This article brings us to the conclusion of a 3-part series on finding the right contraceptives. We will cover intrauterine devices with some deeply personal stories and wrap up our discussion on non-hormonal contraception by discussing Ormeloxifene pills, tubal ligations along with non-hormonal emergency contraception. Let’s dive straight into it.

Part III: Women & Sex - Continuing the 360-degree view of the contraceptives landscape.

Disha Dewan is a biotechnologist and lawyer with a love for writing. She is passionate about travel, books, scuba diving, horse riding, mindfulness, art and wine. She has always cared about empowering women through information and education – be it financial, technological, legal or sexual.

Intrauterine Devices (IUDs)

We’ve come a long way from Lippes loops in the 1960s to IUDs today. Shaped like a “T” and about the size of a matchstick, the IUD is fitted inside your uterus by a doctor.

5 different brands of IUDs are FDA approved for use in USA: Paragard, Mirena, Kyleena, Liletta, and Skyla. Paragard contains copper whereas the others are hormonal IUDs containing the hormone progestin (levonorgestrel) to prevent pregnancy. Many of these are available in India too, some under generic brand names although hormonal IUDs are more widely available in urban areas. 

The IUD prevents the sperm from physically fertilizing the egg – copper itself acting as a spermicide. In women using hormonal IUDs, the eggs are not released from the ovaries and the cervical mucus is also thickened further preventing conception.

While Paragard protects from pregnancy for up to 10 years, Liletta for up to 6 years, Mirena and Kyleena work for up to 5 years and Skyla for up to 3 years. 

In India, the prevalence and usage of IUDs is quite low for a number of reasons ranging from misconceptions to well-founded fears articulated beautifully here. It says something about the low popularity of IUDs when less than 2% of lower income women in urban slums/rural areas get the IUD, while 33% choose sterilization. In fact, a 2018 article downright refers to the (sad but true) current state of affairs as IUDs being the most “unpopular, censured, even reviled form of birth control’ in India while attempting to extol the virtues of the IUD which are many.

All types of IUDs are highly effective and on correct use, there is a less than 1% chance of pregnancy. They are long-lasting and reversible. They provide peace of mind as women can forget about daily, weekly and monthly compliance once the process is done. Hormonal IUDs even help reduce period pains. Also, IUDs work effectively for all women including those who are overweight or have a BMI>30, where other contraceptives may not work.

Disadvantages include no STD/STI protection, mandatorily visiting the doctor for insertion, periodic checking and removal. While the copper IUDs are provided for free by the Government of India, they can cost up to INR 500 when bought privately, and hormonal IUDs are 5 times more expensive at around INR 2500-3000. There can be pain when the IUD is inserted (the intensity depends on the individual) and it may slip out of place. Paragard can cause heavier periods and worsen menstrual cramps. There may also be spotting and irregular periods for 3-6 months with all IUDs. There are possible risks with an IUD, but serious problems are really rare. It is possible — though extremely unlikely —that the IUD may push through the wall of the uterus or to get pregnant even if the IUD is in the right spot. If you get pregnant, you should have the IUD removed as soon as you find out. If you get pregnant with an IUD in place, there’s an increased risk of ectopic pregnancy which has serious repercussions. An ectopic pregnancy, also called an extrauterine pregnancy, is when a fertilized egg grows outside a woman’s uterus, usually in the fallopian tubes.

I had two friends say completely different things about IUDs to me and:

Friend from India

“After I gave birth to my daughter I asked my gynae (sic) about choices of contraceptive methods and she quickly suggested IUDs, reassuring that it was the best, reliable and the most convenient one. Made appointment about 3 weeks later to get it inserted. So IUD is really tiny and after reading many scary stories about how painful it would be, I came in very prepared. Opened my legs wide and my God it was awful! Extremely painful, but very quick. A nurse was next to me during the whole process to sort of calm me down. Gynae said I did excellent as most women would scream…or perhaps she was just being nice. She then did an ultrasound to ensure that it sat nicely in my uterus. 

It felt great not having to worry about being pregnant again. I chose the IUD for 3 years. Didn’t even feel anything strange down there. However, every period was always with a series of bad cramps and very heavy bleeding. Other than these two things, IUD was pretty good.

Just a few months before I needed to get it out and change it to a new one, I had the worst cramps for several days and this was the pain that was unbearable at times. I rang my gynae and she said that I should see her as soon as I could. Met her and explained everything and she suspected that I might be having a complicated pregnancy!! Having an IUD implanted means you still have that 0.01% of getting pregnant. There was however an infection from the IUD and I needed to get it out of my body right away. Did the urine test, went back home and gynae called in the afternoon saying that I wasn’t pregnant. Phew! So all the bad cramps were caused by an IUD infection. I was probably one of the unlucky few who did not find IUD suitable. Gynae said I should wait for another month or so to be fully recovered before I can have another IUD. For 7 days after seeing her, I was on antibiotics to ensure that I was really clean.

If one is very compatible with IUDs, like my sister, it is very very convenient. She just needs to get it changed every 5 years and not worry about anything else. I myself didn’t go for the procedure again.”

And from my friend in the USA:

“Most of my friends here use IUDs. I knew people on the pill before but I was pretty much the last one to get off them last year. I only know of one person who had to have it taken out because her cramps got worse after. Everyone else is a huge advocate. I wish I had done this a lot earlier. Yup it did hurt when it was inserted. I was cramping hard when it happened and then for several weeks/months after though but apparently that’s not common. I had a fibroid in my uterus that the IUD was touching and that was causing the pain, not the IUD itself.

By the way mine is the hormonal kind. I got it primarily for period pains and to stop them altogether

Most of my friends have non-hormonal and their experiences with it were smoother than mine.”

While these two experiences are not representative of all experiences with the IUD, they do shed light on people’s reservations around the contraceptive, but their popularity is definitely on the rise. At the end of the day, it is and will always be your choice to make based on factual information and personal preferences. 

Non-Hormonal Emergency Contraception

There are 2 main types – first, the Copper T IUD which is one of the most effective methods of emergency contraception. This interesting article discusses a study conducted at Princeton University, where it was found that out of 7,034 subjects, only 10 pregnancies were reported after the insertion of an IUD within five days of unprotected sex. 

Second, there is Ella – a non-hormonal drug containing ulipristal acetate which can be used up to 5 days after sexual activity. Like Esmya & Elata, its first indication is to treat fibroids in the uterus. Ella requires a doctor’s prescription in India and is less widely available and generally not used for these reasons alone. It is about 85% effective as opposed to 99% with the IUD. It is also more expensive and has been known to cause more headaches and is deemed unsafe for asthmatics while some sources report it to be very safe. Some doctors however  prescribe it over telemedicine when a woman is a candidate for Ella due to very heavy bleeding with the IPill. 

Permanent Birth Control

A tubectomy or tubal ligation is a permanent birth control option consisting of a surgical procedure that blocks, ties, or cuts the fallopian tubes so that eggs do not travel to the uterus thus eliminating any possible contact with sperm and preventing fertilization. It is 100% effective but does not protect against STD/STIs.

A vasectomy is a permanent birth control option for men. Vasectomy is the surgical closure of the vas deferens, the tubes that transport sperm from the testes. Instead of ejaculating sperm, the body will absorb the sperm and release sperm-free ejaculate. Even though vasectomies are highly effective, come with fewer risks than tubal ligations and can be done in a 10-minute outpatient procedure, pervasive myths combined with coercive and forced procedures in previous decades mean that just 1 percent of Indian men undergo them.

Some vasectomies & tubectomies are reversible but require surgery.

Ormeloxifene

Centchroman – also known as ‘Saheli’ or ‘Chhaya’ – containing Ormeloxifene – was interestingly first developed in India at the Central Drug Research Institute (CDRI), Lucknow and approved for use in the 1990s. It is also part of the National Family Planning Programme guidance to ASHAs (Accredited Social Health Activist) throughout the country. This non-steroidal, non-hormonal oral contraceptive pill acts as a selective estrogen receptor modulator (SERM) and is taken twice a week for the first three months then once a week thereafter. The only reported side effect is delayed and irregular periods in the first few months. Apart from prolongation of the menstruation cycle in some women, it is not known to cause any side effects.

 

So there you have it. Your sexual health is important. It is up to you to empower yourself with knowledge about all your options and be informed. Contraceptives are not a ‘one size fits all’ and so deciding a birth control method must be a partnership between you and your health care provider based on your personal preferences, medical and sexual history, priorities and circumstances. Don’t be afraid to discuss your options in detail. Take up space, take up time to do so. Let’s start talking about choices, the multiple contraceptive choices that all women have instead of narrow, limited options. Let’s start talking about women’s comfort and safety. And let’s start exercising our right to choose.

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