IUD for EC: Check the Utah experience
New research to emerge
Can increased use of the copper T intrauterine device (ParaGard IUD, Teva Women’s Health, North Wales, PA) for emergency contraception (EC) make an impact on the rate of unplanned pregnancy at your clinic? Take a look at results from a study of two Utah family planning clinics.1
Study results indicate that 12 months after presenting for emergency contraception (EC), women selecting the copper T intrauterine device (IUD) for EC were more likely to be using an effective method of contraception and less likely to have had an unplanned pregnancy than those who chose EC pills.
- In the prospective cohort study, 40% chose the copper IUD, with the remainder choosing EC pills. More than half (58.7%) had never been pregnant; 16% had had a prior abortion.
- Among nulliparous women, 27 of 138 (19.6%) IUD insertions were unsuccessful. Results of a subsequent intervention that provided best practices education and trained all providers to do paracervical blocks and cervical dilation are forthcoming.
Researchers with the University of Utah in Salt Lake City designed the prospective cohort study to follow women who chose the copper IUD or oral levonorgestrel emergency contraceptive pills for emergency contraception at Planned Parenthood Association of Utah clinics in Salt Lake City and West Valley City. The primary outcome was unplanned pregnancy 12 months after presenting for EC. Analysis was by intent to treat.
Of the 548 women who presented for EC and agreed to participate in the trial, 218 women (39.7%) chose the copper IUD and 331 (60.3%) chose oral levonorgestrel (LNG) pills. More than half (58.7%) of the women had never been pregnant; 16% had had a prior abortion.
Twelve months after presenting for EC, use of an effective method of contraception (typical use failure rate 8% or less) was greater in the IUD group (125/183 [68%]) than the oral LNG group (106/257 [41%], p<0.0001). The 12-month cumulative pregnancy rate in the IUD group (6.5%) was less than that in the oral LNG group (12.2%) (hazard ratio 0.53 [95% confidence interval, 0.29-0.97], p=0.041).1
Twelve months after presenting for emergency contraception, women selecting the copper IUD for EC were more likely to be using an effective method of contraception and less likely to have had an unplanned pregnancy than those who chose oral levonorgestrel, researchers conclude.
Failed IUD insertions?
In the Utah study, a total of six nurse practitioners performed 197 EC IUD insertion attempts. These providers had a mean of 14.1 years of experience (range 1-27, standard deviation ±12.5).
Patients included in the trial presented as walk-ins and, thus, were not scheduled into IUD insertion time slots. Providers inserted EC IUDs in the following standard fashion: after bimanual exam and placement of speculum, the cervix was prepped with betadine and a tenaculum was placed on the anterior lip of the cervix. The uterus then was sounded using a 4-mm stainless steel sound, and IUD insertion was attempted. Adjuvant measures to facilitate difficult IUD insertions, such as cervical anesthesia, dilation, pain medication, and use of ultrasound guidance, were not used, the researchers note. Data from providers performing less than five insertions during the study period were excluded.
In an already published analysis of the IUD insertion failures, 27 of 138 (19.6%) nulliparous women had unsuccessful IUD insertions. In parous women, eight of 59 IUD insertions were unsuccessful (13.6%). The adjusted odds ratio (aOR) showed that IUD insertion failure was more likely in nulliparous women compared to parous women (aOR=2.31, 95% CI 0.90-6.52, p=.09).2
Women who presented at the clinics for EC did not come in expecting an IUD insertion, so they might have experienced anxiety in placement, researchers note. However, patient anxiety was not assessed in the study, so the role it might have played on insertion success is not clear. Previous research indicates that women with anxiety over the procedure have higher level of perceived pain, which potentially contributes to a more difficult insertion.3
Intrauterine devices are safe, effective choices for women of all ages who have never given birth. In 2012, the American College of Obstetricians and Gynecologists (ACOG) issued a committee opinion stating that long-acting reversible contraceptives such as the IUD and the contraceptive implant are safe, effective, and appropriate options for adolescents.4 (To read more about the opinion, see the Contraceptive Technology Update article, "Long-acting methods safe for teens: include options in your counseling," December 2012, p. 133; also review research covered in "Old myth debunked: data show IUD is safe birth control option for teens," July 2013, p. 73.)
Look to new research to emerge from the Utah clinic experience, says David Turok, MD, associate professor in the University of Utah Department of Obstetrics and Gynecology in Salt Lake City. Following the initial study, fellow researcher Amna Dermish, MD directed an intervention, training all providers to do paracervical blocks and cervical dilation, as well as presenting education on best practices. Dermish then observed providers performing a few blocks and dilations. Forthcoming research will be published.
- Schwarz EB, Turok D. She needs EC... does your emergency response team offer an IUD? Presented at the Reproductive Health 2013 annual meeting. Denver; September 2013.
- Dermish AI, Turok DK, Jacobson JC, et al. Failed IUD insertions in community practice: an under-recognized problem? Contraception 2013; 87(2):182-186.
- Murty J. Use and effectiveness of oral analgesia when fitting an intrauterine device. J Fam Plann Reprod Health Care 2003; 29:150-151.
- American College of Obstetricians and Gynecologists. Committee Opinion #539. Adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2012; 120(4):983-988.
