Insertion of an Intrauterine Contraceptive Device After Induced or Spontaneous Abortion: A Review of the Evidence

Abstract

Immediate postabortal insertion of an intrauterine contraceptive device (IUCD) has many benefits, including the imminent return of ovulation, immediate protection, and avoiding the discomfort and bleeding of a separate procedure. Some clinicians, however, are concerned that IUCD perforation and expulsion may be more frequent in the postabortal uterus and that immediate insertion may increase the risk of upper genital tract infection. In addition, the contraceptive efficacy of the IUCD in this setting is not clear. Consequently, the authors reviewed eight randomized trials with at least one treatment arm entailing IUCD insertion immediately after induced or spontaneous miscarriage. Women of any age and gravidity were eligible for inclusion. The trials, in general, were of fair methodological quality. After 2 years of follow-up in a trial of IUCD insertion immediately after induced abortion, there were three perforations, representing 1 per 1000 insertions, and 157 expulsions (7%). The 70 intrauterine or ectopic pregnancies represented 2 per 100 woman-years. Twelve cases of pelvic inflammatory disease translated into 0.4 per 100 woman-years. In this trial and one of IUCD insertion after miscarriage, continuation rates at 12 months ranged from 54% to 64%. The Copper T 220C proved better than the Lippes Loop D and Copper 7 models in World Health Organization trials. Pregnancy rates after 1 year ranged from 0.6% to 2.1%. There were no significant differences in the one trial that directly compared immediate with delayed postabortal insertion. The risk of expulsion increased with advancing gestational age. The investigators believe that postabortal IUCD insertion is an effective and safe practice. Rates of pelvic inflammatory disease are low. A higher risk of IUCD expulsion with increasing gestational age may be outweighed by the opportunity for immediate, highly effective contraception in a single procedure.