INTRODUCTION

Several long-term or permanent methods of birth control are available. These are best for women who do not want to become pregnant in the near future (or ever). These methods work well, mostly because the woman does not have to remember anything on a regular basis.

This article discusses long-term methods of birth control, including the intrauterine device (IUD), contraceptive implant, and sterilization. Hormonal and barrier birth control methods are available separately. (See "Patient information: Hormonal methods of birth control (Beyond the Basics)" and "Patient information: Barrier methods of birth control (Beyond the Basics)".) An overview of all birth control methods is also available. (See "Patient information: Birth control; which method is right for me? (Beyond the Basics)".)

CHOOSING A BIRTH CONTROL METHOD

It can be difficult to decide which birth control method is best because of the variety of options available. The best method is one that you will use consistently and that does not cause bothersome side effects. Other factors to consider include:

• How well does it work?
• Do I need to remember anything to use it?
• How long does it work?
• Can I get pregnant when I stop using it?
• Will I bleed more or less?
• Will I have side effects?
• How much does it cost?
• Does it protect me against sexually transmitted infections?

No method of birth control is perfect. You must balance the advantages of each method against the disadvantages and decide which method you prefer. A list of helpful questions is in the table (table 1).

INTRAUTERINE DEVICE (IUD)

IUDs are placed by a doctor or nurse through the vagina and cervix, into the uterus. Most are made of molded plastic and have a string that you can feel in the vagina. IUDs currently available in the United States do not increase a woman's risk of ectopic pregnancy, infertility, or long-term risk of infection.

Two IUDs are currently available:

• Copper-containing IUD (Paragard®) (picture 1) prevents pregnancy by preventing sperm from reaching the fallopian tubes. Copper-containing IUDs last for at least 10 years; the pregnancy rate in women who use a copper-containing IUD is less than one percent in the first year of use (table 2). Some women who use a copper-containing IUD have heavier and longer menstrual periods.
• Levonorgestrel-releasing IUD (Mirena®) (picture 2) prevents pregnancy by thickening the cervical mucus and thinning the endometrium (the lining of the uterus). It also decreases menstrual bleeding by 40 to 90 percent and decreases pain associated with periods. It lasts for at least five years, and is highly effective in preventing pregnancy; the pregnancy rate in women who use a levonorgestrel-releasing IUD is less than one percent in the first year of use (table 2). Some women completely stop having menstrual periods while using a levonorgestrel-releasing IUD; this is not harmful and does not require treatment. Menstrual periods will return when the IUD is removed.

Benefits — An IUD is an ideal method if you do not plan to become pregnant for at least one year (or longer) or you want a method that is highly effective and does not require daily or weekly attention. IUDs are also appropriate for women who do not want to or cannot use estrogen.

IUDs have relatively few side effects, and are reversible. If you decide you want to become pregnant, you can do so by having the IUD removed. IUDs do not affect your chance of becoming pregnant after the IUD is removed by a health care professional.

Risks — There is a small risk that the IUD will come out during your period. You should check your IUD once per month, after your menstrual period, by finding the strings inside the vagina. If you cannot feel the strings, use a backup method (eg, condoms) until you can see a doctor or nurse to be sure the IUD is still there. There is a very low risk of developing an infection after placement of the IUD, and of improper placement.

Precautions — You should not use an IUD if you recently had a pelvic infection such as gonorrhea or chlamydia. If you have more than one sex partner, talk to your doctor or nurse about the risks and benefits of the IUD.

If you become pregnant while using an IUD, you need an ultrasound to be sure that the pregnancy is inside the uterus, rather than in the fallopian tube (called an ectopic pregnancy). The IUD should be removed when the pregnancy is discovered. (See "Patient information: Ectopic (tubal) pregnancy (Beyond the Basics)".)

BIRTH CONTROL IMPLANT

A single-rod progestin implant, Implanon® or Nexplanon®, is available in the US and elsewhere. A doctor or nurse inserts a small device under the skin in the upper inner arm (picture 3). It is highly effective for up to three years, and can be removed sooner if you want to become pregnant or are unhappy with this method.

The implant protects you from pregnancy within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. You can become pregnant quickly after the implant is removed.

STERILIZATION

Sterilization is a procedure that permanently prevents a person from becoming pregnant or able to have children. Tubal ligation and vasectomy are the two most common sterilization procedures. Sterilization should be considered permanent, and should only be considered after a careful discussion of all available options with a healthcare provider. (See "Patient information: Permanent sterilization procedures for women (Beyond the Basics)" and "Patient information: Vasectomy (Beyond the Basics)".)

Tubal ligation — Tubal ligation is a sterilization procedure for women that surgically cuts, blocks, or seals the fallopian tubes to prevent pregnancy. The procedure can be done in an operating room as a day surgery or in the office when Essure is used (see below). Women who have recently delivered a baby can undergo tubal ligation before going home. It may be done at other times as well. A separate topic review is available. (See "Patient information: Permanent sterilization procedures for women (Beyond the Basics)".)

Essure® — Essure® is a method of tubal ligation that requires placement of a tiny coil mechanism into each of the fallopian tubes (picture 4). Over the following three-month period, the fallopian tissue around the coil grows into the coil, causing blockage of the fallopian tubes in most women. The woman is given local anesthesia (numbing medicine is injected into the cervix to prevent pain) before the coil is placed.

A backup method of contraception (eg, oral contraceptive or condom) is needed until testing confirms that the fallopian tubes are completed blocked; testing is usually done three months after coil placement.

Vasectomy — Vasectomy is a sterilization procedure for men that surgically cuts or blocks the vas deferens, the tubes that carry sperm from the testes. It is a safe, highly effective surgical procedure that can be performed in a healthcare provider's office under local anesthesia. Following surgery, another contraceptive (eg, condoms) must be used for approximately three months, until a semen analysis confirms that there are no sperm present. A separate topic review is available. (See "Patient information: Vasectomy (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Birth control (The Basics)
Patient information: Vasectomy (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Hormonal methods of birth control (Beyond the Basics)
Patient information: Barrier methods of birth control (Beyond the Basics)
Patient information: Birth control; which method is right for me? (Beyond the Basics)
Patient information: Ectopic (tubal) pregnancy (Beyond the Basics)
Patient information: Permanent sterilization procedures for women (Beyond the Basics)
Patient information: Vasectomy (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Overview of intrauterine contraception
Contraception: Overview of issues specific to adolescents
Depot medroxyprogesterone acetate for contraception
Emergency contraception
Female condoms
Fertility awareness-based methods of pregnancy prevention
Hormonal contraception for suppression of menstruation
How to fit and use a diaphragm for contraception
Male condoms
Overview of contraception
Overview of the use of estrogen-progestin contraceptives
Progestin-only pills (minipills) for contraception
Risks and side effects associated with estrogen-progestin contraceptives

The following organizations also provide reliable health information.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute of Child Health and Human Development (NICHD)

      Toll-free: (800) 370-2943
      (www.nichd.nih.gov)

• National Women's Health Resource Center (NWHRC)

      Toll-free: (877) 986-9472
      (www.healthywomen.org)

• Planned Parenthood Federation of America

      Phone: (212) 541-7800
      (www.plannedparenthood.org)

• The Hormone Foundation

       (www.hormone.org)

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