Having a child is a life changing decision. No woman would like to be a situation where she has an unplanned and unwanted pregnancy. Sadly, many women find themselves in this moral and ethical dilemma of being faced with the decision to keep or terminate an unplanned pregnancy. Contraceptive methods to avoid unplanned pregnancies are extremely important and should be discussed amongst couples who are not keen or ready to have a child. 

To practice safe and responsible sex, the different methods and efficacy of contraception will be outlined. 

Fertilization and Contraception 

For pregnancy to occur after sexual intercourse, the sperm must swim up the vagina through the cervical opening, upwards through the uterus and into one of the two fallopian tubes. If an egg, released during that month’s ovulation cycle, is in the tube a sperm has the chance of fertilizing it.

Contraceptives are designed to prevent this process, and they work in 4 basic ways: 

  • Block the sperm
  • Disable the sperm before it reaches the uterus 
  • Suppress ovulation
  • Prevent implantation

Blocking Sperm 

  • Condom

Disable Sperm

  • Spermicide

Suppress Ovulation

  • Injection
  • Implant 
  • Patch 
  • Pill 
  • Hormonal IUD

Prevent implantation

  • IUD

Emergency Contraception

Surgery

  • Tubal Ligation
  • Vasectomy
Effectiveness of Birth Control Methods

The vaginal ring and barrier methods for women eg cervical cap, female diaphragm and female condom are not available in Singapore.


Blocking the Sperm 

Also referred to as the Barrier Method, these types of contraception work by keeping a man’s sperm from reaching a woman’s egg. 

Barrier methods are not as effective at preventing pregnancy as other birth control methods, such as the birth control implant, injection, or intrauterine device (IUD). Out of 100 women per year, 18–28 women will become pregnant when using barrier methods. They work best when they are used correctly every time you have sex. Even one act of sex without using a barrier method can result in pregnancy. If your barrier method breaks or becomes dislodged during sex, or if you forget or are unable to use it, you may want to consider emergency contraception.

Condom

It is a thin sheath that acts as a physical barrier to prevent sperm from entering the uterus and reach the egg. Condoms come in two forms one for males and another designed for females. 

Male Condom 

This type of condom is placed over an erect penis. Most of the ones you find in stores are made from latex rubber. These are the ones that are effective in preventing STIs. However, for men who are sensitive to latex, polyurethane (a type of plastic) condoms are also good alternatives.

Check out the proper way to use a male condom, here

Pros

  • Protects against STIs. 
  • Cost less than other birth control methods and easily accessible.
  • No hormonal effects on women. 

Cons

  • Reduced sensitivity during intercourse
  • Excessive friction during intercourse may cause the condom to break. 
  • Those with latex allergies may not be able to use regular condoms. Polyurethane condoms, or those made of lambskin, can be alternatives but these can be expensive.
  • It should not be used with oil-based lubricants such as lotions, baby oil, or petroleum jelly. This can cause the latex material to disintegrate and the condom to break during intercourse. 

Disable sperm 

Spermicide

It is a chemical that is introduced into the vagina to immobilize and destroy sperm. It can also be a barrier method because it prevents the sperm from entering the uterus. Today’s spermicides can be in the form of gels, foams, creams, suppositories, and films (thin sheets) that dissolves in the vagina. 

It can be used alone or with other barrier methods such as condoms, cervical cap, or diaphragm to improve its effectiveness. On its own, a spermicide should be inserted deep into the vagina, close to the cervix. Be sure to read the label to know how long before sexual contact should the product be inserted.

Spermicides are effective for only 1 hour after insertion. You need to reinsert a spermicide for each sexual contact. 

Pros:

  • It increases lubrication during sex. 
  • It doesn’t require a prescription and it can be bought in a lot of stores.
  • It is easy to use. 
  • No hormonal side effects. 
  • It doesn’t affect your milk supply if you are still breastfeeding. 

Cons:

  • It can cause vaginal and penile irritation.
  • It does not protect against certain STI’s and may even increase the risk of getting HIV from an infected partner. 
  • Frequent urinary tract infections

Suppress ovulation

Injection

A birth control injection is a shot of hormones that is administered either in the muscle or under the skin by your healthcare provider 3 monthly. It is a safe and convenient options that provides long-term protection. This injection may contain progestin alone, or a combination of progestin and estrogen. They are formulated to stop the body from releasing eggs and it also thickens the mucus of the cervix.

Pros:

  • Safe and convenient
  • It is discreet. You can get the shot at a doctor’s office which means you don’t have to deal with any evidence that you are using it.
  • It doesn’t get in the way of the sexual experience. 
  • It is temporary, so you can still have the chance to get pregnant once the effect wears off. 

Cons

  • You need to get the injection every 3 months.
  • For it to be effective, you need to get it on time.
  • You may experience side effects (e.g. headaches, weight gain, spotting between periods, or more bleeding days than usual)
  • It may take up to 10 months after stopping the shots for you to be able to get pregnant again.

Implant

A birth control implant is a flexible, plastic rod that is about the size of a matchstick. It is inserted under the skin of the upper arm to release the hormone progestin into the body to prevent you from getting pregnant. 

If you get the implant within the first 5 days of your period, you will be protected right away. If you get it any other time during your cycle, you may have to use other forms of contraception for the first week. After that, you can enjoy protection for up to 3 years. The effectiveness may be long-lasting, but it is also reversible.

Implants work in two ways: 
  • Stops ovulation. Without any eggs released from your ovaries, you can’t get pregnant.
  • Thickens cervical mucus. This creates an environment that will make it hard for the sperm to reach the egg. 

Pros:

  • You don’t have to do anything once it is in place. 
  • No one can tell that you are on birth control.
  • It can be inserted immediately after childbirth or while breastfeeding.
  • It does not interfere with sex. 
  • It reduces the pain during menstrual periods. 

Cons:

  • It does not protect against STDs 
  • It may cause unpredictable bleeding.
  • It may result in certain side effects (e.g. weight gain, acne, breast pain, or headaches)

Patch

It is a small, adhesive patch that is worn on the skin either of your belly, upper arm, back, or buttock. It works by releasing hormones (estrogen and progestin) into your body through your skin to prevent pregnancy. They prevent ovulation which means there is no egg for the sperm to fertilize. The patch can also thicken the mucus on the cervix making it hard for the sperm to swim. 

For it to be effective, a new patch must be worn every week for 3 weeks in a row. On the fourth week, no patch should be worn, and by this time you will have your menstrual period.

Pros:

  • It is simple to use. 
  • It can be highly effective with proper use. 
  • It doesn’t interrupt intercourse.
  • It may improve menstrual pain.
  • It can help improve acne

Cons:

  • It is not comfortable to use in the humid Singapore weather or in an active sporty person.
  • It does not protect against STIs.
  • You must follow a strict schedule in changing it every week for it to be effective. 
  • Some medications or supplements can make it less effective.
  • It may be less reliable on heavier women.

Pill

Oral contraceptive pills (OCPs) contain two hormones, estrogen and progestogen. These prevent ovulation, making fertilization and pregnancy impossible. Along with birth control patch and vaginal birth control ring, the birth control pill is one of the combined hormonal birth control methods. At present, there are three types of OCPs: the combined estrogen-progesterone, progesterone only, and the continuous or extended use pill.

A prescription from a GP or a gynaecologist is necessary to obtain birth control pills in Singapore. They will first assess your risk factors, medical history, and lifestyle needs. 

Type of Pills 
  • 21-day pills. One pill must be taken at the same time everyday for 21 days. You must wait 7 days before starting a new pack. You can expect your period during the 7-day period that you’re not taking the pill. Eg Yasmin, Meliane, Mercilon, Gynera.
  • 28-day pills. A pill is taken at the same time each day for 28 days. Some brands come with 21 or 24 pills that contain estrogen and progestin. The remaining pills may contain estrogen only, or dietary components minus the hormones. During the days that you are taking the hormone-free pills, you can expect your menstruation.
  • 90-day pills. You will take one pill during the same time each day for 84 days. The remaining pills may contain estrogen only or it may not have hormones. You will expect your period to happen during the last 7 days every 3 months. This type of pill is not available in Singapore. However, it’s possible to take the 21-day pill continuously for 84 days (4 boxes) before breaking for a period so it will be like a 90-day pill.

Pros:

  • Aside from preventing unplanned pregnancies, OCPs can also help regulate menstrual cycle, allay painful or heavy menses, control acne, and relieve premenstrual syndrome (PMS). 
  • Starting the pill on your first day of menses provides immediate protection. 
  • It is safe for breastfeeding mothers. 

Cons:

  • It must be taken daily, following a strict consumption schedule, making it unsuitable for women who are forgetful.
  • Like any drug, OCPs come with side effects like headaches, breast tenderness, nausea and breakthrough bleeding.
  • It has the tendency to interact with some medications (e.g. antibiotics, anti-epileptic drugs, and antiretrovirals)

Prevent Implantation

IUD (Intra Uterine Device)

Like the implant, this is considered as one of the long-acting reversible contraceptive method (LARC). It means that it can last for years and they can be removed should you change your mind in the future. They are the most cost effective over the long term, the most efficacious and have no issues with patient compliance unlike the contraceptive pills. During the first year of use, fewer than 1 in 100 women using an IUD or implant will get pregnant. Over time, LARC methods are 20 times more effective than birth control pills or the patch.

It is a small T-shaped device that is inserted and left inside the uterus to stop the sperm from fertilizing with an egg. It uses multiple approaches at the same time. Some IUDs contain synthetic hormones which suppress ovulation, thickens the mucus and thins the uterine lining making implantation difficult. Some contain copper which disables sperm while making it difficult for the embryo to implant in the uterus.

Types of IUDs:

Copper-releasing IUDs – It works immediately after insertion by releasing copper ions that are toxic to the sperm. It can stay in the uterus for up to 10 years. The 5 year copper IUD is available in Singapore and is one of the most popular types of contraceptive.

Progestin-releasing IUDs – It starts to work within 7 days after insertion. It releases progestin which is a hormone that prevents the ovaries from releasing an egg. It can stay in the uterus for up to 5 years. The Mirena ( https://www.mirena-us.com/ ) is available in Singapore and is particularly good for women with heavy or crampy periods.

Pros:

  • It is convenient, since there is no need to do anything once it is in place. 
  • It does not interfere with sex. 
  • It is suitable for almost all women. Sometimes, slight preparation pre insertion is required for patients who have never delivered vaginally before and have a tight cervical opening.
  • Over time, hormonal IUDs can help decrease menstrual pain and heavy menstrual bleeding
  • The copper IUD can also be used as emergency contraception.
  • If removed, it does not affect your ability to conceive in the future. 

Cons

  • Hormonal IUDs may initially cause frequent spotting and heavier bleeding. 
  • Some women may experience side effects like nausea, breast tenderness, headaches, and mood changes.
  • It may slip out of place and would have to be removed. 
  • The IUD may come out of the uterus especially during heavy period days, resulting in unintended pregnancies. The risk is higher in teenagers, those with heavy menstrual bleeding, and in women who had it inserted immediately after childbirth. 
  • It doesn’t protect you against STDs.
  • In the unlikely event that a pregnancy occurs, it may be a tubal ( ectopic ) pregnancy.

Emergency Contraception

This is a form of contraception that is effective if it is administered within a specific period after unprotected sexual contact. It is also referred to as, “the morning after pill,” “the day after pill,” or “morning after contraception.” It can be used right away or up to 5 days after sex. 

Compared to the US where one can be purchased over the counter, emergency contraceptives need to be prescribed in Singapore. 

It is important to note that EC does not cause any abortion. An abortion ends an established pregnancy or harms a developing embryo. 

Instances When Emergency Contraception is Used:

  • If the condom broke or slipped off
  • If you have not used any birth control during sex
  • If you have used other contraception incorrectly
  • If a woman is made to have sex against her will

Two Main Types of Emergency Contraception: 

  1. Copper IUD. This is considered the most effective form of emergency contraception. It causes a chemical change in the sperm and egg before they meet, making fertilization impossible. 
  1. Emergency Contraception (EC) Pills
  • Ulipristal (ELLA)
  • Progestin-only pills eg postinor

Surgery

For those who prefer permanent methods of birth control, either the male or female partner can opt for sterilization. The procedure for women is called tubal ligation, while it is vasectomy for men.

Tubal Ligation 

According to data from the CDC, this method of contraception has surpassed OCPs as the most common form of female sterilization. Tubal ligation is a surgical procedure where the fallopian tubes are occluded to prevent pregnancy. 

Two methods of female sterilization include: 

  • Post-partum sterilization 

This form of female sterilization involves a small incision made in the abdomen under the umbilicus (minilaparotomy) right after a normal vaginal delivery or done together with a cesarean delivery. During this procedure, the fallopian tubes are clipped with metal inert clips to occlude the tubes. 

  • Interval ligation via laparoscopy

This procedure involves the use of a laparoscope inserted through an incision inside the belly button at a time not close to delivery. Using an instrument that is passed through key-hole incision in the belly, the fallopian tubes are closed off using metal clips. 

Vasectomy 

 This is a minor surgical procedure for the sterilization of the male partner. It prevents the sperm and egg from meeting by blocking the vas deferens, the tube that carries the sperm from the testicles to the penis. 

These procedures should only be considered if a couple are certain that they no longer want any more children. While there is no legal requirement for spouses to agree, it is important for partners to thoroughly discuss this matter before coming to a decision. It should be taken as a permanent form of contraception. 

There is a contraceptive method to suit different preferences. However, there are some that may not be available in Singapore. To know which among this would be a safe and suitable option for you, it is good to start with medical advice. Book a consultation with Dr. Pamela Tan today.