Birth Control Services

One can categorize contraceptive options many different ways, based on route of administration, length of duration to reversibility to rate of effectiveness and many more. Here we break it down based on how we practice in our office, and we broadly categorize them into reversible vs not reversible (irreversible) methods.

Irreversible Methods

Permanent Sterilization: These are generally surgical methods done under general anesthesia and are meant to be PERMANENT. Does that mean they are 100% effective all the time though? NO. Remember, the old saying that “only Taxes and Death are permanent consistencies in this world” to quote Benjamin Franklin. These procedures fail, although at much much lower rate than “pull out”, pills, patches etc. I have delivered babies to couples who have failed each and every method of contraception imaginable. Here’s a partial list of procedures:

Fallopian Tube Surgeries: So, this is a tricky one because there’s so much misconception about its labeling. Most people call this procedure “Tube Tying” or “tying my tubes”. Well, the reality is that we never EVER put a knot (tied) anyone’s tube. It is anatomically impossible to tie a knot without damaging a blood vessel or other ligaments, leading to surgical complications. What used to happen was various surgeries performed on the fallopian tube, either a portion of the tube was removed (the fimbriated end or the middle portion) or it was removed in totality or attached to uterus etc. Currently, the recommendation is to remove the fallopian tubes in their entirety to reduce the chance of epithelial ovarian cancer (yes, it arises from the fimbriated end of the fallopian tubes). This can be done laparoscopically (most common and the only way we do them at La Femme Health) or open (typically during a c-section). Only really really old school, out of date & old in age OBGYNs can’t or do not perform the procedure laparoscopically nowadays.

Vasectomy for men: This is a procedure where the tubing that connect the testes and sperm production to penile shaft and urethra is disrupted. This procedure DOES NOT do anything to a person’s masculinity! The testicles continue to produce testosterone as they did in the past, it’s just that the sperm they produce doesn’t go anywhere and gets absorbed into the body. While we don’t offer this one in our office, we’re mentioning it for multiple reasons:

• Completeness sakes
• In MY OPINION, men SHOULD do this procedure since their partners have gone through far tougher procedure of either vaginal birth or a surgery like a c-section, giving birth to their kids and this is the least they can do for their partner. PLUS, they’ve taken charge of their own contraception instead of passing the buck. And please don’t get me started on Men telling women what to do with their bodies etc. NO woman ever got pregnant by herself, and without women, men wouldn’t be able to have children to pass on their legacies. So, come on men, MAN UP and get snipped. Remember a woman always does more with what a man gives her, she turns a sperm into a child, a son to carry on your name or daughter to melt your heart; she turns the raw foods into meals, turns the house you bought into a home.
• Far easier procedure than tubal ligation ad can be done in the office. Bonus: it is easier to reverse than a tubal ligation, cheaper and more successful and if reversal fails men don’t die, where as if a tubal reversal fails, women can die to ectopic pregnancy! (more reason for men to MAN UP and protect their women).

https://www.mayoclinic.org/healthy-lifestyle/birth-control/basics/sterilization/hlv-20049454

Reversible Methods

Now that we’re done with permanent options, let’s talk about reversible methods, and our office recommendations (not a complete list), based on effectiveness, are as follows:

• Intrauterine Contraceptive Device
• Nexplanon
• Patches/rings/pills
• Condoms and barriers
• DepoProvera
• Others

By definition, none of these methods are permanent and they’re all highly susceptible to failure, some more than others, and YES if they fail it is your fault, as a general rule. The following is a list, albeit not a complete list by far, and we’ll list them in order of effectiveness and how we recommend them at our office:

Intrauterine Contraceptive Devices: Our number one recommendation for contraception, Otherwise known as IUDs or IUCDs for short, there are many in the market in the U.S., but they’re generally broken down into hormonal or non hormonal (there is only one, called Paragard). We’ll start with our favorites and those we recommend highly, the Hormone containing ones. You may wonder WHY do we recommend hormonal ones, please read on.

• They do not fall out as often as the ParaGard in my experience,
• They make periods last shorter with less flow & duration in general, they may make your period disappear in its entirety,
• They can be removed at any time without long term issues of ovulation suppression that happens with other methods (like pills, patches etc), as a general rule within a week of IUD removal you can get pregnant (I know of 3 patients that got pregnant within a week), whereas with other methods it can be up to 2 years. The hormones also clear the system much faster because, so little got into your system to begin with (comparatively speaking the circulating levels of hormones from pills/patches and rings is about a1000x higher than what IUDs release into your system).
• The Paragard (non-hormonal one) in our experience does make periods heavier, more painful and longer flow duration, it also falls out more often and over the years; We’ve seen many patients get pregnant with the IUD in place, whereas we’ve seen that only once with hormonal containing ones. Just to put it out there, we put about 20x more of the hormonal ones and saw less pregnancies than we did with the ParaGard, so we are jaded based on our experience.

Now, you may ask what about insertion and removal? You’ve heard it’s painful and hard! And I’d say they CAN be for sure, especially if you’ve never been pregnant before. Owing to a smaller uterus, any distension can cause more pain than a “trained”, previously pregnant uterus. Removal is EASY unless the IUD string can’t be located and it takes some exploration of the cervical canal to find the string, but as a general experience, most of our clients that came in scared because of what they’d heard or seen on internet, were nicely surprised with their experience, whether it was insertion or removal.

You may want to know if there are any dangers to insertion or removal, and YES, as with any medical procedures there are risks. The removal is lesser of two evils and in our office, we use an ultrasound to help if we don’t see the IUD string ( We use ultrasound with removal if needed but we use it in 100% of our IUD insertions) . If we see the IUD string, we will just pull it and voila, you’re done, if unable to see the string we will locate the IUD with ultrasound and approach it directly.

Overall, based on scientific literature IUDs are the safest, longest lasting, and least failed contraceptive options. Whether you choose the non-hormonal (ParaGard) IUD or hormonal IUD (Mirena, Skyla, Liletta, Kyleena) you can rest be assured that you’re getting a great contraception, we offer most in our office and have experience putting over a few thousand in patients, please see us for a consult.

https://www.mirena-us.com/

https://www.mayoclinic.org/tests-procedures/mirena/about/pac-20391354

https://www.skyla-us.com/

https://www.kyleena-us.com/

https://www.liletta.com/

https://www.paragard.com/

https://www.mayoclinic.org/tests-procedures/paragard/about/pac-20391270

https://newsnetwork.mayoclinic.org/discussion/contraception-faqs-intrauterine-device/

https://www.mayoclinic.org/drugs-supplements/levonorgestrel-intrauterine-route/description/drg-20073437

Nexplanon

Nexplanon is an implantable device that SHOULD be implanted in the groove between your biceps and triceps muscle on the inner aspect of your arm. It is good for three years, it contains a progesterone that gets released into your blood stream (so hormone goes everywhere in your body), and I wouldn’t consider it a LOW DOSE contraceptive options. This is a GREAT contraceptive option and has a very low failure rate (like IUDs because the patient doesn’t have to do anything to make it work), however, it does have a few shortcomings. Since you can read all about it from their website, I’m going to relay our experience with it to you. The main issue we have had is IRREGULARLY IRREGULAR bleeding that has led to more than a few patients wanting it removed within the initial first year. The bleeding varies in duration, flow and interval and if it interferes with your sex life, well this isn’t going to make life any easier. However, we also have a lot of patients (my own wife included) who love it and have had little to no issues with it. Based on my experience it’s about 50/50, half the patients love it, half want it out. Because the hormone travels everywhere on your body, you may also have side effects related to it, and it can be from hair loss to facial acne etc, so be prepared for various side effects. Because we approach our recommendations from effectiveness rate side of the equation (instead of say minimizing side effects) Nexplanon is our second-choice recommendation. One thing we have also experienced with, is with its placement. While we haven’t had any issues with the ones we have placed, we have had more than a few clients who came to us wanting it removed and it was so poorly misplaced (like over the biceps, or so deep it could barely be palpated) that it couldn’t be done, so please make sure your practitioner knows where to place it and if they tell you over the muscle is okay (it’s not) go to another safer place.

https://www.nexplanon.com/

https://www.mayoclinic.org/tests-procedures/contraceptive-implant/about/pac-20393619

Pills/Patches/Rings

The reason I lumped all these together is because they’re all very similar to each other and have very similar side effect profiles. Why do they have similar side effects, you may ask? It’s because they all give you various generations of progesterone and an Estradiol component. Most have Ethinyl Estradiol as the estrogenic component (except Nexstellis which has E4) and the progesterone can be very estrogenic to very androgenic (Estrogen, progesterone and testosterone molecules have very similar structures and due to our individual genetic variation, we all respond differently to various progesterones).  Most patients have experience with one or two if not all of the methods. As a general rule, almost all suppress ovulation (hence they’re also used in a variety of other medical conditions such as PCOS and not just for contraception). But because they supply both Estrogen and a progesterone, they simulate pregnancy, so you may initially have some morning sickness, feel more bloated, gain weight or have changes in your skin, hair and emotional patterns, so be warned. A potential lethal side effect is formation of a blood clot in your vascular system (known as Deep Venous Thrombosis) which can get dislodged and travel to your lungs and impede blood flow (known as Pulmonary Embolus or PE). The rate of DVT/PE formation is 4 per 100,000 individuals, for comparison, the rate in pregnancy is 10 per 100,000; while in a non-pregnant state the rate is 1 in 100,000. So, yes, the rate is more than when you’re on no birth control, but less than half of pregnancy. Also, various other methods, such as IUDs and Nexplanon give you the same cautions but from medical literature their DVT/PE rates are lower; but manufacturers practice legal protection for themselves by putting it in their literature.

The route of administration really determines the dosage and side effects of the various methods. It also helps to know that since their initial introduction, the dosage of Estrogens have decreased significantly to reduce side effects and increase compliance (at the expense of effectiveness). So, if you’re taking a pill, you’re more likely to have GI side effects, if you use a patch you may have local skin changes where it was applied and if you use the vaginal rings, well they might fall out during horizontal mambo sessions and you won’t know it until it’s too late (operator failure if you will).

There’s also a pill that is generally referred to as “The Mini pill”, this one just contains progesterone and is most often used during breast feeding immediately post-partum (to avoid the detrimental effects of Estrogen on milk production).  This is NOT a great birth control when NOT breastfeeding, so please don’t think it’s just as effective but has less hormones. This pill works by thickening the cervical mucous but counts on ovulation suppression that is happening via prolactin hormone production (the hormone responsible for breast feeding).

https://www.mayoclinic.org/healthy-lifestyle/birth-control/in-depth/best-birth-control-pill/art-20044807

https://www.nuvaring.com/

https://www.annovera.com/

https://www.mayoclinic.org/tests-procedures/minipill/about/pac-20388306

https://www.mayoclinic.org/tests-procedures/combination-birth-control-pills/about/pac-20385282

https://www.mayoclinic.org/tests-procedures/birth-control-patch/about/pac-20384553

https://www.mayoclinic.org/healthy-lifestyle/birth-control/basics/birth-control-pills/hlv-20049454

Condoms and Barriers

This bunch is mostly over the counter stuff you can find at a variety of places from 7-eleven and gas stations to pharmacies and sex shops. While these are great for STD prevention (none of the other ones are), they’re highly dependent on the operator.

If a male condom breaks, do you think the guy is “with it” enough to stop and say “I’m going to stop my orgasm and pull out and get another one”?? While many guys are “with it” enough, the great majority aren’t and combine that with frequency of usage, we’re not big on male condoms, because the woman gets pregnant but here, she is counting on the guy to care more than her; why do you think 51% of pregnancies are Unintended?? Female condom maybe more robust, but in my 20+ years of doing this I can count on one hand the number of patients that used it regularly. A cervical cap is also another option but placing it correctly can be hard and again prone to failure.

Depo-Provera

This is an injection, once every 3 months. It has great bleeding profile (most patients don’t bleed it on it) however, it is also the most common birth control with bleeding complaints and the only one I’m aware of that has been shown to cause weight gain (1.5 lbs). Also, it has been black labeled by FDA due to its effects on bone synthesis, or rather how it slows and stops bone synthesis. The reason for this is that women make denser and denser bones until age 35 y/o, and after that they begin losing bone density with most of the loss occurring during the first 5 years after menopause. So, if you were on Depo for 10 yrs prior to age 35, your bone density is 10 yrs less than it would have been, and that maybe enough to increase your chance of osteoporosis and fractures when you get older. Hence, for us, in our office, we almost never recommend it.

https://www.mayoclinic.org/tests-procedures/depo-provera/about/pac-20392204

Other methods

There are other methods that rely on women figuring out their ovulation and avoiding intercourse during those times (for example by checking body temperature or cervical mucous), or breast feeding (only during the first 6 months after birth).  You can read about these online or ask us when you come in for your contraception consult.

https://www.cdc.gov/reproductivehealth/contraception/index.htm#Birth-Control-Methods

https://www.mayoclinic.org/healthy-lifestyle/birth-control/basics/other-birth-control-options/hlv-20049454?reDate=27022015&p=1