What is the preferred contraceptive method for a woman with a history of ectopic pregnancy?

Contraceptive Recommendations for Women with Prior Ectopic Pregnancy

Women with a history of ectopic pregnancy should use long-acting reversible contraceptives (LARCs)—specifically the levonorgestrel intrauterine device (LNG-IUD) or subdermal etonogestrel implant—as first-line contraception due to their superior efficacy in preventing the life-threatening recurrence of ectopic pregnancy. 1

Why LARCs Are Optimal for This Population

Superior Efficacy Profile

• LARCs have failure rates of less than 1% per year, making them the most effective reversible contraceptive methods available 1, 2
• The typical-use failure rate for LARCs (0.05-0.6%) is dramatically lower than combined oral contraceptives (9%), condoms (18%), or withdrawal methods 3, 4
• Because ectopic pregnancy is life-threatening and women with prior ectopic pregnancy have reduced fertility potential and increased risk of recurrence, the highest efficacy method is medically imperative 5

No User-Dependent Compliance Required

• LARCs do not depend on daily adherence, eliminating the risk of method failure from missed pills or inconsistent use 3, 6
• This is critical because any contraceptive failure in a woman with prior ectopic pregnancy carries disproportionate risk of another ectopic pregnancy 5

Specific LARC Options

Levonorgestrel Intrauterine Device (First Choice)

• The LNG-IUD is particularly advantageous as it provides 3-8 years of highly effective contraception depending on the specific device 2
• Can be inserted at any time if reasonably certain the patient is not pregnant 1
• Requires bimanual exam and cervical inspection before placement 1
• No restriction for use in women with history of ectopic pregnancy per CDC Medical Eligibility Criteria 3

Subdermal Etonogestrel Implant (Equally Effective Alternative)

• Provides 3 years of highly effective contraception 1, 2
• Can be inserted at any time during the menstrual cycle if reasonably certain patient is not pregnant 1
• Requires backup contraception for 7 days if inserted more than 5 days after menses started 1
• No pelvic examination required for placement 1

Pre-Initiation Requirements

For IUD Placement

• Bimanual exam and cervical inspection are required 1
• Screen for sexually transmitted infections if risk factors present, but do not delay IUD placement to await results unless purulent cervicitis is visible 1

For Implant Placement

• No examination required 1
• Blood pressure measurement not required 1

Why Other Methods Are Suboptimal

Combined Hormonal Contraceptives (Pills, Patch, Ring)

• Typical-use failure rate of 9% is unacceptably high given the life-threatening nature of recurrent ectopic pregnancy 3
• Require daily or weekly adherence, introducing user-dependent failure risk 3

Barrier Methods

• Condoms have an 18% typical-use failure rate 3
• While appropriate as adjunctive STI protection, inadequate as sole contraception in this high-risk population 3

Progestin-Only Pills

• While safer than combined hormonal methods for many conditions, still require daily adherence 1
• Backup contraception needed for 2-7 days depending on formulation if started more than 5 days after menses 1

Depot Medroxyprogesterone Acetate (DMPA)

• Less effective than LARCs with typical-use failure rates around 6% 3
• Requires clinic visits every 3 months for reinjection 3

Clinical Implementation Algorithm

1. Confirm patient desires contraception and counsel on all options within shared decision-making framework 3
2. Strongly recommend LARC methods given prior ectopic pregnancy history 1
3. If patient prefers IUD:
   • Perform bimanual exam and cervical inspection 1
   • Screen for STIs if risk factors present 1
   • Insert LNG-IUD (do not delay for STI results unless purulent cervicitis visible) 1
4. If patient prefers implant:
   • Confirm not pregnant using clinical criteria 3
   • Insert subdermal implant 1
   • Provide backup contraception for 7 days if inserted >5 days after menses 1

Critical Pitfalls to Avoid

• Do not recommend less effective methods (pills, patch, ring, condoms alone) as first-line in this population 1, 4
• Do not delay IUD placement for routine STI screening in low-risk women 1, 7
• Do not require cervical cancer screening before IUD insertion 7
• Do not restrict IUD use based on nulliparity—this is an outdated contraindication 7
• Do not schedule IUD insertion only during menses—this is an unnecessary barrier 7