Questions and Answers

Q: Which birth control method is the most effective?

Heather Reynolds, CNM, MSN

A: That's a great question. Before I give you statistics, though, let me stress that any birth control method is only as good as the person using it. So, for instance, don't expect your birth control pill to prevent pregnancy as well as it does in studies if you don't take it as directed. And don't expect a condom to work up to 90 percent of the time (as studies show) if your partner doesn't put it on properly or use them every time you have intercourse—or come close to having intercourse.

The most effective forms of birth control are abstinence—not having sex—or sterilization. There are three forms of sterilization: vasectomy for men, in which the tubes through which sperm move into the penis are blocked or cut; tubal ligation for women, in which the fallopian tubes are blocked, burned or clipped shut; and Essure procedure for women, in which micro-inserts are placed into the fallopian tubes where they form a tissue barrier that prevents sperm from reaching the egg. Each is considered nearly 100 percent effective, and each is permanent.

The intrauterine device ParaGard also prevents pregnancy more than 99 percent of the time, and it can remain in place for up to 10 years. Another intrauterine device called Mirena has a similar efficacy rate, but it also releases the hormone progestin into your body. It may remain in place for up to five years. Another option in the 99-percent-or-more-effective category is Implanon, a tiny rod that is inserted into your arm where it releases a continuous amount of progestin to prevent pregnancy. It can remain in place up to three years.

Other hormone-related options, including birth control pills, the OrthoEvra patch, the NuvaRing vaginal ring and progestin injections like Depo-Provera, are considered "very effective," meaning they prevent pregnancy 91 to 99 percent of the time. Depo-Provera works for three months; the others for one month.

These invasive options are followed by more moderately effective options, which typically prevent pregnancy 81 to 90 percent of the time. They include male and female condoms, the Today Sponge and a diaphragm.

The least effective category of birth control options, which typically prevent pregnancy up to 80 percent of the time, includes natural family planning, which you may know as the "rhythm method," the cervical cap (FemCap or Lea's Shield), and spermicide foams, creams, jellies, films and suppositories.

What's right for you depends on your age and health, the type of relationship you're in and your current concerns about pregnancy. I urge you to have a discussion with your health care professional about these issues and your various options before making any decision.
Posted 3/12/2008

References:
Which contraceptive is right for you? Association of Reproductive Health Professionals. 2007.

Steven R. Goldstein, MD

Q: I had my tubes "tied" several years ago. Now I'm interested in having another child and was wondering if the procedure could be reversed.

A: The simple answer is yes, the procedure can be reversed, often through a laparoscopic procedure that doesn't require an abdominal incision. But before you pick up the phone to make an appointment with your doctor, you need to understand that the tubal ligation procedure you had is intended to be a permanent form of sterilization. The phrase "getting your tubes tied" is often used but it's misleading because the fallopian tubes are not actually tied. Instead, they are blocked with a ring or burned or clipped shut. They cannot simply be "untied." Surgery to reverse the procedure, while possible, carries risk, significant costs, and is not always successful. Another option to surgery, in-vitro fertilization (IVF), while less invasive, also carries significant costs and a similar rate of success.

If you choose surgery to reverse the tubal ligation, you will require general anesthesia, which also carries some risks. Then the surgeon typically uses microsurgical techniques to reopen the tubes. With IVF, you are given medication to spur your ovaries to make more than one egg and then the eggs are removed and fertilized with your partner's sperm in the laboratory. The resulting embryos (usually two or three) are placed in your uterus. This avoids the fallopian tubes and is often used for women whose tubes are blocked by infection and can't be opened. In fact, IVF was invented just for this purpose.

Neither option is likely to be covered by your health insurance. Costs vary, but tubal reversal costs between $10,000 and $15,000, about the same as a single cycle of IVF. However, you may need more than one IVF cycle to become pregnant, which could significantly increase the cost. Overall pregnancy rates for tubal ligation range between 55 and 85 percent, usually higher when the procedure is performed through an abdominal incision. Most women become pregnant within a year of the procedure.

One of the few studies (if not the only) to compare pregnancy rates between the two found that surgical reversal seemed to be the best option based on cost and pregnancy rate for women under 37, and IVF seemed slightly better for older women. In this group of women, delivery rates were similar: 52 percent in the IVF group and 59.5 percent in the tubal reversal group. Overall, the average cost per delivery was $17,167 for IVF and $7,263 for tubal ligation. This study, however, was conducted in Belgium, so the costs may differ in the United States.

Risks of the procedures include a relatively high rate of ectopic, or tubal, pregnancy in women undergoing tubal reversal and high risk of multiple births with IVF. In the study described above, five women (12 percent of the 79 patients) had twins. Also, the women underwent an average of two IVF cycles, which is likely behind the higher cost.

The decision about which procedure to have will depend on the type of tubal ligation you had and if it can be reversed (sometimes it can't); where you live (do you live near an IVF center?); and your own personal preferences. Good luck to you!
Posted 1/15/2008

References:
Sacks G, Trew G. Reconstruction, destruction and IVF: dilemmas in the art of tubal surgery. BJOG. 2004 Nov;111(11):1174-81. Review.
Boeckxstaens A, Devroey P, Collins J, Tournaye H. Getting pregnant after tubal sterilization: surgical reversal or IVF? Hum Reprod. 2007 Oct;22(10):2660-4.

Steven R. Goldstein, MD

Q: I was wondering if you can get pregnant while on birth control. I have been taking the pill for five days. And I was wondering if the male has to ejaculate inside you every time you have intercourse to become pregnant?

A: Wow, you certainly ask some important questions! Let's start with your question about oral contraception, or the birth control pill. Studies find that, used as recommended, oral contraception is 91 percent to 99 percent effective in preventing pregnancy. However, that still means there is a very small risk of pregnancy. In most instances, however, women who become pregnant while taking oral contraceptives either miss one or more doses; take a dose at a time different from their normal time (i.e., in the evening instead of the morning); take medications (such as antibiotics) that interfere with the way birth control pills work in your body; or have unprotected intercourse too soon after starting the pills.

This last reason answers your other question: If you begin taking birth control pills within six days of the first day of your period, it's effective immediately. If you start at any other time, however, you need to take it for a full month before it's effective, and you must use another form of birth control until you've completed one full cycle of pills.

You also ask about ejaculation and pregnancy. While ejaculation during intercourse is, obviously, the most common reason for pregnancy, you can get pregnant even if your partner ejaculates outside your vagina but close to the vaginal entry or withdraws his penis just before ejaculation. That's because sperm, by their very nature, are pretty hardy swimmers. And if you're ovulating and the sperm manage to make it from the vaginal entrance to your fallopian tubes, a pregnancy could certainly occur. Also, even though a man hasn't ejaculated during intercourse, some semen may still escape from his penis during intercourse. Keep in mind that it only takes one sperm and one egg—and one episode of sexual activity—to get pregnant.

If you absolutely do not want to get pregnant, yet you still plan to be sexually active, your partner should use a condom in addition to your chosen method of contraception. While no method of contraception other than sterilization is 100 percent effective against pregnancy, the more precautions you take, the less likely you are to get pregnant. Plus, if you are not in a long-term, monogamous relationship, your partner should be using a condom anyway to protect you both against sexually transmitted diseases.
Posted 10/17/2007

Susan A. Ballagh, MD

Q: I'm a first-time birth control pill user. I was told the best way to begin taking them was to wait until my next period begins. However, while my last period arrived at the time it should, two days after it stopped I began spotting on and off. This has continued for a week and is now getting a bit heavier. My question is, should I wait to see if this stops and begin the pills when my next cycle starts, or can I begin them now?

A: Before we get into the issue you ask about, I want to address your prolonged, heavy bleeding. Menstrual bleeding rarely continues beyond seven days, with the amount of bleeding diminishing throughout that time. I strongly recommend you contact your health care provider for a complete examination.

Now, as for your question about when to start taking oral contraceptives, there's really no hard-and-fast rule about when to start taking birth control pills. Starting in the first few days of your cycle is the surest way to prevent inadvertently taking pills while you are pregnant. If there is any chance you might be pregnant (you feel fatigue, you had to take emergency contraception last cycle, etc.), you can always check a home pregnancy test. Alternatively, you can start on the Sunday after your period starts which provides a point-in-time for when a new pill pack should begin, and, unless you're taking continuous oral contraceptives, ensures that you don't have a period on the weekend (always a nice benefit!). Some providers even suggest that you start pills as soon as you get them, provided you are reasonably sure that you are not likely to get pregnant this current cycle.

However, we still recommend you use a backup form of birth control during the first month of oral contraceptive use just to be on the safe side. This could be a condom, diaphragm, the Today sponge, etc.

What's most important about oral contraceptive timing is that you take your pill at the same time every day. This helps you remember to take it (i.e., you always take your pill after you brush your teeth) and helps maintain steady hormone levels. It is also important that you don't miss a day. If you do miss a day, take two pills the following day. If you miss two pills, take two pills a day for two days. But if you miss more than that, you should use an alternative form of birth control until you start another pill pack. You should also check with your health care professional as to whether you should continue the current pack or just start over again once your period begins.
Posted 7/3/2007

Heather Reynolds, CNM, MSN

A: Absolutely not. And the beautiful thing is, you have so many other options. The most common option for women at your age is permanent birth control or sterilization. You have three possibilities:

• Essure permanent birth control procedure, the newest form of permanent contraception. This is a non-surgical procedure that can be performed in your doctor's office with a local anesthetic. The doctor uses a special instrument called a hysteroscope to place specially designed spring-like coils or micro-inserts through your vagina and cervix into the opening of your fallopian tube in your uterus. Within three months, the micro-inserts cause your body to form a tissue barrier that prevents sperm from reaching the egg. During this three-month period, you need to use another form of birth control. After three months, the doctor performs a special x-ray to make sure your tubes are completely blocked. Essure may reduce the risk of tubal (ectopic) pregnancy compared to tubal ligation. Mild pain may occur immediately after insertion. Typically, women are able to return to their normal activities within a day or two.
• Vasectomy, in which your partner's vas deferens, the tube through which sperm travels from the testicle to the penis, is tied or cut.
• Tubal ligation, in which your fallopian tubes are blocked with a ring or burned or clipped shut. This procedure is typically performed under general anesthesia in a hospital. Risks include pain, bleeding, infection and other postsurgical complications, as well as an ectopic, or tubal, pregnancy.

All forms of sterilization carry a failure rate of less than one pregnancy per hundred women (less than one percent).

Another good option is Implanon, a matchstick-sized rod that contains a progestin called etonogestrel. It is implanted in your upper arm and provides protection for up to three years. Common side effects include abnormal bleeding, headache and depression, and it isn't recommended for women with a history of breast cancer. This birth control method is 99 percent or more effective when consistently and correctly used as directed.

The IUD, either with or without hormones, is another long-term, but not permanent, contraceptive option. One type of IUD continuously releases progestin called levonorgestrel and can remain in place five years or longer. One advantage for perimenopausal women is that it significantly reduces bleeding from your period or stops bleeding altogether. The only major side effect is some irregular bleeding. A copper IUD may also be an option. Depending on the type of device, the copper IUD can be left in place for up to 10 years. But, if you have heavy or painful periods, the copper IUD isn't for you. IUDs are more than 99 percent effective at preventing pregnancy.

The vaginal contraceptive ring, called NuvaRing, is another hormonal-based birth control option that you might not have heard of but might work for you. You insert NuvaRing into your vagina like a tampon, where it releases a steady amount of estrogen and progestin throughout the month. You wear it for three weeks, then take it out for a week and have your period. Then you insert a new ring. Side effects include hormone effects similar to those from the pill and a mild increase of vaginal discharge. As with oral contraceptives, NuvaRing may increase the risk of blood clots and stroke, primarily in women who smoke. NuvaRing is 91 to 99 percent effective when used consistently and correctly as directed.

Of course, you can choose barrier methods, such as a diaphragm, cervical cap or condom. The benefit of these options is that you only use them when you're having intercourse, so they don't have any effect on your body at other times. Barrier methods are between 81-90 percent effective; using spermicidal jelly or cream with these methods increases their effectiveness.

As you can see, you have a variety of options available to you in this time of your life. I suggest you make an appointment with your health care professional to discuss which one is right for you.
Posted 5/7/2007

This content was developed with the support of an educational grant from Conceptus, Inc.