During the reproductive period, which extends from puberty to menopause, women and couples face birth planning—with the desire to have a wanted child. Based on this, most go through several phases, namely:

• in the initial periods, we primarily want to prevent unwanted pregnancy,
• this is usually followed by a period of planning conception with spacing between births,
• then another period follows where we want to prevent unwanted pregnancy.

And to prevent unwanted pregnancy, we have several different contraceptive methods available, and choosing one is an important decision. The consequence of an ineffective method can be an unplanned pregnancy, while a method that is not safe can cause serious negative health effects.

The method must also align with your lifestyle and be used correctly and consistently; otherwise, it will be less effective. Most often, individual methods are chosen based on:

• effectiveness,
• safety,
• personal factors,
• method accessibility,
• (non-contraceptive) benefits of the method.

Within one year, 85% of women who do not use contraception and are sexually active become pregnant. The effectiveness of an individual method is measured by unplanned pregnancies that occur during exposure to conception while using contraception—this is the so-called contraceptive failure rate.

Unwanted pregnancy can be prevented by different contraceptive methods: reversible (pregnancy is prevented only temporarily) or permanent (sterilization).

REVERSIBLE CONTRACEPTIVE METHODS

Barrier Contraception

Acts as a physical barrier (condom, female condom, diaphragm) or chemically (spermicides).

1. Condom

A contraceptive device used by men. For individuals allergic to latex, polyurethane condoms are available. It is in the form of a sheath, with a seminal fluid reservoir at the tip, and is usually coated with lubricant. The condom mechanically prevents semen from entering the vagina. With typical use of a condom, 4-18 out of 100 women become pregnant in one year. With consistent use, it is a harmless and effective contraceptive device. Protects against the transmission of sexually transmitted diseases and unwanted pregnancy. With the dual method (simultaneous use with effective contraception, e.g., HC or IUD), it offers dual protection.

2. Female Condom (Femidom)

A medical device used by women, made of polyurethane and coated with lubricant. It is inserted into the vagina and, like a condom, mechanically prevents semen from entering the vagina and partially protects the external genitalia. With typical use, 21 out of 100 women become pregnant in one year of regular use, while with regular and consistent use, 5 out of 100 women become pregnant. Available in some countries.

3. Diaphragm

It prevents unwanted pregnancy by blocking the entrance to the uterus and preventing sperm from traveling through the cervix into the uterus. With diaphragm use, 12 out of 100 women become pregnant in one year. For greater effectiveness, it is used simultaneously with spermicides. The size of the diaphragm is determined by a gynecologist, or a one-size-fits-all diaphragm can be used.

4. Spermicides

These are chemical substances that immobilize and destroy sperm. They are available in the form of creams, vaginal suppositories, or soluble films and are inserted into the vagina. These are less effective contraceptives, as 28 out of 100 women become pregnant in one year of use. They are only sufficiently effective when used with a condom or diaphragm.

Natural Family Planning (In Slovenia, we have quite a few girls who deal with natural methods, each with their own. Look them up on IG)

Natural Family Planning (NFP) or natural contraceptive methods are based on understanding fertility and sexual abstinence during fertile days. For effective use of natural methods, the couple must have a good understanding of reproductive anatomy and physiology. NFP is among the less effective methods, as on average, 24 out of 100 women become pregnant in one year of use, making it more suitable for planning a desired conception. NFP is based on determining fertile days, which relies on 5 assumptions that are not always reliable: the alternation of fertile and infertile days in the menstrual cycle; only one ovulation occurs in one menstrual cycle; the egg is capable of being fertilized 12-24 hours after ovulation; sperm survive in the reproductive tract for 3-5 days; and the woman is capable of accurately observing her cycle.

We must also know that stress levels, sleep, medication use, and similar factors significantly affect us. Therefore, if you want to learn any of the natural NFP methods, choose an instructor who will teach you about all the exceptions.

1. Calendar (Ogino-Knaus) Method

Based on estimating fertile days according to the length of the menstrual cycle, which is counted from the first day of menstrual bleeding to the last day before the next menstruation, and must be recorded for six consecutive menstrual cycles. To determine fertile days, subtract 18 days from the shortest and 11 days from the longest menstrual cycle. Abstinence from sexual intercourse is practiced during fertile days.

2. Ovulation (Billings) Method

Based on assessing the mucus secreted by the glands of the cervix. With this method, we assess the mucus at the entrance to the vagina before urination and simultaneously assess the sensation of dryness and wetness. Ovulation occurs one day before, during, or one day after the release of abundant, stretchy, and clear mucus. After ovulation, the mucus becomes thick, dense, and cloudy. Safe days are from the first day of the menstrual cycle until the onset of wet mucus and after the fourth day from the most pronounced secretion of ovulatory mucus.

3. Sympto-Thermal Method

Based on the simultaneous use of the basal body temperature method and the ovulation method.

4. Measuring Basal Body Temperature

Based on measuring core body temperature in the morning, always in the same place (mouth, vagina, or rectum), before getting up, after at least three hours of sleep. Immediately after ovulation, basal temperature rises by at least 0.2-0.4 degrees Celsius and remains elevated for at least three days. Safe days begin on the fourth day after the rise in basal temperature.

5. Fertility Test

Intended for both planning and preventing conception. Tests work by detecting visible changes in saliva or mucus, or by detecting changes in hormones in urine (LH, estrogen metabolites) around the time of ovulation.

Hormonal Contraception

1. Combined Hormonal Contraception

It is among the most effective contraceptive methods, as 0.3 to 2 (or up to 9 in the USA) out of 100 women become pregnant in one year of use. It contains two types of hormones, estrogen and progesterone. It prevents egg maturation and ovulation by inhibiting gonadotropin-releasing hormone, follicle-stimulating hormone, and luteinizing hormone, and thickens cervical mucus to make it impenetrable to sperm. This method is not suitable for women with high blood pressure, smokers over 35 years of age, women with migraines or focal symptoms, known thrombophilia, cardiovascular disease, liver disease, acute gallbladder disease, diabetes with vascular complications, breast cancer, and a personal history of venous thromboembolism or thromboembolism in first-degree relatives under 45 years of age. It is also not a good choice for women with severe obesity, women who exclusively breastfeed for the first 6 months, or those taking medications such as antiepileptics and antituberculosis drugs postpartum. Due to estrogens, they have more undesirable side effects on the vasculature.

It can be used in the following forms:

• Contraceptive patch – highly effective; one patch is applied per week for three consecutive weeks in one cycle. This is followed by a 7-day break. Side effects are similar to combined oral contraception.
• Combined oral contraception – requires adherence to the dosing regimen.
• Vaginal ring – same effectiveness as the other two methods. It is a silicone ring that a woman inserts into the vagina for three weeks and then removes for 7 days.

2. Progestogen-Only Contraception

Contains only progestogens and no estrogens, unlike combined HC. It can be used when combined HC is contraindicated due to high blood pressure, smoking after age 35, migraines with focal symptoms, known thrombophilias, cardiovascular disease, diabetes with vascular complications, a history of venous thromboembolism, and breastfeeding. It prevents egg maturation and ovulation, thickens cervical mucus, reduces fallopian tube motility, and alters the uterine lining. This method is not suitable for women with breast cancer.

• Progestogen-only pill – pills are taken continuously. With regular use, effectiveness is the same as with combined HC.
• Contraceptive depot injection – administered intramuscularly or subcutaneously every 3 months. In one year of use, fewer than 1 in 500 women become pregnant, making this method highly effective for preventing unwanted pregnancy.
• Subdermal implant – a silicone implant inserted under the skin of the forearm, preventing pregnancy for three to seven years.

3. Intrauterine Device (IUD)

A medical device inserted into the uterine cavity by a gynecologist. It is made of plastic covered with copper or the hormone progestogen and is usually T-shaped, about 3 cm in size. A nylon thread is attached to the lower end of the device, extending approximately 2 cm into the vagina. An IUD can remain in the uterine cavity for 3-12 years, depending on the type of device.

• Copper IUD – inhibits fertilization because copper is toxic to eggs and sperm. It causes inflammation, thereby inhibiting implantation. It is among the most effective contraceptive methods, as 0.6-0.8 out of 100 women become pregnant in one year of use.
• Progestogen-releasing IUD – reduces sperm motility, thickens cervical mucus, causes atrophy of the uterine lining, and inhibits ovulation in a quarter of cases. This method is also among the most effective, as 0.2 out of 100 women become pregnant in one year of use. Because it reduces heavy bleeding, it is also used to treat hypermenorrhea. It is not suitable for women with unexplained vaginal bleeding, cervical, uterine lining, or breast cancer, pelvic inflammatory disease, sexually transmitted infections, and uterine cavity abnormalities. Caution is needed for women who change sexual partners or whose partners have multiple partners.

Emergency Contraception

Also known as postcoital contraception, urgent contraception, or the “morning-after pill,” it is used as an emergency measure after unprotected sexual intercourse and is not suitable as regular contraception. It primarily works by inhibiting ovulation; when used just before the LH surge, it prevents follicle rupture. If used before ovulation, it delays ovulation by 5-7 days. With the use of emergency contraception, pregnancy is prevented in 98-99% of cases. A copper IUD can also be used as emergency contraception.

1. Progestogen-Only Emergency Contraception

Must be taken within 72 hours of unprotected sexual intercourse. In many countries, it is available over-the-counter at pharmacies.

2. Yuzpe Method

Within 72 hours, a specific dose of ethinyl estradiol and levonorgestrel must be taken, and the dose repeated after 12 hours. Due to high estrogen doses, there is a greater chance of side effects (nausea, vomiting).

3. Ulipristal Acetate

This is a newer type of hormonal contraception, with high effectiveness and a longer time window for efficacy. It must be taken within 120 hours of unprotected sexual intercourse.

4. Copper Intrauterine Device

The IUD must be inserted within 5 days of unprotected sexual intercourse.

Withdrawal Method

The man withdraws his penis from the vagina before ejaculation. On average, 22 out of 100 women become pregnant in one year of use. It is suitable for couples who cannot or do not wish to use other contraceptive methods and are willing to accept the risk of unplanned pregnancy.

Lactational Amenorrhea Method (LAM)

We discussed this in the video “Menstruation and Ovulation.” This is a temporary contraceptive method, only under the conditions that you exclusively breastfeed and do not have menstruation. With perfect use of this method, 2 out of 100 women become pregnant in the first 6 months postpartum, while with typical use, 9 out of 100 women become pregnant. The effectiveness of the method decreases if the frequency of breastfeeding decreases, due to stress, or due to illness of the mother or baby.

UNDESIRABLE SIDE EFFECTS

Given the large number of methods, carefully consider which method is right for you and discuss it with your gynecologist. The frequency of drug side effects is listed in the Summary of Product Characteristics. The frequency of side effects is classified as very common, common, occasional, rare, very rare.

Serious side effects are most commonly observed in users of combined hormonal contraception, especially those with associated risk factors.

SLOVENIAN GUIDELINES FOR CONTRACEPTION USE

Based on WHO recommendations and other international organizations, Slovenian guidelines for contraception use have been issued, which also define criteria for the suitability of using a specific contraceptive method in women with certain medical conditions or when using certain medications concurrently.

Based on anamnesis, a targeted physical examination, and, if necessary, additional laboratory tests, a user can be classified into one of 4 categories of suitability for using a specific contraceptive method, depending on her health status.

The suitability categories refer to the safety of using a specific contraceptive method in women with certain medical conditions or for a specific contraceptive method:

Category 1 no restrictions for using the contraceptive method

Category 2 the advantages or benefits of using the contraceptive method generally outweigh the theoretical or proven health risks; the contraceptive method is usually used

Category 3 a condition where the theoretical or proven risk is usually greater than the advantages or benefits of using the contraceptive method, and therefore its use is not recommended, except in exceptional cases if other more suitable methods are not available or acceptable

Category 4 a condition where the use of the contraceptive method poses an unacceptable health risk and is therefore not used.

And precisely because of the classification into these categories, consultation with a gynecologist is necessary.

PERMANENT CONTRACEPTIVE METHODS

Sterilization is a medical procedure for permanent pregnancy prevention, performed on women. It is a surgical procedure that causes the fallopian tubes to become impassable, thus preventing the egg cell from contacting sperm. The procedure is performed by a gynecologist. Laparoscopic sterilization is 99.9% reliable.

Vasectomy is a surgical procedure in which the vas deferens is severed in men, resulting in no sperm in the seminal fluid. The procedure is performed as an outpatient procedure by an andrologist or urologist. Over 99% effective.

To avoid hasty decisions, the law stipulates that every woman or man who decides on sterilization or vasectomy must submit an application to the first-degree commission for artificial termination of pregnancy. The procedure is approved only for competent individuals over 35 years of age, and only exceptionally for younger individuals when other protection is not possible. The procedure is performed only 6 months after the commission’s approval, unless it is recommended for health reasons to be performed earlier or if it is performed concurrently with other surgical procedures.

Abortion and feticide are not types of contraception but are terminations of pregnancy!

The only 100% protection against unwanted pregnancy (and against the transmission of sexually transmitted diseases) is abstinence.

Source:

Pinter, B (2016). Contraception. Gynecology and Perinatology. First edition. Maribor, University of Maribor, Faculty of Medicine (145 – 153).

Ban Frangež, H & Drobnič, S. Sterilization. Gynecology and Perinatology. First edition. Maribor, University of Maribor, Faculty of Medicine (154 – 157).