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Tuesday, July 19, 2011

Non Hormonal Contraception - Sterilization, Barriers, and Natural Methods

by Philip Darney, MD MSc
Professor and Chief
Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco General Hospital Division, UCSF

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Introduction

Many women who want to avoid pregnancy prefer not to use hormones. Male and female sterilization operations (vasectomy in men and various methods of closing the tubes or oviducts in women), vaginal barriers (condoms, diaphragms and crèmes or foams), and the “natural” methods (ovulation timing, abstinence, and breast feeding) all provide contraception without the use of hormones. In fact, these are the most frequently used methods around the world, including the USA, where sterilization and condoms provide protection against unintended pregnancy to more people than all the other methods combined.



Depending on the method chosen and how it is used, non-hormonal methods have a much wider range of effectiveness than the hormonal contraceptives (pills, patches, rings and implantable methods), but they avoid the side effects of taking hormones. The most effective of these methods (male and female sterilization) are not reversible; the reversible non-hormonal methods are usually much less effective than hormonal contraceptives, but some people achieve much greater success than “typical” users. Our description of these methods will begin with the most effective and proceed to the less effective ones.
Sterilization
Female Sterilization Operations (Tubal Ligation or Tubal Occlusion)
Key points:

* Tubal sterilization remains a popular and highly effective method of contraception worldwide.
* The 12 year U.S. Collaborative Review of Sterilization (CREST) study reported a 10 year cumulative pregnancy rate of 1.8%, with the lowest failure rate in post-partum partial salpingectomy and highest among bipolar electrocautery.
* Other large series suggest 10 year failure rates for interval sterilization of 0.23% - 0.9%, with the Filshie clip having the lowest failure rate.
* Successful bilateral placement of Essure coils occurs in 92-95% of procedures.
* On the day of the procedure, current pregnancy should be excluded prior to tubal sterilization.
* While no pregnancies were reported in Essure clinical trials, five year data suggest a failure rate of 2.6 per 1000, with no reported ectopic pregnancies; most of these pregnancies were in women who did not follow-up after the procedure. Confirmation of tubal occlusion is crucial, and this method should be reserved for patients who are likely to follow up and to use an interval method of contraception.

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