Contraception

(Birth Control)

 “Contra-“ means to oppose and “-ception” refers to conception or conceiving a new child.  So contraception literally means “against conceiving”.  This section gives information about different forms of contraception and DOES NOT ADVOCATE ANY ONE METHOD OF BIRTH CONTROL.  SPEAK TO YOUR HEALTHCARE PROVIDER FOR INDIVIDUALIZED RECOMMENDATIONS FOR BIRTH CONTROL IF PREGNANCY IS NOT DESIRED.

 

Many couples desire to plan when and how many children they will have.  Various methods of contraception can be used to prevent pregnancy.  Some couples may choose to wait before starting a family, some may want to have a little space between children, and when the family is “complete” or as older age approaches many couples desire to remain sexually active but don’t feel that having another child is right for them.  Also, some health concerns with either individual may warrant the use of contraceptives (health problems, sexually transmitted infections, etc.).

It is also important for a couple to discuss their ethical and/or religious beliefs about preventing pregnancy.  Some birth control prevents conception while other types of birth control prevent a conceived zygote (baby) from implanting in the uterus.  For some couples, birth control methods that rely on nature (natural contraception) may be what they feel comfortable with, while others may be fine with contraception that prevents conception only.  Yet others may feel comfortable with any type of contraception.  This is a conversations that should be had before starting contraception (especially before marriage) and the more information couples have, the better they are able to make decisions that fit their personal ethical values.

 

There are multiple forms of birth control that can be divided into five main areas:

  • Barrier contraception

  • Hormonal contraception

  • Non-Hormonal contraception

  • Natural contraception

  • Surgical contraception

 

Below is a brief overview of the types of contraception available.  Note – ALL forms of birth control can fail, so sexual activity even when birth control is being used can lead to pregnancy.

 

 

Barrier Contraception

Barrier contraception involves preventing ejaculated sperm from entering the cervix.  Two of these (male and female condoms) are the only form of contraception that protects against the transmission of sexually transmitted infections (STD’s). 

 

There are five main methods of barrier contraception:

  • Male condoms

  • Female condoms

  • Cervical caps w/spermicide

  • Diaphragms w/spermicide

  • Sponge w/spermicide

 

Hormonal Contraception

Hormonal contraception is the most commonly used type of birth control.  Hormonal contraceptives “trick” a woman’s natural hormonal rhythms to disrupt her fertility. 

 

There are six main methods of hormonal contraception:

  • Birth control pills

  • Hormonal patches

  • Hormonal cervical rings

  • Hormonal injections

  • Hormonal implants

  • Hormonal intrauterine devices (IUDs)

 

 

Non-Hormonal Contraception

 

The only contraceptive in this category are copper IUD’s.  Some have suggested that copper IUD’s prevent sperm motility at copper is toxic to sperm; however, it mainly prevents implantation of a fertilized egg in the uterus.    

 

Natural Contraception

 

Natural contraception does not require any medication or product.  These “natural” methods are the least reliable methods of birth control and work by avoiding sex during the “fertile” days of the month or preventing semen from entering the vagina without using barrier contraception.

 

There are five main types of natural contraception:

  • Abstinence

  • Timing method

  • Non-intercourse sexual activity

  • Withdrawal

  • Breastfeeding

 

Surgical Contraception

 

Surgical contraception can be performed either on the man or the woman.  There are three main surgical procedures in women and one in men. 

Now we will discuss each of these birth control methods in detail:

 

 

BARRIER CONTRACEPTION

Male Condoms

Condoms are often made of latex, but can also be made from non-latex materials such as polyurethane, polyisoprene, and natural sheep/lamb intestine.  There are multiple choices for men which can often be overwhelming – especially if you’re standing in the condom aisle hoping you aren’t seen by anyone you know. 

 

For some common questions about condom selection, use, or other issues, see our section on condoms

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Female Condoms

Many men have actually not heard of a female condom.  They aren’t used as commonly for a few reasons – the size of the packages are large, they’re hard to find, than can may intercourse “noisy”, and they can be messy as semen can spill out of them quite easily after ejaculation.  A female condom looks like a large male condom.  It is unrolled and a ring at the tip of the condom is place high inside the vagina, while the ring of material at the base of the condom (which is quite large) is placed over the vulva.

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  • Q:  Why would a female condom be preferred over a male condom?

    • A: Some men who find that male condoms are too restrictive and interfere with sexual stimulation often find that female condoms do not cause this same issue.

 

  • Q: Where do you even buy female condoms?

    • A:  They are available in some stores, but can often be purchase online.  However, choose a reputable distributor.

 

  • Q: Why are female condoms noisy?

    • A: There is a lot of excess latex that can fold and overlap thus causing the material to “squeak” as the penis forces the condom material to rub against itself.

 

Spermicide

 

Spermicides are chemicals that immobilize sperm after ejaculation and are used to reduce the number of sperm that can swim to the egg.  Spermicide should never be used by itself as a form of birth control.  However, it is used in combination with cervical caps, diaphragms, and sponges.  Spermicides are often only active for 20-30 minutes (or less) so they must be placed in the vagina shortly before sex or they become less effective.

 

Cervical Caps & Diaphragms

 

Cervical caps are exactly what they sound like – they are a rubber-like cap that is placed high in the vaginal over the cervix to prevent sperm from entering the os.  Diaphragms on the other hand are flexible cup that covers the cervix so they are slightly larger as well as slightly more effective than cervical caps.  Cervical caps/diaphragms are not available over-the-counter for birth control.  A healthcare provider will often measure a woman for device that will fit her cervix (if the cap is too large, semen may pass around the cap and result in pregnancy).  Spermicides are placed inside the cup area of the device before it is placed snuggly into the vagina against the cervix. 

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  • Q: How effective are cervical caps/diaphragms?

    • A: Both devices become less effective after a woman has had a baby.  This makes sense as the cervix has dilated.  Anywhere from 10-20% of women who have not had a baby will become pregnant after one year when using this form of birth control.  That number increases to 25-40% in women who have had a baby before.  Diaphragms are slightly more effective than cervical caps.  In fact, many clinics will not carry cervical caps because they have been shown to be highly ineffective.  Because both devices have a high rate of pregnancy – they are almost never used for contraception anymore.

 

  • Q: I’ve seen cervical caps that are over the counter, but they say they are for infertility treatment.  Can I use these as birth control rather than making an appointment with my doctor?

    • A: NO.  The over the counter cervical caps are designed for infertility in order to hold semen next to the cervix, not keep semen away from the cervix.  A properly sized and fitted cervical cap or diaphragm by a healthcare professional is crucial to its effectiveness as a contraceptive.

 

  • Q: Do I have to use a spermicide with these devices?

    • A: Yes. 

 

  • Q: How long can these be left in place?

    • A: It depends on the product.  However, it must stay in place for a certain number of hours (typically 6-8 hours) after sex to prevent semen in the vagina from moving through the cervix if it is removed to early.  However, they cannot be left in place long-term.  Diaphragms often need to be removed within one day and cervical caps within 2 days, but check with your healthcare provider.

 

  • Q: Can they be used anytime, even if she is having a period?

    • A: Cervical caps cannot be used when a woman is having a period as the menstrual flow can loosen the cap off the cervix.

 

  • Q: Can having sex knock the device out of place?

    • A: It is possible that intercourse itself can loosen a device and cause it to be ineffective.  Yet another reason why these types of products have fallen out of favor.

 

Sponges

 

The sponge is exactly what it sounds like – it is a small sponge that contains some spermicide.  The spermicide is activated by putting the sponge in a small amount of water.  It is then place in the vagina prior to sex to soak up semen and potentially inactivate the sperm.  Additional spermicide may be used.  Like cervical caps and diaphragms, the sponge must be kept in place for at least 6 hours after sex but cannot be kept in place for longer than 30 hours.  The sponge is not very effective at all, resulting in one in four couples becoming pregnant each year when using sponges as the primary source of birth control.  Most healthcare providers do not provide these products anymore due to their low effectiveness.

 

 

HORMONAL CONTRACEPTIVES

Hormonal contraception is the most commonly used type of birth control used today.  Hormonal contraception is just that – administering progesterone and/or estrogen to a woman to decrease her fertility.  These drugs work in four different ways:

  • Prevent ovulation by tricking the pituitary gland into not releasing the hormones that cause ovulation

  • Thicken the mucus in the cervix making it difficult for sperm to swim through

  • Decreasing motility in the fallopian tubes lessening the chance of an egg entering the tubes and becoming fertilized

  • Preventing implantation of the conceived fetus in the uterus

 

Different birth control products have different side effects.  These are caused by the amount of estrogen in the tablets or in the type of progestin.  Higher doses of estrogen prevent spotting (bleeding between periods).  However they can also increase the chance of blood clots, breast tenderness, nausea, and bloating.  Lower doses of estrogen lessen the chances of blood clots, breast tenderness, nausea, and bloating; however, women may be more likely to have breakthrough bleeding. 

Blood clots can form in the veins of the legs but may dislodge potentially leading to heart attacks and strokes.  These clots occur in 2-3 women out of 10,000 who don’t take birth control.  For women who take products that only contain progestins, the risk stays at this same low level.  However, the rate of blood clots doubles or triples to 6 women in 10,000 on most oral birth control products.  The birth control ring can increase the risk to 8 in 10,000 women, and the patch and pills that contain drosperidone can increase the risk all the way up to 10-15 women in 10,000.  Age and smoking status also increase the risk of clots, with smokers over the age of 35 having the highest risk of clots.

Progestins are hormones that are related to progesterone.  Progesterone works in many ways in the female body and is the chief hormone produced during pregnancy.  So progestins in a way “trick” the female body into thinking she’s pregnant and preventing “another” pregnancy.  In addition, progestins can eventually be converted into testosterone so they can disrupt androgen levels in a woman which can have sexual side effects such as changes in libido and sexual response (ability to achieve orgasm).  This is rarely discussed, but hormonal birth control can and often do disrupt normal female sexual function – so there’s often a trade-off between her experiencing sexual pleasure to its fullest in order to reduce fertility (this is not true for all birth control or for all women).  Different progestins have different side effect profiles which often help prescribers choose a birth control pill best for each woman.

Progestins are divided into five main families:

  • 1st Generation – Norethindrone and Ethynodiol

    • Side effects include weight gain, acne, and some breakthrough bleeding

    • These are the progestins most often used in progestin only birth control pills

 

  • 2nd Generation – Norgestrel and Levonorgestrol

    • Advantages – some women report an increase in libido compared to other pills

    • Side Effects – because these drugs “act” more like androgens weight gain, acne, and even male-like body hair growth (facial and even chest hair) can occur

 

  • 3rd Generation – Desogestrel and Norgestimate

    • Advantages – cause little to no weight gain and help clear acne up (these are actually sometimes used in women to control acne)

    • Side effects – there is a slight increase risk of blood clots which can cause strokes

  

  • 4th Generation – Drosperidone

    • Advanatages – this progestin is an “anti-androgen” and is often prescribed in women that have unwanted body hair growth on the face and/or chest.

    • Side effects – this birth control pill has the highest rate of blood clots

 

  • Others

    • Dienogestrel – used in a certain birth control pill to reduce heavy bleeding, this is not used as a routine form of birth control although it can prevent pregnancy.  It is used more for its properties to control heavy menstrual bleeding in women.

    • Etonogestrel – used in hormone implants

    • Medroxyprogesterone – used in injectable birth control

 

Let’s go into a little more depth now on the different types of birth control medications available, side effects, and other factors that can help couples make an educated decision if their considering whether or not hormonal birth control is appropriate for them.

 

Birth control pills

 

There are two main groups of birth control pills.  The first and most common contain both estrogen and a progestin.  These products prevent pregnancy in all four ways described above.  The second type of birth control only contains progestins – these are often called “mini-pills”.  Mini pills are used when a woman is breastfeeding to prevent estrogen from being passed to the nursing infant.

 

Birth control pills can come in varying package sizes.  The 21 day packs contain 21 active pills that a woman takes once a day.  At the end of the three weeks the woman goes the next 7 days without taking any pills.  After a week of taking no pills, she restarts a new 21 day pack.   

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Birth control pills also com in 28 day packs.  These packages contain take 3 weeks (21 days) of hormones followed by one week of blanks or placebo pills to help her remember how many days have gone by before she needs to start a new pack.  The placebos are usually a different color than the pills that contain hormones.

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For many pills, the levels of hormone from one week to the next remain constant and are called “monophasic”.  Other products have hormone levels that change from one week to the next in an effort to “mimic” a woman’s natural menstrual cycle while still preventing pregnancy.  Oftentimes these changes in hormones are indicated by different colors of pills.  These are called “biphasic” or “triphasic” birth control and are often used to regulate a woman’s periods if they have been irregular in the past.

The drop in progestin levels that occur when a woman takes the placebos in a 28 day pack or skips pills for a week after using a 21 day pack, is what triggers a woman to have a period.  Some birth control pills are in packages that have 12 weeks of hormones then one week of placebos to allow women to only have a period every three months rather than once a month.  In fact, some placebos still have small amounts of estrogen and but no progestin – this also causes a period to occur (though the period is oftentimes lighter).

 

One question that often comes up is “what happens if my wife misses or is a half a day late taking her birth control pill”.  Timing of birth control pills is very important.  Any disruption in the hormone levels can trigger ovulation and create a window of fertility.  Mini pills need to be taken at the exact same hour each day – being as little as three hours late can lead to fertility.  With estrogen-containing birth control, ovulation typically will not occur after one day of missed tablet, but it can happen.  It is best for the woman to get back on track with taking her birth control, but if pregnancy is not desired, the man should use a condom for at least the next week or until she has her next period in order to prevent pregnancy.

 

In addition, some medications, especially antibiotics, can interfere with birth control pills and can increase the risk of pregnancy.  Be sure to ask your healthcare provider if medications or antibiotics can affect her birth control.  It is often wise to use a condom for extra prevention when women are taking antibiotics and for one week after she has stopped her course of antibiotics.

 

Another question that some couples have is surrounding a type of birth control pill called “emergency contraception” or “the morning after pill.”  Emergency contraction is administered after unprotected sex or a broken condom to prevent pregnancy – however, it oftentimes only prevents implantation, not conception.  There are two products available.  The first (levonogestrel) is available over the counter and works to delay ovulation slightly and prevent implantation in the uterus of a fertilized egg.  They are often ineffective after three days.  A prescription product (ulipristal) is often used in cases of rape or sexual assault because it “freezes” the ovary, delaying ovulation by up to 5-9 days.  It also prevents implantation.  Emergency contraception should not be used as a form of long term or “lazy” contraception (simply taking it every time a woman has sex).  As stated previously, contraception should be taken into consideration with the ethical values of the couple and having these conversations as a couple before an “emergency” occurs.  

Birth Control Patches & Cervical Rings

 

For women who don’t want to swallow birth control pills or have a hard time remembering to take the pill every day on time, there are patches and cervical rings. 

 

The patches are applied to the upper arm and kept in place for a week, then replaced.  After a week the patch is removed and another patch is applied.  After three weeks of medication, no patch will be used during the 4th week allowing the woman to have a period.  Patches have fallen out of favor in recent years due to the much higher chance of the woman having a blood clot that could result in a heart attack or stroke. 

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The cervical rings are likewise used for one week at a time.  A woman places the ring high in the vagina so it surrounds the cervix. 

After a week the ring is removed and another ring is inserted.  After three weeks of medication, no ring will be used during the 4th week allowing the woman to have a period.  These products have fallen out of favor in recent years as well due to the much higher chance of the woman having a blood clot that could result in a heart attack or stroke.  Men may wonder if they can feel or dislodge a cervical ring during sex.  It is possible, but as long as it is firmly put back into place after intercourse, there should be no problems as long as it has not been out for more than three hours.  If a falls out and has been out for more than 3 hours, then a condom should be used for the next week or until her next period.  If it was dislodged during intercourse and not found replaced within three hours, ovulation and pregnancy may occur.

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Hormonal Implants

 

There are also hormonal implants or rods that are placed beneath the skin (usually in the upper arm).  These are about the size and shape of a match stick and release progestins into the body to once again mimic pregnancy levels of progesterone and to prevent pregnancy.  These can be left in as long as three years.  At right is a picture of an implant being inserted into a woman’s arm.

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Hormonal injections

 

The only injectable hormonal contraceptive available in the U.S. is medroxyprogesterone.It is given as in intramuscular injection every three months.Like the IUDs, medroxyprogesterone mimics the high progesterone states found in pregnancy in order to prevent fertility.Side effects can include weight gain (more than one-third of women will experience this).It can also affect libido and cause headaches and anxiety in 10-15% of women.The downside of this option is that once the injection is given, there is no going back if side effects occur or a couple decides they want to have children.The medication will have to take the three or more months to wear off.

 

Hormonal IUDs

 

IUDs or intrauterine devices are just that.  They are a device that looks a lot like a “T” or “Y” that is placed by a healthcare provider into the woman’s uterus.

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Most IUD’s contain a progestin like levonogestrel.  These products work much the same way as mini-pills but there is no remembering to take a pill.  In addition, IUDs prevent pregnancy by mimicking a baby growing in the uterus thus preventing another pregnancy.  They are also very irritating to the uterus thus making it nearly impossible for a conceived egg to implant in the uterus if conception has occurred. 

There are a few considerations with IUDs.  First, they can work for a long period of time.  Some hormonal IUDs may be kept in place for three years and others as long as five years.  So many women choose this option because they don’t have to remember to take medication or make a monthly trip the pharmacy to pick up their medication. 

There are some downfalls as well.  IUDs act as an irritant to the uterus so cramping and back pain can be common.  It is also possible for the IUD to puncture the uterus or cervix, or even fall out.  Usually, women are aware when an IUD falls out, but in some cases they aren’t.  This may lead to a woman unknowingly being fertile (thinking she has an IUD when it has fallen out).  If pregnancy does occur, it is more likely to be an ectopic pregnancy which is when pregnancy occurs outside of the uterus.  This often leads to the loss of the baby and can be life threatening to the mother if not treated in some cases. 

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Placement of the IUD can also be quite painful during and after the placement, especially in women who have not given birth before.  This is because the IUD is place up through the vagina and cervix.  The cervix actually has to be dilated to allow the healthcare provider to insert the IUD into the uterus.  In order to place and remove an IUD, strings that go inside it are pulled by a healthcare provider to allow the T or Y to collapse into a straight rod to make inserting and removing the IUD possible.  These strings hang through the cervix into the vagina.  Many healthcare providers clip these strings and wrap them around the cervix so they don’t get in the way during sex.  If they are not clipped short enough, a man may feel these strings against his penis during sex.  However, if they are clipped too short, they may not be long enough to wrap around the cervix and may actually jut out of the cervix like two short fishing lines.  These short ends can poke the tip of the penis during intercourse and for some men this can be very uncomfortable or even painful.  Options for strings that are too long would be to go back into the provider to have them cut shorter.  For strings that are poking the husband, the IUD can either replaced or a man can avoid penetrating as deeply during intercourse to prevent getting poked by strings that have been clipped too short.   

 

 

Non-Hormone IUDs

 

There is only one non-hormonal IUD available – the copper IUD.  This IUD doesn’t work through hormonal means, but works as an irritant to the uterine lining prevent a fertilized egg from implanting and growing.  So, copper IUDs largely prevent pregnancy rather than preventing conception (compared to hormonal forms of birth control).  There are also thoughts that the copper can actually inhibit the sperm from swimming as well as they pass by the IUD on the way to the fallopian tubes; however, it is unclear how effectively a single copper IUD can incapacitate millions of sperm at once.    IUD’s can also trick the woman’s body into thinking she’s pregnant (however this is more true of IUD’s that contain hormones).  

Copper IUDs may be kept in place for up to 10 years and are the longest acting form of birth control.In addition to the side effects described for hormonal IUD’s, addition side effects can include major bleeding.

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NATURAL CONTRACEPTION[i]

As stated earlier, natural contraception does not require any medication or product.  These “natural” methods are the least reliable methods of birth control and work by avoiding sex during the “fertile” days of the month or preventing semen from entering the vagina. There are five main types of natural contraception:

  • Abstinence

  • Timing method

    • Calculation Method

    • Basal Body Temperature

    • Cervical Mucus Method

    • Symptothermal Method

  • Non-intercourse sexual activity

  • Withdrawal

  • Breastfeeding

WITH THE EXCEPTION OF ABSTINENCE, COUPLES SHOULD NOT RELY ON NATURAL CONTRACEPTION TO PREVENT PREGNANCY, 

Abstinence

 

Because of false beliefs that circle in some groups, it is important to define abstinence.  Abstinence is avoiding all sexual contact.  Some young adults and adolescents have engaged in sexual behavior thinking that pregnancy can’t occur because they “weren’t having sex”.  Any activity that causes a man to ejaculate and allows semen to come in contact within or near the vagina can result in pregnancy.  Indirect transfer of semen to the vaginal area by unwashed hands or even semen soaked bedding can allow sperm to gain access to the female reproductive tract and thus result in pregnancy.  If you don’t engage in sexual activity, then pregnancy definitely will not occur. 

Prior to marriage, abstinence is the best form of birth control; however, after marriage, sexual relationships are a vital part of the relationship itself.  Abstinence during marriage can lead to strain and stress in the relationship and removes a healthy part of the relationship.  However, having said that, there may be times when abstinence can be appropriate (for example, the first few weeks after she delivers a baby when the vagina/birth canal is healing, times of illness, etc.).

Timing Method

 

This method is the only contraceptive method approved by some religions.  This method avoids sexual intercourse during the times of the month when ovulation is most likely to occur.  There are three ways in which a couple can estimate the “fertile” window – calculating ovulation from past menstrual cycle lengths, measuring basal body temperature, and monitoring cervical mucus.  This is the LEAST “reliable” method, resulting in 1 in 5 couples becoming pregnant the first year (usually because they get a little lazy with it).

So let’s back up and remind ourselves about how conception occurs.  At ovulation, an egg is able to be fertilized for less than a day.  Sperm are able to survive in for 2-3 days.  So avoiding sex within the 3 days before ovulation is vital.  However, ovulation doesn’t always occur on the same day in many women, and even being one day off can result in sperm being available when the egg is ovulated.   Pregnancy usually cannot occur if more than one day has passed after ovulation.  So this creates times before and after ovulation which are “fertile” when sex should be avoided as well as days that are largely “infertile”, allowing a couple to be sexually active with a lower chance of becoming pregnant.

The calculation method is the most common.  If used perfectly, pregnancy will only occur in the first year in 1 in 10 couples.  This is performed by taking the length of a woman’s menstrual cycles for the last year to calculate the fertile window.  Women typically have their first day of bleeding on their period 14 days after ovulation.  This allows couples to calculate backwards to determine which days she’ll most likely ovulate in the future.   Day 1 is the first day a woman starts bleeding on her period. 

Here is the calculation method (you cannot use cycle lengths that occurred while taking or shortly after taking hormonal contraception):

  • Take the shortest menstrual cycle and subtract 19 days – this will give you the last day you can have sex

  • Take the longest menstrual cycle and subtract 10 days – this will give you the first day you can restart having sex

  • The chart below gives you the last day of her menstrual cycle that you can have sex

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For example, if a woman’s shortest cycle was 25 days and her longest cycle was 33 days, then the “safest” days to have sex ae days 1-6 and 23 until her next period (basically day 23 of her period until day 6 of her next period).  this would lead to avoiding intercourse on days 7 to 22.  However, women that have wide ranges in their cycles (say 21 days to 35 days) may have large “fertile” windows that may only allow for five “safe” days if she should have a 28 days cycle that month.  For women that consistently have a period that is the same length, the “fertile” window last only nine days.

The basal body temperature (BBT) method requires that a woman measure her body temperature (using a digital thermometer) immediate upon waking in the morning and before getting out of bed.  Right before a woman ovulates, her body temperature will drop then spike over the next day or so.  This is an indicator that ovulation has occurred.  These body temperatures changes are small (often a drop of less than half a degree although the spike can be a full degree higher).  Any activity in the morning getting out of bed to use the bathroom or morning sex for example, will increase body heat as the woman’s body gets moving thus throwing the body temperature calculation off.  Using a heading pad or electric blanket can also throw temperatures off.  Using this method, sex can occur during the first 3-4 days of the menstrual cycle (the first three days your wife is bleeding) and cannot resume until 3 days after the temperature spike during ovulation.  Sex can then continue until your wife’s next period.  Because temperature shifts are so small, there can be a false rise (or lack of a rise) which can either give a green light when there shouldn’t be one, or no green light at all.   Again, this method is about 80% effective in preventing pregnancy (although it can be more effective if used perfectly).

The cervical mucus method relies on your wife checking her vaginal secretions each day.  During the first days of the menstrual cycle a woman will be bleeding.  After the bleeding stops, a low level of estrogen will usually dry up these secretions.  As estrogen levels rise before ovulation, the vaginal secretions get clear and white (much like a raw egg white).  When ovulation occurs, estrogen levels drop and progesterone rises causing this mucus to become thick and sticky.  Intercourse can resume after this change in consistency from clear to thick and sticky.  One problem that arises with this method is a woman’s own familiarity with her body.  It also requires that she be able to tell the difference between her vaginal secretions and any infectious discharge or even seminal fluid that may still be in the vagina.  This is not the easiest method for newlyweds but can be more effective later on.  When used perfectly, this method is more effective at preventing pregnancy than the other two methods, but not as effective as other contraception.

The symptothermal method combines the BBT method with watching for other signs of ovulation such as the cervical mucus method, breast tenderness, and other signs.  When combining these methods and when used perfectly, pregnancy rates can drop to around 1 chance in 50 of becoming pregnant during the year – better, but not 100%

Non-Intercourse Sexual Activity

 

Pregnancy can occur when sperm is introduced into the female reproductive tract.  For some couples, engaging in sexual activity that does not include intercourse (petting and other forms of physical stimulation) can reduce the chance of semen coming in contact with her reproductive tract.  Couples must be on the same page as to their comfort level and not expect sexual activity that makes them or their spouse feel uncomfortable or uneasy.  One of the downfalls of this method is handling of male sexual fluids (pre-ejaculate and semen).  Neither of these can come in contact with the woman’s reproductive tract.  Although this seems obvious, unwashed hands, soaked bedding or materials, etc. can create opportunities for sperm to be introduced into the female reproductive tract. 

Withdrawal

 

Perhaps the least reliable method of natural birth control is withdrawal.  This occurs when a couple engage in intercourse then just as the man is about to ejaculate, he withdraws from the vagina and ejaculates outside the female reproductive tract.  This method can result in pregnancy rates in about one in three couples during a year.   Like non-intercourse sexual activity, it’s important to know how you feel about engaging in withdrawal.  Some feel there are issues with their religious beliefs while others do not.  One of the main reasons this method is so unreliable is due to two factors – pre-ejaculate and self-control. 

 

It is widely debated as to whether sperm can be present in pre-ejaculate secretions.  Depending upon the last time a man ejaculated and if he expresses small amounts of sperm into the urethra prior to ejaculation are probably key factors into why some men have sperm in their pre-ejaculate secretions and other do not.  So in short, it is possible for sperm trapped in pre-ejaculate secretions to be released into the vagina, even if ejaculation itself occurs outside of the vagina. 

The second reason is perhaps the most common reason couples become pregnant using the withdrawal method.  This is the lack of timing on the man’s part when withdrawing.  Ejaculation occurs in a two-step process –emission and ejaculation.  Most men often proceed with intercourse until emission occurs as it is the time when orgasm begins and ejaculation will continue without any additional stimulation.  Expulsion is the time when semen is expelled from the penis.  There can be anywhere from a one to three second delay between emission and expulsion.  If a man thinks he has three seconds and ends up only have one second or less, then ejaculation will occur in the vagina or even on the vulva as he withdraws.  This definitely can cause pregnancy.  Men may also have difficulties withdrawing if orgasm is strong enough to inhibit some of their muscular coordination thus not allowing them to withdraw fully before expulsion begins.  In addition, if a man engages in withdrawal intercourse shortly after having ejaculated previously, any semen remaining on the exterior of the penis can be introduced into the female reproductive system by reinsertion of the penis.

Breastfeeding

 

As stated earlier, breastfeeding can reduce or delay fertility, but it does not eliminate fertility.  Breastfeeding does change hormone levels thus makes getting pregnant more difficult.  In addition, menstrual periods typically don’t resume quite as quickly after birth in women who breastfeed compared to those who don’t.  The chances of pregnancy are lower in the first couple of months and then rise from there.  Some have suggested that the chance of pregnancy in the first two months is less than 1 in 100 increasing to a 1 in 50 chance by month six (but only if the mother is breastfeeding regularly and has not resumed her period).  However, every woman is different and you probably know of someone who thought that breastfeeding would prevent pregnancy but got pregnant.  Once periods have resumed, chances are her fertility has resumed as well.  Some couples use the first period as a “warning period” that fertility is resuming; however, ovulation can occur before the first period (and hence pregnancy can occur).  If you look historically at old census records – most families had a child every 18-36 months when no other forms of birth control were available other than breastfeeding and abstinence.  This may be appropriate for parents hoping to have a little space between their children but not opposed to getting pregnant again earlier should that occur.

SURGICAL CONTRACEPTION

Surgical methods involve creating a physical barrier to the transport of sperm in men or eggs in women.  Surgical methods of birth control should be considered as permanent decisions, even though in some cases they can be reversed.  However, not everyone that has a reversal will become fertile again.  Some religious groups frown upon using surgical methods as a form of elective contraception.  It’s important to take all factors into consideration when making these decisions.

Vasectomy

 

Men can have a vasectomy to prevent sperm from moving from the testicles up to the sexual glands that produce semen.  This basically allows a man to make semen that has no sperm in it.   A vasectomy occurs when the vas deferens inside the scrotum is clipped or clamped to seal sperm from moving up rest of the vas deferens to the ampulla and prostate.  Many men have questions about what happens during a vasectomy and what to expect.  These can best be answered by a urologist, but a few explanations are worth noting here.  The procedure itself usually takes less than a half hour.  The provider will cleans and perhaps even shave part of the scrotum.  After a small injection or compressed air administration of medication to the scrotum to deaden the area, the provider will cut a small slit in the scrotum.  At this point, the vas deferens can be hooked and pulled outside of the scrotum where it is clipped and then stitched, tied off, or cauterized to create scar tissue – thus trapping sperm.  Another method involves placing a small instrument through the slit in the scrotum and placing a clamp on the vas deferens thus blocking the flow of sperm.  The procedure is then repeated on the other side.  Afterwards, a stitch may be placed in the scrotum which usually doesn’t need to be removed as it will dissolve on its own over time.[ii]  However, oftentimes the incision in the scrotum is so small that no stitches are required.

After a vasectomy, there may be swelling in the scrotum and some pain.  During this time, icing the scrotum as well as elevating it above the body can be important.  This might sound a little hard to do, but elevation of the scrotum can simply be placing a washcloth under the scrotum and lying down with your legs together to keep the scrotum higher than the legs and abdomen.  This allows fluids collecting in the scrotum to drain out thus reducing swelling.  For some men, epididymitis can occur.  If you think about it, now that sperm don’t have anywhere to go, they can back up into the epididymis causing swelling an inflammation which can be uncomfortable and sometimes painful.  For most men, this excess sperm volume is very small and the body can start resorbing much of this fluid and dead sperm cells – so most men have little to no problems down the road. 

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Men often wonder if they will immediately be infertile.  This is actually not the case.  Sperm have been produced over the man’s life and many sperm are still in the upper portions of the vas deferens and in the ampulla of the vas deferens where it is available to mix with semen.  It can take 20 ejaculations or more for the sperm to be exhausted (but don’t count on just using the number of ejaculations as the “all clear” that you’re now infertile).  Another form of birth control must be used for two to three months.  At around two months, your provider may have you provide a semen sample to see if there are still sperm in your semen.  If there are still sperm, you will need to use other birth control until you have a zero sperm count.  Once you have a zero sperm count then no other contraception is needed to prevent pregnancy. 

Some men wonder if a vasectomy will reduce their sex drive, ability to get erections, ejaculate, or experience orgasm.  Vasectomies do not interfere with any of these things.  In addition, the fluid from the epididymis that helps make up semen only accounts for a very, very small portion (<5% or a few drops) so men don’t often even notice a decrease in the amount of semen they ejaculate. 

 

However, it is important to keep in mind that vasectomies should be considered a permanent form of birth control.  Although in theory the two ends of the vas deferens should be able to be re-cut and sewn back together, this does not always work.  Scarring of this very tiny tube – even upon reconstruction can prevent passage of enough sperm to make a man “fertile” again.  In addition, if the male body is exposed to sperm outside of the vas deferens during the procedure – then his body may form antibodies against his own sperm and kill them as they are produced, thus leaving him nearly infertile permanently. 

 

Female Surgical Contraception

 

The most common surgery in women is tubal ligation.  This occurs when the fallopian tubes are either cut or kinked in order to prevent eggs from transporting to the uterus (or sperm meeting up with the egg).  Hysterectomy (removal of the uterus) and oophorectomy (removal of the ovaries) are not used as forms of birth control but do cause infertility in women and prevent pregnancy.

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Before making the decision to opt for surgical birth control (either vasectomy or tubal ligation), it’s important to recognize there’s almost no going back if either of you change your mind about having children down the road at some point.   

CONCLUSION

Preventing pregnancy is a deeply person decision.  There are multiple factors that should be taken into consideration.  These include flexibility as to when a couple may want to have children in the future, how they would feel if pregnancy did happen to occur unexpectedly, what the side effects may occur, effects on sexual responsiveness, personal/ethical/religious beliefs, difficulty in using certain devices, and many more.  Healthcare providers can often be a source of information in helping couples make decisions that are best for them.

[i] Handbook of Non-Prescription Drugs. American Pharmaceutical Association, 1996, ISBM 0-917330-77-3

[Ii] http://www.webmd.com/sex/birth-control/vasectomy-14387 (viewed 11/11/2016)

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