Katrin Freidman

Pregnancy, Birth & Postpartum

Postpartum: Sex, fertility, and contraception

by Barbara Santen, Author
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Intercourse after birth

After the birth of a baby, most healthcare providers (HCPs) advise waiting six full weeks before resuming vaginal intercourse. This is for two reasons: the possible need for healing of the vaginal, perineal and/or abdominal tissues and also for the theoretical risk of uterine infection. After a baby is born, the uterus has a fresh, open wound as big as the placenta. This wound can be susceptible to bacteria introduced into the vagina via intercourse. The wound takes about six weeks to heal completely.

There are many factors which will determine the best time to resume intercourse, whether it’s at six weeks or earlier or later. Some of these are: pain, healing of tissues and libido. If you’ve had a cesarean section or vaginal surgery it might be extra important to wait the full six weeks in order for tissues to heal properly and to prevent tearing, infection and pain.

Some people resume before six weeks with no complications or adverse effects. A good rule of thumb is to wait for any bright red vaginal bleeding to cease. If you are unsure what is right for you or if it is safe to resume intercourse, ask your healthcare provider. Waiting longer than six weeks is, of course, completely up to you.

The return of fertility

The most important thing to know is that you can be fertile before the return of your period. This is because ovulation happens before menstrual bleeding. After pregnancy, the body goes back to its normal reproductive functions. There are many factors at play in the timing of the body’s return to fertility, including breastfeeding and the characteristics of your pre-pregnancy cycle.

If you’re exclusively breastfeeding your baby it could postpone your cycle significantly. Conversely, if you’re bottle-feeding exclusively with formula (no breastfeeding at all and no pumping) your ovulation and menstruation will return much more rapidly and can be as early as the very next month after the baby is born. Some people return to their normal ovulation and menstrual cycle shortly after birth even if they are breastfeeding, while others can delay fertility for the entire duration of breastfeeding their baby. This is just an example of how individual we all are and no one form of pregnancy prevention is a fit for everyone.

What are the options?

There are many ways to prevent pregnancy after childbirth. There are barrier methods (like condoms), hormonal methods, non-hormonal intrauterine devices (IUDs), lactational amenorrhea (LAM), rhythm method and surgical sterilization. It is important to remember that most of these methods are not protective against sexually transmitted infections (STI).

Hormonal methods: Progestin-only hormonal contraceptives are the recommended method of hormonal birth control when breastfeeding. These include the oral contraceptive pill (not the combined pill), the hormonal IUD, the progestin-only vaginal ring (some ring brands containing estrogen and are not typically recommended), hormonal implant and progestin shots. All of these methods are progestin-only forms of birth control and are highly effective and considered safe. There are some concerns about the effects of the hormone estrogen on breast milk and therefore healthcare providers will often recommend the progestin-only pill for people who are breastfeeding.

Progestin-only methods primarily work by thickening the cervical mucus, preventing sperm from reaching an egg. They may also sometimes prevent eggs from being released from the ovary altogether (like typical combined-hormonal birth control), in some people.

If you are not breastfeeding, you can use any kind of hormonal contraception that you feel is right for you. Ask your healthcare provider or clinic for all of the options available for you.

Emergency contraception: Depending on where you live, you might have access to emergency contraception if one of your preferred methods of contraception failed and you act quickly. Emergency contraception can be taken within 3–5 days after unprotected intercourse, but is not for use as a regular birth control method.

Levonorgestrel/progestin-only ECPs are considered the only type that are safe to take while breastfeeding continuously. The pill called ella, containing ulipristat acetate has not been researched enough to be considered safe during breastfeeding.

Copper Intrauterine devices (IUD): A copper IUD is a device that is inserted by a healthcare provider in a clinic or office. The copper wire interferes with the sperm’s ability to swim to the fallopian tube to the egg and hence fertilization is prevented. If by chance sperm does travel to the egg and fertilizes it, the IUD prevents the embryo from implanting. This type of IUD has a reputation for causing more bleeding and cramping in some people but don’t let that deter you from wanting to try it. Some people have great success with this device and you can always have it taken out quickly and safely by your HCP. IUDs are highly effective and can be kept in for several years.

Fun fact: The copper IUD can be used as emergency contraception if inserted up to five days after unprotected intercourse.

Lactational amenorrhea method (LAM): LAM is the natural suppression of ovulation from the hormonal shifts that happen from a person who breastfeed their baby exclusively. Research has shown this method to be over 98% effective during the first six months postpartum — but only if you breastfeed exclusively. It is recommended that for every time you bottle-feed your baby with breast milk you also incorporate an extra pumping session to mimic a baby feeding — and limited bottle feeding of breast milk is recommended if you’re using LAM (1). You can read more about it here.

Surgical sterilization: Surgical sterilization for females usually refers to the procedure of tubal ligation (getting tubes tied). The fallopian tubes are not actually “tied” as much as they’re cut and then cauterized or stitched to prevent any passage of an egg from the ovary. Tubal ligation is often offered before a planned cesarean section so that after the baby is born the person can immediately prevent future pregnancies if they choose.

Men can get surgically sterilized too, called a vasectomy. The surgeon cuts and cauterizes and/or stitches a tube in the scrotum, called the vas deferens, to prevent sperm from traveling with the semen. A man who has had a vasectomy will have semen that does not contain sperm.

Barrier methods: Barrier methods are contraceptive measures that prevent sperm from passing through entering the cervix. These include male or female condoms, the diaphragm and cervical cap. Even spermicidal foam, sponges and film are considered barrier methods. Condoms, diaphragms and cervical caps are even more effective against pregnancy if used together with a spermicide and vice versa. There is evidence that spermicide use with a condom is as effective as taking the birth control pill.

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