iucd

1. CONTRACEPTION
MADE EASY
By
Dr Nurjawahir WM Hasbullah
29 October 2018
Edited by Dr Tan Lay Chin
28 October 2018

2. NATURAL FAMILY PLANNING

3. The Methods:
• Abstinence (100%)
• Fertility awareness
• Lactational Amenorrhea (LAM)
• Coitus interruptus (withdrawal method)

4. Fertility Awareness
• Determine when fertility period starts and ends (time for
ovulation)
• Avoid SI during fertility period

5. Fertility Awareness
• Calendar/rhythm (if menstrual cycle is consistent)
• Basal body temperature
• Cervix mucous
• Ovulation method
• Symptothermal method (combination: BBT, cervical
mucous, calendar)
• Hormonal monitoring

6. Hormones Controlling Ovulation
Estrogen - secreted by the ovary’s follicle
• Stimulates cervical mucous production
FSH/LH - secreted by the pituitary
• Stimulates ovulation
Progesterone - secreted by the corpus luteum
• Raises basal body temperature
• Dries cervical mucous

7. Female Menstrual Cycle
LH
FSH
Estrogen
Progesterone
Hormone Levels 28 Day Cycle
Day 5 10 14 22 25

8. The Beginning of Fertile Phase
• Presence of cervical mucus
• Rising levels of the hormone estrogen
• Shortest cycle minus 20 days; or day “8”

9. Markers of Peak Fertility
• Cervical mucus – clear, stretchy, slippery
• Rise in basal body temperature
• LH hormone peaks

10. The End of the Fertile Phase
• Peak in cervical mucus plus count of 3
• Rise in temperature plus count of 3
• Peak in LH plus count of 3
• Longest cycle minus 10 days; or day “19”

11. Cervical Mucus Cycle
Peak
Fertility
Beginning End

12. Withdrawal Method
(coitus interruptus)
• practice of withdrawing the penis from the vagina and
away from a woman's external genitals before ejaculation
to prevent pregnancy. The goal of the withdrawal method
is to prevent sperm from entering the vagina.

13. Benefits Drawbacks
Easy Reduce satisfaction
Free High failure percentage
Does not require prescription Requires very high self-
control from Male partner
No side effects Male partner with
prematured ejaculation
Increased male partner
involvement in FP

14. Lactational Amenorrhea (LAM)
• 3 criterias must be fulfilled:
• Amenorrhea
• Exclusive BF
• Baby <6 months

15. • Persona monitors changes
in 2 key fertility hormones –
estrogen and luteinising
hormone
• to identify the days when
you can have sex without
using contraception (green
days) and the days when
you are at high risk of
becoming pregnant (red
days).
• During the first cycle of use
you will be asked to test on
16 days. After your first
cycle you will be asked to
do a test on 8 days each
cycle.

16. Things to remember:
• How to recognise your ‘safe’ time for sex. This takes time,
effort and practice.
• Using fertility awareness requires a commitment to keeping
careful note of daily body changes and is more difficult for
women whose periods are not regular.
• Failure rates are higher than the other methods.
• Both the woman and her partner must be prepared not to
have vaginal intercourse during her fertile time unless a barrier
method is used.
• Illness and vaginal infections can interfere with mucous and
body temperature and may make tracking fertility more difficult.
• Natural methods do not protect you against STIs or HIV.

17. BARRIER METHODS

18. •Mechanical
Methods
• Condom male
• Condom female
• Cervix cap
•Chemical
Methods
• Spermicide
• Sponge
(spermicidal foam)
• Diaphragm
Contraindicated: Allergic to latex or
condom lubricants

20. Spermicidal
foam
Examples of
spermicidal
gel

21. INTRAUTERINE DEVICE

23. Long acting reversible contraception
(LARC)
Long-acting
• These types of contraception last for many years and you
don’t have to remember to use contraception every day or
every time you have sex
Reversible
• Also able to get pregnant as soon as the contraception
removed from your body

24. Intrauterine devices (IUD)
Definition
• A small, molded plastic devices that is inserted
into a woman's uterus to prevent pregnancy
which disrupt the normal uterine environment
• There are two types of IUD; hormonal and non-
hormonal (copper)

25. Ancient history
• Contraception, birth control, family planning — it's
nothing new.
• Ancient Egyptians used a mixture acacia leaves,
honey and lint as a block inside the vagina to keep
out unwanted sperm. In Ancient Greece, so
popular was the plant silphium (a.k.a. Laserwort)
as a contraceptive that it became extinct in
Greece.
• Some of the devices shown here are pessaries,
which are tools for blocking the cervix. This type of
tool is also an ancient method - some cultures
have also used oiled paper shaped into a cone, or
even half of a lemon

26. Development of modern history
• The first published paper on actual IUD insertions was made
by Dr. Richard Richter in 1909 in Germany. The device he
inserted was a ring made of silkworm gut, with 2 ends which
protruded from the cervical os enabling him both to check the
device and remove it.
• In the mid 1920s, Ernest Graefenberg the silkworm gut with
a coiled metal ring made of an alloy of copper, nickel, and
zinc. Although the Graefenberg ring was widely used, it was
considered a risky method in continental Europe and in the
U.S.
• As late as 1959, Dr. Alan Guttmacher co-authored a paper in
which the IUD was condemned for its ineffectiveness, potential
source of infection, and its carcinogenic potential.
• Since 1960, various kinds of IUDs have been developed, and
various organization such as the Population Council showed a

28. Pro & Cons IUD
Pro Cons
 Highly effective
 Cost effective
 No interruption during
sexual intercourse
 ‘Insert and forget’
 Immediate return to
fertility once been
removed
 Protection against
endometrium
malignancy
 Heavy bleeding
 Cramping
 Infections (PID)
 Per vaginal discharge
 Need trained staff to
insert

29. Copper-containing IUCD
Most copper IUDs have a plastic T-shaped frame that is wound
around with pure electrolytic copper wire and/or has copper
collars (sleeves)

30. Mechanism of action
1.Damaging sperm and disrupting their motility
2.Preventing sperm from traveling through the cervical
mucus, or destroying it as it passes through
3.Act as a spermicide within the uterus by increasing levels
of copper ions, prostaglandins, and white blood cells
within the uterine and tubal fluids
Approved effectiveness depend on the copper content
• Multiload Cu – 250 : 3 years
• Cu – 375 : 5 years
• Cu – 380 :10 years

31. Most commonly used
Multiload Cu-250

32. Hormonal-containing IUD
Definition (IUS)
• Is known as hormonal releasing
IUD
• Work by releasing a small amount
of levonorgestrel (52mg),
a progestin
Eg : MIRENA, Liletta, Skyla and
Kyleena
Each type varies in size, amount of
levonorgestel released, and duration
Most of hormonal IUD last for 5

34. Mechanism of action
• Thinning the endometrial lining and potentially impair
implantation

35. IUCD insertion

36. When to insert
Women with menses
- Anytime within 12 days from
LMP
Amenorrheic women
- Not Post-partum:
- anytime if not pregnant
Post-partum (BF or not):
- Within 48 hours post
partum
- 4 weeks postpartum and
still amenorrheic and not
pregnant
After abortion
- Immediately
Switch from other method
- Immediately
As emergency
contraception
- Immediately after or within 5
days of unprotected sex

37. Contraindication
Absolute:
• Pueperal sepsis
• Pregnancy
• After septic abortion
• Unknown causes of vaginal bleeding
• Cervical cancer
• Endometrium cancer
• Uterine Fibroid
• Current PID or hx
• Cervicitis with pus discharge
• STDs or high risk for STDs
• Allergy to copper
• Wilson’s disease

39. Thank you

40. Emergency contraception

41. Emergency contraception
EC is intended for occasional emergency use and should
not be considered a substitute for effective regular
contraception
Interest in emergency contraception has grown
considerably in the past few years

42. In April 1995, expert from around the world met in Bellagio, Italy
and produced on emergency contraception, calling on providers
to learn about the methods and to make them available to all
women who may need them
Later in 1995, seven organizations involved in women’s
reproductive health joined to form the Consortium for emergency
contraception
The aim to promoting access to the method worldwide
In December 1995, emergency contraceptive pills (Yuzpe
method) was added to the WHO model list of essential drugs

43. file:///C:/Users/musS/Downloads/fsrh-
guideline-emergency-contraception-
2017..pdf

44. Who may need EC
Any women of reproductive age may need EC at some
point to avoid an unwanted pregnancy, following situation
such as;
• After voluntary sexual intercourse that took place with no
contraceptive protection
• After incorrect or inconsistent use of regular contraceptive
methods or where there has been an accidental failure of
other contraceptive methods
• When a woman has been a victim of sexual assault and
has had no contraceptive protection

45. Method of user failure
• Condom breakage or spillage
• Miscalculation of the infertile period when using periodic
abstinence of failure to abstain from SI during the fertile
days
• Expulsion of IUDs (with h/o SI 5/7 prior)
• Failed coitus interruptus
• Failure to take OCP for more than 3 days in a row
• Being late for contraceptive injection

46. Methods of
Emergency
Contraception
Oral Device
COC Cu-IUCD
LNG UA

48. Efficacy
The failure rate of emergency contraceptive pills
ranges from 1 to 3 per 100
and
The failure rate of copper IUDs is below 1 per
100
It has been calculated that
emergency contraceptive pills
prevent around 75% and copper
IUDs prevent more than 98% of
the pregnancies that would occur
if no emergency contraception
were used

49. Levonogestrel (LNG)
• It is a progestogen, is thought to act by inhibiting ovulation
• It should be taken within 72hours of UPSI (more effective
the sooner it is taken)

50. • Levonogestrel 1.5mg stat
OR
• Levonogestrel 0.75mg stat then repeat in
12 hours
POP AS EMERGENCY
CONTRACEPTION (POEC)

51. Side effects of LNG
• About 20% will experience nausea and 5% vomiting
• Other side effect include headache, beast tenderness, or
abdominal pain
• Menstrual disturbances may occur after taking LNG

52. Ulipristal Acetate (UPA)
• UPA, a selective progestogen receptor modulator
(SPRM), acts but preventing or delaying ovulation
• Should be taken as soon as possible, within 96 hours and
not later than 120 hours (5days)
• Condoms has to be used until next menstrual period
because UPA may reduce the effectiveness of the
contraceptive pills

54. Cu-IUCD
• Can be inserted up to 5 days after UPSI
• It works by stopping an egg from being fertilised or
implanting in the uterus
• It prevents 99% of expected pregnancy and also provide
continuing contraception if wanted
• Suitable if the user is too late to take LNG, does not want
to take hormones, or want to use the most effective
method of EC

55. Cu-IUCD
• Ideally, should be inserted at the time a woman is first
seen, but some women may need time to think. In this
case, and if within 72 hours or 120 hours of UPSI, LNG
and UA respectively will be prescribed
• Most women can use IUCD. However, if a person is at risk
of STI, there is risk of pelvic infection
• There is six fold increase in the risk of pelvic infection in
the 21 days following insertion of IUCD

57. YUZPE method
• Take 4 low dose pills containing-ethinyl estradiol dan
levonorgestrel within 72 hours after SI
eg: nordette, microgynon 30, regividon
( or 5 ultra low dose pills)
• Repeat in 12 hours
*YUZPE regime was the only method of EC until LNG
and Ulipristal Acetate came along

58. Ultra low
Low dose pills
*It should contain at least 100mcg ethinyl estradiol and
50mcg levonogestrel

59. YUZPE method
• Its effectiveness is greatest when taken within the first
24hours of UPSI
• About 50% will experience nausea and 20% will vomit
after taking the first or second dose
• Repeat if the women vomit within 2 hours after taking the
pills

60. References
1. Modul Pengajar Program Perancang Keluarga Bahagian
Pembangunan Kesihatan Keluarga Kementerian Kesihatan Malaysia,
Mac 2009
2. http://www.familyplanning.org.nz/advice/contraception/intra-uterine-
device-iud

61. Thank you! 