Dear Dr. G,

I read with caution the article you published on the effectiveness of the pull-out technique as a form of contraception.

Indeed, I am aware of the fact the pre-ejaculatory fluid does contain motile sperm that can potentially be a source of trouble.

My wife and I are both enjoying a carefree life with grown-up kids who are still young, and we are aware that a mistake or accident could leave us with an unwanted pregnancy.

My wife reckons she is too old to get oral contraceptive pills and that leaves me to shoulder the responsibility of wearing the condoms, and occasionally attempting to ejaculate outside.

On several occasions when the condoms broke, and my poor control ended up in internal ejaculations, we were very stressed and prayed for menses over the next few days.

I would like to put Dr. G on the spot for the morning after emergencies.

Can you tell me the risks of getting pregnant using the withdrawal technique?

Do you have any data on the chances of getting pregnant with unaware broken condoms?

Lastly, can you tell me about the morning after pills?

What is the timing for effective usage of the morning after pills?

What are they? What are the efficacy and side effects of such intervention?

Emergency Eddie

The withdrawal of the penis from vagina prior to ejaculation as a form of contraception is also known as coitus interruptus. This remains one of the most popular methods of family planning, with estimated 38 million couples worldwide utilising such a mode of birth control. It requires no artificial devices, needs no prescriptions, and has no side effects. However, many studies revealed a high concentration of sperm in pre-ejaculatory fluid compromises the effectiveness of pulling out, irrespective of the timing of withdrawal. In addition, men with premature ejaculation may not be able to control the precise timing of their ejaculation, making coitus interruptus having a failure rate of up to 22% per year.

On the other hand, the failure rate for correct use of condoms can be as low as 2% per year. Of course, the failure rate increases exponentially if the condom breaks. Previous studies quoted 7.3% of men surveyed admitted to having had the experience of a condom breaking over a course of a year. However, recent publications revealed that 29% of men and 19% of women reported at least one broken condom in the prior three months. And many of the participants were unaware of the breakage until well after intercourse. Even if the condoms are not visibly torn, micro-tears that are not visible to the naked eye can also occur, allowing the passage of sperm, attributing to further condom failures.

Emergency contraceptive pills (ECPs), sometimes simply referred to as the morning-after pill, are medication intended to disrupt or delay ovulation or embryo fertilization. This is a form of birth control taken to reduce the risk of pregnancy following unprotected sexual intercourse or failure of the regular contraceptive. This is not a form of medical abortion, as it is hormonal manipulation offered to women having had unprotected intercourse on any day of the menstrual cycle.

Emergency contraceptive pills are available in various formulary, these include combined oestrogen and progestin pills, progestin-only and anti-progestin pills. Combined oestrogen and progestin pills are less commonly used as dedicated emergency contraceptive pills due to less effective outcome and higher risk of nausea and vomiting. Progestin-only pills can be effective when used within 72 hours of exposure, while the single tablet of anti-progestin pills can be effective up to 120 hours following the failure of the regular contraception.

The combined regime of the emergency contraception is reported to have an efficacy ranging from 47% to 74% while the progestin and anti-progestin formulations have an efficacy as high as 89%. This translates to seven out of every eight women who would have been pregnant will no longer become pregnant with the intervention. The common side effects of all the emergency contraceptive pills are nausea and vomiting. This affects nearly a quarter of the women consuming the pills. Vomiting occurring within two hours of the medication will require repeated dosing, while other side effects such as irregular bleeding and menses, abdominal pain and fatigue are usually mild and tolerable.

The art of contraception is essentially the act of maximizing the pleasure of sex without exposing the hazardous consequences of an unwanted pregnancy. Of course, the risk increases with the lack of control in the withdrawal method, or completely exposed in the roughness of broken condoms. The American writer and poet, Ambrose Bierce once said: “Coward is the one who in perilous emergency, thinks with his legs.”

Couples living the “contraception life” dangerously often put Dr. G on the spot for his opinion on the morning after SOS. His view is: “Getting the snip will forever prevent the cowardly third leg from getting you into a future perilous emergency!”

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