June 2018

For patients who need emergency contraception (EC) and wish to use an LNG IUD as their ongoing method of contraception, there is no need to delay IUD placement, according to James Trussell, Kelly Cleland, and E. Bimla Schwarz, writing in the new edition of Contraceptive Technology (CT).[1] When an LNG IUD is placed at the time LNG EC pills are taken, pregnancy rates within 2 weeks have been less than 1%.[2] Studies are now underway to assess the efficacy of the LNG IUD alone as EC, as the copper IUD is now used as EC.

A recent study compared women seeking EC compared copper IUDs to the combination of oral LNG ECPs with concomitant placement of an LNG IUD.² There were 0 pregnancies in the copper IUD group, and 1 pregnancy in the LNG group, which was determined to be a luteal phase pregnancy rather than a failure. This could be welcome news to your patients, as more women in this study chose a LNG IUD with oral LNG EC (121 women) over the copper IUD (67 women) at the time of their visit.

Of course, the copper IUD remains a well-tested and very effective option for those needing an emergency contraceptive. The TCu380A is the most effective method of EC—more effective than use of ECPs— and is highly effective for up to 7 days from unprotected inter­course. In 42 studies conducted in 6 countries between 1979 and 2011 that included a total of 7,034 participants, the pregnancy rate was 0.09%.³ There were only 10 known failures.

Although most guidelines recommend placing a copper IUD for EC within 5 days of unprotected sex, limited data support using the copper IUD as emergency contraception through 10 days from unprotected sex.[3] Some evidence suggests that a copper IUD is highly effective if placed at any time in the menstrual cycle.[4]

Eligibility criteria and contraindications for emergency placement of an IUD are the same as for all IUD placements. If concern exists about sexually transmitted infection (STI) (e.g. after unprotected intercourse with a new sexual partner or sexual assault), testing for STIs should occur at the time of IUD placement; if clinical sus­picion of STI is high, empiric antibiotics may be given. Patients who are found to harbor an STI after an IUD has been placed can be effectively treated with antibiotics with the IUD in place.

Side effects after emergency placement of an IUD are similar to those seen after routine placement and may include abdominal discomfort and vaginal bleeding or spotting.

Instructions for patients who have emergency placement of an IUD are the same as for anyone who has an IUD placed. However, if there is concern of luteal phase pregnancy, a pregnancy test should be completed within 3 weeks of taking EC. After taking EC pills, a period may start a few days earlier or later than usual. If she thinks she may be pregnant, she should see her clinician as soon as possible, whether or not she plans to continue the pregnancy.

Most women, including teens, are good candidates for intrauterine contraception, write Gillean Dean and E. Bimla Schwarz in the upcoming new edition of Contraceptive Technology.[5] IUDs can be used safely by individuals who are nullipa­rous, have multiple partners, have history of ectopic pregnancies, or those with a history of PID as long as they have no symptomatic cervical infec­tion at the time of IUD placement. All IUDs can also be used by people with contraindications to estrogen. IUDs can be removed whenever desired, and may be appropriate for women who desire pregnancy in the next year or two.

For longer term contraception (i.e., not for emergency contraception), IUDs are typically over twenty times as effective as oral contraceptives.[6] IUDs with 52 mg LNG are the most effective IUDs,[7] with a cumulative 7-year pregnancy rate of 0.5%, compared with 2.5% for the TCu380A.[8] As an IUD’s LNG dose decreases, the efficacy of the IUD decreases; however, the 13.5 mg LNG IUD appears to be at least as effective as the TCu380A.[9]

[1] Trussell J, Cleland K, Schwarz EB. Emergency contraception. In: Hatcher RA, Nelson A, Trussell J, et al. (eds) Contraceptive Technology. 21^st edition. New York, NY: Ayer Company Publishers, Inc., in production.

[2] Turok DK, Sanders IN, Thompson IS, Royer PA, Eggebroten J, Gawron LM. Preference for and efficacy of oral levonorgestrel for emergency contraception with concomitant placement of a levonorgestrel IUD: a prospective cohort study. Contraception 2016; 93: 526-32.

[3] Cleland K, Zhu H, Goldstuck N, Cheng L, Trussell J. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod 2012;27:1994-2000.

[4] Turok DK, Godfrey EM, Wojdyla D, Dermish A, Torres L, Wu SC. Copper T380 intrauterine device for emergency contraception: highly effective at any time in the menstrual cycle. Hum Reprod 2013;28:2672-6.

[5] Dean G and Schwarz EB. Intrauterine devices (IUDs). In: Hatcher RA, Nelson A, Trussell J, et al. (eds) Contraceptive Technology. 21^st edition. New York, NY: Ayer Company Publishers, Inc., in production.

[6] Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012;366:1998-2007.

[7] HeinemannK Reed S, Moehner S, Minh TD. Comparative contraceptive effectiveness of levonorgestrel-releasing and copper intrauterine devices: the European Active Surveillance Study for Intrauterine Devices. Contraception 2015;91:28003.

[8] Rowe P, Farley T, Peregoudov A, et al. 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.

[9] Nelson A, Apter D, Hauck B. et al. Two low-dose levonorgestrel intrauterine contraceptive systems: a randomized ontrolled trial. Obstet Gnecol 2013;122:1205-13.