Postabortion IUD use: Safety and timing

Last reviewed: October 7, 2022

Recommendation:

• When an individual chooses an intrauterine contraceptive device (IUD), it should be placed immediately following a successful, uncomplicated vacuum aspiration or dilatation and evacuation (D&E) abortion.
• When an individual chooses an IUD following medical abortion, it should be placed when it is reasonably certain they are no longer pregnant.

Strength of recommendation: Strong

Quality of evidence: High

IUD placement after abortion before 13 weeks gestation

The World Health Organization’s (WHO) 2015 Medical Eligibility Criteria for Contraceptive Use classifies IUDs as category one, or safe for immediate use, following first-trimester abortion; recommendations do not differ based on type of abortion.

In comparison to short-acting methods, long-acting reversible methods of contraception such as implants and IUDs have higher continuation rates and lower pregnancy and abortion rates (Blumenthal et al., 1994; Cameron et al., 2012; Korjamo, Mentula & Heikinheimo, 2017b; Langston, Joslin-Rohr, & Westhoff, 2014; Peipert, Madden, Allsworth, & Secura, 2012; Pohjoranta, Mentula, Gissler, Suhonen, & Heikinheimo, 2015; Roberts, Silva, & Xu, 2010). A 2014 Cochrane review of 12 trials including 7,119 women concluded that IUD insertion following vacuum aspiration and D&E is safe and practical (Okusanya, Oduwole, & Effa, 2014). The review found no differences in serious adverse events, such as infection or perforation, between immediate and delayed insertion. A 2011 trial randomized 575 women to immediate or delayed IUD insertion after uterine aspiration before 12 weeks (Bednarek et al., 2011). Although rates of IUD expulsion were slightly higher following immediate postabortion insertion (5% compared to 2.7%), women assigned to the delayed insertion group were significantly less likely to receive an IUD (75% compared to 100% in the immediate group) and more likely to have a subsequent pregnancy (five compared to none). A historical cohort study compared immediate postprocedure IUD insertion performed by midlevel providers to physicians, and found no difference in adverse outcomes between the two groups (Patil et al., 2016).

Following a medical abortion before 13 weeks gestation, IUDs may be placed as soon as it is reasonably certain that the individual is no longer pregnant (WHO, 2022). IUDs placed within 5-10 days of a successful medical abortion have low rates of expulsion, high continuation rates (Betstadt et al., 2011; Sääv et al., 2012) and lower pregnancy rates than delayed insertion (Pohjoranta et al., 2017; Saav et al., 2012; Shimoni et al., 2011). A systematic review of three randomized trials found no differences between early and delayed insertion after abortion at gestations less than nine weeks, and higher rates of expulsion, continuation and uptake after immediate compared to delayed insertion at 9–12 weeks of gestation (Schmidt-Hansen et al., 2020). Uptake of IUDs is higher after surgical abortion as compared to medical abortion, despite similar contraceptive choices and desires (Fang, Sheeder, & Teal, 2018; Rocca et al., 2018).

IUD placement after abortion at or after 13 weeks gestation

The WHO Medical Eligibility Criteria for Contraceptive Use (2015) classifies IUD use following uncomplicated second-trimester abortion as category two, meaning the advantages of using the method outweigh risks, due to an increased risk of IUD expulsion. The Cochrane review of immediate postabortion insertion of IUDs following an abortion procedure referenced above concluded that although expulsion rates may be higher with immediate placement, continuation is higher with no increase in complications (Okusanya et al., 2014). In two randomized controlled trials of immediate versus delayed IUD placement after D&E, rates of IUD use were significantly higher with immediate insertion, without an increase in infection or complication rates (Cremer et al., 2011; Hohmann et al., 2012). Expulsion rates for those who had immediate insertion in both studies were low (3.1% and 6.8%) and were not different from delayed insertion. Notably, in both studies, about half of women randomized to delayed insertion did not return to have the IUD inserted. Requiring a follow-up visit for IUD insertion is a significant barrier to obtaining the IUD (Stanek et al., 2009).

A 2022 study that randomized 114 people seeking medical abortion between 17 and 20 weeks gestation to receive either an immediate postabortion copper IUD, or placement three weeks later, found that many more people in the immediate group were using an IUD after 6 weeks (56%, compared to 19%), despite a significantly higher expulsion rate in the immediate group (32%, compared to 7%) (Constant et al., 2022).  A smaller study randomized 57 people to immediate or delayed hormonal IUD placement following medical abortion between 12 and 20 weeks gestation. and found that insertion is feasible and safe; however the study was underpowered to assess rate of expulsions (Korjamo, Mentula, & Heikinheimo, 2017a; Korjamo et al., 2017b). The WHO Medical Eligibility Criteria for Contraceptive Use (2015) recommendations for IUD use after second-trimester abortion do not differ based on the type of abortion performed, whether medical or surgical. Although not directly translatable, the evidence from post-partum IUD insertion is reassuring (Lopez et al., 2015). An IUD may be placed following fetal and placental expulsion.

Young people

The IUD for people under the age of 20 is classified by WHO as category two, in which the benefits generally outweigh the risks (WHO, 2015). A large, US-based, prospective cohort study which examined pregnancy, birth and abortion rates in women provided all birth control methods at no cost included 1,056 women under the age of 20 and found that 62% of young women chose a long acting reversible contraceptive method—either the IUD (22%) or implant (40%)—compared to 71% of older women (Mestad et al., 2011). Continuation rates at 12 and 24 months were the same among older and younger women (Birgisson, 2015). Pregnancy, birth and induced abortion rates among the young women in the study were reduced by 75% compared to national averages (Secura et al., 2014).

A large 2017 systematic review and meta-analysis exploring risk factors for repeat pregnancies among teens, which included 26 studies reporting on more than 160,000 adolescent women, found that use of long acting reversible contraceptives exerted a significant protective effect, along with improved educational attainment and school continuation (Maravilla, 2017).

A 2017 systematic review examining risk of adverse outcomes in young women using the IUD found no differences in rates of perforation, contraceptive failure, pelvic inflammatory disease, or heavy bleeding in women younger than 25 compared to older women; rates of IUD expulsion were slightly higher in young women (Jatlaoui, Riley, & Curtis, 2017). IUDs do not increase young women’s risk of infertility (Grimes, 2000), and women’s fertility returns to baseline rates rapidly following IUD removal (Hov, Skjeldestad, & Hilstad, 2007).

Who can insert and remove IUDs?

WHO makes service delivery recommendations for the provision of IUDs (WHO, 2022), recommending that IUD insertion and removal is within the scope of practice of specialty and generalist medical practitioners, associate and advance associate clinicians, nurses, midwives, and auxiliary nurse midwives, based on expected skills and knowledge for these health worker roles. WHO suggests that in settings where established mechanisms exist to include traditional and complementary medicine professions in other tasks related to maternal and reproductive health care, they can safely and effectively insert and remove IUDs, and that auxiliary nurses can insert and remove IUDs in the context of research. For further information about health worker roles in abortion care, see Appendix C: World Health Organization recommendations for health worker roles in abortion care.

References

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Pohjoranta, E., Mentula, M., Gissler, M., Suhonen, S., & Heikinheimo, O. (2015). Provision of intrauterine contraception in association with first trimester induced abortion reduces the need of repeat abortion: First-year results of a randomized controlled trial. Human Reproduction, 30(11), 2539-46.

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World Health Organization. (2022). Abortion care guideline. Geneva: World Health Organization.

World Health Organization. (2015). Medical eligibility criteria for contraceptive use (5th ed.). Geneva: World Health Organization Press.