the american college of obstetricians and gynecologists

women ’ s health care physicians

P R AC T I C E
BUL L E T I N
clinical management guidelines for obstetrician – gynecologists

Number 121, July 2011 Replaces Practice Bulletin Number 59, January 2005. Reaffirmed 2013

Long-Acting Reversible Contraception:

Implants and Intrauterine Devices
Intrauterine devices and contraceptive implants, also called long-acting reversible contraceptives (LARCs), are the
most effective reversible contraceptives. The major advantage of LARCs compared with other reversible contraceptive
methods is that they do not require ongoing effort on the part of the user for long-term and effective use. In addition,
return of fertility is rapid after the removal of the device (1, 2). The purpose of this Practice Bulletin is to provide
information for appropriate candidate selection and the management of clinical issues and complications associated
with LARC use.

Background or the contraceptive implant (4). Encouraging the use

of LARC methods for appropriate candidates may help
There are currently three LARC methods available in lower U.S. unintended pregnancy rates because gaps in
the United States, two of which are intrauterine devices use and discontinuation of shorter acting methods are
(IUDs), 1) the copper T380A IUD, 2) the levonorgestrel associated with unintended pregnancy rates in high-risk
intrauterine system, and 3) the etonogestrel single-rod women (5). Typical-use pregnancy rates for LARCs are
contraceptive implant. The use of IUDs has increased lower, and continuation rates are higher, when compared
over the past decade, from 1.3% in 2002 to 5.5% in with oral contraceptives (see Table 1) (6). In an econ-
2006–2008, according to the most recent data from the omic analysis, both types of IUDs were among the three
National Survey of Family Growth (3). The single-rod least expensive contraceptive methods over a 5-year
contraceptive implant was approved by the U.S. Food period (7).
and Drug Administration (FDA) in 2006, and use has
not yet been tracked; however, millions of women world- Long-Acting Reversible Contraceptive
wide have used the method. Preliminary data reported Devices
from the Contraceptive CHOICE project, a prospective
cohort of women aged 14–45 years, showed that in the Copper Intrauterine Device
absence of financial, knowledge, health care provider, The copper T380A is a T-shaped device of polyethylene
or logistical barriers, the rate of initiation of LARC was wrapped with copper wire around the stem and arms.
higher than any other contraceptive method. Of the first A number of different mechanisms of action have been
2,500 women enrolled in the study, 67.1% chose an IUD proposed, including inhibition of sperm migration and

Committee on Practice Bulletins—Gynecology. This Practice Bulletin was developed by the Committee on Practice Bulletins—Gynecology with the
assistance of Eve Espey, MD, MPH, and Rameet H. Singh, MD, MPH. The information is designed to aid practitioners in making decisions about appropri-
ate obstetric and gynecologic care. These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice
may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.
 Table 1. Comparison of First-Year Unintended Pregnancy and Continuation Rates Among
Intrauterine Device and Implant Users in the United States

Percentage of Women
Experiencing an Unintended Percentage of Women
Pregnancy in the First Year of Use Continuing Use*

Method Typical Use† Perfect Use‡

Intrauterine Device
Copper T 0.8 0.6 78
Levonorgestrel 0.2 0.2 80
Implant 0.05 0.05 84
Combined pill and 9 0.3 67
progestin-only pill
Female sterilization 0.5 0.5 100
Male sterilization 0.15 0.10 100
*Among couples attempting to avoid pregnancy, the percentage reflects women who continue to use a method for 1 year.
†
Among typical couples who initiate use of a method (not necessarily for the first time), the percentage reflects women who
experience an accidental pregnancy during the first year if they do not stop use for any other reason. Estimates of the probability
of pregnancy during the first year of typical use for spermicides and the diaphragm are taken from the 1995 National Survey of
Family Growth corrected for underreporting of abortion; estimates for fertility awareness-based methods, withdrawal, the male
condom, the pill, and Depo-Provera are taken from the 1995 and 2002 National Survey of Family Growth corrected for under-
reporting of abortion.
‡
Among couples who initiate use of a method (not necessarily for the first time) and who use it perfectly (both consistently and
correctly), the percentage reflects women who experience an accidental pregnancy during the first year if they do not stop use
for any other reason
Modified with permission from Trussell J. Contraceptive failure in the United States. Contraception 2011;83(5);397–404. Epub
2011 Mar 12.

viability, change in transport speed of the ovum, and both prefertilization and postfertilization—occur before
damage to or destruction of the ovum. The evidence sug- implantation.
gests these prefertilization effects constitute the primary The levonorgestrel intrauterine system is FDA
mechanism of action for pregnancy prevention in the approved for up to 5 years of use, but may be effec-
copper IUD (8). Postfertilization effects, including dam- tive for up to 7 years (11). The 1-year failure rate is 0.2
age to or destruction of the fertilized ovum, also may per 100 women (6). It releases 20 mg of levonorgestrel
occur (9). All effects, both prefertilization and postfer- daily, and this small amount of steroid confers minimal
tilization, occur before implantation. systemic adverse effects, although some women may
The FDA has approved use of the copper IUD for up experience hormone-related effects, such as headaches,
to 10 continuous years, during which it remains highly nausea, breast tenderness, depression, and cyst formation.
effective. It has a reported failure rate at 1 year of 0.8 per Most women ovulate normally but experience diminished
100 women, and a 10-year failure rate comparable with menstrual bleeding because of the local effect of levo-
that of female sterilization (1.9 per 100 women over 10 norgestrel on the endometrium (12, 13). One small study
years) (6). The most common adverse effects reported reported ovulation in 63% of the amenorrheic group and
are abnormal bleeding and pain (10). in 58% of the regularly menstruating group (13).
Overall, complications with IUDs are uncommon
Levonorgestrel Intrauterine System and mainly include expulsion, method failure, and per-
The levonorgestrel intrauterine system is also T-shaped foration. The expulsion rate is between 2% and 10% dur-
and contains a polydimethylsiloxane sleeve containing ing the first year (6). Perforation occurs in 1 per 1,000
52 mg of levonorgestrel on the stem. The levonorgestrel insertions or less (14).
intrauterine system and copper IUD have similar pri-
mary mechanisms of action. In addition to these effects, Contraceptive Implants
the levonorgestrel intrauterine system causes endome- The contraceptive implant is placed subdermally and
trial suppression and changes the amount and viscosity consists of an ethylene vinyl acetate copolymer core con-
of cervical mucus. As with the copper IUD, all effects–– taining 68 mg of etonogestrel surrounded by an ethylene

2 Practice Bulletin No. 121

vinyl acetate copolymer skin. The ethylene vinyl acetate
copolymer allows for a controlled release of etonoges- Box 1. U.S. Medical Eligibility Criteria
trel over a period of 3 years. Etonogestrel is the active Categories for Classifying Hormonal
metabolite of desogestrel (15). The single-rod implant Contraceptives and Intrauterine Devices
is 4 cm in length and 2 mm in diameter and is packaged
1 = A condition for which there is no restriction for the
preloaded in a disposable sterile applicator. It does not use of the contraceptive method
contain latex, is not biodegradable, and is currently not
radiopaque (16). 2 = A condition for which the advantages of using
the method generally outweigh the theoretical or
The primary mechanism of action of the implant is
proven risks
suppression of ovulation by altering the hypothalamic–
pituitary–ovarian axis (15, 17, 18). Additional contracep- 3 = A condition for which the theoretical or proven
tive efficacy may be conferred by the implant’s thickening risks usually outweigh the advantages of using the
method
of cervical mucus (18, 19) and alteration of the endo-
metrial lining (19, 20). The contraceptive implant is the 4 = A condition that represents an unacceptable health
most effective method of reversible contraception, with a risk if the contraceptive method is used
typical-use pregnancy rate of 0.05% (6). Data from U.S. Medical Eligibility Criteria for Contraceptive Use,
After implant insertion, changes in menstrual bleed- 2010. Centers for Disease Control and Prevention. MMWR Recomm
ing patterns are common and include amenorrhea or infre- Rep 2010;59(RR–4):1–86.
quent, frequent, or prolonged bleeding. Other reported
adverse effects include gastrointestinal difficulties, head-
aches, acne, breast pain, vaginitis, and weight gain (21–23). Clinical Considerations and
Complications related to implant insertion (1.0%)
and removal (1.7%) are uncommon. Insertion complica- Recommendations
tions include pain, slight bleeding, hematoma forma- Are IUDs and implants appropriate for
tion, difficult insertion, and unrecognized noninsertion.
nulliparous women and adolescents?
Removal may be complicated by breakage of the implant
and inability to palpate or locate the implant because of Nulliparous women and adolescents can be offered
deep insertion (22, 23). Fertility returns rapidly after the LARC methods, including IUDs. In 2005, FDA-approved
discontinuation of the implant (17, 23). All health care changes were made to the package insert of the copper
providers who perform implant insertions and removals IUD, removing language suggesting IUD candidates be
must receive training from the manufacturer. limited to those having one or more children. The levo-
norgestrel intrauterine system is not specifically approved
Long-Acting Reversible Contraceptive for nulliparous women. However, the U.S. Medical
Eligibility Eligibility Criteria for Contraceptive Use classifies use
in nulliparous women for both IUDs as Category 2, find-
Long-acting reversible contraceptive methods have few ing the advantages to generally outweigh the risks (25).
contraindications, and almost all women are eligible The U.S. Medical Eligibility Criteria for Contraceptive
for implants and IUDs. The World Health Organization Use also assigns a Category 2 rating for use of both IUDs
(WHO) and the Centers for Disease Control and Pre- by adolescents (25).
vention (CDC) have developed evidence-based medical Available evidence suggests that IUDs are more
eligibility criteria for contraceptive use (24, 25). Separate effective and have higher rates of satisfaction in nul-
recommendations are given for both the initiation and liparous women compared with oral contraceptives. In
continuation of use, and guidelines are assigned to the levonorgestrel intrauterine system group, 89.7% of
one of four categories based on their level of risk participants reported that this contraceptive method was
(see Box 1) (25). Both IUD and contraceptive implant moderately good to very good compared with 87.7% in
use in women with a variety of characteristics and medi- the oral contraceptive group (P=0.36) (26). Although
cal conditions are addressed in the U.S. Medical Eligi- good quality comparative data are lacking, it appears
bility Criteria for Contraceptive Use “Summary of that expulsion rates for the levonorgestrel intrauterine
Classifications for Hormonal Contraceptive Methods system and the copper IUD are similar (4.4% and 3.3–
and Intrauterine Devices” (available at http://www. 9.2%, respectively) in nulliparous versus parous women
cdc.gov/mmwr/pdf/rr/rr59e0528.pdf), which has been (27, 28). A systematic review reported expulsion rates
endorsed by the American College of Obstetricians and for adolescents ranging from 5% to 22%. These rates
Gynecologists. were reported to be inversely related to age in two of the

Practice Bul­le­tin No. 121 3

studies, but may have been influenced by type of IUD have recently given birth are often highly motivated to
and parity (29). The rate of removal of the copper IUD use contraception, they are known not to be pregnant,
for reports of pain and bleeding in nulliparous women and the hospital setting offers convenience for both the
ranges from 3.6% to 24% in most studies and may be patient and the health care provider. In addition, women
slightly higher than the rate of removal for these adverse are at risk of an unintended pregnancy in the period
effects in parous women (27). Overall, IUD continuation immediately after delivery. In a study in which women
rates for nulliparous women are high and may be viewed were instructed to abstain from sexual intercourse until
as a surrogate for satisfaction. 6 weeks postpartum, 45% of participants reported unpro-
There are no studies demonstrating an increased tected sex before that time (33).
risk of pelvic inflammatory disease (PID) in nulliparous
IUD users, and no evidence that IUD use is associated Intrauterine Device
with subsequent infertility (30). In a 2001 case–control
The U.S. Medical Eligibility Criteria for Contraceptive
study of 1,895 women with primary tubal infertility
Use classifies immediate postpartum copper IUD insertion
using several control groups to minimize bias, previous
as Category 1 and immediate postpartum levonorgestrel
copper IUD use was not associated with an increased
intrauterine system insertion in both nonbreastfeeding
risk of tubal occlusion in nulliparous women. Those
and breastfeeding women as Category 2 (25). Immediate
with tubal infertility were more likely to have antibodies
postpartum IUD insertion, which is an insertion within
to chlamydia, indicating that the presence of a sexually
10 minutes of placental separation, appears safe and
transmitted infection (STI), was the likely explanation
effective (34, 35). Insertion of both the copper IUD
of infertility (30).
and levonorgestrel intrauterine system after 10 minutes
The U.S. Medical Eligibility Criteria for Contra-
postplacental separation up until 4 weeks postpartum
ceptive Use assigns a Category 1 rating to the use of the
is classified as a U.S. Medical Eligibility Criteria for
contraceptive implant by nulliparous women and adoles-
cents. Although limited evidence exists on the use of the Contraceptive Use Category 2, and insertion at or after
implant in adolescents, evidence suggests that implants 4 weeks postpartum is classified as a U.S. Medical
are well accepted in this population. Contraceptive accept- Eligibility Criteria for Contraceptive Use Category 1
ability and continuation rates were studied in a group of (25). Patients should be seen 1–2 weeks after insertion
137 postpartum adolescents (31). At 24 months, continu- to have the strings cut.
ation rates were higher in contraceptive implant users The expulsion rate associated with immediate post-
compared with contraceptive injection and combined partum insertion is higher than that for interval insertion
contraceptive pill users (P<0.001) (31). and may be as high as 24% (34, 36). Differences in expul-
sion rates are similar with manual insertion versus use of
When is an appropriate time to insert an IUD ring forceps, but may differ depending on the experience
or contraceptive implant? of the inserter. Immediate insertion after cesarean delivery
may be associated with a lower risk of expulsion than
Insertion of an IUD or an implant may occur at any time after vaginal delivery (35). The benefits of immediate
during the menstrual cycle as long as pregnancy may insertion may outweigh the increased risk of expulsion.
be reasonably excluded. Clinicians have traditionally Disadvantages of waiting 4–6 weeks postpartum for
inserted the IUD during menses, but no major advantage interval insertion include failure to return for follow-up
of this practice has been documented. No backup contra- and not obtaining an IUD at the follow-up visit (34, 37).
ceptive method is needed after inserting the copper IUD, An advantage of the copper IUD is its lack of hor-
regardless of when in the menstrual cycle it is inserted monal content, avoiding any theoretic effect on breast-
(32). Backup methods of contraception (ie, use of a feeding. However, in a single randomized control trial
condom) should be used for 7 days after insertion of examining the effect of IUDs on breastfeeding in women
the levonorgestrel intrauterine system, or contraceptive randomized either to insertion of a levonorgestrel intra-
implants unless these devices are inserted within 5 days uterine system (n=163) or a copper IUD (n=157) at
of initiating menses, immediately after childbirth or after 6–8 weeks postpartum, there were no differences in
abortion, or immediately upon switching from another breastfeeding duration or infant growth between the two
hormonal contraceptive (17). groups (38).
Immediate postpartum insertion is contraindicated
Postpartum Insertion among women in whom peripartum chorioamnionitis,
The immediate postpartum period is a particularly favor- endometritis, or puerperal sepsis is diagnosed. The Inter-
able time for IUD or implant insertion. Women who national Planned Parenthood Federation, in collaboration

4 Practice Bulletin No. 121

with WHO and other international organizations, devel- Women who have an abortion are at high risk of
oped guidelines that include the restriction of IUD inser- repeat unintended pregnancy, and ovulation may resume
tion within 3 months of treatment of puerperal sepsis (39). within 10 days of abortion (48). Thus, prompt initiation
of a contraceptive method is critical. Women who have
Contraceptive Implant an IUD inserted immediately after abortion have higher
Insertion of the implant is safe at any time in nonbreast- rates of use compared with interval insertion, and lower
feeding women after childbirth (Category 1 rating). The rates of repeat abortion than those who choose another
U.S. Medical Eligibility Criteria for Contraceptive Use method (49, 50).
classifies the placement of an implant in breastfeeding Intrauterine device insertion immediately after first-
women less than 4 weeks after childbirth as Category trimester suction aspiration appears to have a low risk of
2 because of theoretic concerns regarding milk produc- complications similar to that of interval insertion (51).
tion and infant growth and development. Implants may One randomized controlled trial has evaluated immedi-
be offered to women who are breastfeeding and more ate versus delayed insertion of IUDs after first-trimester
than 4 weeks after childbirth because the U.S. Medical abortion. The immediate insertion group showed a
Eligibility Criteria for Contraceptive Use classifies higher risk of expulsion versus the delayed group, but
delayed insertion as Category 1 (25). 42% of women in the delayed group did not return for a
Although long-term data on the effect of hormonal follow-up visit (52). Immediate IUD insertion is contra-
methods on breastfeeding are limited, observational stud- indicated within 3 months after septic abortion (25, 39).
ies of progestin-only contraceptives suggest they have no
effect either on a woman’s ability to successfully initiate What are the adverse effects of IUDs and the
and continue breastfeeding or on an infant’s growth and contraceptive implant on the menstrual cycle?
development (40). A randomized trial compared postpar- Long-acting reversible contraceptive methods have an
tum insertion of the etonogestrel contraceptive implant at effect on menstrual bleeding, and patients should be
1–3 days with standard insertion at 4–8 weeks postpar- given anticipatory guidance about these effects. New
tum. The study reported no differences in breastfeeding onset abnormal uterine bleeding should be evaluated
outcomes between groups, including lactogenesis and similarly to that of non-LARC users, and the differential
the risk of lactation failure (41). In addition, a prospec- diagnosis remains similar, including failed contraception
tive nonrandomized comparative study examined breast (ie, pregnancy) and gynecologic malignancy. However,
milk composition in 80 women using the contraceptive because many LARC users are young women, they
implant versus a nonhormonal IUD, initiated at least may expect irregular, unpredictable bleeding over the
28–56 days after childbirth. Breast milk composition, entire course of LARC use, which would not necessarily
measured by total protein, fat, and lactose content, did not require further evaluation.
differ between the groups, nor did the quantity of breast
milk (42). After a 3-year follow-up, there was no differ- Intrauterine Devices
ence between the groups in terms of neonatal body length, A randomized trial found that long-term copper IUD users
biparietal head circumference, and body weight. (43). were more likely to discontinue the device because of
heavy menstrual bleeding and dysmenorrhea (9.7 per 100
Postabortion Insertion women using the copper IUD versus 1.3 per 100 women
Insertion of an IUD or implant immediately after either using the levonorgestrel intrauterine system), whereas
an abortion or miscarriage is safe and effective and has levonorgestrel intrauterine system users were more likely
many of the same advantages as immediate postpartum to discontinue the device because of amenorrhea and spot-
insertion. Immediate insertion of the copper IUD or ting compared with copper IUD users (4.3 per 100 women
levonorgestrel intrauterine system after a first-trimester versus 0 per 100 women, respectively) (53).
abortion is classified as Category 1 in the U.S. Medical Patients should be advised that menstrual bleeding
Eligibility Criteria for Contraceptive Use, and Category and cramping may initially increase with use of the cop-
2 for second-trimester postabortion insertion (25) because per IUD. Good evidence supports first-line treatment of
of a higher risk of expulsion compared with insertion after dysmenorrhea with nonsteroidal anti-inflammatory med-
a first-trimester abortion. Contraceptive implant insertion ications (54). In addition, evidence demonstrates that
immediately after a first-trimester abortion or second- reports of bleeding and dysmenorrhea decrease over time
trimester abortion also is classified as Category 1, but is in copper IUD users. In one analysis, the prevalence of
based on studies of a levonorgestrel implant system no pain decreased from 1.1 events per 100 women-weeks
longer marketed in the United States (44–47). in the first period assessed (0–9 weeks) to 0.3 events

Practice Bul­le­tin No. 121 5

per 100 women-weeks after 39 weeks of use. However, unfavorable pattern had a 50% chance of improving (22,
intermenstrual spotting and pain did not decrease over 58, 59). Body weight appears to have an effect on bleed-
time (55). ing among implant users. Women with low body weight
The levonorgestrel released from the levonorgestrel had fewer bleeding and spotting days than women with a
intrauterine system concentrates in the endometrium higher body weight (59).
and produces a thin decidualized endometrial lining that A recent study of 137 adolescents in the postpartum
becomes unresponsive to endogenous estrogen stimula- period aged 18 years and younger assessed acceptability,
tion. Most women continue to ovulate while using the continuation, and repeat pregnancy rates in implant users
levonorgestrel intrauterine system. However, because of versus nonusers. Of those adolescents that discontinued
levonorgestrel’s effect on the endometrium, the amount the implant before 24 months of use, 40% cited abnormal
and duration of menstrual bleeding is reduced. This bleeding as the main reason for discontinuation (31).
effect may begin during the first menstrual period after
placement of the device, and bleeding becomes progres- In pregnant women, does removal of the IUD
sively less over time. affect pregnancy outcome?
In a large randomized control trial comparing the levo-
The FDA and the WHO recommend that IUDs be
norgestrel and copper IUDs, one third of women using the
removed from pregnant women when possible without an
levonorgestrel device developed oligomenorrhea immedi-
invasive procedure (32, 61). Complications of continuing
ately (ie, no more than one episode of bleeding in a 90-day
a pregnancy with an IUD in place include an increased
interval) or amenorrhea, and 70% of women experienced
risk of spontaneous abortion and septic abortion.
oligomenorrhea or amenorrhea at the end of 2 years (56).
Few studies examine the outcomes of pregnancies
Similarly, symptoms of dysmenorrhea were reduced in
that result from contraceptive failure of the IUD. Most
levonorgestrel intrauterine system users. The reduction in
reports about complications date from the 1970s and
bleeding is significant and consistent. The levonorgestrel
1980s, and suggest an increased risk of miscarriage, with
intrauterine system was recently FDA approved for the
a higher loss rate if a copper IUD is retained (62, 63) than
treatment of heavy bleeding in women who use the method
if it is removed (64). A 2005 study of 318 pregnant women
for contraception, and it is used widely for this indica-
with a copper IUD in place documented similar findings
tion. A review of 18 studies of levonorgestrel intrauterine
(65). A population-based retrospective review of all preg-
system use for the treatment of menorrhagia found a men-
nancies beyond 22 weeks that occurred from 1998–2007
strual blood loss reduction of 79–97% (57). In addition,
studies document an overall high rate of patient satisfac- in a large hospital in Israel reported that women with a
tion and continued use in patients with menorrhagia. retained IUD had significantly more placental abruption,
placenta previa, preterm delivery, cesarean delivery, low
Contraceptive Implant birth weight babies, and chorioamnionitis compared with
women who conceived without an IUD in place. Women
A noncontraceptive benefit of the implant is a significant
who conceived with an IUD in place but whose IUD
decrease in dysmenorrhea (58–60). However, uterine
was removed had outcome values that were intermediate
bleeding patterns with contraceptive implant use are
between the other two groups (66).
unpredictable and are cited as the most common reason
A pregnancy conceived with a levonorgestrel intra-
for discontinuation. An integrated analysis of 11 interna-
uterine system that is retained raises the theoretic concern
tional clinical trials that included 923 women document-
of the effect of fetal exposure to hormones. A review of
ed the variable bleeding patterns among users, assessed
the literature of fetal exposure to levonorgestrel from
in 90-day reference periods (59). Women usually expe-
a retained levonorgestrel intrauterine system during
rienced infrequent bleeding (33.6% of the reference
pregnancy revealed only 36 reported cases; however, the
periods) or amenorrhea (22.2% of the reference periods).
amount of systemic levonorgestrel released is equal to
Frequent bleeding was found in 6.7% of the reference
or less than that in a combined contraceptive pill and is
periods and prolonged bleeding in 17.7% of the refer-
unlikely to have an effect on an ongoing pregnancy (67).
ence periods. Only 11.3% of patients discontinued the
implant because of bleeding irregularities, mainly due Do IUDs cause ectopic pregnancy?
to frequent and prolonged bleeding. Overall, the mean
number of spotting or bleeding episodes was less than The U.S. Medical Eligibility Criteria for Contraceptive
the number reported in normal menstrual cycles. Women Use classifies use of both the copper and levonorgestrel
with favorable bleeding profiles in the first 3 months of IUDs in women with a history of ectopic pregnancy as
use were likely to continue with that bleeding pattern Category 1. The contraceptive implant does not increase
for the first 2 years, whereas those who started with an the risk of ectopic pregnancy in women with a previous

6 Practice Bulletin No. 121

history of ectopic pregnancy and also is classified as evaluation in women with IUDs (74). Cervical colpos-
Category 1 in the U.S. Medical Eligibility Criteria for copy, cervical ablation or excision, or endometrial sam-
Contraceptive Use (25). Use of an IUD does not appear pling, may be performed with an IUD left in place. During
to increase the absolute risk of ectopic pregnancy. Cohort these procedures, IUD strings may be tucked into the cer-
data demonstrate an ectopic pregnancy rate of 0–0.5 per vical canal if possible, or cut. A case series reports use of
1,000 women-years among women using either the cop- the hollow handle of a sterile absorbent-tipped applicator
per IUD or the levonorgestrel intrauterine system, com- as a protecting tube for the IUD strings during the loop
pared with a rate of 3.25–5.25 per 1,000 women-years electrosurgical excision procedure in order to avoid hav-
among women who do not use contraception (68, 69). ing to trim the strings (75).
A meta-analysis of 16 case–control studies concluded
that IUDs do not increase the risk of ectopic pregnancy What treatment options are appropriate for
because they prevent pregnancy so effectively (70). an asymptomatic patient with an IUD who
However, if pregnancy does occur with an IUD has actinomyces identified by cervical
in place, the pregnancy is more likely to be ectopic. cytology screening?
Although case–control studies of ectopic pregnancy
associated with IUD use indicate relative risk, prospec- Although options for management have included oral
tive data from randomized controlled trials describe a antibiotics, removal of the IUD, or both, current recom-
low absolute risk, a measure that is more useful clinically mendations for asymptomatic patients with an IUD and
(68, 69). In other words, the proportion, not the risk, of actinomyces found by cervical cytology screening focus
ectopic pregnancies is increased (71). Given this very on expectant management. Both the UK Faculty of Family
low risk, intrauterine devices may be offered to women Planning and the Standards and Guidelines of the Planned
with a history of ectopic pregnancy. Parenthood Federation of America recommend continued
IUD use and patient education about the small risk of
When should an IUD be removed in a actinomycosis (76). Most frequently, however, IUD users
menopausal woman? whose Pap test results incidentally report a finding of acti-
nomyces are asymptomatic and are at extremely low risk
Awaiting 1 year of amenorrhea in women using a cop- of pelvic actinomycosis. The prevalence of actinomycosis,
per IUD to ensure menopausal status is advisable before characterized by granulomatous pelvic abscesses, has been
removing the device. Given that amenorrhea may be a estimated to be less than 0.001% (76).
secondary effect of the levonorgestrel intrauterine sys-
tem, measuring follicle-stimulating hormone levels in When is an IUD appropriate for emergency
serum may be considered to confirm menopausal status contraception?
for women using this system. Alternatively, there is no
compelling evidence for the removal of an IUD before its Insertion of a copper IUD is the most effective method
expiration date in menopausal women. of postcoital contraception when inserted up to 5 days
No clinical trials have examined the risks from after unprotected intercourse (77). The levonorgestrel
prolonged IUD retention in asymptomatic menopausal intrauterine system has not been studied for emergency
women. Generally, menopausal women tolerate IUDs contraception. In a study of 1,963 women who underwent
well, and the levonorgestrel intrauterine system has been insertion of a copper IUD for postcoital contraception,
studied and found to be effective for noncontraceptive including 95 nulliparous women, the pregnancy rate was
indications, such as the progestin component of hormone 0.23% (78). Women who use the copper IUD for postco-
therapy (72) and for endometrial protection in women ital contraception may benefit from retention of the device
using tamoxifen as part of breast cancer therapy (73). for long-term contraception because the same study found
that only 5.7% of participants discontinued copper IUD
What procedures (ie, endometrial biopsy, use before the 12-month follow-up period. No random-
colposcopy, loop electrosurgical excision ized controlled trials have compared IUD insertion with
procedure) can be performed with an IUD medical regimens for emergency contraception.
in place?
Is routine screening for sexually transmitted
An endometrial biopsy may be performed without remov- infections (eg, gonorrhea and chlamydia)
ing the IUD. Endometrial sampling can be performed required before insertion of an IUD?
with a small endometrial suction curette. As with other
women who experience dysfunctional bleeding in the peri- Current data do not support routine screening for sexu-
menopausal period, unexpected bleeding should prompt ally transmitted infections (STIs) before IUD insertion

Practice Bul­le­tin No. 121 7

for women at low risk of STIs. For women at high risk analysis of four randomized controlled trials of women
of STIs (eg, aged 25 years or younger or having mul- with a low prevalence of STIs, antibiotic prophylaxis at
tiple sex partners), it is reasonable to screen for STIs the time of IUD insertion did not decrease the risk of
and place the IUD on the same day (and administer PID nor did it reduce the likelihood of removal within
treatment if the test results are positive) or when the test the first 3 months (84). The risk of developing pelvic
results are available. Screening for IUD users should infection is increased only in the first 20 days after IUD
follow current CDC guidelines for STI screening (79). insertion (85), suggesting that bacterial contamination
An asymptomatic woman with a positive test result associated with the insertion process is the cause of
for chlamydia or gonorrhea at the time of IUD inser- infection, and not the IUD itself. Although the relative
tion may be treated and the IUD may be left in place. risk of PID is increased in the first 20 days, the absolute
The U.S. Medical Eligibility Criteria for Contraceptive risk of developing PID remains quite small (84).
Use assigns a Category 2/3 for IUD initiation among
women with an increased risk of STIs, clarifying that How should patients be counseled about the
the Category 3 classification specifically applies to potential adverse effects of implants?
women with a very high individual risk of exposure to
gonorrhea or chlamydial infection. Intrauterine device
continuation is considered a Category 2 among women
Metabolic Effects
with an increased risk of STIs. A Category 2 rating is The U.S. Medical Eligibility Criteria for Contraceptive
given to continuing IUD use in a woman found to have Use classifies implant use in women with type 1 diabe-
a chlamydia or gonorrhea infection and then treated with tes and type 2 diabetes as Category 2, including women
appropriate antibiotic therapy (25). with diabetic vascular complications, indicating that the
Women with an STI at the time of IUD insertion benefits of implant use outweigh any risks (25). The
are more likely to develop pelvic inflammatory disease contraceptive implant may have an effect on carbohy-
(PID) than women without an STI (80); however, even drate metabolism by causing mild insulin resistance,
in women with an untreated STI, the risk appears low with no significant change in serum glucose levels in
(81, 82). Prevalence of STIs in a given population is normal women (86).
an important predictor of pelvic infection. In most U.S. Data from current studies conflict on the effects
populations, the prevalence of STDs is low (less than of etonogestrel on liver function tests (87, 88). Limited
10%), so the risk of PID with IUD insertion is low. In studies suggest no adverse effects on the lipid profile of
populations with a high prevalence of STIs (rates greater implant users (89, 90).
than 10%), screening based on history may be helpful in
identifying women at higher risk (83). Women with a Weight Gain
mucopurulent cervico–vaginal discharge or with known Weight gain is a major concern of contraceptive users.
chlamydia or gonorrhea cervicitis should be treated Although commonly reported in contraceptive studies,
before IUD insertion. it is often difficult to ascertain whether weight gain is
The optimal time for IUD insertion among these caused by the contraceptive itself because most studies
women is unclear. The International Planned Parenthood lack a control group. Between 6% and 12% of implant
Federation restricts IUD insertion within 3 months of users in contraceptive studies report weight gain (23,
diagnosis and treatment of STIs that produce cervical 57) but few discontinue the implant because of weight
infection (39). For women at high risk of an interval change. Studies suggest the overall implant removal rate
pregnancy during delayed insertion, a negative STI test because of weight gain varies from 3% to 7% (23, 57).
result at 3– 4 weeks after completing therapy may be an
appropriate requirement before IUD insertion. Because of Dermatologic Reactions
the high risk of reinfection, the CDC recommends repeat Acne is a commonly reported adverse effect of proges-
testing at 3–6 months among women who received a terone-only contraceptives. Overall, most women using
diagnosis of gonorrhea and chlamydial infection (79). the implant have either no change or an improvement in
reports of acne and 10–14% of users experience a wors-
Does antibiotic prophylaxis before IUD ening of symptoms.
insertion decrease the risk of subsequent
pelvic infection? Bone Mineral Density
Routine antibiotic prophylaxis to prevent pelvic infection The limited evidence available is reassuring that implants
is not recommended before IUD insertion. In a meta- do not have a major effect on bone mineral density

8 Practice Bulletin No. 121

(BMD), a surrogate marker for fracture risk. No studies The following recommendations and conclusions
have evaluated fracture risk in current or past implant are based on limited or inconsistent scientific evi-
users, change in BMD after discontinuation of the dence (Level B):
implant, or the BMD effects of the implant in women
younger than 18 years. Extrapolating from pharmaco- Intrauterine devices may be offered to women with
kinetic studies of the etonogestrel implant and data on a history of ectopic pregnancy.
BMD assessment in women aged 18 years and older, the Insertion of the implant is safe at any time in non-
implant should not affect ovarian estradiol production or breastfeeding women after childbirth.
BMD in adolescents (91–93).
Implants may be offered to women who are breast-
feeding and more than 4 weeks after childbirth.
What are the difficulties associated with IUD
insertion and continuation, and how are they Insertion of an IUD or implant immediately after
either an abortion or miscarriage is safe and effective.
best addressed?
Immediate postpartum IUD insertion, which is an
Overall, difficulties with IUD insertion rarely occur. insertion within 10 minutes of placental separation,
Difficulties that have been reported include vasovagal appears safe and effective.
reaction, the need for cervical dilation, severe pain,
inability to insert the IUD, and uterine perforation. Use The following recommendations and conclusions
of pretreatment analgesia with oral nonsteroidal anti- are based primarily on consensus and expert opin-
inflammatory drugs, paracervical block, mechanical ion (Level C):
dilation, and concomitant ultrasonography also may
ease the discomfort of insertion. Uterine perforation is The U.S. Medical Eligibility Criteria for Contra-
estimated to occur in approximately 1 in 1,000 inser- ceptive Use classifies placement of an implant in
tions (94). Adherence to insertion guidelines included breastfeeding women less than 4 weeks after child-
with IUD packaging may help avoid uterine perforation; birth as Category 2 because of theoretic concerns
regarding milk production and infant growth and
the risk of perforation appears to decrease with increas-
development.
ing insertion experience. If either the copper IUD or the
levonorgestrel IUD perforates into the peritoneal cavity, Nulliparous women and adolescents can be offered
the location of the IUD should be confirmed by X-ray, LARC methods, including IUDs.
and the IUD should be removed by laparoscopy or lapa- The FDA and the WHO recommend that IUDs be
rotomy (94, 95). removed from pregnant women when possible with-
Partial expulsion should be ruled out if the strings out an invasive procedure.
are longer than expected. If the male partner reports Long-acting reversible contraceptive methods have
penile discomfort during vaginal penetration, the strings few contraindications, and almost all women are
may be trimmed to the level of the external cervical os eligible for implants and IUDs.
or even shorter to a level within the endocervical canal.
Insertion of an IUD or an implant may occur at any
time during the menstrual cycle as long as preg-
nancy may be reasonably excluded.
Summary of For women at high risk of STIs (eg, aged 25 years
Recommendations and or younger or having multiple sex partners), it is
Conclusions reasonable to screen for STIs and place the IUD on
the same day (and administer treatment if the test
The following recommendation and conclusion are results are positive) or when the test results are
available.
based on good and consistent scientific evidence
(Level A): Long-acting reversible contraceptive methods have
an effect on menstrual bleeding, and patients should
Routine antibiotic prophylaxis to prevent pelvic be given anticipatory guidance about these effects.
infection is not recommended before IUD insertion. An endometrial biopsy may be performed without
Insertion of a copper IUD is the most effective removing the IUD. Cervical colposcopy, cervical
method of postcoital contraception when inserted up ablation or excision, or endometrial sampling, may
to 5 days after unprotected intercourse. be performed with an IUD left in place.

Practice Bul­le­tin No. 121 9

Proposed Performance 13. Nilsson CG, Lahteenmaki PL, Luukkainen T. Ovarian
function in amenorrheic and menstruating users of a
Measure levonorgestrel-releasing intrauterine device. Fertil Steril
1984;41:52–5. (Level III)
Percentage of eligible women seeking contraception 14. World Health Organization. Mechanism of action, safety
who are offered LARC and efficacy of intrauterine devices: report of a WHO
scientific group. World Health Organization Technical
Report Series 753. Geneva: WHO; 1987. (Level III)

References 15. Diaz S, Pavez M, Moo-Young AJ, Bardin CW, Croxatto

HB. Clinical trial with 3-keto-desogestrel subdermal
implants. Contraception 1991;44:393–408. (Level II-3)
1. Hov GG, Skjeldestad FE, Hilstad T. Use of IUD and
subsequent fertility—follow-up after participation in a 16. Schering-Plough Corporation. Implanon (etonogestrel
randomized clinical trial. Contraception 2007;75:88–92. implant). Schering-Plough: Kenilworth (NJ); 2009. Avail-
(Level II-3) able at: http://www.spfiles.com/piimplanon.pd.pdf. Retrieved
March 31, 2011. (Level III)
2. Andersson K, Batar I, Rybo G. Return to fertility after
removal of a levonorgestrel-releasing intrauterine device 17. Makarainen L, van Beek A, Tuomivaara L, Asplund B,
and Nova-T. Contraception 1992;46:575–84. (Level I) Coelingh Bennink H. Ovarian function during the use of
a single contraceptive implant: Implanon compared with
3. Mosher WD, Jones J. Use of contraception in the United Norplant. Fertil Steril 1998;69:714–21. (Level I)
States: 1982-2008. Vital Health Stat 23 2010;(29):1–44.
(Level II-3) 18. Davies GC, Feng LX, Newton JR, Van Beek A, Coelingh-
Bennink HJ. Release characteristics, ovarian activity
4. Secura GM, Allsworth JE, Madden T, Mullersman JL, and menstrual bleeding pattern with a single contracep-
Peipert JF. The Contraceptive CHOICE Project: reduc- tive implant releasing 3-ketodesogestrel. Contraception
ing barriers to long-acting reversible contraception. Am J 1993;47:251–61. (Level III)
Obstet Gynecol 2010;203:115.e1–115.e7. (Level II-2)
19. Croxatto HB. Mechanisms that explain the contraceptive
5. Raine TR, Foster-Rosales A, Upadhyay UD, Boyer CB, action of progestin implants for women. Contraception
Brown BA, Sokoloff A, et al. One-year contracep- 2002;65:21–7. (Level III)
tive continuation and pregnancy in adolescent girls 20. Van den Bosch T, Donders GG, Riphagen I, Debois P,
and women initiating hormonal contraceptives. Obstet Ameye L, De Brabanter J, et al. Ultrasonographic features
Gynecol 2011;117:363–71. (Level II-2) of the endometrium and the ovaries in women on etono-
6. Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, gestrel implant. Ultrasound Obstet Gynecol 2002;20:377–
Kowal D, editors. Contraceptive technology. 19th rev. ed. 80. (Level II-3)
New York (NY): Ardent Media; 2007. (Level III) 21. Zheng SR, Zheng HM, Qian SZ, Sang GW, Kaper RF.
7. Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L, Gricar J. A randomized multicenter study comparing the efficacy
Cost effectiveness of contraceptives in the United States and bleeding pattern of a single-rod (Implanon) and a
[published erratum appears in Contraception 2009;80: six-capsule (Norplant) hormonal contraceptive implant.
229–30]. Contraception 2009;79:5–14. (Level III) Contraception 1999;60:1–8. (Level I)

8. Rivera R, Yacobson I, Grimes D. The mechanism of 22. Blumenthal PD, Gemzell-Danielsson K, Marintcheva-
action of hormonal contraceptives and intrauterine contra- Petrova M. Tolerability and clinical safety of Implanon.
Eur J Contracept Reprod Health Care 2008;13(suppl
ceptive devices. Am J Obstet Gynecol 1999;181:1263–9.
1):29–36. (Level II-3)
(Level III)
23. Darney P, Patel A, Rosen K, Shapiro LS, Kaunitz AM.
9. Stanford JB, Mikolajczyk RT. Mechanisms of action of Safety and efficacy of a single-rod etonogestrel implant
intrauterine devices: update and estimation of postfertil- (Implanon): results from 11 international clinical trials.
ization effects. Am J Obstet Gynecol 2002;187:1699–708. Fertil Steril 2009;91:1646–53. (Level II-3)
(Level III)
24. World Health Organization. Medical eligibility criteria
10. Brockmeyer A, Kishen M, Webb A. Experience of IUD/ for contraceptive use. 4th ed. Geneva: WHO; 2009.
IUS insertions and clinical performance in nulliparous Available at: http://whqlibdoc.who.int/publications/2010/
women--a pilot study. Eur J Contracept Reprod Health 9789241563888_eng.pdf. Retrieved March 31, 2011.
Care 2008;13:248–54. (Level III) (Level III)
11. Sivin I, Stern J, Coutinho E, Mattos CE, el Mahgoub S, 25. U S. medical eligibility criteria for contraceptive use,
Diaz S, et al. Prolonged intrauterine contraception: a 2010. Centers for Disease Control and Prevention (CDC).
seven-year randomized study of the levonorgestrel 20 MMWR Recomm Rep 2010;59(RR-4):1–86. (Level III)
mcg/day (LNg 20) and the Copper T380 Ag IUDS.
26. Suhonen S, Haukkamaa M, Jakobsson T, Rauramo I.
Contraception 1991;44:473–80. (Level I)
Clinical performance of a levonorgestrel-releasing intra-
12. Barbosa I, Olsson SE, Odlind V, Goncalves T, Coutinho E. uterine system and oral contraceptives in young nullipa-
Ovarian function after seven years’ use of a levonorg- rous women: a comparative study. Contraception 2004;
estrel IUD. Adv Contracept 1995;11:85–95. (Level II-3) 69:407–12. (Level I)

10 Practice Bulletin No. 121

27. Hubacher D. Copper intrauterine device use by nullipa- tum use of the contraceptive implant. Obstet Gynecol
rous women: review of side effects. Contraception 2007; 2011;117:1114–21. (Level I)
75(6 suppl):S8–11. (Level III) 42. Reinprayoon D, Taneepanichskul S, Bunyavejchevin S,
28. Paterson H, Ashton J, Harrison-Woolrych M. A nation- Thaithumyanon P, Punnahitananda S, Tosukhowong P,
wide cohort study of the use of the levonorgestrel intra- et al. Effects of the etonogestrel-releasing contraceptive
uterine device in New Zealand adolescents. Contraception implant (Implanon) on parameters of breastfeeding com-
2009;79:433–8. (Level II-2) pared to those of an intrauterine device. Contraception
29. Deans EI, Grimes DA. Intrauterine devices for adoles- 2000;62:239–46. (Level II-3)
cents: a systematic review. Contraception 2009;79:418–23. 43. Taneepanichskul S, Reinprayoon D, Thaithumyanon P,
(Systematic Review) Praisuwanna P, Tosukhowong P, Dieben T. Effects of
30. Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F, the etonogestrel-releasing implant Implanon and a non-
Guzman-Rodriguez R. Use of copper intrauterine devices medicated intrauterine device on the growth of breast-fed
and the risk of tubal infertility among nulligravid women. infants. Contraception 2006;73:368–71. (Level II-3)
N Engl J Med 2001;345:561–7. (Level II-2) 44. Kurunmaki H. Contraception with levonorgestrel-releas-
31. Lewis LN, Doherty DA, Hickey M, Skinner SR. Implanon ing subdermal capsules, Norplant, after pregnancy termi-
as a contraceptive choice for teenage mothers: a com- nation. Contraception 1983;27:473–82. (Level II-2)
parison of contraceptive choices, acceptability and repeat 45. Kurunmaki H, Toivonen J, Lahteenmaki PL, Luukkainen T.
pregnancy. Contraception 2010;81:421–6. (Level II-3) Immediate postabortal contraception with Norplant: levo-
32. World Health Organization. Selected practice recom- norgestrel, gonadotropin, estradiol, and progesterone
mendations for contraceptive use. 2008 update. Geneva: levels over two postabortal months and return of fertil-
WHO; 2008. Available at: http://whqlibdoc.who.int/hq/ ity after removal of Norplant capsules. Contraception
2008/WHO_RHR_08.17_eng.pdf. Retrieved March 31, 1984;30:431–42. (Level III)
2011. (Level III) 46. Lahteenmaki P, Toivonen J, Lahteenmaki PL. Postabortal
33. Brito MB, Ferriani RA, Quintana SM, Yazlle ME, Silva contraception with norethisterone enanthate injections.
de Sa MF, Vieira CS. Safety of the etonogestrel-releasing Contraception 1983;27:553–62. (Level III)
implant during the immediate postpartum period: a pilot 47. Ortayli N, Bulut A, Sahin T, Sivin I. Immediate posta-
study. Contraception 2009;80:519–26. (Level I) bortal contraception with the levonorgestrel intrauterine
34. Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, device, Norplant, and traditional methods. Contraception
Creinin MD. Postplacental or delayed insertion of the 2001;63:309–14. (Level II-2)
levonorgestrel intrauterine device after vaginal deliv 48. Lahteenmaki P, Luukkainen T. Return of ovarian function
ery: a randomized controlled trial. Obstet Gynecol 2010; after abortion. Clin Endocrinol 1978;8:123–32. (Level III)
116:1079–87. (Level I)
49. Fox MC, Oat-Judge J, Severson K, Jamshidi RM, Singh
35. Grimes DA, Lopez LM, Schulz KF, Van Vliet HA, RH, McDonald-Mosley R, et al. Immediate placement of
Stanwood NL. Immediate post-partum insertion of intrauterine devices after first and second trimester preg-
intrauterine devices. Cochrane Database of Systematic nancy termination. Contraception 2011;83:34–40. (Level
Reviews 2010, Issue 5. Art. No.: CD003036. DOI: 10. II-2)
1002/14651858.CD003036.pub2. (Systematic Review)
50. Goodman S, Hendlish SK, Reeves MF, Foster-Rosales A.
36. Celen S, Moroy P, Sucak A, Aktulay A, Danisman N. Impact of immediate postabortal insertion of intrauterine
Clinical outcomes of early postplacental insertion of intra- contraception on repeat abortion. Contraception 2008;
uterine contraceptive devices. Contraception 2004;69: 78:143–8. (Level II-2)
279–82. (Level II-3)
51. Grimes DA, Lopez LM, Schulz KF, Stanwood NL.
37. Ogburn JA, Espey E, Stonehocker J. Barriers to intrauter- Immediate postabortal insertion of intrauterine devices.
ine device insertion in postpartum women. Contraception Cochrane Database of Systematic Reviews 2010, Issue 6.
2005;72:426–9. (Level III) Art. No.: CD001777. DOI: 10.1002/14651858.CD001777.
38. Shaamash AH, Sayed GH, Hussien MM, Shaaban MM. pub3. (Systematic Review)
A comparative study of the levonorgestrel-releasing intra- 52. Gillett PG, Lee NH, Yuzpe AA, Cerskus I. A comparison
uterine system Mirena versus the Copper T380A intrauter- of the efficacy and acceptability of the Copper-7 intra-
ine device during lactation: breast-feeding performance, uterine device following immediate or delayed insertion
infant growth and infant development. Contraception after first-trimester therapeutic abortion. Fertil Steril
2005;72:346–51. (Level I) 1980;34:121–4. (Level I)
39. IMAP statement on intrauterine devices. International 53. Andersson K, Odlind V, Rybo G. Levonorgestrel-releas-
Medical Advisory Panel. IPPF Med Bull 2003;37(2):1–4. ing and copper-releasing (Nova T) IUDs during five years
(Level III) of use: a randomized comparative trial. Contraception
40. Kapp N, Curtis K, Nanda K. Progestogen-only contracep- 1994;49:56–72. (Level I)
tive use among breastfeeding women: a systematic review. 54. Grimes DA, Hubacher D, Lopez LM, Schulz KF. Non-
Contraception 2010;82:17–37. (Systematic Review) steroidal anti-inflammatory drugs for heavy bleeding or
41. Gurtcheff SE, Turok DK, Stoddard G, Murphy PA, pain associated with intrauterine-device use. Cochrane
Gibson M, Jones KP. Lactogenesis after early postpar- Database of Systematic Reviews 2006, Issue 4. Art. No.:

Practice Bul­le­tin No. 121 11

 CD006034. DOI: 10.1002/14651858.CD006034.pub2. (Sys- report and review of the literature. Contraception 2009;79:
tematic Review) 323–7. (Level III)
55. Hubacher D, Chen PL, Park S. Side effects from the 68. Sivin I. Dose- and age-dependent ectopic pregnancy risks
copper IUD: do they decrease over time? Contraception with intrauterine contraception. Obstet Gynecol 1991;
2009;79:356–62. (Level II-3) 78:291–8. (Level III)
56. Sivin I, Stern J, Diaz J, Diaz MM, Faundes A, el Mahgoub S, 69. Sivin I, Stern J. Health during prolonged use of levo-
et al. Two years of intrauterine contraception with levo- norgestrel 20 micrograms/d and the copper TCu 380Ag
norgestrel and with copper: a randomized comparison of intrauterine contraceptive devices: a multicenter study.
the TCu 380Ag and levonorgestrel 20 mcg/day devices. International Committee for Contraception Research
Contraception 1987;35:245–55. (Level I) (ICCR). Fertil Steril 1994;61:70–7. (Level I)
57. Varma R, Sinha D, Gupta JK. Non-contraceptive uses of 70. Xiong X, Buekens P, Wollast E. IUD use and the risk of
levonorgestrel-releasing hormone system (LNG-IUS)--a ectopic pregnancy: a meta-analysis of case-control stud-
systematic enquiry and overview. Eur J Obstet Gynecol ies. Contraception 1995;52:23–34. (Meta-analysis)
Reprod Biol 2006;125:9–28. (Systematic Review) 71. Furlong LA. Ectopic pregnancy risk when contraception
58. Funk S, Miller MM, Mishell DR Jr, Archer DF, Poindexter fails. A review. J Reprod Med 2002;47:881–5. (Level III)
A, Schmidt J, et al. Safety and efficacy of Implanon, a 72. Sitruk-Ware R. The levonorgestrel intrauterine system for
single-rod implantable contraceptive containing etono- use in peri- and postmenopausal women. Contraception
gestrel. Implanon US Study Group. Contraception 2005; 2007;75(6 suppl):S155–60. (Level III)
71:319–26. (Level III)
73. Chan SS, Tam WH, Yeo W, Yu MM, Ng DP, Wong AW,
59. Mansour D, Korver T, Marintcheva-Petrova M, Fraser IS. et al. A randomised controlled trial of prophylactic
The effects of Implanon on menstrual bleeding patterns. levonorgestrel intrauterine system in tamoxifen-treated
Eur J Contracept Reprod Health Care 2008;13(suppl 1): women. BJOG 2007;114:1510–5. (Level I)
13–28. (Level III) 74. Ozalp S, Kabukcuoglu S, Tanir HM. Should endometrial
60. Walch K, Unfried G, Huber J, Kurz C, van Trotsenburg M, hyperplasia be regarded as a reason for abnormal uterine
Pernicka E, et al. Implanon versus medroxyprogester-one bleeding in users of the intrauterine contraceptive device?
acetate: effects on pain scores in patients with symp- Eur J Contracept Reprod Health Care 2003;8:17–20.
tomatic endometriosis—a pilot study. Contraception 2009; (Level III)
79:29–34. (Level I) 75. Bailey AP, Darracott MM. Loop electrosurgical excision
61. U.S. Food and Drug Administration. Mirena (levonorg- procedure with an intrauterine device in place. Am J
estrel-releasing intrauterine system) July 2008. Detailed Obstet Gynecol 2010;203:291.e1–291.e3. (Level III)
view: safety labeling changes approved by FDA Center 76. Westhoff C. IUDs and colonization or infection with
for Drug Evaluation and Research (CDER) -- July 2008. Actinomyces. Contraception 2007;75(6 suppl):S48–50.
Silver Spring (MD): FDA; 2008. Available at: http:// (Level III)
www.fda.gov/Safety/MedWatch/SafetyInformation/
77. Cheng L, Gulmezoglu AM, Piaggio GG, Ezcurra EE,
Safety-RelatedDrugLabelingChanges/ucm121936.htm.
Van Look PP. Interventions for emergency contracep-
Retrieved March 31, 2011. (Level III)
tion. Cochrane Database of Systematic Reviews 2008,
62. Foreman H, Stadel BV, Schlesselman S. Intrauterine Issue 2. Art. No.: CD001324. DOI: 10.1002/14651858.
device usage and fetal loss. Obstet Gynecol 1981;58: CD001324.pub3. (Systematic Review)
669 –77. (Level II-3) 78. Wu S, Godfrey EM, Wojdyla D, Dong J, Cong J, Wang C,
63. Tatum HJ, Schmidt FH, Jain AK. Management and et al. Copper T380A intrauterine device for emergency
outcome of pregnancies associated with the Copper T contraception: a prospective, multicentre, cohort clinical
intrauterine contraceptive device. Am J Obstet Gynecol trial. BJOG 2010;117:1205–10. (Level II-2)
1976;126:869–79. (Level II-3) 79. Workowski KA, Berman S. Sexually transmitted diseases
64. Skjeldestad FE, Hammervold R, Peterson DR. Outcomes treatment guidelines, 2010. Centers for Disease Control
of pregnancy with an IUD in situ--a population based and Prevention (CDC) [published erratum appears in
case-control study. Adv Contracept 1988;4:265–70. MMWR Recomm Rep 2011;60:18]. MMWR Recomm
(Level II-3) Rep 2010(RR-12);59:1–110. Available at: http://www.
cdc.gov/std/treatment/2010/default.htm. Retrieved April 6,
65. Inal MM, Ertopcu K, Ozelmas I. The evaluation of 318 2011. (Level III)
intrauterine pregnancy cases with an intrauterine device.
Eur J Contracept Reprod Health Care 2005;10:266–71. 80. Mohllajee AP, Curtis KM, Peterson HB. Does insertion
(Level II-3) and use of an intrauterine device increase the risk of
pelvic inflammatory disease among women with sexually
66. Ganer H, Levy A, Ohel I, Sheiner E. Pregnancy outcome transmitted infection? A systematic review. Contraception
in women with an intrauterine contraceptive device. Am J 2006;73:145–53. (Systematic Review)
Obstet Gynecol 2009;201:381.e1–381.e5. (Level II-3)
81. Ladipo OA, Farr G, Otolorin E, Konje JC, Sturgen K,
67. Hopkins MR, Agudelo-Suarez P, El-Nashar SA, Creedon Cox P, et al. Prevention of IUD-related pelvic infection:
DJ, Rose CH, Famuyide AO. Term pregnancy with intra- the efficacy of prophylactic doxycycline at IUD insertion.
peritoneal levonorgestrel intrauterine system: a case Adv Contracept 1991;7:43–54. (Level I)

12 Practice Bulletin No. 121

82. Sinei SK, Schulz KF, Lamptey PR, Grimes DA, Mati JK,
Rosenthal SM, et al. Preventing IUCD-related pelvic The MEDLINE database, the Cochrane Library, and the
infection: the efficacy of prophylactic doxycycline at American College of Obstetricians and Gynecologists’
insertion. Br J Obstet Gynaecol 1990;97:412–9. (Level I) own internal resources and documents were used to con­
duct a lit­er­a­ture search to lo­cate rel­e­vant ar­ti­cles pub­lished
83. Morrison CS, Murphy L, Kwok C, Weiner DH. Identifying be­tween January 1990–February 2011. The search was
appropriate IUD candidates in areas with high preva- re­strict­ed to ar­ ti­
cles pub­ lished in the English lan­ guage.
lence of sexually transmitted infections. Contraception Pri­or­i­ty was given to articles re­port­ing results of orig­i­nal
2007;75:185–92. (Level III) re­search, although re­view ar­ti­cles and com­men­tar­ies also
84. Grimes DA, Lopez LM, Schulz KF. Antibiotic prophyl- were consulted. Ab­stracts of re­search pre­sent­ed at sym­po­
axis for intrauterine contraceptive device insertion. sia and sci­en­tif­ic con­fer­enc­es were not con­sid­ered adequate
Cochrane Database of Systematic Reviews 1999, Issue 3. for in­clu­sion in this doc­u­ment. Guide­lines pub­lished by
Art. No.: CD001327. DOI: 10.1002/14651858.CD001327. or­ga­ni­za­tions or in­sti­tu­tions such as the Na­tion­al In­sti­tutes
(Systematic Review) of Health and the Amer­i­can Col­lege of Ob­ste­tri­cians and
Gy­ne­col­o­gists were re­viewed, and ad­di­tion­al studies were
85. Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O. located by re­view­ing bib­liographies of identified articles.
Intrauterine devices and pelvic inflammatory disease: an When re­li­able research was not available, expert opinions
international perspective. Lancet 1992;339:785–8. (Level I) from ob­ste­tri­cian–gynecologists were used.
86. Biswas A, Biswas S, Viegas OA. Effect of etonogestrel Studies were reviewed and evaluated for qual­it­y ac­cord­ing
subdermal contraceptive implant (Implanon) on liver func- to the method outlined by the U.S. Pre­ven­tive Services
tion tests—a randomized comparative study with Norplant Task Force:
implants. Contraception 2004;70:379–82. (Level I) I Evidence obtained from at least one prop­ er­
ly
87. Dilbaz B, Ozdegirmenci O, Caliskan E, Dilbaz S, Haberal A. de­signed randomized controlled trial.
Effect of etonogestrel implant on serum lipids, liver II-1 Evidence obtained from well-designed con­ trolled
function tests and hemoglobin levels. Contraception tri­als without randomization.
2010;81:510– 4. (Level II-2) II-2 Evidence obtained from well-designed co­ hort or
case–control analytic studies, pref­er­ab­ ly from more
88. Nasr A, Nafeh HM. Effect of etonogestrel contraceptive
than one center or research group.
implant (Implanon) on portal blood flow and liver func-
tions. Contraception 2009;79:236–9. (Level II-2) II-3 Evidence obtained from multiple time series with or
with­out the intervention. Dra­mat­ic re­sults in un­con­
89. Mascarenhas L, van Beek A, Bennink HC, Newton J. trolled ex­per­i­ments also could be regarded as this
Twenty-four month comparison of apolipoproteins A-1, type of ev­i­dence.
A-II and B in contraceptive implant users (Norplant and III Opinions of respected authorities, based on clin­i­cal
Implanon) in Birmingham, United Kingdom [published ex­pe­ri­ence, descriptive stud­ies, or re­ports of ex­pert
erratum appears in Contraception 1998;58:following committees.
389]. Contraception 1998;58:215–9. (Level I) Based on the highest level of evidence found in the data,
90. Dorflinger LJ. Metabolic effects of implantable steroid recommendations are provided and grad­ed ac­cord­ing to the
contraceptives for women. Contraception 2002;65:47–62. following categories:
(Level III) Level A—Recommendations are based on good and con­
91. Beerthuizen R, van Beek A, Massai R, Makarainen L, sis­tent sci­en­tif­ic evidence.
Hout J, Bennink HC. Bone mineral density during Level B—Recommendations are based on limited or in­con­
long-term use of the progestagen contraceptive implant sis­tent scientific evidence.
Implanon compared to a non-hormonal method of contra- Level C—Recommendations are based primarily on con­
ception. Hum Reprod 2000;15:118–22. (Level II-2) sen­sus and expert opinion.
92. Bahamondes L, Monteiro-Dantas C, Espejo-Arce X, Dos
Santos Fernandes AM, Lui-Filho JF, Perrotti M, et al. A
prospective study of the forearm bone density of users of Copyright July 2011 by the American College of Ob­ ste­
t-
etonorgestrel- and levonorgestrel-releasing contraceptive ri­cians and Gynecologists. All rights reserved. No part of this
implants. Hum Reprod 2006;21:466–70. (Level I) publication may be reproduced, stored in a re­triev­al sys­tem,
93. Tolaymat LL, Kaunitz AM. Use of hormonal contracep- posted on the Internet, or transmitted, in any form or by any
tion in adolescents: skeletal health issues. Curr Opin means, elec­tron­ic, me­chan­i­cal, photocopying, recording, or
Obstet Gynecol 2009;21:396–401. (Level III) oth­er­wise, without prior written permission from the publisher.

94. Long-term reversible contraception. Twelve years of expe- Requests for authorization to make photocopies should be
rience with the TCu380A and TCu220C. Contraception directed to Copyright Clearance Center, 222 Rosewood Drive,
1997;56:341–52. (Level I) Danvers, MA 01923, (978) 750-8400.

95. Speroff L, Darney PD. A clinical guide for contraception. ISSN 1099-3630
5th ed. Philadelphia (PA): Wolters Kluwer/Lippincott The American College of Obstetricians and Gynecologists
Williams & Wilkins; 2011. (Level III) 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920
Long-acting reversible contraception: implants and intrauterine devic-
es. Practice Bulletin No. 121. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2011;118:184–96.

Practice Bul­le­tin No. 121 13