Post Abortion Contraception

Abstract

A safe induced abortion has no impact on future fertility. Ovulation may resume as early as 8 days after the abortion. There is no difference in return to fertility after medical or surgical abortion. Most women resume sexual activity soon after an abortion. Contraceptive counseling and provision should therefore be an integrated part of the abortion services to help women avoid another unintended pregnancy and risk, in many cases an unsafe, abortion. Long-acting reversible contraceptive methods that includes implants and intrauterine contraception have been shown to be the most effective contraceptive methods to help women prevent unintended pregnancy following an abortion. However, starting any method is better than starting no method at all. This Special Report will give a short guide to available methods and when they can be started after an induced abortion.

When a woman presents for an abortion as a result of an unintended pregnancy, much of the counseling involves the abortion procedure itself. However, in order to help women avoid future unintended pregnancies following an abortion, options for postabortion contraception needs to be addressed. Women undergoing an abortion are at risk of another unintended pregnancy and induced abortion. According to official statistics the rate of repeat abortions in Northern Europe is between 30–41% [1] and reaches 48% in the USA [2]. Women have been shown to be most motivated to start effective contraception immediately following an abortion. Furthermore, many women do not return for a follow-up visit. Therefore, contraceptive counseling should not be delayed. Knowledge on all contraceptive methods and when to initiate them after an abortion is essential for all healthcare providers offering abortion counseling. All contraceptive methods should be offered and provided immediately following the procedure. As many as 30–50% of women with an unintended pregnancy had not used any method of contraception at the time that they became pregnant [3]. Women may have rudimentary knowledge of the available contraceptive options as well as how they impact one's fertility. A basic understanding of female fertility is often required for an understanding of the effectiveness of the contraceptive method chosen. Furthermore, it is frequently an advantage if contraceptive counseling also includes the male partner. The partner's acceptability of the method chosen will help increase compliance as well.

Contraception should be started immediately following an abortion. Ovulation may return as early as 8 days following an abortion (medical or surgical) and 83% of women ovulate at the first cycle following an abortion [4]. Women should be informed about the rapid return of fertility after an abortion and that ovulation most often precedes the first post abortion menses. More than 50% of women have been found to reinitiate sexual activity within 2 weeks after an induced abortion [5], and consequently this intercourse often precedes the first ovulation and puts the women at risk for another unintended pregnancy. Despite this knowledge, the routine in many places is still to delay contraceptive counseling or start of hormonal or intrauterine contraceptives until the first postabortion menses. Many times women are also referred for contraceptive counseling and provision instead of including this on site at the time of the abortion care. Knowledge of available postabortion contraception and access to post abortion contraceptive options is necessary to improve women's reproductive health and reduce the incidence of unintended pregnancy.

Contraception following first-trimester termination of pregnancy: combined hormonal methods (pills, patch, ring & injections) & progestin-only pills

The WHO's medical eligibility criteria for contraceptive use (WHO MEC) states that combined hormonal contraception (pills, patch and ring) and progestin only pills may be started immediately post abortion on the same day as the abortion or the day following the abortion. Immediate start following medical or surgical first trimester abortion does not affect the efficacy of the abortion process or post abortion bleeding. However, immediate initiation of contraception does effectively prevent ovulation in the next cycle and reduces the risk of another unintended pregnancy. Furthermore, immediate start of combination-steroid contraceptives is not associated with increased irregular vaginal bleeding or clinically significant changes in coagulation parameters when compared with women using nonhormonal or no contraceptive method following an abortion [6–8]. Thus, combined hormonal contraception (pills, patch and ring) and progestin only pills should be started on the day of – or the day after – surgery or misoprostol administration for medication abortion. To avoid the need for back up barrier methods these methods should be started within 5 days post abortion. Limited evidence on women using the combined vaginal contraceptive ring immediately after first-trimester medical or surgical abortion found no serious adverse events and no infections related to use of the ring during three cycles of follow-up post abortion [9]. It has been suggested that hormonal uptake in the vaginal epithelium may be reduced due to heavy bleeding but no adverse events have been shown. Immediate start should therefore be preferred due to the high motivation of women to start effective contraception immediately after an abortion. If start is delayed to more than 5 days, back up contraception with barrier methods should be strongly recommended.

Long-acting reversible contraception: intrauterine contraception & implants

Long-acting reversible contraception (LARCs) such as intrauterine contraceptive devises (IUD) and contraceptive subdermal implants have been shown to be highly effective for prevention of unintended pregnancy and repeat abortion [1,10–13]. Most contraceptive methods depend on user adherence. For example, women have to remember to take a pill daily or present for an injection every 3 months. Furthermore, fertility awareness based methods require rigorous discipline and male condoms and diaphragms have to be purchased and available for every coital act. In contrast, IUD and implants do not rely on user adherence and therefore are equally effective at all times. This may explain why LARC methods are superior to user-based methods at prevention of unintended pregnancy and repeat abortion [14]. Furthermore, LARCs are equally effective in young women with high fertility compared with older women, and efficacy of these methods is not affected by body weight or BMI. LARC may be particularly beneficial in adolescents as younger women have lower compliance for contraceptive methods that require daily adherence [14].

Although approximately 30% of adult women presenting for abortion have never used contraception, most women presenting for an abortion have used a contraceptive method but failed to use it correctly [3]. These women in particular may have difficulty adhering to a daily pill regimen. LARC methods are not only user independent but are in fact also long acting and the current available methods last for several years. Most women having abortions are young with a long-term need for effective contraception to prevent unintended pregnancy at a time in life with fertility is high. LARC methods are therefore especially suited for younger women and should be routinely offered and promoted for post abortion contraception.

Surgical abortion

Implants should be inserted immediately following a first trimester surgical abortion. Most studies on implants following an abortion are limited to levonorgestrel (LNG) implants [15,16], but the results can most probably be extrapolated to all available implants in relation to effectiveness and compli ance. A few studies however study the etonogestrel implant [17,18].

The WHO MEC states that IUDs can be inserted immediately after first-trimester, spontaneous or induced surgical abortion. It may be of importance to note that all studies on post abortion insertion of IUD listed by the WHO are limited to surgical evacuation or surgical abortion. There was no difference in risk of complications such as expulsions, perforations, incomplete abortion or pelvic infections for immediate versus delayed insertion of an IUD after a surgical abortion [19–22]. Furthermore, there were no differences in safety or expulsions for postabortion insertion of a LNG releasing intrauterine system, (LNG-IUS) compared with a copper-IUD [19–22]. In case of a septic abortion, an IUC should not be inserted until treatment of the infection has been successful. Alternative contraceptive methods should be offered in the meantime.

A higher expulsion rate may be observed for immediate post abortion IUD insertion when compared with delayed insertion [23]. In an American multicentre trial including women randomized to immediate (insertion directly at surgery) or delayed insertion at follow-up after the abortion The 6-month expulsion risk was 5.0% (13 of 258 women) after immediate insertion and 2.7% (6 of 226) after delayed insertion (difference, 2.3 percentage points; 95% CI: −1.0 to 5.8). However, 42% of women in one study of delayed IUD insertion did not return for their appointment thus making the case for immediate insertion [20]. Furthermore, women with a successful insertion were more likely to use an IUD after 6 months if they had it inserted immediately compared with several weeks after the abortion (92.3% use in the immediate insertion group vs 76.6% following delayed insertion).

Medical abortion in first trimester

Medical abortion with mifepristone followed by the prostaglandin analouges gemeprost or misoprostol was first approved in 1988 and has been available in Europe since more than 25 years [24]. Today it is the most common method for pregnancy termination in many European countries with rates up to over 90% of the induced first trimester abortions. The combined regimen has been available in the USA since 2000 and is now approved in more than 60 countries worldwide. A less effective but still acceptable alternative in settings where mifepristone is not available is to use misoprostol alone regimens [24]. Protocols on medical abortion frequently recommend a follow-up visit at about 2 weeks following the abortion. A possible disadvantage of medical abortion when compared with surgical abortion is the delayed insertion of LARC methods. Common practice in some European and other countries is to wait 2 but sometimes up to 4 weeks or until postabortion menstruation before insertion of a LARC method. In the USA, insertion is routinely done at 10–14 days at the time of postmedication abortion follow-up. This delayed insertion poses a risk for repeat unintended pregnancy. This practice may also discourage women from an LARC method secondary to the requirement of multiple follow-up visits. This is particularly cumbersome for women traveling long distances for abortion care or in resource poor settings. In some parts of the world, the clinical practice has changed and contraceptive implants are inserted on the day of medical abortion. This has been shown to be safe and effective and should be offered [24]. Women having home administration of misoprostol for early medical abortion should be offered insertion of the implant as soon as possible after the home administration of misoprostol as women are most motivated to start contraception at the time of abortion. Data are still lacking for implant insertion done at the time of administration of mifepristone in regard to abortion efficacy. Since mifepristone is a progesterone receptor antagonist which binds with high affinity to the progesterone receptor it may interact with the progestin in the implant. An interaction between a progesterone receptor modulator and a progestin has previously been reported when studied for contraceptive use [25]. A small pilot study including 20 women confirmed the acceptability of immediate implant insertion [26]. However, the study was too small to draw any conclusions on a possible drug interaction. This will have to be shown by on-going studies.

It has also been shown that IUD can be inserted as soon as expulsion has been confirmed (by inspection of the expelled material or by ultrasound) after medical abortion [27–29]. Expulsion rates were not increased if the IUD insertion was done at one week following the medical abortion versus at 3–4 weeks follow-up [30]. Furthermore, endometrial thickness or inhomogeneous uterine content at ultrasound examination did not correlate with expulsion rate. Significantly more women randomized to early insertion returned for the IUD insertion compared with women scheduled for delayed insertion at 3–4 weeks after the treatment. Early insertion of the LNG-IUS reduced days of heavy bleeding post medical abortion [30]. Taken together to avoid a repeat unplanned pregnancy it is recommended that IUD insertion is done as soon as a continuing viable pregnancy can be excluded preferable within 1 week following a medical abortion in the first trimester.

Progestogen only injectables

Progestogen only injectables (DMPA or norethisterone enanthate) can be administered immediately following a surgical, medical or spontaneous abortion [13,31]. The first injection should be offered before the woman leaves the abortion care facility or as soon as possible following home administration of misoprostol for medication abortion.

While DMPA is frequently used following abortion and post abortion care, there are no published studies recommending the use of DMPA at the time of mifepristone administration. However, clinical trials are currently ongoing addressing this important clinical question.

Contraception following second trimester termination of pregnancy

Despite the lack of specific studies it seems logic based on first trimester data, postpartum data and clinical routine to assume that the recommendations on the use and initiation of hormonal contraception can also be applied in second trimester abortion.

The risk for IUD expulsion when inserted immediately following surgical abortion or uterine evacuation after medical abortion seems to increase with gestational length and uterine size. Expulsion was greater when an IUD was inserted following a second-trimester surgical abortion versus following a first-trimester abortion (6.8 vs 5%) [19,32]. However this risk may be compensated for by the advantage of the immediate insertion, especially in women judged to be at high risk of repeat unintended pregnancy and abortion or for women living far away from the abortion care facility In a clinical trial continuation rate at 6 months in immediate insertion group was 85 versus 63% in the delayed group. Only 15% of women in the delayed group returned for their IUD insertion [33].

There are no studies on IUD insertion following medical abortion in the second trimester. However, several studies have focused on postplacental insertion of IUD postpartum showing higher expulsion rates but also higher rates of IUD continuation compared with delayed insertion [34,35]. Only one study included women with a gestational duration at the abortion of >12 weeks for both DMPA and implants immediately after the abortion. In a study of women postpartum, implant insertion was done as early as 3 days after delivery versus delayed insertion at routine follow-up [36]. Significantly higher rates of insertion were reported in the early versus delayed group (97 vs 70%) again pointing to the importance of initiation of contraception as soon as possible after an abortion [36].

Permanent contraception

The WHO MEC advise that permanent contraception including vasectomy and tubal procedures may be performed after an uncomplicated abortion but should be avoided in case of any complication. However, regret is more common among younger women or men (<30 years of age) after permanent contraception is performed especially if it is done immediately postpartum or within the first year after delivery [37]. In sum, permanent contraceptive methods should not be routinely done at the time of an abortion particularly in young women if other alternatives are available/possible and only after extensive counseling. LARC initiation is as effective as permanent contraception and should be immediately offered and available.

Other methods

Condoms can be initiated immediately post abortion. According to the WHO MEC, the diaphragm and cervical cap are not recommended until 6 weeks after a second-trimester abortion when the uterus has resumed its normal size.

When a risk of STI/HIV transmission exists, it is important that dual protection is recommended with the simultaneous use of condoms and another effective method.

Emergency contraceptive pills should be offered to women relying on less effective methods and should be used in combination with these methods.

Fertility awareness based methods cannot be used until the menstrual cycle has resumed. Initiation of such methods should be preceded by careful counseling and information should also be given about the high dependence on user adherence. These methods should be reserved for highly motivated women and couples. These methods can only be used by women with regular menstrual periods where ovulation can be reasonably predicted.

Conclusion

Abortion has no known negative impact on future fertility. Women should be offered contraceptive counseling and initiation at the time of the abortion. The motivation to initiate an effective contraceptive method is highest immediately after the abortion. However, the proportion of women who do not receive effective post abortion contraceptive methods is high in resource poor settings. Immediate start of LARC methods has been shown to be the most effective to help women to prevent unintended pregnancy following an abortion. A potential advantage with implants and injections could be that insertion/injections could be done at the same time as administration of mifepristone administration for medical abortion. Studies are underway to ascertain that this practice has no negative effect on the efficacy of the abortion treatment through drug interaction.

Future perspective

Increased use of LARC (intrauterinecontraception and implants) is encouraged to help women to avoid unplanned pregnancy and to reduce unsafe abortion. There is a need to increase this under utilized group of highly effective, safe and accepted group of contraceptive methods. Recent and ongoing studies will further stress the advantage of immediate start of LARCs following an abortion. Guidelines and clinical practice will need to be updated to reflect the current evidence on LARC post abortion.

Executive summary

• Contraceptive counseling and provision should be an integrated part of the abortion care or postabortion care to help women avoid unintended pregnancy.

• The current pregnancy confirms the fertility of the woman and an uncomplicated abortion has no negative consequences on future fertility.

• There is no difference in the return of ovulation following a surgical compared with a medical first trimester abortion.

• Contraception should be started within the first week of an abortion as ovulation may occur as early as 8–10 days after an abortion.

• Immediate start of contraception following medical or surgical first trimester abortion does not affect the abortion process or post abortion bleeding.

• Long-acting reversible contraceptive methods are the most effective contraceptive methods to help women avoid a repeat unintended pregnancy.