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Non-Hormonal Birth Control (NHBC)
This Vulvapedia entry covers the many non-hormonal birth control options available. Note that you can read up on hormonal birth control options as well.
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What is Non-Hormonal Birth Control (NHBC)?
Non-hormonal birth control (NHBC) encompasses all types of birth control that do not involve taking hormones. As with hormonal birth control, the end result is to prevent pregnancy. There are a wide range of options for NHBC as well as a wide range of success rates. Some methods don't even require leaving the house, such as FAM, while others may require a trip to your local drug store for condoms or contraceptive sponges, or possibly even a visit with your local gynecologist for a small procedure, as with IUD insertions.
In this article we'll discuss many of the different options of NHBC as well as the pros and cons of each. As with all birth control, finding the one that works for you may be a lengthly process of trial and error, so don't be discouraged! We recommend you discuss these options with your health care professional to figure out what works best with your physiology and your lifestyle.
Who should consider NHBC?
There are many reasons why a woman and her partner(s) may consider NHBC options. Some women simply cannot use hormonal birth control. They may have a medical condition that does not allow them to take hormones, or they may experience unwanted side-effects from hormones. For these women, NHBC may be their only choice for contraception. Some women may prefer NHBC because it may be inexpensive in the long-term. Others may like the fact that many of the NHBC options do not interfere with a woman's fertility, while others prefer the permanence of non-hormonal surgical options. It's important for all women interested in contraception to explore all of their options so they can find what works for them. Don't forget that the best plan is to discuss these options with your health care provider to find what will best work for you!
What are the different types of NHBC?
There are a wide variety of NHBC options. To break things down, we'll start with over the counter options, then head to at-home methods, prescription options, and finally surgical procedures.
Over The Counter
Over-the-counter options can generally be bought either at your local pharmacy, or an online pharmacy. These include condoms, contraceptive sponges, and spermicide.
Condoms
Condoms are a popular and inexpensive form of over-the-counter birth control. The basic idea behind a condom is that it provides a physical barrier between the male and female genitals. Male condoms may be made of latex, polyurethane (or other non-latex plastics), or lamb skin. They are unrolled over the erect penis during foreplay and they have a small reservoir in the tip to catch ejaculate; check this University of Wisconsin-Madison page for step by step instructions -- with pictures! (NSFW) -- on how to use them. Female condoms are larger than male condom's and are primarily made of polyurethane. They are placed within the vagina before sex, and are held in place by the vaginal walls. Condoms are each designed for a single use and should be disposed of afterward.
Condoms may come lubricated or non-lubricated. Lubrication can make sex more comfortable for some couples by providing glide. Some condoms are lubricated with nonoxynol-9 spermicide which acts as a secondary protection against pregnancy. Spermicide has its own set of pros and cons that is discussed more in the spermicide section.
These days, the sheer quantity of condom brands and types to choose from can be overwhelming. Consumer Reports released the results of their 2005 study about the safest condoms on the market. Check it out if you're looking for a little direction.
Male Latex Condoms
Male latex condoms have a reputation of being the most popular type of condom available. When used correctly, condoms can not only protect against pregnancy, but they protect against most STIs, including HIV. Some major brands of condoms include Trojan and Durex.
Pros of Latex Condoms:
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Cons of Latex Condoms:
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Male Non-Latex Condoms
In recent years, polyurethane, polyethylene, nitrile and other non-latex condoms have hit the market. These are similar to the male latex condom in shape, though they are thinner and not as stretchy as latex. Despite their thin appearance, non-latex condoms are considered to be stronger than latex. It is believed that non-latex condoms provide the same benefits of preventing pregnancy and STIs as latex condoms do, but there hasn't been an extensive an amount of research done to support these claims. Popular brands include Durex Avanti and Trojan Supra.
Pros of Non-Latex Condoms:
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Cons of Non-Latex Condoms:
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Lamb Skin Male Condoms
Lamb skin, a natural and biodegradable form of condom, is the oldest material used to make condoms. Specifically, lamb skin is made from lamb intestine. When used correctly, lamb skin condoms, such as Naturalamb, can be efficient in preventing pregnancy. However, lamb skin is porous and cannot protect against STIs, including HIV.
Pros of Lamb Skin Condoms:
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Cons of Lamb Skin Condoms:
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Female Condoms
Female condoms are larger than male condoms, an example can be seen here. As with male condoms, they are closed at one end and open at the other. On the closed side, there is a flexible ring that helps stabilize shape and holds the condom against the vaginal walls once inserted. The condom is inserted similarly to a diaphragm, in the sense that one needs to insert it vaginally until it sits beneath her cervix. The open end then hangs outside of the vagina. Lubrication should be applied to the inside of the condom, and/or to the penis before sex.
Currently, there is only one brand of female condom in production, by Reality Female CondomTM. It is made of polyurethane.
According to Managing Contraception, "Among typical couples who initiate use of Reality condoms, about 21% will experience an accidental pregnancy in the first year. If these condoms are used consistently and correctly, about 5% will become pregnant in the course of an entire year."
Pros of Female Condoms:
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Cons of Female Condoms:
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Contraceptive Sponges
The contraceptive sponge (brands include The Today Sponge® and Protectaid), is a polyurethane foam sponge that contains a small amount of nonoxynol-9 spermicide. It's round with a "dimple" on one side and a ring on the other. The dimple end contains the spermicide, and covers the cervix when inserted correctly. The ring, or strap, on the other side faces the opening of the vagina and is used for removal.
For proper use, the sponge is first moistened with water which triggers the spermicide to release and the sponge becomes foamy. The sponge is then inserted into the vagina, dimple side up, until it reaches and covers the cervix. While the sponge can be inserted up to 24 hours before sex, it shouldn't be removed until six hours afterwards. The sponge should never be left in for more than 30 hours. Once removed, the sponge should be disposed of (but NOT flushed down a toilet). Effectiveness for prevention of pregnancy when used correctly is about 89% to 91%; typical use effectiveness is approximately 84% to 87%.
Pros of Contraceptive Sponges:
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Cons of Contraceptive Sponges:
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For more information on contraceptive sponges, please see these resources:
Spermicide
Nonoxynol-9 is the chemical used in spermicide. It attacks the acrosomal membranes of the sperm causing the sperm to be immobilized. Spermicide comes in the form of cream, jellies, foam, gel, suppositories, and vaginal contraceptive film.
There is a wide range of efficacy. From Go Ask Alice:
"The percentage of women who experience an accidental pregnancy within their first year of using spermicides (foam and vaginal suppositories) is between three and twenty-one percent. The gap is so large because of the differing levels of consistency when using the spermicides. The three percent rate is for couples who use the products PERFECTLY (correctly and consistently every time), whereas the twenty-one percent rate reflects the more typical user who may sometimes use the product incorrectly, not use enough of the spermicide, forget to check the expiration date, or choose not to use it on a particular night for one reason or another. The twenty-one percent rate also reflects factors such as age and frequency of intercourse, whereas the three percent rate is simply based on broad laboratory studies. Consistent use is the most important factor in minimizing failure with spermicides."
Pros of Spermicide:
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Cons of Spermicide:
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A note on using condoms lubricated with spermicide (Nonoxynol-9): Regarding the efficacy of condoms lubricated with spermicide when used as a contraceptive, the World Health Organization has this to say:
The experts found no evidence that nonoxynol-9-lubricated condoms provided any more protection against pregnancy or sexually transmitted infections than condoms lubricated with silicone, used as a lubricant for the majority of condoms available in developing countries. Since nonoxynol-9 may cause some adverse effects, the experts recommended that such condoms should no longer be promoted, but noted that "it is better to use a nonoxynol-9-lubricated condom than no condom."
At-Home Methods
At-home methods usually don't require a trip to the pharmacy, though they may require certain commonly-used household items. The methods we will be discussing are The Fertility Awareness Method (FAM), and the pull-out (withdrawal) method.
The Fertility Awareness Method (FAM)
- What is the Fertility Awareness Method?
- The fertility awareness method (FAM), is not the rhythm method. (The rhythm method is an outdated version of the calendar method, described below. The rhythm method assumes that each woman has a 28-day cycle and ovulates on day 14 of her cycle. Since this is often not the case, it is very unreliable.) Fertility awareness monitors and interprets various bodily signals to determine when a woman is fertile. Couples who use FAM then know to use a reliable backup method of contraception, such as abstinence or condoms, during the woman's fertile time. In some discussions, those who -- for religious reasons -- choose to abstain rather than use a barrier method during each fertile period are practicing Natural Family Planning (NFP), which can be viewed as a form of fertility awareness since it involves the same principles of monitoring and interpretation.
- A Background to Understanding Fertility
- Men produce sperm every day; therefore they are fertile every day. Women release one (occasionally two) ovum each cycle and are therefore fertile for only a limited number of days each cycle.
- The lifetime of a single released ovum is less than one 24 hour day (from Ovusoft.com). According to the same site:
"Even in the case of a multiple ovulation, the eggs are released within 24 hours of each other. During those 24 hours, one or more eggs will be released, and then no more until the next cycle."
- When released into fertile-quality cervical fluid, sperm can survive for up to 5 days, though a life-span of 3 days is more common. When released into infertile cervical fluid, sperm survive only a few hours (Weschler: 2002).
- A woman's "fertile window" then, is generally considered to begin when fertile quality cervical fluid is observed until 48 hours after ovulation is confirmed. In most women, this is approximately 7 days.
- What are these observable fertility signs?
- Cervical Fluid--Essentially, during the infertile portions of their cycles, women tend to secrete either no cervical fluid or cervical fluid that is opaque and "sticky." When they are close enough to ovulation to be fertile, the cervical fluid changes to become white or transparent and thinner, often "stretchy;" this is sometimes referred to as "egg white cervical mucus" (EWCM). The appearance of EWCM is an indication that the body is preparing to ovulate; after ovulation, the cervical fluid then shifts back toward the thicker, opaque variety.
- Basal Body Temperature--Basal body temperature, or waking temperature, is the body's temperature upon waking after at least 3 hours' sleep, before any physical activity has occurred. During the follicular phase (from menstruation to ovulation), BBTs typically fall between 97.0 and 97.5 degrees Farenheit (Weschler: 2002). At the point of ovulation, waking temperatures generally rise by 0.2 to 0.4 degrees Farenheit (from Ovusoft.com), a change noticeable when using a basal thermometer, and remain high throughout the luteal phase, the part of the cycle from ovulation until the next menstrual period. A rise in basal body temperature indicates that ovulation has already occurred.
- Cervical Position--In most women, the cervix achieves 3 distinct positions. During menstruation, the cervix sits lower in the vaginal canal; the os (opening of the cervix) may be detectably more open. When the woman is in the infertile phases of her cycle, the cervix is generally low, and the os is closed. During her fertile time, a woman's cervix rises higher into the vaginal canal, and the os dilates. If used as part of FAM, cervical position is generally considered valuable to supplement cervical fluid tracking and/or temperature monitoring.
- What are the different types of FAM? How does FAM use these fertility signs?
- Billings Method--People who use the Billings method monitor only their cervical fluid to help them determine when they are fertile. Women should examine their cervical secretions at least 3 times per day and should assume they are fertile if they see fertile quality cervical fluid at all on any given day. A backup method, such as abstinence or condoms, is required during times when fertile cervical fluid is present.
- Post-Ovulation Method--As Planned Parenthood explains, people who use this method keep track of their waking temperatures. With this method, the "safe" days range from the third day after the temperature shift indicating ovulation until the onset of the next menstrual period. A backup method must be used for all "unsafe" days.
- Sympto-Thermal Method--Those who use the symptothermal method keep track of both their cervical fluid and their waking temperatures. This method allows greater accuracy because it allows the signs of one method to confirm the signs of another. For people using the symptothermal method, a backup method is required from the time fertile quality cervical fluid is observed until after ovulation has been confirmed.
- Calendar Methods--Women who have fairly regular cycles may also benefit from tracking their fertility signs over several months. This will allow them to estimate fertile times in future cycles. While more reliable than assuming a 28-day cycle for every woman, calendar methods assume that each cycle follows a predictable pattern, which is not always the case. For this reason, FAM recommends using calendar methods only to supplement the monitoring of fertility signs, not as a primary means of contraception.
- How effective is FAM?
The different subcategories of fertility awareness have different rates of effectiveness. According to the Guttmacher Institute, the perfect use rates for some of these methods are estimates based on experts "best guesses" rather than statistics that have been clinically evaluated. Planned Parenthood gives the perfect and typical use rates as follows:
- Billings Method--This method is 97% effective with perfect use and 80% effective with typical use.
- Post-Ovulation Method--This method is 98% effective with perfect use and 80% effective with typical use.
- Symptothermal Method--According to Georgetown University's Institute for Reproductive Health, this method is 97-98% effective with perfect use but may only be 80-87% effective with typical use.
- Calendar Method--Planned Parenthood states that this method is 91% effective with perfect use -- which it also defines as tracking one's cycle for at least 8 months before relying on it for contraception -- and 80% effective with typical use.
Keep in mind that if you choose to have sex using a backup contraceptive method during your fertile period, your maximum level of effectiveness for that cycle will only be as high as the effectiveness of the secondary method itself (Weschler: 2002).
Additionally, experts at the World Health Organization have speculated that a substantial portion of FAM's user error involves couples correctly identifying the woman's fertile time but choosing to have sex on that day anyway (from Georgetown IRH).
Pros of FAM:
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The Withdrawal (Pull-Out) Method
The withdrawal methods works like this, according to Planned Parenthood: "The man withdraws his penis from the vagina before or when he feels he has reached ejaculatory inevitability—the point when ejaculation can no longer be stopped or postponed. He ejaculates outside the vagina, being careful that semen does not spill onto his partner's vulva."
It can be a pretty effective method for some people when used perfectly but doesn't come without risks.
Pros of The Pull-Out Method:
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Cons of The Pull-Out Method:
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Despite the many risks, the pull-out method is reported to be 96% effective when used perfectly, according to this table from Contraceptive Technology. It may be worth noting that while most perfect-use rates have been clinically evaluated, the one for withdrawal -- like the one for some forms of FAM -- is an estimate based on clinical expertise. Contraceptive Technology also states withdrawal's "typical use" effectiveness rate as 73%. You can read more about how this typical use rate is determined from the Guttmacher Institute.
As Planned Parenthood suggests, the withdrawal method is really most effective for partners who have self-control, experience and trust because "[t]he men who use withdrawal must be able to know when they are reaching ejaculatory inevitability."
The withdrawal method and pre-ejaculate ("pre-cum")
There can also be concerns about pre-ejaculate (the stuff that men's penises produce before and after ejaculation).
Pre-ejaculate is a fluid that does not originate from the testicles and that is used primarily for lubrication of the male's urethra to prepare for the release of semen. While scientific studies discussed here and here show that on its own, pre-ejaculate has not been shown to viable sperm, the possibility remains that, in real life encounters, small amounts of sperm may be present in a male's pre-ejaculatory fluid. In most cases this would be sperm that was left in the urethra from a previous ejaculation. While it is not often the case, it is still a possibility that should not be taken lightly if one wants to avoid pregnancy. It's also worth noting that the sample sizes in these studies were small, which may limit the conclusions we're able to draw about them. As one of the abstracts explains, "[a] larger study is needed to verify these results."
According to the Feminist Women's Health Center, "it is likely that urination before intercourse washes leftover sperm from the urethra." The clinical evidence that exists on this subject is somewhat mixed. Additionally, it's been obtained in the context of studying retrograde ejaculation and artificial insemination -- during which different substances may be administered to reduce the acidity of urine -- so it's unclear how reliably we can extrapolate this information onto other situations. Studies have found that the ammonia content in urine is "detrimental to sperm motility." The Textbook of In Vitro Fertilization and Assisted Reproduction also states that urine "may be acidic, and will kill sperm almost instantly." However, other studies have reported successful pregnancies obtained from semen that had been mixed with urine.
It is also important to remember that the pull-out method cannot be used for "multiple rounds" without allowing for ample clean-up in between. For example, if a man pulls out successfully and ejaculates, he may have sperm on his penis and genitals, as well as still in his urethra. If he then inserts his penis in the woman's vagina a second time, there is still a chance that those live sperm will be enough to impregnate her.
| Why VP Includes Information on Withdrawal as Birth Control
It is not our goal to present withdrawal as a method of birth control that is appropriate for anyone and everyone. Rather, it is our goal to provide the most accurate information available to our members. According to the Summary Table of Contraceptive Efficacy from Contraceptive Technology, using withdrawal, which leads to pregnancy from 4% to 27% of the time, is certainly much more effective than using no method at all, which leads to pregnancy 85% of the time. For some women, withdrawal is a valid option, and it's not up to us to tell them that it isn't. We think that it would be counterproductive to simply advise members not to use withdrawal, ever, since that doesn't take into account their specific situations and acceptable levels of risk. As Family Health International says, "it should be discussed with those who are interested in it," though it is not the method for everyone. To deny this would be to keep potentially valuable information from our members, which goes against VP's goals. In this respect, we believe we can best help our members when we give them as much credible information as is available and encourage them to make their own educated decisions about what's best for themselves. |
For more information on the withdrawal method, please see these resources:
Prescription Options
While we recommend discussing any of these options with your doctor before trying them, each of the options described here require a visit. Even though these choices are non-hormonal, they may require a consultation, fitting, or possibly a brief procedure, so they do require a prescription. These options include: IUDs, diaphragms, cervical caps, and Lea's Shield.
IUDs
Intrauterine devices, or IUDs, are small, usually T-shaped or coil-shaped devices that are inserted by a doctor into a woman's uterus through her cervix. A plastic string attached to the bottom of the IUD then hangs slightly into the vagina so that the wearer can check the placement of the IUD. They are the #1 type of birth control used in Europe and are becoming a popular method of birth control around the world.
IUDs may be made of polyethylene, copper, silver, silicon, polypropylene or a combination of the above. Some IUDs, such as the Mirena, include a small amount of hormones (specifically levonorgestrel).
While these IUDs are considered to be a type of hormonal birth control, many women who have problems taking HBC can successfully use hormonal IUDs because they contain such a low and localized dose. To read more about hormonal IUDs please see our article on HBC: Non-pill methods of HBC.
One great benefit of IUDs is that they may last 5-10 years, depending on the brand. In the US, IUDs are predominantly recommended to women in monogamous relationships who have previously given birth. However, this is not the case in the rest of the world, and it is possible for nulliparous women to have an IUD inserted as long as their uterus is large enough to accommodate it. The insertion process may be easier for parous women due to the possibility that their cervix may be more open and their uterus may be larger. It is not entirely known how IUDs work to prevent pregnancy, however there are many theories as to why. This is what Go Ask Alice has to say about it:
"Some believe that the coiled wire around the copper IUD creates changes in the uterus and fallopian tubes that may damage or kill sperm to prevent fertilization of the egg. Others believe that the copper may cause the egg to move more rapidly through the fallopian tubes, thus preventing it from being fertilized. Another theory is that the progestin IUDs cause the cervical mucus to thicken, preventing sperm from entering the cervix."
One important fact about IUDs is that they are not abortifacients. They make the uterus an inhospitable environment for both sperm and egg, but in most cases they do not actually harm an implanted egg (which is why they do not provide 100% protection against pregnancy). Statistically, copper IUDs provide 99.2%-99.4% efficacy and hormonal IUDs provide 99.9% effictiveness against pregnancy (which is higher than sterilization).
In the 1970's, a US IUD, branded as The Dalkon Shield, featured a porous braided multifilament string. It is believed that this type of string became a breading ground for bacteria, and allowed the bacteria to climb into the woman's uterus, thereby causing infection. Infections include, but were not limited to, pelvic inflammatory disease (PID), infertility, and in rare cases, death.
The devices were quickly pulled from the market, and modern devices do not use multifilament strings. However, this negatively affected the market for IUDs in America, and is one of the main reasons that health care practitioners recommend IUDs to women in monogamous relationships (to cut down the risk of exposure to disease and/or infection). It is not believed that modern IUDs run the same risk of PID, but IUDs can be used with a condom to cut down the risk of exposure.
Pros of Non-Hormonal IUDs:
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Cons of Non-Hormonal IUDs:
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Examples of Non-Hormonal IUDs (check availaibility--not all brands are available worldwide):
- Paraguard/Cu T-380A: Plastic-coated copper t-shape IUD (1 3/8 inches long). Lasts 10 years.
- Nova T 380: T-shaped device made of polyethylene and wound with copper wire with a silver core and impregnated with barium sulfate. The surface area of the copper is 380 mm². Lasts 5 years.
- Flexi-T 300: A smaller, oval-shaped IUD (length of shaft 32 mm, transverse arm 28 mm.) featuring a copper wire coated in polyethylene mixed with barium sulfate. Features an easy insertion without a plunger. Lasts 5 years.
- MultiLoad Cu 375/Multi-Safe 375 (generic): T-shaped device featuring a copper wire coated in polyethylene mixed with barium sulfate (35mm long). Lasts 5 years.
- Multiload Cu 375 SL: Smaller version of the MultiLoad Cu 375, 30mm in length. Lasts 3 years.
- Neo-Safe T380: Plastic-coated copper t-shape IUD (1 3/8 inches long). Lasts 8 years.
- TCu-380S (Gyne T Slimline) T-shaped device featuring a copper wire coated in polyethylene mixed with barium sulfate. The horizontal arm 32 mm in length and 1.59 mm in diameter. The vertical arm is 36 mm in length and 1.52 mm in diameter. Lasts 2 years.
- Gynefix330 and Gynefix200: Frameless IUD that is becoming widely popular for nulliparous women (can be used in parous women as well). The 330 has 6 copper tubes (each 4mm long), whereas the 200 has four in a straight line threaded on polypropylene suture material. Lasts 5 years.
For more information on IUDs, please see these resources:
- The IUD_Divas Livejournal Community
- Wikipedia
- Escriber Non-Oral Contraception
- Go Ask Alice
- NetDoctor
Diaphragms
A diaphragm is a flexible dome-shaped device, made of latex or silicon, that covers the cervix during sex to prevent pregnancy--hence, it's considered a barrier method (much like a condom or a cervical cap. The diaphragm needs to be inserted before intercourse (this could be hours before) and must remain in place for 6-8 hours post coitus.
Spermicide is normally placed in the diaphragm before insertion so that it faces the cervix. This creates double protection, chemical plus barrier. While the diaphragm does not need to be removed in between sex sessions, spermicide should be reapplied before engaging in another round. A diaphragm used without spermicide is still more effective than spermicide alone, but it is more effective when the two are used together. According to Managing Contraception, "Among typical couples who initiate use of the diaphragm, about 16% will experience an accidental pregnancy in the first year. If the diaphragm is used consistently and correctly, about 6% will become pregnant." So basically, the diaphragm is 84-94% effective.
Pros of Diaphragms:
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Cons of Diaphragms:
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For more information on diaphragms, please see these resources:
Cervical Caps
Cervical caps are thimble-shaped devices made of latex or silicon, that cover the cervix during sex to prevent pregnancy. Like the diaphragm, it is considered a barrier device. Also, like a diaphragm, it is recommended to apply spermicide to the cervix-facing side before use.
The cap can be put into place hours before intercourse, but must remain in place for 6-8 hours after sex (depending on the type of spermicide used). Since it is smaller than the diaphragm it is less conspicuous and most couples do not notice it during sex. The smaller size also means that correct placement is imperative for it to be effective. According to Wikipedia, "The cervical cap is 80-90% effective at preventing pregnancy for women who have never given birth vaginally; effectiveness drops to 60-75% after vaginal birth due to shape changes of the cervix and vaginal canal."
Pros of Cervical Caps:
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Cons of Cervical Caps:
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For more information on diaphragms, please see these resources:
Lea's Shield
The Lea's Shield is similar to the diaphragm and cervical cap in the sense that it is a barrier method that covers the cervix to prevent pregnancy. However, the major difference between the two is that the Lea's Shield comes in only one size and it is held in place by the vaginal walls and suction with the cervix that is created by a one-way valve.
It is made of silicon and is shaped like an elliptical bowl with an anterior loop that assists in removal. The one-way valve is in the center of the "bowl" and allows for cervical fluid to pass through to the vagina, but does not allow fluid to pass up to the cervix--this creates the suction effect.
From the Lea's Shield website FAQ:
"The Lea's Shield fits (the anatomy of the vagina) by volume. Once inserted, the air trapped between the cervix and the device will be vented out of the one-way valve, creating a tight fit (seal) between the vagina’s wall and the device. The bowl of the Lea's Shield is large enough to accommodate any normal sized cervix."
As with the diaphragm and the cervical cap, it is recommended that spermicide be applied to the side of the cap that touches the cervix before insertion. According to Contraception Online, the Lea's Shield has about a 91% efficiency rate when used with spermicide and an 86% efficiency rate when used without. The cap can be inserted hours before sex (their website boasts 48 hours before), but must remain in place for 6-8 hours post coitus depending on the type of spermicide used.
Pros of Lea's Shield:
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Cons of Lea's Shield:
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For more information on diaphragms, please see these resources:
Surgical Procedures
Are you 100% sure you do not want to have a child? Have you already had children and are not looking to conceive in the future? If the answer to either of those questions is "yes" you may want to consider a surgical solution. While some of these procedures may have the option to be reversed, it should always be assumed that a surgical procedure is permanent. The procedures discussed will include tubal ligation, Essure, vasectomy/male sterilization, and hysterectomy.
Tubal Ligation
Tubal ligation, also called "tubal sterilization" or getting one's "tubes tied," is a surgical procedure that involves separating the connection between the fallopian tubes and the uterus.
There are a number of ways in which this result may be achieved. Generally, one or two small incisions are made in the abdomen. This may involve a laparoscopy, in which a tiny camera is inserted into a small incision so that the surgeon can visualize the procedure, a minilaparotomy, or a laparotomy, which is slightly more invasive as it requires larger incisions. The fallopian tube is then singed by cauterization, tied with a Falope ring, or removed entirely in a scalpingectomy.
All of these procedures should be considered permanent, though there are expensive reversal procedures that may be an option for some women--however, they have poor success rates.
Tubal Ligation is normally an outpatient procedure that is done under general anesthesia, so the patient is unconscious. It can also be performed using an epidural which numbs the patient from the waist down, so the patient stays awake. Tubals may be performed directly after a c-section, which can streamline the procedure for patients.
As with any surgical procedure, there are risks. Risks include those associated with undergoing general anesthesia, infection, bleeding, reactions to medications, and accidental damage to nearby organs and tissues. Recovery is going to be different depending on the procedure used. Generally, women heal faster from a lapariscopy than they do from a minilaparotomy, or a laparotomy. Some women heal as quickly as two or three days, while others may take one to two weeks before they feel completely healed.
Success rates are high with tubal ligations, but they are still not 100%. Statistically, tubal sterilization is 95-99.0% effective, making it a popular option of permanent birth control. From Managing Contraception:
"Tubal sterilization is very effective but definitely not 100% effective. The failure rate is as high as 1-5% in the 10 years after the operation. If you think that you are pregnant at any time in the future, return to the clinic immediately. Should a pregnancy occur, there is an increased chance that it will be outside of your uterus (called an ectopic pregnancy)."
Ectopic pregnancy occurs when the sperm fertilizes the egg in the fallopian tube, and then the egg cannot get to the uterus so it implants in the fallopian tube. While this is a rare condition (only occurring in 1-2% of pregnancies), it is extremely dangerous for the female, and requires immediate surgery. From BellaOnline:
"Symptoms of ectopic pregnancy include lower abdominal or pelvic pain, mild cramping on one side of the pelvis, cessation of regular menses, abnormal vaginal bleeding or spotting, breast tenderness, nausea, lower back pain, severe, sharp and sudden pain in the lower abdomen, fainting and referred pain to the shoulder area. Anyone experiencing these symptoms should seek medical counsel as soon as possible."
Pros of Tubal Ligation/Sterilization:
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Cons of Tubal Ligation/Sterilization:
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For more information, please see these resources:
Essure Sterilization
Essure is a more recent form of surgical sterilization (FDA approved in 2002). It involves placing one micro-insert (made of polyester fibers, nickel-titanium and stainless steel) into each fallopian tube.
Over the course of three months, the woman's own tissues grow around the micro-insert to seal off the fallopian tubes from the uterus so that sperm and egg cannot meet. To verify this, a hysterosalpingogram (HSG) needs to be performed. The HSG is a type of x-ray of the uterus, fallopian tubes, and ovaries. The process involves a dye being injected through a tube in the vagina and x-rays are taken as the dye travels through the uterus and the fallopian tubes.
One major difference between the Essure procedure and a tubal ligation is that it is performed via hysteroscopic surgery, which involves routing a camera through the woman's vagina, cervix, uterus, and fallopian tubes. The major benefit to this approach is that it requires no actual incisions be made on the patient, as it follows natural pathways. This also means that general anesthesia does not need to be used (though some doctors might offer it), which cuts down many of the risks involved.
Twilight anesthesia may be used, which is usually administered via IV and allows the patient to stay awake yet in a sedated state during the surgery, or localized forms of anaesthesia or general pain killers may be used. These options make Essure a viable option for women who have allergies or other physiological reasons for not being able to use general anesthesia (such as obesity, multiple sclerosis, or coagulopathy), or women who do not want to be put out during surgery.
The other major benefit of a hysteroscopy, is that it is a fast procedure with a quick recovery time. The surgery is outpatient and only takes about 45 minutes. Since it does not require general anesthesia, it can be performed in a doctor's office. Most women comfortably return to their daily routines within 24 hours after surgery, while others may take 2-4 days to recover. Post-surgical side effects can include: cramps, temporary pain, changes in menstrual cycle (including spotting), and mild nausea or vomiting as well as fainting or lightheadedness (related to anesthesia). Since the Essure procedure takes three months to fully close the fallopian tubes, it's important to use backup contraception in the interim. As Essure is a fairly new form of surgical sterilization there is not extensive research on the efficacy of it. That said, the Essure website states that it is 99.80% effective in a four year study, which makes it one of the most efficient forms of birth control out there.
Pros of Essure Sterlization:
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Cons of Essure Sterilization:
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For more information, please see these resources:
Vasectomy/Male Sterilization
The vasectomy is a permanent surgical sterilization procedure for men. It is one of the most effective forms of contraception, with less than a 1% failure rate. It involves blocking the vas deferens from allowing sperm to flow from the testicles to the prostate.
As with tubal ligation, there are many different ways to perform a vasectomy. The vas deferens may be severed, cauterized, tied, sutured, or held shut with an implant called a Vasclip. Generally, the procedure is quick, lasting only 20-30 minutes. It is normally done under local anesthesia, though some doctors may also offer their patient an oral mild sedative or Twilight anaesthesia, which is usually administered via IV and allows the patient to stay awake yet in a sedated state during the surgery. The testicles and scrotum are cleaned and may be shaved. The surgeon may then make one or two small incisions in the scrotum to reach the vas deferens.
After the vas deferens are operated on, the surgeon uses a couple small stitches to seal the scrotum. These stitches dissolve naturally and do not need to be removed. Alternatively, a small clamp with pointed ends may be used to puncture the scrotum, this is called a "no-scalpel vasectomy". The major benefit to a "no-scalpel vasectomy" is that it creates a much smaller hole that does not require stitches and heals quicker than a traditional vasectomy. Since general anesthesia is not necessary to perform a vasectomy, it may be performed in a doctor's office.
Directly following the vasectomy, the scrotum will be numb for 1-2 hours. Afterwards, the patient may feel some pain and discomfort as the region swells. Ice should be applied on and off for the first few hours, and it's best for the patient to lay down and use a scrotal support like snug underwear or a jock strap. The testicles should be iced for 3-4 hours, and some swelling and discoloration is normal. There is also a possibility of nausea, dizziness, fainting, and other side effects from the pain medication administered. Most men can resume their normal daily activities within 24 hours, though there may be lingering discomfort for 3-4 days.
While sex can be resumed within a week after surgery, vasectomies are not effective until there are no live sperm present in the male's semen. This usually takes 20-30 ejaculations (1-2 months). During this time another contraception needs to be used to avoid pregnancy. Tests can be performed at regular intervals to be sure that the vasectomy is successful. Vasectomies do not interfere with the male's hormones or the consistency and volume of his ejaculate (as sperm does not make up the bulk of ejaculate). It also does not change the appearance of his genitals, once healed from surgery. For these reasons, the male's sex drive is not compromised by a vasectomy.
Vasectomies should be considered a permanent form of birth control. While there are surgeries to reverse a vasectomy (i.e. vasovasostomy), they are expensive and not guaranteed to work. Depending on the type of vasectomy performed, reversal may not be an option.
Pros of Vasectomy:
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Cons of Vasectomy:
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For more information, please see these resources:
Hysterectomy
A hysterectomy is an extreme surgical option if used for contraception. Generally, a hysterectomy is only recommended to women who need it for a medical purpose (i.e. gynecologic cancer, fibroids, endometriosis, uterine prolapse, etc.), and it is considered major surgery.
We frequently get questions in VP in regards to having a hysterectomy as a permanent form of contraception. In most cases, hysterectomy is confused with tubal ligation, which is a much less invasive procedure. This section is provided to give factual information about hysterectomies, however it is not medically recommended for the sole purpose of contraception.
There are many different types of hysterectomies. The most common type of hysterectomy involves removing the uterus, cervix, and fallopian tubes, while preserving the ovaries. This is often called a "total hysterectomy".
More severe, is a hysterectomy with oophorectomy, which involves removing the uterus, cervix, fallopian tubes, and one or both ovaries.
There is also a sub-total or partial hysterectomy that preserves the cervix while removing the upper portion of the uterus and the fallopian tubes.
In severe cases, generally those involving cancer, a radical hysterectomy (aka Wertheim's hysterectomy) may be performed to remove the uterus, cervix, fallopian tubes, ovaries, the upper portion of the vagina and the nearby lymph nodes.
There are also different ways to perform these surgeries. The most common, and easiest type to perform, is an abdominal hysterectomy. This involves an incision in the woman's abdomen which allows the surgeon to easily access and remove the reproductive organs. This type of surgery tends to have a longer recovery time than other options, and it leaves a scar. The vaginal hysterectomy is less invasive than the abdominal hysterectomy. It involves a surgeon making an incision in the vagina, and then detaching and removing the reproductive organs through the vagina. This is a much more specialized surgery and can only be performed when removing a normal-sized uterus that does not have a great deal of scar tissue. It also cannot be used if cancer or cysts are present.
A laparoscopically assisted vaginal hysterectomy (LAVH) is another good option if the patient is a candidate for a vaginal hysterectomy. This is similar to the vaginal hysterectomy, but allows the surgeon to use a small camera to visualize the reproductive organs as (s)he is removing them. However, small incisions are made on the woman's abdomen to allow room for the camera to enter. These incisions may leave scars on the abdomen.
A laparoscopic supracervical hysterectomy (LSH) is similar to an abdominal hysterectomy in the sense that the surgery is done solely through the abdomen of the patient. It is only used for partial hysterectomies, as it leaves the cervix intact. As with the LAVH, it uses small cameras to help the surgeon visualize and remove the tissue. It allows for smaller incisions than with the abdominal hysterectomy, which leads to less scarring.
The ovaries are the main source for producing oestrogen and progesterone, as well as androgens including testosterone (which plays a part in sexual desire). If the ovaries are removed from a woman that has not been through menopause, menopausal symptoms will progress quickly in what's called "surgical menopause". This can cause symptoms such as hot flashes, night sweats and vaginal dryness and also increases the risk of heart disease and osteoporosis.
Even if the ovaries are not removed, there is a chance that the woman may go through premature menopause due to poor blood circulation to the ovaries that may be caused by scarring from surgery.
Pros of Hysterectomy:
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Cons of Hysterectomy:
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For more information, please see these resources:
Sources Consulted:
General
- Wikipedia
- Go Ask Alice
- Managing Contraception
- Contraception Online
- Women's Health at About.com
- Men's Health at About.com
- WebMD
- Consumer Reports: Comparative Guide to Contraceptives
Condoms
Contraceptive Sponges
Fertility Awareness
- Georgetown University Institute for Reproductive Health
- Ovusoft.com Fertility Awareness Primer
- Planned Parenthood
- Weschler, Toni. Taking Charge of Your Fertility, Revised Edition. New York: Harper Collins Publishers, Inc. 2002. ISBN 0060937645
IUDs
- Mirena Statistics
- Mirena
- Paraguard
- Nova T 380
- Flexi-T 300
- MultiLoad Cu 375
- Multi-Safe 375
- Multiload Cu 375 SL
- Neo-Safe T380
- TCu-380S (Gyne T Slimline)
- Gynefix330 and Gynefix200
- Escriber Non-Oral Contraception
- NetDoctor
Lea's Shield
Tubal Ligation
Essure
Vasectomy
Hysterectomy
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NOTES AND DISCLAIMERS: This FAQ (and VP) is no substitute for medical care. Much of the information above has been adapted from the indicated sources. Click on the links to see their original text or to get more information. Any non-quoted items come from the VP Team's personal experience, which, again, is no substitute for medical care. As always, there is a limit to the information internet resources can provide; if you require additional assistance, it's best to contact an appropriate professional.