Immediate postabortal insertion of intrauterine devices: Cochrane systematic review

Abstract

Assessed as up to date: 2014/04/01

Background

The use of an effective contraceptive may be necessary after an abortion. Insertion of an intrauterine device (IUD) may be done the same day or later. Immediate IUD insertion is an option since the woman is not pregnant, pain of insertion is less because the cervical os is open, and her motivation to use contraception may be high. However, insertion of an IUD immediately after a pregnancy ends carries risks, such as spontaneous expulsion.

Objectives

To assess the safety and efficacy of IUD insertion immediately after spontaneous or induced abortion.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov, and ICTRP in January 27, 2014. We also contacted investigators to identify other trials.

Selection criteria

We sought all randomised controlled trials (RCTs) with at least one treatment arm that involved IUD insertion immediately after an induced abortion or after curettage for spontaneous abortion.

Data collection and analysis

We 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. We computed the weighted average of the rate ratios. We computed risk ratios (RRs) with 95% Confidence Intervals (CIs). We performed an intention-to-treat (ITT) analysis by including all randomised participants in the analysis according to the Cochrane Handbook for Systematic Reviews of Interventions.

Main results

We identified 12 trials most of which are of moderate risk of bias involving 7,119 participants which described random assignment. Five trials randomised to either immediate or delayed insertion of IUD. One of them randomised to immediate versus delayed insertion of Copper 7 showed immediate insertion of the Copper 7 was associated with a higher risk of expulsion than was delayed insertion (RR 11.98, 95% CI 1.61 to 89.35,1 study, 259 participants); the quality of evidence was moderate. Moderate quality of evidence also suggests that use and expulsion of levonorgestrel-releasing intrauterine system or CuT380A was more likely for immediate compared to delayed insertion risk ratio (RR) 1.40 (95% CI 1.24 to 1.58; 3 studies; 878 participants) and RR 2.64 (95% CI 1.16 to 6.00; 3 studies; 878 participants) respectively. Another trial randomised to the levonorgestrel IUD or Nova T showed discontinuation rates due to pregnancy were likely to be higher for women in the Nova T group. (MD 8.70, 95% CI 3.92 to 13.48;1 study; 438 participants); moderate quality evidence.

Seven trials examined immediate insertion of IUD only. From meta-analysis of two multicentre trials, pregnancy was less likely for the TCu 220C versus the Lippes Loop (RR 0.43, 95% CI 0.24 to 0.75; 2 studies; 2257 participants ) as was expulsion (RR 0.61, 95% CI 0.46 to 0.81; 2 studies; 2257 participants). Estimates for the TCu 220 versus the Copper 7 were RR 0.42 (95% CI 0.23 to 0.77; 2 studies, 2,274 participants) and RR 0.68, (95% CI 0.51 to 0.91); 2 studies, 2,274 participants), respectively. In other work, adding copper sleeves to the Lippes Loop improved efficacy (RR 3.40, 95% CI 1.28 to 9.04, 1 study, 400 participants) and reduced expulsion (RR 3.00, 95% CI 1.51 to 5.97; 1 study, 400 participants).

Authors' conclusions

Moderate quality evidence shows that insertion of an IUD immediately after abortion is safe and practical. IUD expulsion rates appear higher immediately after abortions compared to delayed insertions. However, at six months postabortion, IUD use is higher following immediate insertion compared to delayed insertion.

Author(s)

Okusanya Babasola O, Oduwole Olabisi, Effa Emmanuel E

Summary

Inserting an IUD right after abortion or miscarriage versus at a later time

Inserting an intrauterine device (IUD) right after an abortion or miscarriage can be good for many reasons. The woman is not pregnant and may be thinking about birth control, and the time and place are convenient for the woman. If asked to delay IUD insertion, many women do not return to get the device. However, the IUD might be more likely to come out on its own if put in right after abortion or miscarriage. This review looked at how safe it was to insert an IUD right after abortion or miscarriage. We also looked at whether the IUD stayed in.

We did computer searches for randomised trials of IUDs inserted right after abortion or miscarriage. We also wrote to researchers to find more studies. Trials could compare types of IUDs or times for insertion. We found 12 studies to include.

Four trials randomised women to an IUD inserted right away or at a later time. One had no major difference. Three recent trials (of levonorgestrel intrauterine system or CuT380A) showed use was greater at six months for an IUD inserted right away compared to one inserted later. Another trial assigned women to the levonorgestrel IUD or Nova T; more women with the Nova T stopped use due to pregnancy. A subanalysis showed more IUDs came out when inserted right after abortion or miscarriage rather than later.

Seven trials looked at inserting the IUD right away. From two large trials, the TCu 220C was better than the Lippes Loop and the Copper 7 for preventing pregnancy and staying in. The IUD was more likely to come out on its own when inserted after a mid-pregnancy abortion than after an earlier one. In other work, when the Lippes Loop had copper arms added, fewer women got pregnant and the IUD stayed in more often.

Moderate level evidence shows that inserting an IUD right after an abortion or miscarriage is safe and practical. However, the IUD is more likely to come out when inserted right away rather than at a later time. Women are more likely to use an IUD at six months if they had it inserted right away compared to some weeks after the abortion or miscarriage.

Reviewer's Conclusions

Implications for practice

Moderate level evidence suggests that immediate insertion of an IUD after abortion is both safe and effective. This was true for both induced and reported 'spontaneous' abortions, many of which may have been induced under clandestine circumstances (WHO 1983b). IUD use is higher at six months with immediate insertion than with delayed insertion, though expulsion of IUD at six months may also be higher for immediate insertion.

Guidelines and package labelling that argue against postabortal insertions lack a scientific foundation. With immediate postabortal insertions, contraceptive efficacy is high, and PID and perforations are rare. While the risk of spontaneous expulsion of an IUD appears to be greater in this setting than with interval insertions, this potential disadvantage may be outweighed by provision of highly effective contraception with one procedure. The one-month follow-up visit (after the next menses) may be especially important for identifying unsuspected complete or partial expulsions. IUD insertion immediately after second-trimester abortion carries a higher risk of spontaneous expulsion than insertion after first-trimester abortion.

Implications for research

Newer data are available on immediate versus delayed insertion. Addition of full reports of three recent studies in this review has shown that expulsion of IUD is more likely after immediate insertion than delayed insertion of IUD. Two ongoing trials are also directly comparing the time of insertion. Those trials should help inform the field in the near future.

Many trials compared different IUDs for immediate postabortal insertion. Hence, these trials cannot address the comparative safety and efficacy of immediate insertion versus insertion at a later time. Also, many of the reports were of suboptimal quality, and communication with researchers was needed for supplementary information. Few reports had a sample size calculation, and several had little power to detect differences. Some IUDs reviewed here are no longer widely used.

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