WDH Mini-guide to contraception

Contraceptives can fail or become less effective due to drug interactions that speed up digestion or change how the body absorbs contraceptive hormones. Non-hormonal contraceptives are less likely to be affected by drug interactions. Common interacting drugs include certain antibiotics, medicine to prevent or control seizures (anticonvulsants), HIV treatment (antiretrovirals), and herbal supplements like St. John's Wort. To lessen these effects, consult a healthcare provider, and consider backup contraceptive methods if taking any of these other medications.

Emergency Contraception is a critical safety net for preventing unintended pregnancy after unprotected sex or contraceptive failure. The sooner this option is used, the more effective it can be. Emergency contraception does not protect against STBBIs and is not to be used as a regular method of birth control. Situations where you may consider using emergency contraception:

• No contraception was used.
• Condom broke, leaked, or slipped off.
• Missed a dose of birth control pill/patch/injection.
• Error in the calculation of your fertility period.

There are two types of emergency contraception in Canada to choose from:

1. Emergency contraceptive pills:
   1. Levonorgestrel (Plan B One-Step®) is a progestin hormone pill and is available in all Canadian pharmacies without a prescription. It is most effective when taken within 24 hours of unprotected sex and then progressively less effective until five days after the sexual encounter at which point they are not recommended anymore. A higher body weight (body mass index > 25) may decrease the effectiveness of these pills.
   2. Ulipristal acetate (Ella®) is another pill now available in Canada, with a prescription. It is effective within five days after unprotected sex and may be less affected by a higher body mass index.
2. An intrauterine device (IUD) is the most effective emergency contraception, but it requires a prescription and must be inserted by a healthcare provider within seven days of unprotected intercourse. Once inserted, an IUD provides ongoing reliable birth control lasting 10 years if you choose to keep it.

Hormonal Contraception

Hormonal Contraception releases hormones such as estrogen and progestin, or progestin alone, to regulate hormone levels during the menstrual cycle. Not everyone can take this medication, and there are potential side effects that should be discussed with your healthcare provider before getting a prescription.

BIRTH CONTROL PILLS are popular worldwide and have a failure rate of 9% (90 in 1000) during the first year of use. There are two types of birth control pills:

1. A combined pill that contains estrogen and progestin.
2. A progestin-only pill, also known as the “mini-pill", which must be taken daily at the same time for effective pregnancy prevention.

THE CONTRACEPTIVE PATCH contains the same estrogen and progestin as the combined pill and has a failure rate of 9% during the first year of use. It is a 4x4 cm patch that sticks to the skin for seven days at a time, totaling three patches applied in sequence over three weeks. The fourth week is a patch free week, allowing a period to occur. The patch is very sticky allowing you to exercise, shower, swim and go to the sauna.

THE VAGINAL RING is a soft, flexible, clear ring inserted by the user into the vagina and has a failure rate of 9% during the first year of use. It slowly releases estrogen and progestin for three weeks. The ring is removed for the fourth week allowing a period to occur. It is 54 mm in diameter (one size only) and held in place by the vaginal walls. The ring does not need to be in a specific position for it to be effective and usually cannot be felt once it is in.

INTRAUTERINE CONTRACEPTION, also known as an intrauterine device (IUD), is a small T shaped device that needs to be inserted into the uterus by a healthcare provider. There are two types:

1. Copper IUD, which is not hormone, based and is discussed below.
2. Levonorgestrel intrauterine system only contains progestin, which is a great option for those who cannot take estrogen and is effective for 3-10 years before needing replacement depending on which type/brand is inserted. This has the second lowest failure rate, only 0.2% (2 in 1000) during the first year of use. This method is also used for menstrual suppression and reduction. Rare complications of insertion include infection, perforation of the uterus or dislodging of the IUD. The contraceptive effect is stopped when the device is removed.

INJECTABLE CONTRACEPTION also known as the Depot shot (Depo-Provera®), only contains progestin, and has a failure rate of 6% (60 in 1000) during the first year of use. The injection is usually given in the upper arm muscle every three months by a healthcare provider, (four times per year).

CONTRACEPTIVE IMPLANTS are new to Canada (2020) but has been in use for many years around the world. It contains only progestin and is the most effective birth control in the world with a failure rate of 0.05% (5 in 10,000). It is a thin rod (4 cm x 2 mm) inserted by a healthcare provider in the office, using medicine to numb the skin. It is effective for three years, then needs to be removed and replaced.

Non-Hormonal Contraception

Non-Hormonal Contraception utilizes methods to prevent the sperm from meeting the egg, without hormones.

THE MALE CONDOM is cheap, and readily available without prescription. It is only effective when used correctly during sexual activity and has a failure rate of 18% (180 in 1000). The condom is worn over the penis which acts as a physical barrier preventing sperm from entering the uterus. Condoms are available in latex, polyurethane, and lambskin. Condoms are disposed of after a single use. Condoms can be used in combination with other methods to increase effectiveness. Condoms must be stored safely, including above 0 degrees but below 38 degrees Celsius and away from any sharp objects.

THE COPPER INTRAUTERINE DEVICE is a small T-shaped device that needs to be inserted into the uterus by a healthcare provider. The failure rate is 0.8% (8 in 1000). The device works by releasing small amounts of copper ions into the uterus that are toxic to sperm and make it difficult for an egg to implant. Depending on the make of the device, it can last 3-10 years, before needing replacement.

THE FEMALE CONDOM is a soft, loose-fitting sheath containing two flexible rings at both ends that act as a physical barrier preventing sperm from entering the uterus. It has a failure rate of 21% (210 in 1000). The internal (smaller) ring has a closed end which is inserted into the vagina, near the cervix and held in place by the vaginal walls. The external (larger) ring has an opening which sits outside the vagina. The condom can be placed in the vagina eight hours before sexual intercourse and is disposed of after a single use.

THE CONTRACEPTIVE SPONGE is a small foam device that is placed inside the vagina to absorb and trap sperm while slowly releasing spermicide over a 24-hour period. The failure rate is 24% (240 in 1000). One side of the device has a concave dimple that fits over the cervix, the other side has a ribbon loop to allow removal afterwards. It can be inserted up to 24 hours before sexual intercourse and starts working immediately. The device needs to be left in the vagina for at least six hours after the last sexual intercourse to be effective but should not remain in the vagina for more than 30 hours. These are disposed of after removal.

SPERMICIDES contain a chemical which destroys sperm and is available as foam or film. This is not an effective birth control method when used alone but can improve the effectiveness of barrier methods such as the sponge, cap, or diaphragm when used together. The failure rate is 28% if used alone.

THE CERVICAL CAP is a reusable silicone cap that covers the cervix and acts as a physical barrier preventing sperm from entering the uterus. The failure rate is very high and therefore it is not a recommended form of birth control.  Spermicidal foam/film must be applied to the device before inserting the cap and must be re-applied using an applicator after each sexual intercourse and/or after two hours have passed. The device must be left inside the vagina for six hours after sexual intercourse but should not remain in the vagina for more than 48 hours. This reusable device requires a prescription and must be replaced every year.

THE DIAPHRAGM is another type of reusable cap that covers the cervix and acts as a physical barrier preventing sperm from entering the uterus. The failure rate is very high and therefore is not a recommended form of birth control. The diaphragm requires the application of spermicidal foam/film for effectiveness before each sexual intercourse. It can be inserted into the vagina up to two hours before sexual intercourse and must be left in the vagina for at least six hours after sexual intercourse, but not longer than 24 hours.

A VASECTOMY is the male surgical procedure to block/remove the tube (vas deferens) that carries sperm to the penis. The failure rate is 2% (2 in 100). The procedure is done by a specially trained healthcare provider in the office using medicine to numb the area and should not affect any other biological functions. It is considered permanent, as reversal is not always possible, therefore only those who are certain of their decision to not have any (more) children should select this option. Success is confirmed by providing a semen sample a few weeks after the procedure to check for sperm.

A TUBAL LIGATION (or removal) is the female surgical procedure to block/remove the (fallopian) tubes that transport the eggs from the ovaries to the uterus. The failure rate is extremely low. This procedure is performed in the operating room by a gynecologist and does not usually require overnight stay in the hospital. It is considered a permanent procedure, as reversal is not always possible, therefore only those who are certain of their decision not to have any (more) children should select this option. For those who are pregnant and scheduled for a C-section (Cesarian) delivery, this procedure can be performed immediately after the birth is complete, if planned with your gynecologist in advance.

Natural Methods

Natural Methods do not involve medications or devices. The failure rates are very high even with perfect use.

FERTILITY-AWARENESS or KNOWLEDGE METHODS involve tracking the menstrual cycle and watching for signs of fertility to avoid unprotected sexual intercourse during the fertile window. The failure rate is 24% (24 in 100). The fertile window opens five days before ovulation and closes one day after ovulation. Signs of ovulation (fertility) include a rise in basal body temperature and changes in cervical discharge which can be tracked on a calendar or by using an ovulation test kit.

THE LACTATIONAL AMENORRHEA METHOD relies on the hormone changes that occur with childbirth and during lactation which stop the body from returning to a fertile state. The failure rate is 2% (2 in 100) in the first six months. This can be highly effective after childbirth so long as the menstrual period has not returned and breast/chest feeding occurs at least every four hours during the day and every six hours during the night. After six months, fertility and the menstrual period can return at any time.

THE WITHDRAWAL or PULL-OUT METHOD is when the penis is removed from the vagina before ejaculation to prevent sperm from entering the uterus. The failure rate is 22%. This method is not reliable because pre-ejaculate fluid can contain sperm and can be released at any time during the interaction.

ABSTINENCE is when a person does not have any sexual intercourse, allowing no opportunity for sperm to meet and fertilize an egg. It is 100% effective with perfect use, which requires a high level of self-control and commitment. Many individuals who plan to practice abstinence may not stick to it consistently over time with a failure rate estimated between 20% and 40% per year.

Choosing Your Contraception Method

When choosing a contraception method, consider several factors to find the best fit for your needs. Consider how effective the method is at preventing pregnancy and protecting against STBBIs. Consider your lifestyle, including the demands of deployment and training, and how convenient the method will be for you, such as whether you prefer to take a daily pill or prefer a long-term solution like an IUD.

Consider any health conditions you may have and potential side effect . Finally, discuss your options with your partner and a healthcare provider to ensure you make an informed decision that aligns with your health and personal preferences. Be patient and open to trying different options until you find the method that works best for you.