Long-term methods of birth control

INTRODUCTION — Several long-term or permanent methods of contraceptive are available for women who know that they do not wish to become pregnant in the near future (or ever). These methods are generally very effective, primarily because the woman is not required to do or remember anything on a regular basis.

This topic discusses long-term methods of birth control, including the intrauterine device, contraceptive implant, and sterilization. A discussion of hormonal and barrier birth control methods are available separately. (See "Patient information: Hormonal methods of birth control" and see "Patient information: Barrier methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").

CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases

No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).

INTRAUTERINE DEVICE (IUD) — IUDs are inserted by a healthcare provider through the vagina and cervix, into the uterus. Most are made of molded plastic and include an attached string that projects through the cervix into the vagina. IUDs currently available in the United States do not increase a woman's risk of ectopic pregnancy, infertility, or infection.

Two IUDs are currently available: Copper-containing IUD (Paragard®, show picture 1), which prevents pregnancy by preventing sperm from reaching the fallopian tubes. Copper-containing IUDs remain effective for at least 10 years; the pregnancy rate in women who use a copper-containing IUD is less than one percent in the first year of use (show table 2A-2B). Some women who use a copper-containing IUD have heavier and longer menstrual periods; this effect is reversed when the IUD is removed. Levonorgestrel-releasing IUD (Mirena®, show picture 2), which prevents pregnancy by thickening the cervical mucus and thinning the endometrium (the lining of the uterus). It also decreases menstrual bleeding by 40 to 90 percent and decreases pain associated with periods. It can be left in place for up to five years, and is highly effective in preventing pregnancy; the pregnancy rate in women who use a levonorgestrel-releasing IUD is less than one percent in the first year of use (show table 2A-2B). Some women completely stop having menstrual periods while using a levonorgestrel-releasing IUD; this is not harmful and does not require treatment. Menstrual periods will return when the IUD is removed.

Benefits — An IUD is an ideal method for a woman who does not plan to become pregnant for at least one year (or longer) or who wants a method that is highly effective and does not require daily or weekly attention. IUDs are also appropriate for women who do not want or cannot use estrogen.

IUDs have relatively few side effects, and are reversible, meaning that a woman who decides she wants to become pregnant can do so by having the IUD removed. IUDs do not affect a woman's ability to become pregnant after the IUD is removed.

Risks — Women who use an IUD should check its placement once per month, after the menstrual period, by finding the strings inside the vagina. There is a small risk of expulsion of the IUD during this time. If it is not possible to feel the strings, another method of contraception (eg, condoms) should be used until a healthcare provider confirms the IUD placement.

There is a small risk (1 in 1000 women) that the IUD will pass through the uterine wall during initial placement (called perforation). This may not be discovered until the first follow-up visit; if the IUD strings are not visible at this visit, a pelvic ultrasound or x-ray is needed to confirm that the IUD is in the uterus (rather than outside the uterus as a result of perforation). An IUD that is outside the uterus is usually removed during a day surgery procedure. A backup method of contraception is recommended after placement until the strings are felt or observed.

There is a small risk of uterine infection (9.6 in 1000 women) for up to 20 days after the insertion procedure; infection as a result of the IUD after this time is rare (1.4 in 1000 women). Testing for cervical or vaginal infections may be recommended before IUD insertion.

Precautions — Since the IUD does not protect against sexually transmitted infections, women at increased risk for STDs (including having multiple partners or a partner with multiple partners) or a history of recently (within three months) treated gonorrhea or chlamydia should consider using a different method of contraception. However, women in nonmonogamous relationships can decrease their risk of STDs by using condoms in addition to their IUD.

IUDs should not be used in women who have: Uterine or cervical abnormalities that severely distort the shape or size of the uterine cavity A current or recent pelvic infection or undiagnosed uterine bleeding

If a woman with an IUD becomes pregnant, an ultrasound is needed to confirm that the pregnancy is inside the uterus, rather than in the fallopian tube (called an ectopic pregnancy). The IUD should be removed when the pregnancy is discovered. (See "Patient information: Ectopic (tubal) pregnancy").

CONTRACEPTIVE IMPLANT — A single-rod progestin implant, Implanon®, has been approved for use in the US and elsewhere. A healthcare provider inserts it under the skin in the upper inner arm (show picture 3). It is effective for up to three years, and can be removed sooner if pregnancy is desired. Insertion and removal can be done in an office or clinic.

It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.

STERILIZATION — Sterilization is a procedure that permanently prevents a person from becoming pregnant or able to have children. Tubal ligation and vasectomy are the two most common sterilization procedures. Sterilization should be considered permanent, and should only be considered after a careful discussion of all available options with a healthcare provider. (See "Patient information: Surgical sterilization of women" and see "Patient information: Vasectomy").

Tubal ligation — Tubal ligation is a sterilization procedure for women that surgically cuts, blocks, or seals the fallopian tubes to prevent pregnancy. The procedure is usually done in an operating room as a day surgery. Women who have recently delivered a baby can undergo tubal ligation before going home. It may be done at other times as well. A separate topic review is available. (See "Patient information: Surgical sterilization of women").

Essure® — Essure® is a permanent birth control method that requires surgical placement of a tiny coil mechanism into each of the fallopian tubes. Over a three month period, the tissue around the coil grows into the coil, causing blockage of the fallopian tubes in most women (show picture 4). Placement is done after the woman receives local anesthesia (numbing medicine is injected into the cervix to prevent pain). A backup method of contraception (eg, oral contraceptive or condom) is needed until testing confirms that the fallopian tubes are completed blocked; testing is usually done three months after coil placement.

Vasectomy — Vasectomy is a sterilization procedure for men that surgically cuts or blocks the vas deferens, the tubes that carry sperm from the testes. It is a safe, highly effective surgical procedure that can be performed in a healthcare provider's office under local anesthesia. Following surgery, another contraceptive (eg, condoms) must be used for approximately three months, until a semen analysis confirms that there are no sperm present. A separate topic review is available. (See "Patient information: Vasectomy").

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)

Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)

Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth

Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America

Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation

(www.hormone.org)


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3. Schwingl, PJ, Guess, HA. Safety and effectiveness of vasectomy. Fertil Steril 2000; 73:923.
4. Hubacher, D. The checkered history and bright future of intrauterine contraception in the United States. Perspect Sex Reprod Health 2002; 34:98.
5. Lethaby, AE, Cooke, I, Rees, M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2005; :CD002126.