Session I: Characteristics of IUDs Copper-Bearing Intrauterine Devices (IUDs) Session I: Characteristics of IUDs Illustration credit: Salim Khalaf/FHI Copper T 380A

Copper IUDs: Objectives Participants will: Describe the characteristics of copper IUDs in a manner that clients can understand Demonstrate how to screen clients for eligibility to use the copper IUD Describe when to start the use of the copper IUD Explain to clients insertion and follow-up procedures, and when to return Explain how to manage side effects Address common concerns, misconceptions, and myths Identify clients in need of referral for IUD-related complications. Demonstrate how to insert and remove the IUD on an anatomical model. Suggested script: The learning objectives for this module are based on input from various stakeholders <insert who provided input: participants, supervisors, health officials>. The objectives of this module are as follows: By the end of this training session, participants will be able to: <click the mouse to advance through the objectives, reading each objective aloud >.

Copper IUDs: Key Points for Providers and Clients 5/25/2012 Small plastic device inserted through the vagina and cervix into the uterus. Works mainly by stopping sperm and egg from meeting. Requires no user action. Requires a clinically trained provider to properly insert and remove. Most women can use copper IUDs, including women who have never been pregnant. Very effective Very effective, with little to remember. A woman can soon become pregnant when IUD is taken out. Long acting Long acting – up to 12 years – depending on type of device. Can be removed whenever woman wants. For older women: should be removed 1 year after last menstrual period (menopause). Adapted from WHO’s Decision-making tool for family planning clients and providers.

Copper IUDs: Key Points for Providers and Clients 5/25/2012 Very safe Copper IUDs act locally on the reproductive tract and have no systemic effects. For this reason, copper IUDs can be used safely by breastfeeding women and by women who cannot use hormonal contraceptives. IUDs do not: Leave the womb and move around the body. Get in the way during intercourse, although sometimes the man may feel the strings. Rust inside the body, even after many years. Some women have side-effects Side-effects usually get better after first 3 months. Side-effects include increase in menstrual bleeding or cramps. No protection against STIS or HIV/AIDS For STI/HIV and AIDS protection, also use condoms. Adapted from WHO’s Decision-making tool for family planning clients and providers.

Copper IUDs Copper IUDs have a small plastic frame with copper sleeves or wire around it TCu-380A, “Copper T” is most widely used copper IUD Multiload 375 is another copper IUD commonly available in some countries Copper T-380A Multiload 375

Levonorgestrel IUDs (LNG-IUD) A T-shaped plastic device that steadily releases a small amount of the hormone levonorgestrel each day Insertion/removal procedure similar to copper IUDs Slightly more effective than copper IUDs Shorter duration of use: 3-5 years, depending on brand Work by preventing sperm from fertilizing an egg Different side effects: lighter/no bleeding and hormonal side effects (such as headaches) Typically less available and more expensive than copper IUDs Fully covered under a different module This slide is only to introduce LNG-IUD to trainees. As the LNG-IUD becomes more available, providers are more likely to hear of it or have a client ask about it. Being able to differentiate it from the copper IUD is valuable. The side effect profile and MEC recommendations are relatively different from the copper IUD due to the LNG-IUD being a hormonal method. Full discussion of these is beyond the scope of the copper IUD TRP module. A full module on LNG-IUD is being developed and should become available in late 2018 or early 2019.

Effectiveness of IUDs In this progression of effectiveness, where would you place copper IUDs? Implants Male Sterilization Female Sterilization Progestin-only Injectables Combined Oral Contraceptives Male Condoms Standard Days Method Female Condoms Spermicides More effective Copper IUDs Less effective

Relative Effectiveness of Family Planning Methods # of unintended pregnancies among 1,000 women in 1st year of typical use No method 850 Withdrawal 220 Female condom 210 Male condom 180 Pill 90 Injectable 60 IUD (Copper/ LNG-IUD) 8 / 2 Female sterilization 5 Vasectomy 1.5 Implant 0.5 Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) 397- 404, Elsevier Inc.

Copper IUDs: Mechanism of Action Prevents fertilization by: Impairing the viability of the sperm Interfering with movement of the sperm Source: Ortiz, 1996

Copper IUDs: Characteristics Safe and highly effective Require no user action Long-acting (up to 12 years) Rapid return to fertility No systemic effects Have health benefits Trained provider needed to insert and remove Require pelvic exam Possible pain or discomfort during insertion Have potential side effects Complications are rare, but may occur Do not protect against STIs/HIV Source: CCP and WHO, 2018.

Copper IUDs: Health Benefits IUDs are known to: Prevent risks of pregnancy Reduce risk of ectopic pregnancy Rate in IUD users is 12 in 10,000 Rate in women using no contraception is 65 in 10,000 May help protect against cervical and endometrial cancer

Possible Side-Effects Copper IUD If a woman chooses this method, she 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 Bleeding or spotting between periods Some spotting for a few weeks Adapted from WHO’s Decision-making tool for family planning clients and providers. More cramps or pain during periods May get less after a few months

Copper IUDs: Counseling about Side Effects Before insertion, describe common side effects: Heavier and/or prolonged menstrual bleeding Menstrual cramping Spotting between periods Explain that side effects: Are not signs of illness Usually become less within the first 3–6 months Encourage to come back with questions or concerns If client cannot tolerate side effects, treatment or discontinuation may be necessary