Contraceptive Methods

Adapted from “New Dimensions in Women’s Health” by Linda Lewis Alexander & Judith H. LaRosa

Hormonal Methods

The pill has changed considerable since its introduction. Although the specific hormones are the same or similar, the dosages and formulations have undergone tremendous changes. There has been considerable concern and debate over the safety of birth control pills. It is important for a woman to understand the spectrum of issues, advantages, and risks associated with birth control pill use.

With birth control pills, the woman’s own reproductive hormone cycle is generally suppressed, and the synthetic estrogen and progestin of the pill produce an artificial cycle. Without the natural signals, the ovary egg follicle cannot mature, and ovulation cannot occur. The pill is responsible for other contracepting events, including the development of thick cervical mucus. This is in contrast to the profuse, slippery mucus associated with ovulation. The thick cervical mucus serves to impede sperm movement through the cervical canal and inhibits chemical changes in sperm cells that would permit the sperm to penetrate the outer layers of the egg. Another contracepting event associated with pill is that the lining of the uterus does not thicken as it normally does in the natural cycle, so even ovulation and conception did manage to occur, successful implantation would be quite unlikely. Birth control pills are effective in preventing pregnancy. Effectiveness rates of 99 percent can be expected when they are taken properly.

Side Effects

Side effects have been associated with birth control pills. These side effects may include both negative and positive changes that are a result of taking birth control pills:

  1. Shorter and lighter menstrual periods. The reduced amount of uterine lining results in less uterine shedding.
  2. Reduction or elimination of menstrual cramps. Cramping is believed to be linked to ovulation, and because ovulation does not occur, cramping is reduced or eliminated. When menstrual bleeding begins, prostaglandin is released by the endometrial cells as they are shed from the uterine lining. Women who have severe cramps have significantly higher levels of prostaglandin in their menstrual fluid than women who do not have cramps. Steady progestin exposure with birth control pills tends to reduce or eliminate cramps.
  3. Mood changes: Birth control pills may influence how a woman feels, or she may react to how she feels about taking the pills. A decreased fear of pregnancy and less anxiety about “getting ready” for sex may result in an increased sex drive. Other women may experience a decreased sex drive. Other reported mood changes include depression, irritability, or mood swings.
  4. Reduction or elimination of premenstrual symptoms. Premenstrual syndrome (PMS) tends to be significantly reduce or eliminated with birth control pills for most women.
  5. Spotting or bleeding between periods. The estrogen level maintained in the body by the pill is often lower than the natural level produced by the ovaries. This lower level may trigger slight uterine bleeding, which is generally referred to as “breakthrough bleeding.” This is more likely to occur when a pill is taken late or forgotten.
  6. Weight changes: Some birth control pill users gain weight with the pill, and others lose weight.
  7. Acne improvement. Most women who have acne notice significant improvement when they take birth control pills. Birth control pills may cause chloasma, however. Chloasma is the darkening of skin pigment on the upper lip, under the eyes, and on the forehead. It is not common and disappears when the birth control pills are discontinued.

Risks and complications

Risks and complications are also associated with birth control pills. The most significant cause of serious and potentially fatal complications are circulatory disorders. The estrogen in birth control pills can alter the blood-clotting mechanisms of the body. Some women may experience abnormal clot formation. Clots are especially serious if they are in a vital organ or if they become dislodged and then travel to a critical site and impede blood circulation. An additional concern is that birth control pills may alter blood lipid levels. Elevated blood lipids, such as cholesterol, place a woman at greater risk for cardiovascular disease. In evaluating the risks associated with birth control pills, it is also important to consider lifestyle and genetic risk factors as well. The risk factors should be carefully evaluated before deciding to take birth control pills. Cigarette smoking is an important determinant with birth control pills. By age 35, the death risk of birth control pills is higher than the death risk of full-term pregnancy, so most clinicians will not prescribe birth control pills to women over 35 who smoke. Having more than one risk factor multiples the risk. A woman who already has had circulatory problems, such as a stroke, thrombophlebitis, a heart attack, or blood clots anywhere in her body, should never take birth control pills. For women who do not have other cardiovascular risk factors, the overall risk with birth control pills is low.

Birth control pills are responsible for changes in the surface of the cervix. These changes may make pill users more vulnerable to sexually transmitted diseases of the cervix, particularly Chlamydia infection. It is wise for women to consider using condoms with birth control pills, particularly if they are younger then 25, have more then one sexual partner, or both.

Some birth control users develop hypertension (elevated blood pressure). Pill-related hypertension usually is not severe and subsides when the pills are discontinued. If a woman’s blood pressure is already high, birth control pills may or may not influence the problem. All women who take birth control pills should have regular blood pressure checks.

Some birth control pill users experience post-pill amenorrhea, a delay in the return of normal menstrual cycles after they stop the pills. This delay is more likely to occur in women who had irregular periods or long intervals between periods before they started taking pills. In most cases, menstrual periods return spontaneously within 3 months. Most women do not experience this hormone suppression, however, and they conceive soon after stopping any method of birth control. If a woman does not want to become pregnant when she goes off the pill, it is important to begin an alternate form of birth control immediately.

Cancer is another area of tremendous concern and discussion with the pill. Despite considerable adverse publicity resulting in great anxiety among women, there is no evidence today that birth control pills cause cancer. Despite this abundance of information, a 1985 Gallop Pool found American women to be misinformed about oral contraceptives. Because it takes a considerable amount of time for cancer to develop, however, continuous studies as they become available. Studies to date have shown important cancer-related benefits of the pill, however, which have significant impact on women’s risk for uterine and ovarian cancer. Pill users have about half the rate of these cancers that would normally be expected, and protection may last as long as 10 years after the pills have been discontinued. Pill users, however, may have a somewhat higher risk for cervical cancer and for a very rare form of liver cancer. The increased risk for cervical cancer may be an effect of the pill itself or perhaps due to other variables, such as frequency of Pap testing or the number of sexual partners. The pill/breast cancer question has not yet been fully resolved, with a recent Centers for Disease Control study finding that pills neither increased nor decreased a woman’s breast cancer risk, and a major report on breast cancer and oral contraceptives found that the weight of evidence still suggests no overall increased risk. Regardless of the contraceptive form, an important consideration is that all potential risk with any form of contraception must always be weighed against the known health benefits and the prevention of unwanted pregnancy. Drug interactions are another area of concern with birth control pills. Several drugs have been shown to reduce the contraceptive effectiveness of the pill and also contribute to bleeding between periods. These drugs include barbiturates, phenytoin (Dilantin), and certain antibiotics such as isoniazid, rifampin, and possibly tetracycline. It is probably wise for any woman on the birth control pill who is taking other medications to use a backup form of contraception while taking the other medication.

Advantages

Birth control pills provide the maximum protection possible with a temporary contraceptive method. They not interfere with the spontaneity of lovemaking. They provide freedom from heavy menstrual cramps and excessive menstrual bleeding, and premenstrual symptoms are often relieved. Menstrual periods become regular and predictable. Birth control pills provide benefits in addition to pregnancy prevention. As mentioned earlier, women who take birth control pills have lower prevalences of ovarian and uterine tumors. In addition, certain common benign breast tumors, fibroadenomas, and fibrocystic disease are less common in women who use birth control pills. Women who take the pill also have fewer ectopic pregnancies and ovarian retention cysts as well as less risk of developing rheumatoid arthritis, pelivc inflammatory disease (PID), toxic shock syndrome, uterine fibroids, osteoporosis, and endometriosis.

Contraindications

A contraindication is a medical condition that renders inadvisable or unsafe a treatment or procedure that otherwise might be recommended. Women who are contemplating birth control pills should carefully review and evaluate the contraindications before deciding to proceed with them. Absolute contraindications, meaning that the pills absolutely should not be taken, that have been specified by the FDA include:

  1. Known cardiovascular disorder, now or in the past, such as thrombophlebitis, stroke, heart attack, or coronary artery disease.
  2. Impaired liver function.
  3. Known or suspected estrogen-dependent neoplasia (abnormal tissue growth).
  4. Current or suspected pregnancy.
  5. Abnormal vaginal bleeding.

Types of Birth Control Pills

There are currently more than 30 different birth control pill brands available in monophasic (each cycle provides 21 identical hormone-containing pills), biphasic (two-phase) and triphasic (three-phase) pills. Triphasic pills are the latest of the combination pills and contain three different progestin does for different parts of each pill cycle. The primary advantage of triphasic pills is that the overall amount of progestin in a cycle is lower than it is with regular, identical-dose pills. Estrogen dose is generally considered to be the single most important factor in selecting a pill. Side effects and complications are reduced with lower estrogen dose.

Minipills are relatively new birth control pills. They are estrogen-free and provide a continuous, low dose of progestin. Minipills are slightly less effective than the phasic pills and often cause irregular menstrual patterns. Minipills do not totally suppress hormone production. Natural estrogen and progesterone production usually remains sufficient to trigger menstrual periods. There is less margin of error with minipills. The likelihood of pregnancy increases substantially with one or two missed tablets. Although menstrual periods tend to be less predictable with the minipills, women who use them generally find fewer premenstrual symptoms.

Hormonal Implants

In late 1990, the first new approach to contraception since the birth control pill, the subdermal contraceptive implant, was approved for use in the United States. It had been studied extensively in clinical trials of more than 55,000 women in 44 countries for several years before being approved for general use in the United States. Norplant is the commercial name of the implant. The system works like the minipill. Hormonal implants consist of six 1 – to 2 inch flexible rods that are filled with hormonal contraceptive, levonorgestrel, a synthetic form of progesterone, and implanted with local anesthesia just under the skin. Usually a ΒΌ -inch incision is necessary. The hormone is gradually and constantly released into the bloodstream with no user compliance necessary after the insertion. Contraceptive protection begins within 24 hours of insertion. The system contains no estrogen and is designed to remain in place and prevent pregnancy for at least 5 years. The contraceptive mechanism is the prevention of ovulation and the thickening of cervical mucosa, impeding the passage of sperm into the uterus.

Menstrual irregularities (prolonged bleeding, spotting, amenorrhea, and an increase in spotting/bleeding days) have been the primary adverse effects reported with the implants. Headache and acne have also been reported as side effects to the implant. Cautions and contraindications for implant use are similar to the minipill. Although many women are concerned about possible pain with insertion of the implant, most women who have had the implant feel that they had either no or only slight discomfort during the insertion procedure, which includes the use of a local anesthetic. The usual site for hormonal implants is the inner aspect of the upper arm. This site is advantageous to other body sites because it is easy to expose, well protected, not highly visible, does not have significant amounts of fat tissue, and does not result in excessive bleeding. Removal of the implant takes a little longer than insertion. Again anesthetic is used, and a small dressing is applied to the site. Fertility is not affected after the implant is removed.

Women who may be candidates for hormonal implants include those women who do not desire children for at least 3 to 5 years and who do desire an effective, convenient form of birth control. Women for whom other methods may be contraindicate or who have had difficulty complying with other methods may also be candidates for implants. When total costs are considered for a 5-year period, the implant is less expensive than oral contraceptives, although the initial cost is high.

Other forms of hormonal contraceptives include injections and vaginal rings. Long-acting progestin injections, sometimes called “the shot,” are used in many countries, and only recently has one been approved for use in the United States. Medroxyprogesterone (Depro-Provera) is the most common of the injectable progestins and has been approved for use. The long-acting progestin injection, which is usually given as an intramuscular injection every 3 to 4 months, has a theoretical and actual-use effectiveness of almost 100 percent. Depro-Provera was delayed for approval in the United States for several reasons, including a concern that laboratory dogs and primates developed cancers with the drug. There was also a concern that Depro-Provera might cause fetal deformities if the method failed as contraceptive. Vaginal rings containing progesterone that are effective for 1 to 6 months are being tested in various countries throughout the world. The rings may be removed during intercourse if they cause discomfort.

Barrier Methods

Barrier methods of contraception were the primary forms of contraception before the pill and IUD. After the introduction of these newer and “high-tech” birth control measures, barrier methods were seen a resurgence in popularity. Feminists and health advocates objected to the pill on the grounds that it introduced unknown chemicals into the body and long-term effects were unknown. The condom has reemerged in the AIDS epidemic as a major form of protection, not only against AIDS, but also against other sexually transmitted diseases, such as herpes and gonorrhea. In addition, the diligent and proper use of spermicides has demonstrated pregnancy protection rates fairly comparable to the pill and IUD. In addition, a major compelling reason is that barrier methods have virtually no health risks associated with them with the exception of rare allergic responses or localized irritation.

Barrier methods, as the name implies, provide a physical or chemical barrier that prevents sperm from fertilizing eggs. All barrier methods (except plain condoms) include spermicide, chemicals that break down the cell walls of sperm. Most barrier methods are used inside the vagina to cover the cervix and prevent sperm form entering the uterus. Condoms are protective sheaths that enclose the penis during intercourse and ejaculation.

Barrier methods are very safe for the user, and problems and risks tend to be rare. One rare but important risk from barrier methods is toxic shock syndrome (TSS), which may be associated with the diaphragm, cap, and sponge, or cervical cap not be used during a menstrual period or when there is vaginal bleeding for any reason. Further recommendations include delaying using these devices 4 to 6 weeks after having baby or until all postpartum bleeding completely stops. TSS risk can also be minimized by not leaving the devices in place in the vagina for longer than the recommended time period. TSS is not the only possible complication of vaginal bacterial infection if it is left in place for more than 24 hours. A foul-smelling discharge is an indication of such an infection and should be evaluated by a clinician.

The advantages to barrier methods are diverse. Overall, barrier methods are very safe. Although the diaphragm and cervical cap require fitting by a clinician, the other barrier methods may be conveniently purchased in pharmacies. Barrier methods have an important advantage in that they help to protect users form sexually transmitted diseases. Spermicides kill the organisms that cause gonorrhea, herpes, and Trichomonas infections. Barrier methods may also help protect against cervical cancer. The virus, human papilloma virus (HPV), that causes genital warts is also responsible for cervical cancer, and the herpes simplex virus (HSV), is believed to be a co-factor for cervical cancer as well. Barrier methods are seen as noninvasive contraceptive measures by those women who do not want to have an IUD inside their uterus and who do not want to manipulate their hormonal system. Barrier methods may also be sued as backup contraceptive measures when pills have been forgotten or during times when an IUD’s effectiveness may be questioned. Some couples have intercourse sporadically or infrequently and find that barrier methods are appealing because they are effective but only have to be used when necessary. Older women and careful users find barrier methods to be more effective than younger women, women who have frequent intercourse, and those who are not careful users.

Spermicides

Spermicidal agents may be in the form of cream, foam, film, suppository, or gel. These agents are available without prescription, and most contain detailed printed materials on their use. Spermicidal barriers work as a mechanical barrier in that they spread over the surface of the cervix and block access to the cervical opening. The more important mechanism by which they work, however, is that they inactivate the sperm by breaking down the surface of the sperm cells on contact. The spermicide should be inserted deep into the vagina. An advantage of these agents is that they are effective rather immediately upon use, but they do have time limits for their effectiveness. It is important to read the printed sheet available with each product and know the range of time for effectiveness. An additional application is needed for each round of lovemaking, and the product should be left in place, with no douching, for at least 6 hours after the last round. Contraceptive film is the newest form of spermicide. It is contained in a small thin sheet of glycerine, which is placed over the cervix before intercourse. Its effect is similar to that of contraceptive suppositories in that as the sheet dissolves, the spermicide is released.

Cervical Cap

Although it has not ever been widely used in the United States, the cervical cap has been a popular contraceptive in Europe. Caps are still not readily available in the United States, although they were approved by the FDA in 1988. The cervical cap looks and works much like a small deep diaphragm. It fits snugly over the cervix and is held in place by suction. Caps require a clinician’s examination, fitting, and prescription. Not every woman who wants to use a cervical cap can be properly fitted, and some women find that insertion and removal of the cap are more frustrating than the diaphragm. The cap shares many characteristics of the diaphragm. It is made of latex and is used with a spermicidal agent such as cream or jelly. It also may be inserted up to 6 hours before having sex so it need not interrupt the activity.

Diaphragm

The diaphragm is a dome-shaped latex cup rimmed with a firm but flexible band or spring. A diaphragm must be first coated with a spermicidal agent before being inserted into the vagina before intercourse. The spermicidal agent is important because the diaphragm does not remain fixed against the cervix, and it does not create a tight seal. It is possible for sperm to enter around the rim of the diaphragm and come in contact with the cervix. The primary function of the diaphragm is to hold the spermicidal agent directly agent directly against the cervix. Because the diaphragm must fit the cervix it is to cover, diaphragms require clinician examination, fitting, and prescription. During the fitting, it is important to evaluate the comfort of the diaphragm as well as practice insertion and removal of the diaphragm.

Diaphragm effectiveness depends on proper fit and diligent use. A diaphragm that is too small may not stay in place and slip off the cervix, and one that is too large may press on the urethra and cause a urinary tract infection. Application of the spermicidal cream or gel and insertion of the diaphragm can occur up to 6 hours before intercourse. If intercourse occurs more than once, it is important to use an additional application of spermicide for each event, regardless of how short a time the diaphragm has been in place. The diaphragm should not be removed or dislodged to add the cream or gel for a follow-up round of lovemaking. The diaphragm may be inserted in a standing, squatting, or lying-down position. For insertion, the diaphragm should be held with dome down (spermicide inside the dome) in one hand. The opposite sides of the rim should be pressed together so the diaphragm folds. The other hand should spread the lips of the vagina to facilitate insertion. The diaphragm should be inserted into the vagina toward the small of the back as far as it will go. A finger can tuck the rim behind the firm bulge in the roof of the vagina that covers the pubic bone. Once the diaphragm is in place, the women should not be able to feel it except with her fingers. If it is uncomfortable, it should be removed and reinserted. It is a good idea to check the position of the diaphragm before having intercourse. This can be done by the woman or her partner. The back rim should be below and behind the cervix, and the front rim should be tucked up behind the pubic bone. It should be possible to feel the cervix through the soft rubber dome of the diaphragm.

Like the cervical cap, an advantage of the diaphragm is that, it may be inserted up to 6 hours before intercourse and need not interrupt or interfere with lovemaking. It should be left in place for a minimum of 6 hours after intercourse, and douching should not occur during that time. It should not remain in place longer than 24 hours. A spermicidal gel or cream must be used with the diaphragm. The gel or cream remains active for six hours. If intercourse does not occur within that time, the diaphragm can be removed and fresh gel or cream inserted. If intercourse occurs more than once, an additional applicator full of spermicide should be used each time. The diaphragm should not be removed or dislodged until 6 hours after the last act of intercourse. The diaphragm may be removed by reaching up inside the vagina with an index finger or thumb and grabbing the front rim of the diaphragm. It then can be pulled down and out of the vagina. A squatting position facilitates removal of the diaphragm for some women. After removal, the diaphragm should be washed with warm water and soap, rinsed, and dried with a towel. It is a good idea to inspect the diaphragm for defects or holes. Petroleum jelly should not be used with a diaphragm for lubrication because it will cause deterioration of the latex. If additional lubrication is desired, a water-soluble lubricant may be used.

Side effects with the diaphragm are infrequent. An allergic response to the latex of the diaphragm or to the spermicide is possible but rare. Symptoms of an allergic response include burning, itching, swelling, or perhaps blistering. Urinary tract infections are another possible side effect of the diaphragm. These infections may be in the form of either cystitis, infection of the bladder, or urethritis, inflammation of the urinary opening. Some diaphragm users feel bladder pressure, rectal pressure, or cramps when the diaphragm is left in place 6 hours after intercourse. A smaller diaphragm or a different rim type might help relieve this side effect.

Condom

Condoms have resurfaced as a popular barrier contraceptive in recent years. Women are now responsible for nearly 40 percent of total condom sales, and condoms are advertised in women’s magazines. Condoms are available with lubricants and spermicides and a variety of colors and textures. An important advantage of condoms is that they are portable and disposable. They may be discreetly carried and thus available for use when necessary. Women do not experience any post-intercourse vaginal leaking, and condoms permit the male partner to take an active role in birth control. The lubrication on prelubricated condoms may help to reduce friction during lovemaking and reduce the risk of vaginal or penile irritation. Condoms should be stored in a cool, dry place. Storage in a heated unit (such as a glove compartment) can result in deterioration. They should not be lubricated with a petroleum jelly (such as Vaseline), which can weaken the latex. If extra lubrication is desired, a water-soluble lubricant (such as K-Y Jelly) or lubricated condoms can be used.

If a couple selects condoms as the method of birth control, it is essential that a condom be used for every lovemaking event. Condom use requires commitment and discipline for effective birth control. A spermicide-coated condom affords the most effective birth control protection as well as additional protection from sexually transmitted diseases. The clear fluid that collects on the end of an erect penis may contain living sperm so the condom should be placed on the penis before the penis comes near the vagina. It is important that room be left at the end of the condom to collect the semen. A condom that is stretched very tightly over the head of the penis is more likely to break or force the seminal fluid along the shaft of the penis and out the upper end of the condom. The penis should be withdrawn from the vagina before the erection subsides, and the condom should be held as the penis is withdrawn from the vagina. As the penis begins to lose its erections. A quick visual inspection to ensure that the contents are inside and that there has been no spill or leakage is a good idea.

Couples should use condoms both during and after treatment for any reproductive tract infection as a precaution against reinfection. Condom use is encouraged with women who are at risk for sexually transmitted diseases, even for those who are using an effective form of birth control, such as the pill.

Female Condom

The female condom has recently been released as another form of barrier contraception. The female condom fits into the vagina, preventing the penis and semen from direct physical contact with the vagina. Two forms of the female condom are available. The first is a latex rubber G-string that contains a condom pouch located in the crotch. When the penis enters the vagina, it pushes the latex pouch into the vagina. The second type is placed in the vagina with an inner circular rim going deep into the vagina and an outer rim that is outside the vagina.

Contraceptive Sponge

The contraceptive sponge is a modern version of a historical form of birth control. For centuries, women have soaked small sea sponges in various solutions and placed them inside the vagina to prevent conception. The sponge acts both as a cervical barrier and a source of spermicide, and the sponge absorbs the ejaculated semen. One side of the sponge has a dimple in it that fits against the cervix, and the other side has a nylon loop for easy removal. It is available without fitting or prescription. Sponge effectiveness depends somewhat on a woman’s previous pregnancy history because this product is less effective for women who have previously completed a full-term pregnancy and delivery that for women who have not done so.

An advantage of the contraceptive sponge is that it is portable and disposable. It can be inserted up to 24 hours before intercourse and need not interrupt lovemaking. It does not require a repeat application of spermicide for a second round of lovemaking, and it is less messy than other spermicidal agents. Before inserting the sponge, it is necessary to moisten the sponge with a small amount of tap water. It is held between two fingers and inserted into the vagina with the dimple side against the cervix. It is a good idea to check for proper placement by feeling the cervix through the sponge. The sponge can absorb vaginal lubrication, so some women use additional lubricant such as K-Y- jelly or spermicidal jelly after the sponge is in place. The sponge is designed for 24 hours of use and should remain in place for 6 hours after the last round of intercourse. Care should be taken to ensure that the sponge is not left in place longer than necessary. Before discarding a used sponge, it is best to check to make sure that it is intact. If the sponge is not intact, it is necessary to check the vagina for fragments.

Permanent Methods

Healthy women and men usually have many years of fertility after they have completed their childbearing. Surgical sterilization offers permanent birth control for those individuals who do not with to have any more children. Surgical sterilization has become the most popular method of birth control among married couples in the United States. Advantages of sterilization include a high rate of effectiveness with relatively quick, simple procedures that have minimal complications and side effects.

Female Sterilization

Trends among contracepting older reproductive-age US women show a dramatic increase in sterilization rates. Sterilization of women has been made much easier in recent years by the development of new instruments and new techniques that have replaced laparotomy, surgically opening the abdomen and tying off the fallopian tubes. Because there were a significant number of unwanted subsequent pregnancies with this procedure, newer techniques have evolved that add destruction or removal of part of the fallopian tube. Laparoscopic sterilization, also known as “band-aid” surgery, is one of these techniques and uses a surgical instrument, the laparoscope, which is a tube equipped with light and magnification lenses. The laparoscope is inserted into the abdomen and provides a view of the uterus and tubes. The fallopian tubes are sealed with a cauterizing instrument or with rings or clips. Minilaparotomy is the latest technique for tubal ligation. It requires a small abdominal incision and is performed under local or general anesthesia. The fallopian tubes are lifted out through the incision, cut, sealed, and replaced. The entire procedure takes a few minutes, and the woman requires a few hours rest and observation and is then able to go home.

Sterilization should be undertaken with the expectation that the procedure is not reversible. Some reversal procedures, however, have been successful. The chances of repairing the tubes for future pregnancy depend on the amount of fallopian tube that was destroyed at the time of the sterilization procedure. Silicone plugs have been placed into tubal openings of recent sterilization procedures with the theoretical possibility that the procedure would be reversible, but sufficient data are not yet available on the procedure to date.

Male Sterilization

Male sterilization is accomplished with a surgical procedure known as a vasectomy. It is usually performed under local anesthesia in a physician’s office. Usually one or two small incisions are made just through the skin of the scrotum. The vas deferens is lifted through the incision where it is cut. The two ends are tied or cauterized to seal them. Most men are able to return to work and normal activities the day after surgery but are advised to avoid strenuous activities, such as straining and lifting, for the first week after surgery. Vasectomy does not provide immediate contraceptive protection. Live sperm may remain in semen for some time because mature sperm are stored in the vas deferens above the surgical site. Vasectomy offers several advantages in birth control. It is extremely effective as a permanent form of birth control with very low risk of problems or complications compared with temporary forms of birth control or tubal ligation for women. Vasectomy does not cause any change in hormone levels or in the appearance or volume of semen. It also permits the male partner to take an active role in contraceptive responsibility.

Other Forms of Contraception

In addition to the temporary and permanent methods of birth control discussed, other forms of contraception have been used. Some of these methods are valid approaches to birth control but are associated with fairly high failure rates, even among motivated partners. These methods include abstinence, withdrawal, and breastfeeding.

Abstinence refers to no penis-in-vagina intercourse and depends on total willpower. Other forms of sex such as oral sex or mutual masturbation do not result in pregnancy and may be considered a form of abstinence.

Withdrawal is also known as coitus interruptus and refers to interrupting intercourse before ejaculation of the semen. Although it is logical to believe that if there is no ejaculate, there is no sperm and thus no conception, withdrawal can fail as a form of birth control when the man is unable to remove his penis in time or because some sperm are released before ejaculation. The failure rate for withdrawal as a form of birth control is fairly high because it is difficult for a man to know exactly when ejaculation will occur, and it is difficult to override mentally the physical activity of intercourse.

Breastfeeding is not considered an effective form of birth control. Although breastfeeding does delay the return to fertility after birth, it is not possible to calculate exactly when fertility returns. One study found that more than half of the breastfeeding women who did not use birth control were pregnant again within months after delivery.

Intrauterine Devices

An IUD is an object placed in the uterus through the cervix. The IUD is left in place for an indefinite period and prevents pregnancy from the time it is placed in the uterus until it is removed. The IUD was a popular form of birth control in the 1970s. Since then, its popularity has declined. Medical problems and lawsuits against the manufacturers have led to decreased production and use of the IUD as a form of contraception. An IUD is inserted by a clinician into the uterus via the cervix with special instruments. There is a string attached to the IUD for identification and removal of the device.

The presence of the IUD inside the uterus alters a number of factors necessary for pregnancy. IUDs reduce the number of sperm cells that reach the oviducts and decrease the viability of those sperm cells that do reach the oviducts. It was once proposed that the primary mode of action of the IUD was to prevent implantation, and therefore it induced abortion. Numerous studies of the mode of action have not found frequent evidence of fertility (as evidenced by biochemical markers of early pregnancy in blood and urine.) Thus it is proposed that IUDs interfere with fertilization and not implantation. Most likely the IUD acts on both fertilization and implantation, with the major action on fertilization.

Pelvic inflammatory disease (PID) has been identified as a significant risk associated with the IUD. In an international study, researchers learned that the risk of PID among IUD users appears highest in the first 20 days after it is inserted. Women who received their UID’s before the age of 25 and before 1980 were more likely to contract PID than those who did not. The researchers also concluded that PID among IUD users is more strongly related to the insertion process and a background risk of sexually transmitted disease than to the type of IUD or to long-term use.

Some women should not have an IUD inserted. Anyone with an active pelvic infection, including gonorrhea, or a pregnant women should never have an IUD placed in her uterus. Insertion of an IUD is strongly contraindicated if a woman has recent or recurrent pelvic infections, inflammation of the cervix or vagina, history of ectopic pregnancies, valvular heart disease, and abnormal Pap smears.

Advantages of the IUD include no suppliers or equipment for lovemaking, normal hormonal cycles are not manipulated, and it is a highly effective form of contraception. Health risks are the primary disadvantage with the IUD. Risk of infection is a major concern with IUDs because IUD-related infection can lad to illness, infertility, and, in rare cases, even death. Total amount of menstrual bleeding tends to increase with the IUD, and spotting between periods commonly occurs. The IUD remains as a birth control choice for a woman who has finished childbearing and whose risk of infection is very low.

Emergency Birth Control

A woman who engages in unprotected sexual activity runs the risk of both sexually transmitted diseases and pregnancy. Birth control measurers must be used in accordance with the manufacturer’s guidelines. Removing a diaphragm too early, failing to sue a spermicidal agent with the diaphragm, and using too little foam are all examples of increasing the risk of an unplanned pregnancy. Occasionally accidents happen. A condom may tear or slide off, or a diaphragm may dislodge from the cervix. In these situations, one option is to use a spermicidal agent immediately. Foam or cream would be more immediately effective than a vaginal suppository, which takes time to dissolve. There are no guarantees, but the spermicide may help reduce the risk of an unplanned sperm/egg union. If spermicides are not available, a douche with warm water is another alternative, but no guarantees are offered.

Another form of emergency birth control includes medications containing synthetic estrogens or progestins (or both), which may be taken within 72 hours of unprotected intercourse to prevent implantation. These are considered emergency methods only and should not be considered as a regular form of birth control. These medications, such as Ovral (high estrogen and progesterone levels) and high-dose progesterone-only pills carry the same risks as oral contraceptives. The synthetic estrogen diethylstilbestrol (DES) is no longer approved for use in the United States as a postcoital contraceptives.

The European drug RU486 has received recent media attention as the “abortion pill.” The drug antagonizes the actions of progesterone and has been used extensively throughout Europe. Some experts argue that even if available in the United States, RU486 would not be the drug of choice as a postcoital contraceptive and that Ovral is preferred immediately after unprotected intercourse.