Medical Examiner

Why There’s Confusion Over Whether Plan B, Ella, and IUDs Cause Abortions

To be clear: they don’t!

An IUD on a pink, blue, and yellow background. The whole vibe is happy!
Photo by Reproductive Health Supplies Coalition on Unsplash

The overturn of Roe v. Wade is detrimental to reproductive health. But, as an OB/GYN and a complex contraception specialist, what worries me just as much is the attack on access to contraception.

There is an eagerness in some legislators to restrict certain methods. In 2021, the Missouri State senate tried to prevent Medicaid holders from accessing IUDs and Plan B, with Republican senator Denny Hoskins noting to a local news outlet that he doesn’t believe in “the morning after pill and things that come after conception.” In Idaho, representative Brent Cane said that he would consider hearings to ban emergency contraception.  The Louisiana House of Representatives is considering legislation to not only define the start of life as a fertilized egg prior to implantation, but also consider abortion a homicide, which some experts say could impact access to IUDs as well.

Advertisement
Advertisement
Advertisement
Advertisement

This is all extremely worrisome. IUDs and Plan B are some of the best tools that we have to help patients manage their health and their futures, especially with abortion access now greatly restricted. What’s all the more frustrating is that at the heart of some of the comments, I see a fundamental misunderstanding about how long term and emergency contraception works in the first place—they do not cause abortions, or operate as “abortifacients.” And only in certain cases will an IUD stop an egg that has become fertilized from implanting (there’s no evidence that Plan B and Ella ever do this). Let me explain how these methods of birth control actually work.

All IUDs create what’s known as a spermicidal environment, or one that is toxic to sperm.  Copper IUDs release copper ions into the uterus, increasing the spermicidal effect. Multiple studies have found that few, if any, sperm reach the egg in the fallopian tube with a copper IUD in place. In fact, multiple studies using sensitive blood and urine pregnancy tests in copper IUD users did not find any evidence that the devices allow fertilization when implanted prior to the user having sex.

Advertisement
Advertisement
Advertisement

Hormonal IUDs do their job by thickening mucus in the cervix, which acts as a barrier to sperm. To a lesser degree, hormonal IUDs can inhibit ovulation, sperm or egg transport, or fertilization, but these are minor in comparison to its mechanism on cervical mucus. There is no evidence that the hormonal IUD prevents a fertilized egg from implanting.

One thing IUDs—copper or hormonal–will never do is removed an already-implanted pregnancy. That doesn’t mean pregnancy is impossible with an IUD in place—it’s rare, but it can happen.

In addition to long-term use, copper IUDs can also be used as emergency contraception, in which case they are inserted after sex and function by making the implantation of a fertilized egg less likely. The hormonal IUD is emerging as a promising emergency contraceptive method as well.

Advertisement
Advertisement
Advertisement

Emergency contraceptive pills like Plan B and Ella work differently, by affecting when the ovary will next release an egg. Ella, or ulipristal acetate, works by delaying ovulation after unprotected sex, while Plan B, or levonorgestrel, prevents or decreases the hormonal surge that causes ovulation. To drive home the point, two studies using animal models found that high doses of levonorgestrel had no impact after fertilization. Neither pill prevents implantation of a fertilized egg.

Advertisement
Advertisement

Scientifically, it’s just not accurate to call emergency contraceptive pills or IUDs “abortifacients.” So how could legislation deeming a fertilized egg a person end up impacting the availability of these tools?

When politicians define the start of life at fertilization, then they may restrict IUDs. To be clear, the American College of Obstetricians and Gynecology defines the start of pregnancy at implantation. From this scientific perspective, an emergency copper IUD works to prevent pregnancy by preventing implantation. And again, IUDs used as long-term contraception do not interrupt a fertilized egg from implanting. But defining personhood at fertilization could permit restrictions on IUD use that may end up preventing their access more broadly.

Advertisement
Advertisement

In the case of Plan B, the FDA label does note that it can prevent implantation. This is outdated information; at the time it was written, it was thought that this dose of levonorgestrel could prevent implantation. In the years since, scientists have gathered evidence that this is not the case. Still, it’s possible that politicians may be able to restrict their use by 1) choosing an arbitrary point very early in the reproductive process as the start of life, and then 2) going off of the outdated information.

Advertisement

I realize there may be people for whom religion plays a big role when considering the start of life, and I respect that. I have seen patients for whom life begins at birth and other patients for whom life begins with fertilization. And I realize that some of my patients might not care what the current science says about various methods of contraception. I support their choices, because the decision about if and when to become pregnant is extremely personal. I want my contraceptive care to be as patient-centered as possible, and I will happily discuss the evidence behind all contraceptive methods to help someone decide on a method that makes them the most comfortable. If you still believe that an IUD would be an abortion-causing device, I would help you choose a different contraceptive method. I want you to have a method that aligns with your beliefs.

Advertisement
Advertisement

But restricting or outlawing contraception altogether because of one politician’s or one religious group’s belief about when life begins, or how contraception works, is wrong. Right now, there are leaders interested in pushing their own religious beliefs on all people in the state, and its potential impact on patients is huge.

Advertisement
Advertisement

Both types of IUDs are more than 99 percent effective at preventing pregnancy, and complications are uncommon. Emergency contraceptive pills are also effective at preventing pregnancy after unprotected sex, and there are no medical conditions for which for which the risks of emergency contraceptive pills outweigh the benefits. This is not true for all contraceptive methods, some of which are less effective and less safe for certain conditions. For example, most birth control pills are unsafe in people with high blood pressure because they increase the risk for stroke, heart attack, and other cardiovascular conditions.

Banning IUDs and emergency contraceptive pills would decrease the birth control options available to patients, many of whom are managing their own difficult medical conditions. I cannot imagine practicing medicine in a state where I am prevented from giving my patients the full range of contraceptive choices. As doctors, we cannot allow politicians with no expertise in our field to make these decisions.

Advertisement