Gunawan Dwi PrayitnoDepartemen Obstetri & Ginekologi

RSPAD-Gatot SoebrotoJakarta

Kontrasepsi Definisi : Usaha-usaha untuk

mencegah terjadinya konsepsi/ kehamilan.

Sifat : Sementara Permanent

Syarat-Syarat Terjadinya Kehamilan

Adanya Oosit/ telur yang matang : Ovulasi Qualitas telur yang baik.

Adanya sperma yang mampu membuahi telur

Transport telur dan sperma, adanya proses fertilisasi dan implantasi

Reseptivitas endometrium

Orkestra Siklus Haid

Transport Sperma, Sel telur dan Embrio

Cara Kerja Kontrasepsi

Mencegah ovulasi Menurunkan kemampuan sperma/

menghambat sperma Mencegah :

Fertilisasi Implantasi

METODE KONTRASEPSI

Metode Amenorea Laktasi Keluarga Berencana Alamiah (KBA) Sanggama Terputus Metode Barier Kontrasepsi Kombinasi Kontrasepsi Progestin Alat Kontrasepsi Dalam Rahim

(AKDR) Kontrasepsi Mantap

Faktor yang berpengaruh dalam pemilihan kontrasepsi

Usia Lama pernikahan Riwayat kehamilan Riwayat kesehatan Jumlah atau jarak anak Pendidikan Pengetahuan.

Kontrasepsi Mekanik/ Antisperma

Menghambat transport sperma Cegah fertilisasi Cegah implantasi

IUD

Kontrasepsi Hormonal

Mencegah ovulasi Menghambat transport oosit /

telur dan sperma Menghambat implantasi

embrio

IMPLANTS

Kontrasepsi MantapMOW : Tubektomi

MOP : Vasektomi

Tubektomi (MOW)

Memilih Kontrasepsi Ideal Aman Nyaman Reversibilitas tinggi Efektivitas maksimal Kontrol Manfaat non kontraseptif

Urutan Efektivitas metode kontrasepsi

SterilisasiPil KombinasiInjeksi/ depotIUDKondomDiafragma+spermaticidDiafragmaSpermaticidKoitus interuptus

Efektivitas

Keuntungan Pil kombinasi Paling efektif Paling banyak diteliti Menormalkan siklus haid Tidak ada nyeri ovulasi Menguragi rasa tegang payudara Mengurangi jerawat (yang mengandung

CPA) Pengobatan PMS

Keuntungan tambahanMengurangi risiko terjadinya :

- Kehamilan di luar kandungan s/d 90 %- Kista ovarium s/d 80 %- PID s/d 50 %- PMS / PMDD s/d 50 %- Anemia dan defisiensi zat besi s/d 50 %- Kanker ovarium dan endometrium s/d 40 %- Benjolan jinak payudara s/d 40 %- Infertilitas primer s/d 40 %- Mioma uteri (setelah 5 tahun penggunaan ) s/d

20%)

ENDOMETRIOSIS NYERI HAID

NYERI HUBUNGAN

PERUT BAWAH KAKU

INFERTILITAS

TERGANTUNG LOKASI

SINDROMA OVARIUM POLIKISTIK (SOPK ) GANGGUAN HAID

OBESITAS

HIPERANDROGEN (BULU,KUMIS,JAKUN)

INFERTILITAS

Jerawat/ Acne : Hiperandrogen

KONTRASEPSI SUNTIK

      * Sangat efektif

* Resiko kesehatan kecil

* Tidak mempengaruhi hubungan suami istri

      * Terdiri dari 2 jenis :

      Gol. Progestin : Depo Provera, Depo Geston, Noristerat.

     Gol. Progestin + Estrogen Propionat : Cyclo Provera

* Selang waktu (interval) pemberian :

         Noristerat 2 bulan

         Cyclofem (cycloprovera) setiap bulan.

DMPA diberikan setiap 12 minggu.

Cara kerja

  - Mengentalkan lendir serviks sehingga

menyulitkanmasuknya sperma.

       - Menekan ovulasi.

Efektifitas :

Sangat efektif 99,6 %

 

IUD (Intra Uterine Device)/ AKDR (Alat Kontrsepsi Dalam Rahim

Penggolongan :

1. First generation device (unmedicated) tanpa tambahan tembaga atau hormon : Ota ring, grafenberg ring, saf T coil, Lippes loop dll.

2. Second generation device (medicated) dengan tambahan tembaga atau hormon :

a. Logam Cu generasi I : Cu T 200, Cu 7, ML Cu 250 b. Logam Cu generasi II : CuT 380 A, CuT 380 Ag, CuT

220C Nova T, Delta T, ML Cu 375.c. Hormon progesteron: Progestasert, LNG 20/ MIRENA

INDIKASI PEMAKAIAN

- 48 Jam Pasca Persalinan- Antara 6-9 Minggu Post Partum- Bagi Ibu Menyusui Secara

Penuh, Dapat Ditunda 6 Bulan Dengan Catatan :

a. Tetap Tidak Haid b. Tidak memberikan Makanan

Tambahan Pada Bayinya

MEKANISME KERJA IUD :

IUD CuT : MENCEGAH BERTEMUNYA SPERMA DAN SEL TELUR

DENGAN CARA PENGURANGAN JUMLAH SPERMA MENCAPAI

SEL TELUR

DAN DAYA SPERMA UNTUK MEMBUAHI SEL TELUR

PRINSIP MENCEGAH TERJADINYA FERTILISASI.

IUD DENGAN PROGESTIN SPERMA DAPAT DICEGAH MELEWATI

SERVIKS DAN DIBUNUH OLEH SEL DARAH PUTIH YANG TIMBUL

DALAM CAIRAN UTERUS SEBAGAI HASIL RANGSANGAN IUD

IMPLANT (SUBDERMAL)= AKBK (Alat Kontrasepsi Bawah Kulit)

Dua macam implant :1. Non-Biogradable Implant

a. Norplant (6 kapsul) Levonorgestrel daya kerja 5 tahunb. Norplant-2 (2 batang) idem daya kerja 3 tahunc. Satu batang hormon ST-1435 daya kerja 2 tahun

d. Satu batang 3-keto desogestrel daya kerja 2 ½ - 4 tahun Implanon implant 1 batang (2-3 tahun)

2. Biogradable Implanta. Capronor Levonorgestrel daya kerja 18 bulanb. Pellets Noretindrone dan kolesterol daya kerja 1 tahun

IMPLANT (SUBDERMAL)= AKBK

Efektifitas Implant1. Angka kegagalan < 1 per 100

wanita per tahun dalam 5 tahun(pearl index).

2. Efektifitas berkurang sedikit setelah 5 tahun tahun ke 6 + 2,5-3% hamil.

3. Norplant 2 sama efektif dengan norplant, untuk 3 tahun pertama.

IMPLANT (SUBDERMAL)= AKBK

Mekanisme kerja implant1. Mekanisme kerja belum jelas benar2. Mencegah terjadinya kehamilan dengan cara:

a. cegah ovulasi b. merubah kekentalan lendir serviks pergerakan spermatozooa c. hambat perkembangan

siklis endometrium

METODE KONTRASEPSI PIL KOMBINASI

Pil Oral Kombinasi Mengandung

estrogen dan progesteron

Mencegah ovulasi

PIL KOMBINASI Mengandung hormon Estrogen dan Progesteron

Tiga macam kemasan :- 21 tablet mengandung hormon dan 7 non hormon- 21 tablet mengandung hormon.

- 24 tablet mengandung hormon dan 4 non hormon

Cara kerja ;Estrogen menghambat ovulasi.

Progestin mengentalkan lendir serviks sehingga menyulitkan masuknya sperma.

Efektifitas : 99,9 % efektif bila digunakan dengan benar

Efficacy (modified from trussell, et. al 1990)

Failure Rate (Percent) During First Year of Use

Pearl Index :

Angka kegagalan metode kontrasepsi :

Angka kehamilan yang terjadi pada 100 wanita setelah menggunakan suatu metode kontrasepsi selama 1 tahun

P.I.(Pearl Index)

1. Pil Kombinasi (Estrogen+ Progesteron)

0.1

2. Pil Sequential (Estrogen + Progesteron bertahap)

2.0

3. POP = Progesterone Only Pill (Progesteron saja)

2.3

SUNTIKAN 1 bulan (estrogen + progesteron) 0.7 - 1.03 bulan (depot progesteron) 0.7 - 1.1

SUSUK / IMPLAN Depot Progesteron 0.7 - 1.0

1. Spiral (IUD = Intra Uterine Device AKDR = Alat Kontrasepsi Dalam Rahim)

1.0 - 2.0 (tembaga)1.0 - 5.0 (plastik)

2. Kondom 103. Diafragma 204. Spermatisida 205. Diafragma +Spermatisida 12

1. Sanggama terputus (Coitus Interruptus) 172. Kalender / Pantang berkala 23

TANPA KONTRASEPSI 80

HORMONAL

MEKANIK

TEKNIK

NON-KONTR.

KONTRASEPSIORAL

ALAT - ALATMEKANIK

TEKNIK

METODE KONTRASEPSI

Kesimpulan : Pemilihan kontrasepsi yang paling tepat

bersifat individual sesuai kebutuhan masing-masing

Pil kontrasepsi kombinasi merupakan pilihan tepat bagi yang tidak ada kontra indikasi

Manfaat non kontrasepsi pil kombinasi dan LNG IUS dapat digunakan untuk PUD/ gangguan siklus haid, endometrium, dismenorhea, PMS/ PMDD.

Levonogestrel – Intrauterin System

(LNG-IUS, MIRENA® )Manfaat Kontrasepsi dan Non

Kontrasepsi

Gunawan D P, MDSpecialist in Ob&Gyn,Reproductive Endocrinology ConsultantCentral Army Hospital-Gatot Soebroto, Jakarta 2009

Indikasi Levonogestrel Intra Uterine System (LNG-IUS) :

1.Kontrasepsi2.Menoragia3.Dismenorhea : adenomiosis/ endometriosis4.Hiperplasia endometrium

Kontrasepsi Pil IUD

• Efektivitas tinggi

• Jumlah darah haid berkurang

• Menurunkan PID

• Tanpa motivasi harian

• Jangka panjang

• Estrogen-free

• Reversibelitas cepat

Levonorgestrelintrauterine system

T-frame 32 x 32mm, impregnated with Barium Sulphate Hormone cylinder 19mm in length, covered with a PDMS membrane Total amount of Levonorgestrel 52mg 2 polyethylene removal threads

MIRENA®

The levonorgestrel intrauterine system

Levonorgestrelintrauterine

system

Detail

Hormone cylinderRate-controllingmembrane

Uterinewall

Section ofsystem

Mode of action: the endometrium

After a few weeks, the endometrium becomes inactive. Morphological changes are uniform from the 1st

month

Days

Days

LNG IUS

Menstrual cycle

Nilsson et al., 1978

Pharmacokinetics of levonorgestrelafter Mirena® insertion

Continuous drug delivery LNG-IUS does not cause ‘peaks and

troughs’, as with oral progestogen dosing Much higher endometrial levels of the

progestogen than with oral preparation:Levonorgestrel concentration

(ng/g wet tissue)LNG-IUS (30μg/day)

Oral preparation

(250μg)Endometrium 808 3.5

Nilsson et al., 1982

LNG IUS

Bleeding & spotting days per month

LNG IUS (n = 1495)Nova-T (n = 739)

8

6

4

2

0Mea

n nu

mbe

r of d

ays

Months

Mea

n nu

mbe

r of d

ays

0

4

8

12

16

0 2 4 6 8 10 12

Bleeding per month in 1st year

Andersson, Contraception 1994;49:56–72

p < 0.001

Bleeding days per month

Mirena®: Changes in bleeding pattern

0–3 months 3–6 months After 6 monthsMuch spotting Less spotting and Amenorrhea

which progressively less menstrual (± 20%) ordecreases blood loss oligomenorrhea

Bleeding pattern during 5 years of use

Amenorrhea26%

Infrequent3.7%

Regular70.3%

Rönnerdag M, Odlind V. Acta Obstet Gynecol Scand 1999;78:716–21

Mirena® vs Cu IUD

Discontinuation due to heavy or prolonged bleeding is more common with Cu IUD

Andersson et al. Contraception 1994; 49: 56–72

Problems

• Prolonged spotting: advice

encouragement bleeding diary

• Late bleedings: ultrasonography hysteroscopy

histology

Ultrasound detection of MIRENA®

MIRENA® on X-ray examination

Contraceptive efficacy of LNG IUS

• Overall pregnancy rate: 0.16 per 100 woman-years

• European multicentre study: cumulative gross pregnancy rate – 1-year rate LNG IUS: 0.1% Cu IUD: 1.0%– 5-year rate LNG IUS: 0.5% Cu IUD: 5.9%

• Risk of ectopic pregnancy: 0.06 per 100 woman-years. Ectopic rate for women not using any contraception: 0.3-0.5 per 100 woman-years

Comparison of Mirena® and sterilization

Mirena Sterilization Efficacy +++ +++ Reversibility Yes No Bleeding Reduced No effect Pain Reduced No effect Cost Low High Complications Rare Rare

Pakarinen et al. Semin in Repr Med 2001;19:365-71

Return of fertility after Mirena®

use Cyclic ovarian function is immediately

restored The endometrium recovers quickly and

normal menstruation is established within 30 days

Overall fertility is unaffected Cumulative conception rate after removal

79─96 per 100 women after 12 months Pregnancies progress as normal

Andersson K, et al. Contraception 1992; 45: 575–584Sivin I, et al. Am J Obstet Gynecol. 1992; 166: 1208–13Belhadj H, et al. Contraception. 1986; 34: 261–7

Return of fertility after removal of thelevonorgestrel intrauterine system

0

20

40

60

80

100

3 6 9 12Months

Cum

ulat

ive

preg

nanc

y ra

te (%

)

Levonorgestrelintrauterine systemCopper IUD

Andersson et al., 1992

The levonorgestrel intrauterine system andcopper-releasing IUD during 5 years of use

a randomized comparative trial

Participants: 10 clinics in Denmark,Finland, Norway, Sweden andHungary

Number: Nova T, n = 937Levonorgestrel intrauterinesystem, n = 1821

Andersson et al., 1994

5-year cumulative gross termination ratesNova T Levonorgestrel p

intrauterine system

Pregnancy 5.9 0.5 ***Expulsion 6.7 5.8 nsBleeding problems 20.9 13.7 **Absence of bleeding 0 6.0 ***Pain 5.8 5.9 nsHormonal 2.0 12.1 ***Pelvic inflammatory disease 2.2 0.8 *Other medical 10.6 7.7 nsPersonal 5.9 4.4 nsContinuation rate 53.1 55.5

*p < 0.05; **p < 0.01; ***p < 0.001Andersson et al., 1994

Hormonal reasons5-year cumulative gross termination rates

Nova T Levonorgestrelintrauterine system

Depression 0 2.9 ***Acne 0.4 2.3 *Headache 0.2 1.9 **Weight change 0 1.5 **Breast tenderness 0 0.8 *

*p < 0.05; **p < 0.01; ***p < 0.001

Perforation rate Incidence in Mirena clinical studies < 1 /

1000 Perforation rate is similar with all IUDs/IUSs. Lack of experience is associated with higher

risk Some reports on increased perforation rate

with IUDs in postpartum/during lactation, data inconsistent

No increased risk in insertions after abortion, after previous CS

Andersson Contraception1998;57:251-5; Chi Contracept Deliv Syst 1984;5:123-130; Grimes 2003.The Cochrane Library, Issue 3; Chi Contraception 1984;30:209-214

WHO recommendation on progestin-only contraception during lactation

to be started ≥ 6 wk post partum to diminish the exposition of the baby to steroids

Does not have a negative influence in the milk production when initiated after 6 weeks postpartum

Progestins are transferred into the breast milk and the infant. No deleterious effects on infant growth or development

Insertion of IUD ≥ 4 wk after delivery

WHO: Medical eligibility criteria for contraceptive use,2004WHO Contraception 1994;50:35-68

MIRENA® after delivery

Insertion should be postponed ≥ 6 weeks after delivery

Bleeding pattern compared to CuIUD: with the exception of the first month post-insertion, menses-like bleeding significantly more common in the Cu-IUD users, compared to both LNG-IUD users. However, initial spotting observed more frequently observed in the LNG-IUD users

Heikkila et al. Contraception 1982:25:561-72

MIRENA® after delivery

Randomized comparative trial of Mirena (n=163) vs CuT380A (n=157) in breast-feeding women: no difference between the groups in Continuation of breast-feeding (full or part-

time) Weaning Continuation rate of the method Infant growth and development (physical

parameters & developmental tests)

Sharmaash et al Contraception 2005:72:346-51

Postabortal insertion of Mirena®

• Fears: uterine perforation, expulsion or infection (PID)

• No increased risk of perforation or PID• Menstrual pattern similar to interval insertion. • Expulsion risk slightly higher than after interval

insertion

Heikkilä et al. Contraception 1982;26:245-59, Andersson et al. Contraception 1994;49:56-72, Ortayli et al Contraception 2001;63:309-14, Pakarinen et al. Contraception 2003;68:31-4

Postabortal insertion of Mirena®:Cumulative discontinuation rate /100 women at 5 years

Pregnancy 9.5 0.8 0.00004Expulsion 15.4 10.5 nsBleeding 22.6 13.7 nsAmenorrh. 0 2.1 nsPain 10.8 5.5 nsPID 2.3 0.7 nsHormonal 3.9 15.9 0.0054

Reason Cu IUD Mirena® P

Pakarinen P et al. Contraception 2003;68:31-4

Postabortal insertion of Mirena® : Conclusions

Safe Effective Special attention should be paid to the

insertion technique Motivation for effective contraception

high after termination of pregnancy High rate of removals for planning

pregnancy highlight the importance of reversibility

Pakarinen P et al., Contraception 2003 68:31-4

Mirena® in clinical practice

Backman et al. Obstet Gynecol 2002; 99: 608–13

Mirena® use is associated with high usersatisfaction in clinical practice

MIRENA® Continuation Rate is high In early clinical studies continuation at 5 years ca. 50% Cumulative continuation rates according to Backman et al

2000

Yearly continuation rate over 90% in every year Relevant counselling significantly increases the

continuation

65%75%

81%

93%87%

0%10%20%30%40%50%60%70%80%90%

100%

1 Year 2 Year 3 Year 4 Year 5 Year

Backman et al. 1992

Amenorrhea rate increases in long-term use

Continuation rates very high Weight and blood pressure change

consistently with aging No difference in body weight increase

compared to Cu IUD

Long-term use of Mirena®

Rönnerdag Acta Obstet Gynecol Scand 1999;78:716-21.

Andersson Contraception 1994;49:56–72

65

64

63

62

610 12 24 36 48 60

Wei

ght (

kg)

Months

Copper IUD

LNG-IUS

Body weight in a randomized comparative trial Mirena ® vs Cu IUD

MIRENA®:

• No difference in body weight compared to Cu IUD

• Endogenous estradiol levels within normal limits irrespective of bleeding pattern

• No adverse effect on bone mineral density• Minimal metabolic effects on

– carbohydrate metabolism– lipid profile

Rönnerdag Acta Obstet Gynecol Scand 1999;78:716–21; Luukkainen Ann Med 1990; Bahamondes Hum Repr 2006 in press; Rogovskaya Obstet Gynecol 2005;105:811-5; Raudaskoski BJOG 2002;109:136-44

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