Immediate postabortion insertion of intrauterine devices
IUD insertion immediately after abortion - whether induced or reported as "spontaneous" - is both safe and practical. IUD expulsion rates are higher after second-trimester abortions than after first-trimester abortions. In postabortion IUD insertion, it is important first to rule out current genital tract infection, risk of infection or haemorrhage and genital tract injury.
RHL Commentary by Nguyen Thi Nhu Ngoc
1. EVIDENCE SUMMARY
The review included nine randomized controlled trials. All but one compared different intrauterine devices (IUDs) inserted immediately following an induced abortion. Only one trial evaluated the safety and efficacy of immediate versus interval (that is, few weeks after abortion) insertion. Overall, the review found immediate postabortion insertion of the IUDs to be safe and effective. Pregnancy rates observed in the trials that compared different IUDs for immediate insertion were about the same when compared with interval insertion (i.e. during or immediately after menses, usually few weeks after an abortion) as well as the occurrence of serious events such as perforation and pelvic inflammatory diseases. However, the expulsion rate of Copper 7 IUD was higher with immediate insertion when compared to interval insertion (Odds ratio: 2.9; 95% Confidence interval: 1.0 - 8.7). IUD insertion after abortion during the second trimester was shown to have higher expulsion rates than during first trimester abortion and therefore was not recommended.
In one recent trial the number of pregnancies were less with levonorgestrel-releasling IUD compared to Nova T.
Counselling is important when IUD insertion is done at the time of abortion. The woman should be warned that there is a higher likelihood of expulsion when IUDs are inserted after abortion and after second trimester abortions compared to first.
When compared between various types of intrauterine contraceptive device (IUDs), the review has concluded that Copper T 220C is the most appropriate for immediate post abortion insertion because its continuation rate was longer and the expulsion rate was less when compared to other devices. Uterine perforation was a rare event for all types of IUD.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
In countries where induced abortions are common and contraceptive prevalence is low, owing to unmet family planning needs, the issue of immediate post-abortion insertion of an IUD continues to be important.
A high number of abortions, often reflects an unmet need for family planning services. Inadequate infrastructure such as a poor transport system, inadequate facilities together with lack of information about contraception might limit access to family planning services. Living conditions limiting women's mobility could also add to the reasons of low use of these services. Unpublished data from Viet Nam show that only one-fourth of women who have undergone an induced abortion return to the abortion service for a contraceptive method. Hence, it may be important to offer a method immediately after the abortion procedure.
Studies from developing countries such as Viet Nam and Tunisia show that approximately 50% of women coming for abortion have a history of induced abortion (1). Therefore, immediate post abortion insertion of an IUD could help to bridge the gap between abortion service and family planning, consequently improving the quality of abortion care and reducing repeat abortions.
2.2. Applicability of the results
The results of this review are applicable to daily practice at abortion services in developing countries especially where the rate of repeat abortions is high.
2.3. Implementation of the intervention
When postabortion insertion of IUDs is considered for inclusion into an abortion service, one should focus strongly on pre- and post-procedure counselling to increase informed choice and women’s acceptability of the method. The insertion of an IUD at the time of abortion seems to be an effective and acceptable solution to the problem of repeated induced abortion (2).
Post-abortion IUD insertion should be considered for adolescent girls and women who have already failed in contraception and required abortion, and would like to use a long term contraceptive method (3).
Although IUDs can be inserted safely after a spontaneous or an induced abortion during the first trimester, it is very important to rule out current infection of the genital tract or risk of infection or haemorrhage and genital tract injury before an IUD is inserted.
3. RESEARCH
Future research should address the following two issues:
1. Comparison of postabortion morbidity between interval and post-abortion insertion of in terms of pain, bleeding patterns and expulsion rates.
2. Acceptability of postabortion IUD insertion to women.
References
- Batya Elul, Selma Hajri, Nguyen thi Nhu Ngoc. Mifepristone-Misoprostone abortion: A simplified regimen of 200mg mifepristone and home administration of misoprostol in 2 developing countries. International family planning perspectives Submitted .
- Bitsch M, Jakobsen AB, Prien-Larsen JC, Frolund C, Sederberg-Olsen J. IUD (NovaT) insertion following induced abortion. Contraception 1990;42:315-322.
- Goldman JA , Dekel A, Reichman J. Immediate post-abortion intrauterine contraception in nulliparous adolescents. Israel journal of medical science 1979;15:522-525.
This document should be cited as: Nguyen Thi Nhu Ngoc. Immediate postabortion insertion of intrauterine devices : RHL commentary (last revised: 18 January 2005). The WHO Reproductive Health Library; Geneva: World Health Organization.