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The diaphragm doesn't offer reliable protection from sexually transmitted infections (STIs).

In a year of typical use of the diaphragm and spermicide, an estimated 21 out of 100 women will get pregnant. Without the use of spermicide, however, an estimated 29 out of 100 women will get pregnant in a year of typical use of the diaphragm.

Consistent and correct use is essential to the effectiveness of the diaphragm. For example, you may get pregnant when using a diaphragm if:

• You don't use the diaphragm every time you have sex
• The diaphragm becomes dislodged from the cervix during sex
• You don't use spermicide
• You remove the diaphragm within six hours after having sex

Spermicide applied to the diaphragm may rarely damage the cells lining the vagina, causing:

• An increased risk of contracting STIs
• Vaginal irritation
• Urinary tract or vaginal infection

Contact your health care provider if:

• The diaphragm slips out of place when you walk, sneeze, cough or strain
• You or your partner experience pain during or following use of the diaphragm
• You have signs or symptoms of toxic shock syndrome, such as sudden high fever, diarrhea, dizziness, vomiting, muscle aches or a rash that looks like sunburn
• You're unable to remove the diaphrag.

The diaphragm comes in different sizes. Your health care provider will fit you for the diaphragm and demonstrate how to insert and remove the diaphragm. He or she may confirm that the diaphragm is in the correct position by doing a pelvic exam.

Before you use the diaphragm for the first time, practice inserting the diaphragm until you're comfortable with it. You may want to use a backup method of contraception, such as a male condom, when you're first using the diaphragm.

Always use the diaphragm with spermicidal cream, foam or gel. Avoid use of body lotions near your vagina and vaginal medications when using the diaphragm. If you're using a diaphragm and douche, wait until at least six hours after sex to avoid washing away spermicide.

Make sure you regularly check your diaphragm for puncture marks or cracks. To search for holes, hold your diaphragm up to the light and gently stretch the rubber between your fingers or fill the diaphragm with water. Replace your diaphragm at least every two years.

You may need to have your diaphragm checked and possibly refitted if:

• Your diaphragm no longer fits snugly or comfortably
• You've given birth or had an abortion
• You've had pelvic surgery
• You've gained or lost more than 20 pounds (about 9 kilograms)
• You have repeated urinary tract infections
• You or your partner feels pain or pressure during sex

To use the diaphragm:

• Apply spermicide. Fill the diaphragm's bowl with about 1 tablespoon (about 15 milliliters) of spermicide. Spread a thin layer of spermicide around the rim of the diaphragm with your finger. Use only water-based lubricants with the diaphragm.
• Insert the diaphragm. Find a comfortable position, such as standing with one foot propped up, squatting or lying on your back. Separate your labia with one hand. With the other hand, hold the diaphragm with the bowl facing upward and squeeze the diaphragm between your thumb and index and middle fingers.

Slide the diaphragm into your vagina and push it along the back wall of your vagina as far as it will go. Use your index finger to push the front rim of the diaphragm up behind your pubic bone.

• Check the diaphragm's position before sex. Make sure you can feel your cervix through the soft dome of the diaphragm. After inserting the diaphragm, apply spermicide inside the vagina before each time you have sex. If the diaphragm is dislodged during sex, reapply spermicide.
• Gently remove the diaphragm. After sex, leave the diaphragm in place for at least six hours and up to 24 hours. To remove the diaphragm, hook your finger under the front rim of the diaphragm and gently pull it down and out of your vagina. If the diaphragm is difficult to remove, insert your finger between the rim of the diaphragm and your vaginal wall to break any suction.

After removal, wash the diaphragm with mild soap and warm water and allow it to air-dry. Store the diaphragm in its provided container.