- Andrew M Kaunitz, MD
Andrew M Kaunitz, MD
- Professor and Associate Chairman
- Department of Obstetrics and Gynecology
- University of Florida College of Medicine-Jacksonville
Contraceptive selection requires consideration of patient preferences and medical factors. For women who have undergone an abortion and desire contraception, additional issues include when to start the method and whether or not back-up contraception is necessary. Prompt initiation of postabortion contraception increases utilization and continuation and thus reduces the risk of future unintended pregnancy.
This topic will review contraception issues specific to women who experience first- or second-trimester abortion (typically <24 weeks of gestation). Discussions on contraceptive counseling and selection and postpartum contraception are presented separately. (See "Contraceptive counseling and selection" and "Postpartum contraception".)
WHEN TO START POSTABORTION CONTRACEPTION
The first ovulation postabortion occurs between a mean of 21 to 29 days after the procedure with a reported range of 8 to 103 days [1,2]. As the resumption of ovulation can be rapid and unpredictable, we advise women who desire contraception to begin the method at the same time the abortion occurs (ie, immediate start).
Advantages of immediate initiation of contraception include that the woman is known not to be pregnant, an additional visit is not required, and the woman leaves with a contraceptive plan in place, although a plan to use condoms or short-acting reversible contraceptives is not likely to be as reliable as immediate initiation of long-acting reversible contraception. In a retrospective cohort study that compared women who needed an additional visit to initiate the intrauterine device or depot medroxyprogesterone acetate injection with those who had immediate access, women with same-day access had significantly fewer subsequent abortions and births within 12 months and were more likely to use an effective or highly effective contraceptive (figure 1) . (See "Contraceptive counseling and selection", section on 'Reduce unintended pregnancy' and 'Long-acting reversible contraception' below.)
Postabortion women can safely use any contraceptive option that is compatible with their medical comorbidities as presented in the Centers for Disease Control and Prevention Medical Eligibility Criteria for Contraceptive Use, 2016 .
- Stoddard A, Eisenberg DL. Controversies in family planning: timing of ovulation after abortion and the conundrum of postabortion intrauterine device insertion. Contraception 2011; 84:119.
- Schreiber CA, Sober S, Ratcliffe S, Creinin MD. Ovulation resumption after medical abortion with mifepristone and misoprostol. Contraception 2011; 84:230.
- Langston AM, Joslin-Roher SL, Westhoff CL. Immediate postabortion access to IUDs, implants and DMPA reduces repeat pregnancy within 1 year in a New York City practice. Contraception 2014; 89:103.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2011; 118:184.
- Hatcher RA, Trussel RA, Nelson AL, et al. Contraceptive Technology, 20th ed, Ardent Media, New York 2011.
- Rose SB, Lawton BA. Impact of long-acting reversible contraception on return for repeat abortion. Am J Obstet Gynecol 2012; 206:37.e1.
- Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol 2012; 206:481.e1.
- Kamel H, Navi BB, Sriram N, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med 2014; 370:1307.
- Park J, Robinson N, Wessels U, et al. Progestin-based contraceptive on the same day as medical abortion. Int J Gynaecol Obstet 2016; 133:217.
- Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
- Pakarinen P, Toivonen J, Luukkainen T. Randomized comparison of levonorgestrel- and copper-releasing intrauterine systems immediately after abortion, with 5 years' follow-up. Contraception 2003; 68:31.
- Ortayli N, Bulut A, Sahin T, Sivin I. Immediate postabortal contraception with the levonorgestrel intrauterine device, Norplant, and traditional methods. Contraception 2001; 63:309.
- Betstadt SJ, Turok DK, Kapp N, et al. Intrauterine device insertion after medical abortion. Contraception 2011; 83:517.
- Ogburn JA, Espey E, Stonehocker J. Barriers to intrauterine device insertion in postpartum women. Contraception 2005; 72:426.
- Fox MC, Oat-Judge J, Severson K, et al. Immediate placement of intrauterine devices after first and second trimester pregnancy termination. Contraception 2011; 83:34.
- Reeves MF, Smith KJ, Creinin MD. Contraceptive effectiveness of immediate compared with delayed insertion of intrauterine devices after abortion: a decision analysis. Obstet Gynecol 2007; 109:1286.
- Drey EA, Reeves MF, Ogawa DD, et al. Insertion of intrauterine contraceptives immediately following first- and second-trimester abortions. Contraception 2009; 79:397.
- Cremer M, Bullard KA, Mosley RM, et al. Immediate vs. delayed post-abortal copper T 380A IUD insertion in cases over 12 weeks of gestation. Contraception 2011; 83:522.
- Black A, Guilbert E, Costescu D, et al. Canadian Contraception Consensus (Part 3 of 4): Chapter 7--Intrauterine Contraception. J Obstet Gynaecol Can 2016; 38:182.
- Birgisson NE, Zhao Q, Secura GM, et al. Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review. J Womens Health (Larchmt) 2015; 24:349.
- Goodman S, Hendlish SK, Reeves MF, Foster-Rosales A. Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion. Contraception 2008; 78:143.
- Heikinheimo O, Gissler M, Suhonen S. Can the outcome of the next pregnancy be predicted at the time of induced abortion? Hum Reprod 2009; 24:820.
- Pohjoranta E, Mentula M, Gissler M, et al. Provision of intrauterine contraception in association with first trimester induced abortion reduces the need of repeat abortion: first-year results of a randomized controlled trial. Hum Reprod 2015; 30:2539.
- Okusanya BO, Oduwole O, Effa EE. Immediate postabortal insertion of intrauterine devices. Cochrane Database Syst Rev 2014; :CD001777.
- Steenland MW, Tepper NK, Curtis KM, Kapp N. Intrauterine contraceptive insertion postabortion: a systematic review. Contraception 2011; 84:447.
- Bednarek PH, Creinin MD, Reeves MF, et al. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med 2011; 364:2208.
- Shimoni N, Davis A, Westhoff C. Can ultrasound predict IUD expulsion after medical abortion? Contraception 2014; 89:434.
- Che Y, Liu X, Zhang B, Cheng L. Oral contraception following abortion: A systematic review and meta-analysis. Medicine (Baltimore) 2016; 95:e3825.
- www.plannedparenthood.org (Accessed on August 01, 2016).
- Raymond EG, Weaver MA, Tan YL, et al. Effect of Immediate Compared With Delayed Insertion of Etonogestrel Implants on Medical Abortion Efficacy and Repeat Pregnancy: A Randomized Controlled Trial. Obstet Gynecol 2016; 127:306.
- Hognert H, Kopp Kallner H, Cameron S, et al. Immediate versus delayed insertion of an etonogestrel releasing implant at medical abortion-a randomized controlled equivalence trial. Hum Reprod 2016; 31:2484.
- Creinin M, August 2016, personal communication.
- Raymond EG, Weaver MA, Louie KS, et al. Effects of Depot Medroxyprogesterone Acetate Injection Timing on Medical Abortion Efficacy and Repeat Pregnancy: A Randomized Controlled Trial. Obstet Gynecol 2016; 128:739.
- Batzer FR. Hormonal evaluation of early pregnancy. Fertil Steril 1980; 34:1.
- Cole LA. Immunoassay of human chorionic gonadotropin, its free subunits, and metabolites. Clin Chem 1997; 43:2233.
- WHEN TO START POSTABORTION CONTRACEPTION
- CONTRACEPTIVE OPTIONS
- Long-acting reversible contraception
- - Progestin-only implant
- - Intrauterine contraception
- Short-acting hormonal contraception
- Barrier contraception
- HOW TO START POSTABORTION CONTRACEPTION
- After surgical or induction abortion
- After spontaneous or medication abortion
- DELAYED CONTRACEPTIVE START (>7 DAYS POSTABORTION)
- RESOURCES FOR CLINICIANS AND PATIENTS
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS