Contraception: Postabortion

INTRODUCTION — People who experience spontaneous or induced abortion have contraceptive needs that differ from those who are postpartum and the general population. Fertility returns quickly, making contraceptive counseling and provision a critical component of care. Contraceptive counseling for postabortion patients includes reviewing their contraceptive preferences (ie, efficacy, convenience) and all contraceptive methods so they can pick a method that meets short- and long-term planning needs. Most contraceptives can be started immediately.

This topic focuses on contraceptive considerations following pregnancies that have ended in the first or second trimester (typically <24 weeks gestation) by surgical or medical management for the indications of induced or spontaneous abortion. Related content on contraceptive counseling and selection in the postpartum setting and among the general population is discussed separately.

●(See "Contraception: Counseling and selection".)

●(See "Contraception: Postpartum counseling and methods".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

CONTRACEPTIVE COUNSELING

Resumption of ovulation — We inform all patients about their ability to get pregnant quickly following an induced or spontaneous abortion. Ovulation postabortion occurs between a mean of 21 to 29 days after the procedure with a reported range of 8 to 103 days [1,2]. Thus, patients can become pregnant before their first period.

Personalized counseling and shared decision making — Selecting a contraceptive method is an important process that should involve shared decision making between patient and clinician. After experiencing an induced or spontaneous abortion, patients may or may not be ready to discuss contraceptive care, and their preferences should be respected [3]. Some patients do not want to become pregnant soon and are highly motivated to prevent pregnancy, while others may feel ambivalent about future pregnancy. It is important to note, as with other preventive care efforts such as smoking cessation, education and counseling by health care providers positively impacts behavior [4]. In general, contraceptive counseling reviews method safety, efficacy, mechanism(s) of action, side effects, protection from sexually transmitted infections (STIs), and other method-specific characteristics such as noncontraceptive benefits (eg, beneficial impact on menstrual bleeding). Our approach to shared decision making in general contraceptive counseling is discussed in detail elsewhere. (See "Contraception: Counseling and selection" and "Contraception: Counseling and selection", section on 'The shared decision-making process'.)

Specific counseling considerations in this setting include the following:

●For people with unintended pregnancy as a result of contraceptive failure, we attempt to identify factors that may have contributed to the method failure and help explore how to avoid this challenge in the future.

●We discuss the patient's short- and long-term reproductive plans, as they often differ. Some patients may desire a repeat pregnancy as soon as medically reasonable, some may require time to grieve a loss, and some may not desire pregnancy in the near future.

●Medical issues can drive both a person's contraceptive options and the timing of pregnancy, if desired. The World Health Organization Medical Eligibility Criteria for Contraceptive Use and the US Medical Eligibility Criteria for Contraceptive Use provide guidance for contraceptive use and timing of initiation for a variety of medical and personal issues [5,6].

Risk of sexually transmitted infection — We assess a person's risk of acquiring an STI as a routine part of contraceptive counseling. Everyone at risk for acquiring an STI is advised to use condoms (internal or external) in addition to their chosen method for pregnancy prevention. Detailed information on the prevention of STIs is presented separately. (See "Prevention of sexually transmitted infections".)

Contraceptive effects on postabortion recovery — Immediate initiation of contraception at the time of induced or spontaneous abortion does not impact the postprocedure recovery process. No differences have been reported for thromboembolic events, infection rates, or patient-reported pain [7-13]. Immediate start of hormonal contraception does not appear to alter bleeding patterns (volume or duration) following abortion [14].

INITIATION OF CONTRACEPTION

Choosing a contraceptive method — All contraceptive methods can be offered immediately after induced or spontaneous abortion; the choice of contraceptive method is highly patient-dependent and tailored to the patient's medical needs [3]. Steps in the shared decision-making process discussed above include identifying the patient's reproductive goals, eliciting informed preferences regarding contraceptive characteristics, educating the patient about the various methods, facilitating decision making, and ultimately selecting and starting a method. Contraceptive efficacy is often a key discussion point (figure 1). These steps do not differ for patients in the postabortion setting compared with other patient groups. Detailed discussions of these steps are presented elsewhere. (See "Contraception: Counseling and selection", section on 'The shared decision-making process'.)

Certain medical conditions or history may direct the selection process. Both the World Health Organization and the US Centers for Disease Control and Prevention maintain evidence-based recommendations for use of contraceptive methods in the context of a range of medical conditions and personal characteristics [5,6]. The World Health Organization Medical Eligibility Criteria for Contraceptive Use and the US Medical Eligibility Criteria for Contraceptive Use are freely available, easy to use, and provide contraceptive prescribers with definitive guidance on safety across a broad range of conditions [5,6]. Although rare, postabortion complications may limit the available contraceptive options (eg, women with postprocedure hemorrhage or infection are not candidates for immediate intrauterine device [IUD] insertion). (See 'Intrauterine device' below.)

When to start — Assuming no immediate complications, nearly all forms of contraception are safe and feasible to begin on the day of the procedure. These include IUD placement; subdermal implant placement; permanent contraception (sterilization); depot medroxyprogesterone acetate injection; and initiation of oral pills, transdermal patches, or vaginal rings. Condoms and single-size pericoital devices (eg, Caya) can also be initiated immediately. Patients with spontaneous pregnancy loss or who elect medication abortion outside of a health care facility often do not have a clearly defined day of completion to know when to "immediately" initiate contraception. In general, contraception is started when it is confirmed that the pregnancy has passed, typically by direct visualization of tissue or with ultrasound. With first-trimester medication abortion, it has been shown to be safe to place an IUD as early as one week following treatment if it has been determined that the uterus is empty [15].

Provision of immediate contraception at the time of the abortion visit eliminates the need for an additional visit and thus reduces barriers of additional cost and time. Immediate initiation of any contraceptive method is generally associated with higher patient satisfaction, higher use rates, and lower repeat unintended pregnancy rates [7,15,16]. The biggest impact on reducing unintended pregnancy is the immediate provision of long-acting contraceptive methods, such as the IUD or implant, because continuation of use to 6 or 12 months is higher than with the use of shorter acting methods [17,18].

Need for back-up contraception — The need for a second method of contraception (ie, back-up contraception) until the primary method is effective depends on the type of abortion.

●Induced abortion – For contraceptive methods started at the time of first- or second-trimester induced surgical or medication abortion, no back-up method is required. For people who start contraception up to seven days from the procedure, back-up contraception or a period of abstinence of seven days is generally advised [15]. Exceptions are the copper IUD, which is effective immediately, and progestin-only pills, which require only two days of back-up contraception.

●Spontaneous abortion – The optimal contraceptive start time is less clear for patients with spontaneous abortion compared with induced abortion because the exact time of pregnancy demise is less clear. We advise patients with spontaneous abortion, even if they undergo medical or surgical evacuation of the uterus, to initiate their desired contraceptive method once the uterus has been determined to be empty. We also advise they use back-up contraception or abstain from sex for an additional seven days because they could be ovulatory.

WOMEN WHO ARE UNCERTAIN ABOUT OR DECLINE CONTRACEPTION — For patients who are uncertain about choosing a contraceptive method or who decline contraception at the time of the abortion, we discuss condoms (internal or external) and emergency contraception. We encourage these patients to make a follow-up appointment for a future date to revisit their family planning desires and potential contraceptive needs.

People who delay starting contraception for more than seven days after a surgical or medication abortion are evaluated and assessed similarly to any other patient starting a contraceptive. We exclude pregnancy, ask about unprotected sexual activity, and assess the need for emergency contraception. (See "Contraception: Counseling and selection", section on 'Starting a method'.)

CONTRACEPTIVE OPTIONS — We counsel all patients about all available contraceptive options to optimize their short- and/or long-term family planning goals.

Permanent contraception (sterilization) — Tubal ligation (tubal occlusion or salpingectomy via laparoscopy or minilaparotomy) can also be safely performed immediately following a first- or second-trimester abortion. Clinicians should be aware that the stress of the immediate situation may influence some patients' choice. If there is any concern that the patient had not previously considered permanent contraception or that the immediate stress of the situation may be affecting the patient's choice, alternate contraceptive methods may be preferred to avoid future regret. There also may be federal or state regulations that restrict this option. Alternatively, the partner with a penis may elect permanent contraception with vasectomy. (See "Overview of female permanent contraception" and "Vasectomy".)

Long-acting reversible contraception — When patients receive contraceptive counseling that highlights the most effective methods (figure 1), they are highly likely to choose such effective methods, particularly when barriers such as cost and access are removed [19].

Intrauterine device — Intrauterine devices (IUDs) can safely be inserted at the completion of a surgical abortion (any trimester) or medical induction of labor in the second trimester [15]. While the day of completion is not always clear for individuals undergoing first-trimester medication abortion, IUD insertion within 48 hours of likely completion is reasonable [20]. (See "First-trimester pregnancy termination: Medication abortion", section on 'Plan for contraception'.)

●Expulsion rate and impact of gestational age – The IUD expulsion rate is increased for devices inserted immediately after a second-trimester procedure (approximately 10 to 15 percent) compared with insertion (immediate or interval) following first-trimester procedures (approximately 5 percent) [11,21]. However, the somewhat higher risk of IUD expulsion is generally outweighed by the benefits of immediate insertion [15].

●Benefits of immediate IUD insertion – Benefits of immediate compared with interval IUD insertion include that it is generally less painful because the cervix is already open and convenience (compared with having to return for a future visit) [20]. Additionally, patients frequently have received pain medication for the abortion procedure, which can also provide additional pain control during the IUD placement.

●General contraindications to immediate IUD insertion – IUDs should not be immediately placed in most cases of hemorrhage, uterine perforation, or hematometra [22]. An IUD should not be placed in the setting of a septic abortion [5]. Instead, we offer the patient an alternate contraceptive method and then place the IUD once the complication has resolved.

Postabortion IUD placement does not appear to increase the rates of postprocedure pain, infection, or irregular or heavy bleeding [7-12]. When these issues do occur, they are unlikely to be caused by the device. Specifically, pelvic infection has been shown to be uncommon after immediate postabortion IUD insertion even in women with a history of pelvic inflammatory disease or positive screening results for chlamydia at the time of abortion [23]. Thus, it is usually not necessary or helpful to remove the IUD while these complications are being evaluated and treated. An IUD does not need to be removed in the setting of endometritis unless the patient does not show clinical improvement with the use of antibiotics [15]. (See "Intrauterine contraception: Management of side effects and complications", section on 'Infection and/or pelvic inflammatory disease' and "Endometritis unrelated to pregnancy".)

Detailed discussions of the IUD device types, patient selection, issues regarding insertion and removal, and management of side effects and complications are presented in separate topics.

●(See "Intrauterine contraception: Background and device types".)

●(See "Intrauterine contraception: Candidates and device selection".)

●(See "Intrauterine contraception: Insertion and removal".)

●(See "Intrauterine contraception: Management of side effects and complications".)

Progestin-only implant — The progestin-only etonogestrel implant has no risks specific to the postabortion setting, regardless of gestational age or surgical or medical management [5]. (See "Contraception: Etonogestrel implant".)

Of note, the US Centers for Disease Control and Prevention's US Medical Eligibility Criteria for Contraceptive Use and Selected Practice Recommendations do not provide explicit recommendations for contraceptive start following medication abortion using mifepristone. Initially, there was theoretical concern that administering mifepristone, an antiprogestin, and progestins in close succession might affect the efficacy of the mifepristone. However, several studies on abortion efficacy that have examined the effect of administering the contraceptive implant concurrently with mifepristone have reported that concurrent use does not decrease medication abortion success up to 70 days gestation [24-26]. There was also increased patient satisfaction among those who were able to immediately start the implant compared with those who were asked to wait until a follow-up visit [25]. This is now common practice in the United States.

Short-acting reversible contraception — Short acting contraceptives include progestin injections, combined estrogen-progestin methods (eg, oral pill, transdermal patch, vaginal ring), progestin-only pills, and barrier methods (ie, female and male condoms). These methods are moderately to less effective options (figure 1).

Depot medroxyprogesterone acetate — As with the progestin-only implant, depot medroxyprogesterone acetate (DMPA) has no risks specific to the postabortion setting, regardless of procedure approach (surgical or medication) or gestational age [5]. With medication abortion, concerns were raised about administering DMPA concurrently with mifepristone and the potential impact on mifepristone efficacy. One study of women undergoing induced abortion up to 75 days of gestation treated with one dose of misoprostol did report a higher ongoing pregnancy rate with concurrent administration of DMPA compared with delayed administration (3.6 versus 0.9 percent) [27]. However, the overall success rates for both groups were above 90 percent. Further studies are evaluating if a second dose of misoprostol may be helpful.

Subcutaneous DMPA 104 mg has not been directly studied in the context of medication abortion. Subcutaneous DMPA 104 mg is absorbed more slowly and produces lower peak serum levels of hormone than DMPA 150 mg intramuscularly [28], but it is unknown how this pharmacokinetic difference may impact any interaction with mifepristone.

Detailed discussions of DMPA are presented in related topics:

●(See "Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration".)

●(See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits".)

Combined estrogen-progestin contraceptives — All combined estrogen-progestin contraceptive methods (oral pill, transdermal patch, vaginal ring) can be started immediately following first- or second-trimester abortion [5]. Concerns were previously raised over early initiation of the vaginal ring because of potential infection risk. However, a study of 81 women who received a contraceptive vaginal ring within one week of first-trimester medication or surgical abortion reported no adverse events [29]. Additionally, there is no evidence that avoiding anything in the vagina changes the risk of infection, and this historic recommendation has been removed from most postabortion guidelines [30].

Progestin-only pills — Progestin-only pills can be started immediately following spontaneous or induced abortion in the first or second trimesters [15]. Unless the medication is started on the day of surgical abortion, patients are advised to use back-up contraception, or abstinence, for two additional days. (See "Contraception: Progestin-only pills (POPs)".)

Single-size diaphragm — Single-size diaphragms (eg, Caya) may be used immediately following medication or surgical abortion in the first or second trimester because they do not require resizing. (See "Pericoital (on demand) contraception: Diaphragm, cervical cap, spermicides, and sponge", section on 'Single size'.)

Barrier contraception — Barrier methods (internal and external condoms) can be used immediately following medication or surgical abortion. They provide the added benefit of protecting from sexually transmitted infections (STIs), particularly for external condoms. (See "Internal (formerly female) condoms" and "External (formerly male) condoms" and "Prevention of sexually transmitted infections".)

Contraceptives requiring a delayed start

Fertility awareness methods — Fertility awareness methods should not be used immediately postabortion because it may take several months for the patient's menses to resume. The World Health Organization advises waiting three postprocedure menses before utilizing fertility awareness methods [31]. (See "Fertility awareness-based methods of pregnancy prevention".)

Sized diaphragm or cervical cap — The size of a fitted diaphragm or cervical cap is influenced by the patient's reproductive history and cervix size. Fitting of a sized diaphragm requires that pregnancy-related cervical changes have regressed, which may take two to six weeks following abortion. Although there are no specific data, the US Medical Eligibility Criteria for Contraceptive Use recommend waiting six weeks after a second-trimester abortion to initiate a sized diaphragm or cervical cap due to possible changes in anatomy that would affect the fit, similar to following term delivery [5]. (See "Pericoital (on demand) contraception: Diaphragm, cervical cap, spermicides, and sponge".)

Emergency contraception — We discuss the availability of emergency contraception with all patients, particularly those who do not start a contraceptive method at the time of abortion. (See "Emergency contraception".)

RESOURCES FOR CLINICIANS AND PATIENTS

●Planned Parenthood – Provides free information on abortion and contraceptive options for patients and health care clinicians.

●US Centers for Disease Control and Prevention – Provides free access to its Medical Eligibility Criteria for Contraceptive Use and Selected Practice Recommendations for contraceptive use.

●World Health Organization Medical Eligibility Criteria for Contraceptive Use

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Contraception".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Birth control; which method is right for me? (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Risk of pregnancy – Following induced or spontaneous abortion, patients should be informed about their ability to get pregnant quickly, before their first period. (See 'Resumption of ovulation' above.)

●Patient-centered contraceptive counseling – Selecting a contraceptive method is an important process that should involve shared decision making between patient and clinician. After having experienced an induced or spontaneous abortion, some patients do not want to become pregnant soon and are highly motivated to prevent pregnancy, while others may feel ambivalent about future pregnancy. (See 'Personalized counseling and shared decision making' above.)

●Contraceptive medical eligibility and selection – The choice of contraceptive method is highly patient-dependent. Certain medical conditions or history may direct the selection process. Both the World Health Organization Medical Eligibility Criteria for Contraceptive Use and the US Medical Eligibility Criteria for Contraceptive Use provide evidence-based recommendations for use of contraceptive methods in the context of a range of medical conditions and personal characteristics. (See 'Choosing a contraceptive method' above.)

•Patients should be counseled about all available contraceptive options to help them choose the method that is safe, effective, convenient, and best meets their short- and/or long-term family planning needs. (See 'Contraceptive options' above.)

•When patients receive contraceptive counseling that highlights the most effective methods (figure 1), they are highly likely to choose such effective methods, particularly when barriers such as cost and access are removed. (See 'Long-acting reversible contraception' above.)

●Timing of contraceptive start

•Immediate start – In the absence of immediate complications, nearly all forms of contraception are safe and feasible to begin on the day of the procedure. Provision of immediate contraception at the time of the abortion visit eliminates the need for an additional visit and thus reduce barriers of additional cost and time. (See 'When to start' above.)

•Delayed start – The only methods that should be delayed include methods that require fitting, including the cervical cap and sized diaphragm, and fertility awareness methods that require that regular monthly menses have returned. (See 'Contraceptives requiring a delayed start' above.)

●STI counseling – We educate all patients about the availability of condoms to reduce sexually transmitted infections (STIs) and emergency contraception in the event of unprotected intercourse. (See 'Risk of sexually transmitted infection' above and 'Emergency contraception' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Andrew Kaunitz, MD, who contributed to an earlier version of this topic review.