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METHODS OF CONTRACEPTION: DIAPHRAGMS

The diaphragm is a round, shallow dome of thin rubber stretched over a flexible ring. After a spermicidal (sperm-killing) jelly or cream is applied inside the dome and around the inner part of the rim, the diaphragm must be inserted inside the vagina and positioned so that it completely covers the cervix. Before the introduction of birth control pills, the diaphragm was the most widely used method of contraception, and it is still popular today.

The diaphragm is a mechanical barrier that blocks the mouth of the cervix so that sperm cannot enter. Because this blocking effect is not very reliable by itself, the use of a spermicide is required to kill sperm that manage to swim inside the rim of the diaphragm.

Diaphragms come in different sizes and must be properly fitted by a trained health care professional to match the anatomy of the user. The size and position of the cervix and the size and shape of the vagina must be taken into account to achieve a proper fit; the actual fitting is done using a set of graduated flexible rings to select the right size. After the fitting, the woman is shown how to insert the diaphragm either manually or with a plastic inserter. Some clinicians recommend that a woman be refitted if she gains or loses ten pounds. However, a recent study found that more women whose weight was stable needed refitting, so the matter is not a clear one. We recommend that women be refitted for a diaphragm after a pregnancy or on an annual basis. If there is a weight change of 15 pounds or more, it also may be advisable to be refitted.

The diaphragm can be inserted up to two hours before intercourse and should remain in place at least six hours afterward. If it is worn for more than two hours before intercourse, the effectiveness of the spermicide may drop. For this reason, a full application of spermicidal jelly, cream, or foam should be placed in the vagina before intercourse in these circumstances. If the diaphragm is removed less than six hours after intercourse, it is possible that live sperm in the vagina may reach the cervix and swim up into the uterus.

The effectiveness of this method is not as high as birth control pills or IUDs, with failure rates in most reports ranging from six to twenty pregnancies in 100 women using this device during a year. Yet since the effectiveness of this method depends on the regularity of its use, the woman's motivation and memory are important factors. A woman who leaves her diaphragm at home and finds herself unexpectedly in a sexual situation might have a "user" failure rather than a "method" failure. In one study with a highly motivated, experienced population of users, the failure rate was only 1.9 per 100 woman-years. Another problem that influences effectiveness is that the diaphragm may slip out of position during sexual play because of improper insertion, a poor fit, or expansion of the inside of the vagina and movement of the uterus during sexual excitation. Even a well-fitted and properly inserted diaphragm can become dislodged during

intercourse when the woman is on top of the man or if the penis is removed and reinserted into the vagina during plateau levels of arousal. Even a tiny hole in the dome of the diaphragm will permit sperm to enter, so it is important to inspect it carefully and to avoid use of Vaseline on it, since this can cause deterioration of the latex. Despite these problems, consistent use of the diaphragm with a condom provides a rate of effectiveness comparable to birth control pills. In addition, the diaphragm seems to offer protection against cervical cancer and against some

sexually transmitted diseases, although recent reports suggest that women who use diaphragms have an increased rate of urinary tract infections.

The only potential side effects are: (1) possible allergic reactions to the rubber in the diaphragm or to the spermicide itself, and (2) the chance of introducing infection into the vagina if the diaphragm is not clean. Both problems are infrequent. In addition, it is not advisable to wear a diaphragm for more than twelve hours at a time because this seems to cause an overgrowth of bacteria in the vagina and cervix that is linked to the toxic shock syndrome. The diaphragm has no effects on hormones or physical processes of the body and poses no danger to later fertility.

Women who have pelvic disorders affecting the vagina or cervix or who do not like to touch their genitals should not use the diaphragm.

The primary sexual difficulty with use of the diaphragm is inconvenience. For example, either partner may experience loss of sexual arousal while the woman takes time to insert and check the diaphragm if she did not insert it before sex play began. Some couples solve this problem by making the insertion of the diaphragm a part of their sexual play preliminary to intercourse. Either partner may find the diaphragm or the process of its insertion unaesthetic. In addition, a diaphragm that is too large may cause pain during intercourse and some men complain that intercourse feels "different" with the diaphragm in place. There is a sexual advantage, however: during menstrual periods, the diaphragm can be used to provide a "reverse barrier" that contains flow during sexual activity.

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Men's Health Erectyle Dysfunction