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REVIEW

The efficacy of intrauterine devices for emergency

contraception and beyond: a systematic review
update
This article was published in the following Dove Press journal:
International Journal of Women's Health

Norman D Goldstuck Background: The copper intrauterine device (IUD) is a very effective form of emergency
Tik Shan Cheung contraception. The failure rate is about 0.1%. IUDs are also very cost-effective when used as
long acting-reversible contraception (LARC). The purpose of this review is to attempt to
Department of Obstetrics and
Gynaecology, Faculty of Medicine and confirm these findings.
Health Sciences, University of Methods: The references for this study were generated by entering the terms “intrauterine
Stellenbosch, Cape Town 7505, South
device” and “emergency contraception” in Medline, PubMed, Popline, Global Health and
Africa
ClinicalTrials.gov. Chinese references were obtained from the Wanfang database. For the
emergency contraception study, articles with a defined population who were followed up
until outcome were eligible. Women who were adequately followed for at least 6 months
were included in the long term arm of the study.
Results: There were 18 (of 228) studies which met our selection criteria and were conducted
in five countries, between August 2011 and January 2018. There were 1720 insertions of
seven types of copper IUD with a failure rate of 0.12%. The maximum time from intercourse
to IUD insertion was 14 days. The discontinuation rate at 12 months was over 20% in the
long term studies.
Conclusion: There are now a combined total of 8550 reported insertions from two reviews
with 8 pregnancies and a failure rate of 0.093%. Copper IUDs remain an effective form of
emergency contraception, for which they are under-promoted. The major limitation of the
studies is the lack of data relating unprotected intercourse to the day of the cycle.
Keywords: emergency contraception, copper intrauterine device, long acting-reversible
contraception, unintended pregnancy

Introduction
Unintended pregnancy remains a public health concern. It is due either to failure to
use contraception, failure to use contraception correctly, or failure of the contra-
ceptive method itself. Emergency contraception (EC) may be used shortly after
unprotected intercourse where there has been a failure to use contraception or a
known failure to use a method correctly.
Correspondence: Norman D Goldstuck There are two main types of EC methods, oral methods and copper bearing,
Department of Obstetrics and
Gynaecology, Faculty of Medicine and intrauterine devices. The most commonly used oral methods are levonorgestrel
Health Sciences, University of (LNG) 1.5 mg (Plan B®, Teva Pharmaceuticals, Petach Tikva, Israel) and ulipristal
Stellenbosch, Francie van Zyl Dr,
Tygerberg Hospital, Bellville, Cape Town acetate (UPA) 30 mg (Ella One®, HRA Pharma, London, UK) given as single doses.1
7505, South Africa The second method is the insertion of a copper intrauterine device (Cu IUD)2 and more
Tel +27 82 341 8200
Email [email protected] recently a combination of an oral method and an intrauterine device has been tried, this

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is the use of a 52 mg levonorgestrel releasing intrauterine PubMed; “intrauterine device” AND “emergency
system (LNG-IUS 52mg) accompanied by the oral LNG contraception”,
method.3 Both oral and intrauterine methods appear to have Popline: “IUD” & “Emergency Contraception”,
low failure rates with pregnancy rates of ~2–3% for oral Global Health: “intrauterine device” and “emergency
LNG EC4 and ~1.4%4 for UPA and 0.09% for Cu IUDs.2 contraception”,
Failure rate and true efficacy are not the same. Oral methods Clinicaltrials.gov: ‘intrauterine device ‘ AND “emer-
act mainly by delaying ovulation.1 UPA is more effective gency contraception”.
than LNG in this regard and the efficacy for UPA is estimated Wanfang data (Chinese): using the Chinese terms for
to be 62–85%5 and LNG 47–53%.5 The true efficacy of the “emergency contraception” and “intrauterine device”.
copper IUD has not been established as there have not been All the Google Scholar citations for the initial systema-
enough studies relating the insertion date to the day of the tic review2 were also searched as well as archived mate-
cycle of unprotected intercourse(s), but appears to be very rial. The references in the Chinese language articles were
effective. Oral LNG should be used within 72 hrs of a single searched to find articles which might have been missed in
act of coitus and UPA within 120 hrs. Since true efficacy rates the database. The review was conducted following the
require randomized studies, the true efficacy values for both “Preferred reporting items for systematic reviews and
types of emergency contraception can only be estimates and meta-analyses” (PRISMA) method.9 The search included
will remain unknown. any peer-reviewed study published between August 2011
The copper IUD was initially recommended to be (the date of the end of the previous period of study)2 and
inserted within 120 hrs of single or multiple acts of unpro- January 2018. In addition any referenced study which was
tected coitus within this period and this remains the posi- not previously entered in the original study was also eli-
tion of the American College of Obstetricians and gible for inclusion. Only English and Chinese language
Gynecologists.2 The World Health Organisation, the studies were included but studies in other languages would
Centers for Disease Control and Prevention, Atlanta, have been eligible if they appeared in the databases. The
Georgia, USA and the UK Faculty of Sexual and methods used were similar to those of the previous study
Reproductive Healthcare specify that an IUD can be and no additional formal protocol was used.
inserted beyond 5 days as long as the time of ovulation This systematic review updates the first one from
can be reasonably determined and is within the 5 day 2012.2 Studies which provided data on women of age
window.2 This may be too restrictive and more recent 18–45 who requested emergency contraception after
data suggest that it may be safe to insert an emergency unprotected intercourse and for whom there was adequate
IUD at any time during the cycle provided a high sensi- follow up until after the next menstruation or absence
tivity pregnancy test is negative.6 thereof, six weeks post insertion were eligible if more
The Cu-IUD and LNG-IUS 52mg are long-acting than 10 participants received an IUD. The secondary ana-
reversible contraceptives (LARC). The benefits of using lysis was to include follow up of standard IUD event rates
LARC methods for effective fertility control are well after 6 months or longer and pregnancy data for those who
established.7 Despite this very few clinicians recommend discontinued the IUD after the initial cycle.
Cu-IUDs for emergency contraception.8 The purpose of Primary eligibility included women who presented for
this review is to update and extend previous information emergency contraception and were provided with an IUD
on the use of the copper IUD as EC. and in which the number of pregnancies and follow up was
determined for the index cycle which was defined as the
Materials and methods cycle in which emergency contraception was needed. Also
The reference list was generated by using some of the included was the long-term follow-up results where avail-
same methods as used in the first study except that able. Relevant articles were identified and abstracted by
PubMed was also searched but we were unable to obtain two independent reviewers (NDG and TC), using trans-
a search of the Weipu (Chinese) data base. The search lated articles by the non-Chinese speaking reviewer. A
included the following databases using the following common data entry form was used to capture publication
terms: language, country of origin, type(s) of IUD used, max-
Medline: “Contraception, Postcoital” [Mesh] AND imum time from unprotected coitus to device insertion,
“Intrauterine Devices” [Mesh], initial study enrolment, efficacy evaluable population,

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Dovepress Goldstuck and Cheung

number of treatment failures (pregnancies), comparative as discussed later. Long term follow up bias is also based
method (if any) and its treatment failures. primarily on lack of follow up, leading to uncounted method
A separate entry form was used for collecting data from failure. Computation of 95% binomial confidence intervals
those studies in which there was long term follow up, defined (CI) for proportions was performed for the index cycle data
as six months or more. This included the usual event rate data using the Clopper-Pearson exact method. The Chi-Square
for IUDs including pregnancy, medical removals, expulsion test was used to determine homogeneity. Pooled data was
and termination of the method for any reason. Since the used to calculate grouped confidence intervals after testing
previous review methods of analysis have become more for homogeneity as in the previous study.2 Calculations were
detailed and some papers had been subjected to secondary performed using EpiTools epidemiological calculators.
analysis.3 Great care was taken to ensure that data were not
used more than once, but data from the secondary10 and in
one instance tertiary analysis11 has been referred to where of Results
interest. All the search and extracted data has been uploaded Search findings
to the Open Science Framework (OFS) data repository There were six new English language studies which met
(https://osf.io/84grx/files/). A summary of the search results our inclusion criteria.3,12–16 Three were from the United
is given in Figures 1 and 2. States and one each from the United Kingdom, Sweden
and Egypt. There is an ongoing study of the LNG-IUS
Analytical methods 52 mg as an emergency contraceptive but no results are yet
Risk of bias may be related to loss of follow up after the index available (Clinical Trials.gov Identifier: NCT01539720).
cycle since the outcome is binary (failure or success in There were two Chinese studies18,19 which were not dis-
preventing pregnancy). The other source of bias is the rela- covered and therefore not included in the earlier systema-
tionship of the day of cycle of insertion to the outcome. This tic review2 and ten new Chinese language studies.20–29
was also not explicitly stated in all studies but likely to have The PRISMA flow diagrams which were used for the
been biased against the IUD rather than the comparator group selection of the English language and Chinese language

All databases
Aug 201-Jan 2018
156 citation(s)

156 Non - Duplicate

citations screened

Inclusion/Exclusion 147 articles excluded

criteria applied after title/abstract screen

6 articles retrieved

Inclusion/Exclusion 0 articles excluded 0 Articles excluded

criteria applied after full text screen during data extraction

6 articles included

Figure 1 Algorithm for the selection of the English language studies.

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Goldstuck and Cheung Dovepress

All databases
Aug 201-Jan 2018
74 citation(s)

71 Non-Duplicate
citations screened

Inclusion/exclusion 61 articles excluded

criteria applied after title/abstract screen

10 articles retrieved

Inclusion/exclusion 0 articles excluded 0 articles excluded

criteria applied after full text screen during data extraction

10 articles included

Figure 2 Algorithm for the selection of the Chinese language studies.

studies is provided in Figures 1 and 2. There was no evaluated further. This review evaluates only the IUD arms of
specific foreign language search but we found no cross these studies.
references and believe most if not all new studies would
have been published in English or Chinese. New studies
A total of 16 studies (6 English language and 10 Chinese
Types of copper IUDs and comparative methods language) over 7 years compares favourably with the pre-
The copper bearing IUDs which were used included the viously evaluated 42 (14 English and 28 Chinese) over
Multiload copper 375mm (MLCu −375, Multilan SA, 35 years2 although this number should be augmented by the
Fribourg, Switzerland), the T copper 380A (TCu −380A, 2 missing studies. A list of all these studies is given in Table 1.
Paragard®, Teva Pharmaceuticals, Petah Tikva, Israel), the T All of the Chinese studies except for two22,24 followed
copper 220mm (TCu -220, Janssen-Cilag, High Wycombe, the usual protocol of limiting insertion to 120 hrs (5 days)
Bucks, UK), the Copper gamma 220mm (Cu γ-220, Calliope, after unprotected intercourse. These two studies limited
Shanghai, China), the Copper Yuan-gong + indomethacin provision of an IUD to 3 days, probably to maintain
(CuY-gong + indom, Yantai Jishengyaoxie Co. Ltd., similarity to the oral comparison group. All of the
Shandong, China) and the GyneFix 200 (GF-200, Contrel, English language studies followed the same protocol (lim-
Ghent, Belgium). In one study the levonorgestrel IUS contain- iting insertion to 120 hrs) except the study by Sanders and
ing 52 mg of LNG (LNG-IUS 52mg, Mirena©, Bayer Pharma, colleagues10 which included subjects with multiple epi-
Berlin, Germany, Levosert©, Lilletta© Actavis, Reykjavik, sodes of unprotected sex in the cycle pushing the length
Iceland) in conjunction with oral LNG 1.5 mg was used as a of time from first exposure to 6–14 days in some instances,
comparator to the copper IUD. The other cohort comparators provided a high sensitivity pregnancy test was negative.
included LNG 1.5 mg, UPA 30 mg and mifipristone 10 mg, None of the studies presented give adequate details of
25 mg, and 50 mg. The comparative oral methods will not be the cycle day of unprotected intercourse which makes

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Table 1 Studies from August 2011 to January 2018 and previously missing studies
Study (English) Country IUD type Max. days to insertion Efficacy population (n) Pregnancies (n) Pregnancy rate (%) (95% CI)a

Turok et al 201415 USA TCu-380A 5 173 0 0 (0–2.11)

Turok et al 20163 USA TCu-380A 14b 66 0 0 (0–5.43)

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Akintomide et al 201513 UK Cu-unspecified 5 38 0 0 (0–9.26)
Mohammed 201516 Egypt TCu-380A 5 174 1 0.57 (0.1–3.18)
Envall et al 201614 Sweden Cu-unspecified Not stated 36 0 0 (0–9.74)
Kohn et al 201617 USA TCu-380A 5 101 0 0 (0–3.52)
(Chinese)
Han 200118 China GyneFix 5 126 0 0 (0–2.83)
Wang et al 200019 China TCu-380A 5 50 0 0 (0–7.14)
Li et al 201620 China Cu-unspecified 5 60 0 0 (0–5.92)
Xu 201321 China Cu-gamma 5 414 0 0 (0–0.89)
He 201722 China MLCu-375 3 37 0 0 (0–9.46)
Mei 201723 China Cu-unspecified Not stated 80 1 1.25 (0.2–6.71)
Wu 201624 China MLCu-375 3 78 0 0 (0–4.66)
Wei 201625 China MLCu-375 5 50 0 0 (0–7.18)
Xu 201626 China Cu-gamma 220 5 60 0 0 (0–5.94)
Zhu 201727 China TCu-220 5 96 0 0 (0–3.78)
Tian 201328 China TCu-220, MLCu-375 5 55 0 0 (0–6.49)
Zhao et al 201529 China Cu Y-gong + indomethacin, various sizes 5 26 0 0 (0–13.23)
b
Note: data from reference 10 in addition to 3.
Abbreviation: IUD, intrauterine device.

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computation of even crude true efficacy estimates impos- Long term follow up
sible. Three of the Chinese studies18,24,28 tried to give One of the earlier emergency IUD studies first noted that
estimates of efficacy for the copper IUD and the compara- subjects who received an emergency IUD did not seem to
tor group using Dixon’s method.30 The UK study was want to keep it,31 although no specific reasons were given.
from multiple clinics and consisted of 103 patients of There were 6 studies that attempted to follow up and document
whom 64 were given oral EC and then the copper IUD the subjects that received an emergency IUD after the index
as well, within 5 days.13 Only the 38 subjects who were cycle.3,15,21,22,29 The data is fairly sparse but in the US and
not given oral EC have been included. There was no Swedish studies the long term combination of expulsion and/
explanation given for this unusual approach in the paper or discontinuation of the LARC method is high leading to an
but after consulting the authors it was because some of the increased pregnancy rate of which most are probably not
subjects had first attended a clinic where IUD insertion intended although this is not explicitly stated. Despite discon-
facilities were not available. The Swedish study did not tinuing the copper IUD, the copper IUD users were more
state the length of time after unprotected intercourse until likely to be using effective contraception (of another type)
the IUD was inserted.14 The overall quality of the evi- after 6 months than the UPA group in the Swedish study.14
dence for all studies is level II-2 (Canadian task force on The long term follow up rate was about 80%. A summary of
preventive health care). the long term follow up data is presented in Table 2.

Index cycle results Discussion

There were 588 insertions reported in the English language This study adds 1720 emergency Cu-IUD insertions to the
studies with one pregnancy with a failure rate of 0.17% first study of 7034.2 In that study there was one report from
(95% CI=0.0–0.1). There were 1132 insertions reported in Egypt which included 4 pregnancies and was a complete
the Chinese literature with one pregnancy with a failure outlier. The data was therefore calculated with and without
rate of 0.09% (95% CI=0.0–0.5). This is the same value the Egyptian study to give a pregnancy rate of 0.09% (95%
previously reported.2 In total there were 1720 insertions CI=0.04–0.19%)2 which is the often quoted rate. The only
with 2 pregnancies and a combined failure rate of 0.12% pregnancy which was reported in an English language study
(95% CI=0.0–0.4). This confirms the findings of the earlier in the new search was again from Egypt. This study has been
review2 The follow up rate of over 99% eliminates the included in our analysis so that there is a truly comparable
uncertainty bias of unrecorded pregnancies. pregnancy rate which is only very marginally higher (0.12%)
These 1720 insertions with 2 pregnancies combined for this study compared to the previously reported rate where
with the 6834 insertions and 6 pregnancies (excluding 4 the Egyptian data was excluded.2 There are now a total of
pregnancies in one study from Egypt, which was consid- 8550 reported emergency IUD insertions and 8 pregnancies
ered to be an “outlier”) from the earlier study2 gives a with a pregnancy rate of 0.093% from two reviews. The total
combined total of 8550 insertions with 8 pregnancies and a is 12 pregnancies if we include the outlier study from Egypt
pregnancy rate of 0.093% (95% CI=0.0–1.8)which is simi- in the first review for a pregnancy rate of 0.14%. While this
lar to the previous rate.2 number appears to indicate that the emergency copper IUD

Table 2 Emergency intrauterine device (IUD) evaluation after 6 months or longer

Study IUD Follow up (months) Events (%)

Pregnancya Expulsion Discontinuationb

Turok et al 201415 TCu380A 12 9 (6) 17 (11.4) 37 (24)

Turok et al 20163 TCu380A 12 0 6 (9) 15 (22.3)
Envall et al 201614 Cu IUD 6 1 (2.7) 0 8 (22.2)c
Xu 201321 Cu Gamma 6 3 (0.72) 20 (4.8) not stated
He 201722 MLCu375 6 2 (5.4) 0 0
Zhao et al 201529 Cu Yuan gong + indomethacin 12 0 1 (3.8) 0
Notes: Values in parentheses are percentages. aPregnancies are those due to method failure and failure to use any contraception after method discontinuation.bIUD
discontinuation is due to removal for medical and non-medical reasons. cThe copper IUD was discontinued in favour of another method.

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provides good efficacy in preventing pregnancy it must be During the early years following the introduction of the
remembered that it is not possible to know how many preg- use of the copper IUD as an emergency contraceptive there
nancies would have occurred in the absence of intervention. was speculation as to whether it would have the same failure
Most of the new studies had comparison groups of an oral rate as when it was used as a LARC method. This followed
EC method. These studies were not randomised and not pow- an early case report of a failure37,38 of the method. The
ered to detect any differences between the two methods. The failure rate as an emergency contraceptive appears to be
pregnancy rates for the different oral methods were higher than very much lower than the cumulative rate at 7 years for
that for the copper emergency-IUD. Furthermore, it is logi- continuous use of the TCu 380A of 2.5 per 100 woman
cally possible that in the absence of randomisation that the years of use,39 suggesting a different immediate mechanism
copper IUD was more likely to be given primarily to those for of action of the copper IUD when being used for emergency
whom the risk of pregnancy was perceived to be greater by the contraception compared to use as LARC contraception.
providers; rather than because individual subjects preferred Further studies which focus on the day of cycle of
this method and wanted to initiate a copper IUD for emergency insertion are necessary to determine true efficacy of the
contraception and have the choice as to whether to continue method. There is also another method of estimating true
with LARC contraception. This may have been a possible efficacy of the copper IUD as an emergency contraceptive.
source of bias against the IUD as mentioned previously, how- The efficacy of the main oral emergency contraceptive
ever this is not explicitly stated in any of the studies and is methods is reasonably established.5 It may be possible to
calculate the relative risk of pregnancy for copper IUDs
conjectural.
versus oral methods from the comparative studies to obtain
In one study the LNG-IUS 52mg was given at the same
an estimate of copper IUD efficacy.
time as oral LNG3 and there is no reason why this
approach cannot be used together with LNG-IUS 13.5mg
(Skyla©/Jaydess©) or LNG-IUS 19.5mg (Kyleena©) which Conclusion
may be more appropriate in nulliparous and uniparous This study confirms the findings of the previous review that
women.32 While consideration has been given to using over 99% of those that use a copper IUD as an emergency
UPA as oral emergency contraception prior to providing contraceptive method do not become pregnant. The true
an LNG releasing IUD10 its role as a partial progestin efficacy of the method however, remains elusive. Women
agonist-antagonist may possibly interfere with the early who present to clinics or pharmacies for emergency contra-
action of the LNG-IUS, especially its pronounced effect ception, as opposed to those who acquire it as OTC medica-
on cervical mucus,33 in the same way that it influences the tion should be informed of the copper IUD option or at least
effect of desorgestrel containing oral contraceptives.34 be advised of continuing with LARC contraception.
Another approach is to use copper IUDs which are Expanding the availability of copper IUD emergency contra-
more likely to be tolerated.35 This is only practical in ception to those women who have had multiple episodes of
those countries which have multiple types of copper unprotected intercourse in the two weeks prior to requesting
IUDs as options. This may help with the problems of emergency contraception10 and who have negative high sen-
sitivity pregnancy tests6 can help those women who are “too
expulsion and acceptability and enable emergency copper
late” for oral emergency contraception. Careful choice of
IUD users to continue to use the device as a LARC
IUD may help to improve the continuation of emergency
method. This is only achievable if the focus is not just
copper IUDs as a LARC method.
on a copper IUD for emergency contraception but the most
appropriate one. The provision of trained providers is
especially important for preventing discontinuation of cop- Acknowledgment
per IUDs inserted as emergency contraception. Hopefully The help of Mr Gao Weiji of the Beijing National library
the manufacturers of the newer copper containing devices for the Wanfang search is gratefully acknowledged. This
like the intrauterine ball (IUB-Ballerine® (Ocon Medical, review was unfunded.
Modiin, Israel) and VeraCept® (Contramed, Charlotte,
North Carolina, USA))36 will complete pilot or larger Disclosure
studies of the IUD as EC to improve our knowledge of The authors do not have any potential conflicts of interest
how different IUDs function in in this area. in this work.

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19. Wang C, Tiaan M, Shao M. A clinical comparative observation among

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