. Sanders JN, Turok DK, Royer PA, et al. One-year continuation of copper or levonorgestrel intrauterine devices initiated at the time of emergency contraception. Contraception 2017;96:99-105.
  2. Turok DK, Jacobson JC, Simonsen SE, et al. The copper T380A IUD vs. oral levonorgestrel for emergency contraception: A prospective observational study. Contraception 2011;84:321-322.
  3. Raine TR, Harper CC, Rocca CH, et al. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: A randomized controlled trial. JAMA 2005;293:54-62.
  4. 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;89:222-228.
  5. Wu S, Godfrey EM, Wojdyla D, et al. Copper T380A intrauterine device for emergency contraception: A prospective, multicentre, cohort clinical trial. BJOG 2010;117:1205-1210.
  6. 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;93:526-532.
  7. Schubert FD, Bishop ES, Gold M. Access to the copper IUD as post-coital contraception: Results from a mystery caller study. Contraception 2016;94:561-566.