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Ever since men and women logically connected the sexual act with the subsequent production of children, they have searched for ways to either avoid or postpone pregnancy. Recent developments in science and technology have produced effective and convenient methods of contraception. None of the methods, however, is 100% effective or 100% free from side effects or risks. Couples must acquaint themselves with the benefits and risks of these various methods so they can select one that meets their individual needs.

When choosing a method of contraception, you will want to consider the effectiveness, safety, and convenience of all methods in relation to your own special needs and circumstances. The effectiveness of a particular contraception method is evaluated in two ways: method effectiveness and use effectiveness.

Method effectiveness is used to describe how well the contraceptive works in theory. In this discussion, it will be expressed as a percentage.

Use effectiveness describes how well a method works in reality. Use effectiveness is not fixed. It varies with how well the couple understands the method they have chosen and how willing they are to use it. Use effectiveness is expressed as the number of pregnancies per 100 women using that method over a one-year period.

When considering the effectiveness and safety of these various methods of contraception, it may be helpful for you to know that with 100 couples engaging in regular sexual intercourse without any contraception over one year’s time, there will be approximately 75–80 pregnancies. This means that 20–25 couples will not conceive.

Another factor to consider is that the risks associated with pregnancy are higher than those associated with most of the methods of contraception. Due to complications in pregnancy, labor, and delivery, approximately 16 women die per 100,000 pregnancies.

In determining your own particular needs and preferences, you may wish to consider some of the following questions:

• How important is it to avoid pregnancy at this time?
• How frequently do you engage in intercourse?
• Will you remember to use something before having intercourse every time?
• Does an interruption while making love bother you or your partner?
• Do you mind using a method that requires you to touch your genitals?
• Can you remember to take a pill daily?
• Are there any factors in your medical or family history that prevent you from using certain methods?
• How willing are you to take certain health risks associated with some of the more effective and convenient methods?

Some of these questions will be easy for you to answer. Some may take more time, and others will require assistance from your physician or nurse midwife.

The information in this discussion is intended to help you understand some of the most frequently used methods of birth control and some of the risks associated with these methods. It is not practical to provide you with all that is known about each method here, but if you want more information, a more detailed information sheet is available on each of the methods.

To understand how each of the various methods works in preventing pregnancy, it is helpful to have a general understanding of the reproductive process.

The Male Reproductive System
Most of the male reproductive system is located outside the body. Its primary function is to produce and deliver sperm to the female. From the time of puberty until death, millions of sperm are continuously produced in the testicles, which are contained in the scrotum. The sperm mature in the nearby epididymis and then travel up two tubes called the vas deferens. The prostate and other glands produce a milky white fluid called semen. At the time of ejaculation (“coming”), this semen is ejected into the vas deferens, which carries the sperm out through the penis. The number of sperm in each ejaculation varies from approximately 125 million to more than 600 million. The sperm are usually capable of fertilizing an egg for at least three days, but sometimes for as long as five days. It is also important to remember that some sperm may be present in the lubricating fluid that leaves the penis before ejacul

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The Female Reproductive System
The female reproductive system is located mostly inside the body. It is more complicated than the male system, because in addition to reproduction and transportation of the egg, the female must provide for the development and delivery of the baby. At birth, a female’s ovaries contain about 350,000 immature eggs. Only 300–400 of these will actually reach maturity. When the ovaries are depleted of eggs, menopause occurs.

At puberty, hormones from the brain and pituitary gland stimulate several eggs each month, but only one reaches maturity. When the one egg is mature, it is released from the ovary by a process called ovulation. The mature egg is then picked up by the fallopian tube and begins traveling toward the uterus. In addition to causing the egg to mature, female hormones are produced, which cause the lining of the uterus to build up so that it will be ready to accept the fertilized egg.

If fertilization of the egg occurs, hormones continue to be produced to maintain the pregnancy. If the egg is not fertilized, the hormone levels drop off and the lining of uterus begins to shed in a process known as menstruation.

Sperm deposited inside the vagina move quickly. As soon as 90 seconds later, they find their way into the opening of the uterus, called the cervix. In a matter of hours they travel through the uterus and into the fallopian tube. If a mature egg is present in the fallopian tube, or if it arrives while the sperm are still alive, fertilization (conception) can occur. The joined egg and sperm then travel through the remaining length of the fallopian tube into the wall of the uterus, about seven days following ovulation. The joined egg and sperm develop into an embryo, which begins to grow into a baby.

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Contraception Methods

The various methods of contraception interrupt the reproductive sequence of events by

• impeding sperm and preventing them from reaching the woman’s internal reproductive tract,
• inhibiting the process whereby eggs are released from the ovaries each month, or
• changing the environment of the uterus so that it is unsuitable for pregnancy.

Periodic Abstinence
Periodic abstinence is also called the rhythm method or natural family planning. This technique requires studying a woman’s cycle to determine the times when she is most likely and least likely to become pregnant. Several techniques are used to determine this, the most effective being a combination of techniques.

The calendar technique requires recording the interval and duration of your periods for 8–12 consecutive months. By subtracting 18 from the shortest cycle and 11 from the longest cycle, you will get two figures that represent the fertile or unsafe period. It is during this period of time each month that intercourse should be avoided or that another method of contraception, such as a barrier or spermicide, should be used.

Another technique of determining the safe period involves taking the basal body temperature daily to determine when ovulation occurs.

The third technique involves daily inspection of the vaginal and cervical secretion to help determine the fertile period.
The method effectiveness is estimated at 98%; however, the use effectiveness is approximately 10–40 pregnancies per 100 women per year (60–90% effective).

Advantages

• No chemicals or mechanical devices are required.
• There are not any health risks related to the technique itself.

Disadvantages

• It is a very unreliable technique because many factors can change the length of a woman’s cycle.
• Intercourse must be avoided during the unsafe times (up to half of each month).
• The couple must be very disciplined and keep very accurate records.

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The Withdrawal Method
The withdrawal method requires the male to withdraw his penis from the woman’s vagina before he ejaculates. Since this requires a great deal of self-control, and since sperm may leak from the penis in the lubricating fluid released before ejaculation, this is considered a very unreliable method of contraception.

Douching
Douching refers to the process of washing the semen and sperm from the vagina after ejaculation has occurred. Because the sperm travel so quickly through the cervix into the uterus, it is also considered a very unreliable method of contraception.

Breastfeeding
Breastfeeding, contrary to some people’s beliefs, is NOT a reliable form of birth control. Nursing women should use a barrier form of contraception to avoid pregnancy. Some birth control pills decrease the milk production in nursing mothers while others, like the mini-pill, do not affect lactation.

Oral Contraceptive Pills
Oral contraceptive pills require taking a combination of hormones daily for three weeks of each cycle. Oral contraceptive pills prevent pregnancy by

• preventing the release of a mature egg from the ovary,
• causing the mucus in the cervix to thicken, thereby preventing penetration of sperm into the uterus, and
• altering the lining of the uterus so that implanting of the fertilized egg cannot occur.

The method effectiveness is approximately 99+%. However, use effectiveness is approximately two to four pregnancies per 100 women per year (96–98% effective). Failure is usually due to forgetting to take the pills.

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Advantages

• It is one of the most effective of the reversible methods of contraception.
• No special preparations are necessary before intercourse.
• Menstrual periods are usually very regular, very light in amount, and menstrual cramps typically decrease.
• Risk of ovarian cancer may be reduced by 50–60%.
• Fibrocystic changes in the breasts are less common.
• There is no increased risk of breast cancer.

Disadvantages

• Side effects such as nausea, breast tenderness, bleeding between periods, skipped periods, pigmentation of the skin, and emotional changes may occur, though most of these side effects disappear after the first two or three cycles of pills. Some side effects may be corrected by vitamin and mineral supplements.
• Serious health risks, including blood clots, heart attacks, high blood pressure, stroke, gallstones, and liver tumors seem to be increased among women who use oral contraceptive pills.
• It should be emphasized that most of these risks occur in women over 35 years of age and women who smoke cigarettes.

Depo-Provera
Depo-Provera is an injectable form of contraception that protects against pregnancy for three months. Its active ingredient is a chemical similar to the natural hormone progesterone. It acts by preventing egg cells from ripening and being released from the ovary. If an egg is not ripened and released from the ovary during the menstrual cycle, it cannot become fertilized by sperm. Depo-Provera also causes changes in the lining of the uterus that make it less likely for pregnancy to occur.

Depo-Provera is a highly effective method of birth control. With an overall effectiveness rate of 99%, it is one of the most reliable methods of birth control available.

Advantages

• It is a long-lasting form of contraception that gives contraceptive protection for three months following the injection.
• It offers greater convenience and privacy than other hormonal methods of birth control.
• It is reversible. When you want to stop using Depo-Provera, simply do not get your next injection.
• It can be used by nursing mothers six weeks after childbirth.
• It does not require minor surgery as with the Norplant System.

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Disadvantages

• Most women who use Depo- Provera will note changes in their menstrual periods, including one or more of the following: irregular bleeding or unpredictable bleeding or spotting, an increase or decrease in menstrual bleeding, or no bleeding at all.
• If used for long periods of time, it may be associated with a decrease in the amount of minerals stored in your bones; this can cause an increased risk of developing thinner bones, which can lead to bone fractures.
• It has the possibility of causing side effects such as irregular menstrual bleeding, amenorrhea, weight gain, headaches, nervousness, stomach pains or cramps, dizziness, weakness or fatigue, and decreased sex drive.

Intrauterine Device (IUD)
The IUD is a small piece of flexible plastic that is inserted into the cavity of the uterus by your health care provider. The device may be wrapped with a copper wire or impregnated with hormones that are slowly released. The IUD prevents implantation of the fertilized egg into the wall of the uterus.
The method effectiveness is approximately 97–98%, and the use effectiveness is the same—that is, three to five pregnancies per 100 women per year.

Advantages

• It is a very convenient method; after the device is inserted, nothing further is required of the user.
• The method can be used while nursing.
• It is considered a very effective method.

Disadvantages

• Menstrual periods tend to be slightly heavier, and there may be more menstrual discomfort; however, this typically can be controlled with aspirin-like medication.
• Bleeding and spotting may occur between menses; however, this usually subsides after the first two to three cycles.
• In approximately two out of 1,000 insertions, the device may penetrate the wall of the uterus, requiring surgical removal.
• The risk of developing an infection in the uterus, ovaries, or tubes is approximately five times higher than among women who are not using an IUD. This infection could cause scarring of the fallopian tubes, which would leave the woman infertile.
• Women who have never had a term pregnancy tolerate the device less well than those who have.
• If a pregnancy occurs, there is a higher risk of miscarriage or a tubal ectopic pregnancy.

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Spermicides
Spermicides contain chemicals that immobilize sperm. They are available in the form of aerosol foams, creams, jellies, or suppositories impregnated with these chemicals. When these substances are placed high in the vagina, close to the cervix, they prevent pregnancy by chemically immobilizing and destroying the sperm. One must be certain not to confuse spermicidal products for the vagina with feminine hygiene products. Spermicides must always be applied before any penile/vaginal contact. Package directions must be followed very carefully or the method will not be effective.

Spermicides alone have a method effectiveness of approximately 96–98%; however, the use effectiveness indicates approximately 15 pregnancies per 100 women per year. Most failures are due to incorrect usage of the product, or failing to use a spermicide during each and every intercourse.

Advantages

• There is no serious health risk.
• They are readily available.

Disadvantages

• Because of the importance of proper timing of the application, there may be interruptions in lovemaking.
• Occasional minor skin and vaginal irritations can occur.
• Some couples consider these methods messy or unpleasant.

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Condoms
Condoms are sheaths of latex rubber or non-synthetic membrane that cover the penis and work by preventing semen from being deposited in the vagina. A condom is placed over the erect penis, leaving a small pouch where the sperm can collect. Condoms must be applied before any penile/vaginal contact. The penis should be withdrawn from the vagina immediately after ejaculation, while the penis is still firm, so that semen does not leak from the condom.

When used as the only method of contraception, the method effectiveness is approximately 96–98%. Use effectiveness indicates 10–20 pregnancies per 100 women per year. By using a spermicide along with a condom, the method effectiveness is approximately 99%, with a use effectiveness rate of three to five pregnancies per 100 women per year.

Advantages

• It poses no serious health risk.
• Condoms may help protect against the transmission of venereal diseases and AIDS.
• The method is easy to use and readily available.
• It is the only commonly used form of reversible male contraception.

Disadvantages

• Use of condoms may be disruptive to lovemaking.
• Some couples note a reduction of sensation during intercourse.
• Occasionally, skin irritation may occur.

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Diaphragm
The Diaphragm is a flexible rim covered by a dome of rubber. The device is coated with spermicidal cream or jelly and inserted into the vagina so that it covers the cervix. The device must be placed before intercourse and must be left in place for at least six to eight hours after intercourse. The diaphragm forms a barrier that prevents sperm from penetrating the cervix, while the spermicidal cream immobilizes sperm deposited in the vagina.

Method effectiveness is approximately 96–98%; however, use effectiveness indicates 5–10 pregnancies per 100 women per year. Most failures occur because the device is not properly inserted, or it is not used every time the woman has intercourse. If the woman has intercourse more than once following its insertion, additional spermicidal cream or jelly should be inserted into the vagina, and the diaphragm should be left in place.

Advantages

• It poses no serious health risks.
• It can be used while nursing.
• It is relatively inexpensive.

Disadvantages

• Insertion of the diaphragm may be disruptive to lovemaking.
• Some women find insertion of the diaphragm difficult or unpleasant.
• There may be a higher incidence of vaginal or urinary infections.

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Cervical Cap
The cervical cap is a thimble-shaped device made of rubber that fits snugly over the cervix. It acts as a mechanical barrier that prevents sperm from entering the uterus or tubes, where they can fertilize the ripened egg. The cervical cap is inserted before intercourse, and it can be left in place for up to 24 hours. It should be used along with a spermicide to enhance its effectiveness. Method effectiveness of the cervical cap is approximately 96–98%.

Advantages

• It is not considered to be as disruptive to lovemaking as the diaphragm.
• There are no serious health risks known at this time.
• It is seldom noticed by male partners.

Disadvantages

• Approximately 30% of women cannot achieve an appropriate fit.
• Some women experience difficulty with insertion and removal.
• Wearing the cap may cause cervical secretions to collect; these can cause irritation.

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Morning-After Contraception
This form of contraception consists of the administration of high levels of hormones. If unprotected intercourse occurs during the fertile time of the menstrual cycle, these hormones can be administered within 24–48 hours to prevent conception. It is thought that this method acts by preventing the implantation of the egg into the uterus.

Effectiveness is thought to be approximately 90%; however, if a pregnancy does occur, there is great concern about abnormalities of the fetus. Long-term health effects for women are not known. It should be emphasized that this method should be reserved for emergency situations such as following rape, or if a condom breaks.

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Permanent Sterilization
Permanent sterilization has been an increasing trend in recent years for the prevention of pregnancy. In both men and women, sterilization means the surgical blockage of the tube through which the sperm or egg passes.

We emphasize that these methods are permanent (though in some cases, male vasectomy may be successfully reversed with surgery) and should be carefully thought through by both partners. One must bear in mind that life situations can suddenly change through divorce, the death of a child, or other life changes. One must also consider the emotional impact of becoming permanently unable to bear children.

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Vasectomy
A vasectomy is a surgical operation that sterilizes the male, in which the vas deferens is tied off in two places and the segment of tube between the two ties is removed. This means that the semen at ejaculation is free of sperm. The operation is usually performed in a doctor’s office under local anesthetic and requires two small incisions in the upper part of the scrotum.

The effectiveness of the procedure is very high, approximately three pregnancies per 1,000 procedures performed.

Advantages

• Following the operation, as soon as the semen is determined to be free of sperm on two occasions, there is no further need to concern oneself about contraception.

Disadvantages

• There is a small risk with both the anesthesia and the surgical procedure itself.
• A 50–75% incidence of the formation of antibodies against one’s own sperm; however, the significance of this is not known.
• Questions have also been raised concerning an increased incidence of the hardening of the arteries, with subsequent heart attack following a vasectomy.

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Female Sterilization
Female sterilization involves interrupting the fallopian tubes so that the eggs cannot reach the uterus. Interruption of the tubes may be done by tying the tubes in two places and removing a segment, placing a rubber ring around the base of a loop of the fallopian tube, or electrical cautery of the fallopian tube. The procedure is performed in a surgical operating room and usually requires a general anesthesia. The operation usually requires approximately a half-inch incision near the umbilicus and/or a small incision just above the pubic bone. The procedure can be performed immediately following a delivery or at other intervals following delivery.
The effectiveness of the procedure is also very high, usually three pregnancies per 1,000 operations performed.

Advantages:

• Once the procedure is performed, there is no need for further contraception.
• There is little effect on sexuality and menstruation. Less than 10% of women find that their menstrual patterns become abnormal following the operation; 80% stay the same; 10% notice that their periods become lighter and shorter.

Disadvantages:

• There are always some risks with anesthesia and surgery.
• Abnormal menstrual patterns occur in about 10% of the women who have the procedure.

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Final Note
When you do not have to worry about getting pregnant, sex can be more relaxed and enjoyable. It is very important that both partners participate in the decision about contraception or sterilization. As your health care providers, we are happy to give you information, but only you can select the method that will suit your needs and preferences. Whichever method of contraception you choose, you should be fully aware of how the method works and how to use it. You also need to educate yourself about the possible side effects and complications so that you will be alert to potential problems.

Finally, the passage of time, along with changes in your life situation, can change your contraceptive needs and desires. By keeping yourself well informed, you will be able to select and use a method of contraception that will meet those needs, thus enhancing sexual fulfillment and promoting your development as a couple.