Intrauterine devices (IUDs) for emergency contraception are highly effective but greatly underused, according to a new meta-analysis by a team of international researchers. The researchers found that IUDs inserted shortly after unprotected intercourse have a failure rate of less than 1 per 1000 and are more effective than “morning-after pills” in protecting women from unwanted pregnancies. The meta-analysis, which included 42 studies conducted in 6 countries between 1979 and 2011 and involved 8 different types of IUDs and 7034 women, found a pregnancy rate of 0.09% among women using IUDs inserted from 2 to 10 or more days (74% within 5 days) after unprotected intercourse, a rate 10 to 20 times better than that found with emergency contraception medications such as ulipristal acetate and levonorgestrel (Cleland K et al. Hum Reprod. doi:10.1093/humrep/des140 [published online May 8, 2012]). (Photo credit: Saturn Stills/www.sciencesource.com) Intrauterine devices can be used for emergency contraception and are more protective against unwanted pregnancies than morning-after pills. Unintended pregnancy accounts for at least 36% of all pregnancies worldwide and nearly half of pregnancies in the United States. An estimated 3.2 million unintended US pregnancies occurred in 2006, the most recent year with data available. Emergency contraception gives women the chance to avoid an unintended pregnancy after intercourse, both in cases of contraceptive accidents or nonuse and in situations of sexual violence. Nonhormonal IUDs, primarily copper-bearing, have been used for emergency contraception for at least 35 years and are an emergency option recommended by advocacy groups and the American Congress of Obstetricians and Gynecologists (ACOG). Yet they have been underused, although the extent of such underuse is unknown. Intrauterine devices have also been underused as a regular form of contraception. In the United States, only 4.9% of women at risk of pregnancy reported using an IUD in 2008; still, that was an increase from 1995, when only 0.7% of women were choosing the devices. This is lower than the rates of IUD use in many other countries, such as 24% in France. Kelly Cleland, lead author of the international article and a staff researcher at the Office of Population Research at Princeton University, Princeton, NJ, blamed the historic low acceptance rate of IUDs on the Dalkon Shield, an IUD available in the 1970s in the United States. The Dalkon Shield caused severe pelvic infections, sepsis, and death in some users and resulted in thousands of lawsuits against the manufacturer. “People were really afraid, and people are still afraid, even though IUD design today is much safer,” Cleland said. Agreeing with Cleland is EveEspey, MD, MPH, professor of obstetrics and gynecology at the University of New Mexico School of Medicine in Albuquerque. “We still are suffering from the hangover of the Dalkon Shield due to fears of infection and fears of litigation,” said Espey, who headed ACOG's writing group on IUD use recommendations. “IUDs are totally wonderful, but totally underutilized.” Beyond the Dalkon hangover, other misconceptions about IUDs, such as increased pelvic infection risk, have also restricted its acceptance among physicians and patients in general. A 2008 survey of physicians, nurse practitioners, and physician assistants found that 40% did not offer IUDs to patients seeking contraception and 36% infrequently provided counseling, although 92% thought patients were receptive to learning about the method. Also, fewer than half of clinicians considered nulliparous women and postabortion women appropriate candidates for IUD contraception even though studies have found these to be appropriate populations. They also found that younger physicians and those trained in residency programs were more likely to offer IUDs (Harper CC et al. Obstet Gynecol. 2008;111:1359-1369). A survey looking at IUD recommendations for emergency contraception also found hesitancy of use among 1246 clinicians in a California family planning program, where contraceptives are available at no cost to low-income women. The survey found 85% of respondents never recommended the copper IUD for emergency contraception, and 93% required 2 or more visits for an IUD insertion, which would take too much time for securing maximum protection in an emergency situation (Harper CC et al. Obstet Gynecol. 2012;119[2 pt 1]:220-226). Espey said costs and reimbursement affect physician and patient choices of emergency contraception. In the United States, a patient typically must choose either to pay the IUD cost of $700 (depending on insurance) and spend time in a physician's office or to pay less than $50 to take a morning-after pill. An IUD, which can remain in place as a general contraceptive device for up to 10 years, is ultimately more cost-effective than other contraceptive products, Espey said, but it might be a hard sell at a moment when a woman is seeking emergency contraception. Reimbursement to physicians poses another barrier. “Reimbursement is very low, so providers wanting to use IUDs need to be very motivated,” she said.
JAMA – American Medical Association
Published: Jun 20, 2012
Keywords: contraceptive methods,intrauterine devices