Contraception


It is an undeniable fact that human beings are by nature sexual beings. Some of us will experience sexual intimacy for the first time in university, whereas others have been sexually active for some time, and still others will choose to abstain from sexual activity altogether. These are personal choices and all are perfectly normal. No one should become sexually active because of pressures from others. If you do decide to become sexually active, you will have two main concerns:

Protection from unwanted pregnancy (this is not just the woman's responsibility, guys!)

Protection from sexually transmitted diseases (STD)

According go the Ontario Women's Directorate, 35,000 young women became pregnant in the last year alone. The wise and informed use of one or more birth control methods will allow you to plan how you live, both now and in the future. You will be able to choose to have a family and choose when in your life you are ready to have a family.

There is no single perfect method of contraception, and the choice(s) made will depend on you and your partner(s). The counsel of your family physician or registered nurse is very helpful when gathering all the information you need to make the right choice. One issue to always keep in mind is that not all forms of contraception will protect you from an STD. Your partner can pass a sexually transmitted infection on to you unknowingly, and you can suffer severe consequences as a result. The next chapter will go into further detail about Sexually Transmitted Infections.

For the purpose of this chapter the term "effectiveness" given for each birth control method describes the number of women who did not get pregnant per 100 women using that particular method in a year.

Contraceptives can be divided into two categories: Permanent Methods and Temporary Methods.


Permanent Methods

  • Female Sterilization: effectiveness - 99.5% cost: covered by government health insurance (OHIP, Medicare, etc)

    Sterilization is a surgical procedure that closes-off the fallopian tubes by cutting (tubal litigation), clipping/clamping/tying (tubal occlusion) or burning (tubal cauterization) them, thus preventing the sperm from reaching the egg.

    The procedure can be performed in several ways. The woman is given general (client is asleep), or local (client is awake) anaesthetic depending on which method is used. Laparoscopy and mini-laparotomy are commonly used and involve making a very small incision in the lower abdomen. Small instruments are then inserted in the opening to visualize and close-off the fallopian tubes. Little scarring occurs from these methods. Other less commonly used methods include laparotomy and vaginal procedures. You and your doctor will determine which method is best for you.

  • Male Sterilization: Vasectomy: effectiveness - 99.5% covered by government health insurance (OHIP, Medicare, etc)

    This is a surgical procedure which prevents sperm from travelling to the penis from the testes. It involves cutting or tying the vas deferens (the tubes in which sperm travel). A vasectomy is commonly performed with local anaesthesia and done on an outpatient basis.

    Female and male sterilization are methods best used when you have decided not to have children or you have already achieved your ideal family size.


    Temporary Methods

  • Hormonal birth control (BCP) effectiveness - 95-98% cost : $15 - 20$/month

    This is the most effective reversible method for preventing pregnancy. Their are several different kinds of birth control pills currently on the market. Most are a combination of estrogen and progesterone which act in three ways to prevent conception.

    1. The estrogen effects include tricking the body into thinking it is already pregnant and so ovulation does not occur.

    2. Estrogen also causes changes in the uterine tissue so that it is inhospitable to an egg.

    3. The progesterone effect causes the cervical mucous to thicken or increase in viscosity thereby preventing the sperm from passing to the uterus and fallopian tubes.

    There are different dosages, such as the low dose pill, which has minimal side effects and their are progestin only pills. Finding the right birth control for you should be discussed with your doctor or nurse.

  • Female Condom Use effectiveness= 75-80% Cost= $3=4/condom

    The Reality vaginal pouch is a soft, loose-fitting polyurethane sheath with two flexible polyurethane rings. One of the rings lies inside at the closed end of the sheath and serves as an insertion mechanism and internal anchor. The other ring forms the external edge of the sheath and remains outside the vagina after insertion. The labia and the base of the penis are covered during intercourse. Reality is pre-lubricated and is intended for one-time use. The female condom should not be used with a male condom.

    Advantages


    Disadvantages


  • Norplant Use effectiveness= 99% cost=?

    Norplant is a long-acting hormonal method consisting of six match-size, flexible capsules made of Silastic, a soft rubber-like material. Norplant is placed just under the skin of a woman's upper arm. A low dose of the synthetic progestin, levonorgestrel, is then continuously released for up to five years. Levonorgestrel is also used in some combined oral contraceptives and one type of mini pill. Norplant prevents pregnancy by inhibiting ovulation and by thickening the cervical mucus. Norplant does not protect against STDs, thus condoms should always be used.

    How is Norplant inserted?

    Norplant is inserted by a health care provider using local anaesthesia. The procedure usually takes five to ten minutes. The capsules are inserted in a fan-like pattern through a single incision in the inner part of the upper arm. Once the capsules are in place, the incision is closed. A pressure bandage is applied to prevent bleeding and should be left on overnight. No sutures are necessary. There will be a slight scar that is usually not noticeable.

    Can you see the capsules once they've been placed under the skin?

    The implanted capsules usually are not visible. They are flexible, should not move, and cannot break inside the woman's arm.

    When is Norplant inserted and when does it become effective?

    Within 24 hours of insertion, a woman is protected from pregnancy.

    How and when should Norplant be removed?

    The capsules are removed by a health care provider by using local anaesthesia in a procedure taking 10 to 30 minutes. Once the capsules are removed, the woman is not protected against pregnancy.

    Norplant must be removed after five years, although it may be removed earlier should you so desire. If you wish to continue to use Norplant, a new set of capsules can be inserted when the old ones are removed.

    Advantages


    Disadvantages


  • Depo-Provera (IUD)
    Use effectiveness=99% cost=?

    Depo-Provera is an injectable progestin (hormone) that acts similarly to other progestin-only contraceptives. Depo-Provera works by preventing the development of the egg and by changing the cervical mucus, thus helping to prevent the sperm from reaching the egg. One injection provides 12 weeks of protection so you must return to your health care provider every 12 weeks for another injection. Depo-Provera can be used safely and effectively as a contraceptive by most women. Depo-Provera does not protect against STDs so always use a condom.

    Advantages


    Disadvantages


    Depo-Provera is not a good choice if you want to be pregnant in the next year or two. Why? Because it may take from nine to twenty-four months to become pregnant after you stop taking Depo-Provera as a contraceptive. When should you see your health care provider?

    Return to the clinic every 12 weeks for another injection.

    Depo-Provera tends to make a woman's periods less regular, and spotting between periods is fairly common. Some women stop having periods completely. If your pattern of bleeding concerns you, return to your health care provider to get a blood test for anaemia, to rule out the possibility of pregnancy, or to rule out the possibility of infection.

    Danger signals:

    Contact your health care provider if you develop any of the following:

    * weight gain * depression * headaches * frequent urination * heavy bleeding

  • Intrauterine Device (IUD)
    Use effectiveness - 95-97%
    Cost - $35-40.00

    IUDs have a long history and have been tested since 1909, but it is not yet clear how and why they work. It is thought that they prevent the sperm from reaching the ovum (egg). The device is made of plastic or plastic and copper, is shaped like a `T' or a `7', and is inserted into the uterus by a doctor. It has a thin thread that lies against the back of the vagina and is used to determine if the IUD is still in its proper place. It can stay in the uterus for 1-3 years (depending on the type of IUD), and is removed when pregnancy is wanted or if problems occur. The main criticism of using an IUD has been that it increases the risk of developing pelvic inflammatory disease (PID), which can lead to fertility problems. PID is caused by STD, most commonly chlamydia and gonorrhea.

  • The IUD is therefore not the best choice for women who have previously had STD or who have many sexual partners. It is also better if you have had a full term pregnancy prior to using an IUD.

    Advantages

    Disadvantages



    Although an IUD needs minimal care to be effective, you must learn how to check the thread regularly to ensure that the IUD is correctly in place. You must also be careful to note any condition, such as a change in menstruation or an abnormal discharge, which could indicate a need for medical attention.

    Barrier Methods

  • Diaphragm
    Use effectiveness - 80-85%
    Cost - $27.00 (gel $15.00)

    The diaphragm is a soft rubber "dome" which covers the cervix during intercourse, theoretically preventing sperm from entering the uterus. It is always used with a spermicidal gel. The diaphragm can be inserted up to 6 hours prior to intercourse, and must be left in place for at least 6 hours afterwards. If you plan on having sex more than once during that period of time, another application of gel is recommended (but the diaphragm is NOT taken out). When a diaphragm is in its proper position, neither partner should be aware of its presence.

    Advantages:



    Disadvantages:

  • Cervical Cap
    Use effectiveness - 85-90%

    This is a rubber device which is shaped like a thimble and fits snugly over the cervix. It must be inserted at least 30 minutes prior to intercourse to ensure that a good seal has been formed, but it can be put in place up to 48 hours prior to having sex. The cap must remain in place for 8 hours after the man ejaculates, and a spermicidal gel should also be used.

    Advantages:


    Disadvantages:

  • Sponge
    Use effectiveness - 85-90%
    Cost - $2.00 each

    This is a relatively new product. It is similar to a diaphragm, in that it is inserted into the vagina and it covers the cervix, acting as a barrier. Spermicidal foam, which comes dried right into the sponge, is released when the sponge is completely soaked with water. The sponge is very soft and can easily be inserted just prior to intercourse, or up to 2 hours earlier. A ribbon is attached to one side, and this is pulled to remove the sponge 6 to 8 hours after intercourse.

    Advantages



  • It allows for repeated, spontaneous intercourse, if inserted some time prior to sex.

    Disadvantages:

  • Condoms
    Use effectiveness - 85-90%
    Cost - less than $1.00 each

  • A condom is a thin sheath of latex (some are made of animal skin, but these are porous and do not prevent the transmission of HIV and other viruses). It covers the penis and traps the fluid when the man ejaculates, preventing sperm from entering the vagina. Condoms come pre-lubricated or non-lubricated, with or without spermicide. In any case, a water-based lubricant (e.g. K-Y Jelly, Surgilube) should be used if further lubrication is desired. Never lubricate a condom with petroleum jelly, since this can cause the latex to break down. The expiry date should be checked (not when you're just about to roll the condom on!), and you should avoid storing condoms in warm places (such as a wallet or your pocket) since this can also cause the latex to deteriorate.

  • Since the penis releases semen (which might contain sperm and even infection) before orgasm, it is important that the condom be put on before the penis gets anywhere near the woman's vagina. The reservoir tip of the condom must be pinched flat to avoid trapping air, which could lead to breakage. If there is no reservoir tip, some space should be left at the end to catch the semen (again, make sure no air gets trapped in this space). The condom is then unrolled right down to the base of the penis.

  • The penis should be withdrawn very soon after ejaculation, and the condom should be held at the base when withdrawing so it does not slip off or leak.

  • Condoms are the only contraceptive method that prevents the transmission of known STD. In cases of herpes, venereal warts and syphilis, the diseases CAN be transmitted if some lesions are not covered by the condom.

    Advantages:

    Disadvantages:

    Chemical Methods


    Use effectiveness - 75-80%
    Cost - $15-20.00

  • Vaginal spermicides (such as nonoxynol-9) kill sperm, or at least inactivate them. They are available as a foam, a gel or suppositories. The foam appears to be the most effective spermicide, and protection against pregnancy is further improved if it is used in combination with a barrier method. For example, using the foam and a condom is 95% effective. Foam or gel spermicides must be inserted no more than 20 minutes prior to intercourse, and suppositories take 15 minutes to melt after insertion. Foam and gel usually require an applicator for use. The first time that they are being used, the introductory pack, which includes the applicator and instructions, should be purchased. Spermicides might offer some protection against particular STD, but they should not be relied upon, on their own, as a means of disease prevention.

    Advantages

    Disadvantages

    Natural Methods


  • Fertility Awareness (natural family planning)
    Use effectiveness - 60-85%
    Cost - free (thermometer $8-18.00)

    This consists of three main methods which can be used on their own, or in combination with each other. They work by identifying the "fertile" period of a woman's menstrual cycle and avoiding intercourse (or using added protection) during that time.

  • Calendar Method

    This is based on the fact that ovulation (release of an egg) occurs 14 days prior to menstruation. An egg can be fertilized for 24 hours after ovulation, and sperm can live for 48 to 72 hours after ejaculation. The woman must keep a careful record of her period for six months (and she cannot be on the Pill or hormones during that time). The "unsafe" period is calculated by subtracting 18 from the shortest cycle to get the first fertile day, and subtracting 11 from the longest cycle to get the last fertile day. The couple must avoid getting sperm near the vagina throughout this entire time period (remember, actual penetration is not required for pregnancy!). The first day of bleeding is always considered to be day 1.

    For example: shortest cycle 26 days longest cycle 31 days

    Therefore, from day 8 to day 20 would be considered "unsafe" and pregnancy could occur. This method cannot be used by women whose periods are very irregular.

  • Basal Body Temperature (BBT)

    This requires taking the woman's temperature every morning before getting up, then charting it. The temperature drops slightly just before ovulation, and increases after ovulation. The first fertile day is calculated by the calendar method, and the "unsafe" period ends when the temperature has been elevated for three days. Many factors can affect this approach - diseases which cause fever or even sexual activity can alter the effectiveness of the method.

  • Cervical Mucus Method (Billings)

    The cervical mucus, which can be examined by touch at the vaginal opening, changes throughout a menstrual cycle. It becomes watery and greater in volume before and during ovulation. The unsafe time is during these "wet days". It takes a lot of practice to master this method, which should be used along with the BBT and calendar methods.

    The advantages of all three methods:



    Disadvantages:

  • Withdrawal (Coitus interruptus)
    Use effectiveness - 60-70%
    Cost - free

    This involves withdrawal of the penis from the vagina before the man ejaculates. This is probably the most widely used method for birth control, despite its low rate of effectiveness. It also ignores the facts that sperm can be present in semen released before ejaculation, and that pre-ejaculate can spread STD.

    Advantages

    Disadvantages


    Post-coital Methods


  • Morning after pill (MAP)
    Use effectiveness - 98% effective
    Cost - usually free

    Occasionally accidents do happen - a Pill is skipped or a condom breaks - and in these situations the MAP is a good emergency measure. Two special high dose birth control pills (prescribed by a doctor) are taken within 72 hours after the man ejaculates (the sooner the better), and another two are taken 12 hours later. These are not just regular Pills that you might have at home. An hormonal change will take place, which prevents the fertilized egg from attaching itself to the wall of the uterus.

    Advantages

    Disadvantages



  • I.U.D.
    Use effectiveness - 98%
    Cost - $35-40.00

    The IUD has also been used as a post-coital (after-sex) birth control method, especially if more than 72 hours, but less than seven days, have passed since ejaculation. It involves all of the same risks for an IUD as explained above.





    Whichever method you are or will be using, it is important to remember that you cannot always determine who has been exposed to STD. It is therefore important to protect yourself against diseases, at least until you are sure that your partners are disease-free. Every sexually active woman should also receive an annual PAP test, whether or not she is monogamous.



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