Contraception 

   Why should people contracept? Is it so they can have free and easy sex? Maybe that is so, but in my mind it is not the most important reason. The most important reason people should contracept is so that every baby is desired, wanted, and tried for. 

   There are many couples who have free and easy sex, but are not contracepting. They may or may not want a baby, but maybe making a baby is not their goal. I am not sure if this is a good lifestyle. When they do get pregnant, it is not something that they were planning for or hoping for. In my mind, pregnancy is something that is so important that they should be planned for. And every baby should have the courtesy of being wanted from the time of conception. Sure, there are many surprise babies that are wanted and loved, that were not attempted for, but it is not the same as hoping for conception at the time the conception happens. 

   I think there is something magical that happens between a man and a women when they attempt to have a conception. I think the feelings go very deep. I think that people can feel the "conception connection" from the beginning to the end of time, when they conceive together. And that is a beautiful thing. People should really try to enjoy that deep spiritual connection. If they try to enjoy that feeling and connection, it feels really good. So, what does contraception do? It enables all babies to be wanted. Inadequate contraception means that all babies are surprises, and are not planned for, prepared for, or cared for in an ideal manner, from the moment of conception.  

   When I do checkups on women, as a gynecologist, I have to ask women, are you contracepting? It is an unbelievably  important part of medical and reproductive care, to make sure that the contraception is understood. Many times, when I ask that question either verbally, or on a questionnaire, the answer is no. This seems to be the answer that many people give. 

   So, as a thought experiment, I would like to put you in my shoes. I am facing a 32 year old women who has sex, who is heterosexual, and in for a checkup. She states she is not contracepting. She has never been pregnant. Yet she appears to be unworried that she is not pregnant. In fact, she is not asking questions about pregnancy at all. Whether she is married or not is irrelevant right now, because she is having sex. Perhaps she may not know that conception and contraception are part of my job. 

   From here forward, I may gently ask some questions about sex. Ultimately, most women like this are either using condoms or withdrawal as a method of contraception. They are not concerned about infertility, because  they are not trying for pregnancy. But there are so many misconceptions about fertility and infertility and contraception that they don't even realize that they are or are not contracepting.  They may not be doing it properly, and may not be doing it optimally. Many people make suboptimal choices based on bad information. I try to give good information, and good counselling. This at least attempts to make all babies wanted, and can make marriages and relationships much better. 

   My goal is to help my patients achieve their life goals, whatever that may be. One life goal is a good marriage. Another life goal is to not get pregnant if they don't want to be, get pregnant if they do want to be, and have a normal sex life if they want to contracept. 

   And, as a said before, a normal sex life is good, but wanting a baby when the time is right is even better. contraception can help that. And then, when the time is right to concieve, the sex can be the best ever, because of the deep connection and meaning of the union between the man and the women. 

   So, how can I help a women achieve her goals of contraception? 

   If a patient wishes to, I will go through the methods available and help her decide if she is doing the best method for her. 

   I will first describe for her that there are barrier methods, and hormonal methods. 

  Barrier methods are: 

• withdrawal
• abstinence
• calendar method 
• spermicides
• condoms
• female condoms
• cervical caps
• sponges
• diaphragms
• IUDs or Intrauterine Devices, copper vs hormonal 
• vasectomy - surgery on men
• tubal ligation - surgery on women
• tubal blockade, Essure 

Hormonal methods are: 

• Oral Contraceptive pills 
• Minpills, or progesterone only pills 
• Morning After Pills, emergency contaception
• Hormonal Implants 
• lactational
• Nuvaring - Same as oral contraceptives but via the vagina  
• Contraceptive shots : progesterone every three months, or monthly "oral contraceptive" shots
• Patches - Same as oral contraceptives but via a skin patch 

Abortion: 

• This needs it's own article. It is legal, but it should be rare

Contraceptive Methods: 

   Some methods are much better than others. Some methods are lousy. Some methods are common even though they are lousy. All methods have a failure rate. Actually, there are two failure rates, the perfect use rate, and the actual use rate. Failure rates are given as the pregnancy rate per 100 women per year. If there are three pregnancies in 100 women in a year, the failure rate is 3 percent. This percentage is called the Pearl index. The Pearl Index of noncontracepted intercourse is 80 to 85 percent. It is not 100 percent because many people are infertile. I blogged about infertility last month. 

   Birth Control Pills have a failure rate, or Pearl index, of 3 percent, with perfect use. That means that 3 in 100 women will get pregnant every year. This is about 1 in 30 women. Most women are surprised when they learn that Oral Contraceptives will allow one pregnancy every 30 years. This means that an average women who uses Oral Contraceptives from 18 to 48 years of age, will have one pregnancy on the pill. The actual pregnancy rate is much higher, because no one on Earth can remember to take a pill every day for 30 years. There will be forgotten days, and there will be days on antibiotics. If there are a lot of those, then the pill is useless and not only will the women get pregnant, but she will have uncomfortable side effects of incorrect use. If she forgets pills she will likely get break thru bleeding. Women really hate break thru bleeding.

   Birth control pills are available as monthly cycles, three monthly cycles, and noncyclic.

   Most women will experience break thru bleeding. Women get so annoyed that they frequently quit the pill. If they stay with it a few months the break thru bleeding usually stops. 

   Perfect use of OCP's, along with perfect use of condoms, make the Pearl index about one in a thousand. Pregnancy is very very unlikely in that case. Women who absolutely cannot get pregnant should use a double method like this. Then they can be secure in their method. 

   Most couples use withdrawal as their method at some time or another. It is  also called coitus interruptus. That is a Latin word. Don't ask me why anyone would want to use Latin, but there is is. Latin is perfectly appropriate in the Vatican, where even the bank machines use Latin, but probably nowhere else outside the medical journals. 

   Withdrawal really sucks as a method. First of all, a couple is asking a man to actually stop having sex right at the moment when it feels really good to continue. Right when it feels the best, you are asking him to stop. That is kind of like making dinner, putting it on the table when your hungry, putting it up to your lips, smelling it, tasting it a bit, and then throwing dinner away. Mother Nature will fight you on that. I can guarantee that the guy will stretch the interruptus part to the very last second, and then pull it out. There will usually be some sperm in the vagina. The guy might say this is ok with him because interrupted sex is much much better than no sex at all. The woman might even say that this is ok, she is ok with getting pregnant. She might say this vigorously, and defend her method. But, as I said before, this deprives the couple of the joy of the actual attempt at conception, which is my mind is a rare and beautiful thing, and it will once again deprive the baby of the courtesy of being wanted from the first moment. 

   In my mind, couples shouldn't just be OK with getting pregnant. They should actually want it. That is much more spiritually satisfying. And a real joy. So actual and true family planning really matters to me. 

   So, I would hardly ever agree with someone that withdrawal is a good choice. It almost never is. Nonetheless, it is extremely common. \

   When a woman tells me that is her method, I will counsel her that the method doesn't work very well, and that the couple didn't even get to enjoy to process of conception properly. Sometimes she agrees and sometimes she doesn't.

   If she asks me what is a better method I will describe barriers vs hormones. If she is young I will advocate Oral Contraceptives, with or without condoms. OCP's have the advantage of lightening the menstrual flow, nearly eliminating cramps, nearly eliminating the problem of ovarian cysts, preventing some infections, controlling the onset of endometriosis, and blunting PMS. The risk of OCP's is that there will be thicker blood. Blood can clot in the leg veins, causing a Deep Vein Thrombosis, which can travel to the heart, block up the heart (as a pulmonary embolism), and kill the women. DVT's happen commonly, and there are hundreds of thousands of cases a year in the USA. Many people die. But DVT's are more common in pregnancy than on the pill, so the pill can actually lower the risk of DVT because it prevents the pregnancies that actually cause more of them. And, a woman can control the risk by staying hydrated and active, and calling right away if she has leg pain or chest pain. In that case we can detect the DVT and the PE before it is too late. So OCP's have many desirable side effects, and some significant risks. Oral Contraceptives work by making the body think it is already pregnant, therefore it will not ovulate, the cervical mucous will be very thick, and the uterine lining should not grow enough to support the embryo. It does this because oral contraceptives are really just pregnancy hormones. OCP's do not cause any sort of cancer. They are just pregnancy hormones, and have some of the hormonal benefits of pregnancy itself, such as much stronger bones.

   The Catholic Church does not support OCP's because there will be at least some embryo's that are created that cannot implant because the uterine lining is too thin. In that sense the OCP's are at least a little bit of an abortion pill. Most religions, but not all, allow the OCP's. Even the Catholic Church, however, will allow the OCP's for a medical diagnosis such as treating chronic pain, or preserving fertility from the damages of endometriosis. So, for Catholics, if they need the OCP's for some medical reason, then the contraception becomes a side effect and the Catholic Theologians will, in my experience, usually allow it.

   In fact, there is only one method of contraception in the entire list above, that the Catholic Church will allow. And that is the Calendar Method. In other words, couples can refrain from sex when the woman is near ovulation, and she can have full intercourse when she is near or in menstruation. This is allowed. Note that Catholics are not allowed even the simple method of withdrawal, as the Catholic Theologians do not want the sperm to be wasted outside the body.

   Interestingly, sometimes Orthodox and Conservative Jewish women are not allowed sex for seven days after menses. After the seven days they need to ritually purify in a special bath called a Mikvah, usually in a temple, before they can have sex again. Since seven days after menses is the time of ovulation, they also cannot do the calendar method, unless they limit sex to the last few days of the menstual month, right before the period. This is highly limiting, the calendar method really sucks for sexually active conservative Jewish couples. They should come up with something else. Usually the pill, because it significantly shortens the period, and makes the Mikvah that much closer so the couple can get together again.

  If a woman is postpartum and breast feeding, she really shouldn't use a hormonal method. Some of the hormones will get to the baby. They should use condoms. I advocate for "lambskin" condoms because they are very slippery, and a postpartum vagina can be very dry, especially if breast feeding. Sponges will work ok too. The only brand available is the Today Sponge. It is hard to find, but you can get it on Amazon.com. The combination of a lactational state plus a barrier method such as condoms or sponges will make contraception very effective, with a Pearl Index of less than one percent.

   If a women is done having children then there are a few choices that are better than any other. An IUD can make it so a women has no periods, no pregnancies, no worries, no contraceptive duties for 5 years, and can be placed in a few minutes and removed in seconds. This is hands down the best method for a lot of women. There are no hormonal risks or side effects, and the reversibility is highly advantageous. The Mirena IUD has a tiny bit of hormones, but those hormones are stretched out over 5 years, and they are at a negligible level in the blood. Those hormones are contained in the uterine cavity, where they are most needed. They do not cause DVT's and pulmonary embolisms as the OCP's do.  In my experience, women who have an IUD really really like it. There are a few where it has to come out due to cramps or infections. These cases are rare, and in my experience they only need a few days of oral antibiotics to get better. The IUD obviously needs to be removed as well. There is a risk of more serious infections and destruction of the uterus. Those women may need surgery or removal of the uterus. I have only seen maybe four pregnancies with an IUD in place in my entire career. The failure rate is very very low.

   The biggest problem with an IUD is getting women past the fear of a foreign device inside their uterus. I try to tell them that foreign devices in humans are very common, and usually ok. But there was a dangerous IUD in the 70's called the Dalkon Shield that caused a lot of infections. Since then women are reluctant to use it. The advantages are profound,  and especially so for conservative Jews who don't have to worry about the Mikva for years. Their husbands are very grateful.

  IUD's are not so great for my business because women feel so good that they forget to come for checkups. But even so, I like the method. It does a lot of good.

   Two other methods that are good for women who are done having kids is either a vasectomy, which men rarely agree to, or a tubal ligation. This is very common. Tubals are done because they are highly reliable and women will never have to worry about pregnancy again. There is a surgical risk. But once healed, there is no more hormonal or method related risks. And no pregnancies.

  A properly done tubal ligation will have no effect on menstrual flow. The women will have completely natural cycles. This is both an advantage and a disadvantage. Natural cycles increase the risk of both endometriosis, as well as ovarian cysts, at a much higher rate than pregnancies themselves would. But if natural cycles are what the woman wants, and many do, than the tubal is a great method. Pregnancies are very rare. If any of my tubals have gotten pregnant, then I am unaware of them. It is possible they have, and have not told me, but I don't think so.

   There is a newer form of tubal called the Essure. This can be done with minimal anesthesia in the office, via the cervix. What happens is that an inflammatory device is screwed into the fallopian tube via the hysterscope. The device has inflammatory material, a stainless steel coil, and a  nickel titanium alloy cover. The tube then slowly inflames and blocks up. A few months later, someone attempts to push xray dye through the fallopian tubes to see if they are properly clogged. If so, the tubal is declared done.

   I still prefer a traditional tubal. I have had perfect success with it, it doesn't rely on any inflammation, it is instantly effective, it has been done forever without problems, and leaves no reactive material in the body. My tubal will usually be done with an inert plastic ring that has the effect of completely avoiding heat and it's risks within the body. I prefer it over the Essure. Women like the Essure because it uses less anesthesia, has no abdominal incisions, but remember that the dye x-ray still has to be done in a few months.

   There is the three month contraceptive shot. This is called Depot Provera. The advantage is that a women only has to think about it once every three months. After a woman's uterus gets use to it, there is frequently no menses at all. This is great for endometriosis, and women who need mikvas, but there will frequently be break thru bleeding for many months while her body gets used to it. Once the body gets used to it, it is great. There is no periods, and the failure rate is very low.

  All of the methods above have some advantages and some disadvantages. The female condom is best for preventing STD's, but it seems very awkward.

  There are women who really like their diaphragms. It needs to be filled with spermicide, and then placed in the vagina before sex. It works ok, but a women needs to stop to place it before she has sex. This can interfere with the mood, unless she placed it well before she was planning to have sex.

   The sponge was taken off the market sometime in the 90's, leading to a great episode on Seinfeld show where Elaine bought up all the remaining sponges, and then invented the word "spongeworthy" for her boyfriend. It has since come back on the market, but it is still hard to find. It is a great method for some people. It has no hormones, and the guy does not have to even know it is there. The only available brand is called the Today Sponge. It is easiest to order it on Amazon.

   So, the most common methods, in my practice and experience, is abstinence, withdrawal, Oral Contraceptives, condoms, surgery, and IUD. Of these, abstinence is great when neccessary, but problematic in a marriage. Withdrawal is unfortunately common but is terrible. OCPS' are great due to their good side effects, but need a second method for some women. Condoms are easy, but interfere with sex a bit. Surgery is great when it is needed and wanted. And IUD is wonderful and much loved by it's users. Unfortunately they are expensive and women have an unnecessary fear of them.  

   All of contraception is good because it enables pregnancies to be wanted, not loathed and feared.

   The Morning after pill, or emergency contraception, is over the counter now. Any women over 17 can just walk into a store and ask for it and get it without a prescription. The main brand is called Plan B. Just ask the pharmacist for it. It may make you nauseus, and it may give you an abnormal menstrual flow with break through bleeding, but it will really reduce the chance of getting pregnant. All women need to know this, but very few do. It is time we educated them.

   This is my take on contraception.

Thanks once again for reading my blog.
This one is much longer than I intended for it to be. There is still a lot more to say, but this can be a basic introduction to contraceptive options. I hope many of you find it useful.

Comments are appreciated.

Dr John Marcus Ob/Gyn
Ridgewood, New Jersey
Phone 201-447-0077
blog at doctorjohnmarcus.blogspot.com