EXECUTIVE SUMMARY

The American College of Obstetricians and Gynecologists (ACOG) has issued an updated Practice Bulletin, “Long-Acting Reversible Contraception: Implants and Intrauterine Devices,” outlining new key data on the safety of long-acting reversible contraception, such as intrauterine devices and implants.

  • Copper IUDs have been shown to be effective for up to 12 years, and while the Liletta levonorgestrel -18.6 IUD was approved recently for four years of use, preliminary data suggest extended efficacy of up to five years. Research also indicates the Nexplanon etonogestrel implant is effective for at least four years.
  • Postpartum LARC insertion is recognized by ACOG as a best practice due to its role in preventing rapid repeat and unintended pregnancy. The copper IUD should be offered routinely to women who request emergency contraception and are eligible for IUD placement.

The American College of Obstetricians and Gynecologists (ACOG) has just issued an updated Practice Bulletin, “Long-Acting Reversible Contraception: Implants and Intrauterine Devices” outlining new key data on the safety of long-acting reversible contraception (LARC), such as intrauterine devices (IUDs) and implants.1 What can family planning clinicians take away from the new guidance?

“The new LARC Practice Bulletin covers some changes since 2011, including better knowledge about effectiveness, candidates, and timing of LARC insertion,” says Bulletin author Eve Espey, MD, MPH, professor and chair of the department of obstetrics and gynecology at the University of New Mexico School of Medicine. “Through the large amount of LARC research over the last few years, we have learned that IUDs are safe and effective for almost all women, including adolescents and women who have not had a baby, and that LARC methods are well tolerated by all groups of women.”

By reducing barriers to LARC access for appropriate candidates, family planning clinicians may aid in furthering the drop in unintended pregnancy rates in the United States, since gaps in contraception use and discontinuation of shorter-acting methods are associated with higher unintended pregnancy rates.2 Research indicates that typical-use pregnancy rates for LARC methods are lower when compared with those for oral contraceptives.3 A 2015 cost-effectiveness analysis from the public payer perspective suggests that LARC use becomes cost-neutral within three years of initiation when compared with use of short-acting methods.4

“LARC methods have been shown to be 20 times more effective than short-acting methods like the Pill in preventing unplanned pregnancy,” observes Espey. “When available free of charge, they are widely chosen by women of all ages and result in a reduction in unintended pregnancy and abortion rates at the population level.”5

New Data Support Extended Use

The new bulletin highlights recently released data that support extended use for some methods of LARC. Copper IUDs have been shown to be effective for up to 12 years.6 While the Liletta levonorgestrel (LNG) IUD (18.6 IUD, Medicines360, San Francisco and Actavis, Dublin, Ireland) was approved in August 2017 by the Food and Drug Administration for four years of use, preliminary data suggest extended efficacy of up to five years. The device may be approved for use for up to seven years since its ongoing Phase III trial accumulates yearly effectiveness data. (Review the data supporting the approval; see the September 2017 Contraceptive Technology Update article, “Data Indicate Efficacy of Liletta IUD for Four Years’ Use,” at http://bit.ly/2zK6cWI.) Data indicate that the Mirena IUD (LNG-20 IUD, Bayer HealthCare Pharmaceuticals, Whippany, NJ), is effective for at least seven years, with a seven-year pregnancy rate of 0.5 per 100 among women using the device.7

The Nexplanon etonogestrel implant (Merck, Whitehouse Station, NJ) is effective for at least four years, the bulletin states. Results of a 2016 study reported no pregnancies among 204 women using the etonogestrel implant for five years.8 Data from a 2017 study reported no pregnancies among 102 study participants who used the implant for five years.9

Anita Nelson, MD, professor and chair of the obstetrics and gynecology department at Western University of Health Sciences in Pomona, CA, says that one of the most important take-home messages from the Practice Bulletin is the long-lasting use of the implant, with no caveats about the age of the user or her body mass index.

“This will undoubtedly change practice,” states Nelson. “Based on this, women should be offered a fourth year of use, but if she is hesitant to go off-label, both providers and third party payors should be willing to give her a new implant at three years.”

When to Initiate LARC Methods

When can women begin to use intrauterine or implant contraception? According to research, an IUD or an implant may be inserted at any point during the menstrual cycle as long as pregnancy may be reasonably excluded.10 Insertion of LARC immediately after an induced or spontaneous abortion is safe and effective, the bulletin notes. The copper IUD should be offered routinely to women who request emergency contraception and are eligible for IUD placement.

Immediate postpartum LARC insertion is recognized by ACOG as a best practice, due to its role in preventing rapid repeat and unintended pregnancy.11,12 Immediately postpartum is particularly favorable for IUD or implant insertion, the Bulletin states. Placing an IUD within 10 minutes after placental delivery in vaginal and cesarean births or inserting a contraceptive implant prior to discharge home after a hospital admission for delivering a baby has many benefits for the woman, observes Espey. Just-published research indicates that postpartum insertion of a hormonal IUD does not affect a woman’s ability to lactate and breast feed.13

ACOG’s LARC Program has established the Postpartum Contraceptive Access Initiative to provide clinical and operational support training for immediate postpartum LARC implementation. Clinicians can check the initiative’s web site, https://pcainitiative.org, for details about the initiative, information about immediate postpartum LARC, and an application to become a participating hospital site.

The Centers for Disease Control and Prevention has established the 6/18 Initiative, a partnership between purchasers, payers, and providers, which considers insurance coverage of immediate postpartum LARC as a way to positively impact both health and costs. The initiative is working to ensure that both public and private payers reimburse for immediate postpartum LARC insertion by unbundling payment for LARC from other postpartum services. (CTU reported on the move to increase postpartum LARC access; see the May 2017 article, “Implement Resources for Immediate Postpartum LARC to Cut Unintended Pregnancy,” at http://bit.ly/2reIWJ2.

REFERENCES

  1. Committee on Practice Bulletins – Gynecology, Long-Acting Reversible Contraception Work Group. Practice bulletin 186: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2017;130:e251-e269.
  2. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012;366:1998–2007.
  3. Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397-404.
  4. Trussell J, Hassan F, Lowin J, et al. Achieving cost-neutrality with long-acting reversible contraceptive methods. Contraception 2015;91:49-56.
  5. Peipert JF, Madden T, Allsworth JE, et al. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012;120:1291-1297.
  6. Wu JP, Pickle S. Extended use of the intrauterine device: A literature review and recommendations for clinical practice. Contraception 2014;89:495-503.
  7. Rowe P, Farley T, Peregoudov A, et al; IUD Research Group of the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction. Safety and efficacy in parous women of a 52-mg levonorgestrel-medicated intrauterine device: A 7-year randomized comparative study with the TCu380A. Contraception 2016;93:498-506.
  8. Ali M, Akin A, Bahamondes L, et al; WHO study group on subdermal contraceptive implants for women. Extended use up to 5 years of the etonogestrel-releasing subdermal contraceptive implant: Comparison to levonorgestrel-releasing subdermal implant. Hum Reprod 2016;31:2491-2498.
  9. McNicholas C, Swor E, Wan L, Peipert JF. Prolonged use of the etonogestrel implant and levonorgestrel intrauterine device: 2 years beyond Food and Drug Administration-approved duration. Am J Obstet Gynecol 2017;216:586.e1-586.e6.
  10. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. selected practice recommendations for contraceptive use, 2016. MMWR Recomm Rep 2016;65(RR-4):1-66.
  11. American College of Obstetricians and Gynecologists. Committee on Gynecologic Practice Long-Acting Reversible Contraception Working Group. Committee Opinion No. 642: Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2015;126:e44-48.
  12. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. Committee Opinion No. 670: Immediate postpartum long-acting reversible contraception. Obstet Gynecol 2016;128:e32-37.
  13. Turok DK, Leeman L, Sanders JN, et al. Immediate postpartum levonorgestrel intrauterine device insertion and breast-feeding outcomes: A noninferiority randomized controlled trial. Am J Obstet Gynecol 2017; doi: 10.1016/j.ajog.2017.08.003.