Pulling out concerns

Dear Dr G,

My wife and I are in our mid-40s and have two teenage children. We don't intend to have any more kids and my wife has been on the pill to that effect. However, the pill seems to be causing more side effects in my wife as she gets older.

Unfortunately, condoms aren't the answer as it puts in a barrier in more than one sense of the word! Not only is there a lack of sensitivity – but at my age, I'm experiencing erectile dysfunction when I try to put one on.

We have now resorted to using the withdrawal technique but from what I've read, this may not be the most reliable form of birth control.

Is there any scientific data on using the withdrawal technique as a form of contraception?

Can we improve the reliability of using this method to prevent unwanted pregnancies?

Interrupted Ian

The withdrawal of the penis from the vagina prior to ejaculation to avoid insemination is known as coitus interruptus. This form of contraception is also referred to as rejected sexual intercourse, withdrawal method or the pull-out technique.

In essence, the goal of this method is to prevent semen – and therefore sperm – from entering the vagina.

This technique of birth control has been documented even from as far back as ancient Greece and Roman civilisations.

Despite modern forms of contraception, the withdrawal method is one of the most popular methods of birth control. According to 1991 estimates, 38 million couples worldwide resort to this and the 2014 US National Survey of Family Growth, 8.1% of women use this method as a form of contraception.

The withdrawal method has many positives – it's essentially free, requires no artificial devices, needs no prescription and has no side effects.

But there are many downsides to using this method – the biggest is that there is still a significant chance of pregnancy. It also does nothing to prevent sexually transmitted infections (STI).

In one study, even if couples perform coitus interruptus correctly, they can expect a failure rate of 4% per year – compared with failure rates of 2% and 0.3% for condoms and intrauterine devices (IUD), respectively.

Other studies have less-optimistic failure rates, ranging from 15-28%. Although some may find this "acceptable" the data revealed women with no previous pregnancies have a failure rate of 8.4% in 12 months but this can increase to a 27% failure rate for women with two previous pregnancies.

The high failure rates can be associated with the emission of pre-ejaculatory fluid, which may contain spermatozoa. This compromises the effectiveness of the withdrawal method, irrespective of the timing of actually pulling out.

However, there is speculation that the viable sperm is actually retained from a previous ejaculation, so urinating to clear the pipes could reduce this.

When Dr G is put on the spot, his response is: "Coitus is the art of certainty, and the interruptus is a science of probability. Therefore, utilising the science of vasectomy, coitus uninterruptus will be guaranteed without the interruption of uncertainty!"