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  3. Birth control

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How to Choose Birth Control for Men and Women? An Interview with Prof. Johannes Bitzer, Part 2

Here’s the second part of our interview with Prof. Johannes Bitzer, an Ex-president of the European Society of Contraception and one of the leading experts in the field of birth control. We talk about choosing the right contraception method, as well as give some advice on how to store birth control and when to talk to kids about sexuality and protection methods.

You can catch up on the first part of the interview here.

We have information from the Ancient Egyptian and Greek cultures. The basic principle was that people understood pregnancy had something to do with the intercourse and the contact between the sperm and the vagina.  So the first methods had to do with putting something into the vagina.

The Ancient Egyptians used to put wool into female private parts. They used to put all sorts of substances in, actually. Some of those substances were not very nice. All of that was to avoid the contact between the sperm and the cervix. They had no knowledge about ovulation at that time.

Also, they’ve already developed some sort of condom made out of the gut of the sheep. So, men also understood they could put something on their penis to prevent the sperm from going out where they didn’t want it to go.

Later, in the Greek culture, there were recommendations for women to get up after the intercourse and jump. Vaginal douching was also probably invented quite early in human history.

Yes, there are permanent, so-called non-reversible birth control options. They consist in the fact that you can surgically (mechanically) interrupt the tubes in the woman or the duct in which the sperm is transported in men. It is simply a mechanical occlusion. 

In women, you can do it by different operations that are either made from the umbilicus or from inside the uterus. The principle is always the same: you close the fallopian tubes so the egg cell and the sperm can’t get together. 

In the male permanent contraception, the new methods are quite simple. You just make a very small incision, get hold of the duct where the sperm is transported and close it by a clip.

This option also exists. It’s called the long-acting reversible methods. There are two major means here. One is intrauterine devices either with copper or hormones. The other method is implants: a hormonal stick put under a woman’s skin. The implant is effective for about 3 years, while IUDs last about 5 to 10 years.

The classical and the most-experienced method is hormonal contraceptives, the pill. 

There are very positive aspects of how the pill affects teenagers:

  • it protects against pregnancy very effectively if you don’t forget it
  • it regulates the cycle
  • it has some positive effects on skin, etc. 

Basically, the pill is still one of the best methods. The biggest disadvantage is that you may forget it. This is why in recent years the long-acting methods I mentioned before have become more popular with teenagers and are more often recommended by the professionals. When I was young, the general recommendation was not to use LARC in young nulliparous women, not to put an IUD into the uterus for the fear of infections. 

Now, this has changed. There is general agreement now that you can use LARCs in adolescents. But I believe in many countries the pill is still quite popular. It reduces dysmenorrhea and strong bleeding which a considerable number of young women have.

There are three options now available for the so-called emergency contraception.

  • The pill containing progestogen. You should take it as soon as possible. It’s probably active during the first 48 hours after unprotected intercourse.
  • Antiprogesterone pill, which is prescribed in many countries. The brand name may differ. It is active until 72 hours and quite effective. 
  • IUD, which is the most effective postcoital method. It may be effective up to 5 days after unprotected sex.

We have quite a bit of options when people realize the condom broke or had intercourse without any protection. In most of the countries, it’s over the counter — you can go to the pharmacy and don't necessarily need a receipt from the doctor.

To answer the first question first: there is no best pill. It really has to be individualized. And it is the advantage that we have a lot of different preparations with different dosages and substances.

Some women need a bit more estrogen because they have irregular bleeding otherwise. Some need more progestogen which is good for the skin but may have a bit higher risk of thromboembolic complications. You have to really individualize. And I think this is very important that doctors and healthcare professionals are well-trained and understand what is inside each pill to individualize the treatment. We call it «tailoring» contraception. 

I think the evolution in this respect is that most of the newer pills have less than a 7-day break.

There is also a tendency now to use the so-called “long cycle” where you don’t make a break. You just continue to take the pills, because you don’t actually need the bleeding. The break was created just to make the cycle look natural. But menstruation is not that useful, it even has a considerable negative impact on health. There are tendencies to either reduce pill-free days or completely make a continuous cycle.

There were some interesting studies going on looking into the possibility for very effective male contraception, apart, of course, from the condom. They found that you can almost do the same thing in men like in women — you would give progestogen to suppress sperm production and extra testosterone so men would have enough testosterone. The progestogen is given as an implant and the testosterone as an injection This combination of implant and injection might work.

The research is still going on. It was quite advanced, but the companies who were developing it, stopped it and now only private research organizations keep investigating. The NIH also continues the research on male contraception to some degree.

Well, there is some new research going on.  Computer scientists and biologists together are trying to develop contraceptive methods based on a good data set. We have new technologies to collect data about all sorts of factors (temperature, the pattern of menstruation, urine hormones,  from which computer programs can calculate the so-called fertile days — 6 days before ovulation to one day after ovulation.

Before that, of course, it was the classical Knaus-Ogino method when people were just counting the days assuming that ovulaton would take place. They thought that from the first day when they have menstruation, ovulation will be two weeks later. If you consider the fact that the egg cells are fertile for 1 day and the sperm is fertile for 6 days, then you can have intercourse until day 8 and then after day 14. But this is only true if ovulation is in the middle of the cycle, which is not the case in many cycles of women. 

Other methods of detecting the fertile days include measuring the basal body temperature or looking at the cervical mucus. In recent years, some hormonal testing methods have been developed: you can look for LH peak in the urine or in the blood. 

If you combine all the methods together, it’s quite effective, but it demands a lot of discipline. As I said, there are now things like Flo and other apps collecting data. And it may well be that in the future we get more of these programs that would allow women to better understand their cycle, determine the fertile days and either strictly use the condom on the fertile days or have no intercourse.

I think it would be very good for parents to talk to kids when they are 5 or 6 years old. As for birth control, I think the conversation about sexuality and contraception should be held as soon as puberty starts. Schools play a very important role and good sexuality education is essential. In recent years the internet has become an important source of information about sex. But there are unfortunately many «fake news» and it is important to get to the facts. Here doctors play an important role.

Well, for oral contraceptives you don’t need any fridge, you can store them as it is. In most countries, you can only get them from the pharmacy with a receipt. 

The only thing you would have to store in a fridge for a while is the vaginal ring, but other things are easy to store.

I think birth control is such an important issue for women’s health that we should continuously educate people, doctors, and other healthcare professionals about it. We do it to help women find the best birth control method that meets their needs in different life phases. By preventing unwanted pregnancies, we make a very important contribution to women's health. Fortunately, we do have many methods now at our hand, but the art is that we find the best method for each individual woman.

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