Interest in intrauterine contraception among seekers of emergency contraception and pregnancy testing

Progestin intrauterine devices versus copper intrauterine devices for emergency contraception

BACKGROUND

The copper intrauterine device (Cu-IUD) is a highly effective method of contraception that can also be used for emergency contraception (EC). It is the most effective form of EC, and is more effective than other existing oral regimens also used for EC. The Cu-IUD provides the unique benefit of providing ongoing contraception after it is inserted for EC; however, uptake of this intervention has been limited. Progestin IUDs are a popular method of long-acting, reversible contraception. If these devices were also found to be effective for EC, they would provide a critical additional option for women. These IUDs could not only provide EC and ongoing contraception, but additional non-contraceptive benefits, including a reduction in menstrual bleeding, cancer prevention, and pain management.

OBJECTIVES

To examine the safety and effectiveness of progestin-containing IUDs for emergency contraception, compared with copper-containing IUDs, or compared with dedicated oral hormonal methods.

SEARCH METHODS

We considered all randomized controlled trials and non-randomized studies of interventions that compared outcomes for individuals seeking a levonorgestrel IUD (LNG-IUD) for EC to a Cu-IUD or dedicated oral EC method. We considered full-text studies, conference abstracts, and unpublished data. We considered studies irrespective of their publication status and language of publication.

SELECTION CRITERIA

We included studies comparing progestin IUDs with copper-containing IUDs, or oral EC methods for emergency contraception.

DATA COLLECTION AND ANALYSIS

We systematically searched nine medical databases, two trials registries, and one gray literature site. We downloaded all titles and abstracts retrieved by electronic searching to a reference management database, and removed duplicates. Three review authors independently screened titles, abstracts, and full-text reports to determine studies eligible for inclusion. We followed standard Cochrane methodology to assess risk of bias, and analyze and interpret the data. We used GRADE methodology to assess the certainty of the evidence.

MAIN RESULTS

We included only one relevant study (711 women); a randomized, controlled, non-inferiority trial comparing LNG-IUDs to Cu-IUDs for EC, with a one-month follow-up. With one study, the evidence was very uncertain for the difference in pregnancy rates, failed insertion rates, expulsion rates, removal rates and the difference in the acceptability of the IUDs. There was also uncertain evidence suggesting the Cu-IUD may slightly increase rates of cramping and the LNG-IUD may slightly increase bleeding and spotting days.  AUTHORS' CONCLUSIONS: This review is limited in its ability to provide definitive evidence regarding the LNG-IUD's equivalence, superiority, or inferiority to the Cu-IUD for EC. Only one study was identified in the review, which had possible risks of bias related to randomization and rare outcomes. Additional studies are needed to provide definitive evidence related to the effectiveness of the LNG-IUD for EC.

Risk of Pregnancy With Levonorgestrel-Releasing Intrauterine System Placement 6-14 Days After Unprotected Sexual Intercourse

Pregnancy is unlikely when a levonorgestrel-releasing intrauterine system (52 mg) is placed 6–14 days after unprotected intercourse.

Acceptability of the copper intrauterine device as a form of emergency contraception in New South Wales, Australia

Background: The copper-intrauterine device (Cu-IUD) is the most effective emergency contraception (EC), and the only method providing ongoing contraception; however, it is underutilised in Australia.Methods: An online cross-sectional survey of clients and clinicians at a family planning service was undertaken. Clients aged 16-55 and identifying as female or transgender male were eligible. The survey explored previous experience with and knowledge of the Cu-IUD as EC among clients, current EC practices among clinicians, and barriers and enablers among clients and clinicians.Results: Of 470 clients, 64.5% had previously used EC. Only 12.7% knew the Cu-IUD was a form of EC and 2% had used it. When given information on effectiveness, side-effects and costs, 46.8% reported they would consider the Cu-IUD for EC. However, 40% viewed cost and possible side-effects as barriers. Of the 58 clinicians surveyed, 55% reported discussing Cu-IUD as EC with clients versus 94% discussing oral EC, with time pressures reported as the main barrier.Conclusion: Low awareness among clients, and limited discussion by clinicians, highlights a need for increased education and promotion strategies for the Cu-IUD as EC. With greater knowledge, demand for this option may increase. This will require processes to ensure timely access to insertions.

The intrauterine device as emergency contraception: how much do young women know?

BACKGROUND

Unprotected intercourse is common, especially among teens and young women. Access to intrauterine device (IUD) as emergency contraception (EC) can help interested patients more effectively prevent unintended pregnancy and can also offer ongoing contraception. This study evaluated young women's awareness of IUD as EC and interest in case of need.

STUDY DESIGN

We conducted a secondary analysis of data from young women aged 18-25 years, not desiring pregnancy within 12 months, and receiving contraceptive counseling within a cluster-randomized trial in 40 US Planned Parenthood health centers in 2011-2013 (n=1500). Heath centers were randomized to receive enhanced training on contraceptive counseling and IUD placement, or to provide standard care. The intervention did not focus specifically on IUD as EC. We assessed awareness of IUD as EC, desire to learn more about EC and most trusted source of information of EC among women in both intervention and control groups completing baseline and 3- or 6-month follow-up questionnaires (n=1138).

RESULTS

At follow-up, very few young women overall (7.5%) visiting health centers had heard of IUD as EC. However, if they needed EC, most (68%) reported that they would want to learn about IUDs in addition to EC pills, especially those who would be very unhappy to become pregnant (adjusted odds ratio [aOR], 1.3; 95% confidence interval, 1.0-1.6, p<.05). Most (91%) reported a doctor or nurse as their most trusted source of EC information, over Internet (6%) or friends (2%), highlighting providers' essential role.

CONCLUSION

Most young women at risk of unintended pregnancy are not aware of IUD as EC and look to their providers for trusted information. Contraceptive education should explicitly address IUD as EC.

IMPLICATIONS

Few young women know that the IUD can be used for EC or about its effectiveness. However, if they needed EC, most reported that they would want to learn about IUDs in addition to EC pills, especially those very unhappy to become pregnant. Contraceptive education should explicitly address IUD as EC.

Knowledge of and Interest in the Copper Intrauterine Device Among Women Seeking Emergency Contraception

OBJECTIVE

Emergency contraception (EC) includes hormonal pills (levonorgestrel or ulipristal acetate) and the copper IUD (Cu-IUD). The Cu-IUD is more effective for EC than hormonal pills but remains underused, possibly because of lack of knowledge or interest. The objective of this study was to examine knowledge of and interest in the Cu-IUD for EC among Canadian women seeking EC.

METHODS

The study used a cross-sectional convenience survey of English-speaking women presenting for EC at two sexual health clinics in Toronto. The anonymous paper-based survey was completed in the waiting room. The main outcome measures were women's knowledge of and interest in the Cu-IUD for EC. Demographic and reproductive health data were also collected.

RESULTS

Between January and December 2013, 124 surveys were completed. Mean age of respondents was 26 years (SD ± 6.9). Most were single (85%), and over one half had completed postsecondary education. Overall, 77% had heard of the Cu-IUD, but only 21% were aware of its use for EC. Over 50% were aware that the Cu-IUD is hormone-free and may be used for long-term contraception. Women were less familiar with the window of administration of the Cu-IUD for EC (26%) and its efficacy (6%). In total, 23% (28 of 124) of women were interested in the Cu-IUD, including eight women scheduled to receive one that day.

CONCLUSION

Women presenting for EC were unaware of the Cu-IUD but were moderately interested in it once informed. Public education and routine counselling about the Cu-IUD at EC visits may increase the uptake of this method.

One-year continuation of copper or levonorgestrel intrauterine devices initiated at the time of emergency contraception

OBJECTIVE(S)

This study compares 1-year intrauterine device (IUD) continuation among women presenting for emergency contraception (EC) and initiating the copper (Cu T380A) IUD or the levonorgestrel (LNG) 52 mg IUD plus 1.5 mg oral LNG.

STUDY DESIGN

This cohort study enrolled 188 women who presented at a single family planning clinic in Utah between June 2013 and September 2014 and selected either the Cu T380A IUD or LNG 52 mg IUD plus oral LNG for EC. Trained personnel followed participants by phone, text or e-mail for 12 months or until discontinuation occurred. We assessed reasons for discontinuation and used Cox proportional hazard models, Kaplan-Meier estimates and log-rank tests to assess differences in continuation rates between IUDs.

RESULTS

One hundred seventy-six women received IUDs; 66 (37%) chose the Cu T380A IUD and 110 (63%) chose the LNG 52 mg IUD plus oral LNG. At 1 year, we accounted for 147 (84%) participants, 33 (22%) had requested removals, 13 (9%) had an expulsion and declined reinsertion, 3 (2%) had a pregnancy with their IUD in place and 98 (67%) were still using their device. Continuation rates did not differ by IUD type; 60% of Cu T380A IUD users and 70% of LNG 52 mg IUD plus oral LNG users were still using their device at 12 months (adjusted hazard ratio 0.72, 95% confidence interval 0.40-1.3).

CONCLUSION(S)

Two-thirds of women who chose IUD placement at the EC clinical encounter continued use at 1 year. Women initiating Cu T380A IUD and LNG 52 mg IUD had similar 1-year continuation rates. These findings support same-day insertion of IUDs for women who are seeking EC and would like to use a highly effective reversible method going forward.

IMPLICATIONS

Providing IUD options for EC users presents an opportunity to increase availability of highly effective contraception.

The safety of available and emerging options for emergency contraception

INTRODUCTION

Emergency contraception (EC) is a way to significantly reduce the chance of becoming pregnant after an episode of unprotected intercourse. Considerable data support the safety of all available and emerging options for EC. Areas covered: This review presents a comprehensive summary of the literature regarding the safety of EC as well as directions for further study. PubMed was searched for all relevant studies published prior to June 2017. Expertopinion: All available methods of EC (i.e., ulipristal acetate pills, levonorgestrel pills, and the copper-IUD), carry only mild side effects and serious adverse events are essentially unknown. The copper IUD has the highest efficacy of EC methods. Given the excellent safety profiles of mifepristone and the levonorgestrel IUD, research is ongoing related to use of these products for EC.

Experiences of Advanced Practitioners with Inserting the Copper Intrauterine Device as Emergency Contraception

INTRODUCTION

The copper intrauterine device (IUD) is the most effective method of emergency contraception (EC) available for use after unprotected intercourse. Family planning clinics, commonly staffed by advanced practice clinicians, fulfill a significant role in health care and contraceptive service delivery for women in the United States. There are limited data assessing the perspectives and experiences of these providers in using the copper IUD as EC in these settings.

METHODS

Semistructured individual interviews were conducted with 12 advanced practice clinicians with experience inserting the copper IUD. A phenomenological approach was used to frame the study and analysis. A modified version of the Van Kaam method of analysis was used to analyze the data from interview transcripts.

RESULTS

Participants reported feelings of responsibility to support long-acting and highly effective methods of contraception. Patients' abilities to provide an accurate history of the last instance of unprotected intercourse in relation to their menstrual cycles and fear of painful insertions influenced participants' willingness to offer the copper IUD. This included provider concerns about causing uterine perforation prompting discontinuation of IUD insertion attempts. The participants perceived patients as having little knowledge about the copper IUD in general and as not being committed to using the copper IUD long term.

CONCLUSIONS

Numerous factors influenced advanced practice clinicians' decisions to present the copper IUD as a method of EC. Promoting support and sharing practitioner experiences with inserting the copper IUD as EC may increase practitioner comfort with the copper IUD as EC.

Preference for and efficacy of oral levonorgestrel for emergency contraception with concomitant placement of a levonorgestrel IUD: a prospective cohort study

OBJECTIVES

We assessed intrauterine device (IUD) preference among women presenting for emergency contraception (EC) and the probability of pregnancy among concurrent oral levonorgestrel (LNG) plus LNG 52 mg IUD EC users.

METHODS

We offered women presenting for EC at a single family planning clinic the CuT380A IUD (copper IUD) or oral LNG 1.5 mg plus the LNG 52 mg IUD. Two weeks after IUD insertion, participants reported the results of a self-administered home urine pregnancy test. The primary outcome, EC failure, was defined as pregnancies resulting from intercourse occurring within five days prior to IUD insertion.

RESULTS

One hundred eighty-eight women enrolled and provided information regarding their current menstrual cycle and recent unprotected intercourse. Sixty-seven (36%) chose the copper IUD and 121 (64%) chose oral LNG plus the LNG IUD. The probability of pregnancy two weeks after oral LNG plus LNG IUD EC use was 0.9% (95% CI 0.0-5.1%). The only positive pregnancy test after treatment occurred in a woman who received oral LNG plus the LNG IUD and who had reported multiple episodes of unprotected intercourse including an episode more than 5 days prior to treatment.

CONCLUSIONS

Study participants seeking EC who desired an IUD preferentially chose oral LNG 1.5 mg with the LNG 52 mg IUD over the copper IUD. Neither group had EC treatment failures. Including the option of oral LNG 1.5 mg with concomitant insertion of the LNG 52 mg IUD in EC counseling may increase the number of EC users who opt to initiate highly effective reversible contraception.

IMPLICATIONS

Consideration should be given to LNG IUD insertion with concomitant use of oral LNG 1.5 mg for EC. Use of this combination may increase the number of women initiating highly effective contraception at the time of their EC visit.

Practical Advice for Emergency IUD Contraception in Young Women

Too few women are aware of the very high efficacy of intrauterine copper devices (IUDs) to prevent pregnancy after unprotected intercourse. Women who frequently engage in unprotected intercourse or seek emergency contraception (EC) are at high risk of unplanned pregnancy and possible abortion. It is therefore important that these women receive precise and accurate information about intrauterine devices as they may benefit from using an IUD for EC as continuing contraception. Copper IUDs should be used as first choice options given their rapid onset of action and their long-term contraceptive action which require minimal thought or intervention on the part of the user. In the United States, there is only one copper IUD presently available which limits treatment options. There are numerous copper IUDs available for use in EC, however, their designs and size are not always optimal for use in nulliparous women or women with smaller or narrower uteruses. Utilization of frameless IUDs which do not require a larger transverse arm for uterine retention may have distinct advantages, particularly in young women, as they will be suitable for use in all women irrespective of uterine size. This paper provides practical information on EC use with emphasis on the use of the frameless IUD.

U.S. Men's Perceptions and Experiences of Emergency Contraceptives

Research suggests that men should be included in reproductive health decision making to help enhance positive health outcomes for their partners. Men affect the use of contraception and what method is used. Men's decisions may be affected by different factors such as gender, education, and the nature of their sexual relationship. A qualitative study was conducted to explore males' experiences and perceptions about emergency contraception (EC), and the meanings males assign to EC. Semistructured in-depth focus groups were held with 15 men who engage in heterosexual activity recruited from a university setting in the United States. Participants expressed egalitarian views of the contraception decision-making processes, a sense of responsibility regarding reproductive decision making, and that society has a negative stigma toward those who use EC. However, there was a lack of knowledge regarding the copper intrauterine device, which was not viewed as a method of EC. Exploring the role and needs of men in reproductive health care discussions and research is an important and growing area. Recommendations are provided for health care practitioners, policy, and future research around men and EC.

A checklist approach to caring for women seeking pregnancy testing: effects on contraceptive knowledge and use

OBJECTIVE

To assess how a checklist reminding clinicians to deliver a bundled intervention affects contraceptive knowledge and use 3 months after women seek walk-in pregnancy testing.

METHODS

Pre-intervention, an inner-city family planning clinic provided unstructured care; during the intervention period, clinic staff used a checklist to ensure women received needed services. Women seeking walk-in pregnancy testing who wished to avoid pregnancy for at least 6 months were asked to complete surveys about their contraceptive knowledge and use immediately after and 3-months after visiting the study clinic. To assess the significance of changes over time, we used logistic regression models.

RESULTS

Between January 2011 and May 2013, over 1500 women sought pregnancy testing from the study clinic; 323 completed surveys (95 pre-intervention and 228 during the intervention period). With this checklist intervention, participants were more likely to receive emergency contraception (EC) (22% vs. 5%, [aOR 4.66 (1.76-12.35)], [corrected] have an intrauterine device or implant placed at the time of their clinic visit (5% vs. 0%, p=0.02), or receive a contraceptive prescription (23% vs. 10%, p<0.001). Three months after visiting the study clinic, participants from the intervention period were more knowledgeable about intrauterine and subdermal contraception and were more likely to report at 3-month follow-up a method of contraception more effective than the method they used prior to seeking pregnancy testing from the study clinic (aOR=2.02, 95% CI=1.03-3.96). The authors would like to apologize for any inconvenience caused. [corrected].

CONCLUSIONS

Women seeking walk-in pregnancy testing appear more likely to receive EC and to have switched to a more effective form of birth control in the 3 months following their visit when clinic staff used a 3-item checklist and provided scripted counseling.

IMPLICATIONS

A checklist reminding clinic staff to assess pregnancy intentions, provide scripted counseling about both emergency and highly-effective reversible contraception, and offer same-day contraceptive initiation to women seeking walk-in pregnancy testing appears to increase use of more effective contraception.

Intrauterine device quo vadis? Why intrauterine device use should be revisited particularly in nulliparous women?

Background

Long-acting reversible contraceptive (LARC) methods, including intrauterine devices (IUDs) and the contraceptive implant, are considered the best methods for preventing unintended pregnancies, rapid repeat pregnancy, and abortion in young women. An opinion paper of 2012 by the American College of Obstetricians and Gynecologists recommends Mirena and Paragard for use in nulliparous and adolescent women. However, these IUDs are not designed for young women and are not optimal as they often lead to early discontinuation.

Objective

This article was written with the objective to respond to the urgent need to improve intrauterine contraception as it is likely that the objectives of LARC will not be met without significant improvement of IUD design. Anatomical variations in size and shape of the uterus are not sufficiently considered, producing harm and suffering, which often lead to early removal of the IUD.

Proposed problem solving

The article describes why IUDs should be revisited to meet the challenge of LARC and proposes how to solve these problems. The opinion statement presented here may be considered provocative but is based on hundreds of women with IUD problems who consult or are referred to the practices of the authors of this article due to the disproportion between the IUD and their small uterine cavity. The solution is simple but requires a revision of the current design of IUDs. One-dimensional (longitudinal) IUDs are likely to be the first option. Framed devices with shortened transverse arm and IUDs which adapt to the width of the given uterus are viewed as second best.

Conclusion

One of the reasons of the high unintended pregnancy rate in the USA may be the paucity of suitable IUDs. Also, the legal climate in the USA seems to be a problem for developers as many lawsuits have recently been reported. Clinical studies conducted in young nulliparous and adolescent women suggest that IUDs that fit well in the uterine cavity, like a shoe, result in better tolerance, less side effects, and last but not least, higher use continuation rates.

IUDs as EC? Limited awareness and high reported acceptability: evidence from Argentina

BACKGROUND

We explored knowledge and attitudes regarding the copper intrauterine device (IUD) as emergency contraception (EC) among women in Buenos Aires, Argentina.

STUDY DESIGN

We interviewed a convenience sample of women attending a family planning center at a public hospital. Participants were asked about knowledge and use of contraceptives, including EC (pre-script). Then they were given information about the IUD as EC and subsequently asked about acceptability of using the copper IUD as EC (post-script), the primary outcome in this analysis.

RESULTS

We analyzed data on 273 women. While only 1.83% of participants knew the IUD served as EC at baseline, 79.85% said they would be willing to use the device as such if the need arose after given relevant information. Multivariate results from a pre-script revealed that women with low levels of education and those born outside of Argentina were less knowledgeable about EC pills. Only previous use of the IUD was associated with high levels of IUD knowledge. Post-script, results indicated that being Argentine [odds ratio (OR)=2.15, 95% confidence interval (CI) 1.21, 3.81] and previous IUD use (OR=2.12, 95% CI=1.07, 4.19) were positively associated with considering the IUD as EC. Nulliparity was negatively associated with willingness to use the IUD as EC (OR=0.44, 95% CI 0.22, 0.86).

CONCLUSION

We examined acceptability of the copper IUD as EC in a Latin American setting and found that, while prior levels of knowledg'e were low, acceptability of the IUD as EC was high. Implications for programming and policy include outreach and education regarding this highly effective method and advocacy to change existing regulations in Argentina prohibiting the use of IUD as EC.

IMPLICATIONS

After given information about the IUD as a method of EC, women interviewed said they would be willing to use the IUD EC despite their limited prior knowledge of this method. With more widespread information and availability of the IUD as EC, more women may opt for this highly effective method, which can provide additional protection against unwanted pregnancy for up to 10 years.

Routine counseling about intrauterine contraception for women seeking emergency contraception

OBJECTIVE

To compare contraceptive knowledge and use among women seeking emergency contraception (EC) before and after an inner-city clinic began providing structured counseling and offering same-day intrauterine device (IUD) or implant placement to all women seeking EC.

STUDY DESIGN

For 8 months before and 21 months after this change in clinic policy, women aged 15-45 who wanted to avoid pregnancy for at least 6 months were asked to complete surveys immediately, 3 and 12 months after their clinic visit. In addition, we abstracted electronic medical record (EMR) data on all women who sought EC (n=328) during this period. We used chi-squared tests to assess pre/post differences in survey and EMR data.

RESULTS

Surveys were completed by 186 women. After the clinic began offering structured counseling, more women had accurate knowledge of the effectiveness of IUDs, immediately and 3 months after their clinic visit. In addition, more women initiated IUD or implant use (survey: 40% vs. 17% preintervention, p=0.04; EMR: 22% vs. 10% preintervention, p=0.01), and fewer had no contraceptive use (survey: 3% vs. 17% preintervention, p<0.01; EMR: 32% vs. 68%, p<0.01) in the 3 months after seeking EC. EMR data indicate that when same-day placement was offered, 11.0% of women received a same-day IUD. Of those who received a same-day IUD, 88% (23/26) reported IUD use at 3-months and 80% (12/15) at 12 months.

CONCLUSIONS

Routine provision of structured counseling with the offer of same-day IUD placement increases knowledge and use of IUDs 3 months after women seek EC.

IMPLICATIONS

Women seeking EC from family planning clinics should be offered counseling about highly effective reversible contraceptives with the option of same-day contraceptive placement.

Emergency contraception with a copper IUD or oral levonorgestrel: an observational study of 1-year pregnancy rates

OBJECTIVE

We investigated the 1-year pregnancy rates for emergency contraception (EC) users who selected the copper T380 intrauterine device (IUD) or oral levonorgestrel (LNG) for EC.

STUDY DESIGN

This prospective study followed women for 1 year after choosing either the copper T380 IUD or oral LNG for EC. The study was powered to detect a 6% difference in pregnancy rates within the year after presenting for EC.

RESULTS

Of the 542 women who presented for EC, agreed to participate in the trial and met the inclusion criteria, 215 (40%) chose the copper IUD and 327 (60%) chose oral LNG. In the IUD group, 127 (59%) were nulligravid. IUD insertion failed in 42 women (19%). The 1-year follow-up rate was 443/542 (82%); 64% of IUD users contacted at 1 year still had their IUDs in place. The 1-year cumulative pregnancy rate in women choosing the IUD was 6.5% vs. 12.2% in those choosing oral LNG [hazard ratio (HR) 0.53, 95% confidence interval (CI): 0.29-0.97, p=.041]. By type of EC method actually received, corresponding values were 5.2% for copper IUD users vs. 12.3% for oral LNG users (HR 0.42, 95% CI: 0.20-0.85, p=.017). A multivariable logistic regression model controlling for demographic variables demonstrates that women who chose the IUD for EC had fewer pregnancies in the following year than those who chose oral LNG (HR 0.50, 95% CI: 0.26-0.96, p=.037).

CONCLUSION

One year after presenting for EC, women choosing the copper IUD for EC were half as likely to have a pregnancy compared to those choosing oral LNG.

IMPLICATIONS

Compared to EC users who choose oral levonorgestrel, those who select the copper IUD have lower rates of pregnancy in the next year. Greater use of the copper IUD for EC may lower rates of unintended pregnancy in high-risk women.

The copper intrauterine device for emergency contraception: an opportunity to provide the optimal emergency contraception method and transition to highly effective contraception

Worldwide, 40% of all pregnancies are unintended. Widespread, over-the-counter availability of oral emergency contraception (EC) has not reduced unintended pregnancy rates. The EC visit presents an opportunity to initiate a highly effective method of contraception in a population at high risk of unintended pregnancy who are actively seeking to avoid pregnancy. The copper intrauterine device (IUD), the most effective method of EC, continues to provide contraception as effective as sterilization for up to 12 years, and it should be offered as the first-line method of EC wherever possible. Increased demand for and supply of the copper IUD for EC may have an important role in reducing rates of unintended pregnancy. The EC visit should include access to the copper IUD as optimal care but should ideally include access to all highly effective methods of contraception.

Improving uptake of the copper intrauterine device for emergency contraception by educating pharmacists in the community

OBJECTIVES

The copper intrauterine device (Cu-IUD) is the most effective method of emergency contraception (EC) and provides ongoing contraception, yet few women choose this option. This study evaluates the impact of an educational initiative involving pharmacists on uptake of Cu-IUDs for EC in an integrated sexual health clinic in the North East of England.

METHODS

Since November 2010, local pharmacists have received intensive education detailing EC options including Cu-IUDs. At the same time a rapid access referral pathway for fitting of an emergency Cu-IUD was established. The impact of this initiative has been assessed by analysing case notes of women attending a large city centre sexual health service who received an emergency Cu-IUD during September and October 2010 (prior to the initiative) and the same 2&emsp14;months in 2011 (9&emsp14;months after the start of the intervention).

RESULTS

The number of women fitted with an emergency Cu-IUD increased by almost three-fold from 11 fitted in September and October 2010 to 30 fitted in these 2&emsp14;months in 2011. One woman was referred from a pharmacist to the service in the first audit period compared with 17 in the second. No pregnancies occurred in the first month after Cu-IUD insertion in these 41 women.

CONCLUSIONS

Educating pharmacists has increased referral and uptake of Cu-IUD used for EC and this has the potential to reduce unintended pregnancies now and in the future.

Emerging options for emergency contraception

Emergency post-coital contraception (EC) is an effective method of preventing pregnancy when used appropriately. EC has been available since the 1970s, and its availability and use have become widespread. Options for EC are broad and include the copper intrauterine device (IUD) and emergency contraceptive pills such as levonorgestrel, ulipristal acetate, combined oral contraceptive pills (Yuzpe method), and less commonly, mifepristone. Some options are available over-the-counter, while others require provider prescription or placement. There are no absolute contraindications to the use of emergency contraceptive pills, with the exception of ulipristal acetate and mifepristone. This article reviews the mechanisms of action, efficacy, safety, side effects, clinical considerations, and patient preferences with respect to EC usage. The decision of which regimen to use is influenced by local availability, cost, and patient preference.

Asking for what she needs? Pregnancy testing or EC?

BACKGROUND

When used within 5 days of unprotected sex, emergency contraception (EC) can reduce the risk of pregnancy. Our objective was to explore how often women seeking clinic-based pregnancy testing who do not desire pregnancy might benefit from EC and examine variables associated with patients asking for EC when use is indicated.

STUDY DESIGN

Women seeking pregnancy testing or EC from an inner-city Title-X-funded family planning clinic between January 2011 and June 2012 were invited to complete surveys.

RESULTS

Twenty-seven percent (n=79) of respondents were seeking EC, and 73% (n=215) were seeking pregnancy testing. Of those seeking pregnancy testing, 39% might have benefited from same-day use of EC pills. Women who had never used EC and who had more than one episode of unprotected sex within the past month were less likely to request EC when use was indicated, while single women were more likely to request EC.

CONCLUSIONS

Counseling regarding EC options is particularly important for women seeking same-day pregnancy testing who do not desire pregnancy.

The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience

BACKGROUND

Intrauterine devices (IUDs) have been studied for use for emergency contraception for at least 35 years. IUDs are safe and highly effective for emergency contraception and regular contraception, and are extremely cost-effective as an ongoing method. The objective of this study was to evaluate the existing data to estimate the efficacy of IUDs for emergency contraception.

METHODS

The reference list for this study was generated from hand searching the reference lists of relevant articles and our own article archives, and electronic searches of several databases: Medline, Global Health, Clinicaltrials.gov, Popline, Wanfang Data (Chinese) and Weipu Data (Chinese). We included studies published in English or Chinese, with a defined population of women who presented for emergency contraception and were provided with an IUD, and in which the number of pregnancies was ascertained and loss to follow-up was clearly defined. Data from each article were abstracted independently by two reviewers.

RESULTS

The 42 studies (of 274 retrieved) that met our inclusion criteria were conducted in six countries between 1979 and 2011 and included eight different types of IUD and 7034 women. The maximum timeframe from intercourse to insertion of the IUD ranged from 2 days to 10 or more days; the majority of insertions (74% of studies) occurred within 5 days of intercourse. The pregnancy rate (excluding one outlier study) was 0.09%.

CONCLUSIONS

IUDs are a highly effective method of contraception after unprotected intercourse. Because they are safe for the majority of women, highly effective and cost-effective when left in place as ongoing contraception, whenever clinically feasible IUDs should be included in the range of emergency contraception options offered to patients presenting after unprotected intercourse. This review is limited by the fact that the original studies did not provide sufficient data on the delay between intercourse and insertion of the IUD, parity, cycle day of intercourse or IUD type to allow analysis by any of these variables.

Copper intrauterine device for emergency contraception: clinical practice among contraceptive providers

OBJECTIVE

The copper intrauterine device (IUD) is the most effective emergency contraceptive available but is largely ignored in clinical practice. We examined clinicians' recommendations of the copper IUD for emergency contraception in a setting with few cost obstacles.

METHODS

We conducted a survey among clinicians (n=1,246; response rate 65%) in a California State family planning program, where U.S. Food and Drug Administration-approved contraceptives are available at no cost to low-income women. We used multivariable logistic regression to measure the association of intrauterine contraceptive training and evidence-based knowledge with having recommended the copper IUD for emergency contraception.

RESULTS

The large majority of clinicians (85%) never recommended the copper IUD for emergency contraception, and most (93%) required two or more visits for an IUD insertion. Multivariable analyses showed insertion skills were associated with having recommended the copper IUD for emergency contraception, but the most significant factor was evidence-based knowledge of patient selection for IUD use. Clinicians who viewed a wide range of patients as IUD candidates were twice as likely to have recommended the copper IUD for emergency contraception. Although more than 93% of obstetrician-gynecologists were skilled in inserting the copper IUD, they were no more likely to have recommended it for emergency contraception than other physicians or advance practice clinicians.

CONCLUSION

Recommendation of the copper IUD for emergency contraception is rare, despite its high efficacy and long-lasting contraceptive benefits. Recommendation would require clinic flow and scheduling adjustments to allow same-day IUD insertions. Patient-centered and high-quality care for emergency contraception should include a discussion of the most effective method.

LEVEL OF EVIDENCE

III.

A qualitative exploration of emergency contraception users' willingness to select the copper IUD

BACKGROUND

The copper T intrauterine device (IUD) is an effective but underutilized method of emergency contraception (EC). This study investigates the factors influencing a woman's decision around which method of EC to select.

STUDY DESIGN

In-depth interviews with 14 IUD and 14 oral EC users aged 18-30 years accessing public health clinics.

RESULTS

Emergency contraception users associated long-term methods of contraception with long-term sexual relationships. Women were not aware of the possibility of using the copper IUD for EC. Cost was identified as a major barrier to accessing IUDs. Perceived side effects and impact on future pregnancies further influenced the EC method a participant selected.

CONCLUSIONS

Women think about contraception in the context of each separate relationship and not as a long-term individual plan. Most women were unaware of the copper IUD for EC. Furthermore, there is little discussion between women and their health-care providers around EC.

A survey of women obtaining emergency contraception: are they interested in using the copper IUD?

BACKGROUND

This study aims to determine if women presenting for emergency contraception (EC) at family planning clinics may be interested in using the copper intrauterine device (IUD) for EC.

STUDY DESIGN

This convenience sample survey was offered to women who presented for EC at four participating clinics in urban Utah. Anonymous written questionnaires were distributed. The outcome variable of interest was interest in using the copper IUD for EC.

RESULTS

Of survey respondents, 320 (34.0%) of 941 said they would be interested in an EC method that was long term, highly effective and reversible. Interested women were not significantly different from noninterested women in relation to age, marital status, education, household income, gravidity, previous abortions, previous sexually transmitted infections (STIs) or relationship status. One hundred twenty women (37.5% of those interested or 12.8% of all those surveyed) would wait an hour, undergo a pelvic exam to get the method and would still want the method knowing it was an IUD. However, only 12.3% of these women could also pay $350 or more for the device. Multivariable regression found the following predictors of interest in the IUD among EC users: non-Hispanic minorities (OR=2.12, 95% CI=1.14-3.93), desire to never be pregnant in the future (OR=2.87, 95% CI=1.38-5.66) and interest in adoption (OR=1.96, 95% CI=1.00-5.73) or abortion (OR=2.68, 95% CI=1.24-4.14) if pregnant when presenting for EC.

CONCLUSION

While one third of EC users surveyed at family planning clinics were interested in a long-term, highly effective method of contraception, only a small portion of all EC users may be interested in the copper IUD for EC. Cost is a potential barrier.

New intrauterine technologies for contraception and treatment in -nulliparous/adolescent and parous women

The IUD (intra uterine device) is a highly effective method of contraception that is underused. New developments in intrauterine technology, smaller frameless copper and levonorgestrel-releasing devices, could help increase the prevalence-- of use in adolescents and nulliparous women. Because adolescents and young nulliparous women contribute disproportionately to the epidemic of unintended pregnancies, long-acting methods of contraception, particularly IUDs, should be considered as first-line choices for interval, emergency and immediate post-abortal contraception in this population of women. As the uterine cavity is generally much smaller in this group than in older women, adapted IUDs may be very useful. Compatibility of the IUD with the small uterine cavity leads to high acceptability and continuation of use, a prerequisite to reduce unintended pregnancies. A strategic advantage of IUDs is that, unlike the Pill, they are genuinely 'fit-and-forget'. In use, they are much more effective than Pills in this age group. However, copper intrauterine devices do not offer protection against sexually transmitted infections (STIs) and, therefore, they are not always the methods of first choice for teenagers and nulliparous women. New evidence, however, from the World Health -Organization and the American College of Obstetricians and Gynecologists, shows that IUDs can be used and that they are safe for most women, including adolescents.