1. 1 Birth Control and Infertility Melissa Schreiber

2. Risk and Responsibility In the U.S., half of all pregnancies are intended Half of unintended pregnancies are terminated by abortion Those who discuss preventing pregnancy are most likely to use contraceptives Over a period of a year, couples who do not use contraception have a 90% chance of conception Every year, 6.3 million of the 60 million women of childbearing age become pregnant

3. Pregnancy Outcomes in the U.S.

4. % Distribution of U.S. Women Age 15-44, By Current Contraceptive Status, 2002

5. Men, Women, and Birth Control: Who Is Responsible? Women may have a greater interest than male partners in controlling fertility Has traditionally been seen as the woman’s job, but society no longer views birth control responsibility as solely women’s Male-controlled methods now account for 35% of reversible contraceptive use

6. Adolescents and Contraception Adolescents are less likely than older individuals to use contraception 55% of women 1 st intercourse before age 16 used birth control compared with 70% at age 19 or older Condoms are preferred method Condom use may be stigmatized

7. 7 Birth Control Methods Regulate the number of children an individual or couple may have Also called contraception (prevent either fertilization or implantation of embryo in the uterine lining) Abstinence – the most reliable method of birth control Not engaging in sexual behavior Preventing transmission of STIs -Refer to page 143 table 9.1

8. Sexual Abstinence Most reliable form of birth control Involves refraining from sexual activity that could cause pregnancy Abstinence does not necessarily rule out affection or non-coital sexual activities Practitioners’ definitions of abstinence vary From a contraceptive perspective, abstinence from vaginal intercourse is required

9. 9 Birth Control Methods Most effective – 90% will not get pregnant Sterilization and hormonal methods such as birth control pill, injectable medicines, ring, patch, contraceptive implants, and intrauterine devices (IUD) Second most effective – 85-90% effective Barrier methods such as diaphragm, cervical cap, vaginal sponge, and condoms Third most effective – less than 85% effective Coitus interruptus and jellies, creams, and foams Least effective Natural family planning

10. 10 Sterilization Permanent and Irreversible Vasectomy Tubal Ligation

11. 11 Vasectomy Cutting the vasa deferens Simple operation Small incisions made on the scrotum to expose the spermatic cords Small section of the vasa deferens is removed Each end sealed so sperm are unable to travel to the urethra

12. 12 Fig. 09-02

13. 13 Tubal Ligation Uterine tubes are first cut and either tied or sealed Prevents sperm from reaching egg Laparoscopy – two incisions are needed Hysteroscopic sterilization – uterine tubes are sealed with an electric current 25% failure rate

14. 14 Fig. 09-03

15. Hormonal Methods 15

16. 16 Birth Control Pill Usually a combination of estrogen and progesterone Usually taken for 21 days out of a 28-day cycle No pill or inactive pill is taken for the remaining 7 days Exceptions Lybrel – hormones taken 365 days Seasonale/Seasonique/Quasense – hormones taken for 12 weeks and inactive pills for 7 days Yaz – hormones taken for 24 days and inactive pills for 4 days

17. 17 Fig. 09-01a

18. 18 Biological Activity of the Pill Estrogen and progesterone shut down pituitary production of FSH and LH No follicle begins to develop in ovary Ovulation does not occur Pregnancy cannot occur Pill provides female sex hormones for the patient

19. 19 Secondary Biological Activities of the Pill Prevents the cervical mucus from entering midcycle phase of being thin and watery Affects the transport of an embryo down the uterine tubes so implantation does not occur Prevents normal buildup of the lining of the uterus so an embryo is unable to implant Pill accounts for the menstrual cycle to last fewer days and flow is lighter

20. 20 Side Effects of the Pill Beneficial Relief of discomforts with menstruation and relief of acne Adverse Nausea, vomiting, irregular spotting, breast swelling, weight gain, dizziness, blood clots

21. % of Women Age 15-44 Who Have Ever Used the Pill, 2002

22. 22 Alternate Routes of Administration Depo Provera (only progesterone) Injectable form administered every 12 weeks (~three months) Causes changes in the endometrium that makes pregnancy less likely to occur Lunelle (both estrogen/progesterone) Once-a-month injection Vaginal Ring/Nuva Ring (both estrogen/progesterone) Worn in the vagina for 21 days and removed for 7 days Hormone Patch – Ortho Evra (both estrogen/progesterone) Changed every week for three weeks and not worn on the fourth week

23. 23 Fig. 09-01f

24. 24 Morning After Pill Also known as emergency contraception, Preven, or Plan B Medication that will prevent pregnancy after unprotected intercourse One, two, or four synthetic progesterone pills Taken up to 72 hours after unprotected intercourse and 12 hours later Upsets the normal female reproductive cycle, making it difficult for an embryo to implant itself

25. 25 Intrauterine Device (IUD) Small piece of molded plastic that is inserted into the uterus by a physician Copper type – copper wire wrapped around the stem Progesterone-releasing type – progesterone embedded in the plastic Mirena – smaller and more flexible Stays in place for 5 years

26. 26 Fig. 09-01b

27. IUD

28. 28 Biological Activity and Side Effects of IUD Biological activity Prevents implantation of the embryo because there is often an inflammatory reaction where the device presses against the endometrium Other theories Side effects Expulsion, pain, irregular bleeding, profuse menstruation Pelvic Inflammatory Disease (PID)

29. 29 Contraceptive Implant Norplant Long lasting contraceptive implanted under the woman’s skin Six, inch long, silicone rubber tubes containing progestin (synthetic progesterone) Implanon Only used today Only one tube, easier to insert and remove than norplant

30. 30 Fig. 09-01e

31. Barrier Methods 31

32. 32 Diaphragm, Cervical Cap, and Vaginal Sponge Diaphragm – soft rubber or plastic cup with a flexible rim that fits over the cervix Inserted at most two hours before sexual relations Used with spermicide and left in place for at least 6 hours after intercourse Cervical Cap – thicker and smaller than the diaphragm Is effective even if left in place for several days Vaginal Sponge Does not need to be fitted by a physician One size fits all

33. 33 Fig. 09-01c

34. 34 Fig. 09-04

35. 35 Condoms Male Condom – thin skin or sheath that fits over the erect penis Ejaculate is trapped inside the sheath and does not enter vagina Protection against STIs Female Condom – large polyurethane tube with a flexible ring that fits onto the cervix Also protects against STIs

36. 36 Fig. 09-05

37. 37 Fig. 09-01d

38. 38 Fig. 09-06

39. 39 Coitus Interruptus Withdrawal Discharge the semen outside of the vagina Advantage Always available Disadvantage First drop of semen is released before orgasm and contains numerous sperm

40. 40 Spermicidal Jellies, Creams, and Foams Contains sperm killing ingredients such as nonoxynol-9 Inserted into the vagina with an applicator up to 30 minutes before intercourse Disadvantage Women may have an allergy

41. 41 Natural Family Planning Rhythm method of birth control Based on the fact a woman ovulates only once per month and egg and sperm are viable for a limited number of hours or days Subtract 18 from the shortest cycle Unsafe period begins Subtract 11 from longest cycle Unsafe period ends

42. 42 Natural Family Planning Calendar Shortest cycle: 25 days Longest cycle: 29 days

43. Natural Family Planning Calendar

44. Natural Family Planning More reliable method is to await the day of ovulation and wait three more days before engaging in intercourse Body temperature is lower before ovulation Preceding ovulation temperature drops 0.2°F and following ovulation the temperature rises 0.6°F Level of sugar in the vagina increases near ovulation (Tes-Tap: yellow turns blue) pH can be tested (acid to alkaline, ovulation is near) Weight of cervical mucous decreases at ovulation 44

45. 45 Oral Body Temperature

46. Abortion Medical definition: expulsion of the conceptus Can happen naturally (miscarriages) Can be medically or surgically induced Abortions are not all the same Circumstances of pregnancy vary Differences by stage of pregnancy

47. Abortion Conditions matter Under safe, clean, legal conditions abortion is a safe medical procedure Self-administered or illegal clandestine abortions can be very dangerous, sometimes fatal

48. Weeks of Pregnancy When Women Have Abortions

49. 49 Abortion Termination of pregnancy before the fetus is capable of surviving, fetal weight of less than 1 pound Surgical Abortion – legally available in most states Abortion Pill – mifepristone (anti-progesterone) and misoprostol (induces contractions)

50. Methods of Abortion Surgical Abortion Vacuum Aspiration Used in first trimester and performed under local anesthesia Most widely used abortion procedure in the U.S. Dilation and Evacuation (D&E) Used in second trimester Only 1.5% of U.S. abortions Hysterotomy Used in later stages of pregnancy Like a cesarean section, extremely rare

51. Vacuum Aspiration

52. Methods of Abortion Abortion Pill A two-drug regimen (mifepristone with misoprostol) that can terminate early pregnancy Mifepristone prevents the cells of the uterine lining from getting the progesterone they need to support the fertilized ovum Misoprostol causes uterine contractions Most effective when used during the 1 st 9 weeks (63 days) after the beginning of the pregnant woman’s last period

53. Mifepristone and Misoprostol

54. Prevalence of Abortion A common experience among U.S. women Approximately half of unintended pregnancies end in abortion Highest rates among Ages 18-29, unmarried, Black or Hispanic, and/or economically disadvantaged women Number of abortions decreased between 1994 and 2000 Emergency contraception accounts for as much as 43% of decrease

55. Rate of Abortions in Women Aged 15-44 By Year

56. The Abortion Debate A pro-life argument Human life begins at fertilization Same rights in utero as after birth Abortion is moral equivalent of murder A pro-choice argument Women should be able to choose whether or not they will have children Abortion should be available as a back-up birth control method Women will get illegal and unsafe abortions if the procedure is made illegal

57. 57 Infertility Failure of a couple to achieve pregnancy after one year of regular, unprotected intercourse AMA estimates that 15% of couples are infertile Attributed to males (40%), female (40%), or both (20%)

58. 58 Causes of Infertility Males Low sperm count and/or abnormal sperm Environmental influences Females Extreme underweight Pelvic inflammatory disease (PID) Endometriosis – presence of uterine tissue outside the uterus Stress

59. 59 Assisted Reproductive Technologies (ART) Techniques used to increase the chances of pregnancy Artificial insemination – sperm placed in vagina Drugs are given to stimulate the ovaries In vitro fertilization (IVF) – conception occurs in laboratory glassware, embryo is transferred to uterus

60. Assisted Reproductive Technologies (ART) Techniques used to increase the chances of pregnancy Intracytoplasmic sperm injection – single sperm injected into an egg Gamete intrafallopian transfer (GIFT) – egg and sperm placed in uterine (fallopian) tubes immediately after they have been brought together in laboratory glassware Surrogate mothers 60

61. 61 Fig. 09-09