Sexual & Reproductive Healthcare 28 (2021) 100615

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Sexual & Reproductive Healthcare

journal homepage: www.elsevier.com/locate/srhc

The intrauterine device versus oral hormonal methods as emergency

contraceptives: A systematic review of recent comparative studies
Tik Shan Cheung, Norman D. Goldstuck *, Gabriel S. Gebhardt
Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Francie van Zyl Dr, Tygerberg Hospital, Bellville, Cape
Town 7505, South Africa

A R T I C L E I N F O A B S T R A C T

Keywords: Oral emergency contraceptives do not appear to be as effective as the copper IUD as an emergency contraceptive.
Emergency contraception There is as yet no estimation of the relative efficacy rates rather than the failure rates. The references for this
IUD study were obtained by entering the terms “intrauterine device” “and “emergency contraception” in Medline,
Long-acting contraception
PubMed, Popline, Global Health and ClinicalTrials.gov. Chinese references were obtained from the Wanfang
Oral
Reversible
database. For the short term study articles with a defined population who were followed up after the index cycle
were eligible. Women who were adequately followed for at least 6 months were included in the long term study.
There were 13(of 228) studies which met our selection criteria and were conducted between August 2011 and
January 2019. There were 960 insertions of four types of copper IUD with a failure rate of 0.104%. There were 22
failures out of 1453 oral emergency contraception users with a failure rate of 1.51%. The relative risk of failure
for an intrauterine device versus an oral method was 0.1376(95% CI − 0.03–0.58). The 6 month to 12 month
pregnancy rate was 0–6% for IUDs and 2.7–12% for oral methods.
The copper IUD appears to be more effective than oral methods as an emergency contraceptive. The 6 to 12
month pregnancy rates after using either method is 4–10%. Emergency contraception is not a solution to un­
intended pregnancy.

Introduction introduced for emergency contraception. This type of mechanical

The rate of unintended pregnancy in the United States (US) is
dropping but remains high [1]. Emergency contraception is the latest
opportunity to prevent unintended pregnancy before it begins and be­
comes established. Humans have attempted to interrupt the course of
pregnancy from ancient times by all manner and means, including the
use of both largely toxic oral compounds and by mechanical interven­
tion in the genital tract [2]. From the 1960s emergency contraception
became scientifically based, first with the use of oral estrogens [3], then
estrogen-progestin combinations, progestin only products as well as
anti-progestins and selective progesterone receptor modulators(SPRM)
like ulipristal acetate [2].
Our modern chemical interventions appear to work better than those
of the ancients with less toxicity. The use of mechanical methods to
disrupt pregnancy was historically fraught with danger due to infection
and bleeding and would very often result in death and surely must have
been used only by the very desperate. In the 1970s the modern use of
mechanical methods in the form of a copper intrauterine device was
intervention appeared to be safe and effective [4]. While IUDs appear to
be more effective than oral methods [5], and may also be used as long-
acting reversible contraceptive methods (LARC), they remain relatively
underused as emergency contraceptives [6]. There have been no studies
of randomly allocated oral versus IUDs for emergency contraception.
There have been non-randomly allocated comparative studies. This re­
view examines some of the more recent examples.
Materials and methods
The reference list was generated by using the methods used in two
earlier emergency IUD studies [5,7]. This is a separate analysis of those
IUD studies which included a comparative oral hormonal emergency
contraception group [7].
The search included the following databases using the following
terms:
Medline: ‘Contraception, Postcoital’ [Mesh] AND ‘Intrauterine De­
vices’ [Mesh],

* Corresponding author.
E-mail address: nahumzh@gmail.com (N.D. Goldstuck).

https://doi.org/10.1016/j.srhc.2021.100615
Received 22 July 2020; Received in revised form 4 March 2021; Accepted 16 March 2021
Available online 23 March 2021
1877-5756/© 2021 Elsevier B.V. All rights reserved.
T.S. Cheung et al.
Fig 1. Algorithm for selection of studies.
PubMed; ‘intrauterine device’ AND ‘emergency contraception’,
Popline: ‘IUD’ & ‘Emergency Contraception’,
Global Health: ‘intrauterine device’ and ‘emergency contraception’,
Clinicaltrials.gov: ‘intrauterine device ‘ AND ‘emergency
contraception’.
Wanfang data (Chinese): using the Chinese terms for ‘emergency
contraception’ and ‘intrauterine device’.
No terms relating to oral emergency methods was included as there
are far more studies on these agents and all the comparative studies with
IUDs would be captured when searching for the IUD emergency
contraception studies.
The references in the Chinese language articles were searched to find
articles which might have been missed in the database. The review was
conducted following the ‘Preferred reporting items for systematic re­
views and meta-analyses’ (PRISMA) method [8], using a new protocol
which has been lodged with the institution. The search included any
peer-reviewed study published between August 2011 (the date of the
end of the previous period of IUD study) [5] and January 2019. Only
English and Chinese language studies were included but studies in other
languages would have been eligible if they appeared in the databases.
Studies which provided data on women of age 18–45, who requested
2
Sexual & Reproductive Healthcare 28 (2021) 100615
emergency contraception after unprotected intercourse, and for whom
there was adequate follow up until after the next menstruation, or at six
weeks after the method was given were included. Only studies in which
at least 10 subjects had received an oral agent or an IUD were eligible.
Primary eligibility therefore included women who presented for emer­
gency contraception and were provided with an IUD or oral method and
in which the number of pregnancies and follow up was determined for
the index cycle which was defined as the cycle in which emergency
contraception was needed. Also included was the long- term follow- up
results where available. This secondary analysis was to include follow up
of standard IUD event rates after 6 months or longer and pregnancy data
for those who discontinued the IUD and for those who had used an oral
method after the initial cycle.
Relevant articles were identified and abstracted by two independent
reviewers (NDG and TC), using translated articles by the non-Chinese
speaking reviewer. A common data entry form was used to capture
publication language, country of origin, type(s) of IUD or oral method
used, the maximum time from unprotected coitus to device insertion or
use of oral method, initial study enrolment, efficacy evaluable popula­
tion, number of IUD treatment failures (pregnancies), oral comparative
method and its treatment failures. A separate entry form was used for
T.S. Cheung et al. Sexual & Reproductive Healthcare 28 (2021) 100615

Table 1
Studies from August 2011 to January 2019.
Study Country IUD type Max. days to Efficacy population Pregnancies Comparative method(n) Pregnancies(n)
insertion (n) (n) (RR)

Turok et al 2014 [9] USA TCu-380A 5 173 0 LNG 1.5 mg(3 2 7) 4(<0.001)
Turok et al 2016 USA TCu-380A 14a 66 0 Oral LNG1 0.5 mg + LNG-IUS 52 mg 1(<0.001)
[10] (1 0 7)
Mohammed 2015 Egypt TCu-380A 5 174 1 LNG 1.5 mg(1 6 2) 2(0.471)
[11]
Envall et al 2016 Sweden Cu-unspecified Not stated 36 0 UPA 30 mg(36) 0
[12]
Wang et al 2000 China TCu-380A 5 50 0 LNG 1.5 mg(50) mifipristone 10 mg 1(<0.001)
[13] (50)
Li et al 2016 [14] China Cu-unspecified 5 60 0 LNG 1.5 mg(60) 4(<0.001)
mifipristone 25 mg(60) 2(<0.001)
He 2017 [15] China MLCu-375 3 37 0 LNG 1.5 mg(37) 0
Mei 2017 [16] China Cu-unspecified Not stated 80 1 LNG 0.75 mgx2(80) 1(0.46)
mifepristone 25 mg (80) 1(<0.001)
Wu 2016 [17] China MLCu-375 3 78 0 LNG 0.75 mgx2(78) 2(<0.001)
Wei 2016 [18] China MLCu-375 5 50 0 Mifepristone 25 mg (50) 2(<0.001)
Xu 2016 [19] China Cu-gamma 220 5 60 0 LNG 0.75 mgx2(60) 2(<0.001)
Zhu 2017 [20] China TCu-220 5 96 0 Mifepristone 10 mg(1 1 2), 0(<0.001)
LNG 0.75mgx2(1 0 4) 3(<0.001)
EE2/LNG(1 2 0) 0(<0.001)
Tian 2013 [21] China TCu-220, 5 55 0 Mifepristone 50 mg(55) 2(<0.001)
MLCu375
a
data from reference 11 in addition to 3.

collecting data from those studies in which there was long term follow
Table 2
up, defined as six months or more. This included the usual event rate
Emergency IUD and comparator evaluation after 6 months or longer.
data for IUDs including pregnancy, medical removals, expulsion and
termination of the method for any reason. Since the previous review Study IUD and Follow up Events (%)
comparator (months)
methods of analysis have become more detailed and some papers had Pregnancya Expulsion
been subjected to secondary analysis. Great care was taken to ensure Discontinuationb
that data were not used more than once, but data from the secondary Turok et al TCu380A 12 9(6) 17 37(24)
and in one instance tertiary analysis has been referred to where of in­ 2014 [9] Oral LNG 1.5 mg 12 40 (11.4)
terest. All the search and extracted data has been uploaded to the Open (12)
Turok et al TCu380A 12 0 6(9) 15
Science Framework (OFS) data repository(https://osf.io/84grx/files/) . 2016 LNG-IUD 52 mg + 12 3 7(6.3) (22.3)
The results of the search are presented in Fig. 1. [10] oral LNG 1.5 mg (2.7) 18
(16.3)
Analytical methods Envall et al Cu IUD 6 1 0 8c
2016 UPA 6 (2.7)
[12] 3
The relative risk of falling pregnant with an IUD versus an oral (9.3)
method was calculated for each study and for the combined pregnancy He 2017 MLCu375 6 2 0 0
rates for the IUD and oral methods. Calculations were performed using [15] LNG 1.5 mg 6 (5.4)
1
the Omni© risk calculator. The overall quality of the evidence for all
(2.7)
studies is level II-2(Canadian task force on preventive health care).
Values in parentheses are percentages.
a
Results Pregnancies are those due to method failure and failure to use any contra­
ception after method discontinuation.
b
IUD discontinuation is due to removal for medical and non-medical reasons.
The search produced 12 articles in which emergency IUDs were c
The copper IUD was discontinued in favour of another method.
compared to an oral method and there was one publication which was
missed in the original search for the previous review of IUDs only [5]
IUD follow up group (4–5%) and 47 pregnancies (6–10%) in the oral
which was added. There were four English language studies and nine
emergency contraception follow up group. Pregnancy rates were
Chinese language studies. All the studies included women aged 18–35
who were not using any type of contraception at the time of unprotected therefore high in both the IUD and oral group and a breakdown is given
in Table 2. The reasons for this appear to be that those in the oral method
coitus. The copper IUDs consisted of the TCu 380A, TCu 220, MLCu 375
and the Cu-gamma 220. The oral methods included levonorgestrel group did not go onto a reliable form of contraception immediately. The
IUD users also had a relatively high continuing pregnancy rate because
(LNG) 1.5 mg, ulipristal acetate (UPA) 30 mg and Mifipristone 10–50 mg
doses as well as the combination of ethinyl estradiol (EE2) 50 µg and of device expulsion and removals (Table 2). This is not an uncommon
feature of emergency IUD use and was reported in one of the earlier
LNG 250 µg.
There were 2 pregnancies from 960 IUD (0.104%) insertions and 22 studies [23]. This undoubtedly explains why it has not been possible to
show a reduction in pregnancy and abortion rates at the population level
pregnancies from 1453 oral administrations (1.51%). The individual
studies and their associated RRs (relative risks) are given in Table 1. and is discussed further later [24].
These rates are similar to those reported previously [5,22]. The RR for
pregnancy with an IUD was 0.1376(95% CI-0.03–0.58) compared to the Discussion
oral methods. There were four studies which had follow up information
for at least six months after the intervention for the initial episode of The failure rates of the intrauterine device and the oral methods from
these 12 studies are in keeping with earlier reports [5,22]. Failure rates
unprotected intercourse. There were 12 pregnancies in the 6–12 month

3
T.S. Cheung et al.
and true efficacy are not synonymous. There has been a long history of
attempts to calculate the precise risk of pregnancy from a single episode
of unprotected intercourse through various phases of the menstrual
cycle [25–29]. This has been applied to some oral methods to attempt to
obtain an estimate of efficacy from those studies in which the day of the
cycle of unprotected intercourse occurred [22]. Using this data the ef­
ficacy of the EE2 50 µg/LNG 250 µg(Yuzpe) is approximately 30%, LNG
1.5 mg is 50+%, and UPA 30 mg is about 70% [22]. In contrast only a
few emergency IUD studies have detailed the date of the cycle of un­
protected intercourse [30–32], because most of the studies focus on the
number of days after unprotected intercourse the IUD was inserted. This
is because there is no restriction on the number of episodes of unpro­
tected sex that may have taken place in a given cycle provided the 5 day
(or in some cases 7 day) limit is not exceeded. This depends on the
criteria being used. In fact there is evidence that an emergency IUD can
be inserted at any time during the cycle provided a high sensitivity
pregnancy test is negative [33].
In the absence of randomization of the two groups, a consideration of
bias in the selected groups is relevant. While none of the investigators
address this question it is fair to assume that bias is likely to be against
the IUD. The procedure is invasive and perceived as painful. It is logical
to assume that providers are most likely to recommend it when they
think the risk of pregnancy is greatest and the effort to insert the IUD and
the possible ensuing problems and discomfort are warranted. While the
prospect of providing not only emergency contraception but ongoing
LARC as well is appealing, this has not proven to be successful in practice
in both earlier studies [23,34], and in the studies reviewed in Table 2.
None of these newer studies evaluated the risk of pregnancy relative
to the day (or in the case of IUDs the days) of unprotected sex. It was
therefore not possible to confirm efficacy estimates for the two methods
but only failure rates. However if we assume efficacy rates of 50–70% for
the various oral methods then given the relative risk of failure of an IUD
of 0.137 it is not unreasonable to assume an efficacy rate of over 90% for
the IUD. This estimate is independent of the precise type of oral method
used and is not significantly affected by the fact that the different oral
methods have different pregnancy rates. While the evidence from this
review and the other major review of IUDs as emergency contraceptives
[5] suggests that there is no difference in efficacy whatever type of
copper IUD is used for emergency contraception, the same is not true
when copper IUDs are used for long term contraception [35].
Conclusion
The copper containing IUD appears to be much more effective than
oral methods for emergency contraception. IUDs inserted as emergency
contraception are not always successful in providing LARC contracep­
tion. Consideration as to which type of copper IUD should be used as an
emergency contraceptive may be relevant if it is intended to be used as a
LARC contraceptive thereafter.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgment
The help of Mr Gao Weiji of the Beijing National library for the
Wanfang search is gratefully acknowledged.
Role of authors: TSC assisted with search, translated references,
extracted data and helped with writing; NDG conceived study, extracted
data and helped with writing; GSG helped prepare protocol and oversaw
writing.
All authors declare they examined the final version.
4
Sexual & Reproductive Healthcare 28 (2021) 100615
Funding
This research is unfunded.
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