(This article is written from an Australian perspective and was current at the time of publication. Contraceptive options and drug availability may vary from country to country. This article is not intended replace a consultation with your doctor and should be used only as a general guide for educational purposes .Please check with your doctor about your personal needs)
These days there is a ‘designer factor’ in contraception choice: you can tailor the method to suit your relationship and health requirements and if your needs change with time so too can your contraceptive choice.
I believe that contraception choice is now a shared relationship issue. In the past it seemed to be women who ‘carried the contraceptive can’, but these days men are wanting to be more involved.
Men are now thinking more about the health risks and potential side effects that some methods may pose to their partners and they’re more willing to look at ways that they can take responsibility.
However, as the saying goes: it takes two to tango. Both sexual partners need to be comfortable that it’s a mutual decision to use a particular contraception method. They also need to be sure that the method and the partner employing it are reliable. After all much of the success of contraception depends on trust (as does the success of a relationship for that matter!).
Assessing your needs
To work out which method is best for you to avoid a pregnancy you first need to assemble a personal and relationship profile.
Here are some questions that will help you formulate your profile:
In order to complete your profile you will need to chat with your partner, your doctor, and if appropriate, your religious or cultural advisor. You may like to go to the doctor together.
Once you have completed your needs profile you are much better equipped to look at options available.
Reproductive pathways
One way to categorise the contraceptive methods is to identify where they act in the reproductive pathway. Here is a summary of how the reproductive process works It may seem simplistic, but it helps illustrate my point (and besides, I like the KISS principle and this is how I understand it anyway ! ).
Male
Hormones like testosterone drive sperm production. It is a continuous process that happens in the testes.
Sperm move from the testes to the urethra via a tube called the Vas Deferens.
During ejaculation sperm travel out into the world, through the urethra in the penis.
Female
Hormones like oestrogen and progesterone drive the ovaries to hatch eggs in a cyclical pattern. Usually one egg is produced approximately each month (ovulation) during the reproductive years. At this time there are also changes in the mucus produced by the cervix and the body’s temperature.
Once "hatched" the egg travels from the ovary, down the fallopian tubes and sits awaiting a sperm to arrive and fertilise it.
If fertilisation occurs it usually does so in the tube. The fertilised egg then moves down into the body of the uterus over the next few days and implants in the thick bed of endometrium (lining of uterus) where it develops over the next 39 or so weeks.
If no sperm arrives it travels on into the uterus anyway and is expelled at menstruation along with the endometrium which was waiting for a fertilised egg to implant. The endometrium will be replaced in anticipation of the next cycle.
Obviously an egg must meet a sperm to achieve a pregnancy.
Spermatozoa are accomplished swimmers and with the aid of a turbo charged ejaculation from a penis positioned inside a vagina they are remarkably good at making a rendezvous with an egg if she happens to be there. As the comedians say… it’s largely about TIMING.
The Methods
Contraceptive methods act on one or more of the points in the reproductive pathway. Figures of method failure rates are freely available, but the success of most contraceptive agents relies upon the commitment and reliability of the user, as well as its design, chemical make up and mechanical structure. A classic example is the oral contraceptive pill. The Pill has an extremely good reliability rating. However, if you don’t take it regularly it is doomed to failure!
Following is a list of contraceptives classified by mode of action.
Temporary methods of contraception
1. Physically preventing sperm meeting egg
1. Physically preventing sperm meeting egg
Physical barrier
Condom +/- spermicidal gel.
Condom +/- spermicidal gel. Male condoms are widely available and are made of latex or polyurethane and are rolled onto the erect penis just prior to insertion into the vagina. It is essential that they be put on correctly and that the air be removed from the bubble at the end to minimise risk of breakage. Only water based lubricants should be used with condoms. Oil based lube may also cause brakage.
Female versions as polyurethane sheaths inserted into the vagina are avaliable in some countries– these are not commercially available in Australia.
Diaphragm + spermicidal gel. A diaphragm is a latex cup that fits over the cervix. It needs an initial fitting by a doctor. It is inserted before sex and left in place for a critical minimum number of hours afterwards. The down side women complain of is the need for "premeditation" with this method as well as the chemical odour of some of the spermicides ( there are some that have less of a smell )
" Hormonal" barrier
The progesterone only (minipill) acts to thicken cervical mucus making it less penetrable to sperm. Its downfall is that it needs to be taken at almost EXACTLY the same time each day with small margin for error.
Billings method
This method relies on a woman being able to recognise when she is ovulating by a combination of temperature taking and mucus change recognition. Both these parameters alter at the time of ovulation. She then either avoids intercourse or institutes some additional form of contraception at the fertile time.
Rhythm
People sometimes rely on the regularity of the female’s cycle and track fertile times by the calendar. Beware! Ovulation can be a ‘retrospective’ thing! The apparent regularity of ovulation is that it occurs 14 days before the next period. Variation can occur in the time between this period and the next ovulation.
Coitus interruptus (withdrawal )
He removes his penis just prior to ejaculation. This requires a marked degree of ‘operator skill’, and sometimes sperm may be present in pre-ejaculate fluid!
Abstinence from vaginal intercourse
This may mean other sex play, non-penetrative sex, or complete abstinence until reproduction is desired.
Spermicides
These are chemicals in the form of creams or foams, which act to kill the sperm on contact before they get to the egg. For best results they are used in conjunction with barrier methods to increase reliability.
2. Hormonal manipulation of egg and sperm production
Female – Oral combined oestrogen/progestogen pill
These hormones mainly work by a higher than normal level of oestrogen in the blood stream ‘tricking’ the female body into thinking it is already pregnant and accordingly ovulation is turned off. If taken regularly ovulation remains switched off . The packs contain inactive pills which induce a period each month – this period is simply due to the withdrawl of the hormones. Although this is a trusted and successful method there are risks and potential side effects associated and proper medical assessment and follow up is essential.
Female – Slow release progesterone (depot type injection delivery)
This also acts via thickening cervix mucus and thinning the lining of the uterus, and the dose is sufficiently high enough to ‘turn off’ ovulation as well. Given by injection into muscle every three months and slowly releases hormone over that time. There are risks and side effects and these need to be explained before commencing. Proper medical assessment is essential
(Female – implant – a pellet of progesterone is inserted under the skin and it slowly releases hormone over three years preventing ovulation in that time – this is NOT yet available in Australia – despite some news stories to the contrary – it is under assessment by the Theraputic Goods Authority and is awaiting approval for registration .)
(Male – depot type injection delivery- A male hormonal contraceptive is still under research but will be a slow release testosterone depot delivered by injection. It is currently in clinical trials here in Australia )
3. Interference with implantation
Mechanical
Intrauterine devices (IUDs) are plastic and/or metal devices that are inserted by a specially trained doctor into the uterine cavity via the cervix. They work by switching the uterus to ‘occupied mode’ possibly by acting as a foreign body and setting up a low grade inflammatory reaction in the uterus. This makes implantation of the fertilised egg less favourable. Some of the modern IUDs also release doses of hormones that act on other areas of the reproductive pathway. There are restrictions, side-effects and risks associated with IUDs that need to be considered carefully. Some women swear by them – others swear at them. They are not recommended for women who have not had babies.
Chemical/hormonal
Sometimes doctors may prescribe certain high dose combined oral contraceptive pills to be taken in pulse doses over a 12-24 hour period as a ‘morning after’ solution (often called ‘morning after pills’). If taken within 72 hours of unprotected intercourse in the correct dose these pills can act to change the environment inside the uterus and make it less favourable for implantation to occur. It is NOT recommended for regular contraception.
There is some confusion surrounding this method because there is also a controversial chemical agent called the "Morning after Pill" (RU-486), which is not legal in various countries (including Australia) and its status is under review in others. It acts by inducing expulsion of the fertilised egg.
Surgical
When available, surgical abortion is commonly carried out these days to evacuate the contents of the uterus using suction curettage under sterile conditions. It is not recommended as an option for regular contraception. Nor is it legal in all states or countries. It is also not acceptable to some religious or cultural groups. ‘Backyard’ abortions have been an unfortunate part of history and abortion in anything less than a sterile clinical setting in the hands of an expert can be extremely dangerous for the woman.
Permanent contraception methods
Surgical
Male – Vasectomy
A vasectomy is a surgical procedure where the Vas Deferens is cut on both sides and tied or clipped. A small section is usually removed and often the ends diathermied (sealed by extreme heat).
The operation is performed by small rather superficial incisions in the upper groin usually under local anaesthetic . The aim is to prevent passage of sperm from each of the testes.
Men can consider freezing sperm before the procedure as although reversals have been successfully performed I believe no one should go ahead with a vasectomy with a view to reversal at a later date.
Sperm production does continue for a while but gradually tails off as if the testis "realises" that the sperm aren’t going anywhere. These redundant sperm are reabsorbed into the system after being broken down by the body’s scavenger system and recycled. The procedure should not affect the man's sexual performance.
Female – Tubal ligation
Tubal ligation is a surgical procedure in which the fallopian tubes on both sides are cut and clipped. Usually a small portion is removed as well the ends being diathermied.
These days it is usually performed by laparoscope, which does mean opening the abdomen, but the incisions are very small.
The aim is to prevent eggs from being able to travel down the tubes. Ovulation should still occur unaffected and menstrual cycles are not interrupted.
Again, while some women have had this procedure reversed it would be foolish to have a tubal ligation done unless permanent contraception is wanted.
The procedure should not affect the woman’s sexual performance and cyclical ovulation should continue as before, the eggs being reabsorbed without ever moving down the tube.
Contraceptive methods that won’t necessarily work
While the contraceptive methods I’ve explained so far have varying degrees of reliability, there are some age-old methods that simple won’t work.
Here is my Top 7 list of contraceptives of dubious repute or doubtful value:
1. Breast feeding. While lactation may well turn off ovulation in some women most doctors recommend an additional form of contraception to be used as well if a pregnancy is really to be avoided.
2. Crossing one’s fingers
3. Intending to pull out
4. Words like ‘Just trust me, it’ll be OK ‘.
5. Douches/bidet. Beware! Sperm can swim against the tide.
6. Standing up during sex or jumping up and down afterwards
7. Cling wrap /chocolate wrappers… pleeeeease NO!
Oral contraceptive boutique
The pill – a whole range to choose from
These days there is an amazing choice available in combined oral contraceptive pills, generically called ‘The Pill’. These pills are made up of cocktails of the hormones oestrogen and progesterone and act to halt ovulation, thicken cervical mucus and thin the lining of the uterus.
These small tablets are taken once each day for 21 days at approximately the same time. Then there is a break of seven days where the woman either takes placebo (sugar) tablets or simply watches the calendar before recommencing the next cyclic packet.
During these seven days she will usually experience a menstrual period, which is actually a ‘withdrawal bleed’ in response to the removal of the constant oestrogen dose. The thinned uterine lining is shed during this time.
There is debate as to the necessity for inducing a regular monthly withdrawal bleed. If all goes to plan the contraceptive value should remain optimal during this hormone-free week.
The doses and the particular chemical make up of each of the hormones in the pill can be manipulated to maintain optimal contraceptive value while attempting to minimise harmful or unwanted side-effects and maximise some of the more desirable side-effects.
Over the last few decades the dose of oestrogen in these pills has been declining while still maintaining contraceptive effect and there has been a corresponding reduction in some of the unwanted side-effects and risk profiles. The progesterone components have also been altered and the result has been a range of boutique Pills able to suit various women’s requirements. Last year a new Pill hit the market with the lowest effective oestrogen dose yet – 20 Micrograms – It is expensive but worth considering if you have side effects from your current formulation. Or of you are just starting out .
Some Pills, while providing contraception, may also specifically help acne, reduce period pain or heavy bleeding. There are others that may be better for women who experience break through bleeding on other pills.
There are pills that change dose during the cycle and others that are the same dose right the way through.
Generally women commence on the lowest dose pills, and only need to change if problems arise or health circumstances change.
Keeping tabs on tablets
A woman should keep asking her doctor or pharmacist about new findings or warnings about the Pill that may crop up from time to time. It is important to ask about side-effects that may be expected or risks associated with Pill taking. It is also vital to tell a doctor if you are on the Pill when being prescribed new medication because of potential drug interactions.
Also, if you are scheduled for surgery, you should check to see whether the Pill should be stopped prior to the operation and alternative contraception methods sought.
Thrombosis (blood clot formation) is a potential serious side-effect of the combined oral contraceptive pill and smoking or long periods of inactivity like bed rest or having to wear plaster casts. Even some lengthy aeroplane trips may put a woman at increased risk.
Remember however, that pregnancy carries a risk of thrombosis too. Many women around the world use the combined oral contraceptive pills as a reliable convenient method of birth control.
However, a woman must understand the pros and cons of the medication she decides to take. The choice should be her own, based upon sound up-to-date information and advice provided to her by health professionals taking into account her personal risk profile.