Birth Control Types, Side Effects, and Effectiveness

Picture of a variety of birth control options

• The practice of birth control or preventing pregnancy is as old as human existence. For centuries, humans have attempted to avoid pregnancy.
• Ancient Egyptian writings dating back to 1850 BC refer to techniques using a device placed in a woman's vagina made of crocodile dung and fermented dough, which most likely created a hostile environment for sperm. Other items placed in the vagina included plugs of gum, honey, and acacia.
• During the early second century in Rome, a highly acidic concoction of fruits, nuts, and wool was placed on the cervix as a type of spermicidal barrier.
• For the individual woman, the ability to effectively control when and whether she becomes pregnant affects her ability to achieve her own goals and contribute to her sense of well-being. A woman's choice of a birth control method involves factors such as how ease, safety, risks, cost, and personal other considerations.
• There are a variety of methods and types of birth control available, for example:
  • Hormonal methods (the "pill", patch, shot, implant, etc.)
  • Barrier devices (male and female condom, cervical cap, diaphragm, etc.)
  • Spermicides
  • IUDs (intrauterine devices)
  • Behavioral (natural)
  • Permanent (tubal ligation, vasectomy)
  • Emergency contraception

• Birth control side effects depend on the option a woman chooses, for example,
  • Nausea
  • Headache
  • Weight gain
  • Mood changes
  • Breast tenderness
• The effectiveness in preventing pregnancy depends upon the birth control method used.

This article discusses the main methods of contraception (birth control) used in the United States, their pros, cons, types, side effects, and effectiveness.

Types of birth control pills

• Birth control pills, also known as oral contraceptives, have been marketed in the United States since 1962. Over the past 40 years, there have been changes in the types of estrogen and progestin (hormones) used in the pills and lower amounts of hormones overall.
• According to the Centers for Disease Control and Prevention, birth control pills are the leading birth control option used by women under the age of thirty.
• Birth control pills today are designed to improve safety and reduce side effects.
• Lower doses of estrogen are associated with a decrease in side effects such as:
  • Weight gain
  • Beast tenderness
  • Nausea
• Birth control pills are available in an oral pill and chewable pill, usually taken by mouth and swallowed with a liquid.
• Over 30 different combinations of birth control pills are available in the United States.
• The majority of the pill combinations have 21 hormonally active pills followed by 7 pills containing no hormones.
• A woman begins by taking a pill on the first day of her period or the first Sunday after her period has begun.
• By taking a pill a day, a woman can usually take pills consistently throughout her cycle.

Effectiveness of birth control pills

Effectiveness: Pregnancy rates range from 0.1% with perfect use to 5% with typical use.

Pros (advantages): Birth control pills may be used to treat irregular menstrual periods, and a woman can manipulate her menstrual cycle to avoid a period during certain events, such as vacations or weekends by extending the number of intake days of hormonally active pills or by skipping the non-active pill week.

1. Birth control pills help prevent certain conditions, like:
2. Benign breast disease
3. Pelvic inflammatory disease (PID)
4. Functional cysts in the breasts. Functional cysts are reduced by the suppression of ovarian hormone production.
5. Ectopic pregnancies are prevented by the inhibition of ovulation.
6. Birth control pills have also been known to prevent certain ovarian and endometrial cancers.

Side effects of birth control pills

Problems encountered when in taking birth control pills include:

• Nausea.
• Breast tenderness.
• Weight gain.
• Breakthrough bleeding.
• Absent periods.
• Headaches.
• Depression.
• Anxiety.
• Diminished sexual desire (libido).

Disadvantages of birth control pills

It's important to take the pills daily and consistently (same time every day). If a woman stops taking her birth control pills, it may take several months for her to resume normal ovulatory menstrual cycles. If 6 months elapse without the return of menstrual flow she may need to be examined by her health care provider.

Additional risks of birth control pills

• Blood clots. Some women may be at risk for blood clots (venous thrombosis). At particular risk are smokers over the age of 35, as well as women with elevated blood lipid (cholesterol) levels, diabetes, high blood pressure, and obesity.
• Breast cancer. The association of birth control pill use and breast cancer in young women is controversial. The Collaborative Group on Hormonal Factors in Breast Cancer performed the most comprehensive study to date in 1996. The results demonstrated that current pill users, and those who had used birth control pills within the past 1-4 years, had a slightly increased risk of breast cancer. Although these observations support the possibility of a marginally elevated risk, the group noted that the pill users had more breast examinations and breast imaging studies than the nonusers. Thus, although the consensus opines that birth control pills can lead to breast cancer, the risk is small and the resulting tumors spread less aggressively than usual. Current thought is that birth control pill use may be a cofactor that can interact with another primary cause to stimulate breast cancer.
• Cervical cancer. The relationship between birth control pill use and cervical cancer is also quite controversial. Important risk factors for cervical cancer include early age of first sexual intercourse and exposure to the human papillomavirus. The current thinking is that if birth control pills contribute to the risk of cervical cancer, their impact is small and related to risky sexual behaviors. Thus, women who use birth control pills should have an annual Pap test.
• STDs and birth control pills. Birth control pills do not provide protection from STDs.

Progestin-only birth control pills

Progestin-only pills, also known as the mini-pill, are not used widely in the United States. Less than 1% of women use oral contraceptives as their sole method of birth control. Those who use them include women who are breastfeeding or cannot take estrogen.

Contraceptive Implant 

The FDA has approved a contraceptive implant (etonorgestrel, brand name Nexplanon). It is placed in the upper arm of the woman and releases a small, steady dose of progestin. It is extremely effective for up to three years.

• Effectiveness: Implants are as effective as surgical sterilization. Overall, pregnancy rates increase from 0.2% in the first year to 0.5% by the third year.
• Pros: Implants are durable. A woman's fertility returns shortly after implant removal.
• Cons: A minor surgical procedure is necessary to put them in and to remove them. Menstrual irregularities are common, along with other side effects, including weight gain, headaches, mood changes, growth of facial hair, and acne.
• Additional side effects and risks: Implants are often used for women who have just had a child and are breastfeeding; for those who have trouble remembering to take birth control pills or use other birth control methods, and for women who should not become pregnant because of a medical condition. Implants are not recommended for heavy smokers, women with a history of ectopic pregnancy, diabetes, high cholesterol, severe acne, high blood pressure, heart disease, migraine, and depression.
• STDs and the implant: This method does not protect against STDs.

Birth control patch

In the United States a transdermal patch (worn it on the skin) is available that releases estrogen and progesterone directly into the skin (brand name: Ortho Evra). Each patch contains a 1-week supply of hormones. It releases a constant daily dose of hormones equivalent to the lowest-dose oral contraceptive pill formulation.

• Effectiveness: In August, 2002, the FDA listed a failure rate for the patch of 1 pregnancy per 100 women per year, similar to that of other combination methods. It may be less effective for women who weigh more than 198 pounds.
• Pros: Many women find it convenient to use because it works for a week, and they do not have to remember to take a pill every day. You apply a new patch every week for 3 weeks and do not wear a patch during the fourth week when menses are expected.
• Cons: It is only available by prescription.
• Side effects of the patch: Side effects are similar to those experienced by women using oral contraceptives. The patch may cause skin irritation where it is placed (near the bikini line or on the buttocks or thighs). It may come off and not be noticed, for example, in the shower.
• STDs and the patch: The patch does not protect against STDs.

Vaginal ring

The vaginal ring (NuvaRing) is a newer form of birth control. The actual design of vaginal rings for contraception was first developed in the 1970s. Vaginal rings deliver a combination of estrogen and progesterone. The hormones are released slowly and are absorbed directly through the walls of the vagina.

• Effectiveness: Preliminary studies have shown that they work to prevent pregnancy, similar to birth control pills, with fewer side effects.
• Pros: Vaginal rings are used in the same manner as birth control pills, with the ring being left in the vagina for three consecutive weeks, followed by removal for a week during which time a menstrual flow is anticipated.
• Cons: If the ring is expelled spontaneously and remains out for more than 3 hours, another form of birth control should be used until the next period begins, at which time a new ring may be reinserted. The vaginal ring is only available by prescription.
• STDs and the vaginal ring: It does not prevent STDs.

Synthetic hormone Injections

An injection of a synthetic hormone depomedroxyprogesterone acetate (DMPA, brand name: Depo-Provera) can be given every 3 months to stop ovulation. You receive it by injection in the doctor's office. After injection, the medication is active within 24 hours and lasts for at least 3 months. It prevents your ovaries from releasing eggs.

• Effectiveness: DMPA is an extremely effective contraceptive option. Other medications or patient weight do not diminish its efficacy. The failure rate is approximately 0.3% during the first year of use.
• Pros: DMPA does not produce the serious adverse effects seen with estrogen, such as a tendency to increase blood formation. It lowers risk for certain types of endometrial cancers. Problematic irregular periods may normalize with Depo-Provera usage.
• Cons: Some women may cease menstruating within the first year of usage. Irregular bleeding can be treated by giving the next dose earlier or by adding a low-dose estrogen temporarily. Because DMPA lasts in the body for several months in women who have used it on a long-term basis, it can significantly delay a return to normal fertility. About 70% of former users desiring pregnancy conceive within 12 months, and 90% will conceive within 24 months. Other adverse effects, such as weight gain, depression, and menstrual irregularities may continue for as long as 1 year following the last injection. Recent studies suggest a possible link between DMPA and bone density loss. Results are conflicting and limited.
• STDs and Injections: This method does not protect against STDs.

An intrauterine device (IUD) is a small T-shaped plastic device that is placed in the uterus to prevent pregnancy. A plastic string is attached to the end to ensure correct placement and for removal. (An IUD should only be inserted and removed by a medical professional.) Currently in the United States, 2 types of IUDs are available: copper and hormonal. Approximately 2% of women who use birth control in the United States currently use IUDs. The most recently introduced hormonal IUD is the levonorgestrel intrauterine system (LNG IUS or Mirena).

• Effectiveness: The IUD is one of the most effective classes of birth control available. According to the American College of Obstetricians and Gynecologists, only about 8 of 1,000 women who use the copper IUD will become pregnant in the first year of usage. According to Planned Parenthood, fewer than 3 women out of 100 who use the progestin IUD become pregnant during the first year of use. The success rate with the LNG IUS system is even greater. With continued use, even fewer pregnancies occur. A woman can increase her protection by checking the IUD string regularly, and by talking with her doctor immediately if she notices a problem.
• Pros: A woman using an IUD is always protected with nothing to remember. IUDs start working immediately, and they can be removed at any time. IUDs are relatively inexpensive over time. The risk of side effects is low. IUDs can be inserted 6 weeks after the delivery of a baby or following a spontaneous or induced abortion. Women who use a copper IUD after childbirth can breastfeed safely. An IUD is usually not felt by a woman or her partner. Women who cannot use birth control pills because of cigarette smoking or conditions such as uncontrolled hypertension may be able to use an IUD. Most women experience less menstrual blood loss and pain with hormonal IUD usage. The copper IUD can remain in place up to 10 years. The LNG IUS is approved for use to prevent pregnancy for up to 5 years in the United States and up to 7 years in Europe and Asia.
• Cons: A trained professional must both insert and remove an IUD. Serious complications from IUD usage are rare. IUDs are spontaneously expelled during the first year of use in about 5% of women who use them. This is most likely to happen during the menstrual period. During menstruation women using IUDs should check their pads or tampons for expulsion. They should also attempt to feel the IUD string in the vagina on a regular basis. If an IUD is expelled unnoticed, a woman may easily become pregnant. If pregnancy occurs while an IUD is still in place, the risk of miscarriage is 50% greater. This risk is decreased to 25% if the IUD is extracted as soon as possible. If the IUD is not removed, a serious infection may result. An IUD will protect against normal intrauterine as well as ectopic pregnancies. However, if a woman conceives with an IUD in place, she is more likely to have an ectopic than a woman who conceived without an IUD. Women using IUDs who suspect they may be pregnant should contact their clinicians immediately to make certain that the pregnancy is within the uterus, as an ectopic pregnancy is a very serious complication.
• Side effects and serious adverse events: An IUD may perforate the wall of the uterus when it is inserted. This occurs in 1-3 of 1,000 insertions. Cramping and backache may occur in the first few hours after an IUD is placed. Bleeding may occur for several weeks after insertion. Some women have increased menstrual cramps and bleeding while using the copper IUD, but these symptoms are usually decreased in those using the hormonal IUD. Pelvic inflammatory disease is also possible with IUD use if a woman is not in a monogamous relationship and has an increased risk of STD transmission. It should be noted that IUDs do not in and of themselves cause pelvic infection.
• STD protection: IUDs do not protect against STDs. STDs can be more serious in women who have IUDs, and the chance of getting an STD may be higher in women who use IUDs during the first 4 months after they are placed. IUDs are best suited for women in relationships in which both partners are monogamous.

There are a variety of options when choosing a natural or behavioral type of birth control. These include:

Continuous abstinence: Continuous abstinence implies completely refraining from sexual intercourse.

• Effectiveness: It is 100% effective in preventing pregnancy.
• Pros: There are no hormonal side effects.
• STDs and continuous abstinence: This type of birth control prevents sexually transmitted diseases (STDs).

Withdrawal method (coitus interruptus intimate): The withdrawal method involves withdrawal of the entire penis from the vagina before ejaculation (before sperm leaves the penis). Fertilization is prevented because sperm does not contact the female partner's egg. This method remains a significant means of fertility control in less advantaged countries.

• Effectiveness: This depends largely on the man's capability to withdraw prior to ejaculation. The theoretical failure rate is estimated to be approximately 4% during the first year of proper usage of this method. The true failure rate probably approaches 19% during the first year. The failure rate implies that the method is ineffective in preventing pregnancy, and some couples using it will conceive. The higher the failure rate, the more likely a woman is to have an unintended pregnancy.
• Pros: This method can be used at any time, with no devices, cost, and no chemicals or hormones. It may also offer a lower risk for other problems.
• Cons: There is a high risk for unintended pregnancy.
• STDs and withdrawal: This method does not protect against sexually transmitted diseases (STDs).

Natural Family Planning: Natural Family Planning (NFP), endorsed by the Couple to Couple League, is one of the most widely used methods of fertility regulation, particularly for those whose religious or cultural beliefs do not permit using devices or drugs to prevent pregnancy. This method involves periodic abstinence (no sexual intercourse), with couples attempting to avoid intercourse during a woman's fertile period-around the time of ovulation. Ovulation refers to the release of an egg by one the ovaries during a woman's menstrual cycle. The current method of NFP taught by the Couple to Couple League and other organizations is called the symptothermal method. NFP has advantages and disadvantages:

• Effectiveness: The Couple to Couple League states, "the Sympto-Thermal Method of Natural Family Planning can be used at the 99% level of effectiveness in avoiding pregnancy." If a couple takes chances and has intercourse during Phase II, the fertile period, their odds of pregnancy increase dramatically. In August, 2002, the U.S. Food and Drug Administration (FDA) reported a failure rate of 20 pregnancies per 100 women per year for periodic abstinence. This figure did not differentiate for particular methods of periodic abstinence. The American College of Obstetricians and Gynecologists (ACOG) lists a higher failure rate for periodic abstinence of 25%. Again, this figure does not differentiate for the type of periodic abstinence.
• Pros: No harmful effects from hormone use occur. This may be the only method acceptable to couples for cultural or religious reasons. NFP methods can also be used to achieve pregnancy.
• Cons: This is most suitable for women with regular and predictable menstrual cycles. Complete abstinence is necessary during the fertile period. This method requires discipline and systematic charting. It is not effective with improper use. To use this method effectively, a woman or couple should be trained by a medical professional or a qualified counselor. A relatively high failure rate has been reported.
• STDs and NFP: This method does not protect against STDs.

Fertility Awareness Method: Women who use the Fertility Awareness Method (FAM) monitor body temperature and characteristics of cervical mucus similar to those who practice NFP. However, women using FAM may either avoid intercourse or use a backup non-hormonal method of birth control, such as a condom, during the fertile period. Women using the FAM monitor 3 primary fertility signs: basal body (waking) temperature, cervical mucus, and cervical position. Intercourse is not considered "safe" unless all of these conditions are satisfied. It is recommended that 2 full cycles be charted before this method can be relied upon. FAM has advantages and disadvantages.

• Effectiveness: If a couple has intercourse without using backup protection during the fertile period, the odds of pregnancy increase dramatically. In August, 2002, the FDA reported a failure rate of 20 pregnancies per 100 women per year for periodic abstinence. This figure did not differentiate for particular types
• Pros: No harmful effects from hormone use occur. FAM methods can also be used to achieve pregnancy.
• Cons: Complete abstinence without back-up protection is necessary during the fertile period. This method requires discipline and systematic charting. The method is not effective with improper use. For maximal effectiveness, a woman or couple should be trained by a medical professional or qualified counselor. A relatively high failure rate has been reported.
• STDs and FAM: This method does not protect against STDs.

Rhythm method: Couples who practice the rhythm method, also called the calendar method, decide when to abstain from intercourse based on calendar calculations of the previous 6 menstrual cycles. However, allowances are not made for the normal variations in the menstrual cycle which many women experience. This method is not as reliable as the symptothermal method of NFP or FAM.

Cervical mucus method: Also called the ovulation method, the cervical mucus method involves monitoring changes in cervical mucus, but without also recording basal body temperature and/or menstrual history. The safe period is considered to be any dry mucus days following menstruation, as well as the 10 or 11 days at the end of the cycle. Days of menstrual bleeding are deemed to be safe, but pregnancy has been reported following intercourse during menstruation. Vaginal infections, sexual excitement, lubricants, and certain medications can significantly affect the accuracy of cervical mucus assessment.

Basal body temperature method: This method involves monitoring basal body temperature only, without also observing changes in cervical mucus or other signs. Sex is avoided from the end of the menstrual period until 3 days after the increase in temperature.

Breastfeeding and birth control: After the birth of a child, certain hormones prevent a woman from ovulating if she is breastfeeding. The length of time ovulation is suppressed varies. It depends on how often the woman breastfeeds and the length of time since the baby's birth. Ovulation usually returns after 6 months despite continuous nursing.

Breastfeeding used for birth control is also called the lactational amenorrhea method (LAM). When menstrual period resume following pregnancy, another form of birth control is needed.

• Effectiveness: ACOG reports this method to be 98% effective in the first 6 months after delivery if the above criteria are met. Once menstrual bleeding resumes, the risk of pregnancy increases greatly.
• Pros: A woman has no menses during this time.
• Cons: The return of fertility cannot be accurately predicted. Frequent breastfeeding may be inconvenient. This method should not be used if the mother is HIV positive.
• STDs and breastfeeding: Breastfeeding does not protect against STDs.

Male condom: The male condom (also called a rubber) is a thin sheath placed over an erect penis. A man or his partner unrolls the condom over his penis before he places the penis in the woman's vagina. A male condom prevents pregnancy by acting as a physical barrier to the passage of semen into the vagina. A condom can be worn only once. It is one of the most popular methods of contraception. Condoms may be purchased at most drug and grocery stores. They are also sold from dispensers in many public restrooms. Condom use has increased among all women of reproductive age because of their concern about contracting HIV (the virus that leads to AIDS) and other sexually transmitted diseases.

Condoms made from latex are most effective in preventing unwanted pregnancy. They also serve to protect against sexually transmitted diseases such as AIDS and gonorrhea. Condoms should not be used use condoms with petroleum jelly, lotions, or oils, as these may decrease its effectiveness. They can decrease the effectiveness. They can be used with lubricants that are not oil-based such as K-Y Jelly.

• Effectiveness: The failure rate of condoms in couples that use them consistently and correctly during the first year of use is estimated to be about 3%. However, the true failure rate during that period is estimated to be approximately 14%. This marked difference in failure rates reflects errors in usage. Some couples fail to use condoms every time they have sexual intercourse. Condoms may fail (break or come off) if you use the wrong type of lubricant (for example, using an oil-based lubricant with a latex condom can cause it to disintegrate). The condom may not be placed properly on the penis. Also, the man may not use care when withdrawing.
• Pros: Condoms are readily available and are generally low cost. A prescription is not necessary. This method involves the male partner in the contraceptive choice. They are the only type of birth control that is highly effective in preventing HIV disease.
• Cons: Condoms may decrease the enjoyment of intercourse. Some users may have an allergy to latex. Condom breakage and slippage makes them less effective. Oil-based lubricants may damage the condom.
• STDs and male condoms: Besides abstinence, latex condoms are the best protection against STDs.

Female condom: The female condom (brand name: Reality) is a polyurethane sheath intended for 1-time use, similar to the male condom. You can buy them at a drugstore without a prescription. The female condom prevents pregnancy by acting as a barrier to the passage of semen into the vagina. The male partner should not use a condom at the same time because they may adhere to each other, leading to slippage or displacement of either device. If you have to choose between the two methods, the male condom confers better protection.

• Effectiveness: Early tests show a pregnancy rate of 15% within 6 months. In August, 2002, the FDA listed a higher failure rate of 21 pregnancies per 100 women per year. The proportion of women using this method of contraception in the United States is less than 1%.
• Pros: The female condom provides some protection to the labia and the base of the penis during intercourse. Although it may provide limited protection, it is not as effective as a latex male condom in preventing STDs. The sheath is coated on the inside with a silicone-based lubricant. It does not deteriorate with oil-based lubricants. It can be inserted as long as 8 hours before intercourse.
• Cons: The lubricant does not contain spermicide (a substance that kills sperm). The device is difficult to place in the vagina. The inner ring may cause discomfort. Some users consider the female condom awkward. The female condom may cause a urinary tract infection (UTI) if left in the vagina for a prolonged length of time.

Diaphragm: The diaphragm is a shallow latex cup with a spring mechanism in its rim to hold it in place in the vagina. Diaphragms are manufactured in various sizes. A pelvic examination with measurement of the vaginal length of your vaginal canal must be performed by your health-care professional so that the correct size of the diaphragm can be determined. Instructions as to how to prepare and insert the diaphragm will be provided by the physician.

The diaphragm prevents pregnancy by providing a barrier to the passage of semen into the cervix. Once in position, the diaphragm provides effective contraception for 6 hours. After that time, if the diaphragm has not been removed, fresh spermicide must be added with an applicator. The diaphragm must be left in place for at least 6 hours after sex but not more than 24 hours.

• Effectiveness: Effectiveness of the diaphragm depends on the age and experience of the user, the continuity of its usage, and the concomitant use of a spermicide. The typical failure rate within the first year of use is estimated to be 20%.
• Pros: The diaphragm does not use hormones. The woman is in control of her contraceptive method. The diaphragm may be placed by the woman in anticipation of intercourse.
• Cons: Prolonged use during multiple acts of intercourse may increase the risk of urinary tract infection. Use for longer than 24 hours is not recommended due to the possible risk of vaginal erosion and (much less commonly) toxic shock syndrome. The diaphragm requires professional fitting. The diaphragm has a high failure rate, and its usage requires brief formal training. The diaphragm must be cleansed regularly to prevent vaginal odor.
• STDs and the diaphragm: This method does not protect against STDs.

Cervical cap: The cervical cap is a soft cup-shaped latex device that fits over the base of a woman's cervix. It is smaller than a diaphragm and may be more difficult to insert. It too must be fitted by a trained provider, as it comes in different sizes. Spermicide is needed to fill the cap one third full prior to its insertion. It may be inserted as long as 8 hours before sexual activity, and it can be left in place for as long as 48 hours. The cervical cap acts as both a mechanical barrier to sperm migration into the cervical canal and as a chemical agent with the use of spermicide.

• Effectiveness: The effectiveness depends on whether a woman has had previous vaginal childbirth, because this affects the shape of her cervix. With perfect use during the first year, a woman with no previous vaginal deliveries has a theoretical failure rate of 9% (use failure rate approximately 20%), as opposed to a theoretical failure rate of 20% in a woman who has delivered vaginally (use failure rate of 40%).
• Pros: It provides continuous protection as long as it is in place regardless of the number of episodes of intercourse. Unlike the diaphragm, repeat applications of spermicide are not necessary if intercourse is repeated. The cervical cap does not involve ongoing use of hormones.
• Cons: Cervical erosion may lead to vaginal spotting. A theoretical risk of toxic shock syndrome exists if the cervical cap is left in place longer than the prescribed interval period. The cervical cap requires professional fitting and instruction in its use. Severe obesity may make placement difficult. A relatively high failure rate exists. Women must have a history of normal results on Pap smears.
• STDs and the cervical cap: This method does not protect against STDs.

Sponge: The vaginal sponge, introduced in 1983, and taken off the market shortly thereafter, is enjoying a resurgence in its popularity. The sponge is a soft circular polyurethane device that contains a spermicide (nonoxynol-9). It is disposable, and should be discarded after use. It is OTC, and may be appealing to women who wish to avoid using hormonal contraception. It offers an immediate and continuous presence of spermicide throughout a 24-hour period.

• Effectiveness: The FDA lists the failure rate for the previously marketed sponge to be 14-28 pregnancies per 100 women per year.
• Cons: Serious medical risks are rare, but they include irritation and allergic reactions, as well as difficulty with removal. Toxic shock syndrome is a rare but serious infection that can occur if a sponge is left in place longer than recommended. Nonoxynol-9 provides some protection against pregnancy.
• STDs and the sponge: The sponge does not protect against STDs.

Spermicides are chemical barriers to conception. They are a reversible method of birth control in that when a woman ceases usage, full fertility returns immediately. Vaginal spermicides are available OTC, and are available in forms such as foam, cream, jelly, film, suppository, or tablet. Spermicides contain a chemical that kills sperm or makes them inactive so that they cannot enter a woman's cervix. Nonoxynol-9 is the active chemical in most spermicidal products in the United States.

• Effectiveness: Spermicides are not as effective as many other forms of birth control when they are used alone. They are frequently are used with barrier methods of contraception, and they are much more effective when used in combination. When used in combination with a condom, they are very effective. Various sources list failure rates from 20%-50% for a typical first year of usage.
• Pros: Spermicides usually do not affect other body systems.
• Cons: Some spermicides may be inconvenient, as they often require a waiting period of several minutes before they become effective. The spermicide must be reapplied before each act of intercourse. Spermicides may irritate the vagina or penis. Switching brands may alleviate this problem. Serious medical risks are rare, but they include irritation, allergic reactions, and urinary tract infections.
• STD protection: Spermicides were once thought to provide minimal protection against STDs such as chlamydia and gonorrhea. However, this is no longer believed to be the case. In fact, irritation of the vaginal surface may increase susceptibility to some STDs, especially HIV, when the spermicide is used several times a day. Women who want to reduce the risk of STDs should always have their partner use a latex condom.

Sterilization is considered a permanent form of birth control that a man or woman elects to undergo. Although tubal sterilization, or a tubal ligation, for women and vasectomy for men are sometimes reversible, reversal surgery is much more complicated than the original procedure and is frequently unsuccessful. Thus, when choosing a sterilization method you should not have thoughts of future reversal.

Hysterectomy or tubal ligation

Each year approximately one million American women elect to have surgery to occlude their Fallopian tubes (i.e. tubal ligation). Some women have a hysterectomy (removal of the uterus and sometimes the ovaries) each year, but usually primarily for birth sterilization to prevent pregnancy.

Most US women who have undergone sterilization by tubal ligation will have either a postpartum mini-laparotomy procedure or an interval (timing of the procedure does not coincide with a recent pregnancy) procedure. A postpartum tubal ligation is performed through a small incision in the lower crease of the navel right immediately following vaginal childbirth. If a Cesarean section is done, the tubal ligation is performed through the same abdominal incision. An interval tubal sterilization is usually performed using laparoscopy with instruments being introduced through small incisions made in the patient's abdominal wall (laparoscopic tubal ligation).

The Fallopian tubes (through which the egg passes after release from the ovary and where fertilization of the egg normally occurs) may be blocked with clips, bands, segmental destruction with electrocoagulation, or suture ligation with partial removal of the fallopian tube (i.e. partial salpingectomy). Female sterilization prevents fertilization by interrupting the passage through fallopian tube.

• Effectiveness: Sometimes this method does not provide permanent birth control. The United States Collaborative Review of Sterilization has examined the failure rate of female sterilization. Rates vary according to the type of procedure performed. The cumulative 10-year failure rate with each method of tubal ligation is as follows: spring clip method is 3.7%, bipolar coagulation is 2.5%, interval partial salpingectomy (partial removal of tubes) is 2%, silicone rubber bands is 2%, and postpartum salpingectomy (tubes cut after delivery) is 0.8%.
• Pros: Female sterilization does not involve hormones. It is a permanent form of birth control. There are no changes in libido (sexual desire), menstrual cycle, or breastfeeding ability. The procedure is usually a same-day procedure done in a surgical outpatient facility.
• Cons: The procedure involves general or regional anesthesia. It is a permanent form of birth control, and some women may regret the decision afterward. The two most common factors associated with regret are young age and unpredictable life events, such as change in marital status or the death of a child. Regret has also been shown to correlate with external pressure from a clinician, spouse, relatives, or others. Regret is difficult to measure because it encompasses a complex spectrum of feelings that can change over time. This helps to explain that while some studies have shown "regret" on the part of 26 percent of women, fewer than 20 percent seek reversal and fewer than 10 percent actually undergo the procedure. Sterilization does not protect you from sexually transmitted diseases. Sterilization involves all of the risks of surgery. Occasionally, sterilization cannot be done laparoscopically, and an abdominal incision may be necessary to reach the fallopian tubes (mini-laparotomy). There is some short-term discomfort. Tubal sterilization does not protect against sexually transmitted diseases.

Fallopian tube implants (Essure)

The FDA has approved a small metallic implant (Essure) that is placed into the fallopian tubes of women who wish to be permanently sterilized. During the implantation procedure, the doctor inserts 1 of the devices into each of the 2 fallopian tubes. This is done with a special instrument called a hysteroscope that is inserted through the vagina and cervix into the uterus. The device works by inducing scar tissue formation over the implants, blocking the fallopian tubes and preventing fertilization of the egg by sperm.

• Pros: Once placement is confirmed, you do not need another form of birth control.
• Cons: During the first 3 months, women cannot rely on the Essure implants and must use an alternative method of birth control. After three months, women must undergo a final X-ray (hysterosalpingogram) procedure in which dye is introduced into the uterus and an X-ray is taken to confirm proper device placement and bilateral tubal occlusion. Once bilateral occlusion has been confirmed, it is no longer necessary to use a second form of birth control. If the X-ray confirms tubal occlusion, the likelihood of a future pregnancy is remote. The procedure cannot be reversed. This is a permanent form of birth control.
• Additional risks and adverse events: Sometimes doctors may have difficulty placing the implants. There is an increased risk for an ectopic pregnancy.
• STDs and Essure: This method does not prevent STDs.

Vasectomy (male sterilization)

Vasectomy involves an incision made in the scrotal sac, followed by cutting or burning of the vas deferens (tubes that carry sperm), and blocking both cut ends. The procedure is usually performed with the patient under local anesthesia in an outpatient setting. Vasectomy prevents the passage of sperm into seminal fluid by blocking the vas deferens. Some men may develop bruising in their testicles. After the vasectomy, some sperm may remain in the ducts. A man is not considered sterile until he has produced sperm-free ejaculations. Semen is tested in the lab several weeks after the procedure to insure that sperm are no longer present. This usually requires 15-20 ejaculations (the couple should use another form of birth control during this period, or the man may ejaculate by masturbation).

• Effectiveness: The failure rate is determined to be approximately 0.1%.
• Pros: Vasectomy involves no hormones. It is permanent. The procedure is rapid with few risks. It is performed as an outpatient procedure in a clinic or doctor's office.
• Cons: Men may regret the decision later. Short-term discomfort occurs following the procedure. Vasectomy does not protect against STDs.

Douching is a method of rinsing out the vagina. Women use water, vinegar, or pharmaceutical products which are introduced into the vagina using a squeeze bottle or rubber tubing. It has long been thought that women need to cleanse their vaginas and reduce odor. Some women douche after menstrual periods or sex so as to avoid contracting a sexually transmitted disease. Some also believe that douching following intercourse will prevent pregnancy. Douching is not recommended as a form of cleansing, birth control, or STD protection.

• Douching is not recommended. This practice has the potential to alter the delicate chemical and ecological balance within the vagina. Douching may actually facilitate an infection or spread pre-existing infection into other pelvic organs such as the uterus.
• Douching after sex does not prevent pregnancy. In fact, the practice may increase a woman's chance of developing an ectopic pregnancy, a serious condition that can be life threatening, by causing an infection in the Fallopian tubes.
• STDs and douching: This method does not protect against STDs. It actually may increase the chance of developing pelvic inflammatory disease and transmitting STDs.

Emergency contraception (birth control after sexual intercourse) is defined as the use of a drug or device to prevent pregnancy after unprotected sexual intercourse. Emergency contraception can be used when a there is a condom failure, following a sexual assault, or on any occasion following unprotected sexual intercourse. An example is the "morning after pill."

Unwanted pregnancy is common. Worldwide, about 50 million pregnancies are ended each year. In the United States each year, the widespread use of emergency contraception may have prevented over 1 million abortions and 2 million unwanted pregnancies. Emergency contraceptives available in the United States include the emergency contraceptive pills and the Copper T380 IUD. A number of brands of "morning after" contraceptives are available without a prescription. Women who have had unprotected sexual intercourse may elect to use emergency contraception within the following 72 hours (3 days). There are no specific signs and symptoms of pregnancy during the first 2-3 days, when the morning-after pill needs to be employed. A woman will never know whether the pill prevented an unwanted pregnancy.

Emergency contraception should not be used as an ongoing birth control contraceptive method if you are sexually active or planning to be because they are not as effective as any ongoing contraceptive method. The "morning after pills" contain high doses of the same hormones found in standard birth control pills. There are few known risks in emergency hormone pill regimens, because the high-dose of hormones is short lived. Several cases of deep vein thrombosis (blood clotting) have been reported in women using this emergency method. These pills will not work to terminate an existing pregnancy.

Emergency contraceptive pills and the mini-pill emergency contraception method: The emergency contraception pills (Preven) use 2 birth control pills, each containing ethinyl estradiol and norgestrel, taken 12 hours apart for a total of 4 pills. The first dose should be taken within the first 72 hours following unprotected intercourse. The mode of action of this pill regimen has not been clearly established. A menstrual period and fertility return with the next cycle.

• Effectiveness: Some studies show that they are effective if taken after that period of time, but such off-label use should not be encouraged.
• Cons: The Plan B method is 1 dose of levonorgestrel taken as soon as possible, but no later than 48 hours after unprotected sex, with a second dose taken 12 hours later.

Copper T380 intrauterine device: The Copper T380 IUD can be inserted as many as 7 days after unprotected sexual intercourse to prevent an unwanted pregnancy.

• Effectiveness: Emergency contraceptive pills are effective 55%-94% of the time, but most likely about 75% of the time. The effective rate of 75% does not mean a 25% failure rate. Instead, when considering 100 women who have had unprotected sexual intercourse during the middle 2 weeks of their cycle, about 8 will become pregnant. Of those 8 who have used emergency contraception, 2 will then become pregnant. Despite this significant reduction in the pregnancy rate, women must understand that this method of contraception should be used only in emergencies, and that they should be encouraged to use other more consistent forms of ongoing birth control.
• Pros: Insertion of the IUD is significantly more effective than the emergency contraception pills, reducing the risk of pregnancy following unprotected sex by more than 99%.
• Cons: Some women may feel nausea and experience vomiting. There may be minor changes in your menstrual period, some breast tenderness, fatigue, headache, abdominal pain, and dizziness. Ectopic pregnancy is possible if a treatment failure occurs. This is a life-threatening condition. Emergency contraception does not protect against STDs.

A drug called mifepristone (also known as RU-486) can block production of progesterone, a hormone produced by the placenta that is needed for pregnancy to continue, assuming an egg has been fertilized and implanted in the uterus. By taking this drug (and another one called misoprostol), a pregnancy can be terminated if 49 or fewer days have elapsed since the onset of the last menstrual period.

• These drugs should only administered by a physician who has been trained to diagnose problems that may develop such as ectopic pregnancy. You will be asked to sign a statement indicating you understand you are terminating a pregnancy.
• Once you take on oral dose (pill taken by mouth) of mifepristone, you will be given misoprostol 2 days later to cause your uterus to contract and expel the embryo through the vagina.
• You will experience cramping and bleeding, and it is necessary to return to your doctor for follow-up examinations.
• This method is not a preventive form of birth control, as it is used after a pregnancy has already been established.

Although development of new birth control methods in the United States has slowed in the past few years, research outside of the United States continues at a rapid pace. Many new birth control designs are being tested to provide a greater variety of methods with fewer side effects, greater safety, and efficacy.

• Pill for men: One exciting new development is a hormonal contraceptive method for men. The male birth control pill manipulates steroid hormones to decrease viable sperm production.
• Injection for men: A reversible male birth control method utilizing injections of progestin every 3 months has been shown to decrease sperm production. With this method, implants are placed under the surface of the skin every four months. This evolving technology has been shown to reduce male sex drive (libido).
• Vaccine: A pregnancy vaccine is one of the most controversial and exciting forms of birth control under development. The pregnancy vaccine stimulates an immune response against sperm so that fertilization does not occur.