1. Post-Abortion IUC Insertion Eleanor Drey, MD, EdM Assistant Clinical Professor Obstetrics, Gynecology and Reproductive Sciences University of California, San Francisco Sarah Prager, MD, MAS Assistant Clinical Professor Obstetrics and Gynecology University of Washington

2. Disclosures Eleanor Drey, MD, EdM Consultant and Speaker, Organon Research Grant, Ortho

3. Copper vs. Levonorgestrel IUC: Summary Cu T380A (ParaGard) regular menses heavier bleeding 10 years use no follicular cysts no PID protection no therapeutic role effective EC Levonorgestrel (Mirena) irregular bleeding reduced or no menses 5 years use cysts may form some PID protection DUB and HRT role not for EC

4. Why insert IUC immediately following abortion? Patients motivated Increased patient comfort –Cervix open enough for abortion to be done –Pre-medicated for pain control for abortion No longer pregnant at time of placement May not return for interval placement

5. Is it safe to insert IUC immediately following abortion? Does it increase risk of infection/PID? Does it increase risk of bleeding after the abortion? Does it increase risk of perforation or expulsion?

6. Immediate Postabortion Intrauterine Contraception in Nulliparous Adolescents. Goldman, Israel J Med Sci, 1979

7. 1983 WHO Study: PID post abortion insertion

8. 1983 WHO Study: Expulsion of TCu220c post abortion *p<0.01 *p<0.05

9. Immediate Post abortion IUC Insertion versus 2-week Delay of Insertion Moussa, Contraception, 2001 *all p=NS

10. Rates of complications after interval IUC insertion Complication% occurrence interval % occurrence post-abortion Bleeding4-155-27 Infection0.10.2-1.3 Perforation0.1 Expulsion54-8 (1st trimester) Continuation8075-86 Johns Hopkins School of Public Health/Population Information Project; Managing Contraception

11. Conclusions: Immediate Post-abortion IUC Insertion IUD placement after abortion is safe –PID rate not increased Expulsion rate after first-trimester abortion is less than or equal to interval insertion IUDs inserted after abortion provide effective contraception –Pregnancy rate same as interval insertion Limited data about post-second-trimester No data about antibiotics or uterotonics

12. How do LNG and Copper IUC compare?

13. RCT of Mirena vs. NovaT after First- Trimester Abortion 305 patients received Mirena ® 133 patients received NovaT (200 mm 2 copper on same frame as Mirena ® ) Multi-center in Denmark, Finland, Hungary, Norway, & Sweden. Not blinded Inserted after abortion at less than 12 weeks Pakarinen, 2003, Contraception

14. Results of Mirena vs. NovaT: Expulsion after Post abortion Insertion Pakarinen, 2003. *p<0.01

15. Cumulative Termination Rates Per 100 women: LNG vs. Cu T Andersson et al. Contraception 1994;49:56 LNG IUS N=1821 HormonalBleeding ProblemsExpulsion Nova T N=937

16. Post-Abortion Mirena Compared with Norplant and Traditional Methods 2 expulsions at 12 months (4%) No pregnancies in Mirena or Norplant groups 4 pregnancies in group using traditional methods Ortayli, Contraception, 2001 *p<0.01

17. How do you do post-abortion IUC insertion?

18. SFGH IUC Placement Protocol: Operative Technique All D&E procedures done under ultrasound guidance Methergine for bleeding/atony –Methergine is not routinely given IUC placement under ultrasound guidance after D&E (second trimester) Ring forceps used for T380a if >14 weeks Ring forceps used to guide Mirena inserter if difficult to place

19. When not to insert IUC immediately post-abortion: If the patients bleeding post-procedure is not well controlled If the patient appears to be infected If you are concerned about perforation

20. The Womens Option Center at San Francisco General Hospital Abortions up to 23 weeks >2000 terminations per year Contraceptive failure common Diverse patients

21. WOC Post-Abortion IUC Insertion: Patient Satisfaction 90% of patients are very or somewhat satisfied (65% very) Patient quotes: –I am not going to forget to take a pill, and Im not going to get poked every 3 months. –Im thrilled. Its so easy. I dont have to think about it. –My husband is a sex maniac, so I am more comfortable knowing its there

22. What are the benefits to immediate post-abortion insertion? Patients leave with long-term, highly efficacious contraception Dont have to depend on patient follow-up More comfortable insertion

23. Thanks to : Gillian Dean, MD, Assistant Professor, Einstein Univ. Philip Darney, MD, MSc, Professor, UCSF/SFGH Mathew Reeves, MD, Assistant Professor, Pittsburgh