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Women undergoing an abortion can have an intrauterine device (IUD) safely placed immediately after the procedure, with similar rates of expulsions and other complications, a randomized trial found.

Expulsions of the IUD occurred in 5% (95% CI 2.7 to 8.5) of women who had immediate insertion and in 2.7% (95% CI 1 to 5.7) of those who had delayed insertion, according to Paula H. Bednarek, MD, of Oregon Health and Science University in Portland, and colleagues.

That rate of expulsion "was slightly higher but statistically noninferior to that associated with delayed insertion," the investigators reported in the June 9 issue of the New England Journal of Medicine.

Previous work has shown that immediate insertion of an IUD following uterine aspiration is an effective means for reducing the likelihood of repeat abortion, and estimates based on mathematical models suggest that such an approach could prevent at least 70,000 pregnancies each year in the U.S., according to Bednarek and colleagues.

However, there have been concerns about expulsion of the device, infection, and uterine perforation with immediate insertion.

To evaluate the safety and efficacy of this approach, the investigators enrolled women undergoing first-trimester abortions and requesting IUDs, randomizing 258 to immediate IUD insertion and 317 to delayed insertion.

Whereas all women in the immediate-insertion group had the device placed, only 71.3% of those in the delayed group returned for insertion, which was a 28.7 percentage point difference (95% CI 23.7 to 33.7, P<0.001), the investigators reported.

At six months, 92.3% of women who were randomized to immediate insertion continued to have the IUD in place, whereas only 76.6% of those assigned to have delayed insertion were currently using the device (P<0.001).

Most expulsions occurred within the first two months after placement.

In the immediate-insertion group, 3.1% of the expulsions were partial and 1.9% were complete.

In the delayed-insertion group, the corresponding percentages were 2.2% and 0.4%.

During the six months of the trial, five pregnancies occurred in the delayed group -- all among women who had never received the device -- while there were none in the immediate-insertion group (P=0.07).

This difference was not statistically significant, but greater differences would be likely with longer follow-up, according to the investigators.

Adverse events did not differ between the groups.

There were five infections in each group and no perforations.

Among the 19 women who tested positive for chlamydia at baseline, one, who was in the immediate group, developed an infection.

Three who tested negative later developed infections. Two of these were in the immediate group, and the IUDs were removed, while the single case in the delayed group had not yet been given the device.

The investigators noted that IUDs are among the most reliable reversible methods of birth control, with failure rates during the first year ranging from 0.1% to 0.8%.

In comparison, almost one in ten women starting on oral contraceptives for the first time become pregnant within a year.

They also pointed out that most of the women in the delayed group who never returned for insertion went on to use less effective methods -- or none at all.

"Our results confirm previously published data showing that 25% to 68% of women who make an appointment for IUD placement after an abortion do not return," Bednarek and colleagues wrote.

A limitation of the study was the loss to follow-up of about one-quarter of women in each group, and the authors acknowledged that many women having abortions are unwilling to return for follow-up.

They concluded that immediate insertion is safe and effective, but explained that barriers exist to the adoption of this approach, with federal funding for same-day abortion and contraception services in a single facility being prohibited.

"Such policies that require healthcare providers to separate contraception provision from abortion provision reduce the likelihood that women will obtain the contraception needed to prevent unintended pregnancy," they stated.

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