Birth control is a difficult and personal decision. The Bible does not address this issue - probably because in Biblical times there were no good, effective ways to have sex without pregnancy. Because the Bible is silent, there are a wide variety of beliefs about contraception, ranging from those who feel it's sin to use anything (including abstinence when the woman is fertile), to those who feel anything (including abortion) is acceptable. Our goal here is not to debate these theologies, or to provide the final word on contraception - rather we hope to provide factual information that will allow each couple to make an informed, prayerful decision.

No form of contraception is completely effective, but most are fairly good provided they are used correctly and consistently; the vast majority of failures are due to misuse or non-use. Learn all that you can about the method you choose so you can use it properly. More on contraceptive failure, and a chart of failure rates for various methods, here.

Hormonal methods are the most used form of contraceptive today. They are also the most controversial for Christians. Some methods primarily prevent fertilization, while others primarily prevent implantation. The debate about these methods is based on uncertainty about which methods can destroy a fertilized egg, and which do not. If you think life begins when the fertilized egg implants in the womb, the distinction does not matter to you. If you feel it's a sin to do anything that will destroy a fertilized egg, the distinction makes a great deal of difference to you. For detailed investigation of this issue we highly recommend an article by John Guillebaud, Professor of Family Planning and Reproductive Health at University College London, and a dedicated Christian.

Other Considerations for hormonal methods: While the current hormonal methods are much safer than the higher dose pills used a couple of decades ago, there are still side effects to consider. All hormonal forms of contraception contain a progestin like chemical, and progestins are well known for lowering sex drive. Complaints of this happening are most common with the long term injections and implants, but it has been noted as sometimes occurring with pills too. Recent reports have suggested that sexual side effects from hormonal contraceptive can last for a year or more after the method is discontinued. Click here for more on sex drive and hormonal contraception.

Progestin Only Pills: Progestin Only Pills (POP's) almost certainly allow ovulation at least some of the time. That means possible fertilization, followed by destruction of the fertilized egg, because the progestin inhibits implantation. If you see life as starting at fertilization, POP's are not for you. Click here for a list of progestin only pills. Note - progestin only pills are commonly used as a method for breastfeeding women, and are very effective at suppressing ovulation when combined with lactation.

• Cerazette is a progestin only pill, that is taken every day of the year, and is more effective at preventing ovulation than other POP's. We've seen Christian doctors who think it does not allow ovulation when taken properly, but we'd like to see convincing evidence. Currently available in Western Europe, Brazil, Ecuador, Hong Kong, and Mexico.

Combined Oral Contraceptives: There is now good evidence that Combined Oral Contraceptives (COC's), which contain both a progestin and a synthetic estrogen, are so effective at preventing ovulation that fertilization can not occur. It is true that the progestin in the pills could interfere with implantation if an egg was fertilized, but if fertilization never occurs this is irrelevant. There are a couple of caveats to this: firstly the pills must be taken very regularly, not just daily, but at the same time each day, and secondly the week without pills (or with non-hormonal place holder pills) must not be lengthened. (Prof. Guillebaud suggests that one can further improve the ovulation suppression of COC's by reducing the pill free interval to 4 days per cycle - discuss this with your health care provider if interested.)

• Yasmin is a COC that deserves a few extra words. This pill contains a form of progestin that seems to have some unique benefits - Yasmin can reduce acne or excessive hair growth in women suffering from these conditions. However, anecdotal evidence suggests that Yasmin may harm sex drive move than some other methods. Yasmin is available in the US, Australia and Europe.
  
  
• Seasonale is a combination pill that is taken on a different schedule - a pill is taken daily for 12 weeks, then for one week an inactive pill is taken. In addition to providing contraception, this schedule reduces menstruation to four times a year. Prolonged use of "active" pills in this way should be even more effective at preventing ovulation than traditional pill schedules.
  
  While Seasonale is new, such "continuous use" of pills is not. Other pills have been prescribed this way for some time, and a woman looking for fewer periods should discuss with her health care provider various ways of achieving this.

If a woman can take pills very regularly, COC's should be a safe form of contraception, even for a couple that feels life begins when sperm and egg join. Click here for a list of combination pills.

Many new approaches to hormonal contraception are now available. Some of these are progestin only, but because the delivery system ensures a constant, proper level of the hormone, ovulation may be fully suppressed.

• Implants - Norplant, Norplant II (Jadelle) & Implanon: These consist a rod or rods containing slow release progestin which are inserted under the skin. The steady flow of progestin prevents ovulation. Norplant, removed from the market in 2000, worked for 5 years. Norplant II, which is currently available, works for two years. Implanon works for three years. Some women experience prolonged periods, or spotting between periods, with these methods. Removal of the implant(s) results in a fairly rapid return of fertility. We've heard good things about Implanon from both medical personnel and users, and there is good evidence that no ovulation occurs with Implanon - other implants are less successful at preventing ovulation, and loss of fertilized eggs is likely. Implants are available in much of the developed world, but are less available in developing countries.
  
  
• Depo-Provera: is an injection that is given every 12 weeks. It is intended to prevent ovulation and seems to be effective at doing so. If you are concerened about ovulation talk to your medical provider about having it injected every 10 weeks. Fertility can not be reestablished until the drug has left the woman's system, which can happen anywhere from immediately after not getting a scheduled shot to a full year. This method rates a high level complaints from women who've used it, including problems with weight gain and significant loss of sex drive.
  
  Several studies have documented a loss of bone mineral density in long term users of Depo-Provera. The FDA has said Depo-Provera should be used by women only if other contraceptives prove inadequate. While recent studies1 suggest the loss may be fully reversible after the shots are discontinued, the FDA warning seems a wise precaution until there is definitive research on the issue.
  
  
• Nestorone Implants are a new implant currently being developed. Nestorone is being specifically aimed at lactating women in developing countries. Non-lactating women experience prolonged and irregular bleeding with Nestorone. It seems likely that the method will not fully stop ovulation in non-lactating women.
  
  
• Combined Injectable Contraceptives: CIC's are injections that are given monthly. CIC's contains both estrogen and progestin, and it's likely that they are very effective at preventing ovulation - but we have not seen conclusive data yet. It has been suggested that these products may be safer for the user than COC's, and there is limited evidence supporting this. Currently available CIC's:
  
  
  • Lunelle (also called Cyclofem, Cyclofemina, Feminena, and Novafem) does not seem to cause as much weight gain as Depro-Provera, and fertility normally returns more quickly (3-6 months). Primarily available in Latin America and Asia. The FDA approved Lunelle, but it is not currently available in the US, having been withdrawn due to manufacturing concerns.)
    
    
  • Mesigyna (also called Norigynon) is widely available in Latin America and Asia, not currently available in Europe or North America.
    
    
  • Deladroxate (also called Perlutal, Patectro, and Topaselused) is available in Latin American countries.
  
  
• NuvaRing: A ring about two inches in diameter which is placed into the vagina and left in place for 21 days. The ring is held in place by the vaginal muscles, and is not felt by the women once in place. The ring continuously releases small amounts of synthetic estrogen and progestin into the woman's body, preventing ovulation. After 21 days the ring is removed to allow for a menstrual period. After a week a new ring is interested. Because hormones are released in a steady stream, this method is very effective at preventing ovulation. The low, steady dose of hormones may disrupt the woman's body less than the varying levels of hormones that come from daily pill use. This method may have less of an effect on sex drive, as the progestin avoids first-pass metabolism through the liver and therefore has less effect on the Sex Hormone Binding Globulin. Some husbands say they can feel the ring during intercourse, while others do not. NuvaRing seems to be one of those methods a couple either loves or hates. The NuvaRing is currently available in the US, Europe, Brazil and Chile. The company plans to introduce the product in Australia and Canada in 2005. Company web site.
  
  
• Nestorone: A new ring currently being developed, nestorone will be good for 12 months. The ring will be worn for 3 weeks, then removed for one week to allow for menstruation, then reinserted. Not expected on the market before 2006 at the earliest.
  
  
• Progestin rings: There are currently two progestin only rings in development - Progering, and an unnamed product. Progestin only rings have been found to be less effective than rings containing both progestin and synthetic estrogen, and because they greatly thin the uterine lining it is likely they can destroy a fertilized egg.
  
  
• Ortho Evra (also called "the patch" or just Evra): Really just a new way to get the same hormones into a woman's blood stream. The woman wears each 1¾ inch square patch for a week, three weeks in a row, followed by a week with no patch. The patch may have less effect on sex drive since the progestin avoids first-pass metabolism through the liver and therefore has less effect on the Sex Hormone Binding Globulin. Based on data for other methods, the patch should result in effective suppression of ovulation, and prevent any fertilization - but at this time we are unaware of a study which directly shows this. Some users report more severe menstrual cramps and breast pain than pill users, but this is commonly only for the first cycle or two. The patch is not as effective for women over 200 pounds. Currently available in the US, Canada, Europe, Hong Kong, Singapore, and South Korea. Company web site.
  
  
• Plan B (also called levonorgestrel or postinor-2) is a hormonal method that is intended to be used after intercourse has occurred. The method has been widely condemned by Christians as causing destruction of fertilized and/or implanted eggs. There is growing scientific evidence that Plan B stops ovulation, but does not have any effect on a fertilized egg.2
  
  Plan B can prevent pregnancy if taken within 72 hours of intercourse. How effective the method is depends on the timing of intercourse, ovulation, and taking the drug. If intercourse is very close to the time of ovulation, it is unlikely that the drug can be taken soon enough to be effective. Company web site.
  
  
• Centchroman (also called Centron and Saheli) is a non-hormonal once a week pill currently only available in India. Centchroman is free of the side effects common to hormonal pills, and based on limited studies seems to be very effective at preventing pregnancy. The drug does not prevent ovulation, and works only by preventing a fertilized egg from implanting.

Standard IUD: Intrauterine Devices have long been called abortifacients, meaning they allow fertilization but prevent implantation or destroy the egg after it implants. Several studies have proven that the IUD, and particularly those with copper in them, have a powerful spermicidal effect. Further studies have shown that some women with IUDs who did not become pregnant had in their blood a hormone that only occurs after a fertilize egg has implanted. This was less common with copper IUDs, but was seen for both copper and inert IUDs. Clearly in these cases the IUD destroyed the fertilized egg after it implanted. Paragard T380A, which is available worldwide, is currently the most commonly used method of contraception.

Hormonal IUDs:

• Mirena (also called LevoNova) is an IUD that slowly releases the hormone levonorgestrel into the uterine lining during the five years it is in place. Mirena did not show the "implanting hormone" in users, but this does not mean that no fertilizations occurred. This IUD may suppress ovulation sometimes, but is does not do so reliably. There is no reason to think it's sperm killing effect is any greater than copper or inert IUD. Levonorgestrel thins the uterine lining, making it inhospitable to a fertilized egg. While not proven, the evidence strongly supports the theory that Mirena destroys fertilized eggs.
  
  
• Progestasert is an IUD that releases Progestin for the one year that it is in place. We have less data on Progestasert than on Mirena, but thinning of the uterine lining is substantial with Progestasert, and it's likely that destruction of fertilized eggs occurs.

Male condoms are the most common barrier method - and probably the least enjoyable for most men and many women. If you decide to go this way, it's important to try a number of sizes, since this affects both comfort and effectiveness. If a condom is too short, too wide, or too narrow, try another one. (If you can't find a good fit, try the "TheyFit" brand that comes in 55 sizes.) Condoms need to be put on before there is any contact between the penis and the woman's genitals. After ejaculation the penis must be withdrawn before any loss of erection, and the base of the condom needs to be held in place during withdrawal.

A possible side effect of condoms was recently found - women who use condoms have a higher rate of depression than sexually active women who do not use condoms6. The theory is that semen contains chemicals which act as antidepressants when absorbed by the vagina; women using condoms do not receive this benefit from sex.

• Polyurethane condoms are becoming widely available. These condoms are thinner and transmit heat better, making them feel more natural. The down side is that the condoms don't have much stretch - this can increase splitting if the condom is too tight, and slippage if it's not tight enough. Proper sizing is even more critical with polyurethane condoms.
  
  
• New synthetic materials are being tested for condom use, with some products already available in limited areas. New materials are likely to become popular because they will be stronger, thinner, and will transmit heat better.

Tips for more enjoyable condom use:

• Placing a few drops of water soluble lubricant inside the condom before putting it on will improve sensation for the man.
  
• Some men find condoms with over sized tips more enjoyable and natural (Try Pleasure Plus or the Inspiral Condom .)
  
• Because polyurethane condoms are thinner and transmit heat better, some couples find them to be more enjoyable.
  
• So called natural or lamb's skin condoms, which dull sensations much less than other condoms, are still available - but expensive.

Female condoms are similar to the male version, except that they are inserted into the vagina. Since the condom does not move with the penis the sensation is more natural and more enjoyable for the man - however, some women find them uncomfortable. Female condoms have about twice the failure rate of male condoms, and are much more expensive. One selling point has been that they are thought to be better at protecting women from STDs.

• The FC Female Condom (formerly Reality in the US) is a tube of polyurethane stretched between two flexible hoops. The smaller hoop is inserted into the vagina, the larger hoop holds the condom on the outside. The FC Female Condom is widely available through out the world.
  
  
• The Natural Sensation Panty Condom is a reusable panty with a replaceable panty-liner that contains a synthetic resin condom (thinner and stronger than traditional condoms). When intercourse is to occur the condom is pushed into the vagina by the penis. The panty condom is available in parts of South America and parts of Europe, as well as by Internet sales.
  
  
• The Reddy Female Condom (also know as VA and V-Amour) is similar to the FC, except that it's made of latex, and the condom is held inside by a spongy insert rather than an inner ring. At this writing the Reddy is available in Spain and Germany. The company plans to market in in Western Europe, Brazil, India, and South Africa in 2005, and has plans to seek FDA approval.
  
  
• The FC2 Female Condom is a synthetic latex version of the FC. Because of less expansive assembly methods, it is expected to cost half as much as the FC. The FC2 is expected to be available in developing countries in 2005, with plans to seek FDA approval to follow.
  
  
• The PATH Woman's Condom has been through 50 prototypes, looking for a design that combines easy insertion, comfort, stability, and low cost. The final product is made of polyurethane, has a soft outer ring, a dissolving capsule that allows easy insertion, and sections of urethane foam that cause the condom to adhere to the walls of the vagina. In tests users have found the condom to be very satisfactory. Currently finishing trials to prove safety and effectiveness, the PATH may be available in some places as early as 2005. The company expects FDA approval in 2007.

Diaphragms and Cervical Caps are placed over the cervix along with a spermicide. The spermicide kills sperm, while the diaphragm or cap prevents sperm from entering the cervix. Some people find putting in a diaphragm or cap to be a major interruption, while others see it as a minor issue. These methods are very comfortable for both the man and the woman, as neither should be aware of the product once inserted. These methods have fallen out of favor, in part because they do not prevent STDs, but this is not usually an issue for a Christian man and wife. We know couples who have been very happy with these methods for many years, so don't reject them out of hand.

• Lea's Shield, also known as Lea's Contraceptive, is a device similar to a diaphragm or cap, but is one-size-fits-all and does not need to be fitted. Lea's does not have the same post vaginal delivery problems that tractional caps have. Because Lea's has a "one way valve" it can be used during menstruation - something other diaphragms and caps can't do. In the US, Lea's is a prescription item, in Canada and Europe it is available over the counter.
  
  
• Ovès is a disposable cap-like device that comes in three sizes and must be fitted by a doctor - after fitting, the device may be purchased over the counter. Ovès can be worn for up to three days, and is effective for the entire three days without reapplication of spermicide. Ovès is made of a very thin layer of silicone which "clings" to the cervix, presumably providing better protection against pregnancy. To date no large, long term, studies of failure rate have been done; in one small study done by the manufacture there were no pregnancies in 17 women followed for an average of 11 months each. Actual use failure rate has been set at 4% by the manufacturer. Currently Ovès is available in the UK and France.
  
  
• A new one-size-fits-all diaphragm know as SILCS is currently undergoing testing - at this time there is no word on when it will be available.
  
  
• Also in development is BufferGel Duet, a disposable one-size-fits all diaphragm pre-filled with spermicide.

Spermicides can be used by themselves for contraception. There are a number of stand alone spermicides available as suppositories, creams, foams, and even a plastic film. The up side of these methods is that they do not cause a physical separation of the sex organs like condoms. The down sides are timing and possible irritation. Spermicides are only effective for a limited time (typically an hour) and some need to be inside the body for fifteen minutes before intercourse can occur. Some men, and fewer women, are irritated by nonoxynol-9, the active ingredient in all of the stand alone spermicides available in the USA. For women, frequency of use significantly increases the chance of irritation4 - used no more than every other day irritation is rare (3% over placebo). This can range from mild discomfort if they don't wash after sex to strong burning within seconds of contact. Most reactions are actually to one of the non-active ingredients, so changing brands can help in many cases. It should be noted that all stand alone spermicides list the same effectiveness rate, but independent research has shown that higher-dose products (100 mg or more of nonoxynol-9) are more effective, with a quarter fewer failures.5

Sponges: are pieces of foam containing a spermicide that are inserted into the vagina near the cervix. Sponges work both as a block to sperm and by killing sperm. Many women don't care for them, but they a have small loyal following. One advantage of the sponge is that it can be used for multiple sex acts without being replaced. Some men can feel the sponge, or it's removal tab, during sex. The failure rate is high - 9% for women who have not had a child, up to 20% for women who have.

• Protectaid is a Canadian product, also available in Europe, that contains low levels of three different spermicides - it is said to be less likely to cause irritation than sponges with a higher dose of a single spermicide.
  
  
• Pharmatex, available in Canada and Europe, is a small cylinder rather than a cup shape.
  
  
• The Today sponge was withdrawn from the US market a decade ago because of manufacturing problems. Today is currently available in Canada, and having won FDA approval in the spring of 2005 it should be available in the US again by late summer 2005.
  
  
• A new sponge called Advert is currently in development.

NFP and FAM: NFP stands for Natural Family Planning, while FAM stands for Fertility Awareness Method. Both methods involve knowing when the woman is fertile by charting one or more factors such as cycle length, morning body temperature, and condition of cervical mucous.

With NFP the only choices during the fertile time are intercourse with no birth control, and total sexual abstinence. If the signs of fertility are tracked consistently, and the couple does not "fudge" during the fertile time, NFP can be very effective. In fact, couples using NFP correctly have a much lower failure rate than condom users, and about as good as typical pill users. We have theological problems with NFP because it violates the Biblical command to only abstain from sex for the purpose of fasting and prayer (1 Cor 7:5). Note: NFP is the only birth control method approved by the Roman Catholic Church.

FAM uses the same methods as NFP to determine when the woman is fertile, but during the fertile time the couple can have intercourse with a barrier method, or engage in sex that does not include intercourse. Because FAM does not prevent sex, we have no problem with it theologically. Done properly, FAM means a birth control product is only needed for a week to ten days each cycle - this can be nice for both sex and the pocket book. Another advantage of FAM is that both husband and wife are aware of the woman's cycle.
There are devices available to help determine when a woman is fertile and when she is not. The following is a very brief description of three such devices.

• Ladycomp is a fancy thermometer and mini-computer that takes the woman's temperature and does the needed calculations to determine fertility. It's pretty expensive, and it relies on body temperature - which can be thrown off by a fever, use of an electric blanket, or forgetting to use it before you get out of bed on a cold morning.
  
  
• Persona reads hormones in urine. Once you have it calibrated, you only need to test 8 times a month. IN addition to the cost of the device, there is $10 to $15 a month for test strips.
  
  
• Luna reads hormones indirectly. It uses saliva rather than urine, and has no ongoing expense. It's also the least expensive of the three.

Vasectomy involves cutting the vas deferens, the tubes that transport the sperm out of the testicles. This is done by making a small incision in the scrotum in an outpatient procedure. Failure is very rare, and complications uncommon. Reports in the past tentatively linked vasectomy to some long term health issues, but better studies have since disproved any cause and effect relationship. No change in sex drive is caused by vasectomy, although a very few men seem to have a psychosomatic response that interferes with normal sexual function. Since the testicles provide less than 5% of seminal fluid volume, no difference in ejaculation is seen of felt following the procedure. Occasionally a man has significant problems from a vasectomy, and very rarely these can last for years after the procedure. The type of procedure done, and the skill of the doctor, seem to be factors in how likely a man is to have such problems. Do your homework, and find a doctor with a good deal of experience.

• Vasclip is a new method of performing a vasectomy. A small plastic clip, about the size of a grain of rice, is snapped over each vas deferens - preventing sperm from leaving the testicles. Studies have shown the method to be less painful and to have a lower rate of complications. It is also believed that reversal will be more likely to succeed with this kind of vasectomy. The procedure is generally quicker than other forms of vasectomy. While likely to cost slightly more than a regular vasectomy, it is covered by insurance just like any vasectomy. For more information and to locate a doctor in your area, check the manufacturer's web site.
  
  
• Intra Vas Device, a new method of closing the vas deferens, will begin large scale human trials in 2005. Two small two silicone plugs are inserted into each vas, effectively blocking sperm. In animal studies the procedure can be easily and reliably reversed. No word on when this might be available, but don't look for it before 2007 at the earliest.

Tubal ligation cuts and ties the woman's fallopian tubes so sperm cannot reach egg. A tubal is abdominal surgery, and as such carries far more risk than a vasectomy. For this reason, a tubal seems a poor choice unless the woman is having it done while a doctor is in the neighborhood performing a C-section.

• The Filshie clip is a different way of closing the fallopian tubes. The clip is put over the tubes, pinching them closed. The clip can be applied following a C-section, or can be done with laparoscopy surgery which involves only a very small opening being made into the abdomen. Because the surgery is less invasive, complications are fewer and recovery is faster. Because the fallopian tubes are not cut, the complications attributed to traditional ligations seem less likely.
  
  
• Essure - Non invasive female sterilization: A new form of female sterilization has been approved for use in the US. A small metal device that looks like a spring is placed in each fallopian tube by entering through the cervix. The entire process takes well under an hour. After three months scar tissue around the Essure device closes the tubes, causing infertility. The three year success rate is 99.8%, but some women fail to form sufficient scar tissue. Infertility is confirmed by x-rays. Because there is no surgical entry to the body, this method is much easier, has fewer complications, and has a much faster recovery than a tubal ligation. Because nothing is cut, it's likely that the complications attributed to ligations are not a factor with Essure. Currently available in the US, Canada, Europe, Australia, Indonesia, Singapore, and Turkey. For more information and to locate a doctor in your area, check the manufacturer's web site.
  
  
• The Adiana Procedure is another method of blocking the fallopian tubes by working through the cervix. Currently undergoing trials, the developers hope to win FDA approval in 2005.

Birth control is a difficult issue for Christians, and we pray the information given here will help couples make an informed choice.

Footnotes:

1 Epidemiology (2002;13(5):581-587)

2 'Emergency Contraception's Mode of Action Clarified' Population Briefs May 2005, Vol. 11, No. 2 link

3 J Am Acad Dermatol. 1997 May;36(5 Pt 1):705-10

4 Roddy, R., et al. (1993). "A Dosing Study of Nonoxynol-9 and Genital Irritation. International Journal of STD & AIDS, 4(3), 165-70

5 Raymond EG, et al. Contraceptive effectiveness and safety of five nonoxynol-9 spermicides: a randomized trial. Obstet Gynecol March 2004;103:430-9

6 Research from New York University, published in Archives of Sexual Behavior May 20, 2002

7 "The Risk of Ectopic Pregnancy After Tubal Sterilization" March 13, 1997 issue (336:762-767) of The New England Journal of Medicine (abstract)

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