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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.

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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.

Interviewer: Here to speak with us about vasectomy reversal is Dr. James Hotaling, a urologist and the director of the men's health program here at University of Utah Health. Now, Dr. Hotaling, when it comes to a procedure like this, what are some of the reasons a patient might be looking for a reversal?

Dr. Hotaling: About 6% of people who have a vasectomy will ultimately want it reversed. The most common reason is that they have gotten divorced and have a different partner and want kids with that new partner. Although we do see couples who have had kids, had a vasectomy and then decided they want more kids. So those are usually the most common reasons people want it reversed.

Interviewer: I've been seeing some rates that say, "Hey, you know, a reversal is only 30% to 90% effective." How effective is a procedure like this?

Dr. Hotaling: Yeah. It works about a 90% to 95% of the time.

Interviewer: Oh, wow.

Dr. Hotaling: So it's pretty effective. It depends a little bit on how far out you are from your vasectomy. If you're like 20 years out, it has a lower chance of success. Although it, you know, that chances of success still may be like 80%, 85% than if you're two years out, just because there's more scar tissue.

Interviewer: And we're determining success by being the ability to get pregnant.

Dr. Hotaling: Yeah. That's exactly right. You're determining success by having swimming sperm in the ejaculate.

Interviewer: And so what other factors besides just length of time since you've had the procedure?

Dr. Hotaling: Yeah. A little bit it can be exactly how the procedure was done. When you go back in there, you can either put the vas deferens back to the vas deferens, and that has the highest chance of success rate. Sometimes you have to put the vas deferens back to the epididymis or the sperm-holding tank, and that's smaller and that has like a 60% to 70% chance of success. It's lower. But if you can put the vas deferens back to the vas deferens, that success rate is really high. So if you look at all comers, you end up around 90% to 95%. That's really the biggest thing in determining the success rate and then also just, like we mentioned, how far out you are from having the reversal and to some degree just how the individual surgeon did the vasectomy.

Interviewer: If someone say listening to this and considering whether or not they should have their vasectomy reversed, what is, you know, what is the ideal candidate for a procedure like this? Like is anyone say, you know, not a good candidate? What makes a good person for this?

Dr. Hotaling: That's another really good question. So obviously somebody who wants to have kids in the future and somebody who if the wife is younger, that can be helpful, although it's not impossible to do it if their wife is older. Also for couples who want, you know, multiple kids, it can be helpful as well. And just cost considerations. You know, the cost of a vasectomy reversal is a lot less expensive than the cost of in vitro fertilization. It's like a third the price. So that's kind of the other option, the other consideration.

Interviewer: And is reversal ever covered by insurance?

Dr. Hotaling: No.

Interviewer: Okay. So it's out of pocket?

Dr. Hotaling: It's always out of pocket. Yeah.

Interviewer: What are some of the risks with getting this type of procedure, of getting it all back together?

Dr. Hotaling: Well, the biggest risk would be that it wouldn't work, which is really, really low. You know, the recovery is usually pretty minimal, a little bit of bruising, but not terrible, sore for, you know, maybe five days afterwards. We do use long-acting numbing medication that lasts for four days. So patients really don't have much pain from that. And then you have to take it easy for three weeks or so. In terms of the complication, some patients can get pain that lasts longer than that afterwards. As I mentioned, the chance that it couldn't work or just chance of some bruising or a very rare chance of infection, although that is exceptionally, exceptionally rare as in I've been doing this for eight years and I've only ever seen it happen once.

Interviewer: Wow.

Dr. Hotaling: So that's not common.

Interviewer: Okay. So here on The Scope we've talked before about vasectomies and what the procedure is like, what to expect. It's an outpatient procedure, you come on in and, you know, you heal up for a week or so, right? With a reversal, you know, like the day of the surgery, what are they expecting?

Dr. Hotaling: So they'll, you know, they won't have anything to eat or drink after midnight. They'll come in, in the morning. You know, they'll get an IV put in. They'll get drifted off to sleep. They'll go to sleep. Once they're asleep, we make two small incisions, one on either side of the scrotum, and then we go in and find where the blockage and we bring a high powered . . . we have this new digital microscope, it's like a $700,000 microscope that actually allows us to see in 3D with special glasses on.

Interviewer: Wow.

Dr. Hotaling: It actually is really helpful to do the procedure. So we bring that in. Then we put the tubes back together again with 12 sutures that are finer than a human hair and then put the local numbing medication and close everything up. Each incision is shorter than an inch on either side.

Interviewer: Oh, wow.

Dr. Hotaling: So two incisions, really small. Then you would wake up with some . . . And all the stitches melt away on their own. You'd wake up with some sort of biologic superglue over the incisions and then some gauze on the scrotum. And then you'd go home later that day. And most patients just take some Ibuprofen and Tylenol and that's it.

Interviewer: Wow. And you were saying that it's take it easy for a little bit and then three weeks until you're back to . . .

Dr. Hotaling: Yeah. It's really just no like sex, bike riding, or heavy lifting for three weeks. But you could be back on your computer doing work the next day. Often if I do the surgery on a Thursday, patients are back at work again certainly by Monday. And if I did the surgery on say a Tuesday, often by Thursday or Friday.

Interviewer: Once they're all healed up and once they're feeling good, how do we know, I guess, if it was a success?

Dr. Hotaling: Yeah. It's a great question. You know, we have had patients who get pregnant before we ever checked the first semen analysis.

Interviewer: Wow.

Dr. Hotaling: But usually we check in like 8 to 10 weeks, we check the sperm test. And it can take up to a year, even up to a year and a half, depending on the type of like reconstruction that we do.

Interviewer: Oh, wow. So it's not just you magically are?

Dr. Hotaling: Most patients, when it's successful, have sperm right away.

Interviewer: Oh, wow.

Dr. Hotaling: But it can take longer.

Interviewer: Okay. So, you know, you'll do a test and find out if it was successful and go on from there?

Dr. Hotaling: And then we would repeat it again in three to six months if we didn't show any sperm.

Interviewer: And I would imagine that this type of procedure is something you want to make sure you go to a good doctor, a good surgeon, or a good urologist. You know, what should a man be looking for in a doctor to perform this?

Dr. Hotaling: Yeah. So typically somebody who's done a fellowship in male infertility, which both myself and Dr. Gross here have. We're actually getting another partner, who's starting in September, who's also done a fellowship in male infertility. So you want someone who's fellowship trained. You want someone who does a lot of these. And I think also doing it, you know, in the operating room with the patient asleep, with kind of the best equipment you have, and we sort of tick all those boxes here. Some people do do them in the office with local numbing medication. You know, I don't believe that that's necessarily the best way to do it in my opinion.

Interviewer: So we're looking for someone with a fellowship, someone who's performed the procedure a few times and probably a lot of times, right? And a good center, right?

Dr. Hotaling: Yeah. That's exactly right.

Interviewer: For a patient who is considering getting this procedure done, what is it about say University of Utah Health or maybe another medical center? What is the things that a big center like ours can offer to them with their procedure?

Dr. Hotaling: Yeah. Typically we can also . . . we offer the ability, because we have a full IVF lab and andrology or sperm lab, we can do a little biopsy of the testis at the same time and freeze some of that testicular tissue in case the reversal doesn't work, you know, and you could use that, which saves the patient a significant amount of money because they don't have to have another procedure in case it doesn't work. You want somewhere, you know, that does a lot of them and really has the best equipment.

Interviewer: You were just telling me that you have fellows, you have other . . .

Dr. Hotaling: Mm-hmm. We have other people that we work with. And the surgeons here are still doing the entire surgery, but we have really good assistants. A lot of places, it may be, you know, a surgical technician who's assisting the surgeon, and it really helps to have, you know, great assistants, or if it's a super complicated case, myself and my partner, you know, we'll sometimes do those together.

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.

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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.

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Dr. Jones: How do you plan when and how many children to have? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care and this is "Making Babies or Not," 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: Most of us want children and most of us want to have them when the time is right. However, how much are we really willing to do to accomplish this goal of family? Some people prefer to take a more natural approach and some a more technical approach. Natural family planning provides contraceptive methods and a fertility method for creating a family of the right size at the right time.

Today in "The Scope" studio, I'll be talking with Dr. Joseph Stanford, professor in the Department of Family and Preventative Medicine. Dr. Stanford has a special interest in natural family planning and in natural procreative technology. Dr. Stanford and I have spent our careers in helping people have the children they want, but we take different approaches and we're going to talk about that today. Welcome, Dr. Stanford.

Dr. Stanford: Thank you, great to be here.

Dr. Jones: So let's just throw it out there, what is family planning to you?

Dr. Stanford: Family planning, to me, means couples being able to choose how many children to have, and when and how to have them.

Dr. Jones: I agree with that 100%. So there is a large domain of knowledge and practice around natural family planning.

Dr. Stanford: There's some considerable science and there's also . . . my interest is a lot of things we're still learning, but yes, there's a considerable body of science behind it.

Dr. Jones: Okay. So tell me a little bit about your counseling couples or your practice of natural family planning. What does that mean?

Dr. Stanford: So natural family planning means couples understanding when the woman is ovulating, when the days are that intercourse would result in pregnancy, and then making choices to either have intercourse or abstain. Or we can talk about the various choices they might make around that time to decide to either try to get pregnant or not.

Dr. Jones: So how well does it work?

Dr. Stanford: If a couple understands the days that they may get pregnant and does not have intercourse on those days, it's highly effective for avoiding pregnancy. The controversy about effectiveness comes when couples take chances or say, "Well, maybe I'll see what happens." That's where the gray areas and the controversy come for effectiveness.

Dr. Jones: Right. Well, so, for me, I would say I take a more technical approach. I certainly was raised as a reproductive endocrinology with the science of contraception in terms of birth control pills, birth control hormones, IUDs and shots, because my training told me that people are the least predictable about their behavior when they're thinking about sex and that the difference between what they intend to do and what they really do is kind of big. We know that people want to take their birth control pills and they . . . 10% of them screw up and they don't take them right. Well, what about the natural family planning? You must be looking at a very unique group of people who are motivated, highly motivated.

Dr. Stanford: Yes and no. I would say that successful users in natural family planning are highly motivated for a variety of reasons and find a way to make that work, and find it beneficial to their relationship over time. So in that sense, yes, they're highly motivated. I would also say that they, on average, tend to have a little bit different view about when they want to have children. I think natural family planning users, on average, probably have a few more, one or two more children than the contraceptive users, and that's because of their worldview of how many children they want and what methods they want to employ to get there.

Dr. Jones: So I think the people who provide this service may have a unique worldview. That would be you versus what mine might be, and the people who come to practice this method reliably and successfully may have a little bit of a different worldview, so I think . . .

Dr. Stanford: But I would also say there's a spectrum of reasons people use natural family planning or what we might call fertility awareness methods. Some are coming at it from a religious point of view, some are coming at it from an ecological point of view, they don't want hormones, some are coming at it from a point of view of not wanting to have a barrier or they like that idea of understanding their bodies. So there's a spectrum. It's not a monolithic group that use natural family planning.

Dr. Jones: Right, and I understand that, having grown up sort of in the granola culture, that a lot of women didn't want to put anything in their body or take anything unnatural and preferred -- they were well-educated women -- to make their own personal choices, and I can see that that might be very useful for them if they practice it reliably through a lifetime of contraception.

Kids who might be sexually active, when they're still not reliably ovulating or women postpartum, or women in their 40s, are there special tools that you have to use for women who aren't reliably ovulating?

Dr. Stanford: Let's talk about the women in their 40s or women who are not reliably ovulating. Those are cases where I think we do need more research, but I do think we have adequate tools to make it work for those who want to make it work. Is it always the easiest thing? No, sometimes it requires a little more patience. It can work for that group. I hope we have better ways in the future to make it work a little more smoothly or easily.

The teenager, that's another question of motivation and the whole social context of . . . . I believe that teenagers should all be educated in their sexuality, including their fertility and their fertility cycles. Whether or not that means we rely on that as the only way of them not getting pregnant, I would think you need to look at social context and social norms, and other issues. And in some social context for some teenage populations and families, they may think contraception's part of that, but I think that for all teenagers, they should understand their fertility.

Dr. Jones: Right. I thought that if they had sex, they were reflex ovulators like cats, meaning, yes, grown-up women ovulate on a schedule and teenagers only ovulate when they have sex because it seems like it only takes once, at least that's what they've told me.

Dr. Stanford: Well, you know, that's an interesting question that I actually think we need a little more research on, but it's not true that . . . there's no evidence, let's put it that way, that women can go from no mature follicle to ovulating based on one intercourse.

Dr. Jones: Even I know that. Well, so I take it . . . I come at contraception from a perspective of wanting to have a very low failure rate with almost no input.

Dr. Stanford: Right.

Dr. Jones: So for those of us who are interested in what we call long-acting, reversible contraception, or highly effective reversible contraception, we want something that's highly effective and reversible, and you don't have to think about it, that has some side effects, though. It has some downside and women, the tradeoff for highly effective and reversible is some side effects, but I guess . . . what is the failure rate if you follow the rules? Did we talk about that?

Dr. Stanford: Yeah, 1% to 2%.

Dr. Jones: One to two percent, that's pretty good, per year?

Dr. Stanford: er year.

Dr. Jones: Per year.

Dr. Stanford: So I would say that is a fundamental difference in philosophy. Natural family planning is, in some ways, the complete opposite of long-acting, reversible effective contraception in the sense that the goal is to have as little user input as possible, make it completely independent of the user.

Dr. Jones: Right.

Dr. Stanford: Natural family planning is the radical opposite of that. The user, and not just the woman, but the woman and the man together, need to cooperate and understand what's going on and cooperate to make that happen for both of their intentions. So it is a radically user-dependent method, which I think some people see as a weakness, but it is also a strength.

Dr. Jones: I think it is for strength and what I really want is for women to have their choices.

Dr. Stanford: Right.

Dr. Jones: And for couples to have their choices.

Dr. Stanford: Right.

Dr. Jones: And I think that's important to both of us, and whether you choose a very technical approach to your personal contraception, or you want a, what I call radically . . .

Dr. Stanford: User-dependent . . .

Dr. Jones: . . . user-dependent method, meaning your control and your body

Dr. Stanford: Right.

Dr. Jones: We want to have both people to be successful.

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Dr. Jones: You just had your first baby. I mean JUST and the doctors ask you what you want to use for contraception. You blink, go blank, and say, "I'll think about that later." But the best time to think about planning your next baby might be right now. This is Dr. Kirtly Jones from the Department of Obstetrics and Gynecology at the University of Utah Health Care, and this is postpartum contraception on The Scope.

Announcer: Covering all aspects of women's health, this is The 7 Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Traditionally women and doctors have talked about planning for the next baby and spacing your children at the six week postpartum visit. And that's good, but a very high percent of women have already had sex before their first postpartum visit, and a very high percent of women don't even go to their postpartum visit.

Life and the new baby get in the way but there is a very good evidence that it's a very good idea to space your children at least two to three years apart. So what's the evidence? First, there's the case for the mom. Mom needs to have their uterus to heal, especially if they've had a caesarean and about one out of five women American women are going to have a caesarean, and in some places, one in three. And babies born sooner than 18 months from the last pregnancy are more likely to be smaller and more likely to be premature.

And women, hopefully, can breastfeed for 6 to 12 months, which is pretty good contraception, and another pregnancy can get in the way of breastfeeding. So women who've had a caesarian and get pregnant right away are more likely to tear open their uterine scar, rupture their uterus.

But babies need extra time too. We mentioned breastfeeding, but there's also very important mom time that helps with language development and emotional development. Some studies suggest that the ideal spacing for babies is three years apart. Kids should be able to walk, talk, feed themselves, and other important bodily functions before they face competition from another kid. Kids born closer than three years apart are less likely to be reading-ready when they start for school. So why should you think about planning for your next baby right after you've had one, and what can you do?

Number one. If you don't do something, you could get pregnant as soon as 28 days after delivery. This is the earliest that non-breastfeeding women can ovulate after the delivery. Babies born within the same year are affectionately called 'Irish twins'.

Two. You could use breastfeeding as your contraceptive method, but you have to breastfeed exclusively. No bottles, no formula, no food, no juice, no sleeping through the night.

Three. If you're sure that you've finished your family, you can consider having your tubes tied while you're still in the hospital; sometimes, within hours or so of delivery. Of course, you can send your man to have his tubes tied while you're recovering in the hospital from your delivery.

Four. You can have low dose hormonal implant put in your arm in the hospital before you go home. It doesn't affect breastfeeding and it lasts three years.

Five is to have an IUD placed right after the baby and the placenta come out. If you've had a caesarian section, it can be placed right in the operating room, and then you don't have to think about it. You'll have 5 to 12 years of protection depending on what kind of IUD you choose, or you can it removed in a couple of years and plan your next baby.

Are there problems with putting in an IUD so soon? There's an increased chance that it might fall out. The uterus is big, the IUD is tiny, and the cervix is open from the birth. Your doctor should check when you come back for a visit that it's in the right place if you have it placed right after the baby is born. Another problem is not all doctors know how to do this, but we've been doing this at the university hospital for several years now. Insurances may not want to pay for a contraceptive method that usually is done in the clinic when it's done at the time of birth, but several states have taken steps to remove this barrier.

If you're interested in any of these options, make sure that you talk with your doctor or midwife during your pregnancy so they can be ready to get you what you need after you deliver. Putting some time between babies is good for moms and good for babies. Think about what you would like to do and talk about it with your health care provider when you're pregnant. We can give you options that are highly effective and highly reversible and highly forgettable until you're ready for your next baby.

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