By Melinda Young
New research shows that among emergency contraception (EC) clients, one in seven initiated a long-acting reversible contraceptive (LARC) method. And among those who chose LARC, most selected the etonogestrel implant with oral levonorgestrel (Plan B) over an intrauterine device (IUD).1
When people selected oral levonorgestrel for their EC and had a same-day etonogestrel implant inserted, they had a pregnancy rate within the established range of oral EC methods alone, a study showed.2
“When people came in and asked for emergency contraception, they were offered — in the primary study — implants with levonorgestrel or the copper IUD or the hormonal IUD as emergency and ongoing contraception,” says Lori M. Gawron, MD, MPH, FACOG, an associate professor in obstetrics and gynecology at the University of Utah in Salt Lake City, UT. The contraceptive implant also is an option when it is accompanied by Plan B, based on the Centers for Disease Control and Prevention (CDC) Selected Practice Recommendations.3
“You are giving them the oral emergency contraceptive, which was originally marketed as Plan B, but also initiating the implant on the same day,” she explains. “This allows for an ongoing, highly effective contraception.”
Family planning clinics often have patients who ask for EC, and this is a prime opportunity to talk with them about their ongoing contraceptive needs. “Talking with them about more effective, continuous contraceptive options is an important component of the visit,” Gawron says.
For the study, people were given data showing that both of the IUDs were very effective at EC and ongoing contraception. The implant does not have data about its use as an emergency contraceptive, so it would be provided along with over-the-counter oral levonorgestrel.
“We know Plan B is much less effective than either IUD, but if they wanted to be part of the study and get the implant, we wanted them to know the effectiveness of oral emergency contraception along with the implant for ongoing contraception,” Gawron says. “They were choosing between the two IUDs that were more effective as emergency contraception than the oral pill, or they could choose Plan B with the implant, and we could tell them it would only be as effective as Plan B at preventing pregnancy as an emergency contraception.”
Even knowing that selecting the implant, along with Plan B, meant they could expect a less effective form of EC with Plan B, more people chose the implant than either IUD, she says. “There is a demand for using the implant at the time of emergency contraception needs,” Gawron says.
Researchers did not study all of their reasons for selecting the implant instead of an IUD but did hear from participants that their friends were using the implant and that they were concerned about bleeding and wanted to avoid a pelvic exam, she notes.
“The only options for emergency contraception that are supported in clinical guidelines are oral contraception or IUDs,” Gawron says. Both of these options are difficult for patients to obtain from a private OB/GYN office, although family planning centers typically have both in stock for same-day use, she adds.
“The stocking of IUDs and implants is better than it used to be, but for some smaller offices, it is a barrier to having them on the shelf because of upfront costs,” Gawron explains. “Other barriers to getting emergency contraception are that you need to see a physician within five days to have the IUD for unprotected sex, and it can take more than five days to schedule an appointment.”
Obtaining an implant plus Plan B also can be a challenge in smaller offices. “The implant is the most effective ongoing contraception, but we don’t have data on it as an emergency contraception agent,” Gawron says. “We don’t know how much of a benefit there is in taking oral levonorgestrel on top of having an implant.”
In theory, the implant, which has a rapid serum rise after it is placed and is similar to Plan B in that respect, could quickly suppress ovulation. But studies are needed to show if that is the case. There currently is an ongoing, randomized controlled trial to compare the implant with the EC pill to the implant with a placebo to see if the pill is needed.
In the recently published study, researchers enrolled all clients of four Planned Parenthood Association of Utah clinics who were ages 18 to 35 years and who had visited the clinics to request EC from February 2021 to April 2023. They received information on oral EC options. This included counseling on the efficacy of prescription EC — ulipristal acetate (ella) — compared with the over-the-counter levonorgestrel oral EC. Ulipristal acetate can be more effective in people with a body mass index greater than 30 kg/m2.1
Ulipristal acetate would not be an option for people who want the implant at the same time as EC because it blocks progesterone receptors. Placing an implant at the same time could counteract the effect of ulipristal acetate as an EC by giving the person a big surge of progesterone from the implant.
“If you give a prescription to ella, you can’t do pills, patches, rings, Depo shot, or the implant on the same day. There needs to be a delay, so the guidelines recommend Plan B for emergency contraception if they’re initiating an ongoing hormonal contraceptive,” Gawron explains.3
The study suggests this approach to contraceptive counseling for patients who request EC: If they are within a weight range that would work well with Plan B, they can be offered that EC. But they also could be told that the copper IUD and hormonal IUD also work well as EC, and they have the added benefit of being long-acting reversible contraceptives. If the patient prefers the contraceptive implant for ongoing contraception, clinicians may suggest providing the implant along with Plan B, explaining that Plan B would be for EC and the implant for ongoing contraception.
For patients who have higher body weight, providers should discuss the efficacy of their emergency contraceptive options and also what they might desire for ongoing contraception. If a patient wants both EC and ongoing contraception, they could be counseled on the use of either the IUD for EC, or they could be offered ulipristal acetate and told they could have the implant placed five days after they take ulipristal acetate.
“Because of the proportion of Americans who have a higher body weight, that happens not infrequently where people need options for emergency contraception, and there is shared decision-making with the patient about what makes the most sense for them,” Gawron says. “If they want the most effective option for both emergency contraception and ongoing contraception, the IUDs have that efficacy data. If they don’t want an IUD, we can discuss different options for them and make sure they receive the best plan that meets their needs when they know there is a risk of pregnancy.”
References
- Carter G, Pangasa M, Sexsmith CD, et al. Selection of LARC methods by emergency contraception clients: A prospective observational study. Contraception. 2024;Sep 4:110701. doi: 10.1016/j.contraception.2024.110701. [Online ahead of print].
- Gawron LM, Sexsmith CD, Carter G, et al. Efficacy of oral levonorgestrel emergency contraception with same day etonogestrel contraceptive implant: A prospective observational study. Contraception. 2024;131:110344.
- Curtis KM, Nguyen AT, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024;73(3):1-77.
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
