Perspective

The copper intrauterine device

for emergency contraception:
an opportunity to provide
the optimal emergency
contraception method and
transition to highly effective
contraception
Expert Rev. Med. Devices 10(4), 477488 (2013)

Amna I Dermish and
David K Turok*
Department of Obstetrics and
Gynecology, University of Utah,
SaltLake City, UT, USA
*Author for correspondence:
david.turok@hsc.utah.edu
Worldwide, 40% of all pregnancies are unintended. Widespread, over-the-counter availability
of oral emergency contraception (EC) has not reduced unintended pregnancy rates. The EC visit
presents an opportunity to initiate a highly effective method of contraception in a population
at high risk of unintended pregnancy who are actively seeking to avoid pregnancy. The copper
intrauterine device (IUD), the most effective method of EC, continues to provide contraception
as effective as sterilization for up to 12years, and it should be offered as the first-line method of
EC wherever possible. Increased demand for and supply of the copper IUD for EC may have an
important role in reducing rates of unintended pregnancy. The EC visit should include access to
the copper IUD as optimal care but should ideally include access to all highly effective methods
of contraception.

Keywords: copper intrauterine device emergency contraception intrauterine device Paragard

unintended pregnancy

Unintended pregnancy
The worldwide unintended pregnancy rate is
41%, while in the USA, 49% of pregnancies
are unintended [1,2] , higher than the rate in
any other developed country [3] . The US rate
has also remained unchanged for more than a
decade, in stark contrast to the declining unin-
tended pregnancy rates across the rest of the
globe [2] . Unintended pregnancy is an important
issue because of its public health and economic
impact. Nearly half of unintended pregnancies
will result in abortion [1,2] with a considerable
portion of those occurring in illegal and unsafe
conditions. In addition to the risks of unsafe
abortion, women who continue their pregnancy
are at increased risk of poor maternal and neona-
tal outcomes [37] . Unintended pregnancies are
also costly. In the USA, it has been estimated that
unintended pregnancies result in direct medical
costs of US $11 billion per year [8,9] , while con-
traceptive use resulted in direct medical savings
of US $19 billion [10,11] . Similarly, in the devel-
oping world, an investment of US $4 billion
for contraceptive services would result in sav-
ings of US $5.7 billion in healthcare costs [201] .
Recognizing these issues, the US Department of
Health and Human Services has made reducing
the unintended pregnancy rate a target goal of
its Healthy People 2020 campaign [202] . The UN
has also included increasing access to contracep-
tion as vital components of achieving three of
its Millennium Development Goals: improving
maternal health, reducing child mortality and
combating HIV/AIDS [203] .

www.expert-reviews.com 10.1586/17434440.2013.811865 2013 Informa UK Ltd ISSN 1743-4440 477

 Perspective Dermish & Turok
Although half of unintended pregnancies occur among women
who are using some form of contraception, consistent and correct
use of contraception accounts for only 5% of unintended preg-
nancies [1] . The authors know that the most effective methods of
contraception are those that remove user error from the equation
[12] , specifically the intrauterine devices (IUDs) and implant,
collectively referred to as long-acting reversible contraceptives
or highly effective reversible (HER) contraceptives [13] . Some
have suggested substituting use of the term long-acting reversible
contraceptives with HER contraceptives or forgettable contra-
ceptives in order to focus on effectiveness over duration of use
[13,14] . Although some may also include injectables here, because
their comparatively shorter duration of action necessitates regular
follow-up, the authors have excluded them from this category
in this paper. One study examining the impact of increased use
of HER contraceptive methods was the CHOICE study [15] , a
cohort study of 9256 women in St Louis (MO, USA) who were
offered the contraceptive method of their choice at no cost for
a period of 3years. The study was designed to promote use of
highly effective methods, and in the first year of the study, two-
thirds of women chose HER contraceptive methods [16] , increas-
ing to 75% over time [17] . Women who opted to use combined
hormonal contraceptives (pills, ring or patch) were 22-times more
likely to experience contraceptive failure compared with HER
contraceptive users [17] . In addition, data from the CHOICE
study have demonstrated that widespread use of the most effec-
tive methods of contraception can reduce unintended pregnancy
and abortion rates [18] .
EC & unintended pregnancy
The emergency contraception (EC) visit presents an unusual
opportunity to address initiation of highly effective methods of
contraception with women who are using less effective methods
or no method at all. Women who present for EC are unique in
that they are seeking care to not be pregnant and are by defini-
tion not using a reliable method of contraception. EC is the only
opportunity for women to prevent an unwanted pregnancy after
unprotected intercourse or contraceptive failure (such as condom
breaking or missed pills).
Oral EC
Those seeking EC have two main options: single-dose oral EC or
the copper T380A IUD. Within the oral EC category, there are
two available methods: 1.5-mg levonorgestrel (LNG) or 30-mg
ulipristal acetate (UPA). Depending on local laws and regula-
tions, these may be available in pharmacies without a prescrip-
tion. Both methods have been shown to be effective up to 120h
after unprotected intercourse [1921] , although the efficacy of oral
LNG may decrease over time [2224] . Other less commonly used
oral options include use of specific combinations of combined
hormonal contraceptive pills and mifepristone, which is available
for EC in China.
Oral EC offers the benefit of being easy to distribute and use.
Women do not need to undergo an examination or even be seen
by a clinician. While oral EC appears to decrease the risk of
478
pregnancy for a single act of unprotected intercourse for the indi-
vidual woman, it does not have an effect at the population level.
Evidence from multiple prospective trials of advanced provision
of a variety of oral EC products have failed to show an effect on
community-wide rates of unplanned pregnancy and abortion
[2538] . In these studies, women were either given an advanced
supply of EC (intervention) or were given information on how
to access EC through the clinic (control). Although there were
flaws in several studies, such as low baseline pregnancy rates, poor
follow-up and lack of randomization, none of the studies con-
tained all these flaws and several of them were rigorous in design
and execution. Most important of all, the results were consistent
in every one. There are multiple potential reasons for this lack of
effect that have been described in the literature, including lack
of use by those at highest risk of unplanned pregnancy, possible
increased coital frequency and possibly substituting EC for more
reliable methods [36,3942] .
A recent meta-analysis has highlighted several clinical sit-
uations where oral EC has decreased efficacy; these include
increased BMI, when unprotected intercourse occurs in the fer-
tile window (from 5days before ovulation to 1day after), and
further episodes of unprotected intercourse in the same cycle
[43] . EC efficacy is significantly reduced in obese women using
oral LNG or UPA for EC with a greater effect seen in oral LNG
users compared with UPA. The efficacy of oral LNG for EC has
also been studied in relation to time of use during the menstrual
cycle. As oral LNG EC works to prevent pregnancy through
delaying ovulation, using this form of EC after ovulation has
occurred will not prevent pregnancy. In two studies seeking to
examine this hypothesis, data were collected on clinical and
laboratory predictors of ovulation in women using oral LNG for
EC [44,45] . The overall efficacy for women taking oral LNG EC
during their fertile window was 6068%. Looking even more
closely at timing of use found that women who used oral LNG
on the day of ovulation or after experienced the same number of
pregnancies that would have been expected without any use of
EC [44,46] . In both studies, there were no pregnancies in women
taking oral EC prior to the fertile window. This was further
demonstrated in the results of the meta-analysis [43] , showing
that pregnancy rates were four-times higher in women taking
either oral LNG or UPA EC who had unprotected intercourse
the day prior to ovulation compared with those who had sex
outside the fertile window. In addition to elevated BMI and
timing of EC use, this study also identified further acts of
unprotected intercourse in the menstrual cycle during which
EC was used as a predictor of unintended pregnancy [43] . This
is especially important given that studies of oral EC users have
demonstrated up to two-thirds of women will go on to use
condoms or no contraception after their EC visit [47] . These
data further demonstrate the importance of discussing effective
contraceptive use at this visit and highlight the two major ben-
efits of the copper IUD for EC: its exceptional efficacy in the
short term is not influenced by any of these situations (Figure1)
and it continues to provide highly effective contraception for
up to 12years.
Expert Rev. Med. Devices 10(4), (2013)
 Perspective Dermish & Turok
Although half of unintended pregnancies occur among women
who are using some form of contraception, consistent and correct
use of contraception accounts for only 5% of unintended preg-
nancies [1] . The authors know that the most effective methods of
contraception are those that remove user error from the equation
[12] , specifically the intrauterine devices (IUDs) and implant,
collectively referred to as long-acting reversible contraceptives
or highly effective reversible (HER) contraceptives [13] . Some
have suggested substituting use of the term long-acting reversible
contraceptives with HER contraceptives or forgettable contra-
ceptives in order to focus on effectiveness over duration of use
[13,14] . Although some may also include injectables here, because
their comparatively shorter duration of action necessitates regular
follow-up, the authors have excluded them from this category
in this paper. One study examining the impact of increased use
of HER contraceptive methods was the CHOICE study [15] , a
cohort study of 9256 women in St Louis (MO, USA) who were
offered the contraceptive method of their choice at no cost for
a period of 3years. The study was designed to promote use of
highly effective methods, and in the first year of the study, two-
thirds of women chose HER contraceptive methods [16] , increas-
ing to 75% over time [17] . Women who opted to use combined
hormonal contraceptives (pills, ring or patch) were 22-times more
likely to experience contraceptive failure compared with HER
contraceptive users [17] . In addition, data from the CHOICE
study have demonstrated that widespread use of the most effec-
tive methods of contraception can reduce unintended pregnancy
and abortion rates [18] .
EC & unintended pregnancy
The emergency contraception (EC) visit presents an unusual
opportunity to address initiation of highly effective methods of
contraception with women who are using less effective methods
or no method at all. Women who present for EC are unique in
that they are seeking care to not be pregnant and are by defini-
tion not using a reliable method of contraception. EC is the only
opportunity for women to prevent an unwanted pregnancy after
unprotected intercourse or contraceptive failure (such as condom
breaking or missed pills).
Oral EC
Those seeking EC have two main options: single-dose oral EC or
the copper T380A IUD. Within the oral EC category, there are
two available methods: 1.5-mg levonorgestrel (LNG) or 30-mg
ulipristal acetate (UPA). Depending on local laws and regula-
tions, these may be available in pharmacies without a prescrip-
tion. Both methods have been shown to be effective up to 120h
after unprotected intercourse [1921] , although the efficacy of oral
LNG may decrease over time [2224] . Other less commonly used
oral options include use of specific combinations of combined
hormonal contraceptive pills and mifepristone, which is available
for EC in China.
Oral EC offers the benefit of being easy to distribute and use.
Women do not need to undergo an examination or even be seen
by a clinician. While oral EC appears to decrease the risk of
478
pregnancy for a single act of unprotected intercourse for the indi-
vidual woman, it does not have an effect at the population level.
Evidence from multiple prospective trials of advanced provision
of a variety of oral EC products have failed to show an effect on
community-wide rates of unplanned pregnancy and abortion
[2538] . In these studies, women were either given an advanced
supply of EC (intervention) or were given information on how
to access EC through the clinic (control). Although there were
flaws in several studies, such as low baseline pregnancy rates, poor
follow-up and lack of randomization, none of the studies con-
tained all these flaws and several of them were rigorous in design
and execution. Most important of all, the results were consistent
in every one. There are multiple potential reasons for this lack of
effect that have been described in the literature, including lack
of use by those at highest risk of unplanned pregnancy, possible
increased coital frequency and possibly substituting EC for more
reliable methods [36,3942] .
A recent meta-analysis has highlighted several clinical sit-
uations where oral EC has decreased efficacy; these include
increased BMI, when unprotected intercourse occurs in the fer-
tile window (from 5days before ovulation to 1day after), and
further episodes of unprotected intercourse in the same cycle
[43] . EC efficacy is significantly reduced in obese women using
oral LNG or UPA for EC with a greater effect seen in oral LNG
users compared with UPA. The efficacy of oral LNG for EC has
also been studied in relation to time of use during the menstrual
cycle. As oral LNG EC works to prevent pregnancy through
delaying ovulation, using this form of EC after ovulation has
occurred will not prevent pregnancy. In two studies seeking to
examine this hypothesis, data were collected on clinical and
laboratory predictors of ovulation in women using oral LNG for
EC [44,45] . The overall efficacy for women taking oral LNG EC
during their fertile window was 6068%. Looking even more
closely at timing of use found that women who used oral LNG
on the day of ovulation or after experienced the same number of
pregnancies that would have been expected without any use of
EC [44,46] . In both studies, there were no pregnancies in women
taking oral EC prior to the fertile window. This was further
demonstrated in the results of the meta-analysis [43] , showing
that pregnancy rates were four-times higher in women taking
either oral LNG or UPA EC who had unprotected intercourse
the day prior to ovulation compared with those who had sex
outside the fertile window. In addition to elevated BMI and
timing of EC use, this study also identified further acts of
unprotected intercourse in the menstrual cycle during which
EC was used as a predictor of unintended pregnancy [43] . This
is especially important given that studies of oral EC users have
demonstrated up to two-thirds of women will go on to use
condoms or no contraception after their EC visit [47] . These
data further demonstrate the importance of discussing effective
contraceptive use at this visit and highlight the two major ben-
efits of the copper IUD for EC: its exceptional efficacy in the
short term is not influenced by any of these situations (Figure1)
and it continues to provide highly effective contraception for
up to 12years.
Expert Rev. Med. Devices 10(4), (2013)
 The copper intrauterine device for emergency contraception
Copper IUD for EC
Mechanism of action
The copper IUD has been studied for use as an emergency contra-
ceptive for several decades, first described by Lippes in 1976 [48] .
The primary mechanism of action of the copper IUD is to inhibit
fertilization. The copper ions released into the uterine cavity alter
the motility and function of sperm and ova, and also cause physi-
ologic changes in the uterus and fallopian tubes that prevent meet-
ing of the gametes [49] . Although not specifically examined in the
setting of a postcoital insertion, the mechanism of action for EC
is likely the same. However, the mechanism of action after ovula-
tion may differ. Prevention of implantation of a fertilized embryo,
although not a primary mechanism, may play a role in some cases
following postovulatory insertion [49] . Although there have been no
studies to date looking at use of the LNG IUD for EC and its use
alone for EC is not recommended at this time, research into this is
necessary and will be an important contribution to the field [5052] .
Efficacy as EC
While decades of data support the excellent efficacy of the copper
IUD for EC, it is not specifically licensed for this use. However, its
use is supported by the WHO, the US CDC and the UK Faculty of
Sexual and Reproductive Healthcare (FSRH) [5355] . The efficacy
of the copper IUD has been demonstrated in multiple studies and is
clearly the most effective method of EC. In a study of 1963 women
in China receiving the copper T380A IUD, there were no pregnan-
cies reported in the first 3months after insertion, and 12-month
continuation rates were 94% [56] . Another study of 1013 women
using the Multiload copper 375 Cu IUD reported two pregnancies
in the first month [57] . A systematic review of 42 studies of the IUD
for EC, including the two described here, reported an overall failure
rate of 0.09% [58] compared with failure rates of 1.4% for UPA and
2% for oral LNG. Furthermore, continuation rates among IUD
users in these studies are greater than 90% at 12months [56,57] .
Recognizing that real-life continuation rates may be lower [59,60] ,
the IUD still offers the benefit of ongoing highly effective contra-
ceptive protection while it is in place. Women who choose the IUD
for EC are more likely to be using effective contraception and less
likely to have an unintended pregnancy 1year after their visit [60] .
Safety
The IUD can be used for EC by the vast majority of women
who do not wish to get pregnant. Contraindications are rare and
few. They include undiagnosed abnormal uterine bleeding, active
uterine infection, genital tract malignancy, uterine malformation
that prevents device placement or allergy to copper. Since it is a
nonhormonal method, there are no contraindications to use in
women with chronic medical conditions [61] . Table1 provides a
summary of the WHO Medical Eligibility Criteria for use of EC
in women with medical conditions. Common side effects from
IUD insertion include cramping, pain and irregular bleeding,
although these are usually self-limited. Some women may experi-
ence heavier periods while using the copper IUD [62] , so caution
and appropriate counseling is recommended in women who have
baseline heavy menstrual bleeding or painful periods. The risk of
www.expert-reviews.com
Perspective
Further
unprotected
9 intercourse
% becoming pregnant
8
BMI >30
7 Intercourse
6 inside fertile
5 window
4 BMI 2530
3
2 BMI <25
1
0
Clinical factors impacting effectiveness
LNG UPA Copper IUD
Figure 1. Pregnancy risk at 1month based on method of
emergency contraception chosen. Each circle represents the
percentage of women who will become pregnant in first month
after using that method of EC, accounting for various risk factors.
Size of circle is proportional to the risk of pregnancy.
EC: Emergency contraception; IUD: Intrauterine device;
LNG:Levonorgestrel.
perforation at the time of insertion is low at 00.2% [63,64] . Risk
of perforation is greater in postpartum and breastfeeding women.
There is an overall approximately 5% risk of expulsion of the IUD
in the first year of use, and appears to be greater in nulliparous
women using the copper IUD [65,66] ; however, if this occurs, the
IUD can be replaced as soon as this is recognized.
Special considerations for IUD users: pelvic inflammatory
disease, HIV & future fertility
The association between IUD use and pelvic inflammatory dis-
ease (PID) was a major contributor to a decline in its use in many
parts of the world, particularly in populations such as teenagers,
nulliparous women and women who are HIV positive. In the
USA, the Dalkon shield, which was associated with higher rates
of PID, contraceptive failure and miscarriage, as well as reported
cases of infertility and septic abortion, left a legacy that severely
limited IUD use for several decades [67] . While IUD use remained
high in many countries, the USA is not the only country that has
struggled to increase use of this highly effective method of con-
traception [68] . In South Africa, where there is a high prevalence
of HIV, IUD utilization is very low and lack of provider knowl-
edge regarding its use in women at risk of sexually transmitted
infection (STI) has been identified as a contributor [69,70] . A large
body of data, particularly on the CuT380A and LNG IUD, now
supports the safety of the IUD and it is recommended as a first-
line contraceptive for all women, including adolescents [61,7173] .
These safety data have since led to large increases in IUD use in
the USA over the past two decades [74,75] .
Study of the relationship between IUD use and PID is made
difficult by the sometimes nonspecific symptoms and varying
diagnostic criteria for PID [76] , which often leads to empiric treat-
ment. Despite this, reported rates of PID in IUD users remain
low. While studies have identified a higher risk of PID in the first
month of IUD use, this number returns to baseline thereafter.
479
 Perspective Dermish & Turok
Table 1. WHO Medical Eligibility Criteria for
emergency contraception use.
Complication Oral EC Copper IUD
Pregnancy NA
4 much higher rates of pregnancy and were at increased risk of
Cardiovascular disease 2 1
Liver disease 2 1
Migraine 2 1
Repeat EC use 1 NA
Cervicitis NA 4(I)/2(C)
Current PID NA 4(I)/2(C)
Rape
High STI risk 1 3
Low STI risk 1 1
Not indicated if pregnancy is suspected; however, there is no known harm to
the woman, fetus or pregnancy if oral EC is used.
medical eligibility criteria categories: 1: no restriction for use of method;
2:advantages usually outweigh real/theoretical risks; 3: real/theoretical risks
usually outweigh advantages; 4:method presents unacceptable health risk.
C: Continuation of method; EC: Emergency contraception; I: Initiation of
method; IUD: Intrauterine device; NA: Not available; PID: Pelvic inflammatory
disease; STI: Sexually transmitted infection.
The risk of PID is highest in women with an active gonorrheal or
chlamydial infection at time of insertion [77,78] . What is not clear
from currently available data is whether the risk of PID differs in
women with STIs who do not undergo IUD insertion relative to
those who do have an IUD inserted.
Based on available data, insertion is contraindicated in women
with suspected active PID or symptomatic gonorrhea or chla-
mydia [61] . History-based algorithms have been suggested to
determine who is at higher risk of STI, and these can be used to
help determine who should be screened [7982] . Women who are
at higher risk but have no symptoms of active infection should
be screened at the time of insertion and treated if the test returns
positive. However, the procedure should not be delayed until
results are received [83,84] . While there are few data on this topic
specific to EC users, in two studies of copper IUD insertions for
EC, there were no reported cases of PID among the combined
2160 women who received IUDs [56,82] . Women who develop
symptoms of mild-to-moderate PID after IUD insertion can be
safely treated as outpatients without removal of the device [85] .
For women infected with HIV, several studies have demon-
strated the safety of the copper IUD. In a prospective cohort
study of women with and without HIV who received a copper
IUD, there was no difference in overall complications between
the two groups [86,87] . HIV status was not found to be associ-
ated with either PID or infection-related removals at either time
point. CD4 counts, rather than IUD use, were associated with
viral shedding patterns [88] . In a trial where women with the virus
were randomized to the copper IUD or hormonal contraception
[89] , there was one case of PID in the IUD group (0.3%) diag-
nosed in the first month after insertion in a woman who tested
positive for Chlamydia. Many women in the IUD group received
prophylactic antibiotics, which may partially account for the low
480
overall rate. Although prophylactic antibiotics at the time of IUD
insertion have not been shown to provide a benefit in the general
population [90] , but this has never been studied in HIV-positive
women. Women assigned to use hormonal contraception had
disease progression compared with the IUD group. Based on
these data the WHO, FSRH and CDC have listed IUD use in
HIV-positive women as category 2, where the advantages of the
method use outweigh the risks [54,55,61] .
Concerns about the association between IUDs and pelvic infec-
tion also led to fear that IUD use would affect future fertility.
In a review of studies addressing return to fertility, 92100%
of women were able to achieve pregnancy within 12months of
discontinuing the IUD [91] . This does not appear to be affected by
duration of use, age at time of removal, parity or type of device.
A study of the copper IUD in nulliparous women also showed
no association with tubal infertility [92] .
Together, these data consistently demonstrate that it is the pres-
ence of chlamydial or gonorrheal infection that creates the risk
of PID, not the IUD itself. All women at risk of STI should be
counseled on this association between STI and PID, regardless
of their choice of contraceptive, and encouraged to use barrier
protection.
Barriers to use
Unlike oral EC, which is easily distributed and does not require
an office visit, getting an IUD requires access to a provider who
is trained in IUD insertions. As a result of campaigns to increase
awareness of the oral EC option, particularly its easy availability
over the counter, most women simply go to the pharmacy when
in need of EC. Although clearly the IUD cannot be made widely
available as easily as oral EC, when women go directly to the
pharmacy, an opportunity for education about the most effective
method is lost.
Several studies have investigated womens interest in using the
IUD for EC. When women presenting for EC at a US family
planning clinic were asked about their willingness to have an
IUD inserted at that time, 12.8% said they would be willing
to wait 1h, undergo a pelvic exam and have an IUD inserted
[93] . Another study demonstrated a similar level of interest (12%)
among a group of women presenting for EC or pregnancy testing.
Interest in the IUD increased to 16% if the IUD was available
at no cost [94] . In parts of the world where the woman must bear
the burden of covering the cost of contraception, this becomes
an important barrier, especially given the high upfront cost of the
IUD. In studies of EC in the USA when cost was removed as an
issue, women commonly chose the IUD [93,95,96] . Beyond the cost
for an individual, administrators must also be convinced that use
of the IUD for EC is a cost-effective option. A costeffectiveness
analysis of the copper IUD for EC in the USA showed that giving
women the copper IUD over oral EC would cost an additional
US $17.70 to prevent one unintended pregnancy. With the cost
of an uncomplicated term pregnancy estimated at US $4635, this
presents a significant cost saving and makes use of the copper
IUD an extremely cost-effective option for women in the USA
Expert Rev. Med. Devices 10(4), (2013)
 The copper intrauterine device for emergency contraception
[97] .In developing countries, IUDs cost significantly less, and
pregnancies bear a much lower financial cost. However, the high
maternal and neonatal morbidity and mortality in these regions,
particularly associated with unintended pregnancy, carry a sig-
nificant cost burden that can be alleviated through increased use
of the most effective methods of contraception.
Other potential barriers identified from US and European stud-
ies, in addition to concern over cost, are awareness of the IUD
as a method of EC, misconceptions about the IUD and its side
effects, especially regarding future fertility, fear of the insertion
process and the idea of using a long-acting device [98100] . Women
who did not know the IUD could be used for EC were less likely
to choose that method. In qualitative interviews, many women
expressed concern regarding their ability to get pregnant in the
future if they used an IUD. Women viewed it as something to use
once they were finished childbearing. Knowing someone who had
a good experience with the IUD, having prior personal experience
with the IUD, being able to see the device or having accurate
knowledge about the IUD side effects, safety and efficacy were
more commonly seen in women who chose the IUD for EC [94,99] .
The long acting aspect of the IUD was seen as both a benefit
and a reason not to use it [99,100] . Women who were in relation-
ships looked more favorably on the duration of effectiveness, while
those not in a relationship did not think using a longer acting
method was necessary and instead viewed it as a deterrent [100] .
This suggests that rather than emphasizing the long-acting aspect,
providers should focus on the effectiveness of the IUD, namely
that it is the most effective method of reversible contraception
(and EC) available, as well as on the ease of use.
For providers, offering the IUD to women seeking EC presents
another set of barriers. Easy availability of the oral EC, as noted
above, means that women do not necessarily contact their health-
care provider after unprotected intercourse. Conversations about
preventing unintended pregnancy should, therefore, be addressed
at routine visits. However, in a study of clinicians at California
family planning clinics, as few as 15% of clinicians reported dis-
cussing the IUD as an option for EC and as many as 40% never
discuss the IUD as a contraceptive option at all. Clinicians possess-
ing accurate knowledge about IUD use and safety are more likely
to offer the IUD [101103] . Updated guidelines from professional
organizations, such as the American College of Obstetricians
and Gynecologists (ACOG) [50,71,72,101,104] , American Academy
of Pediatrics [105] , WHO [61] , FSRH and the CDC [54] , all reaf-
firm the safety of IUDs, even in adolescents, and should help
clinicians feel more comfortable offering the IUD. The ACOG
committee opinion on access to EC, as well as the FSRH Clinical
Effectiveness Unit, recommend emphasizing the effectiveness of
the IUD in discussions with patients about EC [52,101] .
Having clinicians available who are comfortable and proficient
with IUD insertions is equally important to increasing access
[98,101,102,106] . With more adolescent and nulliparous women using
IUDs, this can present a challenge, even to experienced providers.
In one study of women who received an IUD for EC, 19% had a
failed insertion, meaning that the provider was unable to place the
IUD during that visit and these women received oral EC instead
www.expert-reviews.com
Perspective
[96] . This failure rate is significantly higher than reported else-
where in the literature [65,75,107111] , even accounting for the high
rate of nulliparous women (67%) and the fact that all insertions
were performed by advanced practice clinicians. The EC visit may
present IUD insertion challenges beyond simply nulliparity; for
example, women may not have come in planning on getting an
IUD, and may be anxious about their risk of pregnancy, which
can increase perceived pain and contribute to the difficulty of
the insertion [112] . Providers should anticipate challenges, and
provider training should incorporate strategies to overcome them.
Beyond challenges of knowledge and skill, clinics must also
be set up to accommodate these women for unscheduled visits.
Disruption of workflow is routinely identified by providers as a
barrier to providing the IUD for EC [99,101,102,106,113] . Many clinics
also require two visits prior to inserting an IUD, a practice that is
of no demonstrated benefit and results in poor return rates [98,113] .
In the EC setting, where time from unprotected intercourse is
vital, there is even more incentive to do away with these protocols
and insert the IUD and screen for STIs simultaneously [84] .
Timing of IUD insertion
While oral ECs effectiveness in relation to time from unprotected
intercourse has been clearly defined [20,114] , this is less clear when
it comes to the copper IUD. It is generally accepted that the cop-
per IUD is effective up to 5days after unprotected intercourse
or 5days after ovulation [61,115] . This is based on the idea that
implantation occurs at 612days following ovulation and there-
fore the IUD should be placed prior to implantation in order to
prevent pregnancy. For example, if a woman presented for EC
7days after unprotected intercourse, but based on cycle history
is predicted to have ovulated within the last 3days, she would
still be within the recommended window for insertion. However,
because day of ovulation is often unknown, in practice, most
providers may limit insertion to within 5days of unprotected
intercourse. In a systematic review of studies of the IUD for EC,
five studies reported IUD insertions up to 10days and beyond
unprotected intercourse, and reported no pregnancies in that cycle
among 732women for whom follow-up information was available
[58] . Table2 contains a description of these studies, together with a
secondary analysis of an additional study specifically looking at
timing of insertion [116] , and includes information on the number
of women with IUD insertions beyond 5days after unprotected
intercourse. While the number of women outside the 5-day win-
dow was small in these studies, and further studies would be
beneficial, the IUD appears to maintain its efficacy for EC beyond
this period. In secondary analyses of two studies of the copper
T380A IUD for EC, when looking at when in the menstrual cycle
women had their IUD inserted, there were no pregnancies noted
in women whose insertions occurred during the fertile window
[116,117] . While some clinicians may have concerns about inserting
the IUD beyond the current recommended guidelines, or may be
limited by local regulations, together these analyses suggest that as
long as a high-sensitivity urine pregnancy test is negative, the cop-
per IUD may be safely used for EC, regardless of the menstrual
cycle day or time since unprotected intercourse. To date, there
481
 Perspective Dermish & Turok

Table 2. Summary of studies of the intrauterine device for emergency contraception with insertions
beyond the recommended 5days from unprotected intercourse.
Study (year) Enrolled Follow-up Maximum days Insertions beyond Pregnancies Ref.
(n) available (n) to insertion 5days (n) (n)
Wu etal. (2010); Turok etal. (2012) 1963 1893 >5 84 0 [56,116]

Lippes etal. (1979) 299 299 7 NA 0 [123]

Black etal. (1980) 191 176 10 16 0 [124]

Goldstuck (1983) 71 64 >10 24 (all >10days) 0 [125]

Gottardi etal. (1986) 98 91 7 NA 0 [126]

Luerti etal. (1986) 117 102 7 11 0 [127]

NA: Not available.
Adapted with permission from [58].

have been no recorded pregnancies from women enrolled in IUD in half [118] . However, 5years ago, in 2007, a systematic review of
EC studies where IUD insertion occurred beyond 5days after the trials evaluating advanced supply of EC pills provided over-
ovulation, and women presenting for EC outside the guidelines whelming evidence refuting this hypothesis [40] . Since that time,
should be c ounseled as such. there has been increased interest in the copper IUD for EC, a
method that for several decades has been shown to be much more
Expert commentary & five-year view effective than EC pills [58] . Recent research has addressed both the
In 1992, it was predicted that widespread availability and use of demand side and supply side of the IUD for EC. On the demand
EC pills would cut US rates of unintended pregnancy and abortion side, EC users have shown they are interested in a more effective
method that provides highly effective ongo-
ing contraception and are willing to have
Are you choosing the best emergency contraception for you?
it inserted on the day they present for EC
Oral LNG Ulipristal acetate [93,94] . In addition, women who present for
Copper IUD
EC are willing to participate in prospective
Better than oral trials comparing the copper IUD to oral
LNG if you had sex Best anytime
When did I have Good within
72120 h ago. within 5 days
methods of EC [95] . Awareness of the IUD
unprotected sex? 72 h as a method of contraception is associated
Also works within (120 h)
072 h with women choosing it as an EC option.
Works: Works: In a prospective trial offering oral LNG or
Good for average Best method for
What is my weight
Better for average
obese the copper IUD, 95% of the women who
weight
weight? OK for overweight Best method choose the IUD had heard of it as a method
Not recommended for Good for overweight for any weight of contraception versus 74% of women who
obese OK for obese
choose oral LNG [60] . While it is encourag-
Available over the Available with a
counter for age consultation for Needs an
ing that IUD awareness and use is increas-
How do I get ing for all US women, obstacles to increased
17 years and above; everyone examination
this EC?
with a consultation if (cannot use if to put it in use of the copper IUD remain. The low-
aged under 17 years breastfeeding)
est rates of IUD use are in adolescents and
Does it give me young women [74] , the same groups that
birth control No No Yes are most likely to be EC users. However, in
after I get it today?
these groups, education about the IUD has
For more information just ask a staff member been shown to increase positive attitudes
Average weight BMI 25 or less associated with IUD use [119] . Increasing
Overweight BMI 2630
awareness and use of IUDs in general will
likely make use of the copper IUD for EC
Obese BMI over 30
more attractive to future EC users.
See BMI chart if you are unsure of your weight category. A staff member will be On the supply side, only a small subset of
happy to help you figure out your BMI
contraceptive providers currently offer the
IUD for EC [101] . Low rates of offering the
Figure 2. Sample information sheet for patients on emergency contraception IUD for EC are in part driven by poor pro-
options. vider knowledge regarding contraception in
LNG: Levonorgestrel. general and especially the IUD [120] . While

482 Expert Rev. Med. Devices 10(4), (2013)

 The copper intrauterine device for emergency contraception Perspective

recently there appears to have been more discussion of use of the not only for the meaningful public health outcome of reductions
IUD for EC in the literature, it is difficult to evaluate if there has in unplanned pregnancies but as a result has significant economic
been an increase in the use of the device in the clinical setting. A benefits, a factor that in these fiscally demanding times may pro-
potential influence on increasing use of the IUD for EC is patient vide the impetus to significantly improve contraceptive access and
and provider education materials that highlight the greater efficacy care. The CHOICE study did not just remove provider barriers
of the copper IUD for EC. The FSRH has been a leader in this to IUD insertion but employed a comprehensive effort to reduce
effort as its original clinical guidance on EC recommended offering all barriers to HER contraceptive methods, including providing
the copper IUD for EC to all women within 5days of unprotected all methods without cost, increasing provider numbers and train-
intercourse or 5days after earliest calculated ovulation (whichever is ing, as well as providing participants with thorough counseling and
the longer), due to its superior efficacy. In the recent update of this ongoing support. True reductions in population rates of unintended
document, the recommendation remains [52] . This approach has also pregnancy will likely only result from comprehensive efforts such as
been endorsed by the largest US provider of family planning services, this. Optimizing EC service delivery to offer a near perfect method
Planned Parenthood Federation of America Manual of Medical to reduce short-term risk of pregnancy after unprotected intercourse
Standards and Guidelines 2012, as well as the largest organization is an important step to improve contraceptive care. However, by
of US obstetrician gynecologists, ACOG [121] . Additional publica- itself this will not reduce rates of unintended pregnancy. Use of
tions targeting obstetrician-gynecologists direct EC users and pro- the copper IUD as EC plays a role in increasing access to the most
viders to the IUD as the most effective method of EC and offer effective methods of contraception and its use should be encouraged
an easy to use flowchart to guide this practice [122] . Figure2 offers as a component of an overall strategy to improve access to highly
a sample information sheet on EC that can be used into practice. effective methods. Figure3 shows how outcomes vary at 1year among
Accurate information on EC options is displayed here in an easy to women choosing oral EC versus the IUD, and demonstrates the
understand manner that allows women to
choose the best option for themselves.
Of course, there is a relationship
between the demand and supply sides. As
1000 women
more women prefer and demand IUDs in seeking EC
general and for use as EC, providers will be
more likely to offer the devices to women.
In addition, influencing both sides of the
130 choose
equation is the cost of the IUD and the IUD [93]
870 choose
insertion procedure. This is a major obsta- oral EC
(13% of EC users
cle for patients and providers who must willing to have
IUD placed)
stock the devices in their clinics. In the
USA, this obstacle should diminish as the
Affordable Care Act takes effect, but this
will remain a major determinant of access 17 pregnancies at 853 at continued No pregnancies
to the IUD for EC globally. 1 month [1923,27] risk of pregnancy
(2% failure rate with most using first month
There are several additional factors that of oral EC) less effective
affect both demand and supply sides to methods [47,60]
encourage wider use of IUDs. Evidence-
based practice guidelines for contracep- 26 discountinue IUD
tive care from the WHO and CDC have in first year and use 104 continue IUD
128 pregnancies less effective for 12 months
removed several barriers to IUD insertion
at 1 year methods [59,62] (5%
and supported the use of highly effective [12,27,35,60] expulsions and 15%
methods of contraception [54,61] . These removals in first year
include unrestricted use in adolescents,
nulliparous women and women not in Four pregnancies [12] One pregnancy
long-term monogamous relationships. (15% pregnancy [59]
Women in all of these groups are likely to rate for condom
be EC users. Most importantly, when these users for the
remainder the year)
restrictions are broadly applied, as they were
in the Contraceptive CHOICE study in St
Louis, IUDs become the preferred method Figure 3. Pregnancy outcomes over 1year for 1000 women seeking emergency
of contraception and community-wide contraception.
rates of unintended pregnancy decline [18] . EC: Emergency contraception; IUD: Intrauterine device.
This study provides important evidence Data taken from [12,1923,27,35,47,59,60,62,93] .

www.expert-reviews.com 483
 Perspective Dermish & Turok

potential impact of increasing the proportion of women choosing
the most effective method.
While prior incorrect predictions of the effect of EC should
temper future predictions, we believe that in 5years, there
will be greater awareness for the EC visit as a time to initiate
methods of highly effective contraception. This will include
not only use of the copper IUD for EC but will also include
use of oral methods of EC provided at the same visit as the
LNG IUD, the etonorgestrel contraceptive implant and depot
medroxyprogesterone acetate. In 5years, we may have informa-
tion about alternative options for EC. While it is possible, there
may be data to support the use of the LNG IUD alone for EC
in 5years, for now it should be offered only in conjunction with
a method of oral EC after unprotected intercourse. The true
contribution of the copper IUD for EC is likely not that the
method will by itself reduce rates of unintended pregnancy but
more likely it will be a contribution to making the most effec-
tive methods of contraception available to women at whatever
time they present for care.
Financial & competing interests disclosure
AI Dermish received research support from Bayer Womens Health and
Teva Pharmaceutical for intrauterine device research. DK Turok received
research support from Medicines 360, Bioceptive, Bayer Womens Health
and Teva Pharmaceuticals for intrauterine device research and participa-
tion in an advisory council. The authors have no other relevant affiliations
or financial involvement with any organization or entity with a financial
interest in or financial conflict with the subject matter or materials discussed
in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.

Key issues
The unintended pregnancy rate remains unacceptably high. The emergency contraception (EC)-seeking population are important
targets in attempts to reduce this rate.
The copper intrauterine device (IUD) is the most effective method of EC, considerably more effective than oral EC and should be
recommended whenever possible.
Use of the copper IUD for EC should have no reduction in effectiveness regardless of other clinical factors (e.g., BMI, frequency of
intercourse in the cycle, fertile window).
The copper IUD also provides up to 12years of highly effective reversible contraception.
Barriers to IUD use for EC have been well defined and must be addressed.
Women eligible for the copper IUD for EC should be informed that it can be inserted at any time during the menstrual cycle as long
as a sensitive urine pregnancy test is negative. However, local laws may limit IUD insertion to 57days beyond expected ovulation in
certain countries (UK).
To maximize use of the most effective method of EC, patients as well as providers need to be aware of use of the copper IUD for EC.

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