1. Levonorgestrel releasing IUS (Mirena ® ) after abortion S.Rogovskaya, MD,PhD The Research Center of Obstetrics, Gynecology and Perinatology, Russian Academy of Medical Science, Moscow, Russia

2. Abortion and gynecological morbidity (MH RF) Abortion number 02 -36 -7 Risk of gynecological morbidity % 3 -418 -20100 The higher the number of abortions – The higher the risk of gynecological diseases N.Nikiforovsky et.al, 2000 Abortion rates in RF

3. Special demands for contraception after abortion Long-term Reversible Effective Safe Easy to use

4. Reasons to initiate contraception immediately after abortion The return of fertility after a first trimester abortion is very rapid For women, who usually do not visit a doctor and might not come to a control visit after abortion - an optimal opportunity to initiate contraception is immediately after the procedure

5. Contraception after abortion (tipical use) MethodPearl index COP 1-3 Injection 0,3– 1,0 Implants 0,2-1,0 IUD 0,1 – 3,9 Barrier 5 –25 Sterilization 0,2 – 1,0 Natural 10-30 V. Prilepskaya, 1998

6. Intrauterine levonorgestrel - releasing system was developed to combine contraceptive and therapeutic properties of hormonal agents with advantages of intrauterine devices Long lasting Active progestin Antiestrogenic effect Antiproliferative action on endometrium No metabolic effect Therapeutic properties

7. Advantages of LNG IUS Lighter periods Reduces dysmenorrhea Beneficial effects on adenomyosis and leiomyomas Effective treatment in menorrhagia Decreases the need for hysterectomies Protection from endometrium hyperplasia during hormonal therapy (HRT) Intrauterine release of 20µg LNG/d Approved for 5 years Pearl-index ~ 0.1 Maia et al, Gyn&Endocr 2005; Grigorieva et al, Fertil&Steril 2003; Hurskainen et al, JAMA 2004

8. Various aspects of LNG-IUS were studied in Research Center of Obstetrics, Gynaecology and Perinatology for 8 years Two studies were carried out within framework of WHO and FHI. Published: 1 monograph, 30 articles in domestic and foreign magazines, 16 reports at congresses, conferences and symposia. Detailed survey in 1126 women. V. Prilepskaya, L.Ostreykova, A.Tagieva, 2005

9. LNG-IUS in women with diabetes The continuation rates per 100 women with diabetes mellitus type I 86.7% (95% CI, 68.8-100) The small amounts of levonorgestrel absorbed systemically from LNG-IUS do not impair glucose metabolism S.Rogovskaya et al, The American College of Obstetricians and Gynecologists 2005

10. Glycosylated haemoglobin at baseline and follow-up by treatment group S.Rogovskaya et al, 2005

11. Mirena-IUS after surgical abortion: the first study Immediate postabortal insertion of a LNG- releasing IUS compared with Cu-IUD n= 60 Both devices well tolerated LNG-IUS - regular cycles in 75% at 1 year Cu-IUD - regular cycles in all Continuation rate 75% at 1 year Heikkilä et al., Contraception, 1982; 26:245-59

12. 12-month multicenter trial comparing Mirena ® and Nova T ® Alltogether 2758 women 1821 in Mirena group 937 in NovaT group 440 (16%) postabortal insertions immediately after abortion or in 2 weeks Luukkainen et al 1987

13. Cumulative 12-month events per 100 women EventNovaTMirenaNovaTMirena Pregnancy0.80.12.10 Expulsion3.02.88.36.8 Mestrual/pain7.59.07.77.9 Hormonal0.12.601.7 Other medical1.92.39.27.1 Personal2.82.51.82.7 Continuation83.980.871.373.8 Menstrual IntervalPostabortion Luukkainen et al 1987

14. Results of 12-month study Pregnancies Mirena group 0 NovaT group 2.1 / 100 women Expulsion rate higher in postabortion insertions NovaT 3.0 vs 8.3 Mirena 2.8 vs 6.8 Removals for other medical reasons Most usual in postabortal NovaT group (9.2/100) Removals for hormonal reasons Most usual in menstrual interval Mirena group (2.6 / 100) Luukkainen et al 1987

15. Postabortal contraception with the Mirena, Norplant, and traditional methods Turkey 50 women in each group Pregnancy < 10 weeks Insertion of Mirena or Norplant implants was done immediately after the evacuation of the uterus 12 month follow-up Ortayli et al 2001

16. Postabortal contraception with the Mirena, Norplant, and traditional methods Pregnancies Mirena 0, Norplant 0, traditional method rate 8/100 Continuation rates at 12 months 96 % for Norplant and 90% for Mirena Expulsions 2 in Mirena group Bleeding and spotting After 5 th week no difference between the groups in bleeding Ortayli et al, 2001

17. Postabortal contraception with the Mirena, Norplant, and traditional methods Satisfaction with the methods Most of the users of hormonal methods were satisfied with their method Easy to use Safe Effective The Mirena users appreciated the reduced menstrual bleeding Ortayli et al 2001

18. Randomized comparison of LNG and Cu- releasing IUS’s immediately after abortion - a 5-year follow-up Multicenter study in Denmark, Finland, Hungary, Norway and Sweden Surgical abortion of pregnancies up to 12 weeks Randomized for Mirena (305 patients) or Nova-T (133 patients) IUS inserted immediately after curettage Pakarinen et al., Contraception 2003; 68: 31-34

19. LNG vs Cu-IUS’s after abortion Reasons for discontinuation (/100 women) 1 year5 years p Cu LNG-IUSCu LNG-IUS Pregnancy209.50.8 <0.0005 Expulsion8.67.115.410.5 ns Bleeding 7.75.822.613.7 ns Amenorrhea01.602.1 ns Pain1210.85.5 ns Hormonal023.915.9 <0.01 Pakarinen et al., Contraception 2003; 68: 31-34

20. Reasons for discontinuation 2 pregnancies in Mirena group - (Occurred during the 4th year) The first pregnancy was terminated by curettage and no IUS was found The second pregnancy was after an unnoticed expulsion The incidence of expulsions, bleeding problems, pain and pelvic inflammatory disease (PID) Not significantly different between the groups but tended to be lower in the Mirena group Pakarinen et al., Contraception 2003; 68: 31-34

21. Reasons for discontinuation Planning pregnancy 11.5 for NovaT and 17.7 for Mirena High figures show the importance of a reversible method Amenorrhea Terminations occurred during the use of Mirena The cumulative gross rate was low, 2.1 at 5 years Bleeding disorders Tended to be lower in Mirena group Hormonal reasons higher with the Mirena than NovaT Pakarinen et al., Contraception 2003; 68: 31-34

22. Mirena ® -IUS following medical abortion at Women’s Hospital, University of Helsinki 417 women chose medical abortion between VIII/2000 and VIII/2001 Duration of pregnancy up to 8 weeks Analysis of efficacy, learning curve and future contraception 29% chose IUS/IUD for future contraception 16% (n=65) Mirena 13% (n=53) Cu-IUD 55% of the IUD’s inserted at the control visit at 3 weeks following mifepristone 25% inserted at later occasion at the clinic Insertions without complications Suhonen et al., Contraception 2003; 67: 223-7

23. LNG-IUS after abortion in RC OGP, Moscow N=37 12 months follow-up Effective (no pregnancies) Safe, no serious adverse effects Most reasons for discontinuation – bleeding, spotting Continuation rate 82% V.Prilepskaya, A.Kuzemin, 2004

24. Mirena-IUS after abortion summary Mirena-IUS is highly effective for postabortal contraception (Pregnancy rates low, IP=0.1-0.2) Mirena-IUS can be safely inserted: at the time of 1st trimester surgical abortion or 2-3 weeks after medical abortion High rate of discontinuation of Mirena due to wish for pregnancy - emphasises the importance of reversibility of contraception

25. Mirena-IUS after abortion summary Counselling and insertion technique are important (expulsions increased) Easy method for women Effective immediately after insertion, long-term 5 yrs No daily remembering Offers added health benefits Reduction of menstrual bleeding Better iron balance and prevention of anaemia Reduces dysmenorrhea, smaller risk of bleeding due to adenomyosis and leiomyomas Effective in menorrhagia

26. Mirena – method of contraception after abortion Effective Safe Reversible 5 years