Best Contraception to Prevent Ectopic Pregnancy
Long-acting reversible contraceptives (LARCs)—specifically the etonogestrel implant (Nexplanon) or levonorgestrel IUD (Mirena)—are the best contraceptive methods to prevent ectopic pregnancy because they are the most effective at preventing all pregnancies, including ectopic ones. 1
Why LARCs Are Superior for Ectopic Pregnancy Prevention
The fundamental principle is straightforward: the most effective contraceptive method at preventing any pregnancy is also the most effective at preventing ectopic pregnancy. Since ectopic pregnancies can only occur when conception happens, maximizing contraceptive efficacy is the primary strategy. 2, 1
Efficacy Data Supporting LARCs
Nexplanon (etonogestrel implant) has a typical use failure rate of only 0.05%, meaning 99.95% of women will not become pregnant during the first year of use 2, 1
Mirena (levonorgestrel IUD) has a typical use failure rate of 0.2%, meaning 99.8% of women will not become pregnant during the first year 2, 1
Both methods have continuation rates exceeding 80% at one year, ensuring sustained protection 2, 1
Why LARCs Outperform Other Methods
LARCs eliminate user adherence issues that plague other contraceptive methods, resulting in dramatically higher real-world effectiveness. 1 This is critical because:
Combined oral contraceptives, patches, and vaginal rings have 9% typical use failure rates (only 91% effectiveness) due to missed pills, late applications, or incorrect use 2, 1
Depo-Provera injections have a 6% typical use failure rate due to missed appointments 2, 1
Barrier methods like condoms have failure rates of 18-21% with typical use 2
Clinical Algorithm for Women at Risk
For Women With Prior Ectopic Pregnancy or Risk Factors
First-line recommendation: Offer LARC methods (implant or IUD) as they provide the highest protection against all pregnancies, including ectopic 2, 1
Nexplanon is particularly advantageous for women who cannot use estrogen-containing methods or have contraindications to IUDs 1
Mirena provides additional benefits including reduced menstrual bleeding, which may be desirable for some patients 2, 1
Risk Factors to Consider
Women at higher risk for ectopic pregnancy include those with: 3, 4, 5
- History of pelvic inflammatory disease
- Previous ectopic pregnancy
- Prior fallopian tube surgery or tubal sterilization
- Cigarette smoking
- History of infertility or assisted reproduction
- Presence of intrauterine device (though modern IUDs are still highly protective overall)
Important Caveats About IUDs and Ectopic Pregnancy
A critical distinction must be understood: While IUDs are extremely effective at preventing all pregnancies, if a pregnancy does occur with an IUD in place, there is a higher relative risk that it will be ectopic. 5 However, the absolute risk of ectopic pregnancy is still lower in IUD users compared to women using no contraception because IUDs prevent so many pregnancies overall. 2
- The copper IUD (Paragard) has a 0.6-0.8% typical use failure rate 2
- When IUD failure occurs, up to 50% may be ectopic, but this represents a tiny absolute number of cases 5
Contraceptive Counseling Approach
Contraceptive counseling should begin early in pregnancy or preconception and continue as an ongoing discussion. 2 For women with ectopic pregnancy risk factors:
Start by presenting the most effective methods first (LARCs), as recommended by CDC and American College of Obstetricians and Gynecologists 2, 1
Use the U.S. Medical Eligibility Criteria (US MEC) to ensure the chosen method is appropriate for any comorbid conditions 2
Emphasize that LARCs are easily reversible when pregnancy is desired, allowing for planned conception in a supervised medical setting 2
Immediate Postpartum Considerations
For women who have experienced ectopic pregnancy during their recent pregnancy or have high-risk conditions, immediate postpartum LARC placement should be offered to prevent short-interval pregnancy and allow time for medical optimization. 2 This approach:
- Reduces risk of unintended pregnancy before the 6-week postpartum visit 2
- Allows adequate interpregnancy interval for recovery 2
- Provides highly effective contraception without requiring patient follow-up for initiation 2
Methods to Avoid
Spermicides should not be recommended as they have high failure rates (28% typical use) and have been associated with increased HIV transmission risk in certain populations. 2
Fertility awareness-based methods have 24% typical use failure rates and are inappropriate for women seeking maximum protection against ectopic pregnancy. 2