An emergency contraception algorithm based on risk assessment: changes in clinicians' practice and patients' choices.

Objectives: When ulipristal acetate (UPA) was introduced into the Contraceptive and Sexual Health Services service in June 2011 an algorithm was developed to guide method selection. The aim was to encourage clinicians to assess risk and to offer a copper intrauterine device (IUD) as first-line choice with hormonal methods as second-line choice.

Methods: UPA was the second-line choice for presentations up to 120 hours after high-risk episodes (i.e. around the time of ovulation). Women at lower risk were also offered UPA if presentation was between 72 and 120 hours after unprotected intercourse unless the risk was very low, in which case levonorgestrel 1.5 mg was the second-line choice.

Results: Prior to the protocol only 49% of women were offered an IUD compared with 61.6% afterwards. This improved further in the subgroup of women at high risk where 93.3% were offered an IUD compared with 59% initially. After the introduction of UPA the percentage of women accepting the IUD fell from 30% to 14.1%. Overall 14.5% of women received UPA compared to 7.8% receiving an IUD.

Conclusions: Introduction of a standardised protocol for the provision of emergency contraception has significantly increased the proportion of women offered an IUD as postcoital contraception, particularly in women at high risk of conception. Introduction of UPA has seen a halving of the number of women accepting the IUD. This is cause for concern. Further investigation into the reasons behind this decrease in IUD uptake needs to be undertaken.