Birth Control Overview

The practice of birth control or preventing pregnancy is as old as human existence. For centuries, humans have relied upon their imagination to avoid pregnancy.  

• Egyptian ancient writings dating back to 1850 BC refer to techniques using a device placed in a woman’s vagina made of crocodile dung and fermented dough, which most likely created a hostile environment for sperm. Other items placed in the vagina included plugs of gum, honey, and acacia.
  
  
• During the early second century in Rome, a highly acidic concoction of fruits, nuts, and wool was placed on the cervix as a type of spermicidal barrier.

Today, the voluntary control of fertility is of paramount importance to modern society. From a global perspective, countries currently face the crisis of rapid growth of the human population that has begun to threaten human survival. According to the Population Reference Bureau's 2003 World Population Data Sheet, the world's current growth rate is 1.3%. Based on this growth rate, the population would double in 53.8 years. The less developed world's natural increase rate (births minus deaths, without migration) is 1.6%; therefore, population in these countries would double in 43.8 years. See the Population Reference Bureau's 2003 World Population Data Sheet for more information. The United Nations lists a growth rate of 2.41% for the least developed countries, which would imply that at the current rate, populations in these nations would double in 29 years. See the United Nations Population Database. Keep in mind that doubling time cannot be used to project future population size because it assumes a constant growth rate over decades when growth rates are constantly changing. Nevertheless, these figures do provide a picture of how fast the population is growing at present.

For the individual woman, the effective ability to control when and whether she becomes pregnant affects her ability to achieve her own goals and contribute to her sense of well-being. A woman’s choice of birth control method involves factors such as how easy it is to use, safety, risks, cost, and personal considerations.

This overview discusses the main methods of contraception (birth control) used in the United States and their advantages and disadvantages. 

Continuous abstinence

Continuous abstinence is completely refraining from sexual intercourse. There are no hormonal side effects, and abstinence is endorsed by many religious groups.
 
It is 100% effective in preventing pregnancy, and it also prevents sexually transmitted diseases (STDs). Women who are abstinent until their 20s and have few partners are less likely to get STDs, become infertile, or develop cervical cancer. Abstinence costs nothing.
 
Abstinence may be difficult for some couples to maintain. It is important to discuss this decision with your partner before sexual situations arise.

Coitus interruptus

Coitus interruptus involves withdrawal of the entire penis from the vagina before the man ejaculates (before sperm leaves the penis). Fertilization is prevented because sperm does not contact a woman’s egg. This method remains a significant means of fertility control in less advantaged countries.  

• How effective: This depends largely on the man's capability to withdraw prior to ejaculation. The failure rate is estimated to be about 4% in the first year of using this method exactly. In typical use, the rate is more like 19% during the first year of use. The failure rate means this method does not work to prevent pregnancy, and some couples using it will become pregnant anyway. The higher the failure rate, the more likely a woman is to have an unintended pregnancy. 

• Advantages: This method can be used at any time, with no devices, no cost, does not involve chemicals or hormones, and may offer a lower risk for other problems.   

• Disadvantages: There is a high risk for unintended pregnancy. This method does not protect against sexually transmitted diseases (STDs).   

Natural Family Planning   

Natural Family Planning (NFP), endorsed by the Couple to Couple League, is one of the most widely used methods of fertility regulation, particularly for those whose religious or cultural beliefs do not permit devices or drugs for birth control. This method involves periodic abstinence (no sexual intercourse), with couples attempting to avoid intercourse during a woman's fertile period—around the time of ovulation. (Ovulation is the process in which during a woman's menstrual cycle, one of the woman's ovaries releases an egg.)

The current method of NFP taught by the Couple to Couple League and many other teaching organizations is the symptothermal method. Women who use this method keep track of their cervical mucus signs, their waking temperature (basal body temperature), and their own cycle history. They may also monitor physical changes in the cervix. This method breaks a woman's cycle into 3 phases. Phase I is preovulation infertility, beginning with the first day of menstruation. Phase II is the fertile period, in which conception could occur. Phase III is infertility after ovulation. It is best used by women who have consistent and regular menstrual cycles.

• The symptothermal method determines the first day of no sexual activity based on number of days since the first day of the menstrual period (usually 7) or the first day mucus is detected, whichever is noted first. The end of the fertile period (Phase II) is determined based on basal body temperature (body temperature at rest first thing in the morning, before getting out of bed). The basal body temperature of a woman is relatively low during the follicular phase (first half of her menstrual cycle) and rises in the luteal phase of the menstrual cycle in response so the thermogenic effect of progesterone (the second half leading up to her menstrual period beginning). The rise in temperature can vary from 0.2-0.5° C. The higher temperatures begin 1-2 days after ovulation and correspond to the rising level of progesterone. Intercourse can resume 3 days after the temperature rise. You can obtain a basal body temperature chart at 4women.gov.  
  
  
• To monitor cervical mucus, the woman examines her cervical mucus with her fingers. Under the influence of estrogen, the mucus increases in quantity and becomes progressively more stretchy and abundant until a peak day is reached. This is followed by scant and dry mucus because of the influence of progesterone, which remains until the onset of her period. Intercourse is allowed 4 days after the maximal cervical mucus, coinciding with the rise in temperature, until menstruation.   

NFP has advantages and disadvantages: 

• How effective: The Couple to Couple League states, "the Sympto-Thermal Method of Natural Family Planning can be used at the 99% level of effectiveness in avoiding pregnancy." (See the complete article.) If a couple takes chances and has intercourse during Phase II, the fertile period, their odds of pregnancy increase dramatically. In August, 2002, the U.S. Food and Drug Administration (FDA) reported a failure rate of 20 pregnancies per 100 women per year for periodic abstinence. This figure did not differentiate for particular methods of periodic abstinence. The American College of Obstetricians and Gynecologists (ACOG) lists a higher failure rate for periodic abstinence of 25%. Again, this figure does not differentiate for type of periodic abstinence.
  
  
• Advantages: No harmful effects from hormone use occur. This may be the only method acceptable to couples for cultural or religious reasons. NFP methods can also be used to achieve pregnancy.   
  
  
• Disadvantages: This is most suitable for women with regular and predictable menstrual cycles. Complete abstinence is necessary during the fertile period. This method requires discipline and systematic charting. The method is not effective with improper use. To use this method effectively, a woman or couple should be trained by a medical professional or a qualified counselor. A relatively high failure rate has been reported. This method does not protect against STDs.

Fertility Awareness Method

Women who use the Fertility Awareness Method (FAM) monitor body temperature and cervical signs of pregnancy similarly to those who practice NFP. However, women using FAM may either avoid intercourse or use a backup nonhormonal method of birth control, such as a condom, during the fertile period.

Women using FAM monitor 3 primary fertility signs: basal body (waking) temperature, cervical fluid, and cervical position.

Basal body temperature before ovulation is considered to range from 97-97.5°F. After ovulation, temperatures rise to about 97.6-98.6°F and stay elevated until a woman’s next period, about 12-16 days later. Temperatures usually rise within a day or so after ovulation, so the rise in temperature generally means that ovulation has already occurred. A basal body temperature chart can be obtained at 4women.gov.

Cervical fluid qualities are also charted throughout a woman’s cycle. Cervical fluid qualities aside from during the menstrual period are designated as nothing/dry, sticky, creamy, or eggwhite. A woman is most fertile when her cervical fluid is like a raw eggwhite. During this time, cervical fluid is clear and stretchy.

The cervix becomes softer and opens around ovulation so that the sperm can pass through the uterus and to the fallopian tubes. The cervix also rises during this time during because of the effects of estrogen on the ligaments that hold your uterus in place.

For maximum effectiveness, FAM users follow 4 rules:

1. Intercourse is allowed in the first 5 days of the menstrual cycle (beginning with the first day of your period) if you had an obvious temperature shift 12-16 days before.
   
   
2. Before ovulation, intercourse is allowed the evening of every dry cervical fluid day.
   
   
3. Intercourse can resume the evening of the third consecutive day your temperature rises to postovulatory levels.
   
   
4. Intercourse can resume the evening of the fourth consecutive day after your peak cervical fluid day.

Intercourse is not considered "safe" for avoiding pregnancy unless all of these rules are met. It is recommended that 2 full cycles be charted before relying on this method.

FAM has advantages and disadvantages.

• How effective: If a couple takes chances and has intercourse without backup protection during the fertile period, their odds of pregnancy increase dramatically. In August, 2002, the FDA reported a failure rate of 20 pregnancies per 100 women per year for periodic abstinence. This figure did not differentiate for particular types of periodic abstinence. ACOG lists a higher failure rate for periodic abstinence of 25%. Again, this figure did not differentiate for method of periodic abstinence. 
  
  
• Advantages: No harmful effects from hormone use occur. FAM methods can also be used to achieve pregnancy. 
  
  
• Disadvantages: Complete abstinence is necessary during the fertile period. This method requires discipline and systematic charting. The method is not effective with improper use. For maximal effectiveness, a woman or couple should be trained by a medical professional or qualified counselor. A relatively high failure rate has been reported. This method does not protect against STDs.

Other methods of periodic abstinence 

Several other methods of periodic abstinence exist.

• Rhythm method: Couples who practice the rhythm method, also called the calendar method, decide when to abstain from intercourse based on calendar calculations of the past 6 menstrual cycles. However, allowances are not made for the normal variations in the menstrual cycle that many women experience. This method is not as reliable as the symptothermal method of NFP or FAM.
  
  
• Cervical mucus method: Also called the ovulation method, the cervical mucus method involves monitoring cervical mucus only, without also recording basal body temperature or menstrual history. The safe period is considered to be any dry mucus days just after menstruation and the 10 or 11 days at the end of the cycle. Days of menstrual bleeding are deemed infertile; however, pregnancy can occur during menstruation. Vaginal infections, sexual excitement, lubricants, and certain medications can significantly affect the accuracy of cervical mucus assessment.
  
  
• Basal body temperature method: This method involves monitoring basal body temperature only, without also recording cervical mucus or other signs. Sex is avoided from the end of the menstrual period until 3 days after the increase in temperature.

Breastfeeding
 
After the birth of a child, certain hormones prevent a woman from ovulating and releasing eggs if she is breastfeeding. The length of time hormones are suppressed varies. It depends on how often the woman breastfeeds and the length of time since the baby’s birth. Ovulation usually returns after 6 months despite continuous nursing. 

Breastfeeding used for birth control is also called the lactational amenorrhea method (LAM), meaning breastfeeding prevents your body from producing the hormones that cause ovulation (release of an egg) and a return to fertility. Some women feel this is an adequate form of birth control. ACOG states, "Exclusive breastfeeding helps prevent pregnancy for the first 6 months after delivery, but should be relied on only temporarily and when it meets carefully observed criteria of the lactational amenorrhea method (LAM)." 

ACOG recommends that for best impact on fertility, women should breastfeed at least every 4 hours during the day and every 6 hours at night. Any feedings the infant is given aside from breastfeeding should not be more than 5-10% of the total the child consumes. For instance, one formula feeding out of every 10 might increase the chance of fertility returning. If this schedule cannot be followed, consider using an additional form of birth control. When the menstrual period returns after pregnancy, another form of birth control is needed.

• How effective:  ACOG reports this method to be 98% effective in the first 6 months after delivery if the above criteria are met. Once menstrual bleeding resumes, the risk of pregnancy increases greatly.
   
• Advantages: A woman has no periods during this time.   
  
  
• Disadvantages: When a woman is fertile again is uncertain. Frequent breastfeeding may be inconvenient. This method should not be used if the mother is HIV positive. This method does not protect against STDs.

Douching
 
Douching is a method of rinsing out the vagina. Women use water or vinegar or solutions purchased at a drug store and spray these solutions into the vagina with a bottle or tubing. It has long been thought that women need to clean their vaginas and reduce odor. Some women douche after their menstrual periods or after sex to avoid getting a sexually transmitted disease. Some think douching after sex will prevent pregnancy.
 

• Douching is not recommended. Douching changes the delicate chemical balance in the vagina and may allow an infection to grow or spread an infection into other pelvic organs such as the uterus. This method does not protect against STDs. Douching may actually increase the chance of developing pelvic inflammatory disease and transmitting STDs. 
  
  
• Douching after sex does not prevent pregnancy. In fact, the practice can increase a woman’s chance for developing an ectopic pregnancy, a serious condition that can be life threatening, by causing an infection in the reproductive organs.

See Birth Control Behavioral Methods.

Male condom
 
The condom (also called a rubber) is a thin sheath placed over an erect penis. A man puts a condom over his penis before he places the penis in a woman’s vagina. A condom worn by a man prevents pregnancy by acting as a barrier to the passage of semen into the vagina. A condom can be worn only once. It is one of the most popular birth control barriers. You can buy condoms at most drugstores and grocery stores and dispensers can be found in public restrooms.
 
Condoms made from latex are the best at preventing pregnancy. They also protect against sexually transmitted diseases such as AIDS and gonorrhea. Do not use condoms with Vaseline or other brands of petroleum jelly, lotions, or oils. They can decrease the effectiveness of the condom and increase the chance of pregnancy and transmission of sexually transmitted diseases. They can be used with lubricants that don't have oil, such as K-Y Jelly. 
 
Condom use has increased from 13.2-18.9% among all women of reproductive age because of their concern about getting HIV (the virus that leads to AIDS) and other sexually transmitted diseases. 
 

• How effective: The failure rate of condoms in couples that use them consistently and correctly during the first year of use is estimated to be about 3%. However, the true failure rate is estimated to be about 14% during the first year of typical use. This marked difference of failure rates reflects errors in usage. Some couples fail to use condoms every time they have sexual intercourse. Condoms may fail (break or come off) if you use the wrong type of lubricant (for example, using an oil-based lubricant with a latex condom will cause it to fall apart). The condom may not be placed properly on the penis. Also, the man may not use care when withdrawing. 
  
  
• Advantages: Condoms are readily available and usually are low cost. A prescription is not necessary. This method involves the male partner in the contraceptive choice. Besides abstinence, latex condoms are the best protection against STDs. They are the only kind of birth control that is highly effective in preventing AIDS.  
  
  
• Disadvantages: Condoms possibly decrease enjoyment of sex. Some users may have a latex allergy. Condom breakage and slippage makes them less effective. Oil-based lubricants may damage the condom.

Female condom

The female condom (brand name: Reality) is a polyurethane sheath intended for 1-time use, similar to the male condom. It contains 2 flexible rings and measures 7.8 cm in diameter and 17 cm long. You can buy them at a drugstore without a prescription. The ring at the closed end of the sheath serves as an insertion mechanism and internal anchor that is placed inside a woman’s vagina just before sex. The other ring forms the external edge of the device and remains outside of the canal after insertion.
 
The female condom prevents pregnancy by acting as a barrier to the passage of semen into the vagina. Do not have a male partner use a condom at the same time because they may stick to each other, leading to slippage or displacement of either device. If you have a choice between the two, have the male use a condom for better protection.

• How effective: Early tests show a pregnancy rate of 15% in 6 months. In August, 2002, the FDA listed a higher failure rate of 21 pregnancies per 100 women per year. The proportion of women using this method of contraception in the United States is less than 1%.  
  
  
• Advantages: The female condom provides some protection to the labia and the base of the penis during intercourse. Although it may provide some protection, it is not as effective as a latex male condom in preventing STDs. The sheath is coated on the inside with a silicone-based lubricant. It does not deteriorate with oil-based lubricants. It can be inserted as long as 8 hours before intercourse.  
  
  
• Disadvantages: The lubricant does not contain spermicide (a substance that kills sperm). The device is difficult to place in the vagina. The inner ring may cause discomfort. Some users consider the female condom awkward. The female condom may cause a urinary tract infection (UTI) if left in the vagina for a long time.   

Diaphragm
 
The diaphragm is a shallow latex cup with a spring mechanism in its rim to hold it in place in the vagina. Diaphragms are manufactured in various sizes. You need a pelvic examination and measurement of the diagonal length of your vaginal canal so your health care provider can determine the correct diaphragm size.
 
You insert the diaphragm with spermicide before sex. The spermicidal cream or jelly is applied to the inside of the dome, which then covers your cervix. Your doctor will show you how to insert it and how to know it is in place.
 
It prevents pregnancy by acting as a barrier to the passage of semen into the cervix. Once in position, the diaphragm provides effective contraception for 6 hours. After that time, if you have not removed the diaphragm, you will add fresh spermicide with an applicator. After intercourse, the diaphragm must be left in place for at least 6 hours after sex but not more than 24 hours.
 

• How effective: Effectiveness of the diaphragm depends on the age of the user, experience with its use, continuity of use, and the use of spermicide. Typical failure rate within the first year is estimated to be 20%.  
  
  
• Advantages: The diaphragm does not use hormones. The woman is in control of her birth control. The diaphragm may be placed by the woman in anticipation of intercourse. 
  
  
• Disadvantages: Prolonged use during multiple acts of intercourse may increase the risk of UTI. Use for longer than 24 hours is not recommended due to the possible risk of toxic shock syndrome. The diaphragm requires professional fitting. Poorly fitted diaphragms may cause vaginal erosions. Diaphragms have a high failure rate. Use of a diaphragm requires brief formal training. The diaphragm may develop odor if not properly cleansed. This method does not protect against STDs.

Cervical cap
 
The cervical cap is a soft cup-shaped latex device that fits over the base of a woman’s cervix. It is smaller than a diaphragm and may be harder to insert. It too must be fitted by your doctor because it comes in different sizes. Its use is derived from the eighteenth- to twentieth-century European practice of placing the rind of a lemon or small orange against the cervix prior to intercourse. 
 
A groove along the inner circumference of the rim improves the seal between the inner rim of the cap and the base of the cervix. Spermicide is needed to fill the cap one third full prior to its insertion. It is inserted as long as 8 hours before sexual activity and can be left in place for as long as 48 hours.
 
A cervical cap acts as both a mechanical barrier to sperm migration into the cervical canal and as a chemical agent with the use of spermicide.
 

• How effective: The effectiveness depends on whether a woman has had children before because it affects the shape of her cervix. With perfect use in the first year, woman who has not had children has a failure rate of 9% (but more typically 20%), as opposed to 20% in a woman who has delivered children (and more likely 40% failure rate).
   
• Advantages: It provides continuous contraceptive protection as long as it is in place regardless of the number of intercourse acts. Additional spermicide, unlike for the diaphragm, is not necessary for repeated intercourse. The cervical cap does not involve ongoing use of hormones.  
  
  
• Disadvantages: Cervical erosion may lead to vaginal spotting. A theoretical risk of toxic shock syndrome exists if the cervical cap is left in place longer than the prescribed period. The cervical cap requires professional fitting and training for use. Severe obesity may make placement difficult. A relatively high failure rate exists. Women must have a history of normal results on Pap smears. This method does not protect against STDs.

Sponge 
  
The vaginal sponge, introduced in 1983 and taken off the market shortly after, is making a comeback. A new company has moved production to a new plant and should be available in pharmacies again in fall 2003.
 
The sponge is a soft circular polyurethane device that contains nonoxynol-9, a spermicide. It is disposable, and should be discarded after use. It is over the counter, and may be appealing to women who wish to avoid using hormones. 
 
It offers an immediate and continuous presence of spermicide throughout a 24-hour period. The FDA lists the failure rate for the previously marketed sponge to be 14-28 pregnancies per 100 women per year.
 
Serious medical risks are rare and include irritation and allergic reactions and difficulty with removal. Toxic shock syndrome is a rare but serious infection that can occur if the sponge is left in place longer than recommended. Nonoxynol-9 provides some protection against pregnancy, but the sponge does not protect against STDs.

See Birth Control Barrier Methods for more information.

Spermicides are chemical barriers to conception. They are a reversible method of birth control, meaning when a woman quits using them, full fertility returns. Vaginal spermicides are available in forms such as foam, cream, jelly, film, suppository, or tablet. Spermicides are not as effective as many other forms of birth control when used alone. They are often used with barrier methods of birth control, and are much more effective when used in this context.

Spermicides contain a chemical that kills sperm or makes them inactive so they cannot enter a woman’s cervix. Nonoxynol-9 is the active chemical in most spermicide products in the United States. 

Spermicides are not as effective as many other birth control methods, such as birth control pills or intrauterine devices (IUDs). Various sources list failure rates from 20-50% for a typical user in the first year. Spermicides are most effective when used with a barrier method, such as a condom.      
  
Spermicides are available over the counter. They do not usually affect other systems in the body. When used with a condom, they are very effective. 
 
Some spermicides may be inconvenient, as they often require a waiting period of several minutes before they are effective. The spermicide must be reapplied before each act of intercourse. Spermicides may irritate the vagina or penis. Switching brands may alleviate this problem. Serious medical risks are rare and include irritation, allergic reactions, and urinary tract infections.

Spermicides were once thought to provide minimal protection against STDs such as chlamydia and gonorrhea. However, this is no longer believed to be true. In fact, irritation of the vaginal surface may increase susceptibility to some STDs, especially HIV, when the spermicide is used several times a day. Women who want to reduce the risk of STDs should always use a latex condom. See Birth Control Spermicides for more information.

An intrauterine device (IUD) is a small T-shaped plastic device that is placed in the uterus to prevent pregnancy. A plastic string is attached to the end to ensure correct placement and for removal. (An IUD should be removed only by a medical professional.)  

Currently in the United States, 2 types of IUDs are available: copper and hormonal. Approximately 2% of women who use birth control in the United States currently use IUDs. The most recently introduced hormonal IUD is the levonorgestrel intrauterine system (LNG IUS or Mirena).

With a copper IUD, a small amount of copper is released into the uterus. This type of IUD does not affect ovulation or the menstrual cycle. Copper IUDs prevent sperm from being able to go into the egg by immobilizing the sperm on the way to the fallopian tubes. If an egg does become fertilized, implantation on the wall of the uterus is prevented because copper changes the lining of the uterus.

With hormonal IUDs, a small amount of progestin or a similar hormone is released into the uterus. These hormones thicken cervical mucus and make it difficult for sperm to enter the cervix. Hormonal IUDs also slow down the growth of the uterine lining, making it inhabitable for fertilized eggs. 

The IUD is one of the most effective kinds of birth control available. According to the American College of Obstetricians and Gynecologists, only about 8 of 1,000 women who use the copper IUD will become pregnant in the first year of use. According to Planned Parenthood, fewer than 3 women out of 100 who use the progestin IUD become pregnant during the first year of use. The success rate with the LNG IUS system is even greater. With continued use, even fewer pregnancies occur. A woman can increase her protection by checking the IUD string regularly and talking with her doctor immediately if she notices a problem.   

A woman using an IUD is always protected with nothing to remember. IUDs start working right away and can be removed at any time. IUDs are relatively inexpensive over time. The risk of side effects is low. IUDs can be inserted 6 weeks after the delivery of a baby or after an abortion. Women who use a copper IUD after childbirth can breastfeed safely. An IUD is not felt by a woman or her partner. Women who cannot use birth control pills because of cigarette smoking or conditions like hypertension may be able to use an IUD. Some women experience less menstrual blood loss and pain with hormonal IUDs.

The copper IUD can remain in place up to 10 years, while the LNG IUS is approved to protect women from pregnancy for up to 5 years when used in the United States and 7 years in Europe and Asia.  

A doctor must insert and remove an IUD. Serious complications from IUD use are rare. IUDs come out during the first year of use in about 5% of women who use them. This is most likely to happen during the menstrual period. Women using IUDs should check their pads or tampons daily while menstruating and feel to make sure the string is in place regularly. If an IUD is expelled unnoticed, a woman may easily become pregnant. If pregnancy occurs while an IUD is still in place, the risk of miscarriage is 50% greater. This risk is decreased by 25% if the IUD is taken out as soon as possible. If the IUD is not removed, a risk of serious infection to the woman exists. Ectopic pregnancies in IUD users are half as likely as they are in women using no birth control. Ectopic pregnancies are more likely in women who use Progestasert than copper IUDs; however, the overall risk still remains less than it is in women who do not use birth control. Of those using Progestasert who become pregnant, about half of thepregnancies are ectopic. However, to reiterate, the risk of ectopic pregnancy is much less than itis in women who do not use any contraception. Women using IUDs who suspect they may be pregnant should contact their clinicians immediately.

An IUD may puncture the wall of the uterus when it is inserted. This occurs in 1-3 of 1,000 insertions. Cramping and backache may occur in the first few hours after an IUD is placed. Bleeding may occur for a couple of weeks after an IUD is placed. Some women have increased menstrual pain and heavy periods while using the copper IUD, but these symptoms are decreased in those using the hormonal IUD. Pelvic inflammatory disease is also possible with IUD use if a woman is not in a monogamous relationship and has an increased risk of STD transmission. 

IUDs do not protect against STDs. STDs can be worse in women who have IUDs, and the chance of getting an STD may be higher in women who use IUDs during the first 4 months after they are placed. IUDs are best for women in relationships in which both partners are monogamous.

IUDs are not appropriate for all women. See Birth Control Intrauterine Devices for more information.

Birth control pills
 
Birth control pills, also known as oral contraceptives, have been marketed in the United States since 1962. Over the past 40 years, there have been changes in the type of estrogen and progestin (hormones) used in the pills and lower amounts. 
 
According to the Centers for Disease Control and Prevention, the birth control pill is the leading birth control method used by women younger than 30 years (17% use the pill). 
 
Birth control pills today are designed to improve safety and reduce side effects. Lower doses of estrogen are associated with a decrease in side effects, such as weight gain, breast tenderness, and nausea. 

Birth control pills are usually taken by mouth and swallowed with a liquid. In late 2003, the FDA approved a spearmint-flavored chewable birth control pill called Ovcon 35. They contain the same hormones that are in standard birth control pills. You may chew the pills or swallow them whole. If you chew the pill, you should drink 8 ounces of water afterward to make sure the full dose reaches your stomach.
 
Over 30 different combinations of birth control pills are available in the United States. The majority of the combinations of these pills have 21 hormonally active pills followed by 7 pills containing no hormones. A woman begins taking a pill on the first day of her period or the first Sunday after her period has begun. By taking a pill a day, a woman can usually take pills consistently throughout her cycle. 

• Monophasic pills: These have a constant dose of both estrogen and progestin in each of the hormonally active pills.
  
  
• Phasic pills: These combinations can alter either or both hormonal components to try to mimic the natural menstrual cycle. 
  
  
• 91-day pill: The FDA has approved a birth control pill that you take for 12 weeks (84 days) followed by 1 week (7 days) of an inactive pill. A menstrual period occurs during that week, every three months. The pills (known as Seasonale) contain the hormones already approved for other, 28-day birth control pills. 

If a woman misses 1 or 2 pills, she should take 1 tablet as soon as it is remembered. She then takes 1 tablet twice daily until each of the missed pills has been accounted for. Women who have missed more than 2 consecutive pills should be advised to use a backup method of birth control at the same time, finishing up the packet of pills until her next period.
 
The pills prevent ovulation (release of an egg) and thus prevent pregnancy. 
 

• How effective: Pregnancy rates range from 0.1% with perfect use to 5% with typical use.  
  
  
• Advantages: Birth control pills are used to treat irregular menstrual periods. Women can manipulate the cycle to avoid a period during certain events, such as vacations or weekends by extending the number of intake days of hormonally active pills or by skipping the nonactive pill week. Birth control pills prevent certain conditions, such as benign breast disease, pelvic inflammatory disease (PID), and functional cysts. Functional cysts are reduced by the suppression of stimulation of the ovaries. Ectopic pregnancies are prevented by the cessation of ovulation. Birth control pills have been known to prevent certain ovarian and endometrial cancers.   
  
  
• Disadvantages:  Problems in taking birth control pills include nausea, breast tenderness, weight gain, breakthrough bleeding, no periods, headaches, depression, anxiety, and lower sexual desire. Birth control pills do not provide protection from STDs. It’s important to take the pills daily and consistently (same time every day). If a woman stops taking birth control pills, it may take her a few months to get her normal ovulatory cycle back. After 6 months, she may need to be examined by her health care provider.   
  
  
• Additional risks:  Some women may be at risk for blood clots (venous thrombosis). At particular risk are heavy smokers (especially those older than 35 years), women with high or abnormal blood lipids (cholesterol levels), and women with severe diabetes, high blood pressure, and obesity.

The association of birth control pill use and breast cancer in young women is controversial. The Collaborative Group on Hormonal Factors in Breast Cancer performed the most comprehensive study to date in 1996. The results demonstrated that current pill users, and those who had used birth control pills within the past 1-4 years, had a slightly increased risk of breast cancer. Although these observations support the possibility of a marginally elevated risk, the group noted that the pill users had more breast examinations and breast imaging than the nonusers. Thus, although the consensus states that birth control pills can lead to breast cancer, the risk is small and the resulting tumors spread less aggressively than usual. Current thought is that birth control pill use may be a cofactor that can interact with another primary cause to stimulate breast cancer.
 
The relationship between birth control pill use and cervical cancer is also quite controversial. Important risk factors include early sexual intercourse and exposure to the human papillomavirus. The thinking now is that if birth control pills increase the risk of cervical cancer, the risk is small and related to risky behavior. Thus, women who use birth control pills should have an annual Pap test.
 
Progestin-only birth control pills
 
Progestin-only pills, also known as the mini-pill, are not used widely in the United States. Fewer than 1% of users of oral contraceptives use them as their only method of birth control. Those who use them include women who are breastfeeding and women who cannot take estrogen. 
 
Birth control patch
 
New in the United States is a transdermal patch (you wear it on your skin) that releases estrogen and progesterone directly into the skin (brand name: Ortho Evra). Each patch contains a 1-week supply of hormones. It releases a low daily dose equivalent to the lowest-dose oral contraceptive. It’s easy for women to use because it works for a week, and women don’t have to remember a pill every day. You apply a new patch every week for 3 weeks and do not wear a patch during the fourth week when you have a menstrual period. It is available by prescription. 
 
Side effects are similar to those experienced by women using oral contraceptives. The patch may cause skin irritation where it is placed (near the bikini line or on the buttocks or upper body). Sometimes it may come off and not be noticed, for example, in the shower, and it will be less efficient. In August, 2002, the FDA listed a failure rate for the patch of 1 pregnancy per 100 women per year, similar to that of other combination methods. It may be less effective for women who weigh more than 198 pounds. The patch does not protect against STDs.   
 
Vaginal ring
 
The vaginal ring (NuvaRing) is a new form of birth control. The actual design of vaginal rings as birth control was first developed in the 1970s. Vaginal rings can deliver progesterone or progesterone/estrogen combinations. The hormones are released slowly and absorbed directly by the reproductive organs. Preliminary studies show they safely prevent pregnancy, like birth control pills, with fewer side effects. These would be used in the same schedule as birth control pills, with 3 weeks of ring usage and 1 week without to produce a menstrual period. If the ring comes out on its own, and remains out for more than 3 hours, you must use another form of birth control until the ring has been back in place for at least 7 days. It is available by prescription. The vaginal ring does not prevent STDs.
 
Implant
 
The FDA approved contraceptive use of implants (levonorgestrel, brand name Norplant) in 1990. In 2003, the manufacturer decided not to continue marketing the Norplant System to health care professionals. The company will focus on developing other birth control options. Current users with medical questions may call the Norplant System Information Line at (800) 364-9809.

This method consists of inserting 6 silicone rubber rods about the size of matchsticks under a woman’s skin in her upper arm. They can be seen under the skin and felt.
 
The implant releases medication throughout the period of use and begins to work within the first 24 hours. Protection may be provided for 5 years. The hormone stops ovulation. 

• How effective: Implants are as effective as surgical sterilization. Overall, pregnancy rates increase from 0.2% in the first year to 1.1% by the fifth year.  
  
  
• Advantages: Implants last a long time. A woman can become fertile again once the implants are removed (again, surgically).  
  
  
• Disadvantages: A minor surgical procedure is necessary to put them in and to remove them. Difficulty in removal is a disadvantage. Menstrual irregularities are common, along with other side effects, including weight gain, headaches, mood changes, growth of facial hair, flow of milk from nipples, and acne. This method does not protect against STDs. 
  
  
• Additional risks: Implants are often used for women who have just had a child and are breastfeeding, for those who have trouble remembering to take birth control pills or use other birth control methods, and for women who should not get pregnant because of a medical condition. Implants are not recommended for heavy smokers, women with a history of ectopic pregnancy, diabetes, high cholesterol, severe acne, high blood pressure, heart disease, migraine, and depression.

Although the Norplant system is no longer available, a new single rod system using a form of the progestin desogestrel and providing 3 years of contraception is currently available in Europe (Implanon) and may soon be available in the United States.

Injections
 
An injection of a synthetic hormone depomedroxyprogesterone acetate (DMPA, brand name: Depo-Provera) can be given every 3 months to stop ovulation. You receive it by injection in the doctor’s office. After injection, the medication is active within 24 hours and lasts for 3 months. It prevents your ovaries from releasing eggs.
 

• How effective: DMPA is an extremely effective contraceptive option. Most other medications or a woman’s weight do not change its effectiveness. Within the first year of use, the failure rate is 0.3%.  
  
  
• Advantages: DMPA does not produce the serious adverse effects of estrogen, such as blood clotting. It lowers risk for certain endometrial and ovarian cancers. Problem periods may become regular.    
  
  
• Disadvantages:  Some women may not have a period within the first year. Irregular bleeding can be treated by giving the next dose earlier or by adding a low-dose estrogen temporarily. Because DMPA lasts in the body for several months in women who have used it on a long-term basis, it can delay the return to fertility. About 70% of former users desiring pregnancy conceive within 12 months, and 90% of former users conceive within 24 months. Other adverse effects, such as weight gain, depression, and menstrual irregularities, may continue for as long as 1 year after the last injection. Recent studies suggest a possible link between DMPA and bone density loss. Results are conflicting and limited. This method does not protect against STDs.

Combination injection
 
One of the newest developments in contraception is a combined monthly injection (medroxyprogesterone acetate [progesterone] and estradiol cypionate [estrogen], brand name: Lunelle). It recently received FDA approval in the United States. The injections stop ovulation like birth control pills do. They thicken cervical mucus to prevent sperm from traveling up the fallopian tubes to fertilize an egg and thin the uterine lining to prevent an egg from implanting. 

Women who want to become pregnant may stop using Lunelle at any time. Some women have an immediate return to fertility. Others may have to wait 60-90 days to have normal menstrual cycles.

• How effective: When used correctly, Lunelle is 99.8% effective. One-year failure rates of less than 1% have been reported in clinical trials. In one US study of 782 women, there were no pregnancies after 1 year of use.  
  
  
• Advantages: A woman can regain fertility after 2-3 months after the last injection. There are fewer users with problem periods or no periods. Lunelle can protect the uterus from cancer and endometriosis and reduce ovarian cysts and tumors. 
  
  
• Disadvantages: Disadvantages include irregular spotting, weight gain, possible decrease in sexual desire, headache, and mild depression or mood changes. You are required to see your health care provider each month for the injections and may have to fill the prescription at the pharmacy and then take the medication with you to the provider for the injection. Injections are given every 28-30 days and no later than 33 days after the last injection. Timing is determined by the number of days, not your menstrual period. Some women may not have a period but should have the injection on schedule. In contrast to other hormonal contraceptive methods, due to its novelty, cancer risk is not known. More extensive worldwide use and additional studies may demonstrate the risk, if any, on cancer of the reproductive tract. Some women may experience changes in vision, especially for contact lens wearers. There is a higher risk of gallbladder disease. Any woman with a history of blood clots, stroke, heart disease, breast cancer, unexplained vaginal bleeding, and high blood pressure should avoid this option. Women older than 35 years who smoke should not have these injections. This method does not protect against STDs. 

Pharmacia, the drug's manufacturer, voluntarily recalled all prefilled syringes of Lunelle because of a production error that may have resulted in insufficient dosing on October 10, 2002. For more information on Lunelle, Pharmacia can be reached at (800) 323-4204.

Seek emergency medical care if you experience any of these symptoms:
 
A: Abdominal pain
C: Chest pain
H: Severe headaches
E: Eye changes (blurred vision)
S: Severe thigh or calf pain

See Birth Control Hormonal Methods.

Sterilization is considered a permanent method of birth control that a man or woman chooses. Although tubal sterilization, or a tubal ligation, for women and vasectomy for men can sometimes be reversed, surgery is much more complicated than the original procedure and may not be successful. Thus, when choosing a sterilization method you should not have thoughts of future reversal. 
 
Female sterilization, tubal ligation
 
About a million American women elect to have surgery to tie their fallopian tubes, known as tubal ligation. Some women have a hysterectomy (removal of the uterus and sometimes also the ovaries) each year, but usually not only for birth control.  

Most US women who have undergone sterilization experience either a postpartum minilaparotomy procedure or an interval (timing of the procedure does not coincide with a recent pregnancy) procedure. A postpartum laparotomy consists of a small incision near the navel right after childbirth. An interval tubal sterilization is usually done with the use of small instruments inserted into a woman’s abdomen and is called laparoscopic surgery. Interval minilaparotomy - a small abdominal incision in bikini area - is performed in surgically challenging circumstances, such as when severe pelvic adhesions are present and laparoscopy is deemed inappropriate. 

The fallopian tubes (through which the egg passes from the ovaries and where the egg is fertilized by the sperm) may be blocked with Falope rings, clips, bands, segmental destruction with electrocoagulation, or suture ligation with partial salpingectomy. Female sterilization prevents fertilization by interrupting the passage through fallopian tube. 

• How effective: Sometimes this method does not provide permanent birth control. The United States Collaborative Review of Sterilization has examined the failure rate of female sterilization. Rates vary according to the procedure performed. The cumulative 10-year failure rate with each method of tubal ligation is as follows: spring clip method is 3.7%, bipolar coagulation is 2.5%, interval partial salpingectomy (partial removal of tubes) is 2%, silicone rubber bands is 2%, and postpartum salpingectomy (tubes cut after delivery) is 0.8%.
   
• Advantages: Female sterilization does not involve hormones. It is a permanent form of birth control. There are no changes in libido (sexual desire), menstrual cycle, or breastfeeding ability. The procedure is usually a same-day procedure done in a surgical outpatient clinic.    
  
  
• Disadvantages:  The procedure involves general or regional anesthesia. It is permanent form of birth control, and some women may regret the decision later. The two most common factors associated with regret are young age and unpredictable life events, such as change in marital status or death of a child. Regret also has been shown to correlate with external pressure by the clinician, spouse, relatives, or others. Regret is difficult to measure because it encompasses a complex spectrum of feelings that can change over time. This helps to explain that while some studies have shown "regret" on the part of 26 percent of women, fewer than 20 percent seek reversal and fewer than 10 percent actually undergo the reversal procedure. Sterilization does not protect you from sexually transmitted diseases. Sterilization involves all of the risks of surgery. Occasionally, sterilization cannot be done laparoscopically, and an abdominal incision may be necessary to reach the fallopian tubes. There is some short-term discomfort. Tubal sterilization does not protect against sexually transmitted diseases.

Female sterilization, implants
 
The FDA just recently approved a small metallic implant (Essure) that is placed into the fallopian tubes of women who wish to be permanently sterilized.  
 
During the implantation procedure, the doctor inserts 1 of the devices into each of the 2 fallopian tubes. This is done with a special catheter (tube) that is inserted through the vagina into the uterus, and then into the fallopian tube. The device works by making scar tissue form over the implant, blocking the fallopian tube and preventing fertilization of the egg by the sperm.
 
During the first 3 months, women cannot rely on the Essure implants and must use alternate birth control. At the 3-month point, women must undergo a final x-ray procedure in which dye is placed in the uterus and an x-ray is taken to confirm proper device placement. Once placement is confirmed, you do not need another form of birth control.
 
In studies of the device so far, no women using it have become pregnant.
 
The procedure cannot be reversed. This is a permanent form of birth control. Sometimes doctors have difficulty placing the implants. There is risk for ectopic pregnancy, a life-threatening condition that requires emergency medical care. This method does not prevent STDs.
 
Male sterilization, vasectomy 
 
Vasectomy involves a cut in the scrotal sac, cutting or burning of the vas deferens (tubes that carry sperm), and blocking both cut ends. The procedure is usually performed with the patient under local anesthesia in an outpatient setting. Vasectomy prevents the passage of sperm into seminal fluid by blocking the vas deferens.
 
Some men may develop bruising in their testicles. After the vasectomy, some sperm may remain in the ducts. A man is not considered sterile until he has produced sperm-free ejaculations. Semen is tested in the lab several weeks after the procedure to check that all sperm are gone. This usually requires 15-20 ejaculations (the couple should use another form of birth control during this period, or the man may ejaculate by masturbation). 

• How effective: The failure rate is determined to be approximately 0.1%. 
  
  
• Advantages: Vasectomy involves no hormones. It is permanent. The procedure is quick with few risks. It is performed as an outpatient procedure in a clinic or doctor’s office.
     
• Disadvantages: Men may regret the decision later. Vasectomy does not prevent you from getting sexually transmitted diseases. Short-term discomfort occurs from the procedure. Vasectomy does not protect against STDs.

See Birth Control Permanent Methods for more information on these procedures.

Emergency contraception (birth control after sexual intercourse) is defined as the use of a drug or device to prevent pregnancy after unprotected sexual intercourse. Emergency contraception can be used when a condom breaks, after a sexual assault, or any time unprotected sexual intercourse occurs. An example is the “morning after pill.”
 
Unwanted pregnancy is common. Worldwide, about 50 million pregnancies are ended each year. In the United States each year, the widespread use of emergency contraception may have prevented over 1 million abortions and 2 million unwanted pregnancies that end in childbirth.
 
Emergency contraceptives available in the United States include the emergency contraceptive pills and the Copper T380 IUD. Both the Preven kit and the Plan B kit are pills marketed as emergency contraceptives.
 
Women who may become pregnant and who have had unprotected sexual intercourse may elect to take emergency contraceptive measures within the following 72 hours (3 days). There are no specific signs and symptoms of pregnancy during the first 2-3 days, when the morning-after pill needs to be used. A woman will never know whether the pill prevented pregnancy. However, emergency contraceptives should not be used as a contraceptive method if you are sexually active or planning to be because they are not as effective as any ongoing contraceptive method.  
 
The “morning after pills” contain high doses of the same hormones in birth control pills. There are no known risks because the high-dose of hormones is short lived. There are cases of deep vein thrombosis (blood clotting) in women using the emergency method. Neither of these pills will terminate an existing pregnancy.
 
Emergency contraceptive pills and the mini-pill emergency contraception method: The emergency contraception pills (Preven) use 2 birth control pills, each containing ethinyl estradiol and norgestrel, taken 12 hours apart for a total of 4 pills. The first dose should be taken within the first 72 hours after unprotected intercourse. Some studies show they are effective if taken after that period of time, but use should not be encouraged.   
 
The Plan B method is 1 dose of levonorgestrel taken as soon as possible and no later than 48 hours after unprotected sex and a second dose taken 12 hours later.
 
It’s not clear how these pills work. If taken before ovulation, both methods may stop the egg from developing. If taken after ovulation, the emergency methods may stop a fertilized egg from implanting. A menstrual period and fertility return with the next cycle. 
 
Copper T380 intrauterine device: The Copper T380 IUD can be inserted as many as 7 days after unprotected sexual intercourse to prevent pregnancy. Insertion of the IUD is significantly more effective than the emergency contraception pills, reducing the risk of pregnancy following unprotected sex by more than 99%.    

• How effective:  Emergency contraceptive pills are effective 55-94% of the time but most likely about 75% of the time. The effective rate of 75% does not mean a 25% failure rate. Instead, when considering 100 women who have had unprotected sexual intercourse during the middle 2 weeks of their cycle, about 8 will become pregnant. Of those 8 who have used emergency contraception, 2 will then become pregnant. Despite this significant reduction in the rate of pregnancy, women must understand that this method of contraception should be used only in emergencies and that they should be encouraged to use other more consistent forms of birth control.  
  
  
• Disadvantages:  Some women may feel nausea and vomit. There may be minor changes in your menstrual period, some breast tenderness, fatigue, headache, abdominal pain, and dizziness. Ectopic pregnancy is possible if treatment fails. This is a life-threatening condition. You need emergency medical care. Emergency contraceptives do not protect against STDs.

Wide debate currently exists concerning oral regimens becoming available without prescription (over the counter). As of this writing, an advisory panel to the FDA has recommended that some emergency contraception pill regimens become available without prescription. However, final approval rests with the FDA; that decision is not likely to be made until at least the first quarter of 2004.

See Emergency Contraception for more information.

A drug called mifepristone (also known as RU-486) can block a hormone called progesterone that is needed for pregnancy to continue, if an egg has been fertilized and implanted in your uterus. By taking this drug (and another one called misoprostol), a pregnancy can end if it has been 49 days or fewer since your last menstrual period.

These drugs are given only by a doctor and only by certain doctors who are trained to diagnose problems that may develop such as ectopic pregnancy. You will be asked to sign a statement indicating you understand you are ending a pregnancy.

Once you take on oral dose (pill taken by mouth) of mifepristone, you will be given misoprostol 2 days later to cause your uterus to contract and expel the embryo through the vagina.

You will experience cramping and bleeding, and you must return to your doctor a few times for examination. 
 
This method is not a preventive form of birth control. For more information on pregnancy termination, see Abortion.

Although development of new birth control methods in the United States has slowed in the past few years, research outside of the United States continues at a rapid pace. Many new birth control designs are being tested to provide a greater variety of methods with fewer side effects and that are safer and are more effective.  

• Pill for men: One exciting new development is a hormonal contraceptive method for men. The male birth control pill manipulates steroid hormones to decrease sperm development.
  
  
• Injection for men: A reversible male birth control method, injections of progestin every 3 months suppressed sperm production in an Australian study. Because this hormone reduces a man's sex drive, implants were placed under the men's skin every 4 months.
  
  
• Implants: Newer methods of implants that go under the skin are on the horizon. 
  
  
  • Implanon is a single-rod implant that is 4 cm long and 2 mm in diameter. Its more potent hormones would stop ovulation (release of an egg) in women. The implant is expected to last 3 years. In studies, so far no pregnancies have happened while women were testing this implant. It is not yet approved for use. 
    
  • Another implant (known as Uniplant) is being tested. It would work in place for as long as 1 year.
    
    
  • A biodegradable implant, Capnor, is being tested. Because it dissolves, there is no need to remove it. Birth control protection would last for 1 year. 
    
    
  • Biodegradable pellet implants are currently undergoing testing. They dissolve within 2 years. Insertion of the pellets has been demonstrated to be simple; however, if the woman wishes for removal several months later, removal has been noted to be difficult.  
    
    
• Diaphragm: Lea's Shield is a 1-size-fits-all device like a diaphragm. It will soon be available in the United States. This device consists of a 1-way valve that allows air to escape during placement, thus creating a suction effect against the cervix. Fluids can flow in one direction, out of the vagina, so uterine and cervical fluids can be released into the vaginal canal, but sperm cannot enter.  
  
  
• Tubal ligation, new methods: A few potential methods of tubal sterilization are under investigation. One of these new developments includes chemical scarring of the fallopian tubes. The scarring is a result of a combination of phenol and a thickening agent and phenol quinacrine that ultimately leads to blockage of the tubes. Another nonsurgical form of tubal sterilization uses chemical plugs. Approved for use in Canada, the gluelike substance is placed into the fallopian tube. A reversible chemical plug also can be created by the injection of silicone into the fallopian tubes. The silicone eventually hardens but can be removed later. Chemical scarring and plugs are being tested as potential methods of vasectomy as well.  
  
  
• Vaccine: A pregnancy vaccine is one of the most controversial and exciting forms of birth control under development. The pregnancy vaccine stimulates an immune response against sperm so that fertilization does not occur.

|Web Links|

U.S. Food and Drug Administration, What Kind of Birth Control is Best for You? 
 
U.S. Food and Drug Administration, Birth Control Guide 
 
Planned Parenthood, Facts about Birth Control 

Birth Control Methods 

Planned Parenthood, Is Abstinence Right for You Now?

The Couple to Couple League for Natural Family Planning 

Healthy Pregnancy, Fertility Awareness and Infertility 

American College of Obstetricians and Gynecologists, Contraception While Breastfeeding 

American College of Obstetricians and Gynecologists, Natural Family Planning 

Media file 1: Anatomy of the male reproductive system. Image courtesy of vasectomy.com.

Media type:  Illustration

Media file 2: Female reproductive anatomy.

Media type:  Illustration

contraception, impregnation, pregnancy, preventing pregnancy, Natural Family Planning, NFP, Fertility Awareness Method, FAM, lactational amenorrhea method, LAM, birth control pills, monophasic pills, phasic pills, intrauterine device, IUD, diaphragm, Copper T380, LNG IUS, fertility awareness, coitus interruptus, withdrawal, abstinence, periodic abstinence, rhythm method, calendar method, cervical mucus method, ovulation method, symptothermal method, sympto-thermal method, birth control injection, birth control shot, birth control patch, male condom, female condom, cervical cap, spermicides, nonoxynol-9, octoxynol, birth control injection, Depo-Provera, Norplant, implants, Essure, Lunelle, NuvaRing, emergency contraception,PlanB,  Preven, morning after pill, sterilization, tubal ligation, vasectomy, abortion, RU-486, mifepristone, Mifeprex, Implanon, Uniplant, Capnor, birth control hormonal methods, birth control overview, birth control behavioral methods, birth control permanent methods

Author: Omnia M Samra, MD, Clinical Instructor, Department of Obstetrics and Gynecology, Medical College of Pennsylvania/Hahnemann University.

Editors: Bryan D Cowan, MD, Director, Division of Reproductive Endocrinology, Professor, Department of Obstetrics and Gynecology, University of Mississippi College of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.