Beginning with fundamentals, the basic principle that must be dealt with first is
Sex in Man + Woman = Egg + Sperm = Baby.
I have to break down the basics because I often hear statements like this:
“I only did it once.”
“We weren’t trying.”
“How did this happen?”
What’s more is that I ask every patient if there are sexually active. If they say yes, I ask if they are using condoms or any other form of birth control. If they say no, then I say, “do you want to get pregnant?” The question is not a sarcastic one, nor is it meant to embarrass the patient. The answer is almost always an emphatic, NO.
Then the pause… because if you aren’t trying to get pregnant, what are you don’t to prevent it? When I hear, “well, I don’t have sex that much,” I can’t help but think, do you think you only produce a baby after having a certain amount of sex? Sure couples can try for a long time to get pregnant, but it only takes one time to actually conceive. If you remember the movie, Look Who’s Talking, the classic ’80’s movie with John Travolta and Kirstie (I thought her name was Kristie for the longest) Alley, the sperm swims and swims and gains admission to the egg to make the hilarious talking baby who we all fell in love with. That conception scene was amazing, timeless, and still available for viewing on YouTube. Did you know Bruce Willis was the voice of Mikey? Summary of this point: If you aren’t preventing pregnancy, you ARE “trying.” Oh and the pull-out method doesn’t count.*
On average, not adjusting for age or risk factors, after one year of unprotected intercourse, 86 out of 100 women will get pregnant. Pull-out decreases chances of conception, but enough semen is released prior to ejaculation to leave a substantial chance of conceiving. To be specific, in 1 year of regular unprotected sex using the pull-out method, 22 women out of 100 will be pregnant. The Rhythm method will leave 24 out of 100 women pregnant, and a startling 18 women will be pregnant who use the traditional male condom (sorry rubbers). Part of that risk comes from improper or inconsistent use, while part of it comes from failure of the method itself (a hole for example). I still believe wholeheartedly in condoms for reducing STD transmission, but condoms are not the best at pregnancy prevention. The most comprehensive and accurate contraceptive statistics can be found on the Center for Disease Control (CDC) website. My highlight real includes implants, and IUDs. Less than 1 pregnancy per 100 women in 1 year. These methods aren’t for everyone, but they will bring your Oops chances down substantially.
Anyway, if you don’t want to get pregnant, but you do want to have sex, birth control is a must-have EVERY TIME. The only absolute 100% effective form of contraception is abstinence, which I believe in, support, and practiced myself in my pre-marital days, (fyi, tmi). Now that I’ve made that statement, let’s tackle types of contraception: barrier, pill, patch, ring, shot, IUD, implant and permanent sterilization. Barrier methods include condoms and diaphragms with spermicide. Yes, some women still use diaphragms. They are fit to a woman’s uniquely sized vagina by us gynecologists in the office and ordered at the pharmacy. Proper diaphragm use entails filling the rubber cup with spermicide and placing it in the vagina. A diaphragm can be inserted as many as 6 hours before intercourse and SHOULD stay in place for 6 hours after intercourse. The reason for t is that the spermicide-diaphragm combo has to remain in place long enough to kill the sperm. If that isn’t sexy enough for you, pills can possibly do the trick.
There are different kinds of birth control pills. The term the pill can include combined estrogen-progesterone pills (COCs) or progesterone only pill. 9 women out of 100 will become pregnant over the course of a year on a pill. COCs stop you from ovulating, or releasing an egg, and they regulate the menstrual cycle. They need to be used with caution in smokers, women over the age of 35, and shouldn’t be used in women with certain types of migraines or blood clotting disorders. Blood clotting disorders are not to be confused with blood clots that may come out of your body during a heavy period. The clotting disorders that preclude COC or estrogen use are the ones that develop deep clots within the legs or lungs. These clots can be life threatening and increased estrogen levels can make them more likely to form. Progesterone only pills, implants or IUDs, or even hormone free IUDs may be options for women with clotting disorders. For the sake of perspective, the risk of developing a blood clot off of birth control is about 4 in 10,000, or 0.04%. On an estrogen containing birth control, the risk is about 10-14 in 10,000, or about 0.1%. In pregnancy the risk is about 5 times that of the no birth control group (the NBCs), which is 0.2% (1 in 500). The risk is about 20 times higher in the postpartum period than the NBCs, or about 1% (1 in 100).
Permanent options like tubal ligation during c-section, laparoscopic tubal ligation, or hysteroscopic tubal occlusion are all extremely effective methods of birth control. You MUST be ABSOLUTELY SURE you don’t want to have any more babies when you choose this method. There is no consistently successful reversal of a tubal ligation and the risks are not small in attempting to restore fertility. When I ask my patients if they want their tubes tied, say in the setting of a scheduled c-section, if they say “I think I do” with the pensive, unsure emoji hovering over their head, I generally respond with “you didn’t say it right.” You need to know that you know that you know that you don’t want to have any more children EVER. If you aren’t 100% certain, a LARC (long acting REVERSIBLE contraceptive) can offer you the same effectiveness with the reversibility in case you really do lose your mind and want more.
I know you didn’t think I was going to make my way through the contraceptive topic without talking about vasectomy. Sure, this is not my organ of specialty, but vasectomy is a very reasonable method of contraception. It is one of the least invasive methods of permanent contraception. You just need to make sure that the significant other goes for that confirmatory test ensuring no sperm remain in the ejaculate. Initially, the situation is like that of pipes after you turn the water off. You have to get the remaining water out of the pluming before you start disconnecting pipes. Tell him I said its okay. Manly men get “snipped” too. He can crush a beer can on his forehead and go mow the lawn bare chested after it’s all done.
A common question that is posed is how will birth control impact a woman’s long-term fertility. You shouldn’t worry significantly about fertility after birth control, any more than you would worry about fertility not having been on birth control. The modifiable factor that matters most for fertility is not the length of time you have been on birth control, it is the age that you try to conceive. Fertility changes every year. There is not a magic change that occurs at 35 as many women believe. Every year from when we start menstruating until we become menopausal, our fertility is decreasing and our risks of complications increase. This is a gradual change that becomes slightly more rapid at 35, but a 22-year-old is more fertile than a 27-year-old, who is more fertile than a 32-year-old. While some women have menstrual cycle irregularities that may take a small amount of time to normalize after stopping birth control, some women get pregnant while on birth control, meaning there isn’t a purge period that every woman automatically needs to resume fertility.
The take home point: Use whatever method suites you best for as long as you don’t want to conceive, but never take fertility for granted because you don’t know what hand you’ll be dealt when you are “ready.” Oh and being 40-plus is NOT considered birth control. Surprise babies can occur all of the way up to menopause. The little miracles!
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*Dr. McDonald PRETENDS she is a singer sometimes. Her cover of My Boo will have you second guessing some less-than-effective birth control methods.
Categories: B-LOGIC, Bio-Logic, GYN, The Logic-al Choice
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