Medicine for Africa - Medical Information Service

ONTRACEPTION

Definition:

Contraception means the active involvement in preventing a pregnancy – by way of establishing a (physical or chemical) barrier between the male’s sperm and the female’s ovum (egg).  Contraception is not the unique responsibility of the woman in a partnership to prevent an unwanted pregnancy – it is equally the responsibility and possibility of the male partner to assure that an unwanted pregnancy will not or cannot occur due to his consideration for his partner and their relationship, and due to the preventive methods that he is adopting or making sure that his female partner is adhering to.

          Contraceptive methods

Abstinence – the favored method preached by the Christian church and other religions. Abstinence is obviously the most reliable method of any, provided that abstinence is adhered to in a proper and complete manner.  Considering today’s society and many pressures that are put on young adults by their own peers and public communication (be it TV or societal ‘acceptance’ rules), it is difficult to believe that abstinence can indeed serve as a reliable contraceptive method until the time of marriage – for either partner.

The ‘menstrual cycle method’ also called the ‘rhythm method’ – the date that a woman’s ovum will be released is very specific – usually it is about the 14th day of a regular menstrual cycle (± 2 days).  Thus, considering that the male’s sperm can survive up to three days within the woman’s uterus/fallopian tubes, it can be said that sexual intercourse is safe between day one and day eight (8) of a woman’s regular menstrual cycle (it has to be stressed that an irregular cycle or unusual events such as sudden stress – physical as well as sometimes mental – can interfere with this ‘schedule’ and thus make this ‘timing method’ unreliable!).  This method is often also referred to as ‘Vatican Roulette’, as it is rather difficult and often impossible to be sure that ‘today’ is a ‘safe’ day.  Furthermore, this method does not prevent the transmission of sexually transmitted diseases, STDs.

The so-called ‘Coitus interruptus’ – when the man tries to withdraw his penis from the woman’s vagina prior to his ejaculation – is one of the least reliable ways of contraceptive methods!!  It is not only unsafe to expect that the man can indeed withdraw within time, but often, the man releases a lubricating fluid, the so-called ‘love-drop’ well prior to ejaculation, and this drop can already contain sperms, thus impregnating the woman well ahead of either lover being even aware of the fact.  And again, this method does not prevent the possibility of transmitting any STDs.

Avoiding vaginal intercourse – sexual intercourse without the insertion of the penis into the woman’s vagina – such as oral sex, anal sex, manual sex or ‘non-penetrating sex’ (so-called ‘outersex’) cannot result in pregnancy, although sexually transmitted diseases, such as HIV/AIDS can still be transmitted.

Mechanical barriers – are intended to prevent the male sperm from physically reaching the woman’s ovum.  This can be achieved by a number of ways – the most common and the most reliable way of protection in this section, as well as the best known is, of course, the male condom!  In addition, today, there is also the female condom, giving the woman a strong position in taking her future into her own hands. 

                            Rolled-up male condom                                                   Female condom

In addition, there is the female diaphragm (often enhanced with a spermicidal gel or cream), or the smaller version of it, the so-called ‘cervical cap’, or the so-called ‘sponge’ (containing spermicidal cream).  Mechanical barriers can be very effective and approach a nearly 100% prevention of unwanted pregnancies – provided that they are engaged in a timely fashion (prior to any sexual intercourse) and used properly.  Since there are a number of ‘unreliable’ factors that can interfere in their effectiveness in an unforeseeable or often unpredictable manner, they do have only a limited overall range of safety for preventing an unwanted pregnancy in a reliable manner.  Furthermore, only condoms, both male and female condoms, also provide the inherent safety of having the highest possible chance of preventing sexually transmitted diseases – from a simple infection with trichomonas vaginalis to a fatal infection with the human immunodeficiency virus, HIV.

Intra-uterine devices – IUDs – are either the T-shaped (see picture) or the 7-shaped copper or plastic intrauterine devices, which may or may not have hormones adhered to them. They basically function in such a way that they interfere with the implantation of a fertilized egg (ovum) within the lining tissue (endometrium) of the uterus, and thus cause a ‘natural’ abortion. The plastic IUDs often contain hormones attached to them, while the copper IUDs create a persistent subliminal state of ‘inflammation’ within the uterus and its endometrium, and thus prevent the required build of the uterine lining tissue (the endometrium) which is necessary for the implantation of the fertilized ovum. Their effectiveness is between 99.4% and 99.9%, even exceeding the reliability of condoms.  The latest ‘intra-vaginal’ device consists of a ‘vaginal ring’ that can be put in place and left for up to three weeks, releasing small amounts of hormones (estrogen and progesterone) during this period and thus preventing a potential pregnancy.  Again, the transmission of sexually transmitted diseases is not prevented when the woman is using any of these IUDs. 

Chemical barriers – such as the contraceptive pill (estrogen and/or progestin), contraceptive ring or patch (combined estrogen/progestin), or contraceptive injection (progestin only – good for up to three months), all have in common to prevent the harboring of a potentially fertilized egg within the endometrium by interfering with the woman’s hormone status.  There are also implantable devices (so-called ‘single rod implants’) that can be implanted within the skin of a woman’s arm, and then release small amounts of progestin hormones for up to three years, preventing a pregnancy during this period in a safe and uncomplicated manner – provided that the woman can handle the ‘onslaught’ of hormones and their potential side effects. Any of these contraceptive drugs/devices interfere with the normal hormonal cycle of the woman, which will prevent the release of an ovum from the ovary and/or the fertilization and implantation of the fertilized egg within the uterus.  A variant of these above mentioned drugs is the so-called ‘day-after pill’ or ‘emergency contraceptive pill’, which consists of a large amount of the hormone progesterone, and is intended to interrupt the normal physiological process in cases of unwanted or unexpected sexual intercourse without pre-existing  contraceptive methods in place (such as in a case of rape).

Contraceptive pills usually differ by the amount of estrogen, and the amount and type of progestin that is administered.  So-called monophasic pills distribute the same amount of hormones in each tablet, while so-called multiphasic tablets administer varying doses of estrogen and progesterone throughout the cycle.  Although these drugs can be very effective in preventing a pregnancy, once again, they do not prevent the possibility of the woman becoming infected with any of the many STDs.

In addition, there is the spermicidal cream, another method that not only physically prevents the male sperm from entering the female cervico-uterine tract and fallopian tubes to reach the ovum, it also kills or incapacitates chemically the male sperms sufficiently to prevent a pregnancy.  Recent research is working on a spermicidal gel that also contains a microbicidal component against the human immunodeficiency virus, HIV. However, even if this gel should become reality, it would still leave the woman susceptible to the infection by other sexually transmitted diseases.

One of the latest developments consists of a so-called ‘vaginal ring’ – a flexible ring that is inserted into the vagina and releases either progestogen hormones only, or a combination of estrogen and progesterone. The former ring is especially useful for breastfeeding women and can remain in place for up to four months, while the latter type of vaginal ring can remain inserted and effective for over 12 months.

The pill for the man – is still in research.  While there are very promising results reported for a male contraceptive pill, which will lower the male’s sperm count, there are no sufficiently reliable products available on the market today, or within a foreseeable future to enter the market.

Vaccinations – for both men and women are still not on the market although they do exist. The male vaccination works in an immuno-contraceptive manner by ‘hijacking’ the sperm production via an immune response to the hormone FSH (follicle stimulating hormone), which is also vital for the production of male sperms.  A female vaccine that is directed against the immune system response of HCG (human chorionic gonadotrophin) has been under development for many years, yet without a decisive or effective result to-date.

Overall, it has to be stressed that no contraceptive method, no matter which one, is effective, if not used consistently and correctly.  Even a condom is useless if engaged too late, not appropriately, or not at all…

Lactational contraception – refers to the period immediately following the birth of a baby, which may extend up to several weeks until the woman’s hormonal status develops back to ‘pre-pregnancy’ levels. This in combination with the lactation period can provide some kind of protective effect against a new pregnancy. However, since this is a physiological response to the recent birth of a baby, this method is neither a reliable nor a predictable way of conducting successful contraception.   

          Historic review

Contraceptive methods have been around for as long as mankind has been trying to prevent an untimely pregnancy for whatever reason, including the fact that many men were eager to ‘strive away from home’ without having to bear the consequences.

Thus, contraceptive methods over the centuries included devices such as:

Women using a kind of pessary (a vaginal suppository) consisting of various acidic substances, intended to kill the male sperm – with more or less success.

While Asian women have used oiled paper as a kind of cervical cap, women in Europe used beeswax for the same purpose. 

The first latex condoms were often ‘washed’ and reused during their early years, mainly due to their expense and the unawareness of their proper usage and effectiveness.

‘Pre-latex’ types of ‘condoms’ consisted of everyday devices such as for example male socks with a rather unreliable success rate.

Various so-called abortifacients – drugs or herbs which the woman used intravaginally or ingested, in order to induce an abortion after the fact, have been around throughout human history.  Often, these ‘drugs’ included poisons, such as mercury or arsenic, which killed off more than just the offspring.  Herbal solutions such as tansy or pennyroyal have equally poisoned women by way of well-known folklore, damaging the woman’s kidneys, liver or other organs considerably.       

On the other hand, recent research has even confirmed the (limited) effectiveness of some of the old-style contraceptive methods.  These include the usage of papaya seeds as a male contraceptive, which has recently been studied for its azoospermic (void of sperms) effect in monkeys.  Another herbal product, hibiscus rosa-sinensis, better known as Ayurveda, is investigated as a contraceptive with antiestrogenic properties.

Side Effects:

Adverse side effects can often occur with the ingestion or application of excessive hormones – be it estrogens or progesterones or a combination of both.  These unwanted effects may include:

• Water retention with subsequent swelling of the legs;
• Headaches, migraines and vision problems;
• Mood swings;
• An increased potential of developing a blood clot (thrombus) due to interference with the body’s own blood clotting system – in rare instances, this can result in strokes and heart attacks;
• And more.

Smoking cannot only foster the development of the above side effects, it can also enhance the seriousness and extent of those side effects.

Not every woman who is taking contraceptive pills or other hormone containing contraceptive devices will experience any one or more of these symptoms, thus it is up to the woman and her personal physician to find and decide which will be the best contraceptive hormone method for her individual case.

Condoms usually have no side effects, unless the woman (or man) has a rare allergy against latex-containing products.  Then, an allergic reaction can occur from usually just local reddening and itching to general allergic symptoms including extravasation of fluids, swelling of mucous membranes, asthma and even death, if untreated.

Spermicidal creams can, in rare cases, also cause allergic reactions as described above, or if the cream or gel enters the woman’s bloodstream via small cracks or injuries, it can at times result in the often fatal, so-called disseminated intravascular coagulation (DIC), also called consumptive coagulopathy.  In DIC, the blood clotting system becomes severely disturbed, resulting in the uncontrolled development of small blood clots (thrombi) throughout the vascular system of the body, with subsequent development of equally uncontrollable bleeding into the skin due to the lack of blood clotting substances.

Abortion:

Abortion is the prevention of the development of a fertilized ovum into a fetus and subsequently, a human being. Thus, abortion is the last chance after the fact (after unprotected or unsuccessfully protected intercourse) to prevent the development of a potential new life. While the interpretation of when a human life begins, varies greatly from religious, scientific, medical and personal points of view, the final decision on whether to have an (early) abortion or not, should ultimately be in the hands of the woman who is bearing the unborn life.

One major consideration for having an abortion could also be the general or specific health care status or physical limitations of the mother, which could endanger the mother’s life to an unacceptable extent versus risking the completion of the pregnancy.
 
And finally, if genetic predisposition and/or early genetic tests of the offspring’s DNA reveal that the baby would be physically and/or mentally more or less severely impeded or retarded, a timely abortion often appears to be an acceptable response.

          Induced Abortion

Abortion can be performed surgically by using a suction-aspiration method (within the first trimester) – the so-called ‘dilatation and curettage’ (D&C).  In this procedure, the cervical canal is dilated and the contents of the uterine cavity, i.e. the implanted egg, will be sucked away together with the endometrial tissue that grew in size, in order to allow the embedding of the fertilized ovum.  The same kind of procedure, also called ‘dilation and evacuation’ can even be performed during the second trimester of pregnancy.  However, in most developed countries, including the USA, medically induced abortion is only approved up to the eighth week of pregnancy (within the first trimester).

Some herbs are said to be able to induce an abortion, such as an excessive intake of parsley and other herbal plants or concoctions, although most of these methods are void of reliability or effectiveness, and often harbor serious side effects, including death.

          Accidental / Spontaneous Abortion

Accidental or spontaneous abortion can result from a variety of reasons. The woman’s body may not be ready yet to complete the entire pregnancy, which is often the case if the woman is still a girl, too young and physically too immature for a pregnancy.

Other physical conditions that could lead to an early unintended abortion include:

• A cervical canal that is not sufficiently tight can expand and open up during the course of a pregnancy due to the growth of the fetus which causes an expansion of the uterine cavity and subsequent expansion of the cervical canal. This can result in a sudden and unexpected expulsion of the fetus and a spontaneous abortion; 

• An unphysiologically positioned uterus, such as a so-called ‘retroflexed uterus’, is able to harbor the fertilized ovum, but often not able to adjust to the demands that a growing fetus put on the uterus during the pregnancy;

• Other uterine abnormalities, such as the rare, so-called ‘bicornuate uterus’ with two uterine cavities;

• Sudden hormonal changes, especially early in pregnancy, due to extreme physical or even mental stress, or other medications that may interfere with the normal hormonal status of the woman;

• Malnutrition or some chronic diseases can put such a burden on the mother’s physiology that her body cannot sustain the growing demands of a new growing life within her, resulting in a spontaneous abortion, usually during the first or second trimester.

Sterilization:

There are surgical sterilization procedures available for both men and women.

For men, there is the vasectomy, a rather simple procedure. The vessels (vasa deferentia) that provide the fertile sperms from the epididymis to the ejaculatory duct within the testicles are cut with a scalpel or severed by heat, thus preventing the sperms that are produced by the epididymis to join the seminal fluid which is produced within the seminal vesicles next to the prostate, and makes up the major part of the ejaculate.  This procedure is permanent, rendering the man incapable of impregnating another woman throughout his life.

The surgical procedure for rendering women sterile consists of a so-called tubal ligation – in which both fallopian tubes are severed, thus interrupting the passageway for the sperms to reach and fertilize an ovarian egg (ovum), and equally, to prevent an ovum from reaching the uterine cavity (endometrium).  While this procedure is generally considered permanent, there have been rare instances in which a surgical ‘re-alignment’ of the fallopian tube tissue has indeed resulted in a subsequent (desired) pregnancy.  However, in general, both procedures should be considered final without the future chance of impregnating a woman, or the woman becoming ever pregnant again.

Common Misconceptions:

Common misconceptions and so-called ‘urban legends’ on methods or procedures that are supposed to prevent a pregnancy after or prior to sexual intercourse include:

• Douching following intercourse – while it may seem reasonable to wash the ejaculate out of the vagina, following intercourse, by using any kind of soap or substance, it is highly unlikely to be effective.  For one, some of the semen may already have entered the cervical canal and be on its way towards the ovum up the fallopian tube, right after intercourse, and well prior to the time that the woman could perform a ‘douche’. Secondarily, a douche may in fact push the semen that is present deep within the vagina, towards the cervical canal and into the uterus, thus, promoting the chance of becoming pregnant rather than preventing it.

• A woman can become pregnant at any time following her menarche (the first time that a woman experiences her menstrual period), and sometimes even prior to its imminent occurrence.  Thus, it is a myth that a virgin cannot become pregnant during her first sexual encounter with a man.

• Various sexual positions do not have any influence on the potential possibility of a woman becoming pregnant or not.  There is no sexual position that could prevent the man’s semen from entering the woman’s cervical canal, the uterine cavity and the fallopian tube, and subsequently fertilize a woman’s ovum.

• Voiding (urinating) following sexual intercourse does not prevent pregnancy, as it has no direct effect on the semen that is present within the woman’s vagina.  However, urinating is often advised anyway in order to prevent the possible development of a urinary tract infection.

• Toothpaste is not an effective contraceptive!   

Effectiveness of Contraceptive Methods:

When comparing birth control methods it shows that:

• Surgical sterilization, after a period of adjustment, is obviously the most definite and safest method of preventing future pregnancies (but not the transmission of STDs);

• Contraceptive pills, implants and IUDs have a very low failure rate of less than one percent (< 1%), if used appropriately (which is not always easy to do).  Furthermore, vaginal rings, fertility awareness methods or the ‘lactational amenorrhea method’ (LAM), following the birth of a baby, have a failure rate of anywhere between less than 1% for vaginal rings and contraceptive pills, and even LAM within the first six months post partum, up to 25% failure rates for the fertility awareness method – but be aware that all these numbers are the best outcome numbers.

• Condoms and other cervical barrier methods, such as a diaphragm, have first year failure rates of 14% to 20%, respectively, but these low numbers reflect the often improper or sub-optimal usage of these methods.  Condoms, both male and female condoms, do have a successful pregnancy-prevention rate of close to 99% if used appropriately and at all times; furthermore, condoms are the most reliable way of additionally preventing the transmission of any sexually transmitted disease, including HIV.    

Prevention:

Prevention of an unwanted pregnancy and sexually transmitted diseases is best achieved by:

• Abstinence;

• Faithfulness to one partner;

• Latex male or female condoms at any time during sexual intercourse, including oral or anal sex.

          Community Education

Providing young teenagers, both male and female teenagers, with a thorough and comprehensive sexual education is one of the most important (and relatively cheapest) measurements to prevent unwanted pregnancies, especially in early adulthood, as well as the spread of sexually transmitted diseases. This approach is particularly valid in developing countries, provided that the sexual education courses also take into account the local ethnic mores and sexual behavior attitudes of both sexes.

          Contraception for HIV-positive women

HIV-positive women face a number of serious questions regarding their reproductive choices. Recent drug regimen have proven to be rather effective in preventing the transmission of the HI virus from the mother to her unborn child, if treatment is started early and continued without interruption.  However, the physical stress of a pregnancy can become overwhelming to the expecting mother and result in serious medical complications for the HIV-positive mother during her pregnancy, often with subsequent problems arising in the offspring’s general healthcare situation.  Once again, whether the woman lives in a developed or developing country – education as to the ways and possibilities that are available to the expecting mother prior to her making a decision of whether to become pregnant or not, is one of the most important – if not the most important method of preventing unwanted pregnancies and/or preventing uncontrollable diseases, such as HIV or other genetically based or transmitted diseases or syndromes.   

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