Contraception Cafeteria

Table of Content

Understanding Contraception


Birth control (contraception) is a choice. A choice to prevent pregnancy (conception) till a couple wishes to.

Several factors come into play when deciding which method of birth control is best for the couple. The overall health of the male and female partner, their age, frequency of sexual intercourse, and whether the couple desires to have children in the future must be considered before deciding upon a birth control method.

While contraception has been used widely for over 2,000 years, modern contraceptive methods represent more than a technical advance; they are the instrument of a true social revolution. Contraceptive methods have evolved, right from coitus interruptus, to herbs, to modern methods that are hassle-free, more effective methods including injectable, intra-uterine devices, and barrier devices including condoms, and low dose hormonal pills.

”Contraception Cafeteria” approach means informing the couple of all the contraceptive methods available in the market and allowing them to make a decision that would be right for them.

This article helps the couple understand the different methods of contraception so that they can make an informed choice that's right for their health and lifestyle.

Contraception Cafeteria

Contraceptive methods help women avoid pregnancy and these include all temporary and permanent measures. The contraceptive methods are as follows:

Spacing methods

These include barrier methods, the aim of which is to prevent pregnancy until desired. These include:

  • Male condom
  • Female condom
  • Diaphragm
  • Spermicide
  • Intrauterine devices
  • Combined oral contraceptive pills
  • Mini pill
  • Emergency contraceptive pills
  • Injectables / Depot formulations
  • Others

Termination methods

These include contraceptive procedure for couples who do not want more children. These are:

  • Female sterilization
  • Male sterilization

Male Condom

The condom is the most widely known and used barrier device by males around the world. It is one of the most reliable methods of birth control when used properly and consistently. The condom prevents the semen from being deposited in the vagina. Its effectiveness may be increased by using it with a spermicide (chemical that kills sperms). It is fitted on the erect penis before intercourse (sexual act) and must be held carefully when withdrawing from the vagina to avoid spilling semen (fluid that contains sperms) into the vagina after sex. A new condom should be used for each intercourse. In case extra lubrication is required, a water-based lubricant should be used and it should be applied on the outside of the condom. It is available in different sizes and in lubricated (with spermicide) and non-lubricated forms.

Effectiveness: If used correctly, condoms alone are 90% effective and when used with a spermicide are 95% effective in preventing pregnancy.

Advantages: Provides protection not only against pregnancy but also against STDs (sexually transmitted diseases) and HIV infection, easily available, safe and inexpensive, easy to use, does not need medical supervision and prescription, no medical side effects, light, compact and disposable. Condoms are needed only when you are having intercourse.

Disadvantages: May slip off or tear during intercourse due to incorrect use. In this case, pull out quickly and replace the condom. Keep a check on the condom to make sure it hasn't split or slipped off. If the condom has broken and you feel that semen has come out of the condom, consider emergency contraceptive pill for the female partner.

Female Condom

The female condom is worn by the female inside her vagina during intercourse. It has a ring at each end. One ring, at the closed end of the sheath, lies inside the vagina. The other ring, at the open end of the sheath, lies outside the vagina after the female condom has been inserted. Never reuse the condom.

Effectiveness: If women use the female condom every time they have sexual intercourse and follow instructions every time, it is 95% effective.

Advantages: If used correctly, the female condom acts as a barrier to sperm, provides protection against pregnancy and many STDs by completely lining the vagina, no danger of the condom spilling out during intercourse and semen spilling out into the vagina, protects both internal and external areas of the vagina against infection, can be inserted up to 8 hours before intercourse, does not require erect penis for its insertion and does not require immediate withdrawal after ejaculation.

Disadvantages: The outer ring or frame is visible outside the vagina, which can make some women feel self-conscious, some women find the female condom hard to insert and to remove.


The diaphragm is used by the female as a vaginal barrier. A physician or other trained person is needed to demonstrate the technique of inserting the diaphragm. The diaphragm should be of the proper size. It is held in position partly by the spring tension and partly by the vaginal muscle tone. The diaphragm is inserted just before intercourse or up to 2 hours before it. After washing hands, the inside dome and rim has to be covered with a spermicide and the diaphragm has to be inserted deep into the vagina, as taught. One has to make sure that it is in the right place inside. It must remain in place for not less than 6 hours after intercourse.

Effectiveness: Diaphragm with spermicide is approximately 80% effective in preventing pregnancy.

Advantages: Can be reused after washing it with soap and warm water and drying it.

Disadvantages: Initially a physician or other trained person is needed to demonstrate the technique of inserting the diaphragm. After delivery, it can be used only after the uterus comes back to normal size. Practice at insertion, privacy for this to be carried out and limited facilities for washing and storing the diaphragm might prevent its use. Leaving the diaphragm in the vagina for a longer period (longer than 24 hours) can rarely cause serious infection. It cannot be used during menstruation, does not protect against STDs and HIV infection and has to be used with a spermicide.


Spermicide kills the sperms and is available as a vaginal pessary. The pessary is held between the finger tips and inserted deep into the vagina, 5-10 minutes before intercourse. On dissolving, the pessary releases the spermicide which destroys sperms on contact and thus prevents pregnancy.

Advantages: Safe, convenient, effective, needs no prescription, no side effects, pain or bleeding, dissolves completely and is routinely passed out, is used as a lubricant with a condom.

Disadvantages: There is no spermicide which is effective in preventing pregnancy when used alone; hence it is best used in conjunction with barrier methods, has to be applied every 1-2 hours, does not protect against STDs and HIV infection, needs to be used with each act of intercourse, can cause irritation, can rarely cause local allergic reaction, may increase the risk of urinary tract infection and may seem messy.

Intrauterine Devices (IUDs)

The IUD is one of the most effective reversible methods of contraception. It is a device inserted into the uterine cavity and left for the required period of time for the purpose of contraception. The best time of insertion is at the last few days of menses, any time during the menstrual cycle if pregnancy can be excluded, 6-8 weeks after delivery, 3 months after caesarean and immediately after spontaneous or legally induced first trimester abortion. IUDs work mainly by interfering with the sperm's ability to reach the egg thus preventing fertilization, and interfering with the normal development of the egg. Pregnancy should be excluded before IUD insertion. There are 2 types of IUDs - non-medicated (first generation) and medicated (second and third generation).

i) First generation IUDs: These comprise the inert, non-medicated devices, e.g. Lippes loop. It is made up of a loop that has attached threads or tail, made of fine nylon, projecting into the vagina after insertion, which assures that the loop is in its place and makes it easy to remove the loop when desired.

Effectiveness: They are approximately 97% effective in preventing pregnancy.

ii) Second generation IUDs: These are made by adding copper to the IUD, which has strong anti-fertility effect. The newer copper devices are more effective in preventing pregnancy than the older or inert ones and can be left in place safely up to 3-5 years unless there is a need to remove it due to medical or personal reasons. There are lesser chances of the IUD getting expelled, lower incidence of side effects and increased contraceptive effectiveness.

Effectiveness: They are approximately 97-99% effective in preventing pregnancy.

iii) Third generation IUDs: These slowly release the hormone levonorgestrel. With this, there is lower menstrual blood loss, fewer days of bleeding, low pregnancy rate, lesser side effects and can be used up to 5 years.

Effectiveness: They are more than 99% effective in preventing pregnancy.

Advantages: Simple and quick procedure to be carried out by an experienced doctor, once inserted the IUD stays in place as long as required, there is no need to remember to use the method every day or with every intercourse, well tolerated, reversible contraceptive effect once the IUD is removed, free of side effects related to the body system, reduced dysmenorrhoea (painful menses), highest continuation rates, safe in smoking, breast feeding and sexually active women of any age. It is also effective as post intercourse contraceptive if inserted within 3-5 days of unprotected sex.

Disadvantages: Requires a visit to the doctor for IUD insertion, can produce side effects such as heavy menstruation or spotting, does not protect against STDs or HIV infection, expulsion of IUD, ectopic pregnancy, infection, pain during or after intercourse, pain in lower abdomen or unusual vaginal discharge, fever; rarely the IUD might tear the uterus or cervix.

Should not be used in case of: Suspected pregnancy, immediately after second trimester abortion, illegal abortion, existing infections, unknown cause of vaginal bleeding, cancer of the cervix, uterus, ovaries, fallopian tubes or other pelvic tumours, previous ectopic pregnancy, anaemia, menorrhagia (heavy menses), infection of vagina, abnormal uterus, fibroids.

Combined Oral Contraceptive Pills (OCPs)

OCPs are a combination of two hormones, oestrogen and progesterone. They prevent the pregnancy by preventing the release of the egg from the ovary, changing the cervical mucus which increases the difficulty of sperm entry into the uterus and changing the lining of the uterus which reduces the likelihood of the egg, if fertilized, attaching itself to the lining of the womb. OCPs are taken orally starting from the first day of menstruation or as directed by the doctor. The most commonly used OCPs are available in a 21 pill pack (pills have to be taken for 21 consecutive days, followed by 7 pill-free days where no pills have to be taken. The next pack is started on the day after the 7 pill-free days) and 24 pill pack (pills have to be taken for 24 consecutive days, followed by 4 pill-free days where no pills have to be taken. The next pack is started on the day after the 4 pill-free days). For OCPs to be effective, they have to be taken regularly at the same time each day, preferably after dinner or at bedtime.

Effectiveness: When used correctly, they are more than 99% effective in preventing pregnancy.

Advantages: Apart from preventing pregnancy, some new generation OCPs (like crisanta & crisanta LS) have non-contraceptive advantages like no weight gain, reduced incidences of acne (pimples), seborrhoea (oily skin) and hirsutism (male pattern hair growth), reduced menstrual cramps, PMS (premenstrual syndrome) and PMDD (premenstrual dysphoric disorder), improved menstrual regularity, lower risk of anaemia, less chances of getting PID (pelvic inflammatory disease).

OCPs on long term use decrease the incidence of ovarian and endometrial cancer. In spite of many studies, there isn't enough proof whether OCPs increase the risk of breast and cervical cancer.

Disadvantages: Like all other medicines, OCPs also have some side effects but with new generation OCPs these are fewer and mild. Side effects like nausea, vomiting, appetite change, headache, breast tenderness, moodiness, dizziness, rash and vaginal infections are common but mild and decrease over time. Long term use may increase the risk of heart problems (risk increases with age and cigarette smoking), cancer (of breast, cervix and liver), elevation of blood pressure and blood glucose, increased blood clotting, decrease of HDL (good cholesterol), OCPs do not protect against STDs or HIV infection.

Should not be used in the case of: Pregnancy, age over 40 years, age over 35 years and smoking, high blood pressure, breast feeding, history of blood clots, long-term kidney disorder, diabetes mellitus, breast or genital cancer, heart problems, unknown reason of uterine bleeding, migraine, convulsions, gall bladder disease.

Before starting to use an OCP, you will have to go through some basic medical examination. There are many options of OCPs, ask your doctor which one is suitable for you.

Mini Pill

This is also a type of oral contraceptive but it contains only progesterone which is given in small doses throughout the cycle. It works by thickening the cervical mucus thereby inhibiting sperm penetration or changing the uterine lining, which makes it more difficult for an egg, if fertilized, to implant in the uterus and develop.

Effectiveness: Mini pill is approximately 95% effective, as they don't prevent the egg from releasing from the ovary.

Advantages: They can be used by breast feeding women, can be prescribed to older women who cannot use the combined pill because of cardiac risks.

Disadvantages: Spotting, breakthrough bleeding; does not protect against STDs or HIV infection.

Emergency Contraceptive Pills

These contain either progesterone (levonorgestrel) alone or both oestrogen and progesterone (OCP). They are taken orally within 72 hours of unprotected sex. They work by stopping an egg being released from the ovary, or preventing the sperm from fertilizing it if it is already released. Whether it prevents the fertilized egg from attaching itself to the lining of the womb is not yet clear. Emergency contraception should not be used as regular birth control.

Effectiveness: The sooner you take the pill, the more effective it is. It is 95% effective in preventing pregnancy when taken within 24 hours of unprotected sex.

Advantages: They can be used as a back up in the case of having had sex without using a contraceptive, after forced sex, failure of a contraception method (e.g. tearing of condom or having missed 2 or more OCPs).

Disadvantages: Nausea, vomiting, lower abdominal pain, a feeling of breast tenderness and headache are some common side effects but all this should stop within a day or two. They have no long-term or serious side effects and are safe to use for almost all women except in case of allergy to any of the ingredients of the pill; does not protect against STDs or HIV infection.

Injectables/Depot (Slow Release) Formulations

These are the slow release formulations in which a single injection is sufficient for several months. They act by inhibiting the ovulation. They contain progesterone that is given intramuscularly on or before the 5th day of the menstrual cycle, every 3 months. If it is given later than day 5, barrier contraceptives should be used for the next 7 days. It can also be given at any time after delivery or immediately after first or second trimester abortion or later if necessary. Repeat injections can be given up to 5 days late without the need for additional contraception. If it is given after this time, pregnancy should be excluded and additional contraception used for 14 days.

Effectiveness: Progestogen injectable contraceptives are 99% effective in preventing pregnancy.

Advantages: Highly effective, long lasting, reversible, do not affect breast feeding.

Disadvantages: Disruption of normal menstrual cycle, risk of amenorrhoea, weight gain, delayed return to fertility, breakthrough bleeding, spotting; does not protect against STDs or HIV infection.

Should not be used in case of: Breast and genital cancer, unknown reason of abnormal uterine bleeding, suspected cancer.


a) Coitus interruptus: The male withdraws before ejaculating thereby trying to prevent deposition of semen into the vagina.

Effectiveness: If practised properly, it is 75% effective.

Advantages: No cost and appliances required, no side effects.

Disadvantages: Needs practice, as even a slightest mistake in withdrawal timing can lead to deposition of a certain amount of semen in the vagina leading to pregnancy; does not protect against STDs or HIV infection.

b) Safe period: The period in the menstrual cycle when conception is least likely to occur, typically from 10 days before to 10 days after the onset of menstruation (depending on the regularity of cycles). This method is based on the fact that ovulation occurs from 12-16 days before the onset of menstruation. The days on which conception is likely to occur are calculated as follows-

The shortest cycle minus 18 days gives the first day of the fertile period (chance of pregnancy is high). The longest cycle minus 10 days gives the last day of the fertile period.

For e.g., if a woman's cycle varies from 26-31 days, the fertile period during which she should not have sexual intercourse would be from the 8th - 21st day of the cycle, counting day 1 as the first day of the cycle. Sexual intercourse should be avoided or barrier contraceptives should be used during this period.

Effectiveness: It is 75% effective.

Disadvantages: Calculations are not easy as a female's cycles are irregular, high failure rate due to wrong calculations; does not protect against STDs or HIV infection.

Male Sterilization or Vasectomy

In this operation, a part of the vas deferens (the male tube that carries the sperms) is removed. The male subject is not immediately sterile and contraceptives have to be used for the first 20 ejaculations or for 3 months (whichever comes first) until aspermia (absence of sperms) has been established.

Effectiveness: If properly performed, it is almost 100% effective.

Advantages: Simple, fast and less expensive operation, does not affect male sex hormone secretion, can be done by trained doctors in primary health centers under local anaesthesia.

Disadvantages: Operative procedure; does not protect against STD or HIV infection.

Female Sterilization

This operation is done either after delivery or at the time of abortion or any other time she desires. It can be done in 2 ways:

  • Tubectomy, in which the fallopian tubes (the tubes that carry the eggs) are tied and cut so as to prevent the egg from moving towards the uterus and meeting the sperm.
  • Tubal Ligation, in which the fallopian tubes are clamped, blocked or tied to prevent the eggs from traveling down to the uterus. This procedure is most commonly used for the purpose of family planning.

It can be done by-

  • Laparotomy: The surgery is performed after making a cut in the abdominal wall.
  • Laparoscopy: A laparoscope (an instrument through which structures within the abdomen and pelvis can be seen) is passed through a small surgical cut made in the abdominal wall and then the tubes are tied.

Should not be used in case of: Postpartum patients for 6 weeks following delivery, haemoglobin < 8%, heart and respiratory diseases, diabetes, hypertension.

  • Minilaparotomy (tubes are tied through a small cut in the lower abdomen): Safe, efficient, ease in dealing with complications, suitable for tubal sterilization after delivery, can be done under local anaesthesia at a primary health centre.

Effectiveness: 0.5% failure rate

Advantages: Effective, no long term side effects, short operating time, shorter stay in hospital, nothing to remember, no supplies needed and no repeated clinic visits required.

Disadvantages: Operative procedure has to be done only by specialist gynaecologists, needs anaesthesia; does not protect against STDs or HIV infection.

"Consult your doctor for further queries on contraception."


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