Contraception: your choice

Over the last few decades the fertility rate in Bangladesh declined to 2.1 births per woman and the use of contraceptives rose to 61percent among women between 15-49 years of age (World Bank 2010-2014). 

Despite these successes, over 70 percent of all questions we get on our web and now mobile based question and answer app, "Maya Apa Ki Bole?" are on how to terminate unwanted pregnancies, what to do after unprotected sex and how to prevent pregnancy in general. These questions tell us that women (and men) in Bangladesh have limited information about what kind of contraception is good for them (and their partners). 

Making the right decision about contraception requires quite a bit of self-education and awareness. What form of contraception you choose should depend on your general health, lifestyle, relationships and risks of contracting sexually transmitted infections.

Contraception is not only about condoms, 'the pills' and, the popular, emergency pills. As a matter of fact, emergency pills are not even an appropriate form of contraception. They are for your absolute emergency situation. 

Did you know there are 15 different forms of contraception?  It is important to read about these options and find out the method that suits both you and your partner.

Broadly dividing there are 3 types of contraception: barrier methods, hormonal methods and permanent methods.
Barrier methods include male condoms, female condoms, vaginal rings and diaphragms, the latter three are not available in Bangladesh (with possibility of female condoms coming into the market soon). We were once asked by one of our users why we always suggest using condoms. Well the answer is very simple:

It is up to 97 percent effective and if used along with natural methods such as avoiding sex during fertile period, the effectiveness can increase further. Unless you are allergic to latex, this method does not have any side effects that other hormonal methods have such as headache, predisposing to breast cancer, heart attacks and brain stroke. The method is reversible. Anytime you and your partner decide it's time for a new member of the family, you can stop using it and start trying. It protects you from sexually transmitted infections that your partner may have. No matter how "in love" you are, it is always better to protect yourself.

Couples are usually hesitant to use condoms but it is the best method in terms of effectiveness, costs, side effects and reversibility.
Now moving to the hormonal methods, there are seven different methods: oral combined pills ('the pill'), mini-pills, depot injection, contraceptive patch, contraceptive implant, intrauterine device (commonly known as Copper T) and intrauterine system (IUS). The hormonal methods mostly work by preventing ovulation. Some of these are temporary contraceptive methods and others give long-term protection. We have discussed the common ones below. 

ORAL COMBINED PILLS (OCPS)
These contain oestrogen (as ethinyl oestradiol) and progesterone (as norgestrel) hormones, which act by preventing ovulation. You have to take 21 pills for 21 days then stop and start taking the red pills. During this time there will be withdrawal bleeding. The red tablets have iron that makes up for the iron loss during menstruation. 
The pills make menstruation regular, lighter, less painful and it can reduce symptoms of premenstrual syndrome. This is why oral hormonal pills are given to women with polycystic ovarian syndrome or painful periods. However, it cannot be used if you have high blood pressure, migraines, breast cancer, diabetes and liver disease or gallbladder. 
'The pill' can cause temporary side effects at first, such as headaches, nausea, breast tenderness and mood swings, and if these do not go after a few months, it may help to change to a different pill.

MINIPILL (PROGESTERONE-ONLY PILL)
Progesterone (as norgesterol) is the only component in this pill which must be taken everyday within a specific 3 hour time frame and has an effectiveness of 99 percent. It is suitable for use by women who cannot use combined pills (e.g. high blood pressure, previous blood clots), who are breastfeeding and nearing menopause.
Increases in your blood pressure, lighter, more frequent periods or periods stopping altogether are side effects and you may also get spotting between periods. This pill does not protect you against sexually transmitted infections (STIs) and you need to remember to take it at or around the same time every day. Remember certain types of antibiotics can make it less effective.

DEPOT OR INJECTION
The "injection" that prevents pregnancy, gives a headache that continues for months and stops your periods. It is frequently used by women and although there are only a certain number of times that you can use this injection, women continue to inject them one after the other. This depot formulation contains progesterone and is greater than 99 percent effective in protecting against pregnancy. 
The injection is usually given by a medical practitioner or health worker every 8 weeks or every 12 weeks depending on the brand used. 
The advantages include its safety for breast feeding mothers, reducing heavy painful periods, giving protection from pelvic inflammatory disease (the mucus from the cervix may stop bacteria entering the womb) and may also give some protection against cancer of the womb.
However, it will not protect from STIs, and results in side effects like headaches, nausea and weight gain, may lead to acne and osteoporosis. There may also be mood changes and some disruption of periods and you may gain weight.

CONTRACEPTIVE PATCHES
Oestrogen and progesterone are the chemical components of the patch and it is greater than 99 percent effective.
The first patch is applied on the first day of the menstrual period. Then a new patch is applied every seven days for a total of three weeks. The use of patches is stopped on the 4th week, and during that week there is withdrawal bleeding, like a period. However this may sometimes not happen. At the end of the week, the cycle is resumed again for another 4 weeks and continued.
The advantages are that patches easy to use, it is not affected by vomiting or diarrhoea, it makes your periods more regular, lighter and less painful, helps with premenstrual symptoms and reduces the risk of several types of cancer such as ovarian cancer, womb cancer and colon cancer.
Some disadvantages are that the patch is visible, does not protect against STDs, may cause mild temporary side effects like breast tenderness, headaches, nausea and mood changes, which settle after a few months and break through bleeding may occur during the first few weeks and increase blood pressure.

INTRAUTERINE DEVICE
More commonly known as copper T, this is a T-shaped plastic device inserted into the womb by a trained professional, at any time during your menstrual cycle and prevents pregnancy as long as it remains there. It is used for maximum five years and you do not have to stay at a hospital to insert or remove it. 
You do not have to think about your contraceptives every day, the tube is reversible once it's removed and it does not interfere with lactation. But painful, irregular periods and migraines are common side effects. 
Sometimes the tube may get displaced, may perforate the uterus or cause infection. If you have a lower abdominal pain, high temperature or smelly discharge, you should get the tube checked. 
How to tell if your IUD is in place? An IUD has two thin threads that hang down a little way from your womb into the top of your vagina. The doctor or nurse who fits your IUD will teach you how to feel for these threads and check that it is still in place.
Check that your IUD is in place a few times in the first month, and then after each period or at regular intervals.
The different forms of hormonal contraceptives have side effects and can give rise to complications, so it is important that you consult with a doctor before starting. 

THE PERMANENT METHODS 
These are vasectomy in males and tube ligation in females. 

VASECTOMY
A minor surgical procedure where the tubes that carry sperm from the testis may be cut or blocked so that they are no longer able to carry sperm. It is a simple procedure which takes around 30 minutes and patients can usually return home on the same day. This method is usually 100 percent  effective after 20-30 ejaculations following surgery. 
Can you use IVF to father a child? If you have a vasectomy, and then decide later that you want a child, there may be the option of doing so by IVF (in vitro fertilisation). To do this, a surgeon would retrieve sperm from your testicles and use this to fertilise your partner's egg. However, IVF is not always successful.

TUBE LIGATION
A surgical procedure by which the ducts which carry the eggs to the womb are occluded by clips, rings or more recently using prosthetic implants. They may also be cut and tied. It must be done by a qualified surgeon in a hospital or clinic. You may also ask your surgeon to ligate your tubes during your Caesarean section if you do not want more children.
Your emotional and physical relationship with your partner should be enjoyable and safe. At Maya, we encourage our users to read up on the different forms of contraception to ensure this enjoyment and safety. You can find more information on contraception at http://www.maya.com.bd/en/contraceptives/index/your-contraception-guide-1 and for specific questions and concerns, send your questions to Maya Apa on the website or download the Maya Apa app from Google Playstore now.

By Dr Kazi Mashfia Fardeen, Medical Consultant , maya.com.bd
Photo: Collected