Test 2 - Chapter 5 - Contraception and Abortion

Coitus Interruptus

(withdrawal) involves the male partner withdrawing his penis from the woman's vagina before he ejaculates. Although coitus interruptus has been criticized as being an ineffective method of contraception, it is a good choice for couples who do not have another contraceptive available. Effectiveness is similar to barrier methods and depends on the man's ability to withdraw his penis before ejaculation. The percentage of women who experience an unintended pregnancy within the first year of typical use of withdrawal is about 27%. Coitus interruptus does not protect against STIs or human immunodeficiency virus (HIV) infection.

Female Sterilization - Tubal Occulusion

A laparoscopic approach or a minilaparotomy may be used for tubal ligation, tubal electrocoagulation, or the application of bands of clips. Electrocoagulation and ligation are considered to be permanent methods. Use of the bands of clips has the theoretic advantage of possible removal and return of tubal patency.

Care Management

A multidisciplinary approach to assist the woman in choosing an appropriate contraceptive method. Ideally the method should be safe, readily available, economical, acceptable, and simple to use. Contraceptive choice must meet personal, social, cultural, and interpersonal needs.

Intrauterine Devices (IUD)

An intrauterine device is a small T-shaped device with bendable arms for insertion through the cervix into the uterine cavity. Two strings hang from the base of the stem through the cervix and protrude into the vagina for the woman to feel for assurance that the device has not been dislodged. There are two FDA-approved IUDs. The Copper T380A IUD is made of radiopaque polyethylene and fine solid copper and is approved for 10 years of use. The copper primarily serves as a spermicide and inflames the endometrium, preventing fertilization. Sometimes women experience an increase in bleeding and cramping within the first year after insertion, but nonsteriodal antiinflammatory drugs (NSAIDS) can provide pain relief. The typical failure rate in the first year of use of copper IUD is 0.8%. The levonrgestrel intrauterine system (IUS) (Mirena) releases levonrgestrel from its vertical reservoir. Effective for up to 5 years, it impairs sperm motility, irritates the lining of the uterus, and has some anovulatory effects. Uterine cramping and uterine bleeding are usually decreased with this device, although irregular spotting is common in the first few months following insertion.

TwoDay Method of Family Planning

Based on monitoring and the recording of cervical secretions, an algorithm for identifying the fertile window has been developed by the Institute for Reproductive Health at Georgetown University. The TwoDay algorithm appears to be simpler to teach, learn, and use than other natural methods. Results suggest that the algorithm can be an effective alternative for low-literacy populations or for programs that find current NFP methods too time consuming or otherwise not feasible to incorporate within their services. Two questions are posed. Each day the woman is to ask herself - "Did I note secretions today?" and "Did I note secretions yesterday?" If the answer to either question is yes, she should avoid coitus or use a backup method of birth control. If the answer to both questions is no, her probability of getting pregnant is low. Further studies are needed to determine the efficacy of the TwoDay method in avoiding pregnancy and to assess its acceptability to users and providers.

Implantable Progestins

Contraceptive implants consist of one or more nonbiodegradable flexible tubes or rods that are inserted under the skin of a woman's arm. These implants contain a progestin hormone and are effective for contraception for at least 3 years. They must be removed at the end of the recommended time. The FDA has approved two devices for use in the United States, a two-rod subdermal levonorgestrel implant (Jadelle) and a single-rod etonogestrel implant. Jadelle is unavailable in the United States. Insertion and removal of the single-rod etongestrel capsule are minor surgical procedures involving a local anerthetic, a small incision, and no sutures. The capsule is placed subdermally in the inner aspect of the nondominant upper arm. The progestin prevents some, but not all, ovulatory cycles and thickens cervical mucus. Other advantages of the single-rod implant are that it provides long-term continuous contraception that is not related to frequency of coitus and is quickly reversible. The single-rod implant can be inserted immediately after the birth in breastfeeding women without affecting lactation. Irregular menstrual bleeding is the most common side effect. Less common side effects include headaches, nervousness, nausea, skin changes, and vertigo. The implant does not protect against STIs. As in other hormonal contraception methods, condoms should be used for protection against STIs.

Second-Trimester Abortion - Dilation and Evacuation

D&E can performed at any point up to 20 weeks of gestation, although it is more often performed between 13 and 16 weeks. The cervix requires more dilation because the products of conception are larger. Often laminaria are inserted several hours or several days before the procedure, or misoprostol can be applied to the cervix to soften the tissue. The procedure is similar to that of vaginal aspiration, except that a larger cannula is used and other instruments may be needed to remove the fetus and placenta. Nursing care includes monitoring vitals signs, providing emotional support, administering analgesics, and postoperative monitoring. Disadvantages of D&E include possible long-term harmful effects on the cervix.

Injectable Progestins

Depot medroxyprogesterone acetate (DMPA; Depo-Provera) is given subcutaneously or intramuscularly in the deltoid or gluteus maxmus muscle. It should be initiated during the first 5 days of the menstrual cycle and administered every 11 to 13 weeks. Advantages of DMPA include a contraceptive effectiveness comparable to that of combined oral contraceptives, long-lasting effects, requirement of injections only 4 times a year, and the unlikelihood of lactation being impaired. Side effects at the end of a year include decreased bone mineral density, weight gain, lipid changes, increased risk of venous thrombosis and thromboembolism, irregular vaginal spotting, decreased libido, and breast changes. other disadvantages include no protection against STIs (including HIV). Return to fertility may be delayed as long as up to 18 months after discontinuing DMPA, with the median time being 10 months. Typical failure rate is 3 % in the first year of use.

Emergency Contraception

EC offers protection against pregnancy after intercourse occurs in instances such as broken condoms, sexual assault, dislodged cervical cap, disruption of use of any other method, or any other case of unprotected intercourse. Methods that are available in the United States that could provide postcoital contraception include: Ella (Ulipristal): single 30-mg pill containing an antiprogestin Plan B One-Step: single progestin-only pill containing 1.5 mg levonorgestrel. Next Choice: two levonorgestrel 0,75-mg tablets taken orally 12 hours apart or both together.. Combined oral: estrogen-progestin contraceptive pills. Copper intrauterine device (IUD) insertion within 120 hours of intercourse Plan B One-Step and Next Choice are approved by the FDA for over-the-counter sale to women ages 17 and older with proof of age. Adolescents 16 years and under require a prescription. Ella is available only with a prescription. States vary in the ability of pharmacists to dispense EC, and some states have implemented refusal legislation. In general, for the most effectiveness, EC should be taken by a woman as soon as possible but within 72 hours of unprotected intercourse or a birth control mishap to prevent unintended pregnancy. Research has shown a moderate amount of effectiveness between 72 and 120 hours but no data are available for effectiveness after 120 hours. If taken before ovulation, EC prevents ovulation by inhibiting follicular development. If taken after ovulation occurs, there is little effect on ovarian hormone production of the endometrium. To minimize the side effect of nausea that occurs with high doses of estrogen and progestin, the woman can be advised to take an over-the-counter antiemetic 1 hour before each dose. Nausea is not as common with the plan B regimen. Women with contraindications for estrogen use should use progestin-only EC. No medical contraindications for EC exist, except pregnancy and undiagnosed abnormal vaginal bleeding. If thye woman does not begin menstruation within 21 days after taking the pills, she should be evaluated for pregnancy. EC is ineffective if the woman is pregnant since the pills do not disturb an implanted pregnancy. Risk of pregnancy is reduced by as much as 75% and 89% if the woman takes EC pills. IUDs containing copper provide another EC option. The IUD should be inserted within 8 days of unprotected intercourse. This method is suggested only for women who wish to have the benefit of long-term contraception. The risk of pregnancy is reduced by as much as 99% with emergency insertion of the copper-releasing IUD. Contraceptive counseling should be provided to all women requesting EC, including a discussion of modification of risky sexual behaviors to prevent STIs and unwanted pregnancy.

First-Trimester Abortion - Medical

Early abortion using medication rather than surgery has been popular in Canada and Europe for more than 15 years, but medical abortion is a relatively new procedure in the United States. Medical abortions are available for use in the United States for up to 9 weeks after the last menstrual period. Methotrexate, misoprostol, and mifepristone are the drugs used in the current regimens to induce early abortion. About 17% of all reported abortion procedures in 2008 were medical procedures. Methotrexate is a cytotoxic drug that causes early abortion by blocking folic acid in fetal cells so they cannot divide. Misoprostol (Cytotec) is a prostaglandin analog that acts directly on the cervix to soften and dilate and on the uterine muscle to stimulate contractions. Mifepristone, formerly known as RU 486, was approved by the FDA in 2000. It works by binding to progesterone receptors and blocking the action of progesterone, which is necessary for maintaining pregnancy.

Fertility Awareness Methods

Fertility awareness methods (FAMs) of contraception depend on identifying the beginning and end of the fertile period of the menstrual cycle. When women who want to use FAMs are educated about the menstrual cycle, three phases are identified: 1. Infertile phase: Before ovulation 2. Fertile phase: About 5 to 7 days around the middle of the cycle, including several days before and during ovulation. 3. Infertile phase: After ovulation Although ovulation can be unpredictable in many women, teaching the woman about how she can directly observe her fertility patterns is an empowering tool. In addition, knowledge about the signs and symptoms of ovulation can be very helpful when the couple desires pregnancy. There are nearly a dozen categories of FAMs. To prevent pregnancy each one uses a combination of charts, records, calculations, tools, observations, and either abstinence or barrier methods of birth control during the fertile period of the menstrual cycle. The charts and calculations associated with these methods can also be used to increase the likelihood of detecting the optimal timing of intercourse to achieve conception. Advantages of these methods include low-to-no cost, absence of chemicals and hormones, and lack of alteration in the menstrual flow pattern. Disadvantages of FAMs include adherence needed for strict record keeping, unintentional interference from external influences that may alter the woman's core body temperature and vaginal secretions, decreased effectiveness in women with irregular cycles (particularly adolescents who have not established regular patterns of ovulation), decreased spontaneity of coitus, and the necessity of attending possibly time-consuming training sessions by qualified instructors. The typical failure rate for most FAMs is 24% during the first year use. FAMs do not protect against STIs or HIV infection.

Breastfeeding: Lactational Amenorrhea Method

Lactational amenorrhea method (LAM) can be a highly effective, temporary method of birth control. LAM is more popular in underdeveloped countires and traditional societies in which breastfeeding is used to prolong birith intervals. The method has seen limited use in the United States because most American women do not establish breastfeeding patterns that provide maximum protection against pregnancy. When the infant suckles at the mother's breast, a surge of prolactin is released. Prolactin inhibits estrogen production and suppresses ovulation and the return of menses. LAM works best if the mother is exclusively breastfeeding, if she has not had a menstrual flow since birth, and if the infant is under 6 months of age. Effectiveness is enhanced by frequent feedings at intervals of less than 4 hours during the day and no more than 6 hours during the night, long duration of each feeding, and no bottle supplementation. The woman should be counseled that disruption of the breastfeeding pattern or formula supplementation can increase the risk of pregnancy. The typical failure rate is 2%.

First Trimester Abortion

Methods for performing early elective abortion (less than 9 weeks of gestation) include surgical (aspiration) and medical methods (mifepristone with prostaglandin and methotrexate with misoprostol). About 90% of abortions in the United States are performed during the first trimester, with more than 60% performed by 8 weeks after the last menstrual period. Aspiration (vacuum or suction curettage) is the most common procedure in the first trimester. Aspiration abortion is usually performed under local anesthesia in a physician's office, a clinic, or a hospital. The ideal time for performing this procedure is 8 to 12 weeks after the last menstrual period. The suction procedure for performing an early elective abortion usually requires less than 5 minutes. A bimanual examination is done before the procedure to assess uterine size and position. A speculum is inserted, and the cervix is anesthetized with a local anesthetic agent. The cervix is dilated if necessary, and a cannula connected to suction is inserted into the uterine cavity. The products of conception are evacuated from the uterus.

Methotrexate and Misoprostol

Methotrexate can be given intramuscularly or orally (usually mixed with orange juice). Vaginal placement of misoprostol follows in 3 to 7 days. Women commonly have nausea, vomiting, and cramping after the misoprostol insertion. The woman returns for a follow-up visit to confirm the abortion is complete. if abortion does not occur, misoprostol is repeated, or vacuum aspiration is performed to remove the products of conception.

Male Sterilization - Tubal Reconstruction

Microsurgery to reanastomose the sperm ducts can be accomplished successfully in more than 90% of cases; however, the fertility rate following reanastomosis is only about 50%. The rate of success decreases as the time since the procedure was initially performed increases. The vasectomy may result in permanent changes in the testes that leave men unable to father children. The changes are those ordinary seen in the eldery.

Mifepristone and Misoprostol

Mifepristone can be taken up to 7 weeks after the last menstrual period. The FDA-approved regimen is that the woman takes 600 mg of mifepristone orally; 48 hours later she returns to the office and takes 400 mcg of misoprostol orally (unless abortion has already occurred and been confirmed). Two weeks after the administration of mifepristone, the woman must return to the office for a clinical examination or ultrasound to confirm that the pregnancy has been terminated. In 1% to 5% of cases the drugs do not work, and surgical abortion (aspiration) is needed. With any medical abortion regimen, the woman usually experiences bleeding and cramping. Side effects of the medications include nausea, vomiting, diarrhea, headache, dizziness, fever, and chills. These are attributed to misoprostol and usually subside in a few hours after administration.

Natural Family Planning (Periodic Abstinence)

Natural Family Planning, or periodic abstinence, provides contraception by using methods that rely on avoiding intercourse during fertile days. NFP methods are the only methods of contraception acceptable to the Roman Catholic Church. Signs and symptoms of fertility awareness most commonly used with abstinence are menstrual bleeding, cervical mucus, and basal body temperature. Development and marketing of ovulation predictor kits have also been very helpful for couples who choose NFP. The human ovum can be fertilized no later than 16 to 24 hours after ovulation. Motile sperm have been recovered from the uterus and oviducts as long as 7 days after coitus. However, their ability to fertilize the ovum probably lasts no longer than 24 hours. Pregnancy is unlikely to occur if a couple abstains from intercourse for 4 days before and 3 or 4 days after ovulation (fertile period). Unprotected intercourse on the other days of the cycle (safe period) should not result in pregnancy. Nevertheless the exact time of ovulation cannot be predicted accurately, and couples may find it difficult to abstain from sexual intercourse for several days before and after ovulation. Women with irregular menstrual periods have the greatest risk of failure with this form of contraception.

Calendar Rhythm Method

Practice of the calendar rhythm method is based on the number of days in each cycle, counting from the first day of the menstrual cycle (first day of menstrual vaginal bleeding). The fertile period is determined after accurately recording the lengths of menstrual cycles for 6 months. The beginning of the fertile period is estimated by subtracted 18 days from the length of the shortest cycle. The end of the fertile period is determined by subtracting 11 days from the length of the longest cycle. If the shortest cycle is 24 days and the longest is 30 days, application of the formula to calculate the fertile period is as follows: Shortest cycle, 24-18=day 6 Longest cycle, 30-11= day 19 To avoid conception, the couple would abstain during the fertile period, days 6 through 19. If the woman has very regular cycles of 28 days each, the formula indicates the fertile days to be as follows: Shortest cycle, 28-19=day 10 Longest cycle, 38-11=day 17 To avoid conception the couple would abstain from days 10 through 17 because ovulation occurs on day 14 +/- 2 days. A major drawback of the calendar method is that the couple is attempting to predict future events with past data. The unpredictability of the menstrual cycle is also not taken into consideration. The calendar rhythm method is most useful as an adjunct to the basal body temperature or cervical mucus method.

Oral Progestins (MiniPill)

Profestin-only pills are less effective than COCs. Because minipills contain such a low dose of progestin, they must be taken at the same time every day. If the pill is taken more than 3 hours late (27 hours after the last pill), a backup contraceptive method must be initiated. Much of the contraceptive effectiveness of the minipill depends on progestin-induced changes in cervical mucus, and this effect lasts about 24 hours after oral ingestion of the pill. Users often often complain or irregular vaginal bleeding. The failure rate for typical users of the minipill is approximately 8% during the first year of use. Effectiveness is increased if minipills are taken correctly. There are two instances in which the minipill is quite effective: in lactating women and women over 40. The reduced fecundity of lactation and the perimenopause period enhance the contraceptive effects of the minipill.

Female Sterilization - Tubal Reconstruction

Restoration of tubal continuity and function is technically feasible except after laparoscopic tubal electrocoagulation. Sterilization reversal is costly, difficult (requires microsurgery), and uncertain. The success rate varies with the extent of tubal destruction and removal. The risk of ectopic pregnancy after tubal reanastomosis is increased by 2% to 12.5%.

Spermicides

Spermicides such as nonoxynol-9 (N-9) work by reducing the mobility of the sperm. The chemicals attack the sperm flagella and body, thereby preventing the sperm from reaching the cervical os. N-9, the most commonly used spermicidal chemical in the United States, is a surfactant that destroys the sperm cell membrane. Results from data analyses now suggest that frequent use of N-9 or the use of N-9 as a lubricant during anal intercourse may increase the transmission of HIV and can cause lesions. There is no evidence that the addition of spermicides to male condoms decreases the risk of subsequent pregnancy. Women with high risk behaviors that increase their likelihood of contracting HIV and other STIs are advised to avoid the use of spermicidal products contating N-9, including lubricated condoms, diaphragms, and cervical caps to which N-9 is added.

Cervical Cap

The FemCap is the only type of cervical cap available in the United States. It comes in three sizes and is made of silicone rubber. The cap fits snugly around the base of the cervix close to the junction of the cervix and vaginal fornices. It is recommended that the cap remain in place no less than 6 hours and no more than 48 hours at a time. It is left in place at least 6 hours after the last act of intercourse. The seal provides a physical barrier to sperm; spermicide inside the cap adds a chemical barrier. The extended period of wear may be an added convenience for women.

Basal Body Temperature Method

The basal body temperature method is the lowest body temperature of a healthy person, taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 to 36.3C during menses and for approximately 5 to 7 days afterward. About the time of ovulation a slight drop in temperature (approximately 0.5C) may occur in some women, but others may have no decrease at all. After ovulation, in concert with the increasing progesterone levels of the early luteal phase of the cycle, the BBT increases slightly. The temperature remains on an elevated plateau until 2 to 4 days before menstruation. Then BBT decreases to the low levels recorded during the previous cycle unless pregnancy has occurred. In pregnant women the temperature remains elevated. If ovulation fails to occur, the pattern of lower body temperature continues throughout the cycle.

Cervical Mucus Ovulation-Detection Method

The cervical mucus ovulation-detection method requires that the woman recognize and interpret the cyclic changes in the amount and consistency of cervical mucus that characterize her own unique pattern of changes at the time of ovulation. Cervical mucus changes before and during ovulation to facilitate and promote the viability and motility of sperm. Without adequate cervical mucus, coitus does not result in conception. This method requires that a woman check the quantity and character of mucus on the vulva or introitus with her fingers or tissue paper each day for several months. This way she can learn how her cervical mucus responds to ovulation during her menstrual cycles. To ensure an accurate assessment of changes, the cervical mucus should be free from semen, contraceptive gels or foams, and blood or discharge from vaginal infections for at least one full cycle. Other factors that create difficulty in identifying mucus changes include douches and vaginal deodorants, being in the sexually aroused state (which thins the mucus), and taking medications such as antihistamines (which dry mucus). Intercourse is considered safe without restriction beginning the fourth day after the last day of wet, clear, slippery mucus, which would indicate that ovulation has occurred 2 to 3 days previously.

Diaphragm

The contraceptive diaphragm is a shallow, dome-shaped, latex or silicone device with a felxible rim that covers the cervix. The diaphragm is a mechanical barrier to the meeting of sperm with the ovum. By holding spermicide in place against the cervix for the 6 hours it takes to destroy the sperm, the diaphragm also provides a chemical barrier to pregnancy. Diaphragms are available in a wide range of diameters and differ in the inner construction of the circular rim. The types of rims are coil spring, arcing spring, and wide-seal rim. The diaphragm should be the largest size the woman can wear without being aware of its presence. Typical failure rate is 12%.

Transdermal Contraceptive System

The contraceptive patch delivers continuous levels of progesterone and ethynyl estradiol. The patch can be applied to the lower abdomen, upper outer arm, buttock, or upper torso (except the breasts). Application is on the same day once a week for 3 weeks but not at the same time, followed by a week without the patch. Withdrawal bleeding occurs during the "no patch" week. Mechanisms of ation, contraindications, and side effects are similar to those of COCs. The typical failure rate during the first year of use is under 2% in women weighing less than 198 lbs.

Vaginal Sheath

The female condom is a vaginal sheath made of nitrile, a nonlatex, synthetic rubber and has flexible rings at both ends. The closed end of the pouch is inserted into the vagina and anchored around the cervix; the open ring covers the labia. A woman whose partner will not wear a male condom can use this device as protective mechanical barrier. Rewetting drops or oil - or water-based lubricants can be used to help decrease the distracting noise that is produced while penile thrusting occurs. The female condom is available in one size, is intended for single use only, and is sold over the counter. Male condoms should not be used concurrently because the friction from both sheaths can increase the likelihood of either or both tearing. Typical failure rate in the first year of female condom use is 21%.

Condoms

The male condom is a thin, stretchable sheath that covers the penis before genital, oral, or anal contact and is removed when the penis is withdrawn from the partner's orifice after ejaculation. Condoms are made of latex rubber, which provides a barrier to sperm and STIs; polyurethane; or natural membranes. in addition to providing a physical barrier for sperm, non-spermicidal latex condoms also provide a barrier for STIs and HIV transmission. Condoms lubricated with N-9 are not recommended for preventing STIs or HIV and do not increase protection against pregnancy. Latex condoms break down with oil-based lubricants and should be used only with water-based or silicone lubricants. Because of the growing number of people with latex allergies, condom manufacturers have begun using polyurethane, which is thinner and stronger than latex.

Oral Contraceptives

The normal menstrual cycle is maintained through hormonal feedback mechanisms. FSH and LH are secreted in response to fluctuating levels of ovarian estrogen and progesterone. Regular ingestion of combines oral contraceptive pills (COCs) suppresses the action of the hypothalamus and anterior pituitary, leading to insufficient secretion of FSH and LH; therefore follicles do not mature, and ovulation is inhibited. Other contraceptive effects are induced by the combined steroids. Maturation of the endometrium is altered, making the uterine lining a less favorable site for implantation. COCs also have a direct effect on the endometrium; thus from 1 to 4 days after the last COC is taken the endometrium sloughs and bleeds as a result of hormone withdrawal. The withdrawal bleeding is usually less profuse than that of normal menstruation and may last only 2 to 3 days. Some women have no bleeding at all. The cervical mucus remains thick from the effect of the progestin. Cervical mucus under the effect of progesterone does not provide as suitable an environment for sperm penetration as does the thin, watery mucus that the healthy reproductive woman produces before and during ovulation. Monophasic pills provide fixed dosages of estrogen and progestin. They alter the amount of progestin and sometimes estrogen within each cycle. These preparations reduce the total dosage of hormones in a single cycle without sacrificing contraceptive efficacy. To maintain adequate hormone levels for contraception and enhance compliance, COCs should be taken at the same time each day. Taken exactly s directed, COCs prevent ovulation, and pregnancy cannot occur. The overall theoretic effectiveness rate of COCs is almost 100%. Because taking the pill does not relate directly to the sexual act, COC acceptability may be increased. Improvement in sexual response may occur once the possibility of pregnancy is not an issue. For many women it is convenient to know when to expect the next menstrual flow. Contraindications for COC use include a history of thromboembolic disorders, cerebrovascular or coronary artery disease, breast cancer, estrogen-dependent tumors, pregnancy, impaired liver function, liver tumor, lactation less than 6 weeks pospartum, smoking if older than 35 years of age, migraine with aura, surgery with prolonged immobilization or any surgery on the legs, hypertension, and diabetes mellitus with vascular disease. The effectiveness of oral contraceptives is decreased when the following medications are taken simultaneously: Anticonvulsants such as barbiturates, oxcarbazepine, phenytoin, phenobarbital, carbamazepine, primidone, and topiramate. Systemic antifungals such as rifampican and rifabutin. Anti-HIV protease inhibitors such as nelfinavir and amprenavir. Nursing Considerations: Many different preparations of oral hormonal contraceptives are available. Because of these wide variations in pills, each woman must be clear about the unique dosage regimen for the preparation prescribed for her and follow directions on the package insert.

Standard Days Method

The standard days method is essentially a modified form of the calendar rhythm method that has a fixed number of days of fertility for each cycle. A CycleBeads necklace can be purchased as a concrete tool to track fertility or as a smart phone application. Day 1 of the menstrual flow is counted as the first day to begin counting. Women who use this device are taught to avoid unprotected intercourse on days 8 to 19. Although this method is useful to women whose cycles are 26 to 32 days long, it is unreliable for those who have longer or shorter cycles.

Symptothermal Method

The symptothermal method combines the BBT and cervical mucus methods with awareness of secondary phase-related symptoms of menstrual cycle. The woman gains fertility awareness as she learns the psychologic and physiologic symptoms that mark the phases of her cycle. Secondary symptoms include increased libido, midcycle spotting, mittelschmerz (cramplike pain before ovulation_, pelvic fullness or tenderness, and vulvar fullness. The woman is taught to palpate her cervix to assess for changes indicating ovulation: the cervical os dilates slightly, the cervix softens and rises in the vagina, and cervical mucus is copious and slippery. The woman notes days on which coitus, changes in routine, illness, and other changes that might affect BBT have occurred. Calendar calculations and cervical mucus changes used to estimate the onset of the fertile period; changes in cervical mucus or the BBT are used to estimate the end of the fertile period.

Vaginal Contraceptive Ring

The vaginal ring delivers continous levels of progresterone and ethynyl estradiol. Mechanisms of action, contraindications, and side effects are similar to those of COCs. One vaginal ring is worn for 3 weeks, followed by a week without the ring. Withdrawal bleeding occurs during the "no ring" week. The ring can be inserted by the woman and does not have to be fitted. Some wearers may experience vaginal discomfort, usually related to increased vaginal discharge; but other wearers report that the ring alleviates symptoms of vaginitis. Some couples say that the ring can felt during intercourse. Although it is not recommended that the ring be removed for intercourse, contraceptive effectiveness would not decrease it it were replaced within 3 hours. The typical failure rate of is under 2% during the first year of use.

Contraceptive Sponge

The vaginal sponge is a small, round, polyurethane sponge that contains N-9 spermicide. it is designed to fit over the cervix. The side that is placed next to the cervix is concave for better fit. The opposite side has a woven polyester loop to be used for removal of the sponge. The sponge must be moistened with water before it is inserted into the vagina to cover the cervix. it provides protection for up to 24 hours and for repeated instances of sexual intercourse. It should be left in place for at least 6 hours after the last act of intercourse. Wearing it longer than 24 to 30 hours may put the woman at risk for TSS. Typical failure rate of the vaginal sponge is greater than that of the diaphragm.

Male Sterilization - Vasectomy

Vasectomy is the sealing, tying, or cutting of a man's vas deferens so the sperm cannot travel from the testes to the penis. Vasectomy is the easiest and most commonly used operation for male sterlization. The surgery can be performed with local anesthesia on an outpatient basis. Pain, bleeding, infection, and other postsurgical complications are considered to be possible disadvantages to the surgical procedure. Two methods are used for scrotal entry: conventional and no-scalpel vasectomy. The surgeon identifies and immobilizes the as deferens through the scrotum. Then the vas is ligated or cauterized. Surgeons vary in their techniques to occulude the vas deferens: ligation with sutures, division, cautery, application of clips, excision of a segment of the vas, fascial interpostion, or some combination of these methods. Vasectomy has no effect on potency or volume of ejaculate. Endocrine production of testosterone continues so secondary sex characteristics are not affected. Sperm production continues, but sperm are unable to leave the epidiymis and are lysed by the immune system. Vasectomy does not change the man's transmission of the HIV virus if he is infected. he will need to be instructed to engage in a number of ejaculations until there are no viable sperm remaining above the area of the surgery. Until this occurs, as documented by semen analysis, the couple should use back-up contraception. Complications after bilateral vasectomy are uncommon and usually not serious. They include bleeding (usually external), suture reaction, and reaction to the anesthetic agent. Men occasionally develop a hematoma, infection, or epididymitits. Less common are painful granulomas from accumulation of sperm. The failure rate for male sterilization is 0.15%.

Contraception

is defined as the intentional prevention of pregnancy during sexual intercourse. Birth control is the device and/or practice used to decrease the risk of conceiving or bearing offspring. Intentional prevention of pregnancy. Birth control is the device or practice to decrease the risk of conceiving. Family planning is the conscious decision on when to conceive or avoid pregnancy. May still be at risk for pregnancy. Nearly half of all U.S. pregnancies are unplanned.