Intrauterine devices (IUDs) should be used routinely to provideemergency contraception , according to the authors of the first systematic review of allavailable data from the past 35 years. They found that IUDs had afailure rate of less than one per thousand and were a moreeffective form of emergency contraception than the "morning afterpill". In addition, IUDs continued to protect women from unwantedpregnancy for many more years if they were left in place. The research, which is published online in Europe's leadingreproductive medicine journal Human Reproduction  today (Wednesday), analysed data from 42 studies carried outin six countries  between 1979 and 2011 and published in Englishor Chinese. |
IUD use in China is the highest in the world with 43%of women using them for contraception compared with 13% in the restof the world, according to a 2006 report. The studies includedeight different types of IUDs and 7034 women. An IUD, sometimes known as a "coil" is a small plastic and copperdevice that is inserted into the womb by a trained doctor or nurse.It can be left in place for between five and ten years, dependingon brand. In recent years, intrauterine systems (IUS) have beendeveloped; these are small, plastic devices that release a very lowdose of the hormone progesterone.
The current study looked at IUDsonly, which have been used for emergency contraception for at least35 years. The first author of the study, Ms Kelly Cleland, a staff researcherat the Office of Population Research at Princeton University,Princeton, USA, said: "Unintended pregnancies are a significanthealth problem worldwide. It is estimated that globally at least36% of pregnancies are unintended. We already know from previousresearch that IUDs are very cost-effective forms of regularcontraception. This study is the most comprehensive review to dateof the efficacy of IUDs used for emergency contraception, and ourresults provide clear evidence that they are a highly effectivemethod of emergency contraception, as nearly 100% of users overalldid not become pregnant after unprotected sex when an IUD wasinserted post-coitally.
In contrast, failure rates are at least10-20 times as high for emergency contraceptive pills such asulipristal acetate and levonorgestrel. IUDs also offer veryeffective ongoing contraception. Therefore, we conclude that IUDsshould be included routinely as an emergency contraceptive optionwhenever feasible and appropriate." When IUDs are used for emergency contraception they normally shouldbe inserted within about five days of unprotected intercourse. Themaximum timeframe in the current review ranged between two and tendays or more. However, in the majority of the studies (74%)insertion occurred within five days.
Out of the 7034 post-coital IUD insertions, there was a total of 10pregnancies: six occurred among 5629 women in China, and theremaining four pregnancies in 200 women in one Egyptian study. The researchers believe the unusual and abnormal results in theEgyptian study made it an "outlier" study, probably due to the waythe women were chosen and, therefore, should be ignored for thepurposes of their review. "This high failure rate can possibly beexplained by the fact that women were specifically selected if theyhad had intercourse around the time of ovulation; in any eventEgypt is a clear outlier," write the authors. "If the unusualresults from the Egypt study were excluded, the overall failurerate would be 0.09%.
. .; this is our preferred estimate." By comparison, the "morning after pill" ulipristal acetate is thenext most effective with a failure rate of approximately 1-2%,followed by levonorgestrel with a failure rate of approximately2-3%. Both ulipristal acetate and levonorgestrel become lesseffective with increasing body mass index (BMI), but theresearchers say that IUDs do not lose their effectiveness withincreasing BMI. Despite IUDs being the most effective means of emergencycontraception, research shows that both doctors and patients havelittle awareness of them and they are rarely used in thissituation.
The researchers say a study in the USA showed that 85%of clinicians never recommended IUDs for emergency contraceptionand 93% require at least two visits for an IUD insertion. Professor James Trussell, Professor of Economics and Public Affairsat Princeton University and Visiting Professor at The Hull YorkMedical School in York, UK, who was also involved in the research,said: "This is an extremely difficult problem to deal with,especially as in many countries women can just go to their localpharmacy to obtain the 'morning after pill', but virtually no womenknow to ask for an IUD and many family planning clinics andsurgeries do not offer same-day insertion. Offering same-dayinsertion would remove a huge barrier to the greater use of IUDs." In addition, the upfront cost of IUDs is comparatively high,ranging between $718 for the ParaGard IUD in the USA  to about 10 for IUDs in the UK, although over a period of time they workout as more cost effective than other methods of contraception,emergency or otherwise. Prof Trussell said that "these initially higher costs are vastlyoffset by pregnancies prevented both in the contraceptive emergencyitself and by pregnancies prevented by continued use of the IUD.'Morning after pills' taken today protect against pregnancy fromsex last night but not from sex a week from now." Ms Cleland concluded: "We hope that this study will encourageproviders to consider IUDs for their patients requesting emergencycontraception, and possibly to consider how to structure theirclinic flow so that they are able to provide same-day insertions." Additional References Citations.
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