CONTRACEPTIVE CONUNDRUMS FOR THE GENERAL OBGYN

Case Q: How can I best remove my patient’s difficult-to-find implant?

OBG Manag. 2023 December;35(12):34-39 | doi: 10.12788/obgm.0332

References

Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. Morb Mortal Wkly Rep. 2016;65:1-66. https://doi .org/10.15585/mmwr .rr6504a1
Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. US Selected Practice Recommendations for Contraceptive Use (US-SPR). Accessed October 11, 2023. https://www.cdc.gov/reproductivehealth /contraception/mmwr/spr/summary.html
Nexplanon [package insert]. Whitehouse Station, NJ: Merck; 2018.
US Food and Drug Administration. Implanon (etonogestrel implant) 2006. Accessed November 6, 2023. https://www .accessdata.fda.gov/drugsatfda_docs/nda/2006 /021529s000_Lbl.pdf
US Food and Drug Administration. Jadelle (levonorgestrel implant) 2016. Accessed November 6, 2023. https://www. accessdata.fda.gov/drugsatfda_docs/label/2016/020544s 010lbl.pdf
Chen MJ, Creinin MD. Removal of a nonpalpable etonogestrel implant with preprocedure ultrasonography and modified vasectomy clamp. Obstet Gynecol. 2015;126:935-938.
Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep Morb Mortal Wkly. 2016;65:1-66. https://doi .org/10.15585/mmwr.rr6504a1
Turok DK, Gero A, Simmons RG, et al. Levonorgestrel vs. copper intrauterine devices for emergency contraception. N Engl J Med. 2021;384:335-344. https://pubmed.ncbi.nlm .nih.gov/33503342/
Kaiser JE, Turok DK, Gero A, et al. One-year pregnancy and continuation rates after placement of levonorgestrel or copper intrauterine devices for emergency contraception: a randomized controlled trial. Am J Obstet Gynecol. 2023;228:438.e1-438.e10. https://doi.org/10.1016/j.ajog.2022 .11.1296
Sander PM, Raymond EG, Weaver MA. Emergency contraceptive use as a marker of future risky sex, pregnancy, and sexually transmitted infection. Am J Obstet Gynecol. 2009;201:146.e1-e6.
Ramanadhan S, Goldstuck N, Henderson JT, et al. Progestin intrauterine devices versus copper intrauterine devices for emergency contraception. Cochrane Database Syst Rev. 2023;2:CD013744. https://doi.org/10.1002/14651858 .CD013744.pub2

Is same-day IUD an option?

Yes. This patient needs EC given the recent condom break, but they are still eligible for having an IUD placed today if their pregnancy test is negative and after counseling of the potential risks and benefits. According to the US-SPR it is reasonable to insert an IUD at any time during the cycle as long as you are reasonably certain the patient is not pregnant.⁷

Options for EC are:

1.5-mg oral LNG pill
30-mg oral UPA pill
copper IUD (cu-IUD).

If they are interested in the cu-IUD for long-term contraception, by having a cu-IUD placed they can get both their needs met—EC and an ongoing method of contraception. Any patient receiving EC, whether a pill or an IUD, should be counseled to repeat a home urine pregnancy test in 2 to 4 weeks.

Given the favorable non–contraceptive benefits associated with 52-mg LNG-IUDs, many clinicians and patients have advocated for additional evidence regarding the use of hormonal IUDs alone for EC.

What is the evidence concerning LNG-IUD placement as EC?

The 52-mg LNG-IUD has not been mechanistically proven to work as an EC, but growing evidence exists showing that it is safe for same-day or “quick start” placement even in a population seeking EC—if their pregnancy test result is negative at the time of presentation.

Turok and colleagues performed a noninferiority trial comparing 1-month pregnancy rates after placement of either an LNG-IUD or a cu-IUD for EC.⁸ This study concluded that the LNG-IUD (which resulted in 1 pregnancy in 317 users; pregnancy rate, 0.3%; 95% confidence interval [CI], 0.01–1.70) is noninferior to cu-IUD (0 pregnancies in 321 users; pregnancy rate, 0%; 95% CI, 0.0–1.1) for EC. Although encouraging, only a small percentage of the study population seeking EC who received an IUD were actually at high risk of pregnancy (eg, they were not mid-cycle or were recently using contraception), which is why it is difficult to determine if the LNG-IUD actually works mechanistically as an EC. More likely, the LNG-IUD helps prevent pregnancy due to its ongoing contraceptive effect.⁹ Ongoing acts of intercourse post–oral EC initiation without starting a method of contraception is one of the main reasons for EC failure, which is why starting a method immediately is so effective at preventing pregnancy.¹⁰

A systematic review conducted by Ramanadhan and colleagues concluded that Turok’s 2021 trial is the only relevant study specific to 52-mg LNG-IUD use as EC, but they also mention that its results are limited in the strength of its conclusions due to biases in randomization, including¹¹:

the study groups were not balanced in that there was a 10% difference in reported use of contraception at last intercourse, which means that the LNG-IUD group had a lower baseline risk of pregnancy
and a rare primary outcome (ie, pregnancy, which requires a larger sample size to know if the method works as an EC).

The review authors concluded that more studies are needed to further validate the effectiveness of using the 52-mg LNG-IUD as EC. Thus, for those at highest risk of pregnancy from recent unprotected sex and desiring a 52-mg IUD, it is probably best to continue combining oral EC with a 52-mg LNG-IUD and utilizing the LNG-IUD only as EC on a limited, case-by-case basis.

What we recommend

For anyone with a negative pregnancy test on the day of presentation, the studies mentioned further support the practice of same-day placement of a 52-mg LNG-IUD. However, those seeking EC who are at highest risk for an unplanned pregnancy (ie, the unprotected sex was mid-cycle), we recommend co-administering the LNG-IUD with oral LNG for EC.

CASE 2 Conclusion

After a conversation with the patient about all contraceptive options, through shared decision making the patient decided to take 1.5 mg of oral LNG and have a 52-mg LNG-IUD placed in the office today. They do not wish to be pregnant at this time and would choose termination if they became pregnant. They understood their pregnancy risk and opted to plan a urine pregnancy test at home in 2 weeks with a clear understanding that they should return to clinic immediately if the test is positive. ●

Quick takes: 5 pointers for using an IUD as an emergency contraceptive

A copper IUD is the most effective method of emergency contraception (EC).
52-mg LNG-IUDs are an emerging consideration for EC, but evidence is still lacking that they work as EC (or whether they just prevent pregnancy after placement for subsequent acts of intercourse). Clinicians should utilize shared decision making and advise patients to repeat a pregnancy test at home in 2 to 4 weeks
Any patient receiving EC, whether a pill or an IUD, should be counseled to repeat a home urine pregnancy test in 2 to 4 weeks
Any type of IUD can be placed same day if the clinician is reasonably sure the patient is not pregnant
It appears safe to co-administer the 52-mg LNG-IUD with oral EC for those seeking emergency contraception but also want to use an LNG-IUD for contraception going forward