A study from Finland has shown that immediate, compared with delayed, insertion of a levonorgestrel-releasing intrauterine system (IUS) after medical termination of pregnancy (MTOP) resulted in better uptake and continuation rates, and a lower pregnancy rate in the following year.

A total of 267 women having MTOP, and who planned to have an IUS for future contraception, were randomised either to immediate (i.e. within 0-3 days of termination) or delayed (i.e. 2-4 weeks later) IUS placement. After dropouts and exclusions 133 women (immediate group) and 131 women (delayed group) were included in the intention to treat analysis.
IUS insertion strictly per protocol was performed in 116 of 133 and 101 of 131 women. A further 11 (immediate group) and 10 (delayed group) non-protocol insertions were performed. Therefore, actual IUS insertions were 127 and 111 respectively.

IUS expulsion occurred in six women, three from each group. Partial expulsion occurred in 36 cases; 27 from the immediate group and nine in the delayed insertion group. Partially expelled IUS were removed and replaced. A total of 25 women requested removal of the IUS (10 in the immediate and 15 in the delayed insertion group). The main reasons cited included: pain, bleeding problems, and desire for pregnancy.

After 12 months the intention to treat IUS continuation rates were 83 for immediate and 52 for delayed insertion (62.4 vs 39.7% respectively, RR 1.57 (95% CI: 1.23-2.02; P < 0.001). The strict per protocol continuation figures were 77 in the immediate and 47 in the delayed insertion group (66.4 vs 46.5% respectively; P = 0.004).

A new pregnancy was recorded in 22 women in the intention to treat groups: six in the immediate and 16 in the delayed insertion group (4.5 vs 12.2%) respectively; RR 0.37 (95% CI: 0.15-0.91; P = 0.027). Eleven (50%) of the pregnancies occurred in women who did not have the IUS fitted, eight (36.4%) were in women who requested IUS removal, and two (9.1%) were in women who experienced total or partial IUS expulsion. A new TOP was recorded in nine women, four in the immediate and five in the delayed insertion group (3.0 vs 3.8% respectively; RR 0.79 (95% CI: 0.22-2.87; P = 0.748).

Women having an IUS inserted immediately after MTOP were more likely to be still using it one year later, and less likely to become pregnant during that year, compared with women randomised to a delayed IUS placement.

What the study cannot say is whether the IUS is the most acceptable or reliable form of reversible contraception after TOP. However, what it does show is that fitting an IUS straightaway, or very shortly after MTOP, appears to be a more effective strategy than delaying placement for 2-4 weeks.

Dr Chris Barclay