Why not just have your old man get the snip snip?

Try the pullout method!

Another vote for the IUD! I have never had babies, but after insisting to the lady at Planned Parenthood that I have exhausted my hormonal options, she went ahead and gave me one. I was 21 then, and am 25 now, and it has worked great.

Not the diaphragm, though, unless yr partner LOVES the taste of spermicide.

Another vote for the snip, here. It was the most amazing gift my partner ever gave me (and himself, since I'm pretty much a delicately wombed lady, so no IUD, and have some pretty severe emotional issues on hormones of any kind). Vasectomies are AWESOME!

Why are so many people recommending and IUD when the woman stated in her letter that her doctor doesn't think it would be a good fit for her? Some women become susceptible to toxic shock if they have an IUD. IUD's are good but, like every other form of birth control, are not for everyone.

I had an IUD for eight months, and it was agony. I would have spontaneous cramps that were so bad I would nearly black out. When this started happening while I was driving, I had it removed. The IUD can be great for many women, but from what I've experienced and what I've heard from friends, it is NOT APPROPRIATE for women who haven't had children.

Because the cervix has never been dilated in women who haven't had children, the cervix can be much more cranky, resulting in the symptoms I had. Your mileage may vary, but it was definitely NOT a pain-free straightforward solution for me.

I used the IUD before I had kids and it worked great. My daughter now has one and she is very happy with hers. The diaphram works well, except for the taste. Don't expect to get oral if you are using spermacide. The female condom is a no-brainer if he won't use a condom. But really, if he has his head so far up his own ass that he thinks condom-free sex is more important than his partner's well being? DTMFA.

I found reading the comments following this week's column really interesting as I work as a Sexual and Reproductive Health nurse in the UK - access to free contraception means we are essentially able to offer whatever we want to our patients, provided they have no medical problems or personal objections.

The LW's husband being a dick aside (I agree that seemed to be the central issue, rather than her inability to find a contraceptive method that worked), she should definitely approach another healthcare professional for their opinion as I find it odd that her doctor has changed her brand of pill so frequently, rather than changing to another method entirely.

The copper IUD is certainly the most effective non-hormonal method and the main contraindications are previous pelvic infections and abnormalities to the uterus, as well as heavy, painful periods (in which case an IUS or Mirena coil would be the better option as it reduces bleeding by up to 90%).

Fertility Awareness Methods require a lot of teaching and is not really a method I would recommend to anyone under the age of 35, as being slightly older offers better results due to natural loss of fertility experienced by older women. It is recommended to use two methods of FAM - basal temperature and cervical mucus are the most frequently taught - and does need to be monitored for at least three cycles before being relied upon as a contraceptive method. Fertility beads are crap unless the woman has a perfect textbook 28 day cycle all the time and even then, it only works if she ovulates on day 14 - which not all women will.

While sterilisation has been mentioned quite a few times, you may be surprised to know that the IUD/IUS and subdermal implant are both more reliable than sterilisation (both vascetomy and tubal ligation) as well as being safer in terms of side effects and risks of surgery. The subdermal implant is a great progestogen-only method that lasts up to 3 years, although unacceptable changes to bleeding patterns is a side effect that results in most women having it removed - 70% of women can expect to be amenorrhoeic by the first year.

The other point to make is that a hormonal method that does not agree with a woman at one stage in their life, might be perfect for her at another - so don't rule out a method completely if your circumstances change. Also, any method of hormonal contraception is associated with side effects in the first 3-6 months as the body adjusts to a change in hormonal levels - grinning and bearing the short-term side effects for a longer term benefit of contraception is the price of admittance.

When I got my tubes tied it was a day procedure. Still a bigger deal than a vasectomy, yes, but as surgery goes, not major.

@10 Great post. Nice to compare and contrast different approaches, and sharing your info.

Dan, any chance of throwing some love in the direction of some Eagle Scouts that are returning their medal's back to the Boy Scouts in protest the BSA's Anti-Gay stance? What better way for them to honor their pledge to the commitment of others and caring for the community than by returning them.
http://boingboing.net/2012/07/23/eagle-s…

We planned my vasectomy after our second child.

Wasn't that big a deal and saved me from "are you sure you don't want to have another" conversations that would otherwise come up when she held someone else's baby (body clocks are powerful things). Anyway, getting snipped is the way to go if you know you're done breeding.

I'm training as a family doctor, and I've encountered a lot of doctors who dismiss the IUD for nulliparous women on pretty flimsy grounds. It's certainly easier to pass an IUD through a cervix that a baby has already passed through, and older women in long-term relationships are certainly less likely to have an STI that could become a PID thanks to the IUD insertion... but somehow a lot of docs go from "married women with babies are ideal candidates for IUDs" to "married women with babies are the ONLY candidates for IUDs". I don't get it, but that's the most common reason I've seen doctors give for why an IUD might be "not a good fit". If that's the case, I'd add my voice to the chorus suggesting that TOP help her doctor reconsider this view, if present. (Of course, TOP hasn't told us why her doctor reached this conclusion, and there are legitimate contraindications to IUDs, so her doctor might be right. Maybe she has Wilson's disease, who knows.)

I have had major issues with hormonal birth control, but have been able to use a Mirena hormonal IUD with no issues at all! In fact, quite the opposite: I have had exactly two periods in the past 15 months, each lasting for a day. Because the hormone levels are so low, I get none of the side effects. I know it's not for everyone, but if a Paraguard isn't an option based on longer periods, even women who may have had to avoid hormones in the past might be able to use the Paraguard.

Eh. I got my Mirena at 20 when I hadn't so much as had a pap smear, let alone a baby. It hurt for, oh, two hours? I've been a happy, period-less camper since.

It doesn't prove anything about IUDs, obviously, but since people are dealing in anecdotes, I thought I'd throw one in with a happy ending.

Don't get me wrong, I love my 15-month-old daughter and wouldn't trade her for the moon. BUT... she was born 7 years into my wife's 10-year-rated Paragard IUD.

I'll never forget what the Dr told us upon confirming that my wife was, indeed, pregnant: "Well, 7 years is pretty good, right?"

We weren't planning on having kids.

I just wanted to provide a bit of a counterpoint to the "IUDs are magical and everyone can have one" folks - because while I think they are an underused and under-promoted option, they aren't perfect for everyone and I'm a bit sorry I listened to them.

I was a nullips two years ago when I went to get an IUD placed at a well-travelled planned parenthood clinic associated with a teaching hospital in a major city. I spent 45 minutes with my legs in stirrups as first a med student, then an attending, then the staff doctor tried to jam the thing through my cervix. I was in so much pain that my legs were shaking involuntarily. They were very kind and they eventually placed it, but they told me not to have unprotected sex for 6 weeks until the follow-up appointment. At that appointment, a transvaginal ultrasound revealed that the IUD had not migrated into the correct position, and was in fact stuck in my cervix. I had to have it removed.

I now regret that little adventure in gynaecology. I'm due to have my first child at the end of the summer, and I've read that cervical scarring can impede proper dilation of the cervix during childbirth. I can't imagine that my cervix didn't get a bit scarred.

Further, IUDs leave you vulnerable to PID and infertility if a dishonest and selfish partner gives you one of a couple common STIs. I wouldn't trust the man described in the letter to do that - and not because he doesn't like condoms, but because he rates his pleasure as more important than the health of his partner. I would compare him to my husband who also hates condoms - to the point that we abstained from PIV sex after I had to go off the hormonal bc pill (migraines with aura could produce strokes), and during the whole IUD fiasco until I got on the mini pill. Not one complaint did I hear. Never once did he attempt to guilt me into putting my health at risk. I love that man.

I agree with those who observed that the problem is not birth control, but the husband's inability to make ANY kind of sacrifice or even, it seemed, to acknowledge the sacrifices she's already made.

That said, tubal IMPLANTS (Essure) are not a full-on surgical procedure for female sterilization. Yes, they take several months to work and require some follow-up visits, but there is a permanent option for women that does not require surgery.

Falcon Punch.

you could put it in her butt

Here in Alberta they have free clinics and are giving all of the active teens IUDs because condoms aren't all that great at stopping pregnancy in the end (at least the stats are unacceptable for teens). IUD is considered very safe and obviously this kids don't have previous pregnancies. I got mine at the same clinic although I am older. It is pretty good but my periods are heavy.

For the record, my husband claimed he could feel the IUD, and he didn't like it. Just sayin.' Otherwise the best birth control ever... except for the vasectomy, which tops them all! And if you live in Washington state and you feel you can't afford it we have this great state program called Take Charge, and you can probably get it inserted for free at Planned Parenthood.

I got Essure. It's permanent and there's no hospital stay. Granted it's about as serious as you'd want an outpatient procedure to be, but I still went home the same day with no side effects worse than a period. Took a few days off working out just to be safe.

The worst part was the test to make sure it worked: they pressurize your uterus and it hurts like a bastard. They didn't warn me so I'm warning you -- had I known I'd have asked for drugs for that.

Although it is a patented procedure, my middle-of-the-road medical insurance paid for it. I'm not particularly selling it, but if we're throwing out alternatives it should be on the list.

So is male tantra just a myth? It seems that would be the ideal- to learn how to orgasm and not ejaculate, or else have some non-blue-balls control over it.

My tubal ligation didn't require any hospital stay. It was outpatient surgery--I was home and recuperating the same day. It is an excellent option for anyone who is not considering children, who doesn't want to have a foreign device implanted in their body, and does not want to gamble with the hormonal effects of oral contraceptives.

Something I haven't seen mentioned yet is that when women take hormonal birth control pills, those hormones are passed through her urine. Hormones in water where critters live is a bad thing, and scientists are seeing the results in deformities in amphibians caused by such hormones.

There are good alternatives, as everyone has mentioned. I got a tubal ligation after my daughter was born (part of the 1% IUD failure rate). My eldest was the result of inconsistent use of a diaphragm (I was 19 at the time). My current husband has had a vasectomy, too. Nothing like combining two highly effective methods of BC.

i'm so surprised to see that nobody has mentioned the option of the NuvaRing. i have been using this for five years with no problems -- it's a low dose of hormones, so there's really no weight gain, no raging hormones to speak of, just effective protection that regulates your period like a boss. you insert it and it's in there for three weeks, then you're off a week -- same schedule as the pill. my husband has never complained about being able to feel it during sex, and if your partner does, it can be removed for up to 3 hours at a time anyway. i have found it to be the best method i've ever used.

it's usually classified as a second-tier prescription on most insurance plans -- so it won't be as cheap as being on the pill -- but for the ease, convenience, and effectiveness, it's really worth the extra few bucks.

I'm also a huge fan of my nuvaring. I've been on it for 3 or 4 years now and it has made my periods very light and regular as clockwork. It's even made me less moody! My tits still swell up like blimps, but that's pretty normal, right? I gained a little bit of weight, but nothing horrible. Maybe 10 pounds, but mostly in the right places. I had semi-irregular periods for a short amount of time, but I'm pretty sure that was just due to excessive stress in my life. It's the only method of birth control I've ever used, but I've been really happy with it. I've even used it continuously (pretty much only when i've been too broke to buy tampons) and it's effective that way too.

I guess I feel kinda like a freak because hormonal birth control makes me less cranky and I actually like having my period. I don't exactly look forward to it, but I just don't feel right if I skip a month or two of menstruation.

My wife's got the IUD and a number of my friends wives and girlfriends have it. It's been a huge success for the most part, though my wife has had some complications including spotting and pain sometimes even not near her period. The plan is to remove it when we're ready to have kids and when we're done with that I get snipped.

I really wish there were better options for male birth control. Get on it science!

I tried the Pill (interfered with another medication I need to take), the NuvaRing (kept falling out), and the Mirena (gave me a non-STD infection). After that, my husband said I'd been through enough, and got a vasectomy. I'm very grateful.

From what I've read, Planned Parenthood is more open-minded about giving a woman who's never been pregnant an IUD.

I liked how you listed a variety of options for your original advice-seeker here, Dan.

Yes, go to Planned Parenthood to get an IUD. I had mine put in there after my long-time gynecologist refused on the grounds of "protecting my fertility." PP is very passionate about the effectiveness (both financially and results-wise) of IUDs, and, as a result, have a lot of practice putting them in. This prevents a majority of the potential problems of having an IUD installed. Not everyone's body is made for them, obviously (I have a friend whose cervix is too small), and they fucking hurt for a few days, but totally worth the years of worry-free contraception. I've had mine (Paragard) for 6 years now, and another friend of mine has had one for five.

After being on an estrogen-based pill for slightly under two years, I got a massive, 14-day-long migraine. My doctor took me off the pill immediately. Because of that migraine, estrogen-based pills are no longer an option for me. In fact, no doctor who sees "migraine with aura" on a woman's medical history will prescribe estrogen pills. It's really a bummer, because I liked being on estrogen-based pills--they made my periods a breeze, and there weren't any side effects until the migraine showed up. I went on Progestin-only pills (POPs) for a while, but they were horrible! Weight gain; long, unpredictable periods; weird hair growth; moodiness. Not fun. Plus, my doctor told me that going on POPs long-term is really bad for you. So, my only option is something non-hormonal like a diaphragm or a copper IUD. I haven't gone this route yet, but the IUD makes me really uncomfortable for most of the reasons listed above. Birth control is so important, but it is hell. I think it's really important for guys to know that birth control isn't as simple as taking a pill everyday.

A note to AMN--I had a tubal ligation last December, and it was a completely out patient procedure. I went in to a surgery center (not a hospital), got in my gown, did a few pre op things, got the anesthesia, woke up an hour later to juice and a cookie, went home, took a quick nap, and woke up hungry, alert, and not in any pain. I didn't even take my pain meds. The worst part was that I couldn't put anything inside for 4 weeks, so I had to use pads instead of tampons for my period. I have two nearly invisible scars, each about 3 mm long. It's permanent, which isn't for everyone, but it's not the same procedure as it used to be. Check it out.

I guess my suggestion kind of rests on the assumption that people are knowledgeable about their own biology, which I know is not true, but still.

I wish people had a clue.

@39 I'm not sure which of the reasons listed about the IUD concern you, but I wanted to let you know that just because you cannot take hormonal pills does not necessarily mean you cannot use a hormonal IUD. I have migraines, can't take hormonal pills, and have a MIrena IUD because the copper one would exacerbate the heavy bleeding and cramping I get from PCOS. The hormones in the IUD are a very low dose and they only act locally. I agree that birth control is hell. I would go get a tubal, but then I would get a period, and I love NOT having debilitating cramps that land me in the ER!

TOP and Dan saw the birth control choices for PIV sex as either hormonal birth control or condoms, her responsibility or his. Readers have pointed out the full range of his OR her options: vasectomy, diaphragm, etc. TOP brought up SHARING responsibility for preventing pregnancy, and, to share, communication IS key.
Fertility awareness methods involve shared responsibility and intimate conversations -- a his AND hers option. Very sexy. As an alternative sex advice columnist, Dan, you can help widen people's contraceptive horizons beyond the pill or condom dichotomy, and I encourage you to educate people particularly about lower tech, sustainable options.
Natural methods allow us to do this really intimate act while acknowledging what it was designed to do. Natural methods are not saying sex is ONLY for procreation, but they are saying that sex is ABOUT procreation as well as the many other things you address in your column. Acknowledging the procreative function of intercourse is actually VERY sexy. And, for women, knowing when we're fertile is empowering. Checking my temperature and vaginal mucus, being in touch with the cycles of my body, acknowledging my animal nature is a turn on. O.K. Dan, it's not for everyone, call it a kink, if you want, but please put it out there as an option.
When we talk about women having a right to birth control, we are usually referring to a right to pay big pharma for artificial hormonal birth control. Women also have a right to natural birth control, but unless you and other people in influential places start putting it out there as an option, it's gonna stay submerged in our collective unconscious like it was in mine.

@7, "what I've heard from friends, it is NOT APPROPRIATE for women who haven't had children."

See, this is the problem. People form opinions (and spread those opinions as if they are fact) based on what their friends say, rather than what doctors and scientific studies say. IUDs ARE appropriate for women who haven't had children, whether they want to have kids in the future or not. Mine went in fine (no kids), not particularly painful or difficult insertion.

Do you know what they call people who use the pull-out method?

Parents.

@44: People may not mention "natural birth control" or, as I prefer to call it given the fact that "natural" is an ideogram with no concrete definition, "not engaging in activities likely to result in pregnancy" is that not engaging in activities likely to result in pregnancy is a completely obvious way to avoid pregnancy. Given that the letter writer was specifically asking for advice on how to engage in activities likely to result in pregnancy (PIV intercourse whenever) without becoming pregnant and also without using condoms or hormonal birth control, suggesting that the couple not engage in activities that are likely to result in pregnancy isn't really addressing the question.

@6:

If the doctor thought the Pill was a "better fit" for her than other birth control options, and each formulation of the Pill was causing her horrible problems (hard to think of a "worse fit" than that), a second opinion (taking into account the LW's entire medical history) might not be a god idea. Some doctors aren't fully aware of the range of options, or that nulliparous women can be candidates for IUDs, for example.

I had similar problems after the birth of our first child--the pill had side effects I didn't want, and my husband had issues with condoms. He pulled out. We used the sponge. We tried the rhythm method. Then we had a baby. I tried the diaphragm (loved it, actually) but discovered I have a sensitivity to spermicide. Now I have a Mirena IUD and I love it--I don't get the side effects I got with the Pill, but reactions to various kinds of birth are very individual. I also don't mind being the one responsible for birth control, I find it empowering.

by "might not be a god idea" I mean "might be a good idea." Forgive my typos.

I am fond of "fertility awareness" birth control only because I got my lovely daughter when I was supposedly using that. I still think it probably works great, but doing it correctly is *really difficult*, and we were highly motivated--all it takes is a weak moment...which is why I don't recommend it to people.

@John Horstman #47
Using Fertility Awareness Methods, TOP and her husband can have unprotected condom-free sex the majority of the month. Then, they can choose to use condoms or do other sexual variations the minority of the month. In TOP's situation, that strikes me as a better solution than using condoms all the time, which is basically where Dan had left her.