Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 May 18;5(5):CD013565.
doi: 10.1002/14651858.CD013565.pub2.

Immediate versus delayed postabortal insertion of contraceptive implant

Jen Sothornwit  1 , Nuntasiri Eamudomkarn  1 , Pisake Lumbiganon  1 , Nampet Jampathong  2 , Mario R Festin  3 , Lingling Salang  4
Affiliations

Immediate versus delayed postabortal insertion of contraceptive implant

Jen Sothornwit et al. Cochrane Database Syst Rev. .

Abstract

Background: Contraceptive implants are one of the most effective contraceptive methods, providing a long duration of pregnancy protection and a high safety profile. Hence this method is suitable for optimizing the interpregnancy interval, especially for women undergoing abortion. Women who have had abortions are at high risk of rapid repeat pregnancies. Provision of effective contraception at the time of an abortion visit can be a key strategy to increase access and uptake of contraception. A review of the evidence was needed to evaluate progestin-releasing implants for immediate use at the time of abortion, including whether immediate placement impacts the effectiveness of medical abortion, which relies on antiprogestogens.

Objectives: To compare contraceptive implant initiation rates, contraceptive effectiveness, and adverse outcomes associated with immediate versus delayed insertion of contraceptive implants following abortion.

Search methods: We searched for all relevant studies regardless of language or publication status up to September 2019, with an update search in March 2021. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Ovid EBM Reviews), MEDLINE ALL (Ovid), Embase.com, CINAHL (EBSCOhost) (Cumulative Index to Nursing and Allied Health Literature), Global Health (Ovid), LILACS (Latin American and Caribbean Health Science Information database), Scopus, ClinicalTrials.gov, and the WHO ICTRP. We examined the reference lists of pertinent articles to identify other studies.

Selection criteria: We sought randomized controlled trials (RCTs) comparing immediate versus delayed insertion of contraceptive implant for contraception following abortion.

Data collection and analysis: We followed the standard procedures recommended by Cochrane. To identify potentially relevant studies, two review authors (JS, LS) independently screened the titles, abstracts, and full texts of the search results, assessed trials for risk of bias, and extracted data. We computed the risk ratio (RR) with 95% confidence intervals (CIs) for binary outcomes, and the mean difference (MD) with 95% CIs for continuous variables.

Main results: We found three RCTs including a total of 1162 women. Our GRADE assessment of the overall certainty of the evidence ranged from moderate to very low, downgraded for risk of bias, inconsistency, and imprecision. Utilization rate at six months may be slightly higher for immediate compared with delayed insertion (RR 1.10, 95% CI 1.05 to 1.15; 3 RCTs; 1103 women; I2 = 62%; low certainty evidence). Unintended pregnancy within six months after abortion was probably lower with immediate insertion compared with delayed insertion (RR 0.25, 95% CI 0.08 to 0.77; 3 RCTs; 1029 women; I2 = 0%; moderate certainty evidence). Immediate insertion of contraceptive implants probably improves the initiation rate compared to delayed insertion following medical abortion (RR 1.26 for medical abortion, 95% CI 1.21 to 1.32; 2 RCTs; 1014 women; I2 = 89%; moderate certainty evidence) and may also improve initiation following surgical abortion (RR 2.32 for surgical abortion, 95% CI 1.79 to 3.01; 1 RCT; 148 women; I2 = not applicable; low certainty evidence). We did not pool results for the implant initiation outcome over both abortion types because of very high statistical heterogeneity. For medical termination of pregnancy, we found there is probably little or no difference between immediate and delayed insertion in overall failure of medical abortion (RR 1.18, 95% CI 0.58 to 2.40; 2 RCTs; 1001 women; I2 = 68%;moderate certainty evidence). There may be no difference between immediate and delayed insertion on rates of abnormal bleeding at one month after abortion (RR 1.00, 95% CI 0.88 to 1.14; 1 RCT; 462 women; I2 = not applicable; low certainty evidence).

Authors' conclusions: Provision of progestin-releasing implants concurrently with abortifacient agents likely has little or no negative impact on overall failure rate of medical abortion. Immediate insertion probably improves the initiation rate of contraceptive implant, as well as unintended pregnancy rate within six months after abortion, compared to delayed insertion. There may be no difference between immediate and delayed insertion approaches in bleeding adverse effects at one month after abortion.

PubMed Disclaimer

Conflict of interest statement

Jen Sothornwit: none known

Nuntasiri Eamudomkarn: none known

Pisake Lumbiganon: none known

Nampet Jampathong: none known

Mario R Festin: none known

Lingling Salang: none known

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 Immediate versus delayed postabortion insertion of contraceptive implants, outcome: 1.1 Rate of initiation of contraceptive implants.
5
5
Forest plot of comparison: 1 Immediate versus delayed postabortion insertion of contraceptive implants, outcome: 1.2 Success rate of medical abortion.
1.1
1.1. Analysis
Comparison 1: Immediate versus delayed postabortion insertion of contraceptive implants, Outcome 1: Rate of initiation of contraceptive implants
1.2
1.2. Analysis
Comparison 1: Immediate versus delayed postabortion insertion of contraceptive implants, Outcome 2: Utilization rate of contraceptive implant
1.3
1.3. Analysis
Comparison 1: Immediate versus delayed postabortion insertion of contraceptive implants, Outcome 3: Failure rate of medical abortion
1.4
1.4. Analysis
Comparison 1: Immediate versus delayed postabortion insertion of contraceptive implants, Outcome 4: Bleeding side effects
1.5
1.5. Analysis
Comparison 1: Immediate versus delayed postabortion insertion of contraceptive implants, Outcome 5: Side effects other than bleeding
1.6
1.6. Analysis
Comparison 1: Immediate versus delayed postabortion insertion of contraceptive implants, Outcome 6: Unintended pregnancy
1.7
1.7. Analysis
Comparison 1: Immediate versus delayed postabortion insertion of contraceptive implants, Outcome 7: Patient satisfaction
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD013565

Similar articles

See all similar articles

Cited by

References

References to studies included in this review

Cowett 2018 {published data only}
    1. Cowett AA, Ali R, Cooper MA, Cremer M.Immediate vs. delayed insertion of the etonogestrel contraceptive implant after termination of pregnancy in the second trimester. Contraception 2017;96:284.
    1. Cowett AA, Ali R, Cooper MA, Evans M, Conzuelo G, Cremer M.Timing of etonogestrel implant insertion after dilation and evacuation: a randomized controlled trial. Obstetrics & Gynecology 2018;13(5):856-62. - PubMed
Hognert 2016 {published data only}
    1. Hognert H, Kopp Kallner H, Cameron S, Nyrelli C, Jawad I, Heller R, et al.Immediate versus delayed insertion of an etonogestrel releasing implant at medical abortion—a randomized controlled equivalence trial. Human Reproduction 2016;31(11):2484-90. - PubMed
Raymond 2016a {published data only}
    1. Raymond EG, Weaver MA, Tan YL, Louie KS, Bousiéguez M, Lugo-Hernández EM, et al.Effect of immediate compared with delayed insertion of etonogestrel implants on medical abortion efficacy and repeat pregnancy: a randomized controlled trial. Obstetrics & Gynecology 2016;127(2):306-12. - PubMed

References to studies excluded from this review

Madden 2012 {published data only}
    1. Madden T, Eisenberg DL, Zhao Q, Buckel C, Secura GM, Peipert JF.Continuation of the etonogestrel implant in women undergoing immediate postabortion placement. Obstetrics & Gynecology 2012;120(5):1053-9. - PMC - PubMed
Raymond 2016b {published data only}
    1. Raymond EG, Weaver MA, Louie KS, Tan YL, Bousiéguez M, Aranguré-Peraza AG, et al.Effects of depot medroxyprogesterone acetate injection timing on medical abortion efficacy and repeat pregnancy: a randomized controlled trial. Obstetrics & Gynecology 2016;128(4):739-45. - PubMed
Sonalkar 2013 {published data only}
    1. Sonalkar S, Hou MY, Borgatta L.Administration of the etonogestrel contraceptive implant on the day of mifepristone for medical abortion: a pilot study [Same-day Long-acting Reversible Contraception for Medication Abortion (SaLMA)]. Contraception 2013;88(5):671-3. [NCT01356927] - PubMed

Additional references

ACOG 2017
    1. Committee on Practice Bulletins-Gynecology, Long-acting Reversible Contraception Work Group.Practice bulletin no. 186: long-acting reversible contraception: implants and intrauterine devices. Obstetrics & Gynecology 2017;130(5):e251-69. - PubMed
Aztlan‐James 2017
    1. Aztlan-James EA, McLemore M, Taylor D.Multiple unintended pregnancies in U.S. women: a systematic review. Women's Health Issues 2017;27(4):407-13. - PMC - PubMed
Barros Pereira 2014
    1. Barros Pereira I, Carvalho RM, Graça LM.Intra-abortion contraception with etonogestrel subdermal implant. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2015;185:33-5. - PubMed
Bender 2004
    1. Bender SS, Geirsson RT.Effectiveness of preabortion counseling on postabortion contraceptive use. Contraception 2004;69(6):481-7. - PubMed
Boesen 2004
    1. Boesen HC, Rørbye C, Nørgaard M, Nilas L.Sexual behavior during the first eight weeks after legal termination of pregnancy. Acta Obstetricia et Gynecologica Scandinavica 2004;83(12):1189-92. - PubMed
Covidence [Computer program]
    1. Covidence.Version accessed 7 November 2019. Melbourne, Australia: Veritas Health Innovation. Available at covidence.org.
Darney 2009
    1. Darney P, Patel A, Rosen K, Shapiro LS, Kaunitz AM.Safety and efficacy of a single-rod etonogestrel implant (Implanon): results from 11 international clinical trials. Fertility and Sterility 2009;91(5):1646-53. - PubMed
Deeks 2001
    1. Deeks JJ, Altman DG, Bradburn MJ.Statistical methods for examining heterogeneity and combining results from several studies in meta-analysis. In: Egger M, Davey Smith G, Altman DG, editors(s). Systematic Reviews in Health Care: Meta-Analysis in Context. 2nd edition. London: BMJ Publication Group, 2001:285-312.
Gemzell‐Danielsson 2014
    1. Gemzell-Danielsson K, Kopp Kallner H, Faúndes A.Contraception following abortion and the treatment of incomplete abortion. International Journal of Gynecology & Obstetrics 2014;126 Suppl 1:S52-5. - PubMed
GRADEpro GDT [Computer program]
    1. GRADEpro GDT.Version accessed 11 May 2020. Hamilton (ON): McMaster University (developed by Evidence Prime). Available at gradepro.org.
Grossman 2004
    1. Grossman D, Ellertson C, Grimes DA, Walker D.Routine follow-up visits after first-trimester induced abortion. Obstetrics & Gynecology 2004;103(4):738-45. - PubMed
Higgins 2021
    1. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s).Cochrane Handbook for Systematic Reviews of Interventions Version 6.2 (updated February 2021). Cochrane, 2021. Available from training.cochrane.org/handbook.
Kangatharan 2017
    1. Kangatharan C, Labram S, Bhattacharya S.Interpregnancy interval following miscarriage and adverse pregnancy outcomes: systematic review and meta-analysis. Human Reproduction Update 2017;23(2):221-31. - PubMed
Langston 2014
    1. Langston AM, Joslin-Roher SL, Westhoff CL.Immediate postabortion access to IUDs, implants and DMPA reduces repeat pregnancy within 1 year in a New York City practice. Contraception 2014;89(2):103-8. - PubMed
Liberati 2009
    1. Liberati A, Altman D, Tetzlaff J, Mulrow C, Gotzsche P, Ioannidis J, et al.The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. BMJ 2009;339:b2700. - PMC - PubMed
Lopez 2012
    1. Lopez LM, Newmann SJ, Grimes DA, Nanda K, Schulz KF.Immediate start of hormonal contraceptives for contraception. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No: CD006260. [DOI: 10.1002/14651858.CD006260.pub3] - DOI - PubMed
Meader 2014
    1. Meader N, King K, Llewellyn A, Norman G, Brown J, Rodgers M, et al.A checklist designed to aid consistency and reproducibility of GRADE assessments: development and pilot validation. Systematic Reviews 2014;3:82-90. - PMC - PubMed
Moslin 2011
    1. Moslin TA, Rochat RW.Contraceptive use among clients of the Atlanta Feminist Women's Health Center at three to five weeks post-abortion. Maternal and Child Health Journal 2011;15(6):759-64. - PubMed
Ngo 2014
    1. Ngo TD, Keogh S, Nguyen TH, Le HT, Pham KHT, Nguyen YBT, et al.Risk factors for repeat abortion and implications for addressing unintended pregnancy in Vietnam. International Journal of Gynaecology and Obstetrics 2014;125(3):241-6. - PubMed
Review Manager 2020 [Computer program]
    1. Review Manager 5 (RevMan 5).Version 5.4. Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2020.
Rose 2015
    1. Rose SB, Garrett SM, Stanley J.Immediate postabortion initiation of levonorgestrel implants reduces the incidence of births and abortions at 2 years and beyond. Contraception 2015;92(1):17-25. - PubMed
Schmidt‐Hansen 2020
    1. Schmidt-Hansen M, Hawkins JE, Lord J, Williams K, Lohr PA, Hasler E, et al.Long-acting reversible contraception immediately after medical abortion. Human Reproduction Update 2020;26(2):141-60. - PubMed
Schreiber 2011
    1. Schreiber CA, Sober S, Ratcliffe S, Creinin MD.Ovulation resumption after medical abortion with mifepristone and misoprostol. Contraception 2011;84(3):230-3. - PubMed
Schünemann 2021
    1. Schünemann HJ, Higgins JPT, Vist GE, Glasziou P, Akl EA, Skoetz N, et al.Chapter 14: Completing ‘Summary of findings’ tables and grading the certainty of the evidence. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 6. 2 (updated February 2021). Cochrane, 2021. Available from training.cochrane.org/handbook.
Sothornwit 2017
    1. Sothornwit J, Werawatakul Y, Kaewrudee S, Lumbiganon P, Laopaiboon M.Immediate versus delayed postpartum insertion of contraceptive implant for contraception. Cochrane Database of Systematic Reviews 2017, Issue 4. Art. No: CD011913. [DOI: 10.1002/14651858.CD011913.pub2] - DOI - PMC - PubMed
Upadhyay 2012
    1. Upadhyay UD, Brown BA, Sokoloff A, Raine TR.Contraceptive discontinuation and repeat unintended pregnancy within 1 year after an abortion. Contraception 2012;85(1):56-62. - PMC - PubMed
Wan 2014
    1. Wan X, Wang W, Liu J, Tong T.Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Medical Research Methodology 2014;14:135. - PMC - PubMed
WHO 2005
    1. World Health Organization.Report of a technical consultation on birth spacing. 2005. www.who.int/maternal_child_adolescent/documents/birth_spacing05/en/ (accessed 1 July 2019).
WHO 2014
    1. World Health Organization.Clinical practice handbook for safe abortion. 2014. apps.who.int/iris/bitstream/handle/10665/97415/9789241548717_eng.pdf (accessed 1 December 2019). - PubMed
WHO 2015a
    1. World Health Organization.Medical eligibility criteria for contraceptive use. Fifth edition 2015. apps.who.int/iris/bitstream/handle/10665/172915/WHO%20RHR%2015.07%20eng.... (accessed 1 July 2019).
WHO 2015b
    1. World Health Organization.Health worker roles in providing safe abortion care and post abortion contraception. 2015. apps.who.int/iris/bitstream/10665/181041/1/9789241549264_eng.pdf (accessed 1 July 2019). - PubMed

Publication types