Family planning.

Family planning

prevalence A systematic review estimated contraceptive prevalence among women of reproductive age who were married or in a union was: 63 percent worldwide 77 percent in the United States

About 5 percent of women of reproductive age had an unintended pregnancy that year, comprising 3.2 million pregnancies.

Forty-three(43) percent of the unintended pregnancies were terminated.
These alarmingly high statistics occurred even though most women reported using some form of contraception.

Reasons for unprotected intercourse
33 percent felt they could not get pregnant at the time of conception, 30 percent did not really mind if they got pregnant, 22 percent stated their partner did not want to use contraception, 16 percent cited side effects, 10 percent felt they or their partner were sterile, 10 percent cited access problems, 18 percent selected "other.“

Contraception is a cost-effective approach for reducing these medical costs

CHOOSING A METHOD OF CONTRACEPTION
●Efficacyاثر بخشي ●Convenience سهولت ●Duration of action ●Reversibility and time to return of fertility بازگشت پذيري ●Effect on uterine bleeding ●Type and frequency of side effects and adverse events ●Cost) affordable(مقرون به صرفه ●Accessibilityدسترسي ●Protection against sexually transmitted diseases ●Non contraceptive benefits ●Medical contraindications ● اثر ● سهولت ● طول مدت عمل ● بازگشت پذیری و زمان بازگشت باروری ● اثر بر خونریزی رحمی ● نوع و فراوانی عوارض جانبی و بروز عوارض ● هزینه ● دسترسی ● حفاظت در برابر بیماری های مقاربتی ● مزایای Noncontraceptive ● موارد منع مصرف پزشکی

Contraceptive counseling tool: The top 10 questions that facilitate contraceptive counseling
What are your contraceptive goals? Do you ever plan to get pregnant? When? Are you currently having sex with a male partner? Have you tried any contraceptive methods? If so, which one(s)? What did you like/dislike about the method(s)? Are you a good pill taker?

Are there any methods you have heard about and would like to try?
……Contraceptive counseling tool: The top 10 questions that facilitate contraceptive counseling For user-controlled methods, how often did you forget to use the method? Are there any methods you have heard about and would like to try? How important is spontaneity of use? Is protection from sexually transmitted infections important considering your life situation? Is cost an issue? Does your health insurance plan cover any contraceptive method? Spontaneity انگيزه

National Survey of Family Growth (NSFG):
In the 2002 United States 46 percent of women reported discontinuing at least one method because they were dissatisfied with it. Two-thirds of women discontinue hormonal methods because of side effects. while almost 40 percent of those who discontinue the condom do so because of partner dissatisfaction. long-acting reversible contraceptive methods (intrauterine device [IUD], implant) appears to be lower, less than 10 percent at six months.

●Etonogestrel implant – 84 percent
Among couples attempting to avoid pregnancy, the percentage who continue to use a method for one year is approximately : ●Etonogestrel implant – 84 percent ●Levonorgestrel-releasing IUD – 80 percent ●Copper containing IUD – 78 percent ●Ring or patch or pill – 67 percent ●Diaphragm – 57 percent ●Depot Provera – 56 percent ●Fertility awareness based methods – 47 percent ●Male condom – 43 percent ●Female condom – 41 percent

Effectiveness The effectiveness of a contraceptive method is expressed as both the theoretical (perfect use) efficacy the actual (typical use) effectiveness

Actual effectiveness is usually lower due to inconsistent or incorrect use.
Actual effectiveness is also influenced by frequency of intercourse, age, and regularity of menstrual cycles, as pregnancy is less likely in women who are older, have infrequent sexual intercourse, and have irregular menstrual cycles

Most effective ● Long-acting reversible contraceptives (LARC; ie, intrauterine contraception, contraceptive implants) and sterilization are associated with a low pregnancy rate regardless of the population studied

Effective ● Injectable contraceptives are the most effective in this tier of choices. Oral contraceptives, the transdermal contraceptive system, and the vaginal ring are also associated with a very low pregnancy rate if they are used consistently and correctly, but actual pregnancy rates are substantially higher because of inconsistent/incorrect use. رديف

●Least effective – Other methods of contraception, including diaphragm, cervical caps, condoms, spermicides, withdrawal, and periodic abstinence are associated with actual pregnancy rates that are much higher than perfect use rates. The overall pregnancy rates associated with these methods have varied considerably among studies

Pearl Index Effectiveness in studies is often assessed using the Pearl Index, which is defined as the number of unintended pregnancies per 100 women per year (ie, the number of pregnancies in 1200 observed months of use).

cost ● The cost and effectiveness of any contraceptive method were superior to using no method ●The most cost-effective methods were intrauterine contraception and vasectomy

HORMONAL CONTRACEPTION
orally, injected, subdermal implant, transdermal patch intrauterine contraceptive device intravaginal contraceptive device.

sexually transmitted infections
Hormonal contraceptives are not protective against sexually transmitted infections, including HIV infection . Therefore, women at risk for acquiring a sexually transmitted infection should be advised to use condoms (male or female) in addition to their hormonal method.

May hormonal contraceptive use increase the risk of a woman acquiring HIV infection?
A meta-analysis of over 37,000 women reported that use of depomedroxyprogesterone acetate (DMPA) may slightly increase rate of HIV acquisition whereas use of norethisterone enanthate (NET-EN) or combined hormonal contraceptives

Patient assessment medical history
Screening for hypertension is recommended because it is a risk factor for development of cardiovascular disease

breast and pelvic exams
cervical cancer screening screening for sexually transmitted diseases

Chlamydia screening, if indicated, can be performed on urine.
(BMI)

Excluding pregnancy pregnancy test
these drugs are not teratogenic or abortifacient

Women with medical issues and disabilities — Choosing a hormonal contraceptive method is more complicated for women with certain medical disorders or personal characteristics, since physiologic changes and side effects associated with the method or with pregnancy may increase the risk of morbidity/mortality in these women. Unintended pregnancy can be particularly serious for women with certain medical conditions

One clinical scenario that has not been studied is the optimum hormonal method of contraception for women with limited mobility, such as those in wheel chairs. Factors to consider include the negative effect of DMPA and immobility itself on bone mineral density, as well as the increased risk of thrombosis associated with estrogen-progestin contraceptives and, possibly, third generation progestins.

A levonorgestrel-releasing intrauterine device (IUD) significantly reduces menstrual bleeding and requires little to no attention while not carrying either of these risks appears to be a good option. The etonogestrel implant also contains no estrogen and requires no attention, but is less likely to result in amenorrhea than the IUD. The IUD can be left in place for five years and the implant for three years. Progestin-only pills are an alternative, but must be taken daily, have a higher failure rate, and provoke irregular bleeding.

World Health Organization tables — WHO has published comprehensive tables of medical conditions and personal characteristics that may affect contraceptive choice

COC: low-dose combined oral contraceptive; CIC: combined injectable contraceptives; P: combined patch; R: combined vaginal ring; POP: progestogen-only pill; DMPA: depot medroxyprogesterone acetate; NET-EN: norethisterone enantate; LNG: levonorgestrel; ETG: etonogestrel; ECP: emergency contraceptive pill; Cu-IUD: copper intrauterine device; LNG-IUD: levonorgestrel-releasing IUDs; E-IUD: copper-IUD for emergency contraception; BARR: barrier methods; FAB: fertility awareness-based methods; LAM: lactational amenorrhoea method; CI: coitus interruptus; STER: female and male sterilization. * Risk factors for venous thromboembolism (VTE) include previous VTE, thrombophilia, immobility, transfusion at delivery, BMI >30 kg/m2, postpartum hemorrhage, immediately postcesarean delivery, preeclampsia, or smoking.

Women with a history of cancer
The Society of Family Planning (SFP) provides clinical guidelines for contraception in women with cancer [32]. These recommendations are similar to those published by the CDC, with some additional considerations. The SFP recommends:

Women with active cancer or who have been treated for cancer within six months: avoid estrogen-progestin contraceptives because both cancer and combined hormonal contraception are risk factors for venous thrombosis.

Women who have a history of chest wall irradiation for cancer: avoid systemic estrogen and/or progestin contraceptives because these women are at increased risk of developing breast cancer and the risk may be greater in women who take exogenous hormones.

Women with a history of breast cancer: use a copper-IUD unless they are taking tamoxifen. In the latter case, a levonorgestrel-releasing IUD is preferred to reduce the risk of tamoxifen-induced endometrial changes without increasing the risk of breast cancer recurrence.

Women with anemia: use a levonorgestrel-releasing IUD to minimize menstrual blood loss.

Women with osteopenia or osteoporosis: avoid injectable progestin-only contraception (eg, DMPA). These women may benefit from the effects of an estrogen-containing contraceptive on bone mineral density.

Women who are immunosuppressed: intrauterine contraception is not contraindicated.
●Women at risk of breast cancer or recurrence: emergency contraceptive pills are not contraindicated.

Estrogen-progestin versus progestin-only contraceptives — Both the estrogen and progestin components of combined contraceptives provide contraceptive actions, but the estrogen component also provides cycle control (ie, reduces the frequency and duration of scheduled and unscheduled bleeding), which is beneficial. Another benefit is that estrogen maintains bone density [33,34]. Disadvantages of combined contraceptives include estrogen-related side effects (eg, nausea, breast tenderness, bloating, headache), estrogen-related risks (eg, venous thromboembolism), and the number of medical contraindications to use of exogenous estrogen

The various types of combined contraceptive products (pill, ring, patch) are similarly efficacious (table 5). The side effect profiles differ and depend on the concentration of each hormone, the specific type of progestin, and local factors related to the application site (skin, vagina). (See "Risks and side effects associated with estrogen-progestin contraceptives".) The pharmacokinetics varies by delivery system. Oral estrogen administration is subject to a first-pass effect and enterohepatic recirculation leading to peaks and troughs in serum estrogen concentrations, whereas the controlled release vaginal contraceptive ring and transdermal contraceptive patch are associated with relatively constant serum estrogen levels [35]. Estrogen exposure is lowest with the vaginal ring and highest with the patch.

Progestin-only contraceptives are an option for women who need to avoid estrogen (table 21). Progestin-only contraception is associated with more unscheduled (breakthrough) bleeding. For progestin-only pills, ovulation is suppressed in 57 percent of cycles compared with 95 to 99 percent of cycles with estrogen-progestin pills; however, the mechanism of action relies mostly on thickening of cervical mucus, which inhibits sperm penetration [36]. A major advantage of progestin-only contraception is that it offers the option of long-term, “forgettable” contraception. All long-acting hormonal contraceptives are progestin-only (levonorgestrel intrauterine system, DMPA injections, etonogestrel implant).

There are few contraindications to progestin use
There are few contraindications to progestin use. Progestins should not be used in a woman with current breast cancer. Other conditions where the CDC guidance states that risks outweigh benefits include severe decompensated cirrhosis, malignant liver tumor, past breast cancer, systemic lupus erythematosus with antiphospholipid antibodies, and some other conditions where one progestin-only method may be safer than another such method.

Initiation — Hormonal contraception can be started anytime during the cycle (algorithm 1). We prefer the Quick Start method in which the woman begins taking contraception on the same day that she is given theprescription/injection, as long as pregnancy is reasonably excluded (see 'Patient assessment' above) [37]. Continuation of the contraceptive method is enhanced if the patient receives a prescription for a full year of contraception rather than having to return for a new prescription every few months [37,38].

Follow-up — A specific follow-up exam just to address contraception is not needed [21]. Women should be encouraged to return if they have any concerns about their method, if they want to discontinue or switch methods, or if they have changes in health status that could affect medical eligibility for continued use of the method. Although a specific follow-up visit to measure blood pressure is not necessary in healthy users of estrogen-progestin contraceptives, measurement of blood pressure is desirable at other routine visits, such as when the patient is seen for prescription refills or noncontraceptive issues. Women can also be advised to obtain periodic blood pressure measurements where accessible, such as in a pharmacy. The low risk of new hypertension in these patients was illustrated in a systematic review of five studies examining blood pressure changes after initiation of oral estrogen-progestin contraceptives that found few women, at most 2 percent, developed hypertension in the first year after initiating these drugs; however, methodological differences among the studies limited the reliability of the findings

Return to fertility after discontinuation — Return to fertility after discontinuation of contraception is an important advantage of reversible methods of contraception. Comprehensive reviews of studies that evaluated this issue found that in women who discontinue contraception in order to conceive, the pregnancy rate in the 12 months following discontinuation of oral contraceptives (cyclic combined or extended regimen) is similar to the pregnancy rate after discontinuation of other contraceptives, such as IUDs, condoms, natural family planning, and progestin-only pills [40,41]. For all of these methods, 70 to 95 percent of women trying to conceive became pregnant within 12 months. Prolonged use of combined hormonal contraception (eg, >5 years) does not decrease the odds of conception within 12 months of discontinuation [42]. By comparison, the time to conception after discontinuing use of progestin-only injections is delayed; 50 percent of women conceive six to seven months after the last shot, and greater than 90 percent after two years.

Counseling and strategies to enhance compliance — Counseling about side effects and method convenience generally improves compliance. Not requiring follow-up visits for prescription refills and monitoring is also effective. Strategies for counseling women about choice of hormonal contraception and methods for enhancing compliance are discussed separately. (See "Counseling women considering combined hormonal contraception", section on 'Strategies for enhancing compliance and continuation'.) Switching from one hormonal method to another — Depending on the contraceptive method, switching from one method to another may require a period of back-up contraception if the new method is not begun within the first five days of onset of menses. One expert group’s recommendations for back-up contraception when switching between methods of contraception is illustrated in the table (table 22). This is a reasonable approach, although others have recommended seven days back-up in all cases as a practical clinical approach. Switching from use of an IUD is a special case because there may be residual sperm in the reproductive tract, which theoretically could result in fertilization and implantation. Management of women who are discontinuing the IUD and starting another method is reviewed separately.

Does age matter? — Although women of older reproductive age have lower fecundity and may have less frequent sexual intercourse than younger women, they still need reliable contraception to avoid unintended pregnancy [43]. (See "Effect of advanced age on fertility and pregnancy in women", section on 'Fertility'.) No contraceptive method is contraindicated based on age alone (table 9 and table 20). Some women may no longer be good candidates for combined hormonal contraception as they age because of acquired medical comorbidities. For these women, IUDs, implants, and sterilization are preferred because of their high effectiveness and lack of association with cardiovascular events [43]. For women who remain candidates for combined hormonal contraception, these methods also provide noncontraceptive benefits, such as reduction in hot flashes, regulated and/or reduced menstrual bleeding in the perimenopause, maintenance of bone strength, and reduction in risk of some cancers (endometrial, ovarian, and possibly colorectal). Women who are not candidates for combined hormonal contraception may still be good candidates for progestin-only contraception (see 'Estrogen-progestin versus progestin-only contraceptives' above). Contraception for women at the beginning of the reproductive age group is discussed separately.

Does weight matter? — Some contraceptives may be less effective in obese women. Levonorgestrel andulipristal emergency contraception is less effective or not effective in obese women.

When is it safe to stop using hormonal contraception
When is it safe to stop using hormonal contraception? — Contraception remains important during perimenopause, as women cannot be certain of infertility until they reach menopause (ie, 12 months without menses). A false presumption of infertility is one reason for the high rate of unintended pregnancy in perimenopausal women. Determining when hormonal contraception can be safely discontinued is challenging because the effects of hormones on bleeding patterns (eg, amenorrhea, regular withdrawal bleeding) make it difficult to diagnose menopause and there is no blood test that reliably diagnoses menopause in women using hormonal contraception. One approach in healthy nonsmoking women is to discontinue hormonal contraception when the risk of pregnancy is clearly remote based on age: ACOG and the North American Menopause Society (NAMS) put this age between 50 and 55 years

If a woman in the perimenopausal age group using hormonal contraceptive desires to stop, a reasonable approach is to choose the median age of menopause, 51 years, and switch to a nonhormonal contraceptive. If over time she can be diagnosed as menopausal, then the nonhormonal contraceptive can be discontinued, as well. Measurement of hormones, eg, follicle-stimulating hormone (FSH), is not required to determine need for contraception.

Options for hormonal contraception
Estrogen-progestin pill, patch, or ring — Combined estrogen-progestin contraceptives (pill (table 23), transdermal patch, vaginal ring) inhibit the midcycle surge of gonadotropin secretion, so that ovulation is suppressed. They also alter endometrial receptivity and inhibit the ability of sperm to access the upper genital tract. General principles of the use of combined estrogen-progestin contraceptives, including pharmacology, mechanisms of action, indications, contraindications, efficacy, administration, different preparations, and management of problems are reviewed separately:

When oral contraceptives are given on an extended rather than monthly cycle, the number of episodes of withdrawal bleeding per year is reduced, and can be completely eliminated. In addition, shortening the hormone-free interval may reduce symptoms associated with hormone withdrawal (eg, headache, pelvic pain). (See"Overview of the use of estrogen-progestin contraceptives", section on 'Continuous pill' and "Hormonal contraception for suppression of menstruation".) In contrast to oral contraceptive pills, which are taken daily, the contraceptive patch is applied weekly and the contraceptive vaginal ring is applied monthly. The benefits, risks, and contraindications to use of all three methods are similar. The effects of combined hormonal contraceptives on clotting factors, markers of coagulation and fibrinolysis, and lipids are largely independent of the route of administration [46-48]. However, there are some differences among methods: the patch is associated with a higher frequency of skin irritation and possibly venous thromboembolism, while the ring is associated with a higher frequency of vaginal discharge

Progestin-only pill — Progestin-only contraceptive pills are an option for women who need to avoid estrogen but want to take a contraceptive pill. The "minipill" has a dose of progestin that is close to the threshold of contraceptive efficacy (norethindrone 0.35 mg); therefore, these pills should be taken at the same time each day and are taken every day without a pill-free interval. Variation of only a few hours in administration can reduce contraceptive effectiveness so women should be prepared to use a back-up method not only if one pill is missed, but also if there is a greater than three-hour delay in taking the pill. (See "Progestin-only pills (POPs) for contraception".) Progesterone-only ring — Progesterone-only rings function primarily by thickening cervical mucus to prevent sperm penetration, but also inhibit ovulation and endometrial receptivity. Progesterone-only rings may be less effective over the long-term than rings containing both a progestin and an estrogen, but are still highly effective among breastfeeding women since breastfeeding provides some protection from pregnancy. Unscheduled bleeding, which is a common side effect of all progestin-only methods, is less likely to occur in breastfeeding women because of prolonged lactational amenorrhea [49]. A ring that releases a synthetic progestin (Nestorone) is under development. The progesterone vaginal ring contains 22.5 percent progesterone dispersed in silicone. The system delivers 10mg/day of the physiological hormone progesterone, but serum levels decline during its three-month duration of use [50]. It is available only in South America.

Injectable contraceptives — Injectable contraception is highly effective, reversible, and avoids the need for compliance daily or near the time of sexual intercourse. Progestin-only injection — The only injectable contraceptive available in the United States is the progestin-only DMPA. DMPA (150 mg) is given by deep intramuscular injection and results in effective contraception for three months. Theoretical exceeds actual effectiveness because some users do not return for their injections as scheduled (table 5). A lower-dose DMPA formulation (DMPA-SC, 104 mg/0.65 mL), which is administered subcutaneously every three months, is also available [51]. The sub-Q formulation provides slower and more sustained absorption of the progestin than conventional DMPA, which allows for a 30 percent lower dose of progestin, but with the same duration of effect as conventional DMPA. Administration via the subcutaneous route is less painful than intramuscular injection and potentially may allow patient self-administration. Intramuscular DMPA is available as a generic formulation, which is less costly than DMPA-SC. Otherwise, the risks and benefits are similar to those with intramuscular administration. Local reactions have been reported when DMPA is given subcutaneously

Estrogen-progestin injection — In some other countries, combined estrogen-progestin injectables are available (eg, estradiol cypionate-medroxyprogesterone acetate [Cyclofem], estradiol valerate-norethisterone enanthate [Mesigyna]). In a systematic review of comparative trials of estrogen-progestin versus progestin-only injectable contraceptives, there were differences between preparations in bleeding patterns and discontinuation rates, but the combined injectable drug was not clearly superior to or worse than the progestin-only injectable drug [52]. Progestin-only implants — A variety of contraceptive implants are available worldwide, but only Nexplanon is available in the United States. Etonogestrel implant (Nexplanon) — A single-rod progestin implant (Implanon, Nexplanon) provides contraception for three years by slow release of 68 mg of the progestin etonogestrel. Training sponsored by the manufacturer is required before the practitioner can purchase and insert the implant.

Levonorgestrel implant (Jadelle) — A two-rod subdermal levonorgestrel implant (Jadelle) was approved by the United States Food and Drug Administration (FDA) for five years of use, although it has not been marketed in the United States. It is available in most other countries. The cumulative pregnancy rate in clinical trials was 0.3 at three years and 1.1 percent at five years [53], which is a lower failure rate than that of oral contraceptives, and comparable to that of surgical sterilization. Efficacy may be reduced slightly as body weight increases. In a multicenter study, there were no pregnancies in women weighing less than 50 kg or with levonorgestrel serum concentrations greater than 180 pg/mL [54]. The major side effect is irregular bleeding [55]. Each rod is 0.25 cm in diameter, 4.3 cm long, and contains 75 mg of levonorgestrel. Under local anesthesia, a #10 trocar is used to place the rods in a V configuration subdermally at the inner part of the nondominant upper arm (mean procedure time two minutes). The progestin is released at 80 mcg per day in the first month, gradually decreasing to 50 mcg per day by nine months, and then falling to 25 to 30 mcg per day thereafter. Removal is performed under local anesthesia by grasping the ends of the rods through a 3 to 4 mm incision at the apex of the V (mean time five minutes). Amenorrhea occurs, but is much less common than with DMPA injections. A systematic review determined the weighted prevalence of amenorrhea over successive 90-day periods was 11, 13, 9 and 13 percent, respectively [56]. By comparison, approximately 50 percent of DMPA users are amenorrheic after one year.

Levonorgestrel-implant (Sino-implant) — Sino-implant (II) is a two-rod contraceptive implant; each rod contains 75 mg levonorgestrel. The main difference from Jadelle is that it can be left in place for up to four years (Jadelle can be left in place for up to five years). Four randomized trials with a total of 15,943 women assigned to Sino-implant (II) had first-year probabilities of pregnancy ranging from 0 to 0.1 percent and cumulative probabilities of pregnancy were 0.9 and 1.06 percent in the two trials that presented data for four-year use [57]. Levonorgestrel-releasing IUD — Several terms are used to describe intrauterine contraception, including IUD and intrauterine contraceptive (IUC); the progestin-containing device is also referred to as an intrauterine system (IUS). In this topic, we use the term IUD for all types of intrauterine contraception. Currently available IUDs release either a synthetic progestin or copper (see 'Copper-releasing IUD' below). Levonorgestrel-releasing IUDs inhibit sperm transport and fertilization of ova, and partially inhibit ovulation. It is theoretically possible that an additional mechanism is prevention of implantation. The higher dose levonorgestrel-releasing IUD (52 mg, initial release rate 20 mcg/day [LNg20]) remains effective for at least five years [58]. A smaller and lower dose levonorgestrel-releasing IUD (13.5 mg, initial release rate 14 mcg/day [LNg14]) remains effective for at least three years, thus it may be more appropriate for women planning pregnancy in less than five years and women in whom insertion is difficult.

Current IUDs are not associated with the same problems (eg, increased risk of pelvic inflammatory disease [PID]) that caused previous IUDs (eg, Dalkon shield) to acquire a poor reputation. Women who are at low risk for sexually transmitted diseases do not have a higher incidence of PID with use of an IUD and well-designed studies have found that IUDs do not have adverse effects upon fertility after removal. IUDs decrease the overall risk of ectopic pregnancy compared with women who do not use contraceptives [59,60]. When pregnancy does occur, the site of pregnancy should be immediately determined because the risk of ectopic pregnancy is increased (table 24). A detailed discussion of the IUD can be found separately. (See "Intrauterine contraception: Devices, candidates, and selection".)

Intermittent hormonal contraception — There is currently no hormonal contraceptive method approved for use only at the time of intercourse. Two systematic reviews of observational studies of pericoital use oflevonorgestrel as a method of contraception in women having infrequent intercourse found that it was moderately efficacious and safe [61,62]. A commonly used regimen was 0.75 mg of levonorgestrel within one hour after coitus and a repeat dose if additional intercourse occurred more than three hours later. For this dose, the pooled Pearl index was 5.4 pregnancies per 100 woman-years (95% CI ) [62]. Limiting the analysis to three high quality WHO-sponsored studies yielded a Pearl index of 8.9 pregnancies per 100 women years (95% CI ). By comparison, for sexually active women using no contraception, the estimated Pearl index is approximately 85 pregnancies per 100 women years. The studies were generally of low quality and further research is needed before this approach can be recommended as a novel contraceptive method

NONHORMONAL CONTRACEPTION
Tubal interruption or occlusion — Tubal interruption and occlusion are surgical procedures that result in sterility. While these procedures may be reversible, they should be considered permanent and therefore performed only after thorough patient counseling. Detailed discussions of the various methods are available separately. (See "Surgical sterilization of women".) Copper-releasing IUD — Copper IUDs release copper continuously into the uterine cavity; this interferes with sperm transport and prevents fertilization of ova [63]. It is theoretically possible that an additional mechanism is prevention of implantation. One type of copper IUD, the TCu380A, remains effective for at least 10 years. As discussed above, current IUDs are not associated with the same problems (eg, increased risk of pelvic inflammatory disease [PID]) that caused previous IUDs (eg, Dalkon shield) to acquire a poor reputation. Women who are at low risk for sexually transmitted diseases do not have a higher incidence of PID with use of an IUD and well-designed studies have found that IUDs do not have adverse effects upon fertility after removal. Consequently, the copper IUD revised its package label (September 2005) to remove the prior section on "recommended patient profile" that included multiparity, mutually monogamous relationship and history of PID.

UDs decrease the overall risk of ectopic pregnancy compared with women who do not use contraceptives [59,60]. When pregnancy does occur, the site of pregnancy should be immediately determined because the risk of ectopic pregnancy is increased (table 24). A detailed discussion of the IUD can be found separately. (See "Intrauterine contraception: Devices, candidates, and selection".)

Barrier methods — Condoms (male and female), diaphragm, and cervical cap are the most common forms of barrier contraception. Neither condoms nor the contraceptive sponge require a prescription, but a prescription is needed to purchase a diaphragm. The effectiveness of all barrier methods of contraception is highly user-dependent (table 5 and figure 1). Male condoms provide better protection against acquisition/transmission of sexually transmitted infections, including human immunodeficiency virus (HIV), than any other contraceptive method. Condom — Condoms are available for both men and women. (See "Male condoms" and "Female condoms".)

Diaphragm and cervical cap — Diaphragms and cervical caps provide a barrier between sperm and the cervical canal and serve as a reservoir for spermicide. They require fitting by a trained clinician and are only effective when used with a spermicide since the barrier is not secure (see 'Spermicides' below). They must be left in the vagina for 6 to 8 hours after intercourse; the diaphragm needs to be removed after this period of time, while the cervical cap can be left in place for up to 48 hours. These considerations have caused them to be less desirable methods of contraception for many women. In addition, using a diaphragm can increase the risk of urinary tract infections. (See "Barrier contraception: Diaphragm".) The only cervical cap available in the United States is made of silicone rubber (FemCap). It has a strap to facilitate removal and comes in three sizes; the appropriate size is based on the patient’s obstetric history. It does not require a custom fitting, but can only be purchased with a prescription. In randomized trials, the FemCap was less effective in preventing pregnancy than the diaphragm [64]. However, these trials were performed with the first generation FemCap, which was not approved by the United States Food and Drug Administration (FDA); a second generation device has been approved by the FDA and is available for use in the United States and Europe.

ponge — The Today sponge is a 2-inch wide circular disk, 3/4 of an inch thick, containing 1000 mg of nonoxynol-9 and attached to a loop for removal. It is moistened with tap water before insertion deep in the vagina. The sponge does not require fitting or a prescription and can be left in place and used repeatedly for up to 24 hours. When compared to the diaphragm in randomized trials, the sponge was less effective and had a higher discontinuation rate [65]. Both the contraceptive sponge and diaphragm may be linked to an increased risk of non-menstrual toxic shock syndrome, though rare [66]. Fertility awareness based methods — Fertility awareness-based, or natural, methods are alternative methods of family planning for women who prefer a nonhormonal, nonsurgical form of contraception for health or personal reasons. Fertility awareness-based methods of contraception are discussed in detail separately. (See "Fertility awareness-based methods of pregnancy prevention".)

Other methods Withdrawal — The withdrawal method (coitus interruptus) requires men to withdraw from the vagina before ejaculation. Failure occurs if withdrawal is not timed accurately or if the preejaculatory fluid contains sperm. Pregnancy rates of 18 to 28 percent per year of use have been reported [3,67,68]. Lactation — Women who breastfeed have a delay in resumption of ovulation postpartum due to prolactin-induced inhibition of pulsatile gonadotropin-releasing hormone (GnRH) release from the hypothalamus. Breastfeeding can be relied upon to prevent pregnancy only when the woman meets all three of the following conditions [69,70]: ●She is less than six months postpartum ●She is breastfeeding exclusively (ie, not providing food or other liquid to the infant) ●She is amenorrheic. If these conditions are not met, the risk of unintended pregnancy while breastfeeding is high, and women should add another method of contraception

Contraceptive choices during lactation — Recommendations for nonhormonal and hormonal contraception use during lactation are reviewed in detail elsewhere. (See "Postpartum and postabortion contraception", section on 'Contraceptive choices during lactation'.) Spermicides — Spermicides are among the least effective methods of contraception (figure 1 and table 5) [72]. Spermicides containing nonoxynol-9 are available without a prescription and in a variety of forms including gel, foam, cream, film, suppository, and tablet. They are not a highly effective method of contraception when used alone (without a barrier method). This was illustrated in a trial which randomly assigned 1536 women willingly to accept a moderate risk of pregnancy to use of one of five spermicides [73]. The probability of pregnancy for each nonoxynol-9 preparation during six months of typical use was: 52.5 mg gel (22 percent), 100 mg gel (16 percent), 150 mg gel (14 percent), film (12 percent), and suppository (10 percent). Although the risk of pregnancy was significantly higher with the 52.5 mg gel, none of the preparations reliably prevented pregnancy.

Effectiveness is reduced if the patient does not wait long enough for the spermicide to disperse before having intercourse, if intercourse is delayed for more than one hour after administration, or if a repeat dose is not applied before each additional act of intercourse. Nonoxynol-9 preparations do not appear to significantly disturb the vaginal flora ecosystem, although a small increase in bacterial vaginosis associated flora has been observed in the highest quartile of users [74]. Local irritation is not uncommon with spermicide use, and these agents tend to be messy. Spermicides do not protect against acquisition/transmission of gonococcal or chlamydial infection [75] or HIV infection [76-79], and may cause vaginal irritation thereby increasing susceptibility to HIV [76,80]. A meta-analysis concluded that maternal use of spermicides is not associated with adverse fetal outcomes, including congenital malformations [81]. A subsequent analysis of data from the National Birth Defects Prevention Study (NBDPS) did not find significant associations between reported first trimester spermicide use and any birth defect, except perimembranous ventricular septal defects, which the authors noted may be a chance finding due to multiple comparisons

Chemical methods — Sclerosing chemicals have been used to occlude the fallopian tubes, but are not popular because they require more than one application and because of safety concerns [83]. Quinacrine sterilization — Quinacrine-induced tubal sclerosis is an alternative method of tubal sterilization which does not require surgery [84,85]. It has not been assessed by the FDA for use in the United States, but is widely used in developing countries because of its low cost and its ease of use. Contraceptive effectiveness is lower than with other sterilization techniques (see below) [83]. Over 100,000 procedures have been performed in over 30 countries [86]. The method involves transcervical insertion of seven 36-mg quinacrine pellets (252 mg total) into the uterine cavity on two occasions one month apart under hysteroscopic guidance and using a modified IUD. Histopathological studies in pre-hysterectomy volunteers showed that tubal occlusion occurred as a result of inflammation leading to fibrosis, which was limited to the cornual area and the intramural portion of fallopian tubes [87]. Endometrial changes included atrophy, polypoid reactions, and fine adhesions; long-term effects on the endometrium are not well-described, but available data are reassuring [88-90]. Cumulative pregnancy rates at 1, 5, and 10 years postprocedure range from 0.3 to 3.3 percent, 1.1 to 10 percent, and 4.3 to 12.1 percent, respectively [91].

Disadvantages of the technique include the need for multiple applications and the lack of a reliable method for confirming tubal occlusion. Hysterosalpingography is not recommended because pressure from the dye may force open the scarred tube and allow recanalization [92]. Although quinacrine appeared to be carcinogenic in rodents at doses higher than those used for human sterilization [93], there is no evidence of an increased risk of cancer in human studies [90,94]. When is it safe to stop using nonhormonal contraception? — In menstruating women, experts suggest that women ≥age 50 years continue to use contraception for one year after their last menstrual period (ie, menopause) and women <age 50 years continue to use contraception for two years after their last menstrual period [95-97]. EMERGENCY CONTRACEPTION — All couples using a barrier contraceptive (eg, condom, diaphragm, cervical cap), as well as women using hormonal methods, should be informed about the use and nonprescription availability of emergency contraception for the female partner. Emergency contraception is indicated if there is failure of the barrier contraceptive method (broken condom, failure to use, etc). Emergency (postcoital) contraception is discussed separately.

CONTRACEPTION FOR MEN Condoms — The condom is the only reversible method of contraception available to men. (See "Male condoms".) Vasectomy — Vasectomy (ligation of the vas deferens) can be performed in a physician's office under local anesthesia. It is a safe, highly effective sterilization procedure. Although men should be counseled before vasectomy that the procedure is permanent, the procedure can often be reversed with a return of fertility. (See"Overview of vasectomy".) INVESTIGATIONAL METHODS Vaccines — Contraceptive vaccines are under investigation; none are clinically available. These vaccines either target gamete production (luteinizing hormone-releasing hormone [LHRH]/gonadotropin-releasing hormone [GnRH], follicle-stimulating hormone [FSH]), gamete function (sperm antigens and oocyte zona pellucida [ZP]), or gamete outcome (HCG)

Hormonal methods for men — No male hormonal contraceptives are available for clinical use, although scientists have been attempting to develop them for many years [99]. The current approach to male hormonal contraception is based on the ability of exogenously administered sex steroids to suppress pituitary secretion of luteinizing hormone (LH) and FSH: spermatogenesis is inhibited when the concentrations of these hormones are low. Endogenous testosterone production is also suppressed, so all of these regimens involve administration of exogenous testosterone. A variety of androgen preparations are available; most involve injections or implants, but a transdermal gel [100], a potent synthetic androgen (7a-methyl-19-nortestosterone [MENT]) [101,102], and an oral formulation [103] are being investigated and appear promising. Since testosterone alone does not completely suppress spermatogenesis in all men, most approaches to male hormonal contraceptive involve a combination regimen, such as testosterone and a progestin or testosterone and a GnRH analog, which synergistically suppress gonadotropins [100,104,105]. Combined regimens also enable use of lower doses of testosterone, although androgen exposure is still above physiologic levels. The testosterone-progestin regimen parallels the estrogen-progestin regimen that inhibits ovulation in hormonal contraceptives for women.

In addition to problems with variable suppression of spermatogenesis, efforts to develop an acceptable male hormonal contraceptive regimen have also been hampered by the lack of long-acting, effective oral and transdermal testosterone preparations and undesirable side effects [106]. The current transdermal testosterone patch has not resulted in reliable sperm suppression, presumably due to suboptimal serum testosterone concentrations [107]. There is a theoretical concern that long-term administration of supraphysiological quantities of testosterone might increase the risk of prostate disease. An additional practical limitation of the use of male hormonal contraception is that it takes a few months to significantly reduce sperm counts, thus there is a considerable delay before the contraceptive becomes effective. Vas injection — Vas occlusion methods, such as injectable silicone plugs, block the vas deferens without disrupting it, making reversal easier. Reversible Inhibition of Sperm Under Guidance (RISUG) is another approach in which the vas is injected with a polymer gel that kills sperm. If reversal is desired, the polymer can be flushed out with an injection of dimethyl sulfoxide.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

SUMMARY AND RECOMMENDATIONS — Choosing a contraceptive depends upon a number of factors, including efficacy, reversibility, convenience, cost, availability (prescription versus nonprescription), and side effects. Thus, each patient's choice of contraceptive method should reflect her opinion of the utility of each of these variables and where she is willing to make tradeoffs between desirable and undesirable features of each method (table 3). Women should be counseled about the difference in typical use effectiveness between the methods, and should be counseled to consider a highly effective method such as one of the long-acting reversible contraceptives (LARCs) methods. Some generalizations can be made: ●In addition to any method of contraception, we recommend use of condoms for individuals at risk of sexually transmitted infections (Grade 1B). (See "Male condoms", section on 'Protection from STIs' and"Female condoms", section on 'Sexually transmitted infections'.) ●For couples who desire permanent contraception (sterilization), we suggest vasectomy. Vasectomy is as effective, but less morbid and costly than tubal occlusion. (See "Overview of vasectomy" and "Surgical sterilization of women".)

Women who request sterilization should be counseled about availability of LARC methods, which are comparable to sterilization in terms of efficacy (table 5), but are non-surgical and reversible. (See'Effectiveness' above.) ●For women who desire reversible contraception, we suggest LARC. Pregnancy rates are comparable to sterilization (table 5), and they are more convenient than short-acting methods. (See 'Effectiveness' above.) ●Combined estrogen-progesterone hormonal methods (pills, patch, vaginal ring) are rapidly reversible, but less effective than the methods described above (although still highly effective when used properly) (table 5). Hormone-related side effects are common. Convenience depends upon the specific method and varies from daily administration (oral contraceptive pills, standard or extended cycle) to weekly (patch) to monthly (vaginal ring). Patients should not use these methods if they have a contraindication to taking estrogen preparations. In particular, patch users may be at higher risk of thrombosis than pill users. (See 'Issues to consider when beginning hormonal contraception' above and 'Estrogen-progestin pill, patch, or ring' above.) ●Blood pressure should be measured prior to initiating estrogen-progestin contraception. (See 'Patient assessment' above.) Estrogen-progestin contraception is generally avoided in hypertensive women because of an increased risk of cardiovascular disease, including stroke. (See "Risks and side effects associated with estrogen-progestin contraceptives", section on 'Cardiovascular disease'.) ●The diaphragm and male condom are less effective and less convenient than hormonal methods (table 5). However, they are the most readily reversible methods and not associated with systemic side effects (except for individuals who are sensitive to latex products). Diaphragms are most effective when used with a spermicide. They are not recommended as the primary method for women with serious medical conditions in whom pregnancy is life-threatening; these women require use of the most effective methods of contraception. (See 'Barrier methods' above.) ●Women using a barrier contraceptive (eg, condom, diaphragm, cervical cap) or who are at risk for pregnancy should be informed about use of emergency contraception in case of failure of the barrier contraceptive method (broken condom, failure to use, etc). Women prescribed hormonal contraceptives should also be informed about use of emergency contraception since they may miss doses of their contraceptives and be at risk for unintended pregnancies. (See 'Emergency contraception' above.)

Women who request sterilization should be counseled about availability of LARC methods, which are comparable to sterilization in terms of efficacy (table 5), but are non-surgical and reversible. (See'Effectiveness' above.) ●For women who desire reversible contraception, we suggest LARC. Pregnancy rates are comparable to sterilization (table 5), and they are more convenient than short-acting methods. (See 'Effectiveness' above.)

●Combined estrogen-progesterone hormonal methods (pills, patch, vaginal ring) are rapidly reversible, but less effective than the methods described above (although still highly effective when used properly) (table 5). Hormone-related side effects are common. Convenience depends upon the specific method and varies from daily administration (oral contraceptive pills, standard or extended cycle) to weekly (patch) to monthly (vaginal ring). Patients should not use these methods if they have a contraindication to taking estrogen preparations. In particular, patch users may be at higher risk of thrombosis than pill users. (See 'Issues to consider when beginning hormonal contraception' above and 'Estrogen-progestin pill, patch, or ring' above.)

●Blood pressure should be measured prior to initiating estrogen-progestin contraception. (See 'Patient assessment' above.) Estrogen-progestin contraception is generally avoided in hypertensive women because of an increased risk of cardiovascular disease, including stroke. (See "Risks and side effects associated with estrogen-progestin contraceptives", section on 'Cardiovascular disease'.)

●The diaphragm and male condom are less effective and less convenient than hormonal methods (table 5). However, they are the most readily reversible methods and not associated with systemic side effects (except for individuals who are sensitive to latex products). Diaphragms are most effective when used with a spermicide. They are not recommended as the primary method for women with serious medical conditions in whom pregnancy is life-threatening; these women require use of the most effective methods of contraception. (See 'Barrier methods' above.)

●Women using a barrier contraceptive (eg, condom, diaphragm, cervical cap) or who are at risk for pregnancy should be informed about use of emergency contraception in case of failure of the barrier contraceptive method (broken condom, failure to use, etc). Women prescribed hormonal contraceptives should also be informed about use of emergency contraception since they may miss doses of their contraceptives and be at risk for unintended pregnancies. (See 'Emergency contraception' above.)

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