Preparation for your wedding night—and for your life as husband and wife—will include consideration of whether you want to use contraceptives and if so, what method is best for both of you. Many couples assume the responsibility to plan the number of children they hope to have and when they hope to have them. Family planning is the process of setting up that program for your reproductive life. It is thinking, praying, and talking with each other about this decision. Whenever a couple decides not to allow the wife to get pregnant any time that would happen naturally, they have chosen to control conception.
As you come to grips with the religious and moral issues of contraception, you will work through those issues together. It is best if the family-planning decisions are settled before marriage. Ask yourselves, “How does our reproductive plan fit with our religious beliefs? Would we like to have children? How old would we like to be when we have children? How would we feel if we couldn’t have children? How would we feel if we got pregnant without planning for it?”
Each of you comes to the marriage with attitudes regarding childbearing that will affect your feelings about using contraception. These attitudes need to be cleared with each other. One spouse may be totally against using contraception and the other not ready to allow babies to arrive at random. Agreement concerning your attitudes and feelings about contraception is vital to family planning—and to your marriage.
MAKING THE CHOICE
Contraception prevents the man’s sperm from uniting with the egg cell from the woman. Note that contraception is used to prevent pregnancy, not to interrupt it once conception has taken place. That is an important moral and religious distinction. We are not talking about taking life; we are talking about preventing a new life from beginning.
There is no perfect method of contraception. What works well for one couple may not be suitable for another. All methods currently practiced have both advantages and disadvantages. The method you choose will be as effective as you are in using it.
Today a variety of reliable methods are available. Choosing a proper contraceptive method is a serious matter. It is not the woman’s decision. It is a decision to be made by both spouses with thought and care. In choosing a contraceptive, four issues need to be considered: safety, effectiveness, convenience, and personal preference.
Remember, if you are not going to faithfully use the method you choose, it will not be effective even if it is, by general definition, safe, effective, and convenient. Your personal preference may depend on how a method will interfere with your sexual relations. That is why this issue needs to be discussed by the two of you.
NONMETHODS
Abstinence
Refraining totally from sexual intercourse is 100 percent effective, but is not appropriate for marriage. We believe abstinence is the method of choice before marriage but is clearly against biblical teaching after marriage. First Corinthians 7:3–5 says we are not to withhold ourselves from one another except by agreement for a season of prayer, and then we’re to come together again quickly lest we be tempted. Nowhere does the Bible state that we should abstain from sex to prevent pregnancy.
Withdrawal
Having intercourse (entry of the penis into the vagina) but removing the penis from the vagina before the man ejaculates (releases seminal fluid containing sperm) is frequently practiced as an attempt to prevent conception. It is not a method of contraception, however, and it has many disadvantages. First, it can be emotionally and physically upsetting. Two people have united themselves intensely; then (and at the height of openness and vulnerability) they pull apart. Second, many men do not have complete control over when they ejaculate, so accidents are almost inevitable. Third, and of utmost importance, seminal fluid containing sperm is released before ejaculation. Thus, withdrawal is not effective.
Douching
Using some means to flush the seminal fluid containing sperm out of the vagina has been attempted for ages, but this practice is neither effective nor safe. Those tenacious little sperm are fast and determined; they get into the uterus and go looking for the egg in the fallopian tube long before the woman can get to her douche bag and douching solution! Douching is not a method of contraception even though it is thought to be.
BARRIER METHODS
Barrier methods of contraception prevent the sperm from meeting the egg. Barrier contraceptives include condoms for men and for women, the sponge, diaphragms, cervical caps, and spermicides.
Male Condom
A condom is commonly referred to as a rubber, prophylactic, safety, or sheath. It is a latex polyurethane, or animal-membrane device shaped like the finger of a glove that is placed over the erect penis before entry into the vagina.
Reasons for the condom’s popularity are their inexpensiveness, their advantage of being easy to purchase without a physician’s prescription, and the fact that they require the man’s involvement and prevent a woman’s allergic reaction to the man’s sperm. Except for the occasional allergic reaction to latex, there are no side effects from the use of condoms, so they are safe.
Condoms’ effectiveness depends on how they are used. The failure rate as reported by the Food and Drug Administration in August of 2002 is 11 percent.1 This means that 11 out of 100 couples using condoms perfectly for one year got pregnant. To use condoms successfully, you must be certain the condom is new and free of holes or tears, and follow the detailed instructions for application and withdrawal.
Condoms will be inconvenient; love play must be interrupted to put them on, and the man must keep an erection until he withdraws from the vagina. That can cause considerable anxiety for some men and interfere with their sexual response. Condoms also interfere with some men’s pleasure by reducing sensitivity. For others, it is just a nuisance. Repeated experience with putting on condoms as part of the love play can reduce the inconvenience and enhance their use.
Female Condom
This is a polyurethane pouch, or sheath, that lines the inside of the vagina. A flexible ring on each end holds the condom in place. The inside ring is used for insertion and as an internal anchor. The outer ring remains outside the vagina after insertion and covers part of the perineum providing protection to the labia and the base of the penis during intercourse.
The Food and Drug Administration reports a 21 percent failure rate in the first year with typical use.2 Some women experience irritation and allergic reactions, but the likelihood is reduced since it is not latex and no spermicide is used with the female condom.
The Sponge
The vaginal contraceptive sponge is a two-inch-wide, round, soft, pillow-shaped polyurethane sponge permeated with spermicide (one gram of nonoxynol-9). However, the sponge is not currently marketed.
The Diaphragm
This barrier method has been used effectively for well over one hundred years. The vaginal diaphragm is a dome-shaped rubber with a flexible rim that covers the cervix so that sperm cannot reach the uterus. A spermicidal jelly or cream must be used with a diaphragm to ensure effectiveness since the diaphragm itself cannot prevent all sperm from reaching the cervix.
With typical use, the diaphragm is 83 percent effective in preventing pregnancy. That means seventeen out of one hundred women during the first year of using the diaphragm with spermicide get pregnant. Medications for vaginal yeast infections may decrease effectiveness.3
One advantage of the diaphragm is that it has no side effects. Also, it is usually inserted before intercourse and must be left in place for at least six hours after intercourse. The diaphragm must be prescribed and fitted by a physician. The fit should be checked after pregnancy, pelvic surgery, or a weight change of ten pounds or more. The position of the diaphragm should be checked every time you have intercourse.
Cervical Cap
The cap is similar to the diaphragm in function and effectiveness. It is a soft rubber cup with a round rim that fits over the cervix. Just like the diaphragm, the cap needs to be fitted by a professional on a healthy cervix. It comes in four sizes.
The cap has about the same effectiveness as the diaphragm for women who have never been pregnant, but it has a higher failure rate than the diaphragm for women who have been pregnant at least once.4
Vaginal Spermicides
Spermicidal creams, jellies, film, foam, suppositories, and tablets inserted into the vagina contain both a carrier and a chemical. The chemical nonoxynol-9 kills the sperm. Spermicidals must be inserted at a designated time before intercourse, depending on the type of spermicide used. The effectiveness of most spermicides lasts an hour. Read the directions of the product you are planning to use to determine when effectiveness begins and how long it lasts.
Studies have shown varying failure rates. The Food and Drug Administration reported that anywhere from 20 to 50 out of 100 women get pregnant using only a spermicide.5
Intrauterine Device
The intrauterine device (IUD) is inserted into the uterus by a health professional. The devices have been made of various shapes and materials, including silver, copper, and plastic. A string is attached to the device to allow the woman to check that the IUD is still in place and to allow the physician to remove it. In the 1970s, 10 percent of contraception use in the United States was by the IUD. Today that use is less than 2 percent, and the majority of users are in their thirties and forties. The Centers for Disease Control reports that today’s IUDs are highly effective and safe for long-term contraceptive use for women with a low risk of sexually transmitted diseases (STDs).6
What about effectiveness? The IUD is considered highly effective. However, the skill of the medical person who inserts the IUD and the woman’s checking to make sure it is still in place are essential to its effectiveness. Fewer than 1 percent of women who use the IUD get pregnant.7
Convenience is the IUD’s biggest advantage. A physician can insert it at any time, even ten minutes after delivering a baby. It can remain in place for ten years; thus, it does not require insertion and removal by the user. Nor does the woman have to remember to take a pill.
How does the IUD prevent pregnancy? For some time, the belief was that the IUD caused abortion by expelling the fertilized egg. This theory is currently in doubt because of a study that collected released eggs from women using the IUD and from women using no form of contraception. Half of the eggs from the women not using contraception had been fertilized and expelled, while none of the eggs from the IUD users showed signs of fertilization.8 Mirena, the IUD containing a progestin commonly used in birth control pills, works by making the cervical mucus thick and tacky so the sperm become immobilized and cannot enter the uterus.
HORMONAL PREGNANCY PREVENTION
Various forms of hormonal contraception have been researched and debated before and since the approval of “the pill” by the FDA in 1960. Their convenience and effectiveness make them highly desirable.
The Pill
The pill is a combination of synthetic estrogen and progesterone hormones that, when taken by the woman, shuts off the release of eggs so she no longer ovulates. It also inhibits other processes of impregnation. If the pill is started or resumed on the first through the fifth day of the cycle, day one being the first day of any menstrual spotting or bleeding, inhibition of ovulation is virtually assured.
When the pill is taken consistently, it has an effectiveness of 99.7 to 100 percent. When taken at the same time every day as directed and when extra precautions are used when you have diarrhea or vomiting or are taking certain drugs that may interfere with the pill’s effectiveness, only one out of one thousand women (0.1 percent) will get pregnant during the first year of use.9 Most women get pregnant because they stop the pill to validate whether they are having side effects from it. But when they stop the pill, they fail to use other effective contraception. If you want to test the pill’s effect on you by going off of it for a while, have other contraception planned and ready to use before you stop.
The ratio and amount of the chemical activity of progesterone, estrogen, and androgen vary with the various types and brands of pills. Each woman’s body has to be evaluated to determine which pill will be most effective with the fewest side effects. Unfortunately, some women try one pill, have side effects, and decide this method is not for them. Instead, they may need to change to a lower-level dosage or a pill that has a different proportion of estrogen, progesterone, or androgen.
Managing Contraceptive Pill Patients by Richard P. Dickey can be ordered from Essential Medical Information Systems, Inc., P.O. Box 820062, Dallas, Texas 75382-0062. You may also contact them at 1-800-225-0694 or by going to www.emispub.com. If you are going to use the pill, we recommend that you order this book to help you choose the correct pill for you and to guide you in using it most effectively. As Dr. Dickey says, “I have placed a major emphasis on two indisputable points: 1) patients are different in their responses to OCs [oral contraceptives], and 2) OCs are also different in their steroid contents and, therefore, in the reactions they elicit in patients.”10
You should be aware that certain medications will interfere with the effectiveness of the pill. Some antibiotics, antifungals, sedatives and hypnotics, anticonvulsants, cholesterol-lowering agents, and other substances may interfere with the pill’s ability to prevent pregnancy. This was demonstrated when a granny-to-be wrote a well-known advice columnist saying that her son and daughter-in-law were about to have their first baby. She said the pregnancy was due to the daughter-in-law’s ear infection that was treated with antibiotics while she was trusting the pill for pregnancy prevention. If you are on the pill, check with your physician and consult Dr. Dickey’s Managing Contraceptive Pill Patients before taking any medication. Ask how it interacts with and changes the effectiveness of your hormonal contraceptive.
Benefits. There are other benefits from the pill besides contraception. Premenstrual tension lessons for some women, menstrual cramps may decrease, the duration and amount of blood loss may be reduced, and the time of menstruation becomes totally predictable. Sometimes acne declines, there is less susceptibility to pelvic inflammatory disease, and the risk of ovarian and endometrial cancer is reduced by 40 to 50 percent. The chance of breast cysts and noncancerous breast tumors is lessened by 50 to 75 percent, endometriosis and rheumatoid arthritis are reduced by 50 percent, growth of excessive body hair often diminishes because the OC suppresses androgen activity, and ovarian cysts are reduced by 65 percent.11
The pill can also affect a woman’s sexuality; about-equal numbers of women report an increase or decrease in sexual desire. Pills with high progesterone activity are likely to suppress desire; pills with high androgen activity encourage desire. Some women find the physical changes with their periods and the reduction of acne enhance their sexual desire and body image. Many women using oral contraceptives do not experience any significant change in sexual behavior, sexual interest, or sexual enjoyment.
Risks Versus Benefits. For women in the high-risk categories, the risks outweigh the benefits, but for the majority of women who are of childbearing age and do not want to get pregnant, the benefits typically outweigh the risks if you meet the following criteria:
• You are a woman in your twenties or thirties.
• You do not weigh more than one-third above your ideal weight.
• You do not smoke.
• You do not have high blood pressure.
• You are not an insulin-controlled diabetic, do not have an elevated cholesterol level or a high LDL/HDL cholesterol ratio, and have not had any female in your extended family develop diabetes or have a heart attack before age fifty.
• You do not have a history of liver, heart, or vascular disease.
• You are not susceptible to blood clotting.
Maximizing Effectiveness. To get the highest effectiveness in pregnancy prevention from oral contraceptives, follow these instructions summarized from Contraceptive Technology:12
1. Take the pill at the same time every day. Associate taking your pill with something else you do at the same time each day, such as brushing your teeth.
2. Choose a backup method of contraception to use—
a. During your first month of using the pill for protection
b. In case you run out of pills
c. In case you forget to take your pills
d. If you have to discontinue the pill because of serious side effects
e. If you need protection from sexually transmitted diseases
f. If you have repeated bleeding between cycles
g. If you have to take antibiotics or other medications that interfere with the pill’s effectiveness
3. Start your pills according to your physician’s instructions and take one pill a day until you finish the pack. If you have a twenty-eight-day pack, begin a new pack immediately. If you are using a twenty-one-day pack, start your new pack one week after you stopped the last pack.
4. Check your pack of birth control pills each morning to make sure you took your pill the day before.
5. If you forget to take your birth control pill or you start your pack late, follow the instructions below:
If you miss one pill, take that tablet as soon as you remember it. Take your next tablet at the regular time. You probably will not get pregnant but just to be sure, you may want to use a backup method for seven days after the missed pill.
If you miss two pills in a row, then take two tablets as soon as you remember and take two tablets the next day. Then return to your regular schedule but use a backup method of birth control for seven days after two missed tablets.
If you miss three pills in a row you will probably begin your period. Whether or not you are menstruating throw away the rest of your pack and begin your next pack as you did when you first started the method. For example, if you are a Sunday starter begin your next pack on Sunday. If you started on any other day, you may simply start your next pack immediately. Use a backup method of birth control until you have been back on pills for seven days.
If the only pills you miss are from the fourth week of a twenty-eight-day pill pack, simply throw away the missed pills. Then continue taking pills from your current package of pills on schedule. The pills in this fourth week do not contain hormones. So missing these pills does not increase your risk for pregnancy at all.13
6. “If you have diarrhea or vomiting, use your backup method of birth control until your next period.”14
7. If you do not have a menstrual period when expected while taking oral contraceptives consult your physician.
8. Read and follow the instructions on the pill package insert.
Injection
Depo-Provera is a deep injection of progestins given every three months to inhibit ovulation. It has the advantages of not being absorbed and processed through the liver and giving moderately long protection. It is not quite as effective in preventing pregnancy as the combined pill, and its contraceptive effects may take six months to reverse.
Patch
Ortho Evra, a skin patch, is worn on the lower abdomen, buttocks, or upper body. It releases both progestin and estrogen directly into the bloodstream. A new patch is applied once a week for three weeks. The patch is not worn during the fourth week so the woman has a menstrual period. The patch has a 1 percent failure rate but appears to be less effective with women over 198 pounds.
Vaginal Contraceptive Ring
The NuvaRing is a flexible ring that is about two inches in diameter. When it is inserted into the vagina, it releases the hormones progestin and estrogen. It is inserted by the woman and remains in place for three weeks. She does not wear the ring during the fourth week and has her menstrual period. The failure rate is 1 percent.15
Hormonal methods of contraception are constantly being researched. So new products and current information regarding their effectiveness, risks, and benefits are continually becoming available. Keep yourself informed so your choice is based on fact rather than fear.
NATURAL METHODS
More and more couples today are considering “natural” methods of family planning because they fear the potential risks and side effects of contraceptives. These methods are based on the principle of avoiding sexual intercourse during the woman’s fertile phase of the menstrual cycle. “Rhythm,” or “Billings,” method may be terms you’ve used to describe natural family planning. We cannot provide enough information here to train you to effectively practice natural family planning, but you can access information about the Billings-ovulation method on the Web at www.billings-ovulation-method.org. Or try The Ovulation Method:Natural Family Planning by John J. Billings, which details every dimension of planning pregnancies without using contraceptives or sterilization.16
For disciplined, determined, well-trained couples, natural family planning has been successful and enjoyable. One of the benefits is increased awareness of your hormonal cycle. You can enhance your sexual relations by exploring total-body pleasure without intercourse during your fertile or questionable days.
Surgical Sterilization
The opposite extreme of natural family planning is sterilization, a final form of contraception. It ends one’s capacity to reproduce.
Male vasectomy is the simplest and safest form of surgical sterilization; this procedure prevents the live sperm from reaching the penis. The sperm normally travel from the testes, where they are produced, through the vas deferens, a tube that leads through the prostate gland to the urethra. During a vasectomy, a small portion of the vas deferens is removed and the cut ends are tied off and sometimes cauterized. This procedure interrupts the sperm’s journey so sperm will not be released when a man ejaculates during a sexual experience. He will still produce seminal fluid since some of that is produced in the portion of the duct system above the cut.
One caution: After a vasectomy, a man may have to ejaculate twenty-five times or more before all live sperm are cleared from the duct system above the cut. Several seminal fluid specimens should be taken to the laboratory for confirmation that the sterilization process is complete.
For the woman, sterilization is referred to as tubal ligation. The woman’s fallopian tubes are blocked so the egg and sperm cannot meet. It is a one-time surgical procedure through a small incision in the abdominal wall or through the vagina or the uterus. Many times hospitalization is not necessary.
When tubal methods fail, which is less than 1 percent of the time, it is because the procedure itself failed due to the surgeon’s misjudgment; there are some other surgical risks involved as well.
Neither male nor female sterilization changes the person’s sexuality in any way. The woman will still produce eggs, and the man will still produce sperm. These eggs and sperm disintegrate and are absorbed. The woman continues to menstruate. The man does not usually notice a change in his ejaculation. Hormonal production remains normal for both. Sexual responsiveness and behavior are unaffected except for feeling greater freedom and not having to use contraceptives.
Family planning is a very personal matter. Personal feelings, as well as the technical facts, are important parts of your choice of planned conception. Talk openly with each other about this issue and take responsibility for your sexuality with a focus on the long-term benefits. Choosing a family planning method is not an easy decision because no method is perfect in both effectiveness and safety. Yet everything has risk, including life itself. Remember that no known contraceptive has a death rate as high as pregnancy—and the death rate from pregnancy is very low.
Since it is the woman who gets pregnant, shouldn’t she take responsibility for birth control?
It is certainly true that the woman carries the baby and so needs to feel secure about the method of birth control used. But the responsibility for choosing a particular method needs to be a joint one because it will affect both the husband and the wife. The woman can easily feel alone in making this decision, so husband, don’t desert your wife on this one.
Should we avoid having sex during menstruation and pregnancy?
Not necessarily. Some women will have their highest interest and peak responsiveness during menstruation or pregnancy, possibly because they are not afraid of getting pregnant. You must discover for yourselves what is most comfortable and what brings the most enjoyment for both of you.