Contraception Editorial April 2012

The Copper IUD For Emergency Contraception, A Neglected Option

Peter Belden, Cynthia C. Harper, J. Joseph Speidel

It can be argued that the most important failing of modern family planning is the persistent epidemic of unintended pregnancy. In developing countries, about 75 million pregnancies annually are unintended, a number close to the 80 million growth of world population each year.¹ In the United States, about half of pregnancies are unintended.² By the age of 45 years, about half of women in the United States will have experienced an unintended pregnancy, and one third will have had an abortion.³ The fact that 47% of the 1.2 million annual abortions in the United States are repeat procedures is additional evidence of ineffective or nonuse of contraception.³

Reducing unintended pregnancy requires a multifaceted approach that includes better education about sexuality and contraception, improved access to higher-quality family planning counseling and services, and more affordable methods and services. A transition from contraceptive methods that require continuing motivation and conscientious use to long-acting reversible contraceptives (LARC) would markedly reduce unintended pregnancies.

One neglected gateway to LARC use is to offer women seeking emergency contraception (EC) or after experiencing “pregnancy scares” the copper intrauterine device (IUD) — a safe and effective method of EC.^{4, 5} The copper IUD is more than 99% effective as EC, whereas that of oral levonorgestrel pills or ulipristal acetate is less than 90%.^{4, 5, 6, 7, 8} Although a few large studies in China and a small pilot study in the United States have demonstrated acceptability and continuation rates of the copper IUD as EC, additional research is needed.^{4, 5, 9}

Sustained efforts of the reproductive health community have resulted in the availability of levonorgestrel EC at pharmacies to women aged 17 years or older, and most contraceptive providers currently offer EC pills at their practices. However, a California study of contraceptive providers showed that only 14.5% offered the copper IUD as EC to their clients at least once.¹⁰ The overwhelming majority of women seeking EC in the United States are not being offered the most effective method of EC.

Two studies in the United States found that more than 10% of women seeking EC in a family planning clinic were interested in the copper IUD.^{11, 12} While it is neither practical nor desirable for providers to discuss every method of contraception with every client, those seeking EC deserve information on the major options: oral levonorgestrel or ulipristal and the copper IUD. In fact, withholding information about the copper IUD as EC raises ethical concerns about quality of care. Emergency contraceptive pills will always be an important option as well, as they are easier to access and can be available at 24-hour pharmacies.

There are additional benefits to offering the copper IUD as EC beyond its high efficacy. It confers protection beyond a single act of unprotected intercourse. Unprotected intercourse typically occurs many times among young women seeking EC, not just as a single episode.¹³ Higher use of IUDs as an ongoing method of contraception would lead to fewer unintended pregnancies and would address not only a client’s immediate need for EC, but also her ongoing need for the most effective contraception.⁵

Yet, several barriers to broader availability of the copper IUD as EC exist:

• Many providers lack training on IUD insertion; even if a clinic has a trained provider, that individual would not necessarily be available all days or hours.¹⁰
• Clinic staff may be concerned that offering the IUD as EC would lead to longer appointments that have not been scheduled and to clinic flow problems.
• Some family planning clinics (especially those relying heavily on Title X) are challenged by limited funds for the purchase of devices.
• Some clients cannot afford the full price or co-payment for an IUD.
• Some providers believe an insufficient number of women would choose the IUD as EC because of inconvenience, cost or not wanting a long-term method.
• Some providers erroneously assume that IUDs are not appropriate for EC clients, particularly young women, nulliparous women or women who have recently had unprotected sex.¹⁰

Many of the same barriers listed above have also been cited by those working to increase access to IUDs for women at the time of an abortion.¹⁴ Encouragingly, efforts to increase availability of postabortion IUDs have obtained great success and yielded significant demand for IUDs among abortion clients.^{15, 16}

Efforts in the United States to address the high incidence of unintended pregnancy must include offering the most effective contraceptive methods. Particularly in the many states where contraception is significantly subsidized and where there are trained providers, offering the copper IUD to EC clients should be a routine practice because of a commitment to providing choice for clients and to helping them avoid unintended pregnancy.

The estimated annual cost of family planning per client in publicly supported programs in the United States is $203 (ranging from $124 and $487.¹⁷ With 17 million women in the United States reliant on public funding for contraceptive services, an annual expenditure of about $3.5 billion is needed.^{18, 19} Yet public outlays for contraceptive services were only $1.85 billion in 2006 — about one half of the total needed.²⁰ Moreover, an estimated $11 billion is spent annually on unintended pregnancy in the United States — prevention of these pregnancies would save taxpayers more than $5 billion. Thus, the additional outlays to increase access to contraceptive services are likely to yield substantial cost savings as well as avoid the potentially negative consequences associated with unintended childbearing — including those that may exacerbate ongoing poverty.^{21, 22}

Additional funds for family planning and related reproductive health services must be matched by better policies to ensure their efficient use. Use of the copper IUD for EC and ongoing contraception is a neglected and cost-effective technology that has the potential to significantly reduce unintended pregnancy and subsequently improve the lives of women and their families in both the United States and globally.

Peter Belden
William and Flora Hewlett Foundation
Menlo Park CA

Cynthia C. Harper
J. Joseph Speidel
Bixby Center for Global Reproductive Health
Department of Obstetrics, Gynecology and Reproductive Sciences
University of California
San Francisco, CA

References

1. In:  Singh S,  Darroch JE,  Ashford L, et al. editor. Adding it up: the costs and benefits of investing in family planning and maternal and newborn health. New York (NY): Guttmacher Institute and United Nations Population Fund; 2009;p. 1–40
2. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38:90–96
3. Jones RK, Singh S, Finer LB, Frohwirth LF. Repeat abortion in the United States. New York (NY): Guttmacher Institute;2006;Occasional Report No. 29 November
4. Zhou L, Xiao B. Emergency contraception with Multiload Cu-375 SL IUD: a multicenter clinical trial. Contraception.2001;64:107–112
5. Wu S, Godfrey EM, Wojdyla D, et al. Copper T380A intrauterine device for emergency contraception: a prospective, multicenter, cohort clinical trial. BJOG. 2010;117:1205–1220
6. WHO Task Force on Postovulatory Methods of Fertility Regulation . Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet. 1998;352:428–433
7. von Hertzen H, Piggio G, Ding J, et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomized trial. Lancet. 2002;360:1803–1810
8. Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomized non-inferiority trial and meta-analysis. Lancet. 2010;375:555–562
9. Turok DK, Gurtcheff SE, Handley E, Simonsen SE, Sok C, Murphy P. A pilot study of the copper T380A IUD and oral levonorgestrel for emergency contraception. Contraception. 2010;82:520–525
10. Harper CC, Blum M, de Bocanegra HT, et al. Challenges in translating evidence to practice: the provision of intrauterine contraception. Obstet Gynecol. 2008;111:1359–1369
11. Turok DK, Gurtcheff SE, Handley E, et al. A survey of women obtaining emergency contraception: are they interested in using the copper IUD?. Contraception. 2011;83:441–446
12. Schwarz EB, Kavanaugh M, Douglas E, Dubowitz T, Creinin M. Interest in intrauterine contraception among seekers of emergency contraception and pregnancy testing. Obstet Gynecol. 2009;113:833–839
13. Raine TR, Harper CC, Rocca CH, et al. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized, controlled trial. JAMA. 2005;293:54–62
14. Thompson KM, Speidel JJ, Saporta V, Waxman NJ, Harper CC. Contraceptive policies affect post-abortion provision of long-acting reversible contraception. Contraception. 2011;83:41–47
15. Goodman S, Hendish SK, Benedict C, Reeves MF, Pera-Floyd M, Foster-Rosales A. Increasing intrauterine contraception use by reducing barriers to post-abortal and interval insertion. Contraception. 2008;78:136–142
16. Bednarek PH, Creinin MD, Reeves MF, Cwiak C, Espey E, Jensen JT. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med. 2011;364:2208–2217
17. Frost JJ, Sonfield A, Gold RB. Estimating the impact of expanding Medicaid eligibility for family planning services. Occasional Report No. 28. New York (NY): Guttmacher Institute; 2006;
18. Sonfield A. Preventing unintended pregnancy: the need and the means. New York (NY): Guttmacher Institute; 2003;
19. Frost JJ, Sonfield A, Gold RB. Ahmed FH. Estimating the impact of serving new clients by expanding funding for Title X. New York (NY): Guttmacher Institute; 2006;
20. Sonfield A, Gold RB. Public funding for contraceptive, sterilization and abortion services, FY1980–2001. New York (NY): Guttmacher Institute; 2005;
21. Monea E, Thomas A. Unintended pregnancy and taxpayer spending. Perspect Sex Reprod Health. 2011;43:88–93
22. Sonfield A, Kost K, Gold RB, Finer LB. The public costs of births resulting from unintended pregnancies. Perspect Sex Reprod Health. 2011;43:94–102