1. Abstinence/Outercourse--100% effective at preventing pregnancy
Demands personal discipline and accountability, Hormone-Free
Long Acting and Permanent Methods
2. Levonorgestrel/Hormonal IUD--99.8%
Intra Uterine Device, inserted by health professional, lasts 3-6 years (depending on brand), can be removed at any time, contains Progestin-only
3. Tubal Ligation "Tubes Tied"--99.5%
surgical procedure, no maintenance, permanent contraception, Hormone-Free
4. Copper/Non-hormonal IUD--99.2%
Intra Uterine Device, insertion by health professional, lasts 10-12 years, can be removed at any time, Hormone-Free
5. DMPA Injection "The Shot"--94%
Get repeat injection every 12-13 weeks, contains Progestin only
6. Oral Contraceptives "The Pill"--91%
Take a pill every day, contains Progestin and Estrogen (combined hormonal)
Progestin Only Pills (POPs) or "Mini Pills" must be taken within the same three hours every day and contain progestin-only
Short Term and Other Methods
7. Male Condoms--82%
Use correctly every time, protects against pregnancy and STIs, Hormone-Free
8. Withdrawal "Pull Out"--78%
Penis must be removed from vagina before a man ejaculates, and no semen can touch the vagina, Hormone-Free
9. Fertility Awareness Based Methods--76%
Requires daily documentation and personal accountability/discipline, abstain or use condoms during fertile days, Hormone-Free
Condoms and Abstinence are the only forms of birth control that protect against STIs and HIV. STIs can be spread through any genital contact, and can also be present in the upper thighs, buttocks, and mouth. Anal sex receivers (bottoms) are at the highest risk for HIV contraction.
STIs--Sexually Transmitted Infections can cause infertility if not treated, some STIs can be cured, some are incurable
HIV--Human Immunodeficiency Virus is incurable, but can be treated to make the virus non-contagious
per US CDC and WHO Department of Reproductive Health and Research 2011
What about breastfeeding as birth control?
Breastfeeding can be used as a natural form of birth control, but only for six months. When a woman is breastfeeding (lactating), she commonly will not have a period (amenorrhea). Thus, using breastfeeding as birth control is called "Lactation Amenorrhea Method," or LAM.
LAM/Breastfeeding is a temporary form of birth control only available to women who meet the following three criteria:
1. Menstrual bleeding, including spotting, has not returned after two months post-partum
2. Mother exclusively/primarily breastfeeds on a consistent basis, and baby does not eat any other food, water, or liquids
3. Gave birth less than six months ago
--LAM is 98% effective only if a woman meets all three criteria.
--Women must breastfeed their baby on demand, or at least every four hours during the day time, and every six hours during the night time, otherwise she is risking pregnancy.
--Pumping does not protect against pregnancy, only nursing. Avoid pacifiers.
--If your baby has a weak suckle, it can reduce LAM effectiveness. Contacting a nurse, doula, or lactation consultant may help increase LAM effectiveness.
--After six months, breastfeeding women may continue to not have a period, but will not be protected against pregnancy, even if they exclusively breastfeed with a strong suckle.
(Criteria established by US Dept of Health and Human Services, last reviewed Aug 2017)
Emergency Contraception (EC) pills are an effective form of emergency contraception. EC does not terminate a current pregnancy, but prevents pregnancy. A fertilized egg must travel from the fallopian tubes to the uterus, and attach to the uterine wall in order to develop a healthy pregnancy. It takes approximately 72 hours (3 days) for a fertilized egg to travel from the fallopian tubes to the uterus. Because of this, most EC pills are only effective if taken within 72 hours of unprotected sex, as it must be taken before the egg attaches to the uterus. Some EC pills can be effective up to 120 hours (5 days). Non-hormonal/copper IUDs can be used as emergency contraception if inserted within 120 hours of unprotected sex. EC should only be used as an emergency backup, and not taken routinely. If a woman finds herself taking EC routinely, she should consult a doctor for a more reliable and consistent form of birth control.
(If you are currently pregnant, taking EC will not abort your baby, as it is not an abortion pill).
An IUD is an Intra-Uterine-Device. There are two types of IUDs: Hormonal and Non-Hormonal. Hormonal IUDs are a form of progestin-only birth control. Non-hormonal IUDs contain no hormones, but instead contain copper, which is naturally toxic to sperm. IUDs are great option for women who want long term reversible pregnancy prevention. It is recommended a woman wish to delay pregnancy for at least one year before getting an IUD. IUDs are over 99% effective.
How are IUDs inserted?
IUDs are typically inserted via the vagina, through the cervix, and into the uterus. The device itself stays inside the uterus, while two thin, flexible strings hang down into the top of the vagina. Only trained medical professionals can insert and remove IUDs in a sterile, approved facility. IUDs can also be inserted through the abdomen after a cesarean (c-section). Insertions are typically quick. A bi-manual exam is required before insertion, and can be performed immediately before your insertion. You do not require two separate appointments.
Does it hurt?
Insertion can be painful for some women, while others report little to no pain. Women who have never given birth tend to report more pain than woman who have given birth. It is recommended to take NSAIDs (like Ibuprofen) 1 hour before insertion. After insertion, cramping and abdominal pain are the most common symptoms. Women should continue taking NSAIDs every 4-6 hours to alleviate cramping. It is recommended to have someone drive you home after insertion.
What are the side effects?
The most common side effect is changes in menstruation. Your menstrual cycle may be atypical following an IUD insertion. Non-hormonal/Copper IUDs can increase a woman's flow; while hormonal IUDs tend to decrease, lighten, or stop menstruation altogether. This is common of Progestin-only contraceptives, however does not happen to all women. Some women bleed after insertion, others do not. Other potential side effects are: pelvic pain, vulvovaginitis, headache/migraine, and genital discharge. Some women experience mood changes while on birth control. Every woman is different. It is recommended to give your body 3-6 months to adjust to the IUD, as side effects can minimize over time. Some women using IUDs experience ovarian cysts. Most cysts go away naturally. Contact your doctor if you begin to experience severe pelvic pain.
When do IUDs start becoming effective?
Non-Hormonal IUDs are effective immediately, and can actually be used as an emergency contraceptive if unprotected sex occurred five days or less before insertion. Non-hormonal IUDs can last 10-12 years.
Hormonal IUDs take seven days before becoming effective. Abstinence, or condoms should be used for one week after insertion to avoid pregnancy. If a woman is currently taking another form of birth control (like the pill), it is safe to continue use until the IUD becomes effective. (So a week after the IUD is inserted, stop taking the pill.) If a hormonal IUD inserted on Days 1-5 of the menstrual cycle (Day 1 is the first day of the period) it is effective immediately. Hormonal IUDs can last anywhere from 3-6 years depending on brand.
Do I need to do anything after my insertion?
A follow up visit is recommended after insertion. Doctors vary in when they require a follow up. It is important to be compliant in your doctor's recommendation/orders. At this visit your provider will check your IUD position and ask how you are responding. Many IUD users have their doctor check their IUD whenever they go for a Pap smear. Depending on your past pap results, age, and lifestyle, you may need to receive a Pap smear every year, every three years, or every five years. Keep whatever schedule is recommended by your doctor. IUD users will eventually have to return to a doctor to have their IUD removed, either when they desire to become pregnant, discontinue, or if the IUD is soon to expire.
How do I know my IUD is where it should be?
While the actual device stays inside the uterus, two thin, flexible strings attached to the device hang into the top of the vagina. It is recommended to check the strings by lightly touching them (do not push) once per month. Many women combine their monthly string check, with their monthly self breast exam. It's best to check the strings at the same time each month to ensure consistency, as the cervix has different placement depending on the phase of the menstrual cycle. If you can feel only the strings, your IUD is where it should be. If you can feel any part of the device itself, contact your doctor, as your IUD has likely been partially expelled and you are not receiving pregnancy prevention.
What if I cannot feel my strings?
If you cannot feel your strings, contact your medical provider. An ultrasound will be done to ensure your IUD has not expelled or migrated. If your IUD is in place, you can continue having your IUD, just with the strings inside you. Contact your doctor immediately if you begin experiencing severe pelvic pain. An ultrasound should be conducted every two years (or as directed by your doctor) for patients who have their strings inside their uterus. If the IUD is not in the correct position, your doctor will most likely remove the device. If you wish, a new one can replace the old one on the very same day. If the IUD is not present, it means it was expelled and the patient is not receiving any contraceptive protection. If the patient has had unprotected sex in the past five days, emergency contraception may be used, however depending on when the IUD was expelled, the patient may already be pregnant.
Expulsions, perforations, and ectopic pregnancies are among the more serious potential complications. IUD expulsions are not standard, but can happen. A few variables can increase their likelihood: users who are 19 or younger, less than 4 weeks postpartum, immediate post-abortion insertions, and women who are breastfeeding. Perforation of the uterus is less common than expulsions, and typically occurs during insertion, or if the IUD migrates. Women who are breastfeeding have an increased risk for perforation. Women who contract infections easily (like urinary, or yeast infections) should avoid getting an IUD. Pregnancy is rare with an IUD, but pregnancies occurring with an IUD are more likely to result in miscarriage, or be ectopic. Anyone with an IUD who begins to experience severe pelvic pain should contact their doctor immediately.
How is it removed?
IUD removals are typically faster and than insertions. Many patients report no pain during removal. When a patient wants to become pregnant, requires a new IUD, or simply wants to try a different method of birth control, a trained medical professional gently pulls the IUD strings until the device is out. If the strings have gone inside the body, the device can still be removed via strings, it just will take a little more time and searching from the provider. It is uncommon for an IUD removal to require surgery, and typically only happens if the IUD has become imbedded. Only a trained professional should remove an IUD. Some women bleed after removal, and some do not. Most women resume a normal period shortly after removal, while others can take a little longer.
Will I be able to get pregnant after an IUD?
Fertility can return quickly after removal. If a woman wishes to become pregnant, she should remove her IUD and begin tracking her periods. It can take a few cycles for natural periods to resume, and women vary on how soon they become pregnant after removal. Some women become pregnant before they even have their first post-removal period! Almost all couples become pregnant within one year of trying to conceive.
(US MEC--United States Medical Eligibility Criteria for Contraceptive Use, revised 2017)
Mirena and Paraguard Full Prescribing Information
There are two main types of female sterilization. There are modern non-surgical implant systems, and the traditional tubal ligation procedure, otherwise known as "getting your tubes tied." Non-surgical implant systems are fairly new, and not currently available in Kosovo; because of this, we will focus on traditional tubal ligation.
What is sterilization?
Sterilization is a surgery that results in permanent loss of fertility, thus causing sterility. Tubal ligation is the most common form of female sterilization. During tubal ligation, the fallopian tubes are cut, tied, blocked, cauterized, or removed completely. This permanently prevents sperm from being able to reach the egg, as sperm and egg are joined in the fallopian tubes. Tubal ligation is not a hysterectomy. During a hysterectomy, part or all of the uterus (and sometimes cervix, ovaries, fallopian tubes) is removed, and the operation changes a woman's hormones. Only the fallopian tubes are touched during tubal ligation, and the operation is non-hormonal.
With my fallopian tubes blocked, won't my eggs build up inside me?
Women who undergo tubal ligation need not worry about their eggs "building/piling up" inside of them. Their ovaries will continue to release an egg(s) every month. However, instead of traveling down the fallopian tubes into the uterus, the egg will simply stop where the surgery occurred, and naturally be absorbed by the body. The woman will continue to menstruate as usual, despite there being no egg released into her uterus.
How do I get a tubal ligation?
Tubal ligation can be done for any woman, at any time. It is a routine procedure, but does require general anesthesia. For this reason, it all standard risks of surgery and anesthesia apply. Notify your doctor of all past surgeries and current medication. Women will need to schedule pre and post operation appointments. Some women schedule their tubal ligation ahead of time, such as after childbirth or a cesarean, as they will already be at the hospital and doing follow up appointments with their doctor after the birth.
Who can get tubal ligation?
Any woman who wishes for permanent sterility can get tubal ligation. It is recommended women undergoing tubal ligation be in a committed, long term relationship, and be over 30, as these recommendations can decrease the likelihood of regret. However, any woman who is absolutely sure she is done having children, and understands the permanency of the decision, is eligible for tubal ligation, regardless of age or marital status. Some women choose tubal ligation if their past pregnancies were very difficult or dangerous, or if they have had multiple cesareans. This decision is made to protect the health and life of the mother.
What happens? Will I have a scar?
During the procedure, a very small incision is made to the abdomen, typically the navel. The abdomen is inflated with gas to allow more room for the surgeon to work, without having to make a larger cut. This technique produces a very small, faint scar usually hidden in navel. The entire procedure is approximately 30 minutes. If a woman is having a tubal ligation directly after a cesarean, or other abdominal surgery, the doctors will use the same incision site as the main surgery, and she will have a scar typical of a cesarean section.
Will I have to stay at the hospital? Will it hurt?
Many women are released once their anesthesia has worn off and have clear vitals. Some women stay at the hospital for one day. Fatigue, cramping, dizziness, and bloating from the gas are common post-op side effects. Some women report feeling pain upon waking from the anesthesia, but it typically wears off after a couple hours. Doctors will discuss pain management before being discharged from the hospital. If you have a tubal ligation after a c-section, you will likely stay in the hospital for 3-4 days, as is standard for a cesarean birth.
How do I recover after surgery?
Follow all doctors orders, which may include, but are not limited to: Avoid getting the incision site wet for 48 hours after surgery. Carefully pat dry after bathing, and avoid rubbing/itching. Avoid heavy lifting, and gradually resume normal activities as healing progresses, with extra care and rest the first week after surgery. Notify a doctor if the wound bleeds through your bandage, persistent and intense abdominal pain occurs, temperature of 38 C or greater, fainting spells, or foul smelling discharge. Women should return for a post-op appointment if instructed by their doctor. Recovery time is typically 1-3 weeks. If a woman has a tubal ligation immediately after a cesarean, it does not increase her recovery time, and she will recover the same as someone who only had a cesarean, which is typically 6 weeks.
When will it become effective? When can I have sex?
Most forms of tubal ligation are effective immediately, however discuss with a doctor when it is safe to resume sex. Most women wait 1-2 weeks after post-op before resuming intimacy. Only have sex if you feel ready in your recovery. If there are no concerns from the doctor or woman, the woman is done worrying about birth control forever. Yearly wellness exams and routine pap screenings (every 3-5 years) are recommended for all women. Less than 1% of sterilized women become pregnant within one year after surgery.
Will tubal ligation change my hormones or period?
Tubal ligation only stops sperm from reaching the egg by blocking the fallopian tubes. It does not change a woman's hormones, and it is non-hormonal. It will not change a woman's menstrual cycle. There are minimal to no side effects after a sterilization, and very few women notice a change in their period. Tubal ligation will not cause a woman to enter menopause early. Tubal ligation is not a hysterectomy. Since a hysterectomy is the removal of part/all of the uterus, it changes a woman's hormones and causes a woman to enter menopause early; tubal ligation does not.
Male sterilization is rarely offered in Kosovo, but is becoming a more popular option in surrounding countries. Male sterilization has a fast recovery time, only requires local anesthesia, and is more effective than female sterilization, although both are more than 99% effective.
Below is more information on male sterilization for any participants who are interested. Do not need to go over in class if participants are not interested, or do not feel their male partner would be interested.
Male sterilization is called a vasectomy. Vasectomies are not offered in Kosovo, but are available in nearby countries. A vasectomy is not the same as a neuter/castration. A neuter/castration involves the complete removal of both testicles, and changes a male's hormones. This is not performed on humans unless there is a serious medical concern and no other options. For male sterilization, the procedure requires only local anesthesia and is typically done directly in the exam room. Vasectomies are non-hormonal; they do not alter a man's hormones, and he will still become aroused and function the same sexually. Vasectomies do not remove anything, but rather cut, tie, clip, or cauterize the vans deferens. The vans deferens are small tubes that connect the testicles to the urethra. When the vans deferens are altered, it prevents sperm from entering the urethra. After a vasectomy, a man will still ejaculate the same, there will simply be no sperm in his semen. His body will naturally absorb the sperm that does not pass through his vans deferens; it will not build up. Vasectomies require minimal recovery. Patients are advised to rest, and avoid sex and heavy lifting for one week. Vasectomies take 3 months/12 weeks to become effective. Condoms or other forms of birth control should be used during this time. Men must return to the doctor 12 weeks after surgery to test their semen. Once they are cleared sterile by a doctor, they will have permanent contraception. Vasectomies are highly effective, over 99%. The most common reason why vasectomies fail is couples have unprotected sex before the man is cleared sterile. Vasectomies are a great way for the male partner to contribute to family planning, are inexpensive, have low recovery time, less risk, and allow for permanent worry free intimacy. Only use sterilization if you are absolutely sure you are done having children/do not want children, or if pregnancy poses a serious health/life risk.
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