IUD Safe When Inserted Immediately After Abortion

流產手術後馬上裝避孕器是安全

June 14, 2011 — Insertion of an intrauterine device (IUD) immediately after an abortion through first-trimester uterine aspiration is safe, with a 6-month expulsion rate not significantly different than that associated with delayed insertion, a new study shows.

"Women assigned to immediate insertion had higher insertion rates and higher rates of IUD use at 6 months, effects that are likely to result in reduced rates of unintended pregnancy," the study authors report.

"Our data add to the growing body of evidence that IUDs are safe and highly effective, and supports expanding access to IUDs to a wider range of women," said principal investigator Paula H. Bednarek, MD, MPH, in a press release about the study.

Immediate insertion of an IUD could prevent more than 70,000 unintended pregnancies annually in the United States, Dr. Bednarek and colleagues write in the June 9 issue of the New England Journal of Medicine. Initiation of any contraceptive method right after an abortion has been associated with a reduced risk for subsequent abortion, but immediate use of an IUD has been shown to be the most effective way to lower this risk.

However, despite evidence that many women are open to receiving an IUD immediately after an abortion, some clinicians have hesitated, because of fears regarding possible expulsion, uterine perforation, infection, and cost. Dr. Bednarek, of the Oregon Health and Science University in Portland, and her colleagues addressed these concerns in 575 women randomly selected to have an IUD inserted immediately after uterine aspiration (the immediate-insertion group) or 2 to 6 weeks later (the delayed-insertion group). The women had a mean age of 27 years and were in their 5th to 12th week of pregnancy. The rate of IUD expulsion 6 months after uterine aspiration was the primary outcome, with an expulsion rate at least 8 percentage points higher in the immediate-insertion group, defined as inferior.

IUDs were placed in 258 (100%) of women in the immediate-insertion group and in 226 (71%) of 371 of women in the delayed-insertion group. Follow-up evaluations were performed at 1, 3, and 6 months after insertion. During that time, expulsions occurred in 13 women (5%; 95% confidence interval [CI], 2.7 - 8.5) in the immediate-insertion group and in 6 women (2.7%; 95% CI, 1.0 - 5.7) in the delayed-insertion group (P = .19; absolute difference, 2.3 percentage points; 95% CI, −1.0 to 5.8).

"This trial showed that when IUD insertion is performed immediately after first-trimester uterine aspiration, the rate of IUD expulsion, although higher than that with delayed insertion, is low and statistically noninferior to the rate with delayed insertion," the study authors write.

At 6 months, the rate of IUD usage in the immediate-insertion group was 92.3% vs 76.6% in the delayed-insertion group (P < .001). "There were no significant differences between groups in rates of any adverse events," the study authors write. Pelvic infections occurred in 5 women from each group.

A study limitation was the high rate of loss to follow-up in both groups: 27% at 6 months in the immediate-insertion group and 25% in the delayed-insertion group. This trend may have led to underestimates for the rates of expulsion, unintended pregnancy, and infection. The women who did not return for follow-up were, on average, younger and less affluent than the other members of their cohort, both characteristics of an increased risk for unintended pregnancy.

In many cases, physicians who would like to encourage women to begin contraception immediately after an abortion are hindered by governmental programs such as the Title X and state Medicaid waiver programs, which forbid provision of contraceptive services on the day of an abortion in the same facility. The study authors warn that "such policies that require healthcare providers to separate contraception provision from abortion provision reduce the likelihood that women will obtain the contraception needed to prevent unintended pregnancy