Search for tag: "birth"

A baby that is wanted and planned for, a child by choice and not by chance, that is what modern contraception offers men and women. But you have to know what's out there, how it works, and where to get it. This is really important now more than ever.

This is Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah Health, and this is the "7 Domains of Women's Health" on The Scope.

Women and men all over the world have wanted to plan their families for thousands and thousands of years, but methods used in Cleopatra's time in ancient Egypt probably weren't as effective as what is available now. If no method of contraception is used, women in sexual relationships that would make them pregnant could expect to have more than 11 babies. That's in these days of good obstetrical and pediatric care, where women are less likely to die in childbirth and babies are much less likely to die in the first five years of life. Eleven babies sound like too much? One more baby sounds like too much right now?

Let's talk about contraception. It's an egg and a sperm problem. You need to stop egg production, stop sperm production, or stop the sperm from getting to the eggs. These are the main ways that modern contraception works.

About 50% of unplanned pregnancies happen to people who are "using" contraception but using it incorrectly. This is the most common reason that methods like abstinence or periodic abstinence, think natural family planning, or methods like barrier methods like condoms or diaphragms actually fail. They weren't used correctly or at all. Methods that you have to think about at the time of sex are more likely to fail because you're more likely to fail to use them. If you combine two methods, abstain during your fertile period and use condoms all the rest of the time, your chance of getting pregnant by accident is much lower. Two methods are better than one, and this is a combo where men can be the important user. You can get condoms most anywhere, and anyone with some smarts and gumption can figure out their fertile period.

So let's talk about hormonal pills, patches, and rings. They are considered moderately effective methods or ones that have an annual failure rate between 1 in 10 to 1 in 100. That means if women use them, the chance of getting pregnant is about 1 in 10 to 1 in 100 per year. Of course, you might be at risk for pregnancy for multiple years, so these chances literally add up. Considering a lifetime of contraception using these methods, it was calculated that women would have about two unplanned pregnancies. These methods work by blocking ovulation and by changing cervical mucus so sperm cannot get to the eggs, but women don't always take the pills, or patches or rings correctly. They miss some days or they stop for a week as directed, but they stop for longer than seven days, and they are very likely to ovulate. But you could team up with your sex partner and use a moderately effective method and condoms and get much more bang for your buck birth control-wise.

Hormonal methods aren't right for everyone, and you should know by reading up or asking knowledgeable clinicians if they're right for you. Now, there may be immense hormonal contraception on the horizon, transdermal hormones to block sperm production. If it has about a 10% failure rate per year, and women taking the pill as they will, not perfectly, have a failure rate of about 10% per year, if both members of the sexually active couple use the method not perfectly, the failure rate would be about 1 in 100 per year. The two methods multiply in terms of their effectiveness. If they both used effectively, if they both, men and women used hormonal methods effectively, it would be about 1 in 10,000 women per year, and that is effective contraception.

Now for highly effective methods, these methods have failure rates of about 1 per 1,000 women per year. They are so good because you don't have to think about them and using them correctly almost always happens. These include copper IUDs, hormonal IUDs, and hormonal implants under the skin. The hormonal implants' primary method of action is to work by blocking ovulation. The IUDs' primary method of action is by blocking sperm. Copper in the copper IUD kills sperm on their way up to the egg, and the hormonal IUD blocks sperm from getting through the cervix. The IUDs and implants are highly successful at preventing pregnancy but require a trained clinician to put them in. They last a long time, the copper IUD for 12 years, the hormonal IUD for 5, and the implant for 3, but they are immediately reversible as soon as they come out.

Now, all contraceptive methods have some side effects and risks, but none have as many risks and side effects as an unwanted pregnancy. Uh-oh, did you just say, "Oops?" Did you forget to take your pills? Did the condom slip off or stay in his back pocket? Was sex forced on you and you weren't using anything? Emergency contraception is for people who had unprotected or under-protected sex. They are pills over the counter or by prescription, that must be used in the first three to five days after the unprotected sex act, and the earlier, meaning the next day or the day after, the better. The copper IUD and hormonal IUD can also be used for emergency contraception, but they aren't FDA approved for that use, and you have to find a clinician to place one in a timely manner.

Using contraception means some work on your part. You have to know what you can use and want to use. You need to know where you can get them. You need to know how you can pay for them. All this information is available from many sources, but an overall good resource is bedsider.org. Many clinics around the country provide contraception on a sliding fee scale based on the ability to pay. Most insurance plans pay for a significant amount of the cost of contraception. There's a national family planning grant called Title X, that provides low-cost contraception to anyone who needs it, and it's available in most states. But you have to lace up your boots or put on your flip-flops and do it. Children deserve to be by choice and not by chance now more than ever. Thanks for joining us on The Scope.

The clinical trial is looking for participants in Utah and elsewhere. Find out if you qualify for the study by clicking here.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: Who has a dog?

Troy: Sorry.

Scot: Was that yours? Was that Charlotte?

Troy: That was Charlotte. If I didn't let her in the room, she would be scratching at the door. So that's where we are.

Scot: Today on "Who Cares About Men's Health," we're going to learn more about a new male contraceptive. It's a gel. It's in clinical trial, but you're going to learn more about the contraceptive. You'll also learn how you can participate in the clinical trial if you wanted to.

This is "Who Cares About Men's Health." My name is Scot Singpiel I bring the BS. Bringing the MD to the table is Dr. Troy Madsen.

Troy: Hey, Scot.

Scot: And our guest today is Dr. David Turok. He is an OB-GYN and also a family practice physician. He is interested in family planning, and he is . . . Are you running this clinical trial? How are you involved exactly?

Dr. Turok: Yeah. I am the site lead for the Utah site, and there are 10 other sites.

Scot: All right. So, Dr. Turok, tell me about this male contraceptive gel that you're running the clinical trials on. What do we need to know?

Dr. Turok: So this is an awesome opportunity for our team and for men in Utah to make a real contribution to increasing the range of contraceptive methods that are available for people. So this is the first study that's been available for people in Utah for a male hormonal method. And this study is looking at a gel that will be applied daily on the shoulders. Literally, this study rests on the shoulders of male participants.

Scot: And what's in the gel? What's going on here?

Dr. Turok: So it's a combination of progestin or progestogen called nestorone and testosterone. And the way this stuff works is very similar to the way the birth control pill or the patch or the ring work in female contraception. Basically, this outside hormone tricks your brain into not producing the sex hormones. In women, it prevents ovulation, and in men, it prevents sperm production. It also prevents testosterone production, and that's why the gel also has some testosterone as add-back.

Troy: Interesting. So it's going to actually maybe drop your body's production of testosterone, but not necessarily affect your body's level of testosterone?

Dr. Turok: Correct. That's the goal.

Scot: Yeah. Okay. Explain that. I'm not buying into this quite yet. What did you just say, Troy?

Troy: I'll let David explain it. I'm guessing.

Scot: I would think a lot of men would be like, "Oh, I don't know about putting something on that's going to decrease my body's level of testosterone." That didn't sound like a great idea.

Dr. Turok: Right. For decades, we've been willing to have millions and millions of women across the globe use methods that interfere with their normal hormonal cycle in ways that are safe and effective. And this is similar to that.

So the bottom line on this is there's messaging from the brain at two levels in the brain for gonadotropin-releasing hormone, and then for FSH and LH in the pituitary. And those sex hormones trigger the production . . . There are two groups of cells in the testes that are affected by those. And getting these hormones from the outside, as application of the gel will produce, essentially deactivates one group of cells that makes sperm and the other group of cells that makes testosterone among other things.

And at that point, in order to avoid side effects that people would not like, the testosterone in the gel essentially adds back what you need.

Scot: Obviously, I'm the one without the MD, so you're going to have to explain this to me a couple of times. But we've done previous shows where we've talked about men who take testosterone, and it can cause side effects like testicle shrinkage and other sorts of things. What is preventing this from causing those types of side effects of taking artificial testosterone?

Dr. Turok: First of all, it's dosing. There likely will be some decrease in the size of the testicles. Not as much as people who are using high levels, for example, of injectable testosterone. And the other side effects are . . . There are some minor cholesterol changes with decreases in HDL. There's maybe a slight bump that can happen with hematocrit, the amount of red blood cells that you have circulating in your body. And the progestogen, the nestorone, can also cause a slight increase in weight.

There are very few things that are side-effect-free. But the vast majority of people who have used this combination and others like it have had very few side effects.

So, in the last large study of a combination of an injectable progestin and testosterone combination, there were fewer than 10% of people who quit the trial because of side effects. And if you compare that to studies of oral contraceptive pills in females, that's actually quite favorable. So I think we're seeing something that's headed in the right direction.

And again, we can only get the answers for newer and better methods if people are willing to participate in trials like this. And this is not just, "Hey, here's something you can try and tell us how you like it." This is a rigorously designed study that's going to have up to 400 couples in it. Everyone is going to get the same evaluation. It's going to be extremely thorough, looking at those outcomes that we talked about, pregnancy and side effects, as well as blood tests with chemistry and looking at people's blood levels of the drugs, of the hormones, of their red blood cell counts.

We're going to have enough people to really evaluate this to see if this is truly safe and effective. And the early signals are from this study and others like it that they are very favorable.

Troy: That's great. And for anyone who's listening who wants to participate, what kind of benefits . . . Obviously, a huge benefit is just contributing to science, which I'm sure you and I would agree is a great benefit. I don't know if Scot would agree.

Scot: Yeah. How much am I going to get paid?

Troy: Scot, that's what we're getting at. Is there any financial . . . Scot is like, "Where's the money? Show me the money." Is there a financial incentive to participating or any other benefits?

Dr. Turok: This is not a casual study. The demands of participants are significant and people are compensated for their time and effort and, I think, in a reasonable and generous way. But the combination reimbursement, if you go through the full trial for a couple, is over $3,000.

Scot: Is another prerequisite for the couples you're looking for couples that are open to if it doesn't work that they were planning on having children anyway? Because you're using a trial for a birth control method that you're not exactly sure of the efficacy yet. They could end up becoming pregnant, right?

Dr. Turok: That is an absolute risk. And people who are entering the study need to be willing to accept that. This is something where there's going to be very close observation. So we're going to be checking people's sperm counts regularly, every month throughout the study.

In normal use, something like that wouldn't happen. But this is something where if there ever was a problem or somebody had initially had a low sperm count and then it came back up, we would be able to identify that and ideally intervene before there was a risk of pregnancy.

And again, that coupled with the inherent relatively low risk of pregnancy makes this a safe and reasonable thing.

Scot: Is there a minimum amount of sexual intimacy? Is there a minimum amount of sex that you have to have while you're in this study?

Dr. Turok: Yeah.

Troy: Is this an additional incentive? Is that what you're trying to get at, Scot?

Scot: Maybe. I don't know.

Troy: Like, "Well, we've got to have sex at least three times a week."

Scot: "The study says so."

Troy: "The study says. This is for science."

Dr. Turok: Yeah, that is for couples to determine. But the minimum, the only requirement . . . And this is true for all contraceptive efficacy studies, not particular to this. But couples have to have at least one episode of intercourse where they're relying only on this method each month for that month to count in the efficacy data. So that's true whether we're studying an IUD or a pill or a new injection or the ring, anything.

Troy: And so hearing this, maybe someone is listening and thinking, "Well, I don't know that I want to be part of a study. I don't know that I would qualify. I don't know that I have the time to do this." But maybe they're thinking, "This sounds really cool." What do you think longer, bigger picture, if this next phase is successful, before this actually becomes a realistic option for men to use? Would you say realistically five years out before you think this would potentially be available by prescription?

Dr. Turok: Five years would be greased lightning.

Troy: So that would be a very optimistic scenario?

Dr. Turok: Yeah. In 2007, I wrote this paper that was a summary. It was called "The Quest for Better Contraception: Future Methods." And I was a young contraceptive researcher at the time and really wanted to do a landscape analysis of all the methods that were out there. And there was a section in that paper on male hormonal methods. 2007. And at the time, for that and several other things, we were like, "Yes, we're 5, maybe 10 years away." And we're still 5 or 10 years away, but we've made significant progress.

All of these things take time because the FDA wants to assure that these are truly safe and there are not going to be harms associated with newly approved medications. This certainly seems like it's on track and has great potential to deliver a safe and effective method over time that will be reversible.

And that's another aspect of the study, looking at what happens when you stop it. How long does it take for sperm counts to come back? And that hasn't been an issue in any of the male hormonal contraceptive studies. Nearly all the participants have had return to normal fertility.

Troy: So it's a ways out. If there's a guy now who's 20, maybe by the time he's 30, he could look at using this.

Scot: Well, sounds more like if there's a guy that's 20, maybe his son will be able to use it.

Dr. Turok: No, no, no.

Troy: I didn't want to go that far with it.

Scot: Troy, we're running out of time here. Do you have any final questions?

Troy: Yeah. Have you talked to anyone who's used this? And if so, what do they say about it? Do they like it? Do they find it's fairly convenient? Any personal feedback you've gotten from any participants?

Dr. Turok: Yeah. So the feedback from some other people who've participated at other sites has been extremely favorable and people have been very satisfied. The gel is easy to use. It's easy to apply. The desired results are delivered, and actually, the decrease in sperm counts is occurring a little bit faster than anticipated, which is great, but still takes two to three months. And the initial efficacy signal has been really good.

So the participants have really done a great job and have had very few concerns and negative aspects of feedback thus far, which is great.

Scot: Cool. We'll put the link to your survey site on our website. Thank you very much, Dr. Turok, and thanks for caring about men's health.

You have done all the right things in planning your family and now you're ready to have a baby. How long after stopping birth control before you try to get pregnant? How long does it take to be fertile again? And how long is too long?

Start from the top. How do you stop your method of contraception? Well, that seems like an easy question, but sometimes it isn't. You can stop using your condom or diaphragm or contraceptive foam right now and you can take off your patch, take out your ring or stop your pills today.

Taking out your implant or your IUD takes a medical appointment with your clinician or your family planning clinic. Really now, we don't recommend that you or a friend try to take out these medical devices on your own, so getting an appointment may take a few weeks.

Now, how long does it take after stopping birth control before you're fertile? Well, it sort of depends. If you're using barrier methods, such as condoms or diaphragms or foams or jellies, you could get pregnant the next time you have sex without your protection. Of course, you have to ovulate, and that will be on your regular schedule, but barrier methods don't change that.

If you're on birth control pills or patches or rings, the hormones in these methods are gone from your body within a week. And in the case of the progestin-only mini-pill, it may just be a couple of days then your body will get back to ovulating, so it may be a month or two before you ovulate.

Now, if you don't have regular periods or have a period on your own in three to four months, you should see your doctor. Maybe you weren't regular before you started hormonal contraception or maybe something in your body has changed, but it's not due to your method that you were using.

If you use an implant, the hormones from the implant will be gone in a couple of days, and then your body will get back to ovulation in a month or so, or sometimes in a week. If you're using a copper IUD, you'll be fertile the first time you have sex after it's removed if you're ovulating that day, but you probably won't be fertile on exactly the day that you have it removed, but maybe the next day.

If you're using a hormonal IUD, the hormones will be gone from your body in the week after it's removed, and you should be back to ovulating either next day or next week with a normal uterine lining within a month or so. Of course, there are very rare cases in which the IUD or the implant didn't come out all the way or you thought it was out and it wasn't. And in those situations, there may be a delay in fertility until the implant or the IUD is completely removed, but this is very rare.

If you're using the Depo-Provera shot, the hormone in the shot is in your muscle for months, and it may take as many as 10 months from the last shot before you ovulate again. Of course, as the shot is designed to be given every three months, you may be fertile in as little as four months after the last shot. Because return to fertility is delayed and a little compared to other methods, we usually counsel women who are hoping to get pregnant in the next year but don't want to get pregnant right now to use a method other than Depo-Provera.

Now, when can you try to get pregnant? Do you have to wait a while? We used to think that women were less fertile or more likely to have a miscarriage if they got pregnant immediately after discontinuing a hormonal contraceptive method. We have clinical data that says now it's not so. So you can start to try to get pregnant right away, even though it might be a couple of weeks before you ovulate.

Now, how long is too long? If it's been a year since you stopped your birth control and you aren't pregnant, you should see your OB-GYN. For women over 35 who have lower fertility related to getting older, maybe you should seek some help in evaluation if it's been six months. Is it your birth control that's contributing to not getting pregnant? The answer is no. Using birth control in the past doesn't contribute to fertility problems, but you did get older while you were using birth control so you naturally would be less fertile when you stopped.

How can we be so sure that birth control doesn't cause fertility problems? We don't have a randomized controlled trial of women using different kinds of birth control compared to women who are abstaining from sex, and then seeing which group of women got pregnant first, but that would be an amazing study to do. However, 22 studies that enrolled a total of 15,000 women who discontinued contraception were looked at, and the rate of pregnancy was 83% within the first 12 months of contraceptive discontinuation.

Now that's not significantly different for hormonal methods and IUD users, and it's not significantly different than women who weren't using birth control before they started to try to get pregnant. The study also showed that how long a woman used contraception did not significantly affect the time to fertility when you take into account the age of the woman.

The amount of time it takes to get pregnant is a function of a lot of things. It's your age, your weight, conditions in your pelvis, such as infections or endometriosis, how regularly you ovulate, how often you have sex, and of course the fertility of your partner.

So make decisions about when to start your family or increase your family based on conditions that matter to you and your family, and not because you're afraid that your longer use of birth control will make a difference. Longer use of hormonal contraception may actually decrease the risk of your having problems because it lowers your risk of conditions in the pelvis, such as endometriosis, and some types of ovarian cysts. And here's hopes for the family of your dreams and thanks for joining us on The Scope.

Dr. Jones: So you ran out of your birth control pills and the condom broke or something like that. You really don't want to get pregnant right now or anytime soon. What do we know about your options?

Many women know about emergency contraception, and many don't, something you can do to decrease your chance of pregnancy if you had unprotected or under-protected intercourse. There are two types of emergency contraceptions approved by the FDA that are available in the U.S., and they are pills, and they decrease the chance of pregnancy if they're taken within five days of unprotected intercourse. But there are other types of birth control that would work and keep on working if you're looking for contraception for more than this month.

With us today is Dr. David Turok. He is an OB/GYN specialist in family planning and chief of the division of family planning at the University of Utah. Thanks for taking some time for us, Dr. Turok.

Dr. Turok: Thank you.

Dr. Jones: What were the background reasons to ask the question of whether the levonorgestrel IUD, which is what we're going to be talking about, would work for emergency contraception? What made you do this question?

Dr. Turok: Well, I speak with people a lot about emergency contraception because I'm very interested in it, and I think it's amazing that you can use something after you've had sex to prevent pregnancy. And every time I talk about it with people during grand rounds or during educational presentations, people always, always, always ask . . . because we know we have great data to say that the copper IUD works very well for emergency contraception, people always ask, "Well, what about the hormonal IUD, the levonorgestrel IUD? Can you use that?" So 10 years ago, we started trying to gather data on this topic, and finally we have an answer.

Dr. Jones: So people came to the clinic wanting emergency contraception and they walked into the clinic thinking that they might get some pills. How did you get so many women to participate in the study when they came for just pills?

Dr. Turok: Like in many aspects of life, Utah is unique. And currently, one of the forms of emergency contraception pills is available without a prescription. You can just walk into pharmacy or supermarket and get them. Sometimes it's behind the counter, you might have to ask, but you can get it without a prescription.

In Utah, because there are many limitations for people, young people especially, with insurance coverage, people seek out the cheapest place to get it, and that is Planned Parenthood where there's a sliding scale and where people have known for a long time that they can get the pills.

And we've done a few different surveys and a few different kinds of projects where we offer people walking in for emergency contraception IUDs, and it's around 12ish percent of people are interested in an IUD in that setting. And that's, I think, potentially driven in Utah by the fact that people don't have adequate insurance coverage and they're looking for opportunities to get better methods of contraception. And when there are low or no-cost options presented, people are interested.

So, at the peak before Plan B, one of the pills was available over the counter. Planned Parenthood statewide distributed more than 50,000 doses of oral emergency contraception. So people know, and lots of people come to Planned Parenthood clinics in our state for the service, and when you present them with IUDs, some are interested in it.

Dr. Jones: So some of them are really looking for something for longer than just this month?

Dr. Turok: Exactly. Yes.

Dr. Jones: Right. So you've known that the copper IUD . . . we've all known from data that goes back 20 years, really, that the copper IUD works. So you then offered them either a copper IUD or a hormone-containing IUD. And what did you discover?

Dr. Turok: So what we found in this study where we randomized people to get one or the other type of IUD, either copper or the hormonal IUD, we found that the pregnancy rate was low, very low, in both groups in the month after.

So with copper IUDs, we had 321 people who were assigned to that, and we got one-month outcome data on. And we expected in that group, zero or one would have a pregnancy. And it was zero.

And with the levonorgestrel group, we really didn't know. We had built into the study stopping points. Like, if there were a bunch of pregnancies early on, we were just going to stop. But what happened was there were 317 people who got the levonorgestrel IUD and there was one pregnancy. Lower than we thought and much better than the pills.

Dr. Jones: Right. That's important because the methods that are currently FDA-approved, that those 50,000 women who came to our clinics seeking pills, the failure rate or the ineffectiveness rate is much higher than what you found with the IUDs, either one of them.

Dr. Turok: Yeah. To me, one of the very cool things about the study is the other studies that got FDA approval for those oral methods, these were things that took a long time and hundreds of millions of dollars were spent to go through the FDA process to get that approval. And in this study, we took a method that was already FDA-approved and we just showed that it works for this as well.

And the upside relative to the pills is, as you know, that people who are getting this can get . . . this is not just better than the pills for this one event, but you can continue to use it as long as you want, up to seven years, or for the copper IUD, up to 12 years. And that is a set-it-and-forget-it method.

Then for the LNG IUD, there's this side benefit, which is why it's more popular than, I think, the copper IUD, in that it dramatically reduces or eliminates both menstrual bleeding and cramping. And that is a big upside. And that's why I think people really wanted an answer to this.

Dr. Jones: Well, we have some evidence from another big study that just gave women what they wanted when they asked for contraception and then followed them, that the IUDs were something like 20 times more effective than birth control pills in preventing pregnancy?

Dr. Turok: Correct.

Dr. Jones: So if a woman comes to our clinic for an emergency contraception and she wants long-term reliable contraception, would she be offered an IUD, do you think, in our clinics? Because now that the work was done around here, I'm hoping that our clinicians know that it's an option. Do you think it's going to be used in the clinics?

Dr. Turok: I want to say absolutely.

Dr. Jones: I do, too.

Dr. Turok: But I would also say as our team is working on getting this paper published, I would occasionally have these pangs of terrible thoughts that 10 years down the road, it's going to be like the authors of this paper and 10 other people that we know that know about this and nobody is going to ever have done any of it.

And so I started making lots of phone calls and sending lots of emails to people who I thought would be critical partners in disseminating the information. And one of the things that helps get the word out a lot is getting the paper published in a high-impact journal.

Dr. Jones: Right. It was published in "The New England Journal of Medicine," which is probably our premier medical research journal, I think, in the United States, or one of them.

Dr. Turok: One of the, I think, nice things about the study is "The New England Journal" publishes papers that change practice. That is their main motivator for selecting research articles. And you have a very low chance of submitting something and getting it published. But it was very reassuring to know that they felt this was important enough to be published there and that they were confident that it would change practice.

And there are lots of other organizations, professional organizations, a variety of health practitioners, and providers that can disseminate this to people who work with them.

I also have been working with the people from UpToDate to revise the article on emergency contraception to incorporate this and they were amazing. ACOG carried a piece on their listserv email and we're going to work with them to try to update Lark information in their emergency contraception information. So there are all kinds of ways to get the information out.

And a really important place to do that is also with Planned Parenthood Federation of America. As you know, they have something called the National Medical Committee that makes decisions on changes in practice. So I just sent an email and lately before this interview responding to questions from people who organize the National Medical Committee about this.

It's, I think, a great opportunity for Planned Parenthood Federation of America to lead on the dissemination of this because the information came exclusively from Planned Parenthood clinics. This is a collaboration between our team at the University of Utah and Planned Parenthood Association of Utah.

If you look at what gets published in "The New England Journal," the vast majority . . . and currently, probably nobody is a more fastidious reader and consumer of their publication than you. If you look at those trials that get published, most of them are these big, multi-site, and sometimes multinational studies with tons of sites and huge numbers of participants. This study is different.

Dr. Jones: It is. It's really amazing that you have a very local group who was completely committed to answering the question. And I think that that's a phenomenal thing.

I think, at The Scope, we're trying to get the word out also to individual women so they might be willing to come in and ask. So not only do clinicians need to know, but if individual women say, "By the way, do you think I could get this IUD today? Do I have to wait?" that changes practice.

Dr. Turok: Absolutely. So the education and dissemination of information have to be from push and pull factors from supply and demand side. And as I had mentioned, we're already working on trying to get providers up to speed. But there's lots of opportunity that we're going to be working on to make sure that people who are seeking emergency contraception will know about this.

Obviously, the internet is a fabulous place to do that. And there are also some organizations that focus specifically on emergency contraception. There's a U.S. Emergency Contraception Consortium and an International Consortium of Emergency Contraception, and they are fabulous at providing consumers information about different products and ways to access them. So we look forward to working with them as well.

Dr. Jones: Right. Well, Dr. Turok, I am very grateful for your time, and we'll work at The Scope in trying to get people the information they need. But the research to answer this kind of question takes years and takes a team of dozens of nurses, and clinic staff, and researchers, and above all, it takes hundreds of women who are willing to participate, answer questions, and follow up. To all of them, we are very grateful because "I hope I just didn't get pregnant" isn't a very good birth control method. And it's been a long time coming and I'm so glad to see it here. Thanks a lot, and thanks for joining us on The Scope.

Dr. Jones: I was talking to a group of 11 college students, all women, about family planning. They said, "We aren't really interested in family planning because we aren't planning any children right now." Really? What am I not getting here?

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Sometimes you think people you are talking to know what you mean. Well, that's a mistake for sure. I make assumptions that young people in college know how their bodies work and about contraception, but maybe I'm wrong.

Today in The Scope studio we're talking to Grace Mason, a college student who knows a lot about contraception and is learning a lot about what her fellow students know and don't know. She is the founder and President of the Campus Contraceptive Initiative here at the University of Utah. Welcome, Grace.

Grace: Thanks for having me.

Dr. Jones: So, Grace, by the time young people get to college with all that's out there on the internet, they're pretty well-informed about contraception. Right?

Grace: Well, you would hope so, but unfortunately since less than half of the United States mandates contraceptive education and sexual education broadly, a lot of students come into college without having any sex ed. And a lot of students don't experience medically accurate sex ed in that regard. So if they come out, they may come out of high school with misinformation.

And so when we hope that students will turn to the internet to get better information, there's also a lot of misinformation on the internet that they're quite easy to find as many different people will tell teenagers what they should believe about sex ed rather than what their bodies do and how their bodies function.

So I think that students frequently come in believing things or not knowing anything and hoping that anyone will tell them the truth about how their bodies work.

Dr. Jones: Well, there's a lot of sex in the media, and there are books and there are songs, but none of them actually represent sexual initiation or contraception at all. No one says, "Oh, yeah, what are you using for contraception?" They never had that on the TV. So I read that one of the main reasons that men and women don't finish community college in the way they planned was an unplanned pregnancy. How can we change that?

I mean, if people are coming to college, they planned their college. But now they have to stop or have an interrupted course because of a baby that they didn't plan. What are we going to do about that?

Grace: I think that it is a broad issue, and it's something that Healthy People 2020, it's a huge part of their initiative is reducing the unintended pregnancy rate and increasing the intended pregnancy rate, because at the moment, 45% of pregnancies are unintended. And for students in college, who are 18 to 25, they are the most likely to experience an unintended pregnancy and they're also the most likely to be uninsured.

So there's a variety of issues there when it comes to a lack of knowledge and education coming into college. There's a coverage gap. There is the expense of care, which tends to be about $600 or more out of pocket for uninsured students.

Dr. Jones: For contraception?

Grace: For contraception.

Dr. Jones: If they want a long-acting method. It's cheaper if you're using condoms, of course.

Grace: Of course, but condoms are less reliable, and a lot of students don't like condoms in the sense of like their pleasure. And as they are less reliable, students are hoping to find a method that works with them.

Dr. Jones: So tell me about the Campus Contraceptive Initiative.

Grace: So the Campus Contraceptive Initiative is a interdisciplinary group of students, researchers and providers who are all targeting that issue of college completion, graduation and promoting family planning.

And so we are working through research and education to expand access to services, because we find that a lot of students don't know about the different options that they have when it comes to contraception. And so when it comes to finding the best method, they first need to have the education and that step of these are all the methods available to you. And then what does it look like in pricing? What does that look like for coverage? Where can you actually get those services?

Dr. Jones: So you've been doing a survey. You did a little survey last year, and you've been working on one this year. Any clues from your science so far in terms of what are people thinking out there?

Grace: Yes. We have definitely found out a lot of interesting things. That first survey, that went out last February, we got about 330 students to respond, and they were asked questions about their current sexual health, their knowledge as well as their desire or interest in a low-cost contraceptive clinic on campus.

We found out that 1% of students are currently going to the Student Health Center on campus, and that really blew us away because we found out that a lot of students are going to their doctor, but we know that a lot of students aren't comfortable with telling their parents about the services that they get.

And so that we have this huge uninsured gap of students where if they were able to access care at the Student Health Center, maybe they're being turned away because of the out-of-pocket prices, maybe they're being turned away of not knowing their options.

Dr. Jones: The Student Health Center, it may be student health, but it still has to be paid for. So students, unless they have that particular kind of student health insurance, still have to come up with money, and maybe their parents, if they use their parents' insurance, then their parents are going to get the bills or get the copays or get the information at home, so privacy becomes an issue.

Grace: It definitely does. And we saw that students, when asked about if they could have low-cost, affordable methods, 95% of students said, "Yes, I am interested in that." And many of those students said that they would actually partake in a service like that.

But broadly students want to know about the methods. We found that it wasn't just the birth control pill that was popular. If we were to have this contraceptive clinic, it was options. Across the board students want options for their birth control.

Dr. Jones: So where can college students get information about contraception? What methods are out there? How they work and where and how to get them? What's good information? What could they do right now?

Grace: Well, I would say that there are two wonderful resources out there. Bedsider.org is one. They have an incredible comprehensive list of different options, how they work, the different varieties. For example, since the IUD, there are several different types of IUDs, being able to click on each one and seeing how they're different and what they might do.

And they are wonderful because they also can connect you with emergency contraception to your door or sending your monthly birth control to your door rather than going in clinic. And so they have a great set of resources. Also Planned Parenthood Learn, which is an offshoot of the broader Planned Parenthood website, also has a really user-friendly interface that can compare methods and look at methods and connect you to one of their clinics.

Dr. Jones: Okay. So both of these options have a place where you could put in your ZIP code and you can find out clinics where you could get healthcare?

Grace: Yes.

Dr. Jones: Well, that's good to know, and people need to know more. And having a reproductive life plan, a family planning plan is important if you want to have the family that you want when you want it, or if you don't want it, get the knowledge that you need and get it right. You worked hard to get into a university and you're working hard to finish, and this part of your life takes a little effort, but it's worth it. And thanks for joining us on The Scope. And thanks, Grace.

Grace: Thank you.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Interviewer: You've had all the children you and your partner want. Your family is complete, and now you're considering permanent birth control. But how do you decide who gets it done? Is it the dad, and he gets a vasectomy, or is it the mom, and she gets tubal ligation?

Dr. Alex Pastuszak is a urologist and a fertility expert at University of Utah Health. What is your take on this question, tubal ligation or a vasectomy?

Dr. Pastuszak: So, Scott, I'm going to come right out and say that I would be strongly in favor of the vasectomy.

Interviewer: All right. But that's what you do, so I would expect that. Do you have some more support for it?

Dr. Pastuszak: Right, yeah. So, no, this has nothing to do with my pocket.

Interviewer: Okay.

Dr. Pastuszak: But it has everything to do with the safety and the cost of the two procedures relative to one another.

Interviewer: All right. Break that down.

Dr. Pastuszak: So I would tell you that vasectomy is the safer and cheaper option compared to tubal ligation. So let's go ahead and, just like you said, break that down.

So what are the risks of tubal ligation? So we know that, just like a vasectomy, it can include bleeding and infection. Unlike vasectomy really, though, it can include injury to other organs because you're dealing with the tubes that are inside a woman's pelvis, which are really close to a lot of other sensitive structures.

Tubal ligation requires general anesthetic or strong regional, so the anesthesia is already more significant, and the side effects from that can be more significant than that for a vasectomy. And then just in terms of pregnancy itself. So while tubal ligation is just as effective, effectively, as vasectomy, so more than 99 percent, you can still run the risk of an ectopic pregnancy or incomplete closure of fallopian tube which results in pregnancy.

Now, if you counterpoint those against the risks of a vasectomy, then you're really just talking about bleeding, infection, some pain, and maybe failure of that vasectomy as the main risks. Very few.

Interviewer: And recovery is also much quicker for a vasectomy versus tubal ligation.

Dr. Pastuszak: Right. Because tubal ligation, again, you need to make an actual hole in the abdomen, which by surgical standards in this case, it's a minor surgery, but it's still much more major than a vasectomy.

Interviewer: Gotcha. What about the cost? I think this'll be a short conversation because vasectomy is cheaper.

Dr. Pastuszak: Well, it's cheaper, and the reason it's cheaper is just because you can do it in the office under local anesthesia.

Interviewer: Gotcha, gotcha. Is there a reason why a couple might actually want to get a tubal ligation versus a vasectomy in spite of the reasons that you just gave? Is there anything that you're aware of?

Dr. Pastuszak: So unless there's an actual reason that a man cannot physically get a vasectomy, and I can't think of one off the top of my head, they may exist, or the woman is already undergoing another surgical procedure, like a Caesarian section, and at the time of that procedure wants to go ahead and have that tubal ligation, I don't see any reason why a tubal ligation would be or should be preferred over a vasectomy.

Interviewer: The difference is, though, a tubal ligation, a pregnancy could still occur that could be . . .

Dr. Pastuszak: That could be damaging to the woman.

Interviewer: Yes, exactly.

Dr. Pastuszak: In the setting of, say, an ectopic pregnancy.

Interviewer: Which means?

Dr. Pastuszak: Which means that the pregnancy actually starts in the fallopian tube, and since that fallopian tube is now closed, that fertilized egg can't get to the uterus, and so it starts growing in the fallopian tube, which becomes an urgent or emergent surgical situation for the woman.

Interviewer: And, as of right now, there are more tubal ligations than vasectomies in the United States, isn't there?

Dr. Pastuszak: That's right.

Interviewer: Yeah. Even though the other one is the clear winner, it sounds like, to me.

Dr. Pastuszak: Yes.

Interviewer: So, in this conversation, is there anything else that you would recommend for a couple to consider while having it, other than just kind of the facts that you laid out?

Dr. Pastuszak: So I think the couple really does need to have the facts because, you know, guys are (a) afraid. I shouldn't say afraid, but guys do not tend to seek medical care, right. In the US, women are often the driver of their own and their partner's and family's medical care. So that is one barrier to more men having vasectomies. In fact, maybe not most, but a lot of the men I see in my office come because their partner, their female partner asked them to come, not because they have taken the responsibility.

You know, and I would kind of put this back in the men's court just to sort of say, well, how sexy do you think your woman thinks you are, you know, if you're sitting there and pushing back against this vasectomy? What do you think she would think if you said, "Honey, I'm going to go ahead and get this vasectomy, and I'm going to do this for us and for our family"?

Interviewer: Yes, because it's a safer and a more economically cheaper option. That's pretty sexy.

Dr. Pastuszak: I think so.

Interviewer: So I think, finally, if in spite of all this information, a guy still has it in about getting that vasectomy, what would you say at that point? Because, to me, the course of action seems obvious, but men can still be hesitant. What would you say at that point?

Dr. Pastuszak: So I really do think information is power, and I know that men are hesitant. You know, at the very least, go get the facts. Go see somebody who knows what they're talking about this. Go see your local urologist. Just talk to him about it. He's not going to commit you to having a vasectomy in the office that day. It's your decision, but at least know objectively what you're walking into. And I will tell you, most of you will go with the vasectomy after you talk to him.

You and your partner now have three kids. And for the whole of your relationship, you've been responsible for the family planning part of family planning. And now, you and your honey decide that your family is full. You guys have all the kids you've wanted. Is it his turn? This is Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah Health, and this is Vasectomy on "The Seven Domains of Women's Health" on The Scope.

Women have largely had the responsibility for reversible contraception in any heterosexual relationship. Whether they took that responsibility seriously and planned all their children, or they had a number of kids by chance, what you do when you're done having kids? About 23% of American couples rely on a permanent form of contraception, such as tubal ligation or vasectomy. That's about one in four.

Now, attitudes about vasectomy vary dramatically around the world. In the U.S., 1 in 5 guys over 35 has had a vasectomy. Men who have more education, have higher income are more likely to choose a vasectomy. Men on the West Coast are more likely to use vasectomy than men on the East Coast, and both are more likely to use vasectomy than men in the South. Hispanic men and African-American men are less likely to choose vasectomy.

In countries such as Canada, in countries in Scandinavia, about 1 out of 3 men over 35 have had a vasectomy. That's a lot of guys. Other high-income countries with high vasectomy use and high gender equity, that's an important thing. Where there's gender equity, more guys have picked up a responsibility for contraception include Australia, the Czech Republic, New Zealand, Spain, South Korea, Switzerland, and the UK. In some cultures, Africa in general, vasectomy is extremely rare.

Firstly, both methods are very safe, with very few complications related to the procedure. However, tubal ligation requires either regional anesthesia, such as an epidural or spinal if a woman's having her tubal right after the baby is born, or need general anesthesia if it's done sometime after a baby when it's done by laparoscopy. A vasectomy is done under local anesthesia, which is much less risky. Women have to have their abdomen entered to have their tubes tied. For men, the vas is right under the skin of their scrotum. So it's much easier. For men, it can be done with an incision so small it doesn't even need stitches and often takes only 15 minutes. The time to recovery is faster with a vasectomy than a tubal, a couple of days for men versus a week or two for women.

Now, although men may have some pain and bruising in the scrotum after vasectomy, long-term pain occurs in less than 1 in 100 men. Contrary to many men's fears, a vasectomy doesn't lower testosterone levels, and there's no change in sexual desire. In fact, in a 2015 Stanford study, found that women whose partners had had a vasectomy were 46% more likely to have sex at least once a week compared to women whose men hadn't had the procedure. Now, that's a complicated number, and there might be a lot of interesting statistics packed in that. But at least it doesn't make you stop doing what you want to do. Both methods are very effective with pregnancy rates less than 1 in 100 couples per year. And 1 study suggested that the rate of pregnancy after vasectomy was as low as 1 in 2,000.

Now, there are some rules. You cannot count on your vasectomy for contraception until you've had an assessment of the sperm to show that there's no more sperm coming out. This may take several months and 20 ejaculations to clear all the sperm in the pipeline. Some men may have cleared the sperm in a shorter period of time. But the important thing is the ejaculate must be checked, confirmed that there are no more sperm.

Now, costs are different, but both methods are usually covered by insurance. Under the Affordable Care Act, some states have actually included vasectomy in the no-cost part of contraception. If you had to pay out of pocket, vasectomy could cost $700 to $1,200. And tubal ligation, if it isn't done at the time of delivery, could be as much as $5,000.

So far, this has been about couples in a committed, long-term relationship. But vasectomy has been increasing in young men who've never had children. It is the only method of contraception that gives men private power over their choice to have children. Increasingly, young men are requesting vasectomy as they're very sure they never want to have kids. In the past, physicians were unwilling to perform a vasectomy on a man who had not fathered children. This behavior on the part of physicians has changed in many places as the role of patient autonomy, the right of a person to make decisions about their own bodies, and healthcare has increasingly informed their attitudes about sterilization.

So what happens if you fall in love with a guy who's had a vasectomy and you always wanted kids? This is the time for an honest discussion about hopes and expectations for a long-term relationship. Perhaps the guy never wanted kids until he met you. The options for returning fertility to a man who's had a vasectomy include vas reversal, which is successful about 50% of the time, depending on the skill of the surgeon who's putting this tiny tube called the vas back together. It also depends on how long ago the vasectomy was performed and the age of the man.

For men in whom the vas reversal doesn't work to restore their fertility, in vitro fertilization to retrieve sperm from their testes can be very successful. If your guy has had a vasectomy in the past and still is quite firm in his desire to never have children, that's a more complicated discussion.

So if you and your guy have decided that he is going to have a vasectomy, where can it be done? Well, some family planning clinics have vasectomy services, and some family docs do vasectomies. It's a short office procedure. Most urologists do vasectomies. Only urologists do vasectomy reversal, and you should choose someone who has this more complicated procedure as part of their regular practice.

If for some reason your guy chooses to have a back-up, some men choose to freeze sperm in case they change their minds for whatever reason, change in circumstances such as change in partners or loss of a child. Most fertility centers that do in vitro fertilization can freeze and store sperm. And if a couple should decide that they want a kid after vasectomy, then IVF is an option. However, you and your partner make your decisions, we offer all of these services at the University of Utah Health, and your family choices are important to us.

Interviewer: Six reasons women love men that get a vasectomy. Dr. Alex Pastuszak is a urologist and reproductive expert at University of Utah Health, and he's counseled thousands of patients through this decision. And today we're going to find out the top six reasons that women love men that get a vasectomy. Let's just start with number one.

Dr. Pastuszak: Reason number one, they don't have to think about birth control anymore. I mean, it's one thing less on your to-do list. Instead of having to go get your birth control every month, either from the pharmacy or from your doctor, you've got your guy who's already taken care of it. Once a vasectomy is done and the lab results come back and there's no more sperm, you're good to go.

Interviewer: All right. Yeah, that's awesome, because so often the woman is responsible for birth control, and, you know, even with other long-term options, in three years you've got to go back or whatever. So it's one and done as they say.

Dr. Pastuszak: One and done.

Interviewer: Okay. Six reasons women love men that get a vasectomy, number two.

Dr. Pastuszak: All right. So a vasectomy is really reliable. I mean, just think about the financial and emotional burden that an unplanned pregnancy can have on someone's life. A vasectomy is more than 99 percent effective. It's really only secondary to abstinence, which most couples, once they're in a partner relationship, don't really want to have. You can test to see that it's been effective, and it's going to prevent you from having a pregnancy down the road.

Interviewer: So that reliability, yeah, I mean a financial hardship or a really tough decision could come if you've decided, you know, we're done having children, and then you have to deal with that. So a vasectomy, very reliable. I like that. What about number three on the top six reasons women love men that get vasectomies?

Dr. Pastuszak: Another great reason is that there are no side effects for the woman, and quite honestly there are almost no side effects for the men either. Remember, the risks of side effects are really about in the 1–2 percent range. So other forms of birth control can have significant side effects for women.

Just think about all the hormonal manipulation that all of these birth control options, except tubal ligation, have. And this can leave women feeling awful, gaining weight, and just in general not wanting to continue with that birth control. Why not just one and done it and get that vasectomy?

Interviewer: All right. Six reasons women love men that get a vasectomy, number four.

Dr. Pastuszak: All right. So this kind of following on what I just said about tubal ligation, you don't need a tubal ligation as the female partner if your male partner has gotten a vasectomy. Why is that important? Because vasectomy is just as effective, safer, and cheaper. So why would a woman need to put herself through a more invasive, riskier, and more expensive procedure when a guy can just go ahead and get his done?

Interviewer: All right. And number five on the top six reasons women love men that get a vasectomy?

Dr. Pastuszak: It's a one-time cost. That's it. And it's usually extraordinarily well covered by insurance. Insurance companies don't want people to have babies. They want them to not have babies. So they'll cover this the vast majority of the time. So pay for it once, and that's it, no more ongoing expenses.

Interviewer: All right. And number six and the final reason that women love men that get vasectomies?

Dr. Pastuszak: It makes a man sexier, Scott.

Interviewer: How's that?

Dr. Pastuszak: What is sexier than a man taking responsibility for the family's birth control? I mean, think about it. Women do so much. A woman, in today's day and age, is still very often both a career person as well somebody who takes care of the kids, raises the kids, and runs the household. A guy can step up and do his part. In no way, any evidence that a vasectomy is going to affect a man's masculinity.

You know, there's

• no impact on testosterone,
• no impact on sexual function,
• no impact on an ejaculatory function,
• no impact on cancer risk,
• etc., etc.

There is absolutely zero reason why a man shouldn't get a vasectomy and be rewarded by being that guy who steps up.

Interviewer: How should a woman bring this topic up in a way that a man might be more open to it if he initially is not? Like if there's a woman listening, that's like, "I don't know if my husband is going to buy into this," and she's already laid out it's going to make you sexier, is there anything else that you would recommend?

Dr. Pastuszak: So I would find that a very compelling reason, but . . .

Interviewer: Yeah, I would think so. I think we should be done really, but, you know, maybe there's that one stubborn guy out there, because, you know, we do exist.

Dr. Pastuszak: You know, it may be a process. You know, but ultimately knowledge is power. I think the facts speak for themselves, and, you know, quite honestly, like getting a man in front of somebody who can actually tell him what the experience is going to be like, either somebody who's had a vasectomy or a urologist who does these day in and day out, is a start.

Interviewer: Got you. What's the next step after you get that buy-in from your man?

Dr. Pastuszak: Go see your urologist. Go see somebody who can give you the facts.

Are you happy with your family size? Have you had all the kids that you planned or a few more? Are you considering having your tubes tied? Let's talk about that.

Prior to the development of effective hormonal contraception, women choosing to end their childbearing through sterilization procedures had major operations to remove their fallopian tubes or had hysterectomies. Although the history of female sterilization is clouded with cases where women may not have given informed consent, since 1960, about the same time that birth control pills came on the market, techniques for female sterilization became less invasive and easier to do with less risk. The term used for these easier techniques is tubal ligation.

Now, there are many techniques and the timing for this procedure, and about 30% of American women have had a tubal ligation. Techniques include taking a suture and tying it around a loop of tube and then cutting the tied-off loop of the tube out. And then there are a number of techniques like this to remove the middle segment of the fallopian tube so sperm cannot get to eggs and fertilize them. Other techniques include putting a clip to close the tube permanently, or cauterize or burning the tube in the middle to close it.

The timing could be shortly after a baby is born, within a day or so, while the woman is still in the hospital, or at the time of Caesarian section when the tube is right there, or anytime between children, when the procedure can be done by laparoscopy. But half of tubal sterilizations occur right after the baby is delivered vaginally or by Caesarian, and that comes to about 350,000 tubal sterilizations a year.

The word "ligation" in the term "tubal ligation" means to tie. This unfortunate term translates into tying your tubes. This has led some women to assume if you had your tubes tied, it would be simple to untie your tubes, like untying your shoelaces. Tubal ligation can be reversed surgically for women who regret having had a tubal sterilization, but it's expensive and it doesn't always work.

For years, it has been noted that tubal sterilization decreased the risk of some types of ovarian cancer by 30% to 50%. Now, that's significant. Now, we're getting to the main topic of this little podcast. The lifetime risk of ovarian cancer in the U.S. is about 1.3 out of 100 women. Ovarian cancer is particularly deadly because it spreads early, and we don't have any early detection methods the way we do with breast cancer, like a mammogram, or cervical cancer with a Pap smear. Ovarian cancer comes in different types, but one of the most common types, serous ovarian cancer, may often actually arise in the end of the fallopian tube near the ovary. For this reason, women who have genetically-linked risks of ovarian cancer, such as the BRCA1 and 2 mutations with familial breast and ovarian cancer, are recommended to have their ovaries and their fallopian tubes removed when they finished having their families.

Recent studies have suggested that women who are planning a tubal sterilization who have their tubes completely removed have about a 60% reduction in the risk of these serous ovarian cancers compared to women who didn't have a tubal sterilization or women who just had part of their tubes removed at tubal ligation.

Now, there are other advantages to having the entire tube removed if a woman is planning a tubal sterilization. Tubal ligations have a known failure rate, a pregnancy after the procedure of as much as 3 to 5 pregnancies per 100 women over 10 years who had their tubal sterilization at the time other than when the baby was delivered, with laparoscopy. Women who had their tubes completely removed have a much lower failure rate, almost zero. Women who have a tubal ligation also have an increased risk of ectopic pregnancy or tubal pregnancy if they do become pregnant compared to women who've had their tubes removed completely.

Now, we know that putting a little clip on the tube, burning the tube, or cutting a loop of tube is quite simple and takes a very short time. Anybody could do it. Removing the whole tube takes a little longer. Studies recently published looked at women who were randomized to removing the whole tube at the time of tubal sterilization or cutting a loop out at the time of Caesarian section an easy time to do it as the tube is right there to look at and operate on.

One study used an advanced technique to take out the tube completely and found that time was only about five minutes longer compared to the standard procedure of taking out just a part of the tube. Another study using older techniques suggested took about 10 to 15 minutes longer. There was not significantly more blood loss with taking the whole tube out compared to just part of the tube.

The other issue is that if the entire tube is removed, you cannot come back and have your tubes untied or put back together again the way you might if only a part of the tube is removed. Of course, these days, many women who choose to have more children after tubal sterilization will use in vitro fertilization and it doesn't matter if you have part of a tube or no tube. Although IVF is expensive, so is surgically putting the tube back together again. And in some cases, IVF may be more successful.

So if you're planning a tubal sterilization, your tubes, not your husband's tubes, that would be a vasectomy, consider the following. If you have a BRCA1 or 2 mutation or have a strong family history of ovarian cancer, you should have your entire tubes removed when you have your tubal sterilization, whether it's right after the baby is delivered or sometime later. And often, women also had their ovaries removed.

If you have concerns about ovarian cancer, and you're planning a tubal sterilization, talk with your OB-GYN about taking the whole tube out. If you don't have a family history of ovarian cancer and the concern of the risk of ovarian cancer isn't high on your worry list, think about the benefits and risks that were just mentioned and discuss your options with your OB-GYN. Many OB-GYNs are discussing tubal removal as an alternative to tubal ligation when women are planning a tubal sterilization. Whatever you choose, we're glad you are informed about new options and old options in planning your family, and thanks for joining us on The Scope.

updated: September 10, 2020
originally published: August 9, 2018

Dr. Jones: What if you didn't have to go to the doctor's office to get your birth control prescription renewed? What if low-income women, that includes moms and students, had access to the most effective means of contraception? This is Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah Health, and this is The Seven Domains of Women's Health on The Scope.

Announcer: Covering all aspects of women's health. This is The Seven Domains of Women Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: What would the world look like if every child was wanted and planned for with a mother in her very best physical, emotional, and financial health? We know that the health status of the mom and the early environment for the infant have long-lasting positive and negative effects on children and the adults that they will become. So planning your children to support their success is a good idea, huh?

It turns out that governments, state and federal, have a heavy hand in determining who gets birth control, what kind they get, and where they get it, and how much they pay for it. The states with the least access to family planning have the highest rates of unplanned pregnancies and the highest rates of maternal deaths. On the other hand, the states that offer women and families the greatest access to family planning do better.

This year, the state of Utah took a step in the direction of making contraception easier to get and more affordable for some women. Firstly, Utah now joins a few other states, including California, Oregon, and Colorado, in allowing women to get their birth control prescription renewed and refilled by a pharmacist. One factor in women having gaps in their contraceptive coverage is when their prescription runs out. They may have to go back and see the doctor or the nurse practitioner. This can be time-consuming, taking time off work or child care, and can be expensive.

Now, for women who've had a prescription by a licensed provider and the prescriptions can be renewed and refilled by a pharmacist, this makes it more convenient for women to continue on their birth control pills, patches, or rings. Just a few years ago, this idea would not have found favor in the Utah legislature, but the reality that unwanted and unplanned pregnancies are expensive for the state in the case of Medicare, covering the pregnancies and deliveries, and that the knowledge that women who get pregnant who aren't healthy have more expensive pregnancies, as well as more complications for their babies that are born, this got the legislators' attention this time.

The new law, which unanimously, I will say that again, unanimously passed the Utah legislature takes effect May 8th, 2018. Women will need to fill out a form at the pharmacy to assess their risks, and they'll need to check with a clinician every two years instead of every year.

At the same time, the governor also signed a bill to increase coverage for the most effective and expensive forms of reversible contraception. The most effective forms of contraception are long-lasting IUDs and implants. They may last for 3 to 12 years depending on the type, but can be removed at any time and fertility resumes very quickly.

The methods aren't so expensive on a month-to-month basis, but because all of the costs have to be paid upfront, many low-income women can't access these methods. Utah now joins many states and by including a Medicaid waiver to allow low-income women to have access to these methods on their Medicaid. Utah was only one of seven states that didn't have this waiver, and now it joins most of the states in the U.S. Of course, these methods require a trained health professional to place them, and many doctors don't know how. So the next job is to make sure that the many clinicians around the state have the knowledge to counsel women and the skills to provide them.

So Utah is in the forefront with the few, mostly blue states in the first bill that allows pharmacists to renew, for a year, a birth control prescription, and that is great. The state is catching up with most states with the second bill about Medicaid waiver. A great part of this news is that the legislators who wrote these bills that were passed were informed by young professionals at the University of Utah. The first bill was suggested by a pharmacy grad student at the University of Utah, and the second bill was proposed by a legislator who spent a lot of time listening to the rationale and ideas of a group of young clinicians and educators at the U. How great is that?

Wouldn't it be great if every baby born in our pretty, great state could be wanted and planned for by a mother in her best physical, psychological, and financial health at the top of her game in all of her seven domains of health? Did I say that already? It would be really great. And I've said great at least seven times in this broadcast, so I'm really excited.

Ladies, at the end of the day, it's really up to you. But now, it just got a little easier. And thanks for joining us on The Scope.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Dr. Jones: Many women fear that their birth control pills, which protect them against unwanted pregnancies, will harm them in the long run. Maybe that's a guilt thing, but what if the opposite is true? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is "Good News" on The Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.

Dr. Jones: Many women make the connection between taking hormones for birth control and female cancers. Breast, ovary, uterus, this is a rational irrational fear, completely understandable. Our female parts are female because of female hormones, so taking female hormones such as the ones in birth control pills might have some effect, right? Well, so many women have taken birth control pills in their lifetime, at least 30% in the United States, and we have the ability to do population studies on a lot of women to see if there is really a risk. And a new study adds to older studies to confirm that women who take pills have a lower risk of uterine and ovarian cancer. A much lower risk, and the risk of breast cancer in pill users is still very small.

This new study showed that the longer women took pills the lower the risk, and the risk reduction was greatest in women who were obese, and smokers, and non-exercisers, and these are women who are usually discouraged from taking birth control pills, and these are women who are usually at higher risk of uterine and ovarian cancer. Almost 40 years ago, the Centers for Disease Control did a study comparing birth control use in women with breast, ovarian, and uterine cancer with women who didn't have these cancers. They found that women who didn't have uterine and ovarian cancer were more likely to have taken birth control pills. From that study it was suggested that taking birth control pills lowered the risk of ovarian and uterine cancer by about half. The study didn't find any increased risk of breast cancer in pill users.

This month, a study was published that followed about 200,000 women from 1995 to 2011. Women at the start of the study reported their diet, their exercise, their weight, tobacco and alcohol use, and many other health and lifestyle factors including past use of birth control pills. None of the women had cancer at the beginning of the study. About half the women had used birth control pills at some time in their lives, half of them. Some just for a short period of time of 1 to 4 years, some for 5 to 9 years, and some for at least 10 years. And that's how they divided it up in this study.

Most of them were menopausal at the beginning of the study, but they reported the use of hormonal birth control when they were younger. The study confirms with other studies that have also shown that the risk of ovarian and uterine cancer in pill users, especially long term users of more than 10 years, is about one third to one half of what the risk is in women who didn't use hormonal birth control. We know that birth control users are less likely to be obese and less likely to be smokers, and obesity and smoking can be risk factors for cancers. But looking at smokers or overweight women who did take the pill, their risk of ovarian or uterine cancer was even lower than overweight women smokers who didn't take the pill. This is important and in addition to our understanding of the decreased risk of uterine and ovarian cancer in pill users.

Importantly, there was no increased risk of breast cancer in pill users, the same finding as in the previous study from the U.S. Centers for Disease Control. But to sum it all up, there may be a very slight increased risk of breast cancer in hormonal birth control users, but it is tiny. Now, the pills that the women used in the study were probably on average a somewhat higher dose of hormones than most of the pills we're marketing today, and we wait to see if lower doses of pills offer the same protection. So the good news is that birth control pills seem to protect women to some degree from ovarian and uterine cancer, and their protection increases with longer use and continues even after women have stopped taking the pills. The protection includes overweight and obese women who are at increased risk of ovary and uterus cancer.

We know that hormonal birth control pills with estrogens do have some risks, particularly the slightly increased absolute risk of blood clots. Overall though, for a medication taken by a large proportion of women around the world, there is mostly good news about the safety and continuing good news about protection against uterine and ovarian cancer. So don't worry when you put that pill in your mouth. It's probably good for you, and thanks for joining us on The Scope.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Dr. Jones: New news and old news about the risk of breast cancer and hormonal birth control. Get ready for some really very big and very small numbers. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University Health and this is The Scope.

Announcer: Covering all aspects of women's health. This is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Today we're going to talk about hormonal birth control and the risk of breast cancer. Primarily, we'll talk about birth control pills, but we'll also talk about hormonal patches, shots, implants, and IUDs. There are now 50 years of data on the topic of hormonal birth control pills and the risk of breast cancer. Largely, the studies have suggested that there's no significant increased risk of breast cancer in birth control pill users except maybe in women who used pills starting early in their teens, used them for a long time, and use them into their 40s. Recently, a study from Denmark looked at 1.8 million women between the ages of 15 to 49 who had used hormonal contraception between 1995 and 2012. They were using contraceptive methods that are commonly prescribed today. Because Denmark has a health system that can follow everyone and link diagnosis with prescriptions and health outcomes, they can really do big studies.

So what did they find? First, the extra risk of breast cancer in women of this age group who took hormonal birth control of any type during this time period was 13 extra breast cancers per 100,000 women per year. That's a very small number, 13, out of a pretty big number, 100,000. That is, for every 100,000 women using hormonal birth control, there are 68 cases of breast cancer annually compared to 55 cases a year among non-users. Another way to crunch these numbers is to say there was one extra breast cancer for every 7,690 women using hormonal contraception.

Of course, the details are a little more interesting. For the users of hormonal patches, the extra breast cancers were 5 per 100,000, but it ranged from 1 fewer and 11 more, and essentially it wasn't different from women not using hormonal birth control. Maybe there are just weren't as many women taking it. It's not clear, because the hormonal patch is kind of like the hormonal pill.

For women using vaginal rings, there were two fewer breast cancers. But the statistical range was 32 fewer to 28 more. So there wasn't any increased risk in this group.

The same kinds of numbers were seen for women using contraceptive implants or injections. There were about 5 to 10 fewer breast cancers, but the ranges were so large that there really wasn't an increase or a decrease.

Hormonal IUD users had about the same increase as pill users with about 16 extra breast cancers per 100,000 women. Importantly, and listen to this, the risk for women under 35 years of age was 2 extra breast cancers per 100,000 women per year, a really small number. Young women had a lower risk of breast cancer on hormonal contraception than older women. And women who had used hormonal contraception for a long time, meaning 10 years or more, had a slightly larger absolute risk than women who only used it a short time.

So what do we do with these numbers? First, don't panic. Every time there's bad news about contraception, even if it's barely bad, women stop their contraception and the unplanned pregnancy rate and abortion rate goes up. Now there, you're really taking some risks. It is really hard to know how to counsel women about a risk that is one extra per 7,960 women. Those are numbers that people don't really understand very well. Also, people really don't like numbers like 7,960. They like 10 or 1,000.

So I consider a significant risk is 1 extra in 10. A low risk is 1 extra in 100. A very low risk is 1 extra in 1,000, and an extremely low risk is 1 extra per 10,000, and that's really what we're talking about. The authors of this study admit that they didn't control for age of first period in these ladies, alcohol consumption, breastfeeding, and physical activity. All of these activities increase or decrease the risk of breast cancer by a little. Breastfeeding decreases the risk of breast cancer, and certainly women who breastfeed are less likely to use hormonal birth control. So that could be part of why there was a slight increase in hormonal birth control users.

Now, there's something called biological plausibility. In population studies, they'd find a correlation of one thing with another. Let's pick alcohol. People who drink alcohol moderately live longer. People who drink alcohol a lot don't live so long. Now, is it the alcohol that makes you live longer? Or is it the people who drink alcohol have more fun, have more friends, and having friends makes you live longer? So this is a biological plausibility issue.

Is there a biological reason that hormonal contraception might very slightly increase the risk of breast cancer? Over the past 20 years, researchers have been more interested in the progestin component of the hormonal contraception and menopausal hormone replacement therapy. We always thought that the risk for breast cancer was all about estrogen, but progestin, that other hormone in hormone replacement or in hormonal birth control, seems to add a little risk as well. So there's a possible biological reason for this very small increase in breast cancer in hormonal contraception users.

The authors of this study also suggest that women don't panic, but they didn't exactly say that. They mentioned that hormonal birth control pills have substantial health benefits. Birth control pills substantially decrease the risk of uterine and ovarian cancer and possibly colon cancer. In fact, women who have the BRCA gene for breast and ovarian cancer have been suggested to take birth control pills because even if the risk of breast cancer is slightly greater, the risk of ovarian cancer, a cancer that's hard to detect and hard to treat, is so much less on birth control pills.

So what should you do? We all know that hormonal contraception comes with risks and benefits. For the vast majority of us, the ability to control when and how often we have children is a fundamental factor in our ability to manage our lives. Many women use hormonal birth control, such as hormonal IUDs, to manage flooding periods and pain that debilitates them every month.

If these recent findings are a major concern for you, talk to your clinician about the risks and benefits for you personally. Not you in 100,000 women. Put things in your own personal perspective. There are options for us, probably more than you know, and thank you for joining us on The Scope.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Dr. Jones: Natural child birth, what is that? No woman wants an unnatural birth. But let's talk about normal labor or physiologic labor and how we can support it. This is Dr. Kirtly Jones from obstetrics-gynecology at University of Utah Health and this is The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Today in The Scope studio, we're talking about normal or physiologic birth with Celeste Thomas, a certified nurse midwife and clinical director of birth care health care with the University of Utah College of Nursing. Welcome Celeste. So we all want a normal birth, but humans have these big babies and as a former of OB, all births looked a little risky to me, so let's talk about normal vaginal birth, or you use the word physiologic birth.

Celeste: Yeah, I prefer physiologic, because all birth is normal, right?

Dr. Jones: Yeah. Sort of.

Celeste: I mean, kind of. I mean, for us humans you're right, we do have big brains and so we have to come out sooner than a lot of mammals have to. So let's talk about physiologic birth though, right? Because when we talk about physiologic birth, we're talking about the things that drive birth, which are the hormones.

Dr. Jones: Oh, I'm all about hormones. Go for it.

Celeste: Right? So we're always about hormones at many different parts of our lives. So a lot of this stuff about keeping the room calm or comfortable sounds really nice, right? But it also serves a physiologic end, which is that when hormones are doing what they need to do, then birth runs more smoothly. We know this, because we know that there are things like: prostaglandins, oxytocin, beta endorphins, catecholamines, norepinephrine, epinephrine. All of these things actually build up and change as birth gets nearer, as spontaneous labor gets nearer, and they really serve good purposes. So we know for instance that epinephrine and norepinephrine and cortisol have effects on the fetal brain, pre-labor effects, so things that happen in the brain that are prepping that baby's brain for birth itself.

Dr. Jones: You mean like for getting squeezed?

Celeste: Yeah, for dealing with less oxygen.

Dr. Jones: Wow. I'd always wondered that we aren't weren't born with traumatic brain injury.

Celeste: Yeah. So they have preparations that happen in the fetal brain for dealing with less oxygen, because birth does lead to decreased oxygen for most babies just in the normal process and babies' brains ideally need to withstand that. And we know that there are synthetic versions of things that we use. For instance oxytocin, we will sometimes use a synthetic version called Pitocin, that's in the hospital, but we know also that the synthetic version of oxytocin doesn't necessarily act in the exact same way as naturally occurring oxytocin.

For instance, the synthetic version of oxytocin which causes contractions doesn't easily cross the blood-brain barrier. So this barrier to get into the brain in the same way that naturally occurring oxytocin that comes from the mother does. So there are things about that that are not exactly the same. So I think that the question is, what in the process . . . So sometimes there are ways to kind of safeguard the physiologic process even when things don't go exactly in the way that we were hoping, right, or even when things kind of go differently.

So some of the ways though that we can safeguard that process and allow these hormones to do what they need to do is we can allow labor to begin on its own when we are able to. We can allow labor to begin that way. And that means that we get this pre-labor up regulation in the uterus and allows that uterus to contract more efficiently with the oxytocin. We can get that pre-labor up regulation in the baby's brain as well to withstand decreased oxygen during labor. It also means we want to avoid excessive stress in labor. So a certain amount of stress in labor is normal and can actually beneficial but if that stress reaches a level that is excessive we've seen in a lot of studies that labor can actually shut down.

Dr. Jones: Well, so there's some good reason for that. I mean when you think about how long labors can be in humans. And maybe the tigers are coming or maybe you need to run away. And the fact that you could actually in early labor run away if you were afraid or if you weren't safe or if your baby wasn't safe, you could run away. Maybe it's a hurricane coming. Well, that's a long time to put it off. But we've known in women if they have a big scary thing, their labor can stop and then you end up having to start it up with external hormones and things like that.

Celeste: Absolutely. And sometimes even just going to the hospital, the smells of the hospital, the people talking to you, the bright lights, that can sometimes slow labor down. And we'll see that sometimes when a woman will get to the hospital and her contractions were two minutes apart at home, but now they're 10 minutes apart and kind of sluggish and not really picking up. So keeping the lights low, making sure she has the people around her that feel safe and comfortable to her. Keeping the questions to minimum, just whatever you need to know but not being excessive with that. Making sure that she has access to a doula which is a trained birth support person. Allowing her to move and eat as she needs to. These things are going to decrease those stress hormones and hopefully keep them in that optimal range.

Dr. Jones: Well, so let's back up just a sec, because certainly I could be in clinic and one in five women in the last couple of weeks of pregnancy will say, "Can't you just induce my labor? I just don't want to be pregnant anymore." That's a common . . . now on the one hand some of them say, "No, no, no, I don't want an induction," meaning start the synthetic hormones. But many women assume that doctors want to induce their labor. And maybe they live far away and they're afraid they won't get there on time, or maybe their husband's leaving to be deployed. I mean, there are thousands of reasons, and we've tried to do fewer and fewer inductions. And I think we're really dropping the number of inductions that we're doing. But women ask for it.

Celeste: Yeah, absolutely. I mean it's hard to say . . .

Dr. Jones: I want to tape your comments and say, "Oh no, your baby's brain isn't ready."

Celeste: Yeah. I mean, there are sometimes really good reasons to induce. We have to weigh the risks and benefits. But when we don't have a really good reason to do it, we need to talk with women about what the risks are. So maybe a baby's brain who isn't as primed to go without oxygen, maybe the baby's brain is not going to do us well in labor as the baby whose brain is primed. So it's something to talk about and really discuss with women, and let them know about the research that we have and the outcomes. They're better for spontaneous labor.

Dr. Jones: Well also women are given this due date which, not necessarily your patients, but mine used to think it was their God-given right to deliver by their due date, and so I'd say, "Here's an approximation. Here's your due date, but it could be a couple weeks on either side. So don't start counting down until it's a week or two after this date that we've given you."

Celeste: I almost feel that we kind of give women a disservice, by not giving them a range and just saying, "You could have your baby between this and this."

Dr. Jones: Right.

Celeste: And that would be totally normal, right? Dr. Jones: Right. Well, what are other good ways to support physiologic birth?

Celeste: The other things that are really important have to do a lot with the postpartum period. So when babies come out, making sure that as little as possible there is as little disruption to the process of baby being on the mother's skin as possible. And this is really interesting too because there are things about that postpartum period that we kind of tend to rush in the hospital. And I'm saying this because I've seen it and I've done it too. Where it's like, that baby is on her chest and it's kind of bobbing around and you're just like, "Baby go to the breast. It's over there." But it takes baby a while to get there.

Dr. Jones: But baby's got a headache.

Celeste: And sometimes baby has a headache. But that, it's interesting in the studies looking at babies who bob and are kind of looking around and don't necessarily get the breast in their mouth yet.

The mother's oxytocin goes much high than babies who are just latched on right away. So there seems to be some reason why these things are happening, so as much as possible to kind of watch for those danger signs of course and make sure mom's not bleeding too much or doing those things. But really allowing mom and baby in that little ecosystem, right? That's really important to a baby survival, allowing that to happen.

And the really interesting thing about these things is that, let's say you end up with a C-section. Well guess what? There's physiologic things we can support even in a C-section. We can allow skin to skin. We've been doing that in the operating room, right? So you can do skin to skin. There's a lot of studies now going on with the vaginal microbes.

Dr. Jones: Oh, we did a study. Listeners, you can actually tune in on that.

Celeste: Yeah. So again, there's a lot of stuff we don't know, but there's a lot of things that we can see physiologically that happen in nature that we can try to really safeguard.

Dr. Jones: Yeah. Well I always liked doing deliveries in the almost dark and especially after the baby was born, to turn off the lights so the mom and the baby aren't squinting. The poor baby, the lights are too bright. All I need is a spot at the other end so I can make sure the bleeding isn't happening and get the placenta delivered and let the mom and the baby be in the dark and quiet. And it gives me a chance for my blood pressure to come down as well, as the deliverer, so until the baby is out my blood pressure is up. So I like the dark.

Celeste: Yeah. Absolutely, and I tend to do a kind of mindfulness exercise when I'm even in that second stage when she is pushing, so I really feel my feet on the ground, I want to stay really present, I don't want to get too anxious, want to kind of create that space for her. But also be vigilant, of course.

Dr. Jones: The other thing is that I've often seen and I can't say I've participated because I'm not a yelling person. But when women are pushing and people want them to push firmly, although I don't think there's any evidence that they have to push hard. The body will make them push hard. But they start yelling at someone to push. And you see this on TV. "Push, push." And I'd rather be sweet talked. So talk about your own practice in this regard.

Celeste: Well, think about it. I mean, in the physiology about birth, they actually call it the fetal ejection reflex. So in some ways it's like a reflex, in that when the baby's head reaches a certain point, you will push, and if you can feel it, you will push. So especially with a woman who doesn't have an epidural, you don't need to . . .

Dr. Jones: It's uncontrollable.

Celeste: Yeah, it's uncontrollable. If you have a woman with an epidural, they do some times need a little more guidance, but again, they'll get the hang of it. And really having to direct them in pushing, there's no evidence that that is beneficial.

Dr. Jones: I just don't think it's beneficial at 60 decibels or 80 decibels. I think you could probably coach someone. But when you watch it on TV, they're kind of yelling at the mom to push, and can't you sweet talk that baby out?

Celeste: Yeah, and it's a less like a sport and more like a bowel movement than anything else, right? I mean it's like there is a certain amount of . . .

Dr. Jones: We'll hold that thought. Let's just hold that thought. Well as we put things together, I want to briefly talk about home births and the safety of home births and some studies from Europe and compare the European experience with the American experience.

Celeste: Yeah. Absolutely. So there's been a number of studies on out of hospital birth, especially home birth in the Netherlands, in the United Kingdom for low risk women. And this is an option that's completely integrated into their health system, meaning these are midwives who work with the National Health Service. They have a set criteria of risk that they look at to see if someone is eligible for an out of hospital birth and they have set criteria for transferring when they need to.

Dr. Jones: And the transfer time is short. They're not a hundred miles from the hospital.

Celeste: Yeah. They actually have to be within about 15 minutes I think it is. So in that scenario, home birth can be a really safe option for low risk women. If you look here in the United States, we have a different health system. It's not comprehensive. It can be rather fractured. And so this ability to kind of transfer seamlessly into the hospital when you're having a home birth is not as smooth. And so there are some challenges that way. When you look at outcomes you can see that Cesarean rate for low risk women is lower when they are out of the hospital. And that's true regardless of if it's a birth center or if it's a home birth. The Cesarean rate is lower for low risk women than low risk women who are having their babies in the hospital.

Dr. Jones: Right, and that the women who aren't transferred. And clearly when get transferred the story is over in terms of . . .

Celeste: But you still need to follow those women, those transferred women, and that's something we're actually doing here in the state of Utah, is that we are now capturing the women who transferred in to see what are their outcomes like? And to be expected, the outcomes are not as good, right? If you transfer.

Dr. Jones: Right. But once you've gone from low risk to high risk at home, then that ends up being a bigger problem than going from low risk to high risk in the hospital.

Celeste: Absolutely.

Dr. Jones: But birth is a physiologic phenomenon and there are many, many of us on the planet, so we must be doing it pretty well. Even though the stories from 150 years ago are heartbreaking with the number of moms and babies that we lost, I think that we really do very well in various settings with people who are informed and supported. The biggest issue is supported. And we all want the safest and most comfortable birthing experiences for mom and we offer options that let women make some choices in their birthing experience. And thanks for joining us on The Scope.

Announcer: Want The Scope delivered straight to your inbox? Enter your e-mail address at thescoperadio.com and click "Sign me up" for updates on our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Dr. Jones: Uh-oh, now you have a family planning emergency. How much time do you have? This is Dr. Kirtly Jones from obstetrics and gynecology at the University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Today in The Scope studio, we're talking with family planning expert in emergency contraception. And what are the options and how do they work? Dr. Jennifer Kaiser is an OB/GYN at University of Utah Health and is currently in the family planning fellowship here. Welcome, and thanks for joining us and helping us out with this emergency on The Scope, Dr. Kaiser.

Dr. Kaiser: Thank you so much.

Dr. Jones: Well, when I was a young woman in the last century, we thought that a douche with Coca-Cola would work for emergency contraception. And douching with various chemicals after intercourse has been used for hundreds of years. Any truth to this ancient medical practice?

Dr. Kaiser: So there might be. I actually think one fascinating aspect of contraceptive care, both prophylactic, so using before intercourse or emergency using after, is how women have attempted to control their fertility for so long, for like you said . . .

Dr. Jones: Of thousands of years.

Dr. Kaiser: Of thousands of years. And in our modern era, though, we have plenty of options for birth control. And on the whole, women have really heard about all of these different options. In the past, this wasn't the case. Prior to the creation of the birth control pill in the 1960s, there really weren't any tried and true methods that were widely known. Women and their partners tried using home remedies that were passed on by word of mouth or methods they had read about in magazines. And douching, like you mentioned, was actually extremely popular as a means of preventing pregnancy following intercourse.

So in the 1800s, women could actually purchase special made syringes to douche with. They would use a wide variety of liquids for this, anywhere from cold water to tepid water, to hot water, boric acid, baking soda, and all sorts of astringents. And so we all know how acidic Coca-Cola is as we've seen people's YouTube videos of it dissolving all sorts of things. And it seems that douching with an acidic or basic compound is probably more effective than just water. So there is likely some truth to this, douching with either Coca-Cola or an astringent kind of liquid.

Sperm are very temperamental, and so they don't do well in a pH that's outside of the seven to eight range. So it may be very likely that the sperm were being killed with these kinds of treatments in the vagina or even the lower cervix. But that doesn't really cover the uterus or the fallopian tube where the sperm can get to in as little as 15 minutes. So if you're not right on top of it, it's really unlikely to work.

Dr. Jones: Oh, well, but let's move on to something that we know works a little bit better. So why do they call it emergency contraception? Why do we use that word?

Dr. Kaiser: Yeah. So in general, emergency contraception is so called because it describes the use of a contraceptive method in an emergent setting to prevent pregnancy. So that can be after unprotected intercourse, a rape, or after method failure. So somebody who was using a condom that broke or maybe they had some pills that they missed. This term has also dramatically changed over the past several centuries. In the 1800s, most contraceptive methods practiced were after intercourse with the notable exception of withdrawal or condoms. And so really, in the past, everything was emergency contraception.

The term post-coital contraception was used by scientists and physicians in the 1960s once the pill was created. And the popular media coined the term the "morning after pill" shortly after, which I'm sure is a familiar term to many listeners. But since the 1990s, the term emergency contraception was adopted to really emphasize that this shouldn't be an ongoing birth control method.

Dr. Jones: Right.

Dr. Kaiser: That it's for emergency use and then it also was used to correct misconceptions about when to take emergency contraception, the fact that it's not just limited to the morning after.

Dr. Jones: Right. But it is kind of urgent, and it's not likely to be available in an emergency room unless you're seeking health care in the ER. That's not the place you go for this unless you're already going there for, perhaps a rape or something violent, unfortunately, right? So what's available?

Dr. Kaiser: Yeah. So right now on the market, there are three current available forms of emergency contraception. There is Plan B, which is a synthetic progestin called levonorgestrel.

Dr. Jones: And it comes in other names too. There are a couple brands of this, yeah.

Dr. Kaiser: There's also Ella which is ulipristal, which is another progestin acting medication. And then there's also the copper IUD or para guard.

Dr. Jones: Okay. So let's pick Plan B or drugs like that. How does it work, and when is it too late for Plan B to work?

Dr. Kaiser: Yeah, those are great questions. So Plan B is an oral synthetic progestin called levonorgestrel. By taking this pill, the progestin in it blocks your body's ability to produce a surge of the hormone called LH or lutenizing hormone. By blocking the surge, ovulation is prevented so no egg is released, and thus fertilization and pregnancy are also prevented.

If it has been more than 72 hours from unprotected intercourse, there is less of a chance that Plan B will work. So in other words, it's best to take it within 72 hours, but it can be taken up to 120 hours from unprotected intercourse. But if you've already ovulated before taking Plan B, it's not going to work to prevent pregnancy.

Dr. Jones: Right. Okay. Well, can anybody take Plan B?

Dr. Kaiser: So the great news is that Plan B is now available over the counter at many pharmacies. There is no age limit as far as who can take or purchase Plan B over the counter at these pharmacies. And really, there's no reason why a woman can't take Plan B. The thought is that it's that there are no medical conditions that outweigh the benefits of taking and using emergency contraception.

Dr. Jones: Right.

Dr. Kaiser: The only aside to that is that there may be a little less efficacy if you weigh over 165 pounds.

Dr. Jones: Okay. Well, then let's talk about ulipristal or Ella.

Dr. Kaiser: Yeah. So ulipristal or Ella, also very similar to plan B in that this pill also interferes with the LH surge and prevents ovulation. But it also does this in a slightly different manner. So ulipristal actually blocks the progesterone receptor in the body which is associated with the LH surge and ovulation. So it mainly works through blocking the LH surge, but it may also postpone the release of the egg from the ovary.

So even if your body has already undergone the LH surge, it might be that Ella helps prevent the egg from being released from the ovary. And because of this and how it works in your body, Ella is actually effective for up to 120 hours from unprotected intercourse. The only downside to this one is that you need a prescription from a physician.

Dr. Jones: Now, neither of these, you know, once you take it, it isn't protecting you for days and days after. So you can say, "Well, I've taken it now and maybe it'll help me out. I just will have unprotected sex for the next week." It really doesn't work that way. In fact, that's often why people think it fails is because they kept having unprotected sex.

Dr. Kaiser: Exactly. So you know, like I mentioned, if you have taken it within the 72 hours for Plan B or the 120 hours for Ella, and your body has not ovulated yet, you are going to be protected from that one episode of unprotected sex. If you continue to have unprotected sex, like you said, Dr. Jones, for the remainder of the week, it's not going to work, you're going to need birth control for that.

Dr. Jones: Yeah. Because eventually you're probably going to ovulate, right?

Dr. Kaiser: Correct.

Dr. Jones: Okay. Well, what about the copper IUD? How does that work? And when is it too late?

Dr. Kaiser: Yeah. The copper IUD is actually a really exciting recent development in emergency contraception. So it combines the best of both worlds, like we're just talking about Plan B and Ella aren't going to protect you going forward. It's just for that one episode of unprotected intercourse. The great thing about the copper IUD is that it can give you really effective emergency contraception, and it gives women a long acting, highly effective method of birth control going forward. So this kind of method, once you get it, you can keep having all the unprotected intercourse that you want.

Dr. Jones: But it won't be unprotected anymore.

Dr. Kaiser: Right. Exactly, exactly. Now you have a great method. So we don't actually really know entirely how this works so well as emergency contraception, but we suspect it has to do with creating an inhospitable environment for sperm to prevent fertilization. But copper IUD may also impair implantation of a fertilized egg in the uterus. But again, we're not really entirely sure just how it works.

The great thing about the copper IUD as well is that it can be used for up to seven days following unprotected intercourse. So if a woman finds herself in need of emergency contraception and isn't interested in a pregnancy in the near future, the copper IUD is really a fantastic option.

Dr. Jones: Right. But it's not something you can get over the counter, and it's not something you can use yourself.

Dr. Kaiser: Correct.

Dr. Jones: You need to see someone who's good at putting in copper IUDs.

Dr. Kaiser: Right. So you would need to see a physician who would be able to place this IUD.

Dr. Jones: Or a nurse practitioner.

Dr. Kaiser: Or a nurse practitioner or a PA, whoever is available that has training, who can place one for you.

Dr. Jones: Right. Well, we don't want any woman to have a family planning emergency. We want everyone who isn't planning a pregnancy protected before they have sex. But you know, if stuff happens and now there are some options and some you can get online, check out our Scope podcast on emergency contraception over the internet. And thanks, Dr. Kaiser, for joining us. And thanks, everyone, for joining us on The Scope.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Dr. Jones: Oops, you now have a contraceptive emergency, but your doctor's clinic is two hours away and you don't have the car. The closest pharmacy is an hour away, but the pharmacist is your father-in-law. So what are your options? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.

Dr. Jones: Okay, the condom broke or you didn't use protection. What are your options?

Number one, you can cross your fingers and hope you don't get pregnant. If you and your partner are young and healthy, and the "oops" came around your fertile period, and isn't that usually just the case, the chance of getting pregnant is between one and three, and one in four.

Two, you can use emergency contraception. Emergency contraception comes in three types, and they're all quite different. One is a progesterone hormone common in birth control pills that's taken in a higher dose in a pill within 72 hours of unprotected intercourse. One brand name is Plan B, and the others are Take Action and Next Choice One-Dose. These are available over the counter in many pharmacies, but not all, and should be taken as soon as possible, as it won't work after you ovulate and become pregnant.

Another pill, called Ella, is available by prescription, and it works for up to five days by blocking ovulation.

And lastly, a copper IUD can be placed, and it's the most effective, but it requires that you see a clinician who can place it and place it right away. And depending on your insurance, it can be hundreds of dollars, but it offers highly effective contraception that's immediately reversible for up to 12 years.

If you want to get emergency contraceptive pills, you can get them online and delivered to your home. This is not cheap, and you need a credit card, but several websites are available to women around the country, and FedEx delivers almost everywhere. You can Google "emergency contraception online," but be careful as you need a credible and reliable source.

The Princeton University website on emergency contraception is good, and the website, bedsider.org, will take you step-by-step. Both of these can direct you to the best places to order emergency contraception online. Both of these will also give you more in-depth information about emergency contraception.

Ella, the pill that works for up to five days, might be the best choice. Plan B needs to be taken sooner and isn't as effective for women over 165 pounds. You need to go to the websites recommended by the Princeton emergency contraception website or bedsider.org and set up an account.

You need to fill out a questionnaire that might take 10 to 15 minutes, and then fill out shipping and billing information. You need a credit card, and the current price for online consultation, the medication, and the overnight shipping, but probably not on Saturday or the weekend, is $67. It comes in a little box wrapped up in a bigger box, and you have to be present to accept it at your home.

If you want them to send the prescription to a local pharmacy, the one where your father-in-law doesn't work maybe, you can give them the number and it's a little cheaper, but you have to pick it up pretty soon. Don't wait a week.

Many women who would choose emergency contraception have limited access. They don't have a doctor. They don't live near a health clinic that will take drop-ins. Emergency rooms don't consider this an emergency, and it's very expensive to use an emergency room for emergency contraception.

Women might prefer privacy and confidentiality, which they might not have in their local small-town clinic or pharmacy, where everyone knows everyone. Getting emergency contraception online is an option, but it isn't cheap. You need to have a home address to receive the delivery, and you need a credit card.

Of course, we all hope that you and your partner are well-covered with contraceptive methods that are effective and that you don't have to think very much about so you won't even need emergency contraception. But if you need emergency contraception, there are some options, much better than crossing your fingers.

Thanks for joining us on The Scope.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com, and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.