perkembangan kontrasepsi terkini

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
Fase
Fase
Fase
Menunda
Kehamilan
Menjarangkan
Kehamilan
Tidak Hamil
lagi
2-4
20
Affandi, 1984
Affandi B. 1978
35
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
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
Cervical Cap:Lea’s 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
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
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
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 μg
– LNG 150 μg
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
KONTRASEPSI IDEAL ?
• Efektivitas maksimal
• Efek samping minimal
• Memberikan keuntungan tambahan ?
OC Plus
(EE + CPA)
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
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
The Contraceptive Patch
Ortho Evra ®
INJECTABLE CONTRACEPTIVE 2003
Formula
Period
Status
monthly
1.
2.
3.
4.
5.
DMPA 25 mg + EC 5 mg
Net-En 50 mg – EV 5 mg
Net-En 20 mg
DMPA 50 mg + EE 10 mg
Others
Market
Market
Phase II
Market
2-3 months
1.
2.
3.
Net-En 200 mg
DMPA 150 mg
Net Microcapsul 100 mg
Market
Market
Phase I - II
6 months
1.
2.
DMPA 450 mg
Net microcapsul 200 mg
Market
Phase I – II
Affandi, 2003
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
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
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
The levonorgestrel intrauterine system
wall
Uterine
system
Section of
Detail
system
intrauterine
Levonorgestrel
Affandi B. Mirena, Beyond
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
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
Implantable contraceptives
The Implanon rod
Rate-controlling membrane (0.06 mm)
2 mm
Core
40 mm
Core:
40% Ethylenevinylacetate (EVA)
60% etonogestrel
Membrane: 100% EVA
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
Phase
DIFFERING
Phase
SPACING
Phase
COMPLETING
2-4
- Pill
- IUD
- Conventional
20
- Inject.
- Implant
Affandi B,1984
- IUD
- Inject.
- Pill
- Implant
- Conventional
- IUD
- Inject.
- Pill
35
- Implant
- Conventional
- Steril
- Steril
- IUD
- Pill
- Implant
- Inject.
- Conventional
Simplified Classification of Eligibility Criteria
(WHO)
WHO guidelines classify conditions that
affect medical eligibility for various
contraceptive methods into 4 categories
1
A condition for which there is no restriction for the use of
the contraceptive method
2
A condition in which the advantages of using the method
generally outweigh the theoretical or proven risks
3
A condition in which the theoretical or proven risks usually
outweigh the advantages of using the method
4
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.
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
Contraceptive choices for breastfeeding women .Journal of Family Planning and Reproductive Health Care 2004; 30(3): 181–189
Affandi B. Kontrasepsi Terkini dan IUD Pascaplasenta . Pertemuan Koordinasi Peningkatan KB Pascapersalinan di Rumah Sakit , Makassar 31 Agustus 2010
•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
apply
Willing is not
enough, we must do
must
…Goethe