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LARC Access COVID-19

Written by Tim Bavinton on .

Please note that this statement was relevant in Australia at the peak of the COVID-19 pandemic, when the risk and consequences of COVID were assessed to outweigh the risk of contraceptive failure with extended use of LARC. Now that restrictions have eased, and regular access to contraceptive services have for the most part resumed, it is advisable to return to practice of replacing LARC at the standard time interval to minimise the risk of contraceptive failure. However should the situation change and restrictions reapplied this statement informs our approach to LARC access in these circumstances.

SHFPACT Position Statement: LARC Access During the COVID-19 Pandemic.

Extended use of and ongoing access to LARCs during the COVID-19 pandemic Provision of contraception is essential during the COVID-19 pandemic to prevent unintended pregnancies.

This is particularly important for individuals most at risk, including young people due to their high levels of fertility, people with serious health conditions, and for those who are post-abortion. Long Acting Reversible Contraceptive methods (LARCs) are more effective than shorter acting methods1 and increased community access and uptake is associated with lower abortion rates. 2-4

Ongoing access to LARC insertion is essential during the pandemic

Contraception is essential health care and all efforts should be made to continue the insertion of LARCs during the pandemic. To reduce the risk of infection with COVID-19, this may require different approaches to insertion such as a wearing mask during insertion of contraceptive implant or using an inserter-only approach for IUD insertion (with an assistant outside the room for emergencies).

Summary of recommendations during the pandemic

  • All efforts should be made to continue access to insertion of LARCs during the pandemic, particularly for younger people, people with serious health conditions, and post-abortion

  • The etonogestrel implant (Implanon NXT) can be extended off-label for use up to 4 years

  • The 52mg LNG IUD (Mirena) can be extended off-label for use up to 6 years

  • The 19.5mg LNG IUD (Kyleena) cannot be extended beyond 5 years

  • Standard sized T shaped banded copper IUDs can be extended off-label for use up to 12 years

  • 5-year copper IUDs (Load 375 and Copper T short) can be extended off-label for use up to 6 years

  • Additional use of condoms and/or a contraceptive pill should be discussed with users for whom the risk of unintended pregnancy is unacceptable during extended use.

Deferral of routine LARC removal during the pandemic

In line with international COVID-19 recommendations5, Family Planning Alliance Australia supports the deferral of routine LARC removal (with or without replacement) according to the recommendations below within the context of informed shared-decision making. LARC methods are more than 99% effective with normal use. Equivalent effectiveness cannot be guaranteed with extended use, however available evidence does not support a significant reduction in effectiveness in the time periods outlined.6-9 The additional use of condoms and/or a contraceptive pill after the method has reached its licensed expiry date should also be discussed and offered, especially with individuals for whom the risk of an unintended pregnancy is unacceptable.

Extended use of intrauterine devices (IUDs) during the pandemic

Current IUDs available in Australia include the 52mg levonorgestrel (LNG)-IUD (Mirena), the 19.5mg LNG-IUD (Kyleena) and copper IUDs which last either 10 or 5 years.

52 mg LNG-IUD (Mirena)

The 52 mg LNG-IUD is licensed for 5 years of use; current practice supports off-label extended use of the device until menopause when it is inserted at ≥45 years of age.10, 11  For users who have had the device inserted <45 years of age, expert opinion supports offering the option of off-label extended use for up to 6 years during the pandemic rather than 5 years; additional use of condoms and/or a contraceptive pill should be discussed; the device must be removed/replaced at or within 6 years from insertion.

19.5mg LNG-IUD (Kyleena)

The 19.5 LNG-IUD is licensed for 5 years of use; extended use of the device is not recommended; if left in place beyond 5 years additional use of condoms and/or a contraceptive pill is advised until safe removal/replacement can be undertaken.

Copper IUDs

Copper IUDs available in Australia are licenced for 5 or 10 years use. Current practice supports offering the option of off-label extended use of any copper IUD approved for use in Australia until menopause when the device is inserted at ≥40 years of age.(10, 11)

10-year Copper IUDs

Standard sized T-shaped banded copper devices are licensed for up to 10 years of use (e.g. copper TT380A  For users who had the device inserted <40 years of age, expert opinion supports off-label extended use for up to 12 years, during the pandemic rather than 10 years; additional use of condoms and/or a contraceptive pill should be discussed; the device must be removed/replaced at or within 12 years from insertion.

5-year Copper IUDs

A number of Copper IUDs used in Australia are licensed for up to 5 years of use (e.g. Load 375 and copper T short).  For users who had the device inserted <40 years of age, expert opinion supports off-label extended use for up to 6 years, during the pandemic rather than 5 years; additional use of condoms and/or a contraceptive pill should be discussed; the device must be removed/replaced at or within 6 years from insertion.

Extended use of the etonogestrel implant (Implanon NXT) during the pandemic

The etonogestrel implant (Implanon NXT) is licensed for 3 years of use with no recommendations in place for off-label extended use. During the pandemic expert opinion supports offering the option of off-label extended use  or up to 4 years rather than 3 years; additional use of condoms and/or a contraceptive pill should be discussed with users for whom the risk of an unintended pregnancy is unacceptable.

The device must be removed/replaced at or within 4 years from insertion.

If contraception is no longer required

If contraception is not required all LARC methods may be left in place until removal can be arranged following the COVID-19 pandemic.

DOWNLOAD PDF
SHFPACT PositionStatement LARC

Sexual Health and Family Planning ACT Inc (SHFPACT) and the following Family Planning Organisations agree on this position. 

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References

  1. Winner B, Peipert JF, Zhao Q, Buckel C, Madden T, Allsworth JE, et al. Effectiveness of long-acting reversible contraception. The New England journal of medicine. 2012;366(21):1998-2007.
  2. Harper CC, Rocca CH, Thompson KM, Morfesis J, Goodman S, Darney PD, et al. Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial. Lancet. 2015.
  3. Ricketts S, Klingler G, Schwalberg R. Game change in Colorado: widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspect Sex Reprod Health. 2014;46(3):125-32.
  4. Connolly A, Pietri G, Yu J, Humphreys S. Association between long-acting reversible contraceptive use, teenage pregnancy, and abortion rates in England. Int J Womens Health. 2014;6:961-74.
  5. FSRH Position: Essential SRH Services during COVID-19 March 2020: Faculty of Sexual & Reproductive Healthcare; 2020 [cited 2020 30 March].
  6. Ti AJ, Roe AH, Whitehouse KC, Smith RA, Gaffield ME, Curtis KM. Effectiveness and Safety of Extending Intrauterine Device Duration: A Systematic Review. Am J Obstet Gynecol. 2020.
  7. Ali M, Akin A, Bahamondes L, Brache V, Habib N, Landoulsi S, et al. Extended use up to 5 years of the etonogestrel-releasing subdermal contraceptive implant: comparison to levonorgestrel-releasing subdermal implant. Hum Reprod. 2016.
  8. McNicholas C, Maddipati R, Zhao Q, Swor E, Peipert JF. Use of the etonogestrel implant and levonorgestrel intrauterine device beyond the u.s. Food and drug administration-approved duration. Obstet Gynecol. 2015;125(3):599-604.
  9. Wu JP, Pickle S. Extended use of the intrauterine device: a literature review and recommendations for clinical practice. Contraception. 2014;89(6):495-503.
  10. Contraception: An Australian Clinical Practice Handbook. 4th ed. Ashfield, NSW: Family Planning New South Wales, Family Planning Victoria and True Relationships and Reproductive Health; 2016.
  11. FSRH Guideline. Contraception for Women Aged Over 40 Years: Faculty of Sexual & Reproductive Healthcare Statement. Clinical Effectiveness Unit; 2017 [cited 2019 6 May]. October 2017

Given the rapidly changing circumstances around the COVID-19 public health emergency, we advise you to continue to monitor the latest health information on the ACT Health Directorate website.