Immediate postabortal insertion of intrauterine devices

Babasola O Okusanya; Olabisi Oduwole; Emmanuel E Effa

doi:10.1002/14651858.CD001777.pub4

. 2014 Jul 28;2014(7):CD001777. doi: 10.1002/14651858.CD001777.pub4

Immediate postabortal insertion of intrauterine devices

Babasola O Okusanya ¹, Olabisi Oduwole ^2,^✉, Emmanuel E Effa ³

Editor: Cochrane Fertility Regulation Group

PMCID: PMC7079711 PMID: 25101364

Abstract

Background

The use of an effective contraceptive may be necessary after an abortion. Insertion of an intrauterine device (IUD) may be done the same day or later. Immediate IUD insertion is an option since the woman is not pregnant, pain of insertion is less because the cervical os is open, and her motivation to use contraception may be high. However, insertion of an IUD immediately after a pregnancy ends carries risks, such as spontaneous expulsion.

Objectives

To assess the safety and efficacy of IUD insertion immediately after spontaneous or induced abortion.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov, and ICTRP in January 27, 2014. We also contacted investigators to identify other trials.

Selection criteria

We sought all randomised controlled trials (RCTs) with at least one treatment arm that involved IUD insertion immediately after an induced abortion or after curettage for spontaneous abortion.

Data collection and analysis

We evaluated the methodological quality of each report and abstracted the data. We focused on discontinuation rates for accidental pregnancy, perforation, expulsion, and pelvic inflammatory disease. We computed the weighted average of the rate ratios. We computed risk ratios (RRs) with 95% Confidence Intervals (CIs). We performed an intention‐to‐treat (ITT) analysis by including all randomised participants in the analysis according to the Cochrane Handbook for Systematic Reviews of Interventions.

Main results

We identified 12 trials most of which are of moderate risk of bias involving 7,119 participants which described random assignment. Five trials randomised to either immediate or delayed insertion of IUD. One of them randomised to immediate versus delayed insertion of Copper 7 showed immediate insertion of the Copper 7 was associated with a higher risk of expulsion than was delayed insertion (RR 11.98, 95% CI 1.61 to 89.35,1 study, 259 participants); the quality of evidence was moderate. Moderate quality of evidence also suggests that use and expulsion of levonorgestrel‐releasing intrauterine system or CuT380A was more likely for immediate compared to delayed insertion risk ratio (RR) 1.40 (95% CI 1.24 to 1.58; 3 studies; 878 participants) and RR 2.64 ( 95% CI 1.16 to 6.00; 3 studies; 878 participants) respectively. Another trial randomised to the levonorgestrel IUD or Nova T showed discontinuation rates due to pregnancy were likely to be higher for women in the Nova T group. (MD 8.70, 95% CI 3.92 to 13.48;1 study; 438 participants); moderate quality evidence.

Seven trials examined immediate insertion of IUD only. From meta‐analysis of two multicentre trials, pregnancy was less likely for the TCu 220C versus the Lippes Loop (RR 0.43, 95% CI 0.24 to 0.75; 2 studies; 2257 participants ) as was expulsion (RR 0.61, 95% CI 0.46 to 0.81; 2 studies; 2257 participants). Estimates for the TCu 220 versus the Copper 7 were RR 0.42 ( 95% CI 0.23 to 0.77; 2 studies, 2,274 participants) and RR 0.68, (95% CI 0.51 to 0.91); 2 studies, 2,274 participants), respectively. In other work, adding copper sleeves to the Lippes Loop improved efficacy (RR 3.40, 95% CI 1.28 to 9.04, 1 study, 400 participants) and reduced expulsion (RR 3.00, 95% CI 1.51 to 5.97; 1 study, 400 participants).

Authors' conclusions

Moderate quality evidence shows that insertion of an IUD immediately after abortion is safe and practical. IUD expulsion rates appear higher immediately after abortions compared to delayed insertions. However, at six months postabortion, IUD use is higher following immediate insertion compared to delayed insertion.

Plain language summary

Inserting an IUD right after abortion or miscarriage versus at a later time

Inserting an intrauterine device (IUD) right after an abortion or miscarriage can be good for many reasons. The woman is not pregnant and may be thinking about birth control, and the time and place are convenient for the woman. If asked to delay IUD insertion, many women do not return to get the device. However, the IUD might be more likely to come out on its own if put in right after abortion or miscarriage. This review looked at how safe it was to insert an IUD right after abortion or miscarriage. We also looked at whether the IUD stayed in.

We did computer searches for randomised trials of IUDs inserted right after abortion or miscarriage. We also wrote to researchers to find more studies. Trials could compare types of IUDs or times for insertion. We found 12 studies to include.

Four trials randomised women to an IUD inserted right away or at a later time. One had no major difference. Three recent trials (of levonorgestrel intrauterine system or CuT380A) showed use was greater at six months for an IUD inserted right away compared to one inserted later. Another trial assigned women to the levonorgestrel IUD or Nova T; more women with the Nova T stopped use due to pregnancy. A subanalysis showed more IUDs came out when inserted right after abortion or miscarriage rather than later.

Seven trials looked at inserting the IUD right away. From two large trials, the TCu 220C was better than the Lippes Loop and the Copper 7 for preventing pregnancy and staying in. The IUD was more likely to come out on its own when inserted after a mid‐pregnancy abortion than after an earlier one. In other work, when the Lippes Loop had copper arms added, fewer women got pregnant and the IUD stayed in more often.

Moderate level evidence shows that inserting an IUD right after an abortion or miscarriage is safe and practical. However, the IUD is more likely to come out when inserted right away rather than at a later time. Women are more likely to use an IUD at six months if they had it inserted right away compared to some weeks after the abortion or miscarriage.

Summary of findings

Summary of findings for the main comparison. Immediate versus delayed insertion (LNG‐IUS or CuT380A IUD) for.

Immediate versus delayed insertion (LNG‐IUS or CuT380A IUD) for
Patient or population: patients with  Settings:   Intervention: Immediate versus delayed insertion (LNG‐IUS or CuT380A IUD)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect  (95% CI)	No of Participants  (studies)	Quality of the evidence  (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Immediate versus delayed insertion (LNG‐IUS or CuT380A IUD)
Expulsion by 6 months   Rate in percentage  Follow‐up: mean 6 months	Study population		RR 2.9   (1.25 to 6.71)	878  (3 studies)	⊕⊕⊕⊝  moderate^1,2
	15 per 1000	43 per 1000   (19 to 100)
	Moderate
	19 per 1000	55 per 1000   (24 to 127)
Removal by 6 months   Rate in percentage  Follow‐up: mean 6 months	Study population		RR 2.01   (0.99 to 4.06)	790  (2 studies)	⊕⊕⊕⊝  moderate³
	28 per 1000	56 per 1000   (28 to 114)
	Moderate
	22 per 1000	44 per 1000   (22 to 89)
Use at 6 months   Rate in percentage  Follow‐up: mean 6 months	Study population		RR 1.4   (1.24 to 1.58)	878  (3 studies)	⊕⊕⊕⊝  moderate⁴
	464 per 1000	650 per 1000   (575 to 733)
	Moderate
	386 per 1000	540 per 1000   (479 to 610)
Pregnancy at six months   Rate in percentage	Study population		RR 0.37   (0.12 to 1.14)	878  (3 studies)	⊕⊕⊕⊝  moderate⁵
	23 per 1000	9 per 1000   (3 to 27)
	Moderate
	23 per 1000	9 per 1000   (3 to 26)
upper genital tract infection   Rate in percentage	Study population		OR 1   (0.32 to 3.14)	878  (3 studies)	⊕⊕⊕⊝  moderate⁵
	13 per 1000	13 per 1000   (4 to 39)
	Moderate
	16 per 1000	16 per 1000   (5 to 49)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).  CI: Confidence interval; RR: Risk ratio; OR: Odds ratio;
GRADE Working Group grades of evidence  High quality: Further research is very unlikely to change our confidence in the estimate of effect.  Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.  Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.  Very low quality: We are very uncertain about the estimate.

TCu 220C compared to Lippes Loop for immediate insertion post‐abortion
Patient or population: patients with immediate insertion post‐abortion  Settings: Clinic  Intervention: TCu 220C  Comparison: Lippes Loop
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect  (95% CI)	No of Participants  (studies)	Quality of the evidence  (GRADE)	Comments
	Assumed risk	Corresponding risk
	Lippes Loop	TCu 220C
Discontinuation due to perforation (750 days)   Tietze‐Potter gross rate (Discontinuation in percentages  Follow‐up: mean 750 days	Study population		RR 0.92   (0.13 to 6.6)	2269  (2 studies)	⊕⊕⊕⊝  moderate^1,2
	1 per 1000	1 per 1000   (0 to 6)
	Moderate
	0 per 1000	0 per 1000   (0 to 0)
Discontinuation due to pelvic inflammatory disease (750 days)     Follow‐up: mean 750 days	Study population		RR 1.17   (0.29 to 4.71)	2269  (2 studies)	⊕⊕⊕⊝  moderate³
	3 per 1000	3 per 1000   (1 to 13)
	Moderate
	0 per 1000	0 per 1000   (0 to 0)
Discontinuation rate due to pregnancy (750days)     Follow‐up: mean 750 days	Study population		RR 0.38   (0.2 to 0.72)	2269  (2 studies)	⊕⊕⊕⊝  moderate⁴
	35 per 1000	13 per 1000   (7 to 25)
	Moderate

Discontinuation rate due to expulsion (750 days)   Tietze‐Potter gross rate (Discontinuation in percentages)  Follow‐up: mean 750 days	Study population		RR 0.51   (0.3 to 0.88)	2269  (2 studies)	⊕⊕⊕⊝  moderate⁴
	100 per 1000	51 per 1000   (30 to 88)
	Moderate

The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).  CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence  High quality: Further research is very unlikely to change our confidence in the estimate of effect.  Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.  Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.  Very low quality: We are very uncertain about the estimate.

TCu 220C compared to Copper 7 for Immediate insertion Post abortion
Patient or population: patients with Immediate insertion Post abortion  Settings:   Intervention: TCu 220C   Comparison: Copper 7
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect  (95% CI)	No of Participants  (studies)	Quality of the evidence  (GRADE)	Comments
	Assumed risk	Corresponding risk
	Copper 7	TCu 220C
Discontinuation due to pregnancy (750 days)   Follow‐up: mean 750 days	Study population		RR 0.44   (0.04 to 4.83)	2274  (2 studies)	⊕⊕⊕⊝  moderate¹
	31 per 1000	14 per 1000   (1 to 149)
	Moderate
	0 per 1000	0 per 1000   (0 to 0)
Discontinuation due to expulsion (750 days)   Follow‐up: mean 750 days	Study population		RR 0.46   (0.14 to 1.5)	2274  (2 studies)	⊕⊕⊕⊝  moderate²
	91 per 1000	42 per 1000   (13 to 137)
	Moderate
	0 per 1000	0 per 1000   (0 to 0)
Discontinuation due to pelvic inflammation   Follow‐up: mean 750 days	Study population		Not estimable	2274  (2 studies)	⊕⊕⊕⊝  moderate³
	7 per 1000	0 per 1000   (0 to 0)
	Moderate

Discontinuation due to perforation   Follow‐up: mean 750 days	Study population		Not estimable	2274  (2 studies)	⊕⊕⊕⊝  moderate⁴
	2 per 1000	0 per 1000   (0 to 0)
	Moderate

The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).  CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence  High quality: Further research is very unlikely to change our confidence in the estimate of effect.   Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.  Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.  Very low quality: We are very uncertain about the estimate.

Date	Event	Description
12 July 2014	New citation required and conclusions have changed	Published report of Bednarek 2011; Hohmann 2012 and Cremer 2011 obtained and included in the analysis. 'Summary of findings' table included
29 January 2014	New search has been performed	Searches were updated and converted to new reporting format

Date	Event	Description
15 April 2008	Amended	Converted to new review format
3 June 2004	New citation required and conclusions have changed	Substantive amendment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Discontinuation due to pregnancy (750 days)	2	2269	Risk Ratio (M‐H, Fixed, 95% CI)	0.43 [0.24, 0.75]
2 Discontinuation due to expulsion (750 days)	2	2269	Risk Ratio (M‐H, Fixed, 95% CI)	0.61 [0.46, 0.81]
3 Discontinuation due to total medical removals (750 days)	2	2269	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.70, 1.08]
4 Discontinuation due to perforation (750 days)	2	2269	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.14, 7.00]
5 Discontinuation due to pelvic inflammatory disease (750 days)	2	2269	Risk Ratio (M‐H, Fixed, 95% CI)	1.27 [0.31, 5.11]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Discontinuation due to pregnancy (750 days)	2	2257	Risk Ratio (M‐H, Fixed, 95% CI)	1.12 [0.71, 1.75]
2 Discontinuation due to expulsion (750 days)	2	2257	Risk Ratio (M‐H, Fixed, 95% CI)	1.12 [0.87, 1.44]
3 Discontinuation due to perforation (750 days)	2	2257	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.11, 3.99]
4 Discontinuation due to total medical removals (750 days)	2	2257	Odds Ratio (M‐H, Fixed, 95% CI)	1.30 [1.01, 1.67]
5 Discontinuation due to pelvic inflammatory disease (750 days)	2	2257	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.12, 1.43]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Discontinuation due to pregnancy (750 days)	2	2274	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.23, 0.77]
2 Discontinuation due to expulsion (750 days)	2	2274	Risk Ratio (M‐H, Fixed, 95% CI)	0.68 [0.51, 0.91]
3 Discontinuation due to total medical removals (750 days)	2	2274	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.87, 1.37]
4 Discontinuation due to perforation (750 days)	2	2274	Risk Ratio (M‐H, Fixed, 95% CI)	0.49 [0.04, 5.38]
5 Discontinuation due to pelvic inflammatory disease (750 days)	2	2274	Risk Ratio (M‐H, Fixed, 95% CI)	0.49 [0.15, 1.63]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Discontinuation due to pregnancy (24 months)	1	400	Risk Ratio (M‐H, Fixed, 95% CI)	6.0 [0.73, 49.39]
2 Discontinuation due to expulsion (24 months)	1	400	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [0.55, 2.46]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Discontinuation due to pregnancy at one year	1	259	Risk Ratio (M‐H, Fixed, 95% CI)	4.0 [0.19, 82.50]
2 Discontinuation due to expulsion at one year	1	259	Risk Ratio (M‐H, Fixed, 95% CI)	11.98 [1.61, 89.35]
3 Discontinuation due to pelvic inflammatory disease at one year	1	259	Risk Ratio (M‐H, Fixed, 95% CI)	5.6 [0.29, 107.33]
4 Discontinuation rates (5‐year) per 100 women due to hormonal reasons after immediate insertion	1		Mean Difference (Fixed, 95% CI)	‐12.0 [‐20.39, ‐3.61]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Discontinuation due to pregnancy (24 months)	1	549	Risk Ratio (M‐H, Fixed, 95% CI)	0.80 [0.22, 2.96]
2 Discontinuation due to expulsion (24 months)	1	549	Risk Ratio (M‐H, Fixed, 95% CI)	1.76 [0.52, 5.93]

Methods	Randomised, blinded (subject, caregiver, investigator), safety/efficacy study. Randomisation in 5:6 ratio
Participants	575 women, 18 years or older, requesting suction aspiration for spontaneous or induced abortion. Inclusion criteria: intrauterine pregnancy documented with ultrasound with gestational age >= 5 weeks but <= 12 weeks; desiring intrauterine contraception; in general good health.  Exclusion criteria: evidence of active cervicitis or PID, PID or STI in past 3 months, history of actinomycosis, unexplained vaginal bleeding, uterine anomaly, leiomyomata, complete molar pregnancy, ectopic pregnancy, AIDS without treatment, prior surgical aspiration during this current pregnancy, use of osmotic dilators or misoprostol during aspiration procedure; allergy to polyethylene, levonorgestrel (for LNG‐containing IUS), or copper (for copper T380A IUD); Wilson's disease (for copper T380A IUD)
Interventions	Insertion of intrauterine device (IUD) immediately after a suction aspiration procedure (within minutes) (n = 258) compared to inserting the IUD 2 to 6 weeks after the procedure (n = 317). Women could choose LNG‐IUS or CuT380A IUD
Outcomes	Primary: expulsion by 6 months  Secondary: continuation, adverse events, and satisfaction by 6 months
Notes	This update has included all 575 randomised participants because the final result has been published
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Randomisation in 5:6 ratio was computer generated.
Allocation concealment (selection bias)	Low risk	Sequentially numbered, opaque envelopes containing cards with computer ‐ generated assignments were used. Envelopes were opened only after the aspiration procedure had been completed and the investigator had determined that immediate IUD was feasible
Blinding of participants and personnel (performance bias)   All outcomes	Low risk	Subject, caregiver, and investigator were blinded to the intervention given
Blinding (performance bias and detection bias)   All outcomes	Unclear risk	Unclear
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Unclear
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Not all randomised participants were included in the final analysis. Participants lost to follow‐up were not included in the analysis of important outcomes
Selective reporting (reporting bias)	Unclear risk	Unclear
Other bias	Unclear risk	Unclear

Methods	Open labelled randomised controlled trial. Randomisation was done using computer generated table of random numbers
Participants	215 women, 16 years or older. Inclusion criteria: intrauterine pregnancy > 14 weeks gestation, desires abortion, desires IUD for contraception, no contraindication for dilation and evacuation abortion Exclusion criteria: uterine anomaly including fibroids if they distort the uterine cavity, acute PID, uterine or cervical neoplasia or unresolved abnormal PAP smear, untreated acute cervicitis or vaginitis, chlamydia or gonorrhoea infection in past 90 days, acute liver disease or liver tumour, woman or partner currently with multiple sexual partners, history of Wilson's disease, hypersensitivity to any component of Copper T IUD
Interventions	Copper T 380A IUD:  Immediate insertion ‐ IUD inserted within 15 minutes after delivery of the placenta immediately following abortion  Delayed insertion ‐ IUD inserted at the post‐operative visit 2 to 4 weeks after the abortion
Outcomes	Primary: use at 6 months  Secondary: satisfaction, expulsion by 6 months, use of other contraceptives, infection and repeat abortion
Notes	This study was previously listed under ongoing studies
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Randomisation was done using computer generated table of random numbers
Allocation concealment (selection bias)	Low risk	Sequentially numbered, opaque sealed envelopes were opened on the day of abortion. Randomisation was not known until final day of procedure if abortion was a two‐day procedure
Blinding of participants and personnel (performance bias)   All outcomes	High risk	No blinding
Blinding (performance bias and detection bias)   All outcomes	Unclear risk	Unclear
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	assessment was done by participants and not by providers
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Not all randomised participants were included in the final analysis. Participants lost to follow‐up were not included in the analysis of important outcomes
Selective reporting (reporting bias)	Unclear risk	Unclear
Other bias	Unclear risk	Not all randomised participants were included in the final analysis

Methods	Randomised controlled trial without blinding. Method of randomisation listed only as 'balanced.' Communication with authors indicated a computer‐generated randomisation sequence and allocation concealment by use of sealed envelopes
Participants	259 women at 3 sites in Canada having vacuum aspiration abortion. The gestational ages were not described
Interventions	Copper 7 inserted immediately versus Copper 7 inserted 3 to 5 weeks after the abortion
Outcomes	Primary outcome measures included pregnancy, expulsion, and removal for bleeding/pain, or other medical reason
Notes	46 women (31.9%) and 27 (42.9) allocated to immediate and delayed insertion respectively failed to return for IUD insertion. The report provided no a priori hypothesis or sample size and power calculation. Denominators for rates were woman‐days of use
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Communication with authors indicated a computer‐generated randomisation sequence. allocation concealment by use of sealed envelopes.
Allocation concealment (selection bias)	Low risk	Allocation concealment by use of sealed envelopes
Blinding of participants and personnel (performance bias)   All outcomes	High risk	No blinding
Blinding (performance bias and detection bias)   All outcomes	High risk	No blinding
Blinding of outcome assessment (detection bias)   All outcomes	High risk	No blinding
Incomplete outcome data (attrition bias)   All outcomes	High risk	46 women (31.9%) and 27 (42.9) allocated to immediate and delayed insertion respectively were lost to follow‐up
Selective reporting (reporting bias)	Unclear risk	We did not have access to study protocol, so it is unclear
Other bias	Unclear risk	The report provided no a priori hypothesis or sample size and power calculation. Denominators for rates were woman‐days of use

Methods	Randomised, open label, safety study
Participants	88 women, 18 years or older were randomised. Inclusion criteria: gestational age 15 weeks to 23 weeks 6 days, already consented to an induced abortion, desires to use the LNG‐IUS for contraception for 12 months or more; lives in specified counties of Pennsylvania Exclusion criteria: allergy to either polyethylene or levonorgestrel, urgent need for abortion (active bleeding or infection), exposure to or treatment for gonorrhoea or Chlamydia in past 90 days, PID in past year, leiomyomata > 3 cm diameter, uterine anomaly (other than repaired septate uterus)  Post‐enrollment pre‐randomisation exclusion criteria (assessed at D&E completion): uterine perforation; haemorrhage as defined by (1) need for transfusion, (2) estimated blood loss > 500 cc, (3) intrauterine placement of a Foley catheter, or (4) use of >= 3 doses of uterotonic medications; infection at time of D&E, including fever (temperature >= 38°C) or pus at the cervical os; subject no longer desires a LNG‐IUS
Interventions	Insertion of LNG‐IUS immediately following dilation & evacuation compared to delayed insertion (3 to 6 weeks post‐abortion)
Outcomes	Primary: use at 6 months  Secondary: uptake, expulsion, continuation, acceptability, utility of ultrasound in predicting expulsion
Notes	This study was completed and data in this update was obtained from the published study
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Subjects were stratified into two strata by parity (parous or nulliparous) with random block sizes of 2,4 and 6 using computer generated sequence
Allocation concealment (selection bias)	Low risk	Eligible subjects were randomised by opening the next sequentially numbered sealed opaque envelope in the operating room
Blinding of participants and personnel (performance bias)   All outcomes	Low risk	A statistician not affiliated to the study prepared the envelopes
Blinding (performance bias and detection bias)   All outcomes	Low risk	Study staff for these evaluations were blinded to subjects' randomisation assignments
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Study staff for these evaluations were blinded to subjects' randomisation assignments
Incomplete outcome data (attrition bias)   All outcomes	High risk	Not all randomised participants were included in the final analysis. Participants lost to follow‐up were not included in the analysis of important outcomes Number of participants lost to follow‐up was high. 17 participants were lost to follow‐up in each group.
Selective reporting (reporting bias)	Unclear risk	unclear
Other bias	Unclear risk	unclear

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Discontinuations due to pregnancy (36 months)	1	331	Risk Ratio (M‐H, Fixed, 95% CI)	0.21 [0.05, 0.94]
2 Discontinuations due to expulsion (36 months)	1	331	Risk Ratio (M‐H, Fixed, 95% CI)	1.64 [0.86, 3.12]
3 Discontinuations due to infection (36 months)	1	331	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [0.58, 3.30]

Outcome or subgroup title	No. of studies	Statistical method	Effect size
1 Discontinuation rates (5‐year) per 100 women due to pregnancy	1	Mean Difference (Fixed, 95% CI)	8.7 [3.92, 13.48]
2 Discontinuation rates (5 ‐year) per 100 women due to expulsion after immediate insertion	1	Mean Difference (Fixed, 95% CI)	4.9 [‐5.99, 15.79]
3 Discontinuation rate (5‐ years) due to bleeding problems	1	Mean Difference (Fixed, 95% CI)	8.3 [‐2.03, 18.63]
4 Discontinuation rate (5‐years) due to Amenorrhea	1	Mean Difference (Fixed, 95% CI)	‐2.1 [‐5.02, 0.82]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Discontinuations due to pregnancy (10 years)	1	400	Risk Ratio (M‐H, Fixed, 95% CI)	3.4 [1.28, 9.04]
2 Discontinuations due to expulsion (10 years)	1	400	Odds Ratio (M‐H, Fixed, 95% CI)	3.35 [1.59, 7.06]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Discontinuation due to pregnancy per 100 women at 24 months	1	464	Mean Difference (IV, Fixed, 95% CI)	‐0.30 [‐0.48, ‐0.12]
2 Discontinuation rate due to expulsion per 100 women at 24 months	1	464	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.28 [‐0.46, ‐0.09]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Expulsion by 6 months	3	878	Risk Ratio (M‐H, Fixed, 95% CI)	2.64 [1.16, 6.00]
2 Removal by 6 months	2	790	Risk Ratio (M‐H, Fixed, 95% CI)	2.01 [0.99, 4.06]
3 Use at 6 months	3	878	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [1.24, 1.58]
4 Pregnancy at 6 months	3	878	Risk Ratio (M‐H, Fixed, 95% CI)	0.37 [0.12, 1.14]
5 Upper genital tract infection	3	878	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.33, 3.07]

Methods	Randomised controlled trial at one hospital among women having induced abortion. Report does not describe the method of randomisation or allocation concealment. Communication with authors indicated computer‐generated randomisation sequence
Participants	400 women in Singapore between the ages of 16 and 40 years. Demographic information was not provided. The report does not describe the abortion procedures
Interventions	Immediate insertion of Nova T or Multiload Cu250
Outcomes	Principal outcomes included pregnancy, expulsion, pain/bleeding, and other medical reasons. Only the first two outcomes are included because of their objective nature
Notes	The report did not contain an a priori hypothesis or sample size and power calculation
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Communication with authors indicated computer‐generated randomisation sequence
Allocation concealment (selection bias)	Low risk	Sealed, opaque envelopes according to communication with authors
Blinding of participants and personnel (performance bias)   All outcomes	Unclear risk	Unclear
Blinding (performance bias and detection bias)   All outcomes	Unclear risk	Unclear
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Unclear
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Unclear
Selective reporting (reporting bias)	Unclear risk	Unclear
Other bias	Unclear risk	The report did not contain an a priori hypothesis or sample size and power calculation

Methods	Randomised controlled international trial without blinding among women after induced abortion at less than 12 weeks' gestation; computer‐generated randomisation. Randomisation was 2:1 (LNG‐IUS:Nova T)
Participants	438 Women in Finland, Sweden, Denmark, Norway, and Hungary. Participants were 18 to 38 years old, healthy and had to have had at least one prior pregnancy. Exclusion criteria included history of ectopic pregnancy, current breastfeeding, recent injectable contraception, anaemia, or acute cervicitis or vaginitis
Interventions	Immediate insertion of Nova T copper IUD versus Mirena levonorgestrel intrauterine system
Outcomes	Principal outcomes included pregnancy, expulsion, bleeding problems, pain, salpingitis, amenorrhoea, hormonal problems, and overall discontinuation
Notes	This report was from a large trial (Luukkainen 1987). Some of the same Finnish participants are included in Pakarinen 2003. A subgroup analysis appears in Suvisaari 1996. Sample size calculation provided for overall trial
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Randomised controlled international trial
Allocation concealment (selection bias)	Low risk	Sequentially‐numbered, sealed, opaque envelopes
Blinding of participants and personnel (performance bias)   All outcomes	High risk	No Blinding
Blinding (performance bias and detection bias)   All outcomes	High risk	No Blinding
Blinding of outcome assessment (detection bias)   All outcomes	High risk	No Blinding
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Unclear
Selective reporting (reporting bias)	Unclear risk	Unclear
Other bias	Unclear risk	Unclear

Methods	Randomised controlled trial with blinding. Computer‐generated random number sequence
Participants	464 women in Rijeka, Yugoslavia, immediately after induced first‐trimester abortion by dilation and curettage
Interventions	Immediate insertion of Hydron‐coated Spring Coil versus Spring Coil. Hydron is a biocompatible hydrogel intended to decrease adverse endometrial response and improve tolerance of IUDs
Outcomes	Principal outcomes included pregnancy, expulsion, removals for bleeding/pain, and continuation
Notes	Raw data not provided, only rates
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐generated random number sequence
Allocation concealment (selection bias)	Low risk	Labels in sealed, opaque, sequentially‐numbered envelopes opened at the time of insertion
Blinding of participants and personnel (performance bias)   All outcomes	Low risk	The type of IUD inserted was not known to the investigators, only the patients order number was known by the investigators so that they are unaware of what participants were assigned to.
Blinding (performance bias and detection bias)   All outcomes	Low risk	The type of IUD inserted was not known to the investigators, only the patients order number was known by the investigators so that they are unaware of what participants were assigned to.
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	The type of IUD inserted was not known to the investigators, only the patients order number was known by the investigators so that they are unaware of what participants were assigned to.
Incomplete outcome data (attrition bias)   All outcomes	Low risk	All participants were accounted for.
Selective reporting (reporting bias)	Unclear risk	Unclear
Other bias	Unclear risk	Unclear

Study	Reason for exclusion
Chowdhury 1979	Violation of informed consent: sham IUD insertion arm
Goldsmith 1972	Violation of informed consent: sham IUD insertion arm
NCT00737178	Immediate was defined as one week
Querido 1985	Although reported to be randomised assignment, methods reveal alternate allocation. Allocation concealment not possible.

Trial name or title	immediate vs delayed insertion of intrauterine contraception after second trimester abortion: study protocol for a randomised controlled trial
Methods	RCT
Participants	716 consenting women choosing to use intrauterine contraception after abortion for a pregnancy for a pregnancy of 12 to 24 weeks will be randomised
Interventions	Levonorgestrel‐releasing IUC or CuT380‐IUC. insertion timing groups either immediately (experimental intervention) or four week (recommended care) post abortion
Outcomes	primary outcome: pregnancy rate at one year; secondary outcomes:costs and cost effectiveness, cumulative annual pregnancy rate, device insertion rate, loss to follow‐up, continuation of methods, infection, perforation, expulsion
Starting date	May 2010
Contact information	wvnorman@interchange.ubc.ca; Contraception and Abortion Research Team, Women's Health Research Institute, Vancouver, British Columbia V6H, 1g3, Canada
Notes	Expected to complete in late 2011 and data on one year analysis will be available in 2014

PERMALINK

Immediate postabortal insertion of intrauterine devices

Babasola O Okusanya

Olabisi Oduwole

Emmanuel E Effa

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Summary of findings for the main comparison. Immediate versus delayed insertion (LNG‐IUS or CuT380A IUD) for.

Summary of findings 2. TCu 220C compared to Lippes Loop for immediate insertion post‐abortion.

Summary of findings 3. TCu 220C compared to Copper 7 for Immediate insertion Post abortion.

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Search methods for identification of studies

Electronic searches

MEDLINE via PubMed

CENTRAL

POPLINE

EMBASE

ClinicalTrials.gov

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

Results

Description of studies

Results of the search

Included studies

Excluded studies

Risk of bias in included studies

Allocation

1.

Blinding

Incomplete outcome data

Selective reporting

Other potential sources of bias

Effects of interventions

Immediate versus delayed insertion

5.2. Analysis.

11.1. Analysis.

11.3. Analysis.

11.4. Analysis.

11.5. Analysis.

8.1. Analysis.

Immediate insertion of different IUDs or IUD modifications

1.1. Analysis.

3.1. Analysis.

1.2. Analysis.

3.2. Analysis.

1.4. Analysis.

2.3. Analysis.

3.4. Analysis.

1.5. Analysis.

2.5. Analysis.

Trial name or title	Better contraceptive choices: immediate or delayed insertion of IUD after second trimester abortion
Methods	RCT
Participants	1372 women, 18 years or older. Inclusion criteria: completed informed consent for abortion at gestation 12 weeks to 23 weeks 6 days, choosing an IUD for contraception postabortion, residents of British Columbia.  Exclusion criteria: contraindications to IUD use (current untreated PID, chlamydia or gonorrhoea; uterine cavity anomalies including fibroids > 5 cm, excluding repaired uterine septum; hypersensitivity to copper or polyethylene or Wilson's Disease; intend to move from British Columbia or to conceive in 1 year.  Post randomisation exclusion: uterine perforation at the time of abortion, bleeding > 500 cc during abortion or use of non‐routine uterotonic agents to manage haemorrhage during abortion or prior to discharge
Interventions	Immediate or delayed timing of insertion for a copper T380A IUD after an abortion. Immediate insertion to occur during visit for abortion immediately after abortion is complete; delayed insertions scheduled for 2 to 4 weeks after abortion
Outcomes	Primary: pregnancy at 1 year
Starting date	Jun 2009; estimated completion of data collection for primary outcome, Dec 2011
Contact information	Wendy Norman, MD; 604‐918‐1134, wvnorman@interchange.ubc.ca
Notes