Birth Control Other Approaches to Family Planning including Rhythm, Basal Temp, Mucus, Tubal Ligation and Abortion

very “standard” birth control method has risks—vanishingly small, perhaps, but risks nonetheless. For some women, these methods are also burdened with unacceptable side effects. For many others, they pose a difficult moral dilemma.

For whatever reason, alternative approaches to family planning remain popular. Fertility awareness methods are gaining new adherents, while voluntary sterilization presents a safe and extremely effective option for all women who have completed their families. And, when all methods fail, termination of pregnancy remains a legal and widely used alternative.

Fertility Awareness

Fertility awareness, also known as natural family planning and the rhythm method, has enjoyed a recent resurgence in popularity because it encourages women to become more aware of their bodies and their monthly menstrual cycles while avoiding the use of chemical or mechanical forms of contraception.

To practice this technique, you must first determine your fertile days—the part of your menstrual cycle in which you are most likely to become pregnant. During these days, you then either abstain from sexual intercourse or use another form of birth control, such as a barrier method. Between 5 and 7 percent of American women use this family planning strategy, not only because it is completely safe and inexpensive, but also because it is the only method acceptable to all religions. Some researchers have theorized that using fertility awareness for family planning also builds self­esteem, since intercourse must be planned around the rhythms of a woman's body instead of relying on the protection of barriers or pills.

Nevertheless, fertility awareness is not as reliable as other contraceptive methods. Although its theoretical effectiveness is as high as 98 percent if used correctly all the time, its average effectiveness is much lower—anywhere from 30 to 70 percent for women who frequently forget their timing. Fertility awareness also is difficult to use if you have very irregular menstrual cycles; and the daily record keeping that's required can be cumbersome.

As a result, some family planning experts advocate fertility awareness only for women who would not be unduly upset by an unintended pregnancy or for those who are motivated to follow the rules carefully. Fertility awareness can provide more reliable protection if you use two or more methods at the same time or add a backup form of contraception on your most fertile days.

No health risks are associated with fertility awareness. However, some researchers have linked this approach with higher rates of birth defects and miscarriages, since accidental pregnancies are more likely to occur very late in a woman's fertile period. Couples who delay intercourse until they believe the woman's fertile period has ended may inadvertently fertilize an “old” egg or fertilize an egg with “old” sperm. Either form of conception may lead to chromosome and other fetal abnormalities.

How Fertility Awareness Works

Although the average menstrual cycle lasts 28 days, the length of a cycle varies from woman to woman and even from one cycle to the next. Nevertheless, the number of days between ovulation and the beginning of the next menstrual period is fairly consistent—about 14 days.

You are most likely to become pregnant if fresh sperm are present in your reproductive tract at the time of ovulation. Since sperm are fertile for 2 to 4 days and a woman's egg is fertile for 12 to 24 hours, you are most apt to conceive if you have intercourse during the 4 days prior to or within 1 day after ovulation.

Certain reliable body signs indicate your most fertile period each month. They include specific changes in the color, amount, and texture of your cervical mucus as well as changes in your basal body temperature. To pinpoint your window of fertility, you can watch these signs, or calculate the most likely time of ovulation based on the average length of your menstrual cycle.

The Mucus Method

The cervical mucus discharged through your vagina changes throughout your menstrual cycle in response to normal hormonal variations. By noting these changes in color and consistency, you can detect ovulation. This technique involves checking your vagina and your cervical mucus daily with your fingers. If you're not comfortable with that, the mucus method is not a good choice for you.

To use the mucus method, also called the “Billings method” after the physician who developed it, place a finger inside your vagina at least once each day and notice how wet it feels. If you can collect any mucus on your finger, check it for stickiness and elasticity. Following menstruation, a woman typically experiences a few days when her vagina feels moist but not exactly wet, days when she has no cervical mucus. These are known as “dry” days.

Next you may notice thick, cloudy, sticky mucus with a white or yellowish tint, though your vagina may not actually feel wet. This mucus is a sign that you may be fertile, so you should avoid intercourse once it appears.

As ovulation approaches, the mucus becomes more abundant, clear, thin, slippery, and elastic—like raw egg white—and your vagina feels increasingly wet. These are signs that you're very fertile. The peak, or last, day of wetness and abundant mucus generally occurs at about the time of ovulation. To avoid pregnancy, refrain from intercourse for 4 days after this peak. By that time, you should notice that your vagina has reverted to the characteristics of the “dry” days.

Because blood masks other sensations of wetness during menstruation, the mucus technique alone may not give you enough advance notice of ovulation to prevent pregnancy—especially if you have very short menstrual cycles. The safest way to follow this method is to abstain from intercourse or use another method of birth control from Day 1 of your cycle until 4 days after your peak mucus day.

KEEPING IN TIME WITH YOUR NATURAL RHYTHM

If you can accurately pinpoint the day when ovulation occurs, avoiding conception is easy. The egg remains fertile for a maximum of 24 hours; so if you refrain from sex for 4 days before ovulation (the longest that sperm can survive) and 1 day after, there's no way you'll get pregnant. The catch word here is “accurately.” The three ways of estimating the time of ovulation all have flaws. Body temperature drops briefly before ovulation, then rises. But other factors, such as fever, stress, or an interruption of regular sleeping habits, can nudge your temperature upward, sending a false “all clear.” Peak production of cervical mucus occurs just as you ovulate. But menstrual flow, douches, and lubricants can all confuse the issue, making the true situation hard to judge. Going strictly by the calendar should work if your cycle is absolutely regular. Unfortunately, in many women it's not. The bottom line: Rely totally on the rhythm method only if you wouldn't mind an unexpected pregnancy all that much.

Before relying on the mucus method as a form of birth control, observe the changes for at least 3 menstrual cycles so you can discern your individual pattern with some degree of confidence. Record your findings on a sheet of graph or notebook paper or on a special chart that you can obtain from your physician or a family planning clinic.

You should also be aware that variables such as vaginal infections, the use of vaginal spermicides, douching, the use of artificial lubricants, certain medications, and even the semen and secretions produced during intercourse can affect the accuracy of your mucus “readings.”

The Basal Body Temperature Method

A woman's temperature often falls during the 12 to 24 hours preceding ovulation, then rises for several days after it. By recording your temperature fluctuations, you can determine the “safe” days for intercourse after ovulation. You can obtain these readings by using a special Basal Body Temperature (BBT) thermometer, an instrument sensitive enough to detect very small changes. Basal thermometers and blank charts to record the changes are available in many drugstores and family planning clinics.

To use the BBT method, take a five­minute reading of your temperature with the BBT thermometer every morning, just before you get out of bed. Be sure to take your temperature before you begin any kind of activity, drink anything, or smoke a cigarette. You may use the thermometer either orally or rectally, but be sure you always use the same technique at the same time.

Record your temperature every day on the special graph and connect the dots, so you can chart a line from one day to the next. When ovulation occurs, your temperature will rise by one­half to one degree Fahrenheit and you should stop having sex. When the temperature has been elevated for 3 days, you can resume intercourse for the remainder of your menstrual cycle.

Before relying solely on BBT charting, you should record at least three menstrual cycles to make sure of your temperature pattern. Because your BBT rises only after ovulation, the safest way to use this technique is to avoid intercourse or use a backup method of birth control until you're certain ovulation has passed—in other words, from the beginning of menstruation—Day 1 of your cycle—until your BBT has been elevated for 3 full days.

A few other difficulties are associated with this method. Your temperature may rise for other reasons, such as illness, stress, or a change in your sleeping habits. According to one research study, one­fifth of women have no regular BBT pattern even when ovulating. Factors such as jet lag, dietary changes, irregular sleeping hours, the use of an electric blanket and even nightmares can also affect the accuracy of your BBT readings.

The Calendar Method

This method is the least reliable of the fertility awareness techniques. Since ovulation generally occurs 14 days prior to the onset of a woman's menstrual period, this technique uses the calendar to track the cycle and predict ovulation. You must then abstain from intercourse during the ovulatory period, which is generally assumed to last at least 7 days. The calendar technique is, of course, more reliable if you have regular menstrual cycles. If they vary widely, you should not expect this technique, alone, to provide adequate contraceptive protection.

Before using the calendar method, you should track at least 8 menstrual cycles. Note the shortest and longest cycles, then calculate the length of your fertile period by subtracting 18 from the total length of your shortest cycle to pinpoint your first fertile, or unsafe day, and subtracting 11 from the total length of your longest cycle to determine your last fertile, or unsafe day.

The first day of your period is called Day 1 of your menstrual cycle. Thus, if your cycle always lasts 28 days, you should abstain from intercourse from Day 10 (28­18=10) through Day 17 (28­11=17) of your menstrual cycle. If, however, your cycle varies from 26 days to 30 days, you should refrain from intercourse from Day 8 (26­18=8) until Day 19 (30­11=19) of your cycle.

Minimizing the Risks of Failure

The cardinal rule of fertility awareness is that self­discipline is essential to prevent pregnancy. When used perfectly and consistently, fertility awareness is a highly effective form of contraception. But if you're inclined to take risks and have intercourse on days when you are likely to be fertile, you would be wiser to choose another form of birth control.

Careful and routine recordkeeping is also essential to these techniques. You can increase your chances of success by attending a fertility awareness class or working with a physician, family planning clinic, or women's health center experienced in these methods. You can also increase the effectiveness of this form of contraception and pinpoint your fertility more accurately by using all three methods together.

Be sure to record several cycles before using any fertility awareness technique for birth control. If you later become confused about changes related to your menstrual cycle, don't take chances. Assume you're fertile and abstain from intercourse or use a backup method. If you miss a menstrual period or suspect for any other reason that you might be pregnant, or if your patterns are not clear, be sure to check with your doctor and get a pregnancy test.

Surgical Sterilization

Voluntary sterilization is the most popular contraceptive method in the world. Tubal ligation, the favored form of female sterilization, is more than 99 percent effective—the highest success rate of any form of contraception.

Numerous studies suggest that tubal sterilization is also remarkably safe. The fatality rate in the United States is reported to be as low as 4 per 100,000—much lower than that associated with many long­term contraceptives as well as with pregnancy itself. Pregnancy can cause serious, even life­threatening problems for women with such conditions as a blood clotting disorder or heart disease. For them, and for others who must avoid pregnancy to maintain their health, voluntary sterilization can be considered the contraceptive method of choice.

Surgical sterilization poses very few risks. In rare cases, a woman may suffer complications from the anesthesia, internal bleeding, or injury to surrounding structures such as the intestines. The risks are slightly higher for those who smoke, are overweight, have diabetes or pelvic inflammatory disease (PID), and for those who have had previous abdominal surgery. In an estimated 4 out of 10,000 operations, the procedure is unsuccessful or the tubes manage to reconnect, opening the way to an unexpected pregnancy, often occuring in the fallopian tubes. If this dangerous situation arises, the embryo must be surgically removed.

Very few women suffer any of these complications. Overall, voluntary sterilization is one of the safest, most economical and most effective methods of birth control available to women who've completed their families.

Male sterilization, or vasectomy, also is safe, simpler than female sterilization, and nearly as effective. The risk of death from a vasectomy is extremely low, and research studies have not identified any long­term health problems associated with the procedure.

Due to the irreversible nature of surgical sterilization, however, it is essential that you consider this choice carefully. Sterilization certainly frees a woman from the fear of an unwanted pregnancy and can actually enhance spontaneity and openness in a sexual relationship. Nevertheless, it will not solve emotional, marital, or sexual problems and should never be chosen if any circumstance—a remarriage, the death of a child, or a change in financial status—might lead you to want another child.

Many women undergo sterilization after childbirth because it is convenient and economical, but you should consider this option with special care. The physical and emotional pressures of pregnancy could prompt you to make a choice you might later regret. In the unlikely case that your newborn develops medical problems or even dies, your decision could magnify your emotional pain. For these reasons, medical professionals often recommend that you take a few months after a pregnancy to make sure you want to proceed with the operation.

Although your partner's consent is not legally required, it's wise to make this decision together since it will have a permanent effect on your relationship. Remember, too, that you have a right to change your mind about surgical sterilization at any time prior to the operation, even if you have already signed a consent form.

THE ULTIMATE IN CERTAINTY

Surgical sterilization in a procedure called “tubal ligation” is a just about 100 percent effective means of contraception. But be very cautious: Once it's done, there's no going back. The operation itself is relatively minor. An incision of no more than 2 inches is required—less if the surgeon does a laparoscopy. The object—to block the route from ovary to uterus via the fallopian tubes—can be accomplished in a variety of ways. Here, the surgeon has removed a section of the tube and sutured closed the remaining ends.

How Sterilization is Done

For women, sterilization means blocking or cutting the fallopian tubes so that eggs can no longer descend from the ovaries to encounter the sperm. This can be achieved through several different surgical procedures referred to jointly as tubal ligation. The actual method you undergo will depend upon your physical condition, the interval since your last pregnancy and, to some extent, your doctor's training and experience.

During a minilaparotomy, or “minilap,” the physician makes an incision less than two inches long in your lower abdomen, near the pubic bone, bringing the fallopian tubes into direct view. The doctor then pulls the tubes through the opening, ties them off with bands or surgical clips, and stitches the incision closed. If this procedure is performed after childbirth, your physician will make the incision in the upper abdomen because pregnancy pushes the fallopian tubes higher in the body.

An alternative method, laparoscopy, is sometimes referred to as “Band­Aid ^®” surgery. The physician makes a small incision near the navel and, possibly, a second lower in the abdomen. Carbon dioxide or nitrous oxide gas is injected through the incision to expand the abdomen. The doctor then inserts a laparoscope—a tube that resembles a telescope equipped with a light—to view the abdominal cavity. The woman is tilted backwards slightly, with her head down, so that the intestines more readily move away from the fallopian tubes.

Once the fallopian tubes are in view, the physician inserts an instrument through either the laparoscope or a second incision and seals them with an electric current or ties them off. Once the tubes have been disconnected, the tiny incision(s) are stitched closed.

Tubal ligations also can be performed through the vagina during procedures known as colpotomy or culdoscopy. Long­term success rates and the risk of complications have not been firmly established for these techniques.

In rare cases, a physician may suggest a hysterectomy, or removal of the uterus, but this more complicated surgery should be considered only if other medical conditions are present and never strictly for the purpose of sterilization.

Getting Ready for the Operation

To prepare for your operation, do not eat or drink anything for 8 hours prior to the procedure. Arrange for someone to accompany you to the hospital or clinic, since you should not drive yourself home afterwards. Before leaving for the hospital, shower or bathe, carefully cleaning the area around your navel and pubic area.

Before the surgery, be sure that you are completely comfortable with your decision. Remember that you are entitled to change your mind at any time before the procedure. If you have any last­minute questions or misgivings, talk with your physician and consider canceling or rescheduling the operation.

The actual procedure is quick and relatively painless. In most cases, you will receive an injection of local anesthesia to numb the skin and surrounding tissue before the surgeon makes the incision. This allows you to remain awake and alert, yet feel no pain. You may also receive medication to help you relax. Sometimes sterilization surgery is performed under general anesthesia; once in a while, spinal anesthesia is administered, numbing the lower half of your body.

Most tubal sterilizations—especially those done under local anesthesia—are performed on an outpatient basis. In these cases, the procedure takes less than an hour, and most women can resume their normal activities in 2 to 4 days. When performed after childbirth, tubal sterilization does not increase the length of your hospital stay beyond that required for regular postpartum recovery.

Minimizing Your Postoperative Problems

Female surgical sterilization is effective immediately. No backup form of birth control is needed after the procedure.

Tubal ligation does not trigger early menopause or alter your sexual functions. Your ovaries will continue to release an egg each month, and you will continue to menstruate. Because the tubes are blocked, however, the egg will dissolve and be absorbed by your body. Since your ovaries and uterus remain intact, your body will also continue to produce normal female hormones.

Though inconclusive, some research has suggested that tubal sterilization may be associated with heavier or more irregular menstrual bleeding and cramps, which may necessitate hysterectomy. On the other hand, a recent study of 78,000 premenopausal women found that tubal sterilization reduces the odds of developing ovarian cancer, the fourth leading cause of death in American women. Researchers theorize that severing the fallopian tubes may reduce the blood supply to the ovaries or cause undetected hormonal changes that inhibit cancer. In any event, women in the study who had received a tubal sterilization were only a third as likely to develop ovarian cancer as women with their tubes intact.

After your tubal ligation, plan to rest for at least 48 hours. Most women can then resume normal activities, though to allow the incision to heal, you should avoid lifting heavy objects for another week. You may bathe 48 hours after surgery, but avoid rubbing or pressing on the incision for at least 1 week, and be certain to dry the incision site carefully after bathing. You should also refrain from having intercourse for 1 week, then resume when it feels comfortable.

For the first few days, you may have some discomfort at the site of the incision, but an over­the­counter pain medicine should make you feel better. You may also feel some mild pain around your shoulders from the anesthesia and gas.

You should contact your doctor immediately if you develop a fever greater than 100.4 degrees Fahrenheit, fainting spells, persistent or steadily increasing abdominal pain, or any bleeding or pus at the incision site.

In addition, you should contact your doctor promptly if, at any time in the future, you suspect you might be pregnant. Though this is very rare after female sterilization, should it occur, the pregnancy is 20 times more likely to develop in the fallopian tubes. This is a dangerous situation that requires immediate medical intervention, since the rupture of a fallopian tube is a potentially life­threatening medical emergency.

Terminating Pregnancy

Abortion, or the termination of pregnancy, can be spontaneous or induced. The medical term for a spontaneous abortion is miscarriage. Termination of an unwanted pregnancy, or induced abortion, has been legal in the United States since 1973.

Abortion is not a method of contraception, since it is performed only after conception has occurred. Nevertheless, according to estimates by the U.S. government's National Institutes of Health, roughly half of the induced abortions in the United States each year follow a contraceptive failure. Some unplanned pregnancies are the aftermath of rape, incest or other forms of sexual abuse, while others are simply a result of inadequate sex education. Some women choose abortion when prenatal testing detects fetal abnormalities, or when personal circumstances change after a planned pregnancy occurs.

Whatever the reason, you should make a voluntary, carefully thought-out choice before having an abortion. Counseling is available from many sources, including your physician, your pastor, family planning clinics, social workers, and nurse practitioners. Although you'll probably want to discuss the situation with your partner and other loved ones, you should not feel forced into making a decision that you feel is irresponsible or immoral. Take time to explore your feelings about all the alternatives—raising the child, seeking an adoption, or having an abortion—before making your decision.

Abortion is safest for you when performed early in pregnancy—within the first 12 weeks after conception. After that time, the risks rise dramatically. An abortion performed before 9 weeks poses a 1 in 400,000 chance of death. But by the time 16 weeks have passed, the risk is 40 times greater, or 1 in 10,000. Although even this higher risk is merely comparable to that of continuing a pregnancy, physicians and family planning experts strongly urge a woman seeking an abortion to undergo the procedure as early in the pregnancy as possible.

A number of different surgical and drug­based techniques are available. During the first trimester, vacuum suction or aspiration is often used to draw the contents of the uterus through a narrow tube (cannula) attached to an electric or mechanical pump. This has become the most common technique, and results in the fewest complications. The procedure can be completed in a physician's office or clinic in less than 30 minutes, using local anesthesia. The size of the cannula is dependent on the length of the pregnancy.

RU­486 (mifepristone), often referred to as the “abortion pill” or “ French pill” because of its widespread use in France, is a relatively safe, effective, nonsurgical early abortion measure. This steroid, which blocks the action of the female hormone progesterone, prevents the implantation of a fertilized egg in the uterus and can initiate menstruation even after implantation. Common side effects include abdominal cramps, dizziness, diarrhea, vomiting, and occasional heavy bleeding. The drug is most effective when used within 8 weeks of a woman's last menstrual period and followed by a dose of the hormone prostaglandin, which increases uterine contractions. Although RU­486 is not yet available in the United States, the U.S. Food and Drug Administration has indicated it would consider an application to market the medication.

From the later part of the first trimester on into the second trimester, other techniques come into use. During a vacuum curettage, the doctor stretches (dilates) the cervical opening so that a larger cannula can be used, then scrapes the uterus with a metal loop called a curette. This technique can be performed in a physician's office, clinic or hospital, usually under local anesthesia.

Dilation and curettage (D&C), a common gynecological procedure for diagnostic and therapeutic purposes, is also an option. Doctors sometimes recommend a D&C to ensure complete evacuation of the contents of the uterus. The procedure is usually performed in a hospital under general anesthesia.

Dilation and evacuation (D&E) is a newer method that combines dilation, suction, curettage and, possibly, forceps to terminate pregnancies after 12 weeks. In fact, this has become the most common procedure used for second trimester abortions. Because fetal tissue is larger and a woman's uterus is softer and more susceptible to perforation at this stage, only a skilled medical professional should perform a D&E. This procedure is typically completed in a hospital under general anesthesia.

During a medically induced or labor­induction abortion, the doctor injects saline, a natural body chemical called prostaglandin, or another solution into the amniotic fluid surrounding the fetus. This provokes uterine contractions, or labor, and expels the fetus and placenta from the woman's uterus. The procedure is typically done after detection of fetal abnormalities, and is used only after 16 weeks of pregnancy. It takes place in a hospital using local anesthesia to ease the discomfort of labor and delivery. An ultrasound may be performed prior to the procedure, and a D&C may be performed afterwards to remove any remaining tissue. Doctors often recommend a hospital stay of 1 to 2 days.

During the second trimester—and even later if a woman's life is in danger—a physician may also perform a hysterectomy. During this major surgical procedure, the fetus and placenta are removed through an incision in the abdomen and uterus, much the way a Cesarean section is performed. The operation is considerably riskier than other abortion procedures and is generally used only if other methods have failed.

In rare cases that involve other medical complications, the entire uterus is removed, preventing any future pregnancies.

During surgical abortion procedures, if you are Rh­negative, your doctor will give you immune anti­D globulin (RhoGAM) to prevent blood compatibility complications in future pregnancies. Women who undergo abortions may also be given antibiotics to prevent or treat infection, and blood transfusions if excessive bleeding occurs.

Complications can occur after any type of pregnancy termination, including miscarriage, but are more likely following improperly performed abortions and those performed after 16 weeks gestation. The problems, which range from mild to severe, include infection, bleeding, retained pregnancy tissue, perforation or tearing of the cervix or uterus, or allergic reaction to drugs or anesthesia used during the procedure. Some procedures—especially a vacuum aspiration performed very early in the pregnancy—can fail, and the pregnancy may continue. Some studies have suggested that chronic pelvic infection, which can increase a woman's risk for an tubal pregnancy or infertility, can be a delayed effect of abortion.

After most abortion procedures, you can resume your normal diet and activities. If possible, keep your schedule flexible for the first week following the abortion and avoid any strenuous activities during that time.

It's normal to experience some bleeding and cramps during the first 2 weeks following an abortion, but these should be no heavier than your normal menstrual period. To minimize the risk of infection, do not use tampons, do not douche and refrain from intercourse during the first week following the procedure. You should also check your temperature each day and call your doctor if it exceeds 100 degrees Fahrenheit. Your normal menstrual periods should resume 4 to 6 weeks after the procedure.

Watch for common danger signs that can indicate the presence of an infection, an incomplete abortion, or other complications. These include fever, chills, muscle aches, unusual fatigue, abdominal pain or cramping, tenderness in your abdomen, a bad­smelling vaginal discharge, or bleeding that is heavier than your menstrual period or lasts longer than 3 to 4 weeks. If any of these occur, contact your doctor immediately. And even if you don't experience any complications, schedule a return checkup with your doctor within a few weeks of the procedure.