LARC methods available in the United States
Currently there are five IUDs and one contraceptive implant available in the United States.
Copper Intrauterine Device
Paragard is the copper T380A IUD commercially available in the United States. It is US Food and Drug Administration-approved for use up to 10 years but has been shown to be effective up to 12 years.10 The T-shaped device is a base of polyethylene wrapped with copper wire around the stem and arms. Mechanisms of action (MOAs) include inhibition of sperm migration and viability and damage to or destruction of the ovum.11,12 Postfertilization events may occur, but the copper IUD does not disrupt a pregnancy after implantation. It has a reported 1-year failure rate of 0.8 per 100 women. The most-reported adverse events (AE) are abnormal uterine bleeding and pain.13
Levonogestrel intrauterine systems
There are four levonogestrel intrauterine systems (LNG-IUS) currently available in the United States (Mirena, Liletta, Kyleena, Skyla) (Table 1). All are T-shaped and include a polydimethylsiloxane sleeve containing levonorgestrel in the stem. All LNG-IUS have a similar primary MOA: prevention of fertilization by increasing the amount and viscosity of cervical mucus.14,15 Most women who use an LNG-IUS ovulate but experience diminished menstrual bleeding due to the local effect of the levonorgestrel on the endometrium.16 LNG-IUS are not abortifacients and do not disrupt pregnancy.
The etonogestrel contraceptive implant is placed subdermally and consists of an ethylene vinyl acetate copolymer core containing 68 mg of etonogestrel. The single-rod implant is 4 cm in length and 2 mm in diameter and is preloaded in a disposable sterile applicator. The 2001 version of the implant has been updated and was introduced to the United States in 2011.17 The newer implant is radio-opaque with a new inserter designed to prevent deep placement. Its primary MOA is ovulation suppression, but it also thickens cervical mucus and has endometrial effects.18,19 After implant insertion, changes in menstrual patterns are common and include amenorrhea, or frequent, infrequent, or prolonged bleeding. Complications related to implant insertion and removal are rare.
- Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunc. 2005;16:263-267.
- Jackson E, Glasier A. Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstet Gynecol. 2011; 117:657-662.
- McKinney J, Keyser L, Clinton S, Pagliano C. ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstet Gynecol. 2018 Sep;132(3):784-785.
- Danilack VA, Brousseau EC, Paulo BA, Matteson KA, Clark MA. Characteristics of women without a postpartum checkup among PRAMS participants, 2009-2011. Matern Child Health J. 2019 Jan 10. doi: 10.1007/s10995-018-02716-x. [Epub ahead of print]
- White K, Teal SB, Potter JE. Contraception after delivery and short interpregnancy intervals among women in the United States. Obstet Gynecol. 2015;125;1471-1477.
- Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA 2006; 295 (15): 1809-23
- U.S. Office of Disease Prevention and Health Promotion. Available at https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health
- Committee on Gynecologic Practice Long-Acting Reversible Contraception Working Group. Committee Opinion No. 642: Increasing Access to Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy. Obstet Gynecol. 2015 Oct;126(4):e44-e48.
- American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. Committee Opinion No. 670: Immediate Postpartum Long-Acting Reversible Contraception. Obstet Gynecol. 2016 Aug;128(2):e32-e37.
- Wu JP, Pickle S. Extended use of the intrauterine device: a literature review and recommendations for clinical practice. Contraception 2014; 89: 495-503
- Rivera R, Yacobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices. Am J Obstet Gynecol. 1999;181:1263-1269.
- Ortiz ME, Coxatta HB. Copper T intrauterine device and levonorgestrel intrauterine syste; biological bases of their mechanism of action. Contraception. 2007;75:S16-S30.
- Godfrey EM, Folger SG, Jeng G, Jamieson DJ, Curtis KM. Treatment of bleeding irregularities in women with copper-containing IUDs: a systematic review. Contraception. 2013;87:549-566.
- Natavio MF, Taylor D, Lewis RA, Blumenthal P, Felix JC, Melamed A, et al. Temporal changes in cervical mucus after insertion of the levonorgestrel-releasing intrauterine system. Contraception. 2013;87:426-431.
- Lewis RA, Taylor D, Natavio MF, Melamed A, Feliz J, Mishell D Jr. Effects of the levonorgestrel-releasing intrauterine system on cervical mucus quality and sperm penetrability. Contraception. 2010;82:491-496.
- Gemzell-Danielsson K, Schellschmidt I, Apter D. A randomized phase II study describing the efficacy, bleeding profile and safety of two low-dose levonorgestrel releasing intrauterine contraceptive systems and Mirena. Fertil Steril. 2012;97:616-622. E1-E3
- Graesslin O, Korver T. The contraceptive efficacy of Implanon: A review of clinical trials and marketing experience. Eur J Contracept Reprod Health Care. 2008;13 Suppl 1 4-12.
- Davies GC, Feng LX, Newton JR, Van Beek A, Coeling-Bennink HJ. Release characteristic, ovarian activity and menstrual bleeding pattern with a single contraceptive implant releasing 3-ketodesestril. Contraception. 1993;47:251-261.
- Croxatto HB. Mechanisms that explain the contraceptive action of progestin implants for women. Contraception. 2002;65:21-27.
- Update to CDCs U.S. Medical Eligibility Criteria for Contraceptive Use 2010: revised recommendations for the use of contraceptive methods during the postpartum period. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2011;60:878-883.
- Caliskan E. Ozurk N, Dilbaz S. Analysis of risk factors associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care. 2003;8(3):150-155.
- Dahlke JD, Terpstra ER, Ramseyer AM, Busch JM, Rieg T, Magann EF. Postpartum insertion of levonorgestrel-intratuerine system at three time periods: a prospective randomized pilot study. Contraception. 2011;84;244-248.
- Celen S, Sucak A, Yildiz Y, Danisman N. Immediate postplacental insertion of intrauterine contraceptive device during cesarean section. Contraception. 2011;84:240-243.
- Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, Creinin MD. Postplacetnal or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2010;116:1079-1087.
- Levi EE. Stuart GS, Zerden ML, Garrett JM, Bryant AG. Intrauterine device placement during cesarean delivery and continued use 6 months postpartum: a randomized controlled trial. Obstet Gynecol. 2015;126:5-11.
- Sothornwit J, Werawatakul Y, Kaewrudee S, Lumbiganon P, Laopaiboon M. Immediate versus delayed postpartum insertion of contraptive implant for contraption. Cochrane Database Sys Rev. 2017 Apr 22;4.
- Chen BA, Reeves MF, Creinin MD, Schwarz EB. Postplacental or delayed levonorgestrel intrauterine devices insertion and breastfeeding duration. Contraception. 2011;84(5):499-504.
- Whitaker A, Chen BA. Society of Family Planning Guidelines: Postplacental insertion of intrauterine devices. Contraception. 2018;97:2-13.
- American College of Obstetrics and Gynecology. Video on Immediate Postplacental LARC Insertion. Available at https://cfweb.acog.org/district_ii/larc/section4.html
- Glazer AB, Wolf A, Gorby N. Postpartum contraception: needs vs. reality. Contraception. 2011;83(3):238-241.
- Lester F, Kakaire O, Byanugish J, Averbach S, Fortin J, Maurer R, et al. Intracesarean insertion of the copper T380A versus 6 weeks postcesarean: a randomized clinical trial. Contraception. 2015;91(3):198-203.
- Washington CI, Jamshidi R, Thung SF, Naveri UA, Caughey AB, Werner EF. Timing of postpartum intrauterine device placement: a cost-effectiveness analysis. Fertil Steril. 2015;103(1):131-137.
- Gariepy AM, Duffy JY, Xu X. Cost-Effectiveness of Immediate Compared With Delayed Postpartum Etonogestrel Implant Insertion. Obstet Gynecol. 2015 Jul;126(1):47–55.
- Rodriguez MI, Caugher AB, Edelman A, Darney PD, Foster DG. Cost-benefit analysis of state and hospital funded postpartum intrauterine contraception at a university hospital for recent immigrants to the United States. Contraception. 2010; 81(4):304-308.
- Ongoing barriers to immediate postpartum long-acting reversible contraception: a physician survey. Holden EC, Lai E, Morelli SS, Alderson D, Schulkin J, Castleberry NM, McGovern PG. Contracept Reprod Med. 2018 Nov 8;3:23.
- Moniz MH, Dalton VK, Davis MM, et al. Characterization of Medicaid policy for immediate postpartum contraception. Contraception. 2015 Dec;92(6):523-531.
- Hofler LG, Cordes S, Cwiak CA, Goedken P, Jamieson DJ, Kottke M. Implementing immediate postpartum long-acting reversible contraception programs. Obstet Gynecol. 2017 Jan;129(1):3-9.
- ACOG Postpartum Contraceptive Access Initiative. Available at https://pcainitiative.acog.org