A randomised controlled trial of immediate initiation of contraception by levonorgestrel-releasing intrauterine system (LNG-IUS) after medical abortion - one year continuation rates
Riina Korjamo1 ,2, Maarit Mentula1, Oskari Heikinheimo1 ,2
1Helsinki University Hospital/ Obsterics and Gynecology, Helsinki, Finland, 2University of Helsinki, Helsinki, Finland
Objectives: Immediate insertion of intrauterine device at the time of the surgical abortion results into higher uptake of effective contraception and prevent unintended pregnancies. We performed a randomised controlled trial comparing immediate (≤3 days) vs. delayed (within 2-4 weeks) insertion of the LNG-IUS after medical abortion.
Method: Women ≥18 years requesting medical abortion and desiring LNG-IUS contraception were eligible to enter the trial, which was conducted at Helsinki University Hospital between Jan 30nd 2013 and Dec 31st 2014. Trial has registered to www.clinicaltrials.com, NCT01755715. The primary outcome was the LNG-IUS use at 1 year after abortion. Secondary outcomes were expulsions, further pregnancies and abortions.
Results: Altogether 267 women were randomised to immediate (134) and delayed (133) insertion groups, of which 264 (133 and 131, respectively) were analysed. LNG-IUS was inserted in 127 (95.5%) women in the immediate and 111 (84.7%) women in the delayed insertion groups (OR3.81, 95%CI 1.48-9.83, p=0.004). The verified numbers of women continuing the LNG-IUS use at 1 year were 83 (62.4%) and 52 (39.7%), respectively (OR2.52, 95%CI 1.54-4.14, p=0.001). In the best case scenario (the use of LNG-IUS verified or LNG-IUS inserted) 113 (85.0%) women in the immediate, and 88 (67.2%) women in the delayed insertion group continued LNG-IUS use at 1 year (OR2.76, 95%CI 1.52-5.03, p=0.001). Numbers of total expulsions were 3 (2.3%) vs. 3 (2.3%) (OR0.98, 95%CI 0.20-4.97, p=1.00), partial expulsions 26 (19.5%) vs. 9 (6.9%) (OR3.29 95%CI 1.48-7.34, p=0.003), new pregnancies 6 (4.5%) vs. 16 (12.2%) (OR0.34 95%CI 0.13-0.90,p=0.027) and further abortions 4 (3.0%) vs. 5 (3.8%) (OR0.78 95%CI 0.21-2.98, p=0.75), respectively.
Conclusions: Immediate insertion of the LNG-IUS after medical abortion resulted in a higher uptake and continuation rates of intrauterine contraception compared to delayed insertion, despite higher partial expulsion rates of LNG-IUS. Immediate insertion of the LNG-IUS decreased the 1-year pregnancy rates but did not affect the rate of further abortions.
Objective: To analyze long-term satisfaction to intrauterine contraception after medical induced abortion.
Minimizing delay from medical abortion procedure to insertion of intrauterine contraception is a new approach to increase intrauterine contraception uptake and reduce subsequent unplanned pregnancies. Effect of this immediate insertion on womens satisfaction and quality of life is unknown. Materials and methods: Subanalysis of a randomized controlled trial. Total of 267 women were randomized to receive levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena, Bayer, Turku, Finland) immediately (?3 days) or later (2-4 weeks) after medical induced abortion during January, 2013 December, 2014 in Helsinki University Hospital, Finland. Selected demographic factors were collected. Women answered questionnaires concerning satisfaction and quality of life at follow-up visits three months and one year after LNG-IUS insertion. Results: Following three post-randomization exclusions, there were 264 participants. Of the immediate-insertion group 98/133 (73.7%) and the delayed-insertion group 78/131 (59.5%) women returned to the 3-month follow-up, and 89 (66.9%) and 63 (48.1%) to the 1-year follow-up. Median age was 27.8 (IQR 23.033.1) vs. 27.3 years (22.532.1), p=0.54. At 3-month visit the immediate-insertion group was more often satisfied or very satisfied with their contraception compared to the delayed-insertion group (89 [89.9%] vs. 61 [79.2], p=0.048). We found no difference at 1-year (71 [79.8%] vs. 47 [74.6%], p=0.45). Womens experienced health, as measured by visual analogical scale (0100 mm), at 3-month visit was 84 mm (median, IQR 77 91) vs. 87 mm (7795), p=0.19, and at 1-year visit 85 mm (7493) vs. 86 mm (7492), p=0.75. Conclusion: Immediate LNG-IUS insertion following medical abortion did not have a long-term effect on womens satisfaction with intrauterine contraception or experienced health. Loss-to-follow-up rate was high and may have produced a selection bias. However, these results endorse the feasibility of immediate initiation of intrauterine contraception following medial abortion.