1. SAF-PAC/SRMH/CARE Kamlesh Giri April 23rd, 2013
IUD – A Quick Update
SAF-PAC/SRMH/CARE
Kamlesh Giri
April 23rd, 2013

2. Unmet Need for Modern Contraception
At least 215 million women want to prevent or delay pregnancy but are not using effective contraceptives either due to lack of information, social pressures, or due to insufficient access to contraceptive options.
Access to family planning improves child and maternal health and reduces number of abortions.

3. World Modern Contraceptive Prevalence by Method
This slide shows the distribution of modern contraceptive use globally.
The most common types of contraception are permanent or long-acting methods:
34% practicing modern methods choose female sterilization – these are high in China, India and also the United States (30%)
Among reversible contraceptive methods, IUD is the most common method
25% choose IUDs – the highest percentage coming from Asia, substantially contributed by the government supported program in China (40% IUD use)
The IUDs high prevalence can be attributed to favorable government sponsored programs in China, as well as in countries like Egypt, Vietnam and a few previous Soviet Republic Independent States

4. World Map showing IUD Use
This map shows IUD prevalence in different parts of the world. Clearly China and the adjoining geographic regions have a high prevalence rate of over 30% of IUD use.
Certain countries in Europe and Latin America also have a high prevalence of IUD use.

5. [Insert Lecture Name Here]
Worldwide Use of IUDs
% Use for Married Women of Reproductive Age
Asia 18
Europe 15
Latin
America
& Caribbean 8
Africa 5
Oceania 1
North America 2
Talking Points:
IUDs are the most popular form of reversible contraception used worldwide, although not used a lot in Africa and other places
the 5% use shown for Africa includes Northern Africa. If only Sub-Saharan Africa is taken then it is only 1%
The population listed here—women currently married or in a union using family planning, ages 15–49—is the population that is most suited for IUD use
Married Women of Reproductive Age (MWRA)
The IUD: An Important Method with Potential. Population Reports Series B, Number 7. Vol 33, (2), 2006.
References:
Population Reference Bureau. Family Planning Worldwide 2008 Data Sheet
Mosher WD, Martinez GM, Chandra A, et al. Use of contraception and use of family planning services in the United States: Advance Data From Vital and Health Statistics. No. 350, 2004.
Population Reference Bureau
Mosher WD, et al

6. What others are saying about FP!
"[Family planning] means the difference between being empowered and feeling powerless. It means the difference between celebrating a daughter's graduation and watching her drop out of school. It even means the difference between life and death.” Melinda Gates, HuffPost Blog
What are the movers and shakers in this field saying about family planning in general?
Here is a quote from Melinda Gates, of the Gates Foundation, taken from the HuffPost Blog:
“Family Planning means the difference between being empowered and feeling powerless. It means the difference between celebrating a daughter’s graduation and watching her drop out of school. It even means the difference between life and death”.

7. What is an IUD? T-shaped plastic frame with copper wire/sleeves
Highly effective in preventing pregnancy – failure rate is less than 1%
Copper T 380A lasts for 12 years once inserted
Works mainly by preventing fertilization of an egg by sperms
Most women can use IUDs, including women who have never been pregnant
Fertility returns very quickly after removal
Very effective as emergency contraception
So, What is an IUD?
As most of you know, it is a long acting contraceptive device. It is a plastic frame shaped as the letter T with copper wire or sleeve around the stem and arms of the T. In the US it is marketed as ParaGuard and internationally as Copper T-380 A.
A variation of this is the Mirena – a hormone (progesterone) containing IUD.
In this presentation we will be focusing on the Copper T-380 A because of its relevance to our international programs
Together with the Implants – it is referred to as the LARC – long acting reversible contraceptive
It is a highly effective method – with failure rates less than 1%
It is effective for 12 years once inserted in the uterus
Copper is toxic to sperms and works by preventing fertilization of egg by sperms
Most women can use IUDs including those who have never been pregnant
And fertility returns very quickly after removal
Very effective as emergency contraception

8. IUD – Types Copper T 380A IUD LNG IUS (hormonal)
20 mcg levonorgestrel/day
Provides protection for up to 5 years
Copper T 380A IUD
Copper ions
Provides protection for up to 12 years
Copper T-380 A
Copper ions are toxic to sperms as mentioned ealier
LNG IUS – marketed as Mirena IUD – Levoneorgestrel Intra-uterine System
It works similar to other hormonal methods like implants

9. IUD and IUS: Return to Fertility20 40 60 80
100 3 6 9 12
Months
Cumulative pregnancy rate (%)
LNG IUS
Copper IUD
Talking Points
The return to fertility with the IUD and IUS is rapid, much more rapid than that of methods such as Implants.
50% of women become pregnant within 1 year of removal
Sources
Andersson K, Batar I, Rybo G. Return to fertility after removal of a levonorgestrel releasing intrauterine device and Nova-T. Contraception 1992;46:575.
Belhadj H, Sivin I, Diaz S, et al. Recovery of fertility after use of the levonorgestrel 20 mcg/d o copper T 380 Ag intrauterine device. Contraception 1986;34(3):261.
Vessey MP, Lawless M, McPherson K, Yeates D. Fertility after stopping use of intrauterine contraceptive device. Br Med J (Clin Res Ed) 1983 Jan 8;286(6359):106.
Andersson et al. Contraception 1992;46:575
Belhadj et al. Contraception 1986;34:261
New Developments in Contraception

10. Copper-bearing IUD: Timing of Insertion
[Insert Lecture Name Here]
Copper-bearing IUD: Timing of Insertion
Can insert any time reasonably sure woman is not pregnant
Within 12 days after start of menses
Later in cycle/during amenorrhea if reasonably sure not pregnant
< 48 hours postpartum (if no puerperal sepsis)
≥ 4 weeks postpartum (if not pregnant)
Within 7 days postabortion
When can one insert an IUD?
It can be inserted safely:
Within 12 days after menses
Later in cycle – during amenorrhea if reasonably sure woman is not pregnant
Within 48 hours postpartum – if no infections
4 weeks after delivery
within 7 days postabortion
This is the only reversible contraceptive method that can be used immediately after childbirth

11. IUD Efficacy: Comparable to Sterilization
[Insert Lecture Name Here]
IUD Efficacy: Comparable to Sterilization
5-year gross cumulative failure rate
All Sterilization
1.3
TCu 380 IUD
1.4
Postpartum
Salpingectomy
0.6
Talking Point
Because the intrauterine contraception failure rate is comparable to that of sterilization, it could be viewed in this context as reversible sterilization, not just reversible contraception.
References
World Health Organization. Mechanism of Action, Safety, and Efficacy of Intrauterine Devices. Technical Report Series 753. Geneva: WHO; 1987.
Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol. 1996;174(4):1161.
WHO
Peterson HB, et al. Am J Obstet Gynecol

12. Side Effects and Complications
Might increase menstrual bleeding or cramps
Usually gets better after first 3 months
Complications
Rare
Perforation of the wall of uterus by IUD or an instrument
Pelvic inflammatory disease (PID) may occur if the woman has Chlamydia or gonorrhea at the time of IUD insertion
As with all contraceptive methods, IUDs have their own share of side-effects
Some women may experience minimal side effects while others might experience more severe side effects
Increased menstrual bleeding or uterine cramps are common side effects
In most cases these side effects get better after first 3 months of use
Complications with IUD are rare
Perforation of the uterine wall is a recognized complication – most small perforations repair on their own with minimal intervention.
IUD does not cause PID – Chlamydia or gonorrhea cause PID! To quote Dr. Hatcher. Client screening is important to minimize this risk.

13. IUDs Can Be Used by Most HIV-Positive Women
[Insert Lecture Name Here]
IUDs Can Be Used by Most HIV-Positive Women
No increased risk of complications compared with HIV-negative women
No increased cervical viral shedding
MEC Category:
Initiation: not recommended if not fully controlled but can be initiated if clinically well on ARVs if other methods are not available or not appropriate
Continuation: Can continue if more appropriate methods are not available
Talking Points
A 1999 study in Kenya found that copper IUD insertion did not significantly change the shedding of HIV-infected cervical cells.
WHO gives both the copper T and the levonorgestrel IUD a Category 2 medical eligibility rating, suggesting that the benefit of women with HIV infection using an effective contraceptive method outweighs potential risk of infection.
There is no known interaction between AIDS and IUD use but Category 3 for initiation if woman is not well. Category 3 is when the risks of using the contraception outweighs the benefits.
References
World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 4th edition. Geneva: WHO; 2009.
Morrison CS, Sekadde-Kigondu C, Miller WC. Is the intrauterine device appropriate contraception for HIV-infected women? Brit J Obstet Gynaecol. 2001;108:
Richardson B, Morrison C, Sekadde-Kigondu C. Effect of intrauterine device use on cervical shedding of HIV-1 DNA. AIDS. 1999;13:
WHO. Medical Eligibility Criteria for Contraceptive Use Morrison CS, et al. Brit J Obstet Gynaecol
Richardson B, et al. AIDS

14. Dispelling Myths: IUDs……
Do not cause abortion
Do not cause ectopic pregnancies
Do not cause PID
Do not cause infertility
Are not too large for small women
Are unlikely to cause discomfort for male partner
Do not travel to distant parts of the body
Are not contraindicated for HIV-positive women
IUDs are not abortifacients; they prevent fertilization.
IUDs do not increase the risk of ectopic pregnancy; rather, they decrease the risk of both ectopic and intrauterine pregnancy. However, IUDs are more efficient at preventing uterine than ectopic pregnancy, so that compared with other methods, a higher fraction of pregnancies that occur with an IUD are ectopic.
A survey of ob/gyns shows that although attitudes toward the safety and effectiveness of the IUD are very positive, most respondents believe that a long-term causal relationship exists between the modern copper T IUD and PID. The truth is that IUD use, in properly selected patients, does not increase the risk of PID.
Untreated pelvic infection is the most common cause of infertility; IUD use is not associated with infertility. The 2001 New England Journal of Medicine article by Hubacher et al., as well as others, confirms the overall benign impact on women who use copper IUDs.
Some women are hesitant to use the IUD because they perceive it to be larger than it actually is. In truth, both types of IUD are small and can fit in the palm of the hand.
IUDs do not travel to distant parts of the body – as commonly rumored and
HIV-positive women can safely use IUD
References
Hubacher D, Lara-Ricalde R, Taylor D. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. NEJM. 2001;345:561-7.
Stanwood NL, Garrett JM, Konrad TR. Obstetrician-gynecologists and the intrauterine device: a survey of attitudes and practice. Obstet Gynecol. 2002;99:
Forrest JD. U.S. women’s perceptions of and attitudes about the IUD. Obstet Gynecol Surv. 1996;51(12 Suppl):S30-4.
Lippes J. Pelvic actinomycosis: a review and preliminary look at prevalence. Am J Obstet Gynecol. 1999;180(2 Pt 1):265-9.

15. Clinical Aspects Counseling – foundation for FP programs
Client screening
Medical Eligibility Criteria
Pelvic exam
Insertion procedure – doctors, nurses, mid-wives, health assistants, clinic officers
Follow-up
Family Planning Counseling is the foundation for all family planning programs – whether it is community based or facility based
the stronger the counseling practice, the more stable a family planning program
unfortunately, counseling for family planning tends to be neglected in many programs adversely affecting the program
Counseling offers an opportunity to clients to understand the options available and make an informed decision or choice
Client Screening –
WHO provides technical guidance in outlining clinical conditions that are contraindications to different contraceptive methods. The Medical Eligibility Criteria is integrated into a user-friendly tool – the MEC Wheel for contraceptives – a sample is available here for review
Pelvic exams are an integral part of an IUD screening – women in most cultures shy away from pelvic exams, if they can help it. But it is also true that providers tend to avoid pelvic exams because it is more labor intensive, with extra steps in service provision as well as instruments processing and preparation
Almost all countries where we work allow doctors, nurses, mid-wives, clinical officers and health assistants to insert and remove IUDs. Post-partum IUD insertion requires special training to qualify as PP IUD provider.
IUDs are placed high up in the uterus under the dome of the uterus. Expulsions are more common with improperly placed IUD. Good training helps to reduce this common cause of IUD expulsion
Follow-up: A single follow up 4-6 weeks after insertion is recommended. Regular follow ups are not required for IUD clients. They can return to clinic if they have any issues or questions. They are advised to come back if they feel that IUD has been expelled. Or if they are having any side effects!

16. IUD in Humanitarian Settings
Barriers – usual suspects
Weak health infrastructure
Lack of trained providers
Lack of good logistics support
Poor supervision of services
How does IUD perform in humanitarian settings?
IUDs are part of the broader method-mix that we persevere to provide in humanitarian settings (as we do in development setting)
The barriers to services reflect what we find in most low-resource settings – but more severe making it an even bigger hurdle to overcome
Here are some of the usual suspects:
The overall health system/infrastructure is weak, at times with almost no national system level support in crisis affected areas
IUDs are facility based or clinic-based services. There is always a shortage of trained providers as it requires clinicians to provide services, and they are hard to find, even in normal settings in developing countries, let alone in humanitarian settings. The challenge then is to find clinicians in crisis settings, train them quickly to meet service demands without compromising on quality of care, at the same time recognize that high turn-over of staff is the expected norm
Logistics supply of FP commodities is a critical component for services and almost always weak – for numerous reasons, e.g. poor roads, poor political will, problem of the ‘last-mile’ coverage, lack of reliable supply-chain-management system, etc.
Supervision of services is limited if present, and providers have to make it on their own with little feedback, reward or punishment

17. IUD in Humanitarian Settings – contd
Funding – small portion of the overall humanitarian funding pie for FP in general – and even smaller for IUD
An average of $20.8 billion in total ODA annually to 18 conflicted-affected countries in study
$509.3 million (2.4%) for reproductive health
FP represents only 1.7% of RH activities
Reproductive Health care hasn’t yet gained prominence as a life-saving intervention in humanitarian settings. Consequently, the funding for RH intervention is crisis-setting is very limited.
Study: Official Development Assistance (ODA) for Reproductive health in Conflict-Affected Countries
These figures are based on study conducted by RAISE Initiative with data from 18-conflict affected countries analyzed for 2003, 2004, 2005, and 2006 of funds disbursed by Official Development Assistance (ODA). Two data sources were analyzed for the study: The Creditor Reporting System and the Financial Tracking System databases.
Findings:
An average of US$20.8 Billion in total ODA was disbursed annually to the 18 conflicted-affected countries included in the study, of which US$509.3 million (2.4%) was allocated to reproductive health.
This represents an annual average of US$1.30 disbursed per capita in the 18 sampled countries for RH activities
Family planning activities represents only 1.7% of annual ODA disbursement for RH activities annually
Reference: Tracking Official Development Assistance for RH in Conflict-Affected Countries – Preeti Patel, Bayard Roberts, S. Guy, Louise Lee-Jones, Lesong Conteh

18. IUD in Humanitarian Settings – contd
A few caveats:
SGBV is not coded as RH but rather as post-conflict peace building by ODA
Does not include $ from philanthropic organizations: e.g. Gates Foundation, Buffet Foundation
Does not include $ from multilateral organizations: WHO, UNHCR, UNOCHA, WFP
Study: Official Development Assistance (ODA) for Reproductive health in Conflict-Affected Countries
SGBV is not coded as Reproductive Health but rather as post-conflict peace building by ODA
Does not include money from philanthropic organizations e.g. Gates Foundation, Buffet Foundation, etc.
nor from these multilateral organizations: WHO, UNHCR, UNOCHA (office for the coordination of humanitarian affairs), and WFP
Reference: Tracking Official Development Assistance for RH in Conflict-Affected Countries – Preeti Patel, Bayard Roberts, S. Guy, Louise Lee-Jones, Lesong Conteh

19. Supporting Access to FP-PAC
Program in 3 countries
Chad, DRC and Pakistan
Supported by Large Anonymous Donor
Emphasis on providing LARC to most underprivileged women – women in crisis and post-crisis settings
LARC as part of comprehensive FP method mix
SAF-PAC also supports RH services in Mali and Djibouti but at a smaller scale
Supporting Access to Family Planning and Postabortion Care in emergencies or SAF-PAC is supported by a large anonymous donor with CARE programs in Chad, DRC and Pakistan. Program emphasis is on providing long acting reversible contraceptives to populations who are either in crisis or post-crisis settings. LARC is provided as part of a comprehensive FP method mix – considered as important aspect of good quality FP services
SAF-PAC also supports RH services in Mali and Djibouti but at a smaller scale

20. Contraceptive Method Mix – SAF-PAC
This is a method mix graph for our programs form Phase I in the 3 countries, Chad, DRC, and Pakistan
As you can see IUD uptake is quite high in Pakistan in the method mix while it is very low in DRC and Chad
However, it is encouraging to see a very high uptake of Implants, which though not IUDs, but still part of LARC methods

21. Conclusion
Though widely used contraceptive method globally, IUDs are poorly utilized in Sub-Saharan Africa
IUDs can be safely used by nulliparous women, HIV+ women, post-partum women
IUD effectiveness comparable to permanent FP methods
IUD does not cause PIDs
IUD considered best option as an EC
Need to improve funding $ for FP in general and LARC in particular
In Conclusion
Though widely used contraceptive method globally, IUDs are poorly utilized in Sub-Saharan Africa
IUDs can be safely used by nulliparous women, HIV+ women, post-partum women
IUD effectiveness comparable to permanent FP methods
IUD does not cause PIDs or pelvic inflammatory disease
IUD considered best option as an EC
Need to improve funding $ for FP in general and LARC in particular

22. Thank you
Questions?

23. Table 2. ODA disbursement in conflict-affected countries.
Patel P, Roberts B, Guy S, Lee-Jones L, et al. (2009) Tracking Official Development Assistance for Reproductive Health in Conflict-Affected Countries. PLoS Med 6(6): e doi: /journal.pmed