Today, more than ever before, we are aware of the impact of our fertility on our own lives, as well as on the world. Reproduction, once considered strictly a personal matter, is now a subject of open debate and political action. Yet, regardless of our public views, we must each confront fertility on a personal level.
In taking charge of our reproductive potential, we must be informed about the availability and effectiveness of birth control methods, as well as ways to protect ourselves against sexually transmitted infections. But information is only part of the picture. We also need to understand our own personal needs, values, and habits so that we can choose methods that we will use correctly and consistently to minimize our risks of unintended outcomes.
A typical American woman who desires two children spends about 5 years pregnant, postpartum, or trying to become pregnant and 30 years trying to avoid pregnancy. Over the course of this time, her contraceptive needs will change.
Of the 62 million women in the United States of a childbearing age, ages 15 through 44, 38% do not need contraceptives because they are sterile, pregnant, postpartum, trying to become pregnant, or abstinent. Approximately 62% of the remaining women are at risk for unintended pregnancy and must use some method of contraception. This slide shows the breakdown of those figures.
Image: McGraw Hill Library
Because the potential for getting pregnant is so high for a sexually active, childbearing-age couple, it would seem reasonable that sexually active couples would use contraception to avoid unintended pregnancy. Unfortunately this is not the case. In the United States, nearly half of all pregnancies each year are unintended. And about 4 in 10 of these are terminated by abortion.
Most unintended pregnancies are attributed to nonuse, ambivalence, fear of side effects, inconsistent use or incorrect use of contraceptives. Although on average a woman has only about a 2-4% chance of becoming pregnant during intercourse without the use of a contraceptive, timing and age can influence the likelihood. Over the period of a year, sexually active couples who do not use contraception have a 90% chance of conception.
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Women may have more interest than men in controlling their fertility. It is the woman who bears the children and more than often, it is the woman who has the responsibility of raising them. Biologically, it is also easier to stop one egg from being fertilized once a month than stopping millions of sperm during each act of intercourse. The family planning responsibilities are traditionally seen as the woman's job. <br /><br />Studies show that those who discuss preventing pregnancy are most likely to use contraceptives. Education is positively correlated with family planning discussion among couples. Women and men, now more than ever, perceive gender equality in sexual decision making and equal responsibility for decisions about contraception. <br />Male methods account for approximately one-fourth of all reversible contraceptive use . Other ways that men can take contraceptive responsibility includes exploring ways of being sexual without intercourse and helping to pay doctor or clinic bills and sharing the cost of pills, injections, or birth control supplies. They can also check on supplies, help to keep track of his partner's menstrual cycle, and if having children, or more children, is not a desire of the couple in a long-term relationship, having a vasectomy is an option.<br />
Although birth control and contraception are often used interchangeably, there is a subtle difference in the meaning. Birth control are methods that prevent the fertilized egg from implanting in the uterine wall and include emergency contraception pills. Birth control also includes methods that remove the fertilized egg, embryo, or fetus from the uterus, such as nonsurgical and surgical abortions.
Contraception, on the other hand, is the category of birth control in which the sperm and the egg are prevented from uniting. These include barrier methods like condoms and diaphragms, which provide a physical barrier between the sperm and the egg. Diaphragms, cervical cap, and female condoms also protect against diseases of the cervix and uterus. Spermicides kill the sperm before they can get to the egg, and hormonal methods, such as the Pill, the shot, and the patch, inhibit the release of the oocyte from the ovary. Intrauterine contraceptives or devices prevent the sperm from fertilizing the egg. No matter the method, they must be used correctly and consistently, and there is no absolute guarantee against contracting a sexually transmitted infection.
To be fully responsible in using birth control, individuals must know what options they have, how reliable these methods are, and what advantages and disadvantages are of each one. The best method of contraception is one that will be used consistently and correctly.
<br />Most women who are not currently using contraceptives go to a clinic or a doctor's office knowing which method they would like to use. However, many of these women are not aware of other options available to them.
To help make an informed decision about which birth control method is best for each woman, some questions to consider include:
Do you know the advantages and disadvantages of each of the contraceptive methods?
How convenient and easy is it to use this method?
If you or your partner is at risk, does this method protect against STIs, including HIV?
What are the effects of this method on menses?
What other influences such as religion, privacy, past experiences, might affect your decision?
And, have you discussed potential methods with your health-care practitioner?
In the discussion of the method's effectiveness, "perfect use" refers to the percentage of women who become pregnant during their first year of use when they use the method correctly and consistently. "Typical use" refers to the percentage of women who became pregnant during their first year of use, and includes both couples who use the method correctly and consistently and those who do not. Therefore, typical use is the more significant number to use when considering a method of contraception.
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In our discussion of pregnancy prevention, we must acknowledge the oldest and most reliable birth control method of all: abstinence. From a family planning perspective, abstinence is the absence of genital contact that could lead to pregnancy, such as penile penetration of the vagina.
The term "celibacy" is sometimes used interchangeably with "abstinence." However, "celibacy" often implies the avoidance of all forms of sexual activity and, often, the religious commitment to not marry or to maintain a nonsexual life.
There is a wide variety of opinion about what constitutes sexual activity and which activities someone may or may not be abstaining from. Therefore, it is imperative that partners communicate regarding their personal definitions of abstinence to ensure protection.
Individuals who choose not to have intercourse are still free to express affection in a variety of ways that do not lead to a pregnancy. They should also be informed about other forms of contraception in case either partner experiences a change of mind. Sexual abstinence is nearly 100% effective at preventing pregnancy.
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Oral contraceptives, also known simply as "the pill," are the most popular form of reversible contraceptives in the United States. The pill is actually a series of pills containing synthetic estrogen and/or progesterone. Oral contraceptives may be prescribed by a physician or a family planning clinic. There are more than 95 combinations available, containing various amounts of hormones. Some women react differently to different pill combinations, so if a women is having an adverse reaction to one form, it may be advantageous to try another combination. <br /><br />Since none of the hormonal methods of birth control offer protection against sexually transmitted infections, women on the pill should consider using additional protection, such as a condom.
Advantages of oral contraceptives include that they are easy to take and dependable, there are no applications or interruptions before or during intercourse, and they're more regular or reduce menstrual flow, which includes less cramping, enlarged breasts, or less acne.
However, it does have its disadvantages as well. The pill is only effective if taken consistently. It must be taken every day, as close as possible to the same time each day. If one pill is missed, it should be taken as soon as the woman remembers, and the next one taken on schedule. If two pills are missed, the method cannot be relied on, and an additional form of contraception should be used for the rest of the cycle.
Other side effects, such as spotting can occur, along with breast tenderness, nausea or vomiting, and weight loss or weight gain. In addition, there can be spotty darkening of the skin, nervousness and dizziness, loss of scalp hair, headaches, changes in appetite, sex drive, as well as mood changes. These problems can be eliminated by changing the prescription, but that does not always work. And in rare instances more serious problems can occur. <br /><br />There is an acronym called ACHES—A, C, H, E, S. The A stands for abdominal pain, the C stands for chest pain, the H stands for headaches, the E stands for eye problems, including blurred vision, spots, or a change in the shape of the cornea, and the S stands for severe leg pain. Often, these are severe problems.
The health risks with oral contraceptive use also increase with age. Women who are over the age of 35, women who smoke, or women with certain other health disorders are considered high risk.
The synthetic estrogen and progesterone regulates egg production and the menstrual cycle. When taken for birth control, oral contraceptives accomplish some of the following:
They suppress ovulation 90-95% of the time.
They thicken cervical mucus which prevents sperm penetration into the woman's upper genital tract
They thin the lining of the uterus which inhibits implantation of the fertilized egg.
They slow the rate of ovum transport.
They disrupt transport of the fertilized egg.
And, they inhibit capacitation of the sperm, which limits the sperm's ability to fertilize the egg.
When a woman is pregnant, these chemical conditions are created within the body to prevent another pregnancy from occurring. The pill works to prevent pregnancy in much of the same way. It produces basically the same chemical conditions that would exist in a woman's body as if she were pregnant.
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The birth control shot, known by the brand name Depo-Provera, is an injection of the hormone progestin that is used to prevent pregnancy for 12 weeks. The progestin works by stopping ovulation, thickening the cervical mucus, and thinning the lining of the uterus, presumably to prevent a fertilized egg from attaching to the uterus.
The drug is effective immediately. Most women can use the birth control shot safely; however, risks and side effects are similar to those of the pill. Irregular bleeding is the most common side effect, especially in the first 6-12 months of use.
<br />Advantages are that menstruation stops completely after a year of use. But there are various disadvantages including menstrual spotting, weight gain, headaches, breast tenderness, dizziness, loss of libido, and depression. It also may cause a loss of bone mineral density, but recovery will occur after discontinuation.
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The birth control patch, brand name Ortho Evra, is a thin, beige, plastic transdermal reversible method of birth control. It releases synthetic estrogen and progestin to protect against pregnancy for 1 month. Each week for 3 consecutive weeks, one patch is removed and a new one is applied. One week of the month is ‘patch-free' which is when menstruation occurs. The sticker should be applied on the lower abdomen, buttocks, upper arm, or upper torso, but not on the breast.
The combination of hormones work the same way as oral contraceptives do. The patch is most effective when it is changed on the same day of the week for 3 consecutive weeks. Pregnancy can happen if an error is made when using the patch, especially if it becomes loose for longer than 24 hours, falls off, or if the same patch is left on for more than 1 week.
Its advantages include regular and lighter shorter periods, the ability to become pregnant returns quickly upon discontinuance, and it does not interfere with sex. Also, you don't have to remember to take it every day as you do with oral contraceptives. Disadvantages include headache, nausea, application site reaction, breast discomfort, upper respiratory tract infections, dysmenorrhea, and abdominal pain.
The patch has received criticism by the FDA, arguing that it exposes women to higher levels of estrogen than most birth control pills, thus increasing the risk of blood clots.
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A vaginal ring, commonly referred to as NuvaRing, is a form of a reversible, hormonal method of birth control. It is a small, flexible ring inserted high into the vagina once every 28 days. The ring is kept in place for 21 days and removed for a 7-day break to allow for menstruation. It may be removed during the 3 week period, but it must be returned within three hours to ensure success. It must be inserted on the same day of the week as it was on the previous cycle. The ring releases synthetic estrogen and progestin, preventing ovulation in a manner similar to those of other combined hormonal contraceptives. The vaginal ring is prescribed by a doctor.
Many women who use the ring have more-regular, lighter, and shorter periods. A woman can stop using the ring at any time, offering her more control over contraception than with some other hormonal methods of birth control. The ring provides a consistent release of hormones and does not usually cause weight gain.
The side effects of the ring are similar to those associated with oral contraceptives. Additionally, there may be a slight increased risk of blood clots. Vaginal wetness, sensation of a foreign body, expulsion, and headaches may also occur. The ring should not be used by women who have weak pelvic floor muscles.
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Barrier methods are designed to physically keep sperm and egg from uniting. These methods of birth control have become increasingly popular because, in addition to preventing conception, they can reduce the risk of sexually transmitted infections. The effectiveness of all barrier methods is increased by the use of spermicides.
A condom (or male condom) is a thin, soft, flexible sheath of latex rubber, polyurethane, or processed animal tissue that fits over the erect penis to help prevent semen from being transmitted. Condoms prevent infections by covering the portals of entry and exit for many sexually transmitted infection organisms.
Condoms are the third most widely used form of birth control in the United States and are the preferred method of choice for adolescents due to their ease of use and easy accessibility and cost.
Latex condoms should be used with water-based lubricants (like K-Y Jelly) only because oil-based lubricants, such as Vaseline, can weaken the rubber.
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Condoms are easy to obtain and do not cause harmful side effects. They're easy to carry and are often inexpensive or even free. Latex condoms help protect against sexually transmitted infections, including the HIV infection. Addtionally, some men appreciate the slightly reduced sensitivity they experience when using a condom because it can help prolong intercourse.
The chief disadvantage of a condom is that it should be put on after the penis has become erect but before penetration. This interruption is the major reason that users neglect to put condoms on. Some men and women also complain that sensation is dulled. Luckily there are many different types of condoms on the market and couples with dulled sensation should try another type, fit, or brand.
Image: McGraw Hill Image Library
The female condom is known as Reality. It is a disposable, soft, loose-fitting polyurethane sheath with a diaphragm-like ring at each end. One ring, sealed shut, is inside the sheath and used to anchor the condom against the cervix. The larger outer ring remains outside, acting as a barrier and protecting the vulva and the base of the penis. If it is used consistently and correctly, it may provide protection against STIs, including HIV.
<br />Its advantages includes it protects the vagina and the cervix from sperm and microbes. It also offers both protection against disease because it opens and covers the women's external genitals and the base of the partner's penis. It is also less likely than the male condom to break. It does not restrict the penis and provides women with fertility control. The female condom can also be inserted into the rectum to provide protection during anal intercourse. The pouch is lubricated both inside and out and can be inserted up to eight hours before use and used without additional spermicide. <br />
But like other methods, it has its disadvantages. The most notable complaints are aesthetics. Not everyone likes the complete coverage of a woman's genitals. Also, it can produce noise during intercourse, but lubrications can be used to quiet this. It is meant for one time use only, and the female and male condoms should not be used together because they can adhere to each other and can cause one or both to slip out of position or to tear.
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A diaphragm is a rubber cup with a flexible rim that is placed deep inside the vagina, blocking the cervix, to prevent sperm from entering the uterus and the fallopian tubes. Somewhat effective by itself, the diaphragm is highly effective when used with a spermicidal jelly or cream.<br />
After intercourse, it should be left in place for at least 6 hours. If intercourse is repeated within 6 hours, the diaphragm should be left in place and more spermicide inserted with an applicator. To remove a diaphragm, the woman inserts a finger into her vagina and under the front of the diaphragm rim and then gently pulls it out. A diaphragm is available by prescription only and should be replaced about once a year.
The advantages includes that it helps protect against STIs of the cervix and pelvic inflammatory disease, but it has numerous disadvantages. Women dislike the process of insertion and the mess or smell of chemical contraceptives that are used with the diaphragm.
Men complain of rubbing and other discomfort, and individuals can have an allergic reaction. There's also increased risk for urinary tract infections and the risk of toxic shock syndrome. Also, the diaphragm is assumed not to protect against HIV.
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A spermicide is a substance that is toxic to sperm. The most commonly used spermicide in products sold in the United States is the chemical nonoxynol-9. Originally developed as a detergent nonoxynol-9 is a vaginal cream that rapidly kills sperm cells. Although safe and effective, frequent spermicidal use can facilitate the transmission of STIs, including HIV, that could lead to genital ulcerations and irritation. <br /><br />Spermicidal preparations are available in a variety of forms and are considered most effective when used in combination with a barrier method of contraception, such as the male condom or the diaphragm.
Contraceptive foam is a chemical spermicide sold in aerosol containers. It is a practical form of spermicide for use with a condom. Shaking the container before applying the foam increases its foaminess so that it spreads farther. The foam begins to go flat after about half an hour. It must be reapplied when intercourse is repeated.<br />
Contraceptive film contains a paper-thin tissue that contains nonoxynol-9, which dissolves into a sticky gel when inserted into the vagina. The film is placed directly over the cervix at least 15 minutes before intercourse to allow time for the sheet to dissolve and disperse. Like other spermicides, contraceptive film works effectively in conjunction with the male condom.
Spermicides also come in the form of creams and jellies. These come in tubes and are inserted with an applicator or placed inside diaphragm or cervical caps. Suppositories are chemical spermicides inserted into the vagina before intercourse. Body heat and fluids dissolve the ingredients and must be inserted early enough to dissolve completely before intercourse.
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Intrauterine contraception (IUC) is also referred to as an intrauterine device (an IUD). It is a long-acting reversible contraceptive method. It involves the placement of a small flexible plastic device into the uterus to prevent sperm from fertilizing an egg. The type of device inserted determines how long it may be left in place; the range is 5-20 years.
The two IUCs currently available in the United States are the Copper T 380A, marketed as ParaGard, and a hormone-releasing intrauterine system, marketed as Mirena. IUCs are the most inexpensive, long-term, and reversible form of birth control, and must be inserted and removed by a trained practitioner.
Current evidence does not support the common belief that the IUC is an abortifacient. An abortifacient is a device or substance that causes an abortion. It primarily prevents pregnancy by preventing fertilization. Both types of IUCs alter the lining of the uterus.
Once inserted, IUCs require little care and don't interfere with the spontaneity during intercourse. However, insertion may be uncomfortable. Also, heavy cramping typically follows and sometimes persists.
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Fertility awareness methods are based on a woman's knowledge of her body's reproductive cycle, and she must keep track of her menstrual cycle. During the days of ovulation, the woman abstains from sexual intercourse. This method is often referred to as natural family planning. <br /><br />It should be noted that among typical users of fertility awareness, about 24% of women experience unintended pregnancy during the first year because it is very difficult to predict when ovulation will occur. There are four types of natural family planning.
The calendar, or rhythm method, requires the woman to calculate her safe days. This depends on the range of the woman's longest and shortest menstrual cycle, and it may not be practiced or safe for women with irregular cycles.
The second method is the basal body temperature. The woman records the temperature of her body every morning upon waking for 6 to 12 months to gain an accurate idea of her temperature pattern. The women's temperature tends to be slightly lower—a half a degree to a degree—during menstruation and for about a week after that.
The third method is the cervical mucus method. With this method, the woman determines her ovulation stage and her menstrual cycle by examining the mucus secretions of her cervix. In many women, there is a noticeable change in the appearance and character of cervical mucus prior to ovulation.
There's also the symptothermal method. With this method two or more fertility indicators are used together—for example, mid-cycle pain in the lower abdomen on either slide, slight discharge of blood from the cervix, which we call spotting, and breast tenderness, feelings of heaviness, and abdominal swelling are all symptoms that could be used. Of course these are all symptoms of the menstrual cycle beginning to occur.
Sterilization is the surgical intervention making reproductive organs incapable of reproducing or delivery of viable gametes. Sterilization is the most widely used method of contraception in the world, in both developing and developed countries.<br />
Tubal ligation is the procedure for women. It is also known as tying the tubes and is not reversible. There are two common methods for tubal ligation— laparoscopy and transcervical sterilization.
Laparoscopy is the insertion of the instrument at the edge of the navel and closes the tube by electrocauterization or burning. The tubes can also be closed off or blocked with tiny rings, clips, or plugs. Recovery occurs within a week, and the procedure requires general anesthesia.
Transcervical sterization is the insertion of the soft, flexible, micro insert into each fallopian tube in a 35 minute procedure. Tissue grows around the micro-rod blocks the fallopian tubes, which causes sterilization.
Once a women is sterilized, no other method of birth control will ever be necessary. The regularity of menstrual cycles are not affected, and the ovaries, uterus, and hormonal systems do not change. Sexual enjoyment is not diminished, but the procedures are irreversible.<br />
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The vasectomy is a minor surgical procedure in which a small incision is created in the skin of the scrotum. Through the incisions each vas deferens, which are the sperm carrying tubes, is lifted, cut, tied, and often cauterized with electricity. The procedure takes 30 minutes and recuperation can occur in a few days. This procedure should be considered permanent.
A man may retain some viable sperm in his system for days or weeks following a vasectomy. Because it may take 15-20 ejaculations to get rid of these sperm, a couple should use other birth control until the man's semen has been checked.
Compared with other birth control methods, the complication rate for vasectomy are very low.
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Emergency contraception, also known as the "morning-after pill" or Plan B One-Step, is a safe and effective way to prevent pregnancy following unprotected intercourse. To be effective, it must be taken within 3 days after unprotected sexual intercourse.
Emergency contraception is not the "abortion pill" (RU-486) and will not terminate an established pregnancy, in which the fertilized egg has already attached itself to the wall of the uterus, nor will it cause any harm to the developing fetus. Rather, emergency contraception inhibits ovulation and thickens cervical mucus, which prevents the sperm from joining the egg.
Emergency contraception should not be used as a form of ongoing birth control. Nausea and vomiting are among the most common side effects. Other side effects may include breast tenderness, irregular bleeding, dizziness, and headaches.
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Now let's discuss abortion. An abortion is the expulsion of the conceptus. Abortions can happen naturally or can be induced. Many abortions occur spontaneously. These are often referred to as miscarriages. Approximately one-third of all abortions reported annually in the United States are spontaneous abortions, or the death of a fetus before it can survive on its own.
Conversely, induced abortions are when pregnancies are intentionally terminated. This can occur via medical or surgical procedures. In this class, unless otherwise noted, when we examine abortions, we are referring to induced abortions.
Abortions cannot be viewed as if they are all the same. Distinctions must be made, for example, among wanted, unintended, and unwanted pregnancies. The duration of pregnancy, more than any other factor, determines which abortion method is performed.
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Medical abortion (long known as RU-486 and marketed as Mifeprex) became available in the United States in 2000. Widely used in several European countries for over two decades, it has been shown to be safe, effective, and acceptable. It has become an increasingly common alternative to surgical procedures and constitutes 25% of induced early abortions.
Surgical methods include vacuum aspiration, and dilation and evacuation.
Vacuum aspiration is the method used for nearly all first-trimester abortions. This safe and simple method is performed under local anesthesia. The first step involves the rinsing of the vagina with an antiseptic solution. Next, the cervix is dilated with a series of graduated rods. Then a small tube attached to a vacuum is inserted through the cervix. The uterus is gently vacuumed, removing the conceptus, the placenta, and endometrial tissue.
Dilation and evacuation is usually performed during the second trimester of pregnancy. Local or general anesthesia is used. The cervix is dilated, and the fetus is removed by curettage or scraping. Because it is a second-trimester procedure, the D&E is somewhat riskier and often more traumatic than a first-trimester abortion.
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Abortions performed in the first trimester pose virtually no long-term physical or psychological risks. Under safe, clean, legal conditions, abortion is a safe medical procedure. But self-administered or illegal clandestine abortions can be very dangerous and sometimes even fatal. The single greatest factor influencing the safety of abortion is gestational age, with those performed in early pregnancy being the safest. Ninety percent of abortions occur within the first 3 months, thus making the procedure relatively safe.
Regardless of the method performed, however, almost all women have some bleeding after the procedure that lasts from several days to several weeks. The risks of complications increases with the length of the pregnancy.
Making a decision about abortion, regardless of the ultimate outcome, raises many emotional issues for women. There are few painless ways of dealing with an unintended pregnancy.
For many women, such a decision requires a reevaluation of their relationships, an examination of their childbearing plans, a search to understand the role of sexuality in their lives, and an attempt to clarify their life goals. Research indicates that women that were able to rely on their partners for support vastly improves the woman's post-abortion well-being and adjustment. This finding highlights the man's role in the abortion.
In the abortion decision-making process, the vast majority of male partners know about and support the woman's decision. For a man, pregnancy forces him to confront his own feelings. Feeling of guilt and anxiety may conflict with ambivalent feelings about parenthood. If the man was not involved in the decision-making process, he may feel powerless.
Abortions can have lasting effects on a relationship. It is also somewhat common for couples to split up after an abortion; the stress, conflict, and guilt can be overwhelming. Many clinics now provide counseling for women, as well as men, involved in an abortion.
There are two sides to the abortion debate. Those who believe abortion should be prohibited generally identify themselves as "pro-life." Those who support a woman's right to choose for herself whether to have an abortion generally identify themselves as "pro-choice."
The pro-life stance believes that human life begins at fertilization, and the same rights should be provided in utero as after birth. In addition, they believe abortion is the moral equivalent of murder.
The pro-life argument opposes abortion except to save the life of a pregnant woman. They believe abortion is the first step towards a society that eliminates undesirable human beings. Pro-life stances also argue there are thousands unable to adopt because children are aborted.
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On the other hand, the pro-choice is the belief that it is a woman's right to choose for herself whether to have an abortion. The pro-choice argument believes that women should be able to choose whether or not they will have children, and that women continue to bear the primary responsibility for rearing children. <br /><br />They also believe that abortion should be available as a backup birth control method and that women will get illegal and unsafe abortions if the procedure is made illegal.<br />
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The U.S. Supreme Court issued the famous Roe v. Wade decision in 1973. Under the Roe decision, a woman's right to abortion is guaranteed as a fundamental right, part of the constitutional right to privacy. At the time, only four states permitted abortion at the woman's discretion.
The Roe decision created a firestorm of opposition among political and religious conservatives and fueled a right-wing political resurgence. But because abortion was determined a fundamental right by the Roe decision, efforts by states to curtail it have failed.
Since the 1973 Supreme Court decision, states have been undergoing rigorous debate about how to best interpret, regulate, limit, and define under what circumstances a woman may obtain an abortion.
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Birth control provokes emotional controversy. There are many methods of birth control and contraception available. Our own motives, needs, weaknesses, strengths, and, most important, knowledge, influence our decisions about which contraceptive or birth control we will use. But the best method is the one that will be used correctly and consistently. We must be aware and provide choices and options for all, not just some.