Understanding Your Fertility while Breastfeeding

By Evelina Fisher

Introduction
As you journey into motherhood, bonding with and caring for your new baby, the thought of another pregnancy may be distant. Whether or not you want more children in the future, the time to think about your fertility is before or soon after giving birth. Considering options and determining what best meets your personal circumstances can be overwhelming. This article discusses your fertility while breastfeeding and provides links to additional online resources. It is a starting point, which we hope will inspire you to continue this important conversation with your health-care provider and/or your partner.

After birth, when will my fertility return?
Fertility often returns in stages. You may first experience menstruation without ovulation or ovulation without luteal competency (when the uterine lining can support implantation). When you are both ovulating and have luteal competency, your fertility has fully returned. Most women will not start ovulating in the first six weeks after giving birth.¹ Breastfeeding typically delays the onset of ovulation.² Depending on the intensity of breastfeeding, it can be several months or over a year before you regain your fertility. Conversely, absence of breastfeeding may cause you to start ovulating as early as three weeks after giving birth.¹

Why is it important to understand your fertility?
The World Health Organization recommends that women wait 24 months after giving birth before becoming pregnant again.³ Your health improves when you have a chance to recover, physically and emotionally, from giving birth and caring for your new baby. When you are healthy, your family benefits, too. Closely spaced pregnancies increase health risks, including preterm labor and low birth weight.⁴ Women also space childbearing for social and financial reasons. If your first menstruation is preceded by ovulation, you may become pregnant before you are aware that you are fertile again. The possibility of getting pregnant makes it important for women to make and act on decisions about their fertility before or soon after giving birth.

How can fertility be managed?
Contraception refers to methods (and devices and practices) used to reduce the risk of pregnancy. There are many different contraceptive methods, and a little later in this article we’ll look at many of them. First, let’s discuss some of the personal considerations that may influence you as a breastfeeding mother. The following steps can guide your decision-making process:

Establish your fertility goal: For how long do you want to avoid childbearing? How important is it for you to not get pregnant right now? What would you do if you experienced an unintended pregnancy?

Determine what your breastfeeding goal and actual patterns are: How old is your baby? Are you exclusively or partially breastfeeding right now? For how long do you want to breastfeed? How important is it to you that the contraceptive method you use is compatible with breastfeeding?

Consider what fits your personal circumstances and daily routines: How does your relationship status affect your contraceptive choices? How important is ease of use? Do you need a method which is long-acting? Discreet? If you have used certain methods in the past, what did you like and dislike about them?

Respect your own conscientious convictions: What methods are compatible with your personal values and religious beliefs?

Prioritize: Of all these considerations, which ones are more important to you and your family right now?

Consult your health-care provider and/or partner before starting or stopping a contraceptive method. There may be health considerations–such as your age, any illnesses, or smoking–which affect what contraceptive methods you can safely use. Your health-care provider will help you determine your clinical eligibility and identify whether there are methods you should avoid. Your health insurance may restrict what methods are covered under your plan. Talk to your provider about all of your options. Below are some useful questions that you can ask. If you have chosen a method, your provider should also explain or demonstrate how to use it correctly.

Questions to ask your health-care provider:

How does this method prevent pregnancy?
How effective is it in preventing pregnancy?
How long is this method effective?
How do I use it correctly?
What are the side effects and risks of this method?
What evidence exists about its effect on breastfeeding?
Have any breastfeeding mothers in your practice had negative effects on their milk production?
If I experience negative effects on milk production, what do you recommend?
How easily reversible is the method? When do its effects wear off after I stop using it?
If and when I want to have another child, how quickly will my fertility return after I stop using the method?
Is there any medical reason why I should not use this method?
What does it cost? Does my insurance cover it?
What are comparable options?

Contraception
This section looks at how different contraceptive methods prevent pregnancy, their efficacy, and compatibility with breastfeeding. When health professionals talk about efficacy, they usually refer to ‘perfect use’ and ‘typical use.’ Perfect use means that you always use the method correctly. Typical use refers to how most people actually use the method, including incorrect and inconsistent use. Because there are many factors and barriers that influence our use of contraceptives, the average person falls under ‘typical use.’ Failure rates for both perfect and typical use are reported in percentages. The data indicates how many women out of 100, who use the method for one year, will experience an unintended pregnancy.

Lactational Amenorrhea Method (LAM):

Works by suppressing ovulation.² Without an egg, pregnancy cannot happen.
Depends on exclusive breastfeeding and breastfeeding on cue.⁵
Is very effective in preventing pregnancy temporarily.⁶

For LAM to effectively reduce the risk of pregnancy, you need to meet three conditions:

your menses have not returned;
your baby is younger than six months and;
you are exclusively breastfeeding and not allowing long periods of time between feedings.⁷

The last condition means that your baby does not get supplements of foods or liquids, does not use a pacifier frequently, and does not go longer than approximately four hours during the day and six hours during the night without breastfeeding.

With perfect use, the failure rate of LAM is 0.45% for six months after birth. With typical use, it is 2%.^{2, 8} LAM may not be as effective for mothers who are separated from their babies and rely heavily on expressing milk, including mothers who are employed outside the home or are full-time students.⁹ LAM requires that you evaluate and re-evaluate your situation on an ongoing basis to make sure that the three conditions are still met. Whenever one of the conditions is no longer met, the failure rate may be increased, and an alternative contraceptive method would be recommended.⁵

Other natural methods:

Work by avoiding contact between sperm and the vagina, constantly or periodically, when you are at risk for pregnancy.
Are fully compatible with breastfeeding.
Are very to somewhat effective in preventing pregnancy.⁶

Abstinence means refraining from shared sexual activity that can result in pregnancy and sexually transmitted infections. To be effective abstinence needs to be practiced constantly. If you decide to have sex, another method is necessary to prevent pregnancy.

There are different fertility awareness-based methods that can help you identify when you are fertile. The symptothermal method requires you to 1) check your cervical mucus daily; 2) take your temperature each morning at the same time and before voiding, and; 3) chart your ovulation symptoms. ¹⁰ It can be used once your menstrual cycle has started and become regular again.¹¹ During days when you are at risk for pregnancy, you can practice periodic abstinence, withdrawal, or use a barrier method (discussed below).

Withdrawal (or the ‘pull out’ method) requires your partner to completely remove the penis from the vagina before ejaculation to prevent sperm from entering the vagina. If a man ejaculates on the vulva or near the vaginal opening, sperm can still enter the vagina. After an ejaculation, small amounts of sperm may be left in the man’s urethra. There is inconclusive evidence whether the amount of sperm in pre-ejaculatory fluid (precum) can cause pregnancy, and research shows that this is likely to vary greatly between individual men. While withdrawal is more effective in preventing pregnancy than unprotected sex, it is not recommended if avoiding pregnancy is critical for you.

With perfect use, natural methods have very low failure rates (constant abstinence: 0%; symptothermal method: 0.4%; withdrawal: 4%).⁶ These methods are accessible to all women at no or low cost. Their main disadvantage, however, is that they are often used incorrectly and inconsistently. They require user knowledge, significant self-control, and good communication between partners. Failure rates increase exponentially with typical use: (no method: 85%; fertility awareness-based methods: 24%; withdrawal: 22%).⁶

Barrier methods:

Work by blocking sperm from passing through the cervix.¹¹ Without sperm, pregnancy cannot happen.
Are fully compatible with breastfeeding.²
Are effective in reducing the risk of pregnancy.⁶

The most common barrier method is the condom. There are female and male condoms. They are relatively inexpensive and usually easy to acquire. With perfect use, the failure rate for male condoms is 2%, and for female condoms it is 5%.⁶ Many people use condoms incorrectly and inconsistently. With typical use, the failure rate for male condoms is 18%, and for female condoms it is 21%.⁶ Condoms also reduce the risk of sexually transmitted infections. They can be used simultaneously with other contraceptive methods, thus offering ‘dual protection.’ Other barrier methods, such as the cervical cap, diaphragms, and the sponge, are less effective than condoms, especially for women who have given birth. Diaphragms need to be refitted after childbirth or with large weight swings. Diaphragms and cervical caps are more effective when used in conjunction with spermicides.

Hormonal methods:

Work both by suppressing ovulation and making cervical mucus thicker, which blocks sperm from passing through the cervix.^{11, 12, 13, 14} If there is neither an egg nor sperm, fertilization cannot happen. Some of these methods also suppress growth of the uterine lining (details in listing below).^{11, 13}
Are compatible with breastfeeding¹⁵ but are not recommended as the first choice for breastfeeding mothers.^{2, 16}
Are very effective in preventing pregnancy.^{2, 6, 11, 17}

Note: Since this article was published the Academy of Breastfeeding Medicine has changed its recommendations regarding hormonal contraceptive use for lactating women.

“A Cochrane review indicated that evidence from randomized controlled trials on the effect of hormonal contraceptives during lactation is limited and of poor quality: ‘‘The evidence is inadequate to make evidence-based recommendations regarding hormonal contraceptive use for lactating women.’’
Until better evidence exists, it is prudent to advise women that hormonal contraceptive methods may decrease milk supply, especially in the early postpartum period. Hormonal methods should be discouraged in some circumstances (III):

existing low milk supply or history of lactation failure

history of breast surgery

multiple birth (twins, triplets)

preterm birth

compromised health of mother and/or baby

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Hormonal methods can be divided into different sub-categories, including short-acting and long-acting, and combined hormonal and progestin-only contraceptives. Combined hormonal methods, such as the ‘pill,’ the patch, and the vaginal ring, contain both estrogen and progestin. Estrogen may decrease milk production and negatively affect breastfeeding duration.^{2, 16} The World Health Organization recommends that breastfeeding mothers avoid combined hormonal contraceptives in the first six months after birth unless other methods are not available or acceptable.¹⁸ The Academy of Breastfeeding Medicine recommends alternative methods until after the baby has weaned.²

If you are breastfeeding, progestin-only methods are preferred over combined hormonal ones.^{2, 19} Progestin-only contraceptives include the ‘mini pill,’ the implant, injectables, and the intrauterine system (IUS). The earliest recommended use of progestin-only methods by breastfeeding women, who are clinically eligible to use them, is usually six weeks after birth, if milk production is well-established.^{2, 16, 19} There are anecdotal clinical reports that progestin-only contraceptives can decrease milk production, too.^{2, 16}

The possible negative effects on milk production can sometimes be difficult or impossible to fully reverse with either combined hormonal or progestin-only methods, especially with methods that cannot be stopped quickly. A nursing mother needs to carefully consider whether to use any of the hormone-based contraceptives while the baby is dependent on breastmilk for the majority of his nutrition. The importance of pregnancy prevention versus maintaining optimal milk supply is something that only the mother can assess.

The following information is based on evidence current as of the date of publication and is not meant as an endorsement of any particular method or as being compatible with breastfeeding.

Select progestin-only contraceptives^{2, 6, 11, 12, 13, 14, 19}

Progestin-only pill (also called the ‘mini pill’)

Perfect use: 0.3%
Typical use: 5%
Requires taking the pill daily and at the same time. Can be stopped at first sign of adverse effects on milk production.

Implant

Perfect use: 0.05%
Typical use: 0.05%
Requires no daily routine and works for three or five years depending on the brand. Like other hormonal methods, the implant suppresses ovulation and makes cervical mucus thicker, which prevents fertilization. It may also suppress growth of the uterine lining.

Injection

Perfect use: 0.2%
Typical use: 6%
Should be administered every 12 weeks. It takes longer for the hormone from the injectable to leave your system compared to other hormonal methods. If it has adverse effects on breastfeeding, the method cannot be quickly reversed. It must wear off on its own.

Intra-uterine system

Perfect use: 0.2%
Typical use: 0.2%
Requires no daily routine and works for up to five years. The hormone is released locally in the uterus, and it typically has little to no effect on milk production. Like other hormonal methods, the IUS suppresses ovulation and makes cervical mucus thicker, which prevents fertilization. The IUS also suppresses growth of the uterine lining.

If I choose a hormonal method, will hormones in my breastmilk affect my baby?
Hormonal contraceptives have been used by breastfeeding mothers for decades without any reported adverse outcomes for their babies due to ingestion of hormones in the breastmilk.¹⁶ The level of estrogen that transfers to human milk is low. It does not exceed the level that occurs naturally when a woman ovulates.²⁰ Natural progesterone is poorly absorbed by the infant via milk.²⁰ Changes observed in milk composition of breastfeeding mothers who are using hormonal contraceptives are within normal variations.⁵

Copper-bearing intrauterine device (IUD):

Works by releasing copper ions, which change the chemical environment in the uterus and destroys the function of sperm before they can fertilize the egg.¹³
Is fully compatible with breastfeeding.²
Is very effective in preventing pregnancy.⁶

The copper-bearing IUD is available for breastfeeding mothers who want long-acting, reversible contraception without hormones. After the IUD is placed by a trained provider, there is no daily routine, and it can be used for at least 10 years. In the first year, the typical failure rate is 0.8%.⁶ Over the course of 10 years, the typical failure rate is 2%.¹¹ The copper-bearing IUD can also be used as emergency contraception for up to five days after unprotected sex.²¹ When placed after unprotected sex, the copper-bearing IUD prevents fertilization and may also prevent implantation.²²

Permanent methods:

Tubal ligation works by blocking the egg in the fallopian tube. Vasectomy works by keeping sperm out of semen.¹¹
Are fully compatible with breastfeeding. Medications used during the tubal ligation procedure may temporarily affect breastfeeding.²
Are very effective in preventing pregnancy.⁶

If you are positively certain that you have completed childbearing, permanent contraceptive methods may be for you (or your partner). With tubal ligation, the fallopian tubes are surgically cut or blocked. If you want to have the procedure done immediately after childbirth, you have the right to give informed consent before giving birth.^{11, 23} In the first year after the procedure, the typical failure rate is 0.5%.⁶ Over the course of 10 years, the typical failure rate is 2%, and a small risk of pregnancy remains until you reach menopause.¹¹

Vasectomy is also a surgical procedure. The vas deferens that carry sperm to the penis are blocked. It takes up to three months after the procedure until it is effective in preventing pregnancy. After three months, the man can have his semen analyzed to see whether it contains sperm.¹¹ In the first year, the typical failure rate is 0.15%.⁶ If the semen is not analyzed, the failure rate in the first year may be as high as 3%.¹¹ Vasectomy is simpler, safer, and less expensive than tubal ligation.^{2, 11}

Emergency contraception:
Even if you take great care to manage your fertility, you may find yourself in a situation where you are at risk of pregnancy. It takes several days after sex before a pregnancy is established.²⁴ Emergency contraception is a safe and effective way of preventing pregnancy for up to five days after unprotected sex. It is not intended to be used as an ongoing contraceptive method. There are two options, including ‘morning after’ pills and the copper-bearing IUD (discussed above). ‘Morning after’ pills work by disrupting ovulation and preventing fertilization. ^{11, 28} Progestin-only ‘morning after’ pills are generally considered compatible with breastfeeding,^{26, 27} and breastfeeding can continue uninterrupted.¹⁶ Their failure rate is around 10-15% in the first three days after unprotected sex. ²⁸ They become less effective as time passes. Although the ulipristal acetate-containing ‘morning after’ pill has a lower failure rate than the progestin-only ‘morning after’ pill,²⁸ its possible effect on breastfeeding has not been adequately evaluated. Recent research shows that ‘morning after’ pills may also be less effective for obese women.

Unintended pregnancy
If you experience an unintended pregnancy while breastfeeding, you are not alone! About half of all pregnancies in the United States are unintended. As with any pregnancy, you have options, including continuing the pregnancy or having an abortion.

Continuing the pregnancy:
When you breastfeed, the hormone oxytocin is released, and it can cause uterine contractions. These contractions are usually very mild and undetectable. With a healthy pregnancy, continued breastfeeding is considered safe and unlikely to increase the risk for preterm labor.³⁶ Pregnancy, itself, can have a negative effect on milk production. This will have a greater impact on a younger infant who is more dependent on your breastmilk as the primary source of nutrition.

Abortion:
Breastfeeding USA does not take a position on abortion; rather, we are committed to providing evidence-based information.

Three in 10 American women will have an induced abortion in their lifetime. ²⁹ The majority (61%) already have children²⁹ and may still be breastfeeding. In the first trimester, abortion can be done using vacuum aspiration or medicines. If you have decided to terminate a pregnancy and are considering an aspiration abortion, you can discuss pain management options with your health-care provider. Together you can agree on a pain management plan that has no or low adverse effects on breastfeeding.

Medical abortion can be done with a combined regimen of mifepristone and misoprostol.³⁰ Mifepristone passes into breastmilk, and there are no known adverse effects on the breastfed infant.^{30, 31} One small study found that levels of mifepristone in milk samples taken 6-12 hours after maternal intake ranged from undetectable to low, depending on the dose. The study concluded that with the low dose of mifepristone, “breastfeeding can be safely continued in an uninterrupted manner during medical abortion.”³² Alternatively, you can opt to express and discard milk for two days after taking mifepristone.³¹ Misoprostol is used for a range of reproductive health indications, including management of postpartum bleeding.³³ It passes into breastmilk, and drug levels rise and fall quickly. Misoprostol may temporarily cause infant diarrhea.^{20, 31} Within five hours, there are no detectable traces left in breastmilk.³⁴

About one in five confirmed pregnancies end in spontaneous abortion (miscarriage). If you experience an incomplete miscarriage (when some pregnancy tissue remains in the uterus) or a missed miscarriage (when fetal death has occurred but the body does not expel the pregnancy), vacuum aspiration or a misoprostol-only regimen may be used as part of your treatment.

Conclusion
Understanding your fertility is an important aspect of life as a new mother. There are many options available for breastfeeding mothers who want or need to manage their fertility. This article is an introduction to this important subject, and we encourage you to continue the conversation with your health-care provider and/or your partner. Remember, you have the right to decide how to manage your fertility. Only you can decide which option is right for you. Being an active, informed health-care consumer can help you achieve your goal.

Online resources
Information about contraceptive methods:
http://bedsider.org/methods
http://www.choiceproject.wustl.edu/en/METHODS
http://www.plannedparenthood.org/health-topics/birth-control-4211.htm
http://www.arhp.org/MethodMatch/
http://www.acog.org/For_Patients
http://ec.princeton.edu/
http://www.cecinfo.org/what-is-ec/iuds-for-ec/

Information about contraception and breastfeeding:
http://kellymom.com/bf/can-i-breastfeed/meds/birthcontrol/
http://kellymom.com/bf/normal/fertility/
http://www.lalecheleague.org/ba/nov01.html
http://www.breastfeedingbasics.com/articles/breastfeeding-and-birth-control
http://www.mother-2-mother.com/menstruation.htm#BirthControl
http://www.who.int/reproductivehealth/publications/family_planning/WHO_RHR_09_13/en/
http://ec.princeton.edu/questions/ecfeeding.html

Citations
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[2] The Academy of Breastfeeding Medicine. (2005). Clinical Protocol Number 13: Contraception during breastfeeding. (Author’s note: This document cannot be retrieved online because it is out of date. As of May 12, 2014, the Academy had not released its revised version.)
[3] World Health Organization, Department of Reproductive Health and Research. (2007). Report of a WHO technical consultation on birth spacing. Geneva, Switzerland: World Health Organization.
[4] Zhu, B. P. (2005). The effect of interpregnancy interval on birth outcomes: findings from three recent US studies. International Journal of Gynecology and Obstetrics, 89 (Supplement 1), 25–33.
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[13] Ortiz, M. E. & Croxatto, H. B. (2007). Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action. Contraception, 75 (Supplement 6), S16-30.
[14] Health Matters Fact Sheets, Implant. (2010). Retrived on April 23, 2014 from http://www.arhp.org/Publications-and-Resources/Patient-Resources/fact-sh…
[15] American Academy of Pediatrics. (2001). Transfer of drugs and other chemicals into human milk. Pediatrics, 108(3), 776-789.
[16] Mohrbacher, N. (2010). Breastfeeding Answers Made Simple, a Guide for Helping Mothers. Amarillo, Texas: Hale Publishing.
[17] Interventions Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy: RHL commentary. (2008). Retrieved on May 12, 2014 from http://apps.who.int/rhl/fertility/contraception/CD001326_bahamondesl_com…
[18] World Health Organization. (2010). Combined hormonal contraceptive use during the post-partum period. Geneva, Switzerland: World Health Organization.
[19] World Health Organization. (2008). Progestogen-only contraceptive use during lactation and its effects on the neonate. Geneva, Switzerland: World Health Organization.
[20] Hale, T. W. (2008). Medications and Mothers’ Milk, Thirteenth edition. Amarillo, Texas: Pharmasoft Medical Publishing.
[21] International Consortium for Emergency Contraception. (2012). The Intrauterine Device (IUD) for Emergency Contraception. New York, NY: Family Care International.
[22] Schwarz, E. B. & Trussell, J. (2011). Emergency Contraception. Contraceptive Technology, Twentieth Revised Edition. Eds. Hatcher, R. A. et al. New York, NY: Ardent Media.
[23] The American College of Obstetricians and Gynecologists, Committee on Health Care for Underserved Women. (2012). Committee Opinion Number 530: Access to Postpartum Sterilization. Obstetrics and Gynecology, 120, 212-215.
[24] International Planned Parenthood Federation. (2004). Medical and Service Delivery Guidelines for Sexual and Reproductive Health Services, Third Edition. London, United Kingdom, International Planned Parenthood Federation.
[25] The difference between medical abortion and emergency contraceptive pills. (2010). Retrived on April 23, 2014, from http://www.arhp.org/publications-andresources/clinical-fact-sheets/mifep…
[26] Gainer, E. et al. (2007). Levonorgestrel pharmacokinetics in plasma and milk of lactating women who take 1.5 mg for emergency contraception. Human Reproduction, 22(6), 1578–1584.
[27] Polakow-Farkash, S. et al. (2013). Levonorgestrel used for emergency contraception during lactation, a prospective observational cohort study on maternal and infant safety. Journal of Maternal, Fetal and Neonatal Medicine, 26(3), 219-221.
[28] International Consortium for Emergency Contraception. (2013). Clinical Summary: Emergency contraceptive pills. New York, NY: Family Care International.
[29] Guttmacher Institute. (2014). Induced Abortion in the United States. New York, NY: Guttmacher Institute.
[30] Ipas. (2009). Medical Abortion Study Guide. Chapel Hill, North Carolina: Ipas.
[31] My bpas Guide. (2012). Retrived on April 23, 2014 from http://www.bpas.org/js/filemanager/files/my_bpas_guide_jul_12.pdf
[32] Saav, I. et al. 2010. Medical abortion in lactating women: low levels of mifepristone in breast milk. Acta Obstetricia et Gynecologica Scandinavica, 89(5), 618-622.
[33] Allen, R. & O’Brien, B. M. (2009). Uses of Misoprostol in Obstetrics and Gynecology. Reviews in Obstetrics and Gynecology, 2(3), 159-168.
[34] Vogel, D. et al. (2004). Misoprostol versus methylergometrine: Pharmacokinetics in human milk. American Journal of Obstetrics and Gynecology, 191(6), 2168-73.
[35] Abdel-Aleem, H., et al. (2003). The pharmacokinetics of the prostaglandin E1 analogue misoprostol in plasma and colostrum after postpartum oral administration. European Journal of Obstetrics and Gynecology and Reproductive Biology, 108, 25-8.
[36] Ayrim, A., Gunduz S., Akcal B., Kafali, H. (2014). Breastfeeding Throughout Pregnancy in Turkish Women. Breastfeed Med, 9(3), 157-160.

Photo Credit: USBC

Evelina Fisher

Evelina is a Reproductive Health and Rights consultant who has worked with maternal health and youth-friendly services programs across Africa and Asia. She is an accredited Breastfeeding USA Counselor and holds a degree in International Relations.