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Lack of contraceptive use and access to modern contraceptive methods are the major causes of unintended pregnancies in women and adolescent girls.1 Many contraceptive options are available for use by women, but much fewer are for use by men. The failure rates of contraceptive methods are defined as the number of unintended pregnancies per 100 women within the first year of use of each method. Typical use failure rates are a measure of how effective different methods are during actual use. For women, lactational amenorrhea is a very effective temporary method, and emergency contraception pills and placement of a copper intrauterine device are effective in preventing pregnancy after unprotected intercourse. The most effective contraceptive methods include permanent female sterilization, intrauterine devices, and hormonal implants. Very effective methods include combined estrogen and progestin or progestin-only injectables, pills, patches, vaginal rings, and the nonhormonal diaphragm; the least effective methods include the female condom, sponge, spermicide and fertility awareness–based method (Fig. 16-1).2 In contrast to those options available for use by women, the available male-controlled methods are few and include penile withdrawal (typical use failure rate 22%) and condoms (typical use failure rate 18%). These failure rates are substantially higher than the female hormonal methods. In contrast, permanent contraception in males using vas occlusion (vasectomy) has a very low failure rate (typical use failure rate 0.15%).25


Effectiveness of contraceptive methods. (Reproduced with permission from U.S. Department of Health & Human Services. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. Access February 26, 2020.)



The withdrawal method, or coitus interruptus, is the pulling out of the penis from the vagina and away from the women’s external genitalia before ejaculation to prevent pregnancy. This method requires the male partner’s self-control, as spermatozoa (mature sperm cells) may enter the vagina if withdrawal is not timed before ejaculation. The female partner needs to trust that the male partner can exert self-control by withdrawing the penis before ejaculation. Thus, this method is highly unreliable for most couples and especially so in casual relationships.

The studies on withdrawal are few and mostly uncontrolled.6,7 In one study, the typical use failure rate of the withdrawal method was as high as 22%.3 Another study that used self-reported data from the Demographic and Health Surveys in 43 countries estimated typical use failure rate for withdrawal at 13.4%.4 Therefore, if the withdrawal method is used, it is advisable that emergency contraception be readily available for the female partner.

Key Point

Withdrawal depends on the male partner’s self-control, and emergency contraception should be ...

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