[ALERT TO PARENTS: Material below may be inappropriate to young readers.]

I have recently given birth to our third baby. My husband and I think it's time to call it quits to having more children. We can't decide on a method of birth control. I birthed the kids, so I think he should go for the "snip." (He reads this column, so I thought perhaps I could get some support, since he's nervous about the operation.)--"One Tired Mom"

Birth control is an imperfect science because we are all diverse, with different objectives, different lifestyles, and different reactions to the impact of the various available methods. Because you seem to not want more children, sterilization is an option. The most common procedure for a woman is the laparoscopic tubal coagulative procedure, or clip application; for a male, a vasectomy. In my practice (AH), I would attempt to persuade prospective patients to postpone such surgery until they were at least in their 30s. It should always be viewed as a final decision, and also, in my opinion, viewed as an irreversible procedure. I am well aware that it may be reversible, and I have successfully reversed many, but it is best for the couple to view it as irreversible and final. I do not see it as desirable if any foreseen or unforeseen situation would change the opinion of the person undergoing surgery.

I would ask my patients to imagine several scenarios. What if your spouse died or left you? Or your children died? Would this alter your opinion? Often a woman who has had two children is sure she wants no more, but a few years down the road, perhaps a widow and now remarried, she would like another child. So the human side of our interaction is very important. The next question would be, Which partner should undergo surgery? If either one can imagine a scenario where he or she might want a child in the face of the bleakest outcome of their marriage, that spouse would be wise to not have an operation. A 40-year-old woman with three children may feel differently from a 40-year-old man with three children. Remember, a significant number of women undergoing sterilization in the immediate postpartum period later regret their action.

In regards to the surgery itself, a vasectomy is definitely the easiest of the two procedures. It can be performed under local anesthesia. It takes about 10 minutes and usually leaves the man able to work immediately. It can be complicated, however. The most common problem is a hematoma caused when a blood vessel seeps into the soft, nonsupportive tissue of the scrotum. The hematoma can be painful. It settles, but only after several weeks. Following a vasectomy, a major awareness has to be that a "road block" doesn't stop traffic downstream of the blockage. Until the sperm count is verified as zero, one needs to exercise caution.

The laparoscopic tubal occlusion is usually performed under general anesthesia, and as effective as new anaesthetic agents may be, at least a day for recovery will be recommended. Many patients will have discomfort for a couple of days. Most women take two days postoperatively to feel well. Where a "final" solution does not seem appropriate, or more babies are wanted, there are many options to choose.

In your case, the intrauterine contraceptive device (IUCD) would be an option, particularly since you have three children, and the small, but definite risk of infertility (probably less than a 1 percent risk) may not concern you as it would a woman with either no children or an uncompleted family. The IUCD comes in several types. The cheapest and most common being a copper-T variety. The more recently released progesterone loaded device, called "Mirena," offers several advantages. It is able to reduce uterine bleeding and cramping through local release of small amounts of progesterone. It will last effectively for five years as opposed to the two-and-a-half-years of the copper-T. It discourages endometrial overgrowth (hyperplasia), especially in those women approaching menopause.

For those who worry that an IUCD may cause a very early abortion by disrupting the potential "bed" for the ovum, the "Mirena" has an additional advantage of inhibiting ovulation so there is not a fertilized egg to abort. Its main drawback is the cost, but when amortized over five years it is quite reasonable. Unlike subdermal progestin implants, which also work for some five years, the insertion and removal of an IUCD is minimally complicated, and the progesterone effect is localized and not systemic like that of the implant.

IUCDs offer 97-99.9 percent protection-the latter being "Mirena." A cheaper progestin agent is Depo-Provera (medroxyprogesterone acetate), which can be given every three months as an injection of 150 milligrams. This gives excellent contraceptive action (greater than 99 percent), but often disrupts menstrual regularity and flow. It may also cause some systemic changes, such as headaches or feelings of nausea in a minority of patients.

Freedom to Choose In creation--and again through the redemption of Christ--God has given human beings freedom of choice, and He asks them to use their freedom responsibly (Gal. 5:1, 13). In the divine plan, husband and wife constitute a distinct family unit, having both the freedom and the responsibility to share in making determinations about their family (Gen. 2:24). Married partners should be considerate of each other in making decisions about birth control, being willing to consider the needs of the other as well as one's own (Phil. 2:4). For those who choose to bear children, the procreative choice is not without limits. Several factors must inform their choice, including the ability to provide for the needs of children (1 Tim. 5:8); the physical, emotional, and spiritual health of the mother and other caregivers (3 John 2; 1 Cor. 6:19; Phil. 2:4; Eph. 5:25); the social and political circumstances into which children will be born (Matt. 24:19); and the quality of life and the global resources available. We are stewards of God's creation and therefore must look beyond our own happiness and desires to consider the needs of others (Phil. 2:4). --Taken from "Birth Control: A Seventh-day Adventist Statement of Consensus," September 14, 1999.

Birth control pills are still an excellent choice in contraception. In fact, they are of a much lower dosage than ever before. They can be given to women who do not have a contraindication, such as a history of deep venous thrombosis, migraine, hypertension, diabetes, and who are not smokers (if over 35). A modern birth control pill is perhaps 20 percent as potent as a dose of medication women were using 30 years ago. In fact, with lowered dosage may come a danger of failure if tablets are not taken regularly. Another factor to bear in mind is that other medications, such as antibiotics, may alter the metabolism of birth control pills so that they fail to offer protection. Taken as directed, birth control pills offer upward of 99 percent protection. Hormone contraception is now available using the transdermal patch technology and seems to be quite effective.

Other methods, such as spermicidal gels and foam are an option, but less reliable than the methods we have mentioned. Condoms, both the male and female varieties, are fairly effective (a rate of 94-96 percent protection). Condoms offer about 85 percent protection against HIV/AIDS, but the care with which they are used is important. Many women find a diaphragm or cervical cap, which is always used in conjunction with a spermicidal gel, useful.

One thing is certain with such an array of methods: the perfect method does not exist. Coitus interruptus and the Billings Method are thought by many to be "natural." The definition of natural is up for debate. The Billings Method is based on a calculation of ovulation time. Ovulation is followed in 14 days by menstrual flow. This is the most predictable of the many relationships involving the menstrual cycle.

Calculation of the day of ovulation before it occurs is, therefore, an estimate at best. In a woman who is as regular as "clockwork," the fourteenth day prior to onset of menses will be the ovulation day. Avoidance of coitus for some five or six days before, and some four or five days after ovulation will very much reduce chances of pregnancy. Yet it must be remembered that among users of this method some 30 percent of women are unintentionally called "Mommy."

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Allan R. Handysides, M.B., Ch.B., F.R.C.P. (c), is director of the General Conference Health Ministries Department; Peter N. Landless, M.B., B.Ch., M.Med., F.C.P.(SA), F.A.C.C., is ICPA executive director and associate director of Health Ministries.

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While this column is provided as a service to our readers, Drs. Landless and Handysides unfortunately cannot enter into personal and private communication with our readers. We recommend that you consult with your personal physician on all matters of your health.