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Sex, fertility, and contraception after birth

There are many factors at play in the timing of the body's return to fertility postpartum

Top things to know about sex after birth

  • After birth, you can have sex whenever you feel comfortable

  • You can get pregnant before your period starts again

  • Some forms of birth control can be used right after birth

What exactly is postpartum? The postpartum period, sometimes called “the fourth trimester,” is considered the weeks after birth by some guidelines, six months by some research, and up to a year by other standards. Postpartum sex simply means sex that you have during this time.

If you’re not sure how long to wait to have sex after birth, when to start birth control, or what your postpartum birth control options are, we’ve got that all covered in this article. 

How long should I wait to have sex after birth?

During the time following birth, typical sexual patterns and preferences may change (1). Some people feel so bonded to their partners after birth that they want to have sex right away. For others, postpartum sex might be challenging. It’s also common for sexual relationships to evolve throughout the ups and downs of parenting (1). After the birth of a newborn, most healthcare providers will probably tell you to wait six full weeks before trying vaginal intercourse (2, 3). This is because the vaginal, perineal and/or abdominal tissues are still healing (2, 4).

There's also a risk of infection in the uterus because after birth, the space where the placenta attached to the uterus leaves a wound (2, 4). This wound can be susceptible to bacteria introduced into the vagina during sex (4). The wound takes about six weeks to heal completely in some people, but may heal earlier or later (2, 4).

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Deciding how soon to have sex after birth is a personal decision, whether it’s at six weeks or earlier or later (3). You might consider your current pain level, how well your skin has healed, and how much you want to have sex (1, 3). 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 (2).

Some people have sex before six weeks postpartum with no complications (1). A good rule of thumb is to wait until bright red vaginal bleeding has stopped (5). If you are unsure what is right for you or if it is safe to have sex after birth, ask your healthcare provider.

When should I start birth control postpartum?

The most important thing to know about postpartum sex is that you can become pregnant before the return of your period (1, 2, 6). This is because ovulation happens before menstrual bleeding (1, 2, 6). After pregnancy, the body goes back to its typical reproductive patterns (2, 6). 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 (2, 6).

If you’re exclusively breastfeeding your newborn, your cycle can be postponed by months or even a year (6). If you’re bottle-feeding exclusively with formula (no breastfeeding at all and no pumping) your ovulation and menstruation will likely return rapidly and can be as early as the very next month after birth (6). Some people return to their typical ovulation and menstrual cycle shortly after birth even if they are breastfeeding (6).

What are the options for birth control after pregnancy and birth?

There are several birth control options to prevent pregnancy after birth. This might be a main topic of discussion during your postpartum visits, and your healthcare provider can help you find one that fits your body and your needs (2, 3). There are barrier methods (like condoms), hormonal methods, non-hormonal intrauterine devices (IUDs), lactational amenorrhea (LAM), , and surgical sterilization. It is important to remember that only condoms protect against sexually transmitted infections (STIs) (6).

Hormonal birth control after pregnancy and birth 

Progestin-only hormonal contraceptives are the recommended method of hormonal birth control when breastfeeding (6, 7). These include:

  • Oral contraceptive pill (not the combined pill)

  • Hormonal IUD

  • Progestin-only vaginal ring (some ring brands containing estrogen and are not typically recommended)

  • Hormonal implant

  • Progestin shots

All of these methods are progestin-only forms of birth control and are effective and low-risk (6). There are some concerns about the effects of the hormone estrogen on breast milk, so healthcare providers often recommend the progestin-only pill for people who are breastfeeding (7, 8).

Progestin-only methods primarily work by thickening the cervical mucus, preventing sperm from reaching an egg (8). They may also sometimes prevent eggs from being released from the ovary altogether (like typical combined-hormonal birth control), in some people (10).

If you are not breastfeeding or pumping breastmilk, after six weeks postpartum you can use any kind of hormonal contraception that you feel is right for you (6).

The copper intrauterine device (IUD) postpartum

A copper IUD is a device that is inserted by a healthcare provider in a clinic or office. It can even be inserted within 48 hours after birth and can be kept in place for up to 10 years (6). It can be easily removed anytime if you don't adapt or if you decide to get pregnant again (6). The copper wire interferes with the sperm’s ability to swim to the fallopian tube to the egg and fertilization is prevented (11). If by chance sperm does travel to the egg and fertilizes it, the IUD prevents the embryo from implanting (11). This type of IUD had a reputation for causing more bleeding and cramping, but newer studies are showing that most people are satisfied and have less cramping and bleeding 6 months after insertion (11, 14). 

Lactational amenorrhea method (LAM) and breastfeeding

The lactational amenorrhea method naturally suppresses ovulation (2, 6). This happens because hormones that encourage ovulation are replaced by hormones that encourage lactation (2, 6) . Research has shown this method to be over 98% effective during the first six months postpartum — but only if you breastfeed exclusively, meaning you only feed your infant breastmilk ever and express milk every four hours (12). It is recommended to incorporate an extra pumping session to mimic a baby feeding  if you bottle feed — and limited bottle feeding of breast milk is recommended if you’re using LAM (2, 6, 7).

Permanent surgical sterilization after birth

Surgical sterilization for bodies with a uterus 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 (9). Tubal ligation can be done straight after a cesarean section so that after the newborn is born the person can immediately prevent future pregnancies if they choose (9).

Bodies with testes can get surgically sterilized too, called a vasectomy (9). The surgeon cuts and cauterizes and/or stitches a tube in the scrotum, called the vas deferens, to prevent sperm from traveling with semen (9). A man or person with testes who has had a successful vasectomy will have semen that does not contain sperm by 12 weeks after surgery (9). Use a barrier method like a condom until the urologist confirms semen contains no sperm (9). 

Barrier methods and postpartum sex

Barrier methods prevent sperm from entering the cervix. These include male or female condoms, the diaphragm, and the 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 (6). There is evidence that spermicide use with a condom is as effective as taking the birth control pill (6).

Fertility awareness-based methods and postpartum sex

Fertility awareness-based methods (FABMs) rely on knowing where you are in your cycle to prevent pregnancy. There are about six days each cycle that conception is possible. FABMs work by avoiding sex or using condoms on days that are high risk for pregnancy — before, during, and after the time in the cycle when pregnancy can occur. 

You can use FABMs for postpartum birth control after your cycle has returned to your version of typical (13). For most people, this is about a month if you aren’t breastfeeding/chest feeding (13). If you are nursing, the time until your cycle gets back to usual is extremely variable (13). It may be best to wait until you’ve experienced 4 periods/3 cycles and they are predictable to start using an FABM for postpartum

Emergency contraception during postpartum

Depending on where you live, you might have access to emergency contraception if one of your preferred methods of contraception fails 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 because it is not as effective as daily hormonal birth control or IUDs (5, 6).

Levonorgestrel/progestin-only emergency contraceptive pills are considered the only type that are safe to take while breastfeeding continuously. The pill called ella, containing ulipristal acetate has not been researched enough to be considered safe during breastfeeding (8).

Postpartum sex is different for everyone

If you’re wondering when to have postpartum sex, assess how you feel about it beforehand. A newborn in the home might change your family dynamics. Pregnancy and birth might change your body and how you perceive it. Some people experience pain during sex after birth and some people experience vaginal dryness (1, 3), so if you feel like having sex, make sure to have lubricants on hand. It may also be helpful to have an open conversation with your partner about the possibility of pain and what you’ll do if you no longer want to have sex after you’ve started (1, 3). Remember, every body is different, and there is no “right” time to want to start having sex again.

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This article was originally published on January 30th 2017.

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