Insertion of an intrauterine contraceptive device after induced or spontaneous abortion: a review of the evidence.

OBJECTIVE Assess the safety and efficacy of intrauterine contraceptive device (IUCD) insertion immediately after induced or spontaneous abortion. DESIGN Systematic search for randomised trials that had at least one treatment arm that involved IUCD insertion immediately after an induced or spontaneous miscarriage using Medline, Popline, EMBASE, and review articles supplemented by correspondence with investigators. POPULATION Women of any age or gravidity who had an IUCD inserted immediately after evacuation for spontaneous or induced abortion. METHODS Articles were abstracted and the raw data from tables were analysed with RevMan 3.1 software. We focused on Tietze-Potter gross life table probabilities with denominators of person-time of exposure. MAIN OUTCOME MEASURES Rates of perforation, expulsion, pelvic inflammatory disease, contraceptive failure, and method continuation. RESULTS Complication rates for immediate post-abortal IUCD insertion were low. Perforation was rare with a rate of approximately one per 1,000 insertions. One year gross cumulative expulsion rates ranged from 1.8% to 12.6%, pregnancy rates from 0.6% to 2.1%, and continuation rates from 54% to 90%. The net discontinuation rate due to pelvic inflammatory disease was low, ranging from 0.0 to 0.8 per 100 women at one year. Increasing gestational age at insertion was associated with increased expulsion rates. CONCLUSIONS Post-abortal IUCD insertion is safe and effective. The risks of perforation, expulsion, pelvic inflammatory disease and contraceptive failure were low and similar to those reported for interval insertion. Second trimester gestational age is associated with an increased risk of expulsion. Immediate insertion may have a higher expulsion rate than delayed insertion. However, these risks may be outweighed by the benefit of immediate contraception.