Kontrasepsi Update

PERKEMBANGAN KONTRASEPSI TERKINI

Biran Affandi

Klinik Raden Saleh

Departement Obstetri & Ginekologi

Facultas Kedokteran , Universitas Indonesia/

Rumah Sakit Dr. Cipto Mangunkusumo, Jakarta

Affandi B. Perkembangan Kontrasepsi Terkini. Peringatan Hari Kontrasepsi Sedunia , BKKBN , Jakarta , 30 September 2014

OBJECTIVES: 1.To overview basic principles of

family planning

2.To overview the possible pattern of contraceptive methods

3.To review new contraceptives

4.To recommend practical points Affandi B. Perkembangan Kontrasepsi Terkini. Peringatan Hari Kontrasepsi Sedunia , BKKBN , Jakarta , 30 September 2014

PERENCANAAN KELUARGA

1. Seorang wanita telah dapat melahirkan, segera setelah ia mendapat haid yang pertama (menarche)

2. Kesuburan seorang wanita akan terus berlangsung, sampai mati haid (menopause)

3. Kehamilan dan kelahiran yang terbaik, artinya risiko paling rendah untuk ibu dan anak, adalah antara 20-35 tahun

4. Persalinan pertama dan kedua paling rendah risikonya

5. Jarak antara dua kelahiran sebaiknya 2-4 tahun

Affandi, 1984

Affandi B. 1978

POLA PERENCANAAN KELUARGA

2 - 4

20 35

Fase Fase Fase

Menunda Kehamilan

Menjarangkan Kehamilan

Tidak Hamil lagi

Affandi, 1984

Affandi B. 1978

Possible patterns of intervention to fertility

Ideal Contraceptive

100% effective readily reversible use not related to intercourse easy to use cheap readily available no side effects does not affect sexual pleasure health benefits

Contraceptive Options

CDC , 2014

Condom effectiveness at a glance

When used correctly and consistently, condoms are an effective means of preventing pregnancy When used correctly and consistently, condoms are an effective means of preventing STD/HIV Today's condom is manufactured with greater precision Condom use is improved by the right lubricant

Affandi B. Perkembangan Kontrasepsi dan Kesehatan Reproduksi . Expert Meeting , BKKBN , Jakarta ,3 Feb 2009

Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008

Cervical Cap:Leas Shield Cervical Cap yang terbuat dari

Silicone yang bisa dipakai ulang

Kerjanya sebagai Penghalang Sperma untuk masuk

Efektivitasnya 85-90% (tergantung dari spermicida dan tingkat paritas)

Perlu dibantu Provider pada awal pemakaian

Dipasang segera sebelum berhubungan intim dan dibiarkan 8 jam setelahnya


PIL KB Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008

MEKANISME KERJA PIL KB * Mencegah pematangan dan pelepasan sel telur * Mengentalkan lendir leher rahim, sehingga menghalangi penetrasi sperma

* Membuat selaput lendir rahim tidak siap untuk menerima dan menghidupi hasil pembuahan

(Leon Speroff, et.al., 2001, Oral Contraception, A Clinical Guide for Contraception; 2: 39-40) Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008

Seasonale Pack berisi

91 Pil 84 Pil aktif (Pink) 7 Inaktif Pil (Putih)

Dosis kombinasi rendah: EE 30 g LNG 150 g


KONTRASEPSI IDEAL ? Efektivitas maksimal

Efek samping minimal

Memberikan keuntungan tambahan ?

Manfaat: 1. Kontrasepsi

kontrol siklus yang baik

aman untuk jangka panjang

OC Plus (EE + CPA)

Manfaat Tambahan:

2. Kulit halus dan cantik

mengatasi masalah kulit langsung pada akarnya menghilangkan jerawat dan hirsutisme secara cepat dan efektif

OC Plus (EE + CPA)


The Contraceptive Patch Ortho Evra


INJECTABLE CONTRACEPTIVE 2003

Period Formula Status monthly 1. DMPA 25 mg + EC 5 mg

2. Net-En 50 mg EV 5 mg 3. Net-En 20 mg 4. DMPA 50 mg + EE 10 mg 5. Others

Market Market Phase II Market

2-3 months 1. Net-En 200 mg 2. DMPA 150 mg 3. Net Microcapsul 100 mg

Market Market Phase I - II

6 months 1. DMPA 450 mg 2. Net microcapsul 200 mg

Market Phase I II

Affandi, 2003


Contraceptive choices no ideal contraceptive more methods available more likely a

couple or individual will find a suitable method

long-acting reversible contraceptives (LARC): Implanon, Mirena , IUD-T380A have very low failure rates

LARCS require little action on part of user

Strategies to improve compliance

Developing and encouraging use of long-acting methods that require no regular action on part of user

Improving access to information which is provided in a form centred on an individuals requirements

Accurate information about likely side effects and encouragement to continue

Long-acting reversible contraceptives

Sub-dermal implants Implanon

Jadelle

Intrauterine devices Hormonal

Copper-bearing

IUD IUD mencegah kehamilan dengan cara

Mencegah fertilisasi dengan cara membuat sperma menjadi lemah dan tidak mencapai tuba.

Menyebabkan reaksi peradangan di endometrium

Mengganggu transportasi tuba terganggu


The levonorgestrel intrauterine system

Levonorgestrel

intrauterine

system

Detail

Uterine

wall

Section of

system

Affandi B. Mirena, Beyond Contraception

STATUS & DEVELOPMENT OF IMPLANTABLE CONTRACEPTIVES 2006

TRADE NAME PROGESTIN IMPLANTS DURATION STATUS

Norplant LNG 6 rods 5 years Market

Implanon ENG 1 rod 3 years Market

Jadelle LNG 2 rods 5 years Market

Uniplant NMA 1 caps 1 year Phase III-IV

Nestrone ST1435 1 rod 2 years Phase III

Elcometrine ST1435 1 caps 6 months Market

Indoplant LNG 2 caps 3 years Market


Implantable contraceptives

The Implanon rod

R a t e - c o n t r o l l i n g m e m b r a n e ( 0 . 0 6 m m )

C o r e : 40% Ethylenevinylacetate (EVA) 6 0 % e t o n o g e s t r e l

M e m b r a n e : 1 0 0 % E V A

Core 2 mm

40 mm

Implanon

Single rod 4cm x 2mm inserted under the skin of the inner surface of upper arm Preloaded sterile applicator Needle inserted under skin under sterile conditions Inserter removed leaving implant in place Insertion takes 1-2 minutes Removal takes 2-3 minutes through a 2mm incision Implant invisible but can be felt under skin

Implanon Mode of Action

Follicular development without ovulation

LH surge prevented Increased viscosity of cervical mucus Endometrium thin but not atrophic

with weak proliferation Pregnancy rate 0 -0.01% per year Return of ovulation rapid on removal

Kontrasepsi Permanen tanpa Operasi: Essure

Permanen, Non-hormonal Keunggulannya

Tdk ada sayatan, tdk perlu anesthesi umum

Prosedur pemasangan < 1 jam (92 % wanita kembali berkerja< 24 jam)

Efektif (99.8 % setelah 2 tahun pemakaian)

Keterbatasannya Perlu 3 bulan sebelum efektif

Kemungkinan kegagalan insersi (microinsert)

Perlu operasi untuk mengangkat

Perlu Obgyn yg terlatih dalam hysteroscopy

Mahal ( US$ 1,500) Affandi B. Perkembangan Kontrasepsi dan Kesehatan Reproduksi . Expert Meeting , BKKBN , Jakarta ,3 Feb 2009

Essure: Bagaimana kerjanya ?

Merangsang tumbuhnya jaringan parut (scarification) didalam tuba fallopii

Alat ini ditanamkan kedalam masing masing ujung tuba Falopii dengan menggunakan kateter khusus yang dipandu dengan suatu hysteroscope melalui vagina.

Occlusi (Penutupan) di periksa setelah 3 bulan

Affandi B. Perkembangan Kontrasepsi dan Kesehatan Reproduksi . Expert Meeting , BKKBN , Jakarta ,3 Feb 2009

CONTRACEPTIVE METHOD RATIONAL CHOICE

2 - 4

20 35

Phase DIFFERING SPACING COMPLETING

- Pill - IUD - Conventional - Inject. - Implant

- IUD - Inject. - Pill - Implant - Conventional

- IUD - Inject. - Pill - Implant - Conventional - Steril

- Steril - IUD - Pill - Implant - Inject. - Conventional

Phase Phase

Affandi B,1984

Simplified Classification of Eligibility Criteria (WHO)

1

WHO guidelines classify conditions that affect medical eligibility for various

contraceptive methods into 4 categories

A condition for which there is no restriction for the use of the contraceptive method

A condition in which the advantages of using the method generally outweigh the theoretical or proven risks

A condition in which the theoretical or proven risks usually outweigh the advantages of using the method

A condition that represents an unacceptable health risk if the contraceptive method is used

World Health Organization. Medical Eligibility Criteria for Contraceptive Use, 4th ed. 2010.

2

3

4

Unmet Need : Fertility Preferences of Postpartum Women

Key Findings in Indonesia (IDHS 2012)1 : 85% of currently married women and 53% of currently

married men who have 2 living children do not want to have more children. The percentage wanting no more children increases rapidly with the number of living children.

According to many DHS surveys2: 92-97% of women do not want another child within 2 years

after giving birth

But 35% of women had their children spaced at 2 years apart or less

40% of women who intend to use a FP method in the first year postpartum are not using one

1. IDHS 2012, chapter 6, p 63

2. Ross JA and Winfrey WL, 2001

ACOG Recommendations

LARC methods should be offered as first-line contraceptive methods and encouraged as options for most women

LARC methods have few contraindications

Almost all women are eligible for the implant and IUDs

American College of Obstetricians and Gynecologists. Practice Bulletin No. 121, Long-Acting Reversible Contraception: Implants and Intrauterine Devices, July 2011.

American College of Obstetricians and Gynecologists. Committee Opinion No. 450, Increasing Use of Contraceptive Implants and Intrauterine Devices To Reduce Unintended Pregnancy, December 2009.

Nulliparous Women and Adolescents

Can Be Offered LARC Methods

ACOG , 2014

CDC Medical Eligibility Criteria

Category Restriction

1 No restriction

2

Advantages generally outweigh theoretical or proven risks

3

Theoretical or proven risks usually outweigh advantages

4

Unacceptable health risk

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a3.htm#tab3

Counseling about hormonal contraceptive options is an important part of the clinical consultation

even if the users appear knowledgeable about

their contraceptive method, there are likely

some areas where their knowledge could be

improved.

Costa A, et al. 2010 11th Congress of the European Society of Contraception and Reproductive Health

BIRTH RATE

STILL HIGH ! ! !

4.5 5 Million/year

Affandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010

FAKTA 1.Pascasalin OVULASI

dapat terjadi dalam waktu 21 hari

2.Pascakeguguran OVULASI dapat TERJADI dalam waktu 11hari

Affandi B. Kontrasepsi Terkini dan IUD Pascaplasenta . Pertemuan Koordinasi Peningkatan KB Pascapersalinan di Rumah Sakit , Makassar 31 Agustus 2010

Contraceptive choices for breastfeeding women .Journal of Family Planning and Reproductive Health Care 2004; 30(3): 181189

Postplacental (preferably within 10 minutes after expulsion of the placenta) and immediate postpartum insertion during the first week after delivery (but preferably within 48 hours) are convenient effective and safe times to insert copper IUDs.

Affandi B. Perkembangan Kontrasepsi, Teknik Penapisan dan KB Postpartum , BPMPPKB, Balikpapan , 24 Juni 2010

Teknik Pemasangan AKDR

Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010

Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010

Practice Points When counselling men and women about

contraception, remember that there are many different methods available

Balanced messages, giving the advantages and disadvantages of oral pill, lead to greater user acceptability and continuation. Emphasis should be placed on the safety, efficacy & non contraceptive benefits of Yasmin.

Affandi B. Oral Contraceptive Pills & Weight Gain, FKUI/RSCM, April 2008

Good clinical decisions are founded on 3 essential elements:

Experience Perspective Evidence

Providers bring experience, perspective and evidence from their education and clinical practice in specific communities.

Patients bring their own experience and perspectives, coloured by issues such as geography, finance, culture and spirituality.

It is in this context and not in isolation, that available evidence informs decisions.

Affandi B. Oral Contraceptive Pills & Weight Gain, FKUI/RSCM, April 2008

Knowing is not enough, we

must apply Willing is not

enough, we must do Goethe

PERKEMBANGAN KONTRASEPSI TERKINISlide Number 2PERENCANAAN KELUARGAPOLA PERENCANAAN KELUARGASlide Number 5Ideal ContraceptiveContraceptive OptionsSlide Number 8Slide Number 9Slide Number 10Slide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16Cervical Cap:Leas ShieldSlide Number 18Slide Number 20Slide Number 21Seasonale Slide Number 23Slide Number 24Slide Number 25Slide Number 26The Contraceptive PatchOrtho Evra INJECTABLE CONTRACEPTIVE 2003Contraceptive choicesStrategies to improve complianceLong-acting reversible contraceptivesIUDSlide Number 33Slide Number 34Slide Number 35Slide Number 36Slide Number 37Slide Number 38Slide Number 39Slide Number 40Slide Number 41Slide Number 42Slide Number 43Slide Number 44Slide Number 45Slide Number 46Slide Number 47Slide Number 48Slide Number 49Slide Number 50Slide Number 51Slide Number 52Slide Number 53Slide Number 54Implantable contraceptivesSlide Number 56Slide Number 57Implanon Mode of ActionSlide Number 59Kontrasepsi Permanen tanpa Operasi: EssureEssure: Bagaimana kerjanya ?Slide Number 62Slide Number 63Slide Number 64CONTRACEPTIVE METHOD RATIONAL CHOICESimplified Classification of Eligibility Criteria (WHO)WHO guidelines classify conditions that affect medical eligibility for various contraceptive methods into 4 categoriesUnmet Need : Fertility Preferences of Postpartum WomenSlide Number 69Nulliparous Women and Adolescents Can Be Offered LARC Methods Slide Number 71Slide Number 72Counseling about hormonal contraceptive options is an important part of the clinical consultationSlide Number 74Slide Number 75FAKTASlide Number 77Slide Number 78Slide Number 79Slide Number 80Good clinical decisions are founded on 3 essential elements:Knowing is not enough, we must applyWilling is not enough, we must doGoethe

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