Family Planning Methods: Natural and Artificial Contraception

Patients ask you which method to use and why one failed. Know how each method works, its ideal versus typical fail rate, and who should not use it. That is the difference between teaching contraception and just handing out a pamphlet.

What are Contraceptive Methods?

Contraceptives, or birth control methods, prevent or reduce the chance of pregnancy. They work by interfering with conception: blocking ovulation, blocking fertilization, or making the uterus hostile to implantation.

Before starting any method, work the assessment:

• Run a pregnancy test first to confirm the woman is not already pregnant.
• Get the OB history, any past STDs, the status of past pregnancies, and any method that failed before.
• Assess her needs, preferences, desires, and feelings about family planning.
• Assess sexual practices, frequency, number of partners, and any latex allergy.

Natural Family Planning

Natural methods introduce no chemical or foreign body. They appeal to patients with religious objections to other methods and to those who want the lowest cost.

Abstinence

Abstaining from intercourse is the most effective natural method, with an ideal 0% fail rate, and the most effective way to avoid STIs. Most people find it hard to sustain, so few rely on it.

Calendar Method

Also called the rhythm method. The woman avoids coitus on her fertile days. She is likely to conceive 3 or 4 days before and 3 or 4 days after ovulation. To find her safe days, she records her menstrual cycle for 6 months, subtracts 18 from her shortest cycle (the first fertile day) and 11 from her longest cycle (the last fertile day), and avoids coitus from the first fertile day through the last. Ideal fail rate 5%, typical fail rate 25%.

Basal Body Temperature

BBT is the woman's temperature at rest. It falls 0.5°F before ovulation, then rises a full degree at ovulation from progesterone and holds that level through the rest of the cycle. She takes her temperature early every morning before any activity. A slight dip followed by a rise means she has ovulated, and she abstains for the next 3 days. Ideal fail rate 9%, typical use fail rate 25%.

Cervical Mucus Method

Based on cervical mucus changes at ovulation. At ovulation the mucus is copious, thin, and watery, and shows spinnbarkeit: it stretches at least 1 inch and feels slippery. The fertile window lasts as long as the mucus is copious and watery, plus one day after, so she avoids coitus during that time. Typical fail rate 25%.

Symptothermal Method

A combination of BBT and cervical mucus. She takes her temperature every morning before getting up and notes daily mucus changes. She abstains for 3 days after a temperature rise or on the fourth day after the mucus peak. Ideal failure rate 2%.

Ovulation Detection

An over-the-counter kit that predicts ovulation by detecting the luteinizing hormone surge 12 to 24 hours before ovulation. It tests a urine specimen for LH. The kit is 98% to 99% accurate and is becoming a method of choice.

Lactation Amenorrhea Method

Exclusive breastfeeding suppresses ovulation. It only works with exclusive breastfeeding. Advise the woman to plan another method after 3 months of exclusive breastfeeding.

Coitus Interruptus

One of the oldest methods. The man withdraws before ejaculation to deposit sperm outside the vagina. Pre-ejaculation fluid carries a few sperm that can fertilize, so it is only 75% effective.

Hormonal Contraception

Hormonal methods manipulate the hormones that drive the menstrual cycle so ovulation does not occur.

Oral Contraceptives

The pill contains synthetic estrogen and progesterone. Estrogen suppresses FSH and LH to block ovulation. Progesterone decreases cervical mucus permeability to limit sperm access to the ovum.

• She takes the first pill on the first Sunday after menstrual flow begins, or as soon as it is prescribed.
• The first 7 days give no protection, so the couple uses another method during those 7 days.
• If she skips one day, she takes it as soon as she remembers, then resumes the regular schedule.
• If she misses more than one day, the couple uses alternative contraception to avoid ovulation.
• Side effects: nausea, weight gain, headache, breast tenderness, breakthrough bleeding, vaginal infections, mild hypertension, depression.
• Contraindications: breastfeeding, age 35 and above, cardiovascular disease, hypertension, smoking, diabetes, cirrhosis.

Transdermal Patch

Combines estrogen and progesterone in a patch. For three weeks, she applies one patch a week to the upper outer arm, upper torso, abdomen, or buttocks. No patch in the fourth week, when menstrual flow occurs. The site should be clean, dry, free of other applications, and without redness or irritation. She can wear it bathing or swimming. If it loosens, she replaces it immediately. If it has been loose less than 24 hours, no backup is needed. If she is unsure how long it has been loose, she replaces it, starts a new week cycle, and uses a backup method.

Vaginal Ring

A silicone ring that releases estrogen and progesterone and surrounds the cervix. Inserted vaginally, it stays for 3 weeks and comes out in the fourth week for menstrual flow. She is fertile as soon as it is removed. Same effectiveness as oral contraceptives.

Subdermal Implants

Two rod-like implants placed under the skin during menses or on the 7th day of menstruation to confirm she is not pregnant. They contain etonogestrel, desogestrel, and progestin. Effective for 3 to 5 years. Fail rate 1%.

Hormonal Injections

Medroxyprogesterone and progesterone, given intramuscularly once every 12 weeks. It inhibits ovulation and changes the endometrium and cervical mucus. Do not massage the site, so it absorbs slowly. Almost 100% effective. Because it risks decreased bone mineral density, advise adequate dietary calcium and weight-bearing exercise.

Intrauterine Device

A small, T-shaped device inserted into the uterus through the vagina. It creates a local sterile inflammatory condition that prevents fertilization and implantation. Only a physician fits it, and it goes in after menstrual flow to confirm she is not pregnant. It contains progesterone and is effective for 5 to 7 years. Advise her to check her menstrual flow and the IUD string monthly and to have a yearly pelvic exam.

Chemical Barriers

Spermicides, vaginal gels, creams, and glycerin films kill sperm before they enter the cervix and lower vaginal pH so it is not conducive to sperm. They do not prevent STIs but need no prescription. Ideal fail rate 80%.

Diaphragm

A circular rubber disk that fits the cervix and blocks sperm from entering. Placed before coitus. With spermicide, the failure rate is 6% ideal and 16% typical. A physician fits it. It stays in for 6 hours after coitus and no more than 24 hours total to avoid inflammation or irritation.

Cervical Cap

A soft rubber barrier shaped like a thimble with a thin rim, fitted on the rim of the cervix. Stays in place no more than 48 hours.

Male Condoms

A latex or synthetic rubber sheath placed on the erect penis before penetration to trap sperm at ejaculation. It prevents STIs and is bought over the counter with no fitting. Ideal fail rate 2%, typical fail rate 15% from breaks or spilling. Remove and dispose after intercourse.

Female Condoms

Latex sheaths designed for females and prelubricated with spermicide. An inner ring covers the cervix and an outer open ring sits against the vaginal opening. Disposable, no prescription. Fail rate 12% to 22%.

Surgical Methods

Surgical sterilization is among the most effective methods and is permanent. One version is for males, one for females.

Vasectomy

A small incision on each side of the scrotum. The vas deferens is tied, cauterized, cut, or plugged to block sperm. Done under local anesthesia, with mild local pain afterward. Sperm can stay viable in the vas deferens for 6 months, so the patient uses a backup method until two negative sperm counts. Accuracy 99.5%, with few complications.

Tubal Ligation

The fallopian tubes are cut, cauterized, or blocked to stop sperm and ova from meeting. Done after menstruation and before ovulation through a small incision under the umbilicus, with a laparoscope for visualization and local anesthesia. She may resume sexual activity 2 to 3 days after. The menstrual cycle continues. Coitus before ligation must be protected to avoid ectopic pregnancy. Effectiveness 99.5%.