U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 8

David Turok, MD, MPH

EMERGENCY CONTRACEPTION UPDATE David Turok

Utah Ob/Gyn Post-grad courseFeb 12, 2020

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OBJECTIVES AND OUTLINE

1. Copper IUD is most effective

2. Ulipristal acetate (Ella) most effective oral

3. Weight matters for oral methods

4. Prioritize EC efficacy, ongoing contraception, or both

5. Additional benefits with IUDs

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WHAT IS EC?

• Prevents pregnancy after intercourse• EC doesn't interrupt an existing pregnancy• Must be initiated in a specific time frame

– Copper IUD within 5-7 d of UPI– Ulipristal acetate 30 mg (UPA, Ella) within 5 d– Levonorgestrel 1.5 mg (LNG, Plan B) within 3 d– Mifepristone

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BUT FIRST, A LITTLE PHYSIOLOGY

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The Fertile

Window:-5 to +1

days fromovulation

Wilcox, et al. New Engl J Med. 1995;33(23):1517-1521.

Day 3 - 4

Day 6

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SPERM ATTRITION

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THE FERTILE WINDOW

https://www.manyweekspregnant.com/ovulation-calculator/

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https://helloclue.com/articles/sex/emergency-contraception-when-its-most-effective

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HOW DOES IT WORK?

• Disrupts ovulation– LNG blocks LH surge– UPA blocks ovulation prior to the LH peak

? Disrupts fertilization +? But not pregnancy-Copper IUD

Brache et al. Contraception 2013;88:611.Marions et al. Contraception 2004;69:373.Gemzell-Danielsson et al Contraception 2013;87:300.Noe et al. Contraception 2011;84:486. 11

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WHEN TO USE IT

• When giving a new contraception RX• After unprotected intercourse• New contraceptive start• After sexual assault

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HOW WELL DOES IT WORK? EC EFFICACY

EC Method Cycle pregnancy risk

Copper IUD 0.1%

UPA 1.2-1.8%

LNG 1.5-2.6%

Cleland, Hum Reprod 2012;27:1994.Shen, Cochrane Database Syst Rev 2019; 1:CD001324Glasier Lancet 2010; 375:555

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HOW DO I SHARE THE INFO WITH MY PATIENTS?

PERCENT OF EC PREGNANCIES AMONG ULIPRISTAL ACETATE & LNG EC USERS BY BMI

0

1

2

3

4

5

6

7

BMI <25 kg/m2 BMI 25-29.9 kg/m2 BMI ≥30 kg/m2

UPALNG

Glasier et al. Contraception. 2011;84(4):363-7

RESULTS – TOTAL LNG AUC0-24

RESULTS – TOTAL UPA AUC0-24

PERCENT OF PREGNANCIES AMONG UPA & LNG EC USERS

0

1

2

3

4

5

6

7

8

Sex outsidefertile window

sex inside fertilewindow

No furtherintercourse

Yes furtherintercourse

UPALNG

Glasier et al. Contraception. 2011;84(4):363-7

THE COPPER IUD FOR EC WORKS EXCEPTIONALLY FOR ALL WOMEN

• Elevated BMI = 0-0.1%• Intercourse in the fertile window = 0-0.1%• Further intercourse in the cycle = 0-0.1%

ONGOING CONTRACEPTION

EC method Ongoing contraception

Cu IUD Easy, ready to goOral LNG Start, Abstain or

backup x 1 weekUPA Hold hormones

for 5 days

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DO PROGESTOGENS MESS WITH UPA?IMPLICATIONS FOR ONGOING CONTRACEPTION AFTER UPA

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Brache et al. Hum Reprod 2015; 30:2785.

• 3 arm RCT of 71 people • Primary outcome: ovulation < 6 days UPA & desogestrel – 13/29 (45%) UPA & placebo – 1/29 (3%) Placebo & desogestrel 11/29 (38%)

P = 0.0054

Copyrights apply

Desires IUD?

Insert IUD Assess risk of pregnancy

High risk:Multiple &/or mid-cycle UPI

Low risk:UPI outside fertile window, contraception failureOffer UPA*

Use back up. Delay hormonal contraception for 5 days

Copyrights apply

Prefers more effective EC or ongoing contraception?

More effective EC

Ongoing hormonal contraception

Offer LNGDelay hormonal contraception for 5 days, continue abstain/backup x 1 week

Offer UPA*Delay hormonal contraception for 5 days, continue abstain/backup x 1 week (12 days total)

Copyrights apply

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STUFF WE’VE LEARNED ABOUT IUDS AND EC

Fewer pregnancies with CuT380 than oral LNG x 1 year

CuT380 IUD anytime with a negative pregnancy test

AND what about the LNG IUD for EC???????

COPPER IUD EC CLINICAL TRIAL

• Participants select oral LNG or the copper IUD

• Primary outcome: difference between unplanned pregnancy between the 2 groups at 1 year

• Secondary outcomes:– IUD expulsion/removal rates– Use of an effective method of contraception

Contraception 2014;89:222-8

COPPER IUD VS. ORAL LNG

IUD n=215

Oral LNG n=327

p-value

Mean (SD) Range

Mean (SD) Range

p-value

Age 23.1 (3.5) 22.0 (3.3) <0.001 n (%) n (%) p-value Race White Hispanic/Latino

144 (67) 36 (17)

212 (65) 68 (21)

0.47

Income <$20,000 $20,001-$40,000 >$40,000

136 (63) 59 (27) 16 (7)

205 (63) 85 (26) 30 (9)

0.85

Insurance Private Insurance Medicaid Uninsured

80 (37) 11 (5)

117(54)

123 (37) 43 (13) 156 (48)

0.014 Nulligravid Prior Abortion

127 (59) 34 (16)

172 (53) 48 (15)

0.079 0.72

Heard of IUD for birth control Yes

203 (94)

240 (73)

<0.001

Contraception 2014;89:222-8

TIME TO PREGNANCY

P=0.04

Contraception 2014;89:222-8

PREGNANCY CHECKLIST*

*Except for pill, patch, ring, injectable, and implant users.

CDC. MMWR. June 2013.

The copper IUD can be placed for EC:

IF… within 5 days of UPI

BUT…if the day of ovulation can be estimated

THEN…it can be inserted after 5 days after UPI

IF…it’s not more than 5 days after ovulation

COULD THIS BE SIMPLER?

METHODS: ORIGINAL INCLUSION CRITERIA

• Secondary analysis of a prospective trial of copper T380 IUD EC users in China (n=1,963)

• Age 18-44• Regular cycles between 24-42 days• Known last menstrual period (LMP)• Within 5 days (120 hours) of UPI• All participants had a negative urine

pregnancy test (hcg 25 IU/L)Wu et al. BJOG 2010;117:1205-20.

RESULTS

• No pregnancies

• 1840 participants (93.7%) had usual cycle lengths of 25-35 days

• 850 (46.2%) UPI in the fertile window

• 84 (4.6%) had IUD insertion > 5 days after ovulation

• 52 (2.7%) had insertion > 5 days after UPI

Human Reproduction 2013; 28(10):2672-6

IUD EC INSERTION BY DAYS SINCE LMP

Human Reproduction 2013; 28(10):2672-6

RISK OF PREGNANCY WITH CUT380 IUD PLACEMENT 6-14 DAYS AFTER UPI

134 people

0 pregnancies(97.5% CI 0-2.7%)

36Thompson, Contraception 2019; 100(3):219-221.

NEXT UP: RAPID EC

• RCT Assessing Pregnancy with IuDs (RAPID) for EC

• Women interested in an IUD for EC

• Randomly assigned to copper or LNG IUD

• Primary outcome: non-inferiority pregnancy at 4 weeks

• Secondary outcome: IUD continuation continuation

• Recruitment goal = 706

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CONCLUSION

1. Copper IUD is most effective

2. Ulipristal acetate (Ella) most effective oral

3. Weight matters for oral methods

4. Prioritize EC efficacy, ongoing contraception, or both – Beware UPA

5. Additional benefits with IUDs

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