Birth control refers to restricting the number of children by various methods designed to control

fertility and prevent conception. No single, ideal method of birth control exists. The only method of
preventing pregnancy that is 100% reliable is complete abstinence, the avoidance of sexual
intercourse. Several other methods are available; each has its advantages and disadvantages. These
include surgical sterilization, hormonal methods, intrauterine devices, spermicides, barrier methods,
and periodic abstinence. Table 28.3 provides the failure rates for various methods of birth control.
Although it is not a form of birth control, in this section we will also discuss abortion, the premature
expulsion of the products of conception from the uterus.
Birth Control Methods 1. Surgical Sterilization Sterilization is a procedure that renders an individual
incapable of further reproduction. The principal method for sterilization of males is a vasectomy in
which a portion of each ductus deferens is removed. In order to gain access to the ductus deferens, an
incision is made with a scalpel (conventional procedure) or a puncture is made with special forceps
(non-scalpel vasectomy). Next the ducts are located and cut, each is tied (ligated) in two places with
stitches, and the portion between the ties is removed. Although sperm production continues in the
testes, sperm can no longer reach the exterior. The sperm degenerate and are destroyed by
phagocytosis. Because the blood vessels are not cut, testosterone levels in the blood remain normal,
so vasectomy has no effect on sexual desire or performance. If done correctly, it is close to 100%
effective. The procedure can be reversed, but the chance of regaining fertility is only 3040%.
Sterilization in females most often is achieved by performing a tubal ligation (l-GA -shun), in which
both uterine tubes are tied closed and then cut. This can be achieved in a few different ways. Clips
or clamps can be placed on the uterine tubes, the tubes can be tied and/or cut, and sometimes they
are cauterized. In any case, the result is that the secondary oocyte cannot pass through the uterine
tubes, and sperm cannot reach the oocyte.
Non-incisional Sterilization Essure- is one means of non-incisional sterilization that is an alternative to
tubal ligation. In the Essure procedure, a soft micro-insert coil made of polyester fibers and metals
(nickel titanium and stainless steel) is inserted with a catheter into the vagina, through the uterus,
and into each uterine tube. Over a three-month period, the insert stimulates tissue growth (scar
tissue) in and around itself, blocking the uterine tubes. As with tubal ligation, the secondary oocyte
cannot pass through the uterine tubes, and sperm cannot reach the oocyte. Unlike tubal ligation,
nonincisional sterilization does not require general anesthesia.
Hormonal Methods Aside from complete abstinence or surgical sterilization, hormonal methods are the
most effective means of birth control. Oral contraceptives (the pill) contain hormones designed to
prevent pregnancy. Some, called combined oral contraceptives (COCs), contain both progestin
(hormone with actions similar to progesterone) and estrogens. The primary action of COCs is to inhibit
ovulation by suppressing the gonadotropins FSH and LH. The low levels of FSH and LH usually prevent
the development of a dominant follicle in the ovary. As a result, levels of estrogens do not rise, the
midcycle LH surge does not occur, and ovulation does not take place. Even if ovulation does occur, as
it does in some cases, COCs may also block implantation in the uterus and inhibit the transport of ova
and sperm in the uterine tubes.
Progestins thicken cervical mucus and make it more difficult for sperm to
enter the uterus. Progestin-only pills thicken cervical mucus and may block implantation in the uterus,
but they do not consistently inhibit ovulation. Among the noncontraceptive benefits of oral
contraceptives are regulation of the length of menstrual cycle and decreased menstrual flow (and
therefore decreased risk of anemia). The pill also provides protection against endometrial and ovarian
cancers and reduces the risk of endometriosis. However, oral contraceptives may not be advised for
women with a history of blood clotting disorders, cerebral blood vessel damage, migraine headaches,
hypertension, liver malfunction, or heart disease. Women who take the pill and smoke face far higher
odds of having a heart attack or stroke than do nonsmoking pill users. Smokers should quit smoking or
use an alternative method of birth control.
Following are several variations of oral hormonal methods of contraception: Combined pill. The
combined pill contains both progestin and estrogens and is typically taken once a day for 3 weeks to
prevent pregnancy and regulate the menstrual cycle. The pills taken during the fourth week are
inactive (do not contain hormones) and permit menstruation to occur. An example is Yasmin.
Extended cycle birth control pill. Containing both progestin and estrogens, the extended cycle birth
control pill is taken once a day in 3-month cycles of 12 weeks of hormone-containing pills followed by

1 week of inactive pills. Menstruation occurs during the thirteenth week. An example is Seasonale.
Minipill. The minipill contains low dose progestin only and is taken every day of the month. An
example is Micronar.
Non-oral hormonal methods of contraception are also available. Among these are the following:
Contraceptive skin patch. The contraceptive skin patch (Ortho Evra) contains both progestin and
estrogens delivered in a skin patch placed on the upper outer arm, back, lower abdomen, or buttocks
once a week for 3 weeks. After 1 week, the patch is removed from one location and then a new one is
placed elsewhere. During the fourth week no patch is used.
Vaginal contraceptive ring. A flexible doughnut-shaped ring about 5 cm (2 in.) in diameter, the
vaginal contraceptive ring contains estrogens and progesterone and is inserted by the female herself
into the vagina. It is left in the vagina for 3 weeks to prevent conception and then removed for one
week to permit menstruation.

Emergency contraception (EC). Emergency contraception (EC), also known as the morning-after
pill, consists of progestin and estrogens or progestin alone to prevent pregnancy following
unprotected sexual intercourse. The relatively high levels of progestin and estrogens in EC pills
provide inhibition of FSH and LH secretion. Loss of the stimulating effects of these gonadotropic
hormones causes the ovaries to cease secretion of their own estrogens and progesterone. In
turn, declining levels of estrogens and progesterone induce shedding of the uterine lining,
thereby blocking implantation. One pill is taken as soon as possible but within 72 hours of
unprotected sexual intercourse. The second pill must be taken 12 hours after the first. The pills
work in the same way as regular birth control pills.
Hormone injections. Hormone injections are injectable progestins such as Depo-provera given
intramuscularly by a health-care practitioner once every 3 months.
Intrauterine Devices An intrauterine device (IUD) is a small object made of plastic, copper, or
stainless steel that is inserted by a health-care professional into the cavity of the uterus. IUDs
prevent fertilization from taking place by blocking sperm from entering the uterine tubes. The
IUD most commonly used in the United States today is the Copper T 380A, which is approved
for up to 10 years of use and has longterm effectiveness comparable to that of tubal ligation.
Some women cannot use IUDs because of expulsion, bleeding, or discomfort.
Spermicides Various foams, creams, jellies, suppositories, and douches that contain spermkilling agents, or spermicides (SPER-mi-sds), make the vagina and cervix unfavorable for
sperm survival and are available without prescription. They are placed in the vagina before
sexual intercourse. The most widely used spermicide is nonoxynol-9, which kills sperm by
disrupting their plasma membranes. A spermicide is more effective when used with a barrier
method such as a male condom, vaginal pouch, diaphragm, or cervical cap.
Barrier Methods Barrier methods use a physical barrier and are designed to prevent sperm
from gaining access to the uterine cavity and uterine tubes. In addition to preventing
pregnancy, certain barrier methods (male condom and vaginal pouch) may also provide some
protection against sexually transmitted diseases (STDs) such as AIDS. In contrast, oral
contraceptives and IUDs confer no such protection. Among the barrier methods are the male
condom, vaginal pouch, diaphragm, and cervical cap. A male condom is a nonporous, latex
covering placed over the penis that prevents deposition of sperm in the female reproductive
tract. A vaginal pouch, sometimes called a female condom, is designed to prevent sperm from
entering the uterus. It is made of two flexible rings connected by a polyurethane sheath. One
ring lies inside the sheath and is inserted to fit over the cervix; the other ring remains outside
the vagina and covers the female external genitals. A diaphragm is a rubber, dome-shaped
structure that fits over the cervix and is used in conjunction with a spermicide. It can be
inserted by the female up to 6 hours before intercourse. The diaphragm stops most sperm from
passing into the cervix and the spermicide kills most sperm that do get by. Although diaphragm
use does decrease the risk of some STDs, it does not fully protect against HIV infection because
the vagina is still exposed. A cervical cap resembles a diaphragm but is smaller and more rigid.
It fits snugly over the cervix and must be fitted by a health-care professional. Spermicides
should be used with the cervical cap.
Periodic Abstinence A couple can use their knowledge of the physiological changes that occur
during the female reproductive cycle to decide either to abstain from intercourse on those days
when pregnancy is a likely result, or to plan intercourse on those days if they wish to conceive

a child. In females with normal and regular menstrual cycles, these physiological events help to
predict the day on which ovulation is likely to occur. The first physiologically based method,
developed in the 1930s, is known as the rhythm method. It involves abstaining from sexual
activity on the days that ovulation is likely to occur in each reproductive cycle. During this time
(3 days before ovulation, the day of ovulation, and 3 days after ovulation) the couple abstains
from intercourse. The effectiveness of the rhythm method for birth control is poor in many
women due to the irregularity of the female reproductive cycle. Another system is the symptothermal method (STM), a natural, fertility-awareness-based method of family planning that is
used to either avoid or achieve pregnancy. STM utilizes normally fluctuating physiological
markets to determine ovulation such as increased basal body temperature and the production
of abundant, clear, stretchy cervical mucus that resembles uncooked egg white. These
indicators, reflecting the hormonal changes that govern female fertility, provide a double-check
system by which a female knows when she is or is not fertile. Sexual intercourse is avoided
during the fertile time to avoide pregnancy. STM users observe and chart these changes and
interpret them according to precise rules.
Female reproductive system The organs of the female reproductive system (Figure
28.11) include the ovaries (female gonads); the uterine (fallopian) tubes, or
oviducts; the uterus; the vagina; and external organs, which are collectively called
the vulva, or pudendum. The mammary glands are considered part of both the
integumentary system and the female reproductive system.
Ovaries The ovaries ( egg receptacles), which are the female gonads, are paired
glands that resemble unshelled almonds in size and shape; they are homologous to
the testes. (Here homologous means that two organs have the same embryonic
origin.) The ovaries produce (1) gametes, secondary oocytes that develop into
mature ova (eggs) after fertilization, and (2) hormones, including progesterone and
estrogens (the female sex hormones), inhibin, and relaxin. The ovaries, one on
either side of the uterus, descend to the brim of the superior portion of the pelvic
cavity during the third month of development. A series of ligaments holds them in
position (Figure 28.12). The broad ligament of the uterus, which is a fold of the
parietal peritoneum, attaches to the ovaries by a double
layered fold of peritoneum called the mesovarium . The ovarian ligament anchors the ovaries
to the uterus, and the suspensory ligament attaches them to the pelvic wall. Each ovary
contains a hilum (HI -lum), the point of entrance and exit for blood vessels and nerves along
which the mesovarium is attached.
Histology of the Ovary Each ovary consists of the following parts : The germinal
epithelium (germen sprout or bud) is a layer of simple epithelium (low cuboidal or squamous)
that covers the surface of the ovary. We now know that the term germinal epithelium in
humans is not accurate because this layer does not give rise to ova; the name came about
because, at one time .
The tunica albuginea is a whitish capsule of dense irregular connective tissue located
immediately deep to the germinal epithelium. The ovarian cortex is a region just deep to the
tunica albuginea. It consists of ovarian follicles (described shortly) surrounded by dense
irregular connective tissue that contains collagen fibers and fibroblast-like cells called stromal
cells. The ovarian medulla is deep to the ovarian cortex. The border between the cortex and
medulla is indistinct, but the medulla consists of more loosely arranged connective tissue and
contains blood vessels, lymphatic vessels, and nerves.
FUNCTIONS OF THE FEMALE REPRODUCTIVE SYSTEM
The organs of reproduction in females include the ovaries, uterine (fallopian) tubes, uterus,
vagina, vulva, and mammary glands.
1. The ovaries produce secondary oocytes and hormones, including progesterone and
estrogens (female sex hormones), inhibin, and relaxin.
2. The uterine tubes transport a secondary oocyte to the uterus and normally are the sites
where fertilization occurs. 3. The uterus is the site of implantation of a fertilized ovum,
development of the fetus during pregnancy, and labor. 4. The vagina receives the penis during
sexual intercourse and is a passageway for childbirth.
5. The mammary glands synthesize, secrete, and eject milk for nourishment of the newborn.
Ovarian follicles (folliculus little bag) are in the cortex and consist of oocytes (O -o-sts) in
various stages of development, plus the cells surrounding them. When the surrounding cells
form a single layer, they are called follicular cells (fo-LIK-ular); later in development, when
they form several layers, they are referred to as granulosa cells (gran-u-LO -sa). The

surrounding cells nourish the developing oocyte and begin to secrete estrogens as the follicle
grows larger.
A mature (graafian) follicle (GRA -fe-an) is a large, fluidfilled follicle that is ready to rupture
and expel its secondary oocyte, a process known as ovulation (ov-u-LA -shun).
A corpus luteum ( yellow body) contains the remnants of a mature follicle after ovulation.
The corpus luteum produces progesterone, estrogens, relaxin, and inhibin until it degenerates
into fibrous scar tissue called the corpus albicans (AL-bikanz white body).
Oogenesis and Follicular Development The formation of gametes in the ovaries is termed
oogenesis . In contrast to spermatogenesis, which begins in males at puberty, oogenesis
begins in females before they are even born. Oogenesis occurs in essentially the same manner
as spermatogenesis; meiosis (see Chapter 3) takes place and the resulting germ cells undergo
maturation. During early fetal development, primordial (primitive) germ cells migrate from the
yolk sac to the ovaries. There, germ cells differentiate within the ovaries into oogonia (o-oGO -ne-a; singular is oogonium). Oogonia are diploid (2n) stem cells that divide mitotically to
produce millions of germ cells. Even before birth, most of these germ cells degenerate in a
process known as atresia . A few, however, develop into larger cells called primary oocytes that
enter prophase of meiosis I during fetal development but do not complete that phase until after
puberty. During this arrested stage of development each primary oocyte is surrounded by a
single layer of flat follicular cells, and the entire structure is called a primordial follicle . The
ovarian cortex surrounding the primordial follicles consists of collagen fibers and fibroblast-like
stromal cells. At birth, approximately 200,000 to 2,000,000 primary oocytes remain in each
ovary. Of these, about 40,000 are still present at puberty, and around 400 will mature and
ovulate during a womans reproductive lifetime. The remainder of the primary oocytes undergo
atresia.
Each month after puberty until menopause, gonadotropins (FSH and LH) secreted by the
anterior pituitary further stimulate the development of several primordial follicles, although
only one will typically reach the maturity needed for ovulation. A few primordial follicles start to
grow, developing into primary follicles (Figure 28.14b). Each primary follicle consists of a
primary oocyte that is surrounded in a later stage of development by several layers of cuboidal
and low-columnar cells called granulosa cells. The outermost granulosa cells rest on a
basement membrane. As the primary follicle grows, it forms a clear glycoprotein layer called
the zona pellucida between the primary oocyte and the granulosa
Figure