FAMILY PLANNING

METHODS
TEMPORARY

PERMANENT

NATURAL

1.ABSTINENCE, 2.COITUS INTERRUPTS, 3.BREAST

FEEDING

HORMONAL

1.ORAL, 2.INJECTABLES

BIOLOGICAL

CALENDER, TEMPERATURE, MUCUS & CERVICAL

CHEMICAL

FOAMS, VAGINAL TABLETS, GELS & CREAMS ,

CONTRACEPTIVE FILMS

MECHANICAL

EMERGENCY

CONDOMS, DIAPHRAGM, FEMCAP, SPONGES,

IUDs

IUDs

INTRA-UTERINE
DEVICES

TYPES OF IUDs
Non medicated / inert IUDs
Medicated / bioactive IUDs
Both are usually made of polyethylene or
other polymers
Medicated IUDs release either metal ions
(copper) or hormones (progesogens)

GENERATION IUDs
First generation IUDs
Second generation IUDs
Third generation IUDs

GENERATION IUDs
Non medicated or inert IUDs are often referred to
as -First generation IUDs
The copper IUDs comprise the Second generation
IUDs
The hormone releasing IUDs comprise Third
generation IUDs

Medicated IUDs were developed to

reduce the incidence of side-effects
and increase the contraceptive
effectiveness
They are more expensive and must be
changed after a certain time to
maintain their effectiveness

FIRST GENERATION IUDs

This comprise the inert or non-medicated
devices, made of polyethylene, or other
polymers
They appeared in different shapes and
sizes-loops ,spirals ,coils ,rings ,and bows

 Of all the models , the Lippes Loop is

the best known and commonly used
devise in the developing countries.

LIPPES LOOP
It is double-S shaped device made of
polyethylene , a plastic material that is
non-toxic, non tissue reactive and
extremely durable
It contains a small amount of barium
sulphate to allow X-ray observation

 The loop has attached threads or tail made

of fine nylon, which project into the vagina
after insertion
The tail can be easily felt and is a reassurance to
the user that the loop is in its place.
The tail also makes it easy to remove the loop
when desired

 The lippes loop exists in four sizes A,B,C, & D

C & D are larger loops and are more suitable
for multiparous women
These devises has a greater anti-fertility effect
and a lower expulsion rate but a higher removal
rate because of side-effects such as pain &
bleeding

SECOND GENERATION IUDs

A new approach-1970, adding copper to
the IUD
It was found that metallic copper had a
strong anti-fertility effect
Addition of copper has made it possible to
develop smaller devices which are easier
to fit , even in nulliparous women

Commercially available copper

bearing devices
Earlier devices
Copper-7
Copper T -200

Earlier devices

Copper-7

Copper T -200

NEWER DEVICES
Variants of the T devise
1.Cu-T-220 C
2. Cu-T-380 A or Ag
Nova T
MULTILOAD DEVICES
1.ML-Cu-250
2. ML-Cu-375

Cu-T-220 C

Cu-T-380 A or Ag

Nova T

 Nova T and Cu-T-380 Ag are distinguished

by a silver core over which is wrapped the
copper wire

ML-Cu-250

ML-Cu-375

Copper IUD

Copper IUD

Small device that fits inside the womb

Very effective
Keeps working up to 10 years,
depending on type

We can remove it for you

whenever you want
Very safe
Might increase menstrual
bleeding or cramps
No protection against STIs
or HIV/AIDS

About the IUD:

Small flexible plastic frame with copper sleeves and/or wire.
Give client a sample IUD to hold.
Works mainly by stopping sperm and egg from meeting.
Most women can use IUDs, including women who have never
been pregnant.
Very effective, with little to remember.
Copper T 380A lasts for 10 years.
For older women: should be removed 1 year after last
menstrual period (menopause).
Can soon become pregnant when IUD taken out.

Check for concerns, rumours: What have you heard about

the IUD? (See Appendix 10 on myths about contraception.)
Explain common myths:
IUD does not leave the womb and move around inside the
body.
IUD does not get in the way during intercourse, although
sometimes the man may feel the strings.
IUD does not rust inside the body, even after many years.
Side-effects usually get better after first 3 months (see page IUD3).

For STI/HIV/AIDS protection, also use condoms.

 The numbers included in the names of the

devices refer to the surface area(in sq.
mm) of the copper on the devise.
The newer copper devices are significantly
more effective in preventing pregnancy
than earlier copper ones or the inert IUDs

 The newer copper IUDs Multiload

devices and variants of the T device- offer
the further advantage of having an
effective life of at least 5 years .
They can be left in place safely for the
time, unless specific medical or personal
reasons call for earlier removal

Advantages of copper devices

Low expulsion rate
Lower incidence of side effects, eg: pain,
bleeding
Easier to fit even in nulliparous women
Better tolerated by nullipara
Increased contraceptive effectiveness
Effective as post-coital contraceptives, if
inserted within 3-5 days of unprotected
-intercourse

THIRD GENERATION IUDs

This is based on principle i.e release of a
harmone
The most widely used hormonal devise is
progestasert- T shaped devise filled with
38mg of progesterone, the natural
harmone

 The hormone is released slowly in the

uterus at the rate of 65mcg daily
It has a direct local effect on the uterine
lining, on the cervical mucus and possibly
on the sperms
Because the hormone supply is gradually
depleted , regular replacement of the
device is necessary

harmonal
device
LNG Another
20(Mirena) is a T-shaped IUD releasing
20mcg of levonorgestrel (a potent
synthetic steroid)

Advantages

It has a low pregnancy rate (0.2 per 100)

Lower menstrual blood loss
Fewer days of bleeding than the copper
devices
It has an effective life of 10 years
Drawback:
But these devises are more expensive

Mechanism of action of IUDs

IUD causes a foreign-body reaction in the
uterus
Cellular & bio-chemical changes in the
endometrium uterine fluids takes place
These changes impair the viability of the
gamate
Thus reduces its chances of fertilization,
rather than its implantation

Medicated IUDs MOA

Copper seems to enhance the cellular
response in the endometrium
It also affects the enzymes in the uterus
By altering the biochemical composition
of cervical mucus, copper ions may affect
sperm motility , capicitation and survival

Hormone-releasing devices MOA

These increase the viscosity of the cervical
mucus and thereby prevent sperm from
entering the cervix
They also maintain high levels of
progesterone in the endometrium and
thus, relatively low levels of oestrogen,
thereby sustaining an endometrium
unfavorable to implantation

Effectiveness of IUD
The IUD is one of the most effective
reversible contraceptive methods.
IUDs have longer continuation rates than
the hormonal pills or injections,

Change of IUD
Inert IUDs-lippes loop may be left in place
as long as required, if there are no side
effects
devices
cannot
be
used
Copper
indefinitely because copper corrodes and
mineral deposits build up on the copper
affecting the release of copper ions

 The Cu-T-380A is approved for use for 10

years
The Cu-T-200 is approved for 4 years
Nova Y for 5 years
The progesterone-releasing IUD must be
replaced every year because the reservoir
of progesterone is depleted in 12-18
months
The levenorgestrel IUD can be used fir at
least 7 years, & probably 10 years

Advantages
Simplicity:no complex procedures are
involved in insertion, no hospitalization is
required
Insertion takes only a few minutes
Once inserted IUD stays in place as long
as required
Inexpensive
Contraceptive effect is reversible by
removal of IUD

 Virtually free of systemic metabolic sideeffects associated with hormonal pills

Highest continuation rate
There is no need for the continual
motivation required to take a pill daily or
to use a barrier method consistently

CONTRAINDICTIONS
ABSOLUTE:
Suspected pregnancy
Pelvic inflammatory disease
Vaginal bleeding of undiagnosed etiology
Cancer of the cervix, uterus & other pelvic
tumours
Previous ectopic pregnancy

 RELATIVE:
Anaemia
Menorrhagia
History of PID since last pregnancy
Purulent cervical discharge
Distortions of the uterine cavity due to
congenital malformations , fibroids
Unmotivated person

The ideal IUD candidate

The planned parenthood federation of
America(PPFA) gas described the ideal IUD
candidate as a women:
Who has borne at least one child
Has no history of pelvic disease
Has normal menstrual periods
Is willing to check the IUD tail
Has access to follow-up and treatment of
potential problems
Is in a monogamous relationship

Who can and cannot use the IUD

Most women can safely
use the IUD

But usually cannot use IUD if :

May be
pregnant

Gave birth
recently
(more than 2
days ago)

At high risk for

STIs

Unusual
vaginal
bleeding
recently

Infection or
problem in
female organs

Copper IUD

Who can and cannot use the IUD

Most women can safely use the

IUD. But usually cannot use
IUD if:
May be pregnant
Gave birth recently
(more than 2 days ago)
At high risk for STIs
Unusual vaginal bleeding
recently

We can find out if the IUD is safe for you. Usually, women with any of these
conditions should delay insertion or use another method.
If in any doubt, use pregnancy checklist in Appendix 1 or perform
pregnancy test.

IUD should not be inserted between 48 hours and 4 weeks after childbirth
because of expulsion risk.

If at high risk for chlamydia or gonorrhoea infection.

Those at high risk for these STIs include anyone who:
has more than 1 sex partner without always using condoms;
has sex partner who may have sex with others without always using
condoms.
Unusual bleeding should be assessed before IUD insertion.

Infection or problem in
female organs

STI or Pelvic Inflammatory Disease (PID):

Treat PID, chlamydia, gonorrhoea or purulent cervicitis BEFORE
inserting IUD. Offer to treat partner too.
Can insert IUD if client has genital ulcer disease or vaginitis (bacterial
vaginosis, trichomonas vaginalis), but check risk for chlamydia or
gonorrhoea. Treat infections.
HIV or AIDS:
If client has HIV, can insert IUD.
If client has AIDS, do not insert IUD. But if client is being treated with
antiretroviral drugs and is healthy, can insert IUD.
Infection after childbirth or abortion:
Any infections should be fully treated before IUD insertion.
Cancer in female organs or pelvic tuberculosis (TB):
Do not insert IUD if known cervical, endometrial or ovarian cancer;
2
benign or malignant trophoblast disease; pelvic TB.

IUD is not a method of choice for

nulliparous women

Expulsions
Low abdominal pain
Pelvic pain & pelvic infection

In 1985 , the American college of obstetricians

& gynecologists stated that IUDs are not
recommended for women who have not had
children or who have multiple partners,
because of the risk of PID & possible infertility

Timing of insertion
Loop can be inserted at almost anytime during a
womens reproductive years ( except during
pregnancy)
The most favorable time for loop insertion is
during menstruation or with in 10 days of the
beginning of a menstrual period(diameter of the
cervical canal is grater , uterus is relaxed )
The IUD insertion can also be taken up during the
first week after delivery before the women leaves
the hospital immediate postpartum insertion

 A convenient time for loop insertion is

6-8 weeks after delivery-postpuerperal insertion
ADVANTAGES:
It can be combined with the follow-up
examination of the women and her
child

 IUD insertion can also be taken up

immediately after a legally induced
first trimester abortion.
But IUD insertion immediately after a
second trimester abortion is not
recommended.

Follow up:
Important aspect of IUD
OBJECTIVES
To provide motivation & emotional
support for the woman
To confirm the presence of the IUD
Diagnose & treat any side-effect or
complication

 The IUD wearer should be examined after

her first menstrual period , for the chances
of loop expulsion are high during this
period
After third menstrual period- to evaluate
the problems of pain & bleeding &
thereafter at six-month or one-year
intervals depending upon the facilities &
the convenience of the client.

What will happen when

you get your IUD
Steps:

Pelvic examination
Cleaning the vagina and cervix
Placing IUD in the womb
through the cervix

May hurt at insertion

Please tell us if it hurts
Rest as long as you like afterwards
May have cramps for several
days after insertion

Afterwards:
you can check
your IUD from
time to time

Copper IUD

What will happen when you get your IUD

Steps:
Pelvic examination

Ask if she has any questions or concerns.

Explain who will do the procedure.
No anaesthesia needed. Woman stays awake.

Cleaning the vagina and cervix

Placing IUD in the womb
through the cervix

May hurt at insertion

Please tell us if it hurts
Rest as long as you like afterwards
May have cramps for several
days after insertion

Afterwards: you can check your IUD

from time to time

If it is her first pelvic exam, explain exam, including position

during exam. Let client hold a speculum. Explain its use.

Done slowly and gently.

Show sample IUD with arms folded in inserter.

Any immediate pain usually lasts 30 minutes at most.

When to check:
Once a week in first month.
After a menstrual period from time to time.
How to check:
Wash hands, sit in squatting position, insert a finger into
vagina and feel for IUD strings at cervix. Dont pull on
the strings.
If unable to feel strings, or strings feel longer or shorter,
she should come back to the clinic. IUD may have been
expelled, and she may need emergency contraception.

Instructions to the IUD wearer

She should regularly check the threads or
tail to be sure that the IUD is in the
uterus-if she fails to locate threads
consult, she must consult the doctor
She should visit the clinic whenever she
experiences any side-effects such as fever,
pelvic pain & bleeding
If she misses a period, she must consult
the doctor.

What to remember
Your kind of IUD:

When to have IUD taken out:

Bleeding changes and

cramps are common. Come
back if they bother you.
Come back for a check-up in 3 to
6 weeks or after next menstrual
period

See a nurse or doctor if:

Missed a
menstrual
period, or
think you
may be
pregnant

IUD strings
seem to
have
changed
length or are
missing

Could have an
STI or
HIV/AIDS

Bad
pain in
lower
abdomen

Copper IUD

What to remember

Your kind of IUD

When to have IUD taken out
Bleeding changes and cramps are
common. Come back if they bother
you.

Give client an information card or copy of clients page

and explain. Tell her to keep card in a safe place.
Copper T 380A lasts for 10 years.
For older women, IUD should be left in place until 1
year after last menstrual period (menopause) for full
protection from pregnancy.

Make appointment to check IUD is still in place and no

infection.
Encourage her to come back any time to discuss
problems or have the IUD removed.

Come back for a check-up in 3 to 6

weeks or after next menstrual period

See a nurse or doctor if:

Missed a menstrual period, or think you
may be pregnant
Could have an STI or HIV/AIDS
IUD strings seem to have changed length
or are missing
Bad pain in lower abdomen

Return Signs:
These signs mean a doctor or nurse should check if a
problem is developing.
I want you to know about them and remember them.

She should tell other health care providers that she

has an IUD.

SIDE EFFECTS
AND
COMPLICATIONS

Possible side-effects
If you choose this method, you may have some side-effects.
They are not usually signs of illness.
After insertion:

Other common side-effects:

Some cramps
for several days

Longer and
heavier periods

Some spotting
for a few weeks

Bleeding or spotting
between periods
More cramps or pain
during periods

May get less after a few months

Copper IUD

Possible side-effects

If you choose this method, you may

have some side-effects. They are not
usually signs of illness.

After insertion:
Some cramps for several days
Some spotting for a few weeks
Other common side-effects:
Longer and heavier periods
Bleeding or spotting between
periods

It can take time for the body to adjust.

Different people have different reactions to methods.
Discuss:
If these side-effects happened to you, what would you
think or feel about it?
What would it mean to you?
Discuss any rumours or concerns.
(See Appendix 10).
Please come back any time you want help or have
questions.
It is okay to switch methods any time.
For dealing with side-effects, see Returning Client tab.

For cramps after insertion, can take aspirin,

paracetamol, or ibuprofen.

For longer, heavier and more painful periods, she can take
ibuprofen or a similar medication (NOT aspirin).

More cramps or pain during

periods
May get less after a few months

Cramps and bleeding usually get less after 3 to 6 months.

Increased vaginal bleeding

Pain-second major side

effects

Pelvic infection-PID

Uterine perforation

 Pregnancy
Ectopic pregnancy
Expulsion:12-20%
Fertility after removal
Cancer & teratogenesis
Mortality-extremely rare 1 per 1,00,000

 Of all the available spacing methods of

contraception, IUDs are among the most
effective, with an average pregnancy rate
after one year of about 3-5% per 100
typical users
Inexpensive- long life
IUD use is independent of the time of
intercourse
High continuation rates
Lack of systemic metabolic effects
associated with oral pills

For a fully informed women, the IUD

can provide a satisfactory , highly
effective, relatively low-risk method of
contraception