Coitus interrupius
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Coitus Interruptus (Withdrawal Method)
Definition: Coitus interruptus is the withdrawal of the penis from the vagina before ejaculation, directing the ejaculate away from the female genitalia to prevent fertilization. It is among the oldest known methods of voluntary fertility control.
Mechanism
The method works by preventing sperm from entering the vaginal canal and cervix. For it to succeed, the penis must be completely withdrawn from the vagina and external genitalia before ejaculation - pregnancy has been reported even from ejaculation on the external genitalia alone, without penetration.
- Berek & Novak's Gynecology
Efficacy
| Use Type | Failure Rate (pregnancies/100 women in year 1) |
|---|---|
| Perfect use | 0.4% |
| Typical use | ~22% |
Some studies report failure rates as high as 25% with general use. Notably, women with no prior births have a 12-month failure rate of ~8.4%, rising to ~20-28% for those with prior births.
A key finding from Jones et al. (cited in Berek & Novak) is that withdrawal is likely as effective as the male condom when used consistently and correctly.
- Berek & Novak's Gynecology; Park's Textbook of Preventive and Social Medicine
Why It Fails
- Pre-ejaculatory fluid (pre-cum): The precoidal secretion of the male may contain sperm. Even a single drop of semen is sufficient to cause pregnancy.
- Timing errors: The slightest mistake in timing the withdrawal may result in some semen being deposited in the vagina.
- Incomplete withdrawal: The penis must be fully clear of the external genitalia, not just the vaginal canal.
Advantages
- Immediately available - no prescription, no device, no cost
- No hormonal side effects
- Can be used as a backup when no other method is available
- Reported as having been used at least once by up to 60% of women worldwide (Goldman-Cecil Medicine)
Disadvantages / Limitations
- High typical-use failure rate (~22%)
- Requires significant self-control and cooperation from the male partner
- Provides no protection against STIs
- Requires the ability to recognize and accurately time the pre-ejaculatory sensation
Historical & Epidemiological Context
Coitus interruptus - along with abstinence and induced abortion - is believed to account for most of the decline in fertility in preindustrial Europe during the 18th and 19th centuries. Currently, an estimated 85 million couples use this method worldwide, making it one of the most commonly used forms of contraception globally. It accounts for approximately 5% of the total contraceptive burden (Textbook of Family Medicine).
- Park's Textbook of Preventive and Social Medicine
Alleged Side Effects (Now Reconsidered)
Historically, side effects such as pelvic congestion, vaginismus, and anxiety neurosis were attributed to this method. However, modern expert opinion has largely discounted these concerns. If a couple prefers this method, there is no strong objection to its use - it is better than no contraception at all.
Summary vs. Other Methods
| Method | Typical Use Failure Rate | Perfect Use Failure Rate |
|---|---|---|
| No method | 85% | 85% |
| Withdrawal (coitus interruptus) | 22% | 0.4% |
| Male condom | 18% | 2% |
| Female condom | 21% | 5% |
| IUD (copper) | 0.8% | 0.6% |
| Combined OCP | 9% | 0.3% |
Sources: Berek & Novak's Gynecology; Kaplan & Sadock's Comprehensive Textbook of Psychiatry
Basal body method
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Cervical mucus thinig method
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cervical mucus method Billings ovulation method contraception how to use efficacy
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Cervical Mucus Method (Billings / Ovulation Method)
What It Is
The cervical mucus method - also called the Billings method or ovulation method - is a natural family planning (NFP) technique in which the woman observes and interprets changes in her cervical secretions to identify her fertile and infertile days. It is one of three main NFP methods, alongside the BBT method and the calendar/rhythm method.
- Park's Textbook of Preventive and Social Medicine
Physiological Basis
The method exploits the well-established hormonal control of cervical mucus:
| Phase | Hormone Dominant | Mucus Character |
|---|---|---|
| Post-menses (early follicular) | Low estrogen | Dry - no noticeable secretions (3-4 days) |
| Pre-ovulatory | Rising estrogen | Sticky, elastic, white/cloudy (3-4 days) |
| Peak fertility (peri-ovulatory) | Peak estrogen (LH surge) | Clear, watery, profuse, slippery - like raw egg white; maximum spinnbarkeit ("spinnbarkeit" = stretchability) |
| Post-ovulatory (luteal) | Progesterone dominant | Thick, scant, dry - hostile to sperm |
The estrogen-dominant pre-ovulatory environment is conducive to sperm transport to the ovum. Progesterone after ovulation physically obstructs sperm penetration by thickening the mucus.
- Pfenninger and Fowler's Procedures for Primary Care; Berek & Novak's Gynecology
How to Use It (Practical Instructions)
- Observe cervical secretions at the vulva several times each day - typically before urination
- Chart each day: menses, type and quantity of secretions, and whether pregnancy is likely
- Avoid unprotected intercourse during:
- All days of menstrual bleeding (bleeding can mask fertile secretions)
- Pre-ovulatory days that follow a day of intercourse (semen can be confused with fertile mucus)
- All days with fertile (wet/slippery/clear) secretions
- "Peak day" = last day of the wet, slippery, clear mucus; ovulation typically occurs on or just after this day
- Intercourse may resume from the 4th day after the peak day (post-ovulatory infertile phase) until the next menses
- Berek & Novak's Gynecology; Pfenninger and Fowler's Procedures for Primary Care
Mucus Pattern Through the Cycle
A typical 26-32 day cycle shows this progression:
- ~3-4 days: dry (no secretions) after menses
- ~3-4 days: sticky and elastic (early fertile sign)
- ~3-4 days: clear and wet (peak fertility window)
- ~11-14 days: dry again until next menses
TwoDay Simplified Version
A simpler variant asks only two questions each day:
- "Were there any secretions today?"
- "Were there any secretions yesterday?"
If both answers are No - the woman is in a non-fertile period. If either answer is Yes - she is potentially fertile and should avoid unprotected intercourse.
- Pfenninger and Fowler's Procedures for Primary Care
Efficacy
| Use Type | Pregnancy Rate |
|---|---|
| Perfect use (method effectiveness) | 97-99% effective (3% or less failure) |
| WHO 5-country study (perfect use) | 3.1% probability of pregnancy in 1 year |
| Typical/imperfect use | Up to 20-24 pregnancies per 100 women per year |
| Incorrect/failed use | 86.4% probability of pregnancy (WHO study) |
A review of 15 national surveys from developing countries estimated a 12-month gross failure rate of 24 pregnancies per 100 women. The large gap between perfect-use and typical-use rates reflects the high demand for consistent, correct observation and couple cooperation.
- Berek & Novak's Gynecology (WHO data); Pfenninger and Fowler's Procedures for Primary Care
Contraindications / Who Should Not Rely on This Method Alone
- Breastfeeding (alters mucus patterns)
- Recent menarche or recent childbirth
- Recent discontinuation of hormonal contraceptives
- Perimenopausal state
- Persistent reproductive tract infections (alter secretions)
- Women unable to correctly interpret secretion changes
Advantages
- No cost, no hormones, no devices
- No medical side effects
- Acceptable to those with religious objections to artificial contraception
- Can equally be used to achieve pregnancy (identify fertile days)
- Promotes body awareness and couple communication
Disadvantages
- Requires high motivation and daily discipline from both partners
- Demands a period of training under a skilled instructor
- Provides no protection against STIs
- Unreliable during irregular cycles, illness, vaginal infections, or hormonal fluctuations
- WHO advisory: current NFP methods have "very little application particularly in developing countries" due to the educational and motivational demands
Relationship to Symptothermal Method
When cervical mucus observation is combined with BBT charting, it becomes the symptothermal method - which is more accurate than either technique alone. The end of the fertile window is confirmed when both the mucus is "drying up" (4+ days post-peak) AND a sustained thermal shift (>0.2°C for 3+ days) is confirmed.
- Pfenninger and Fowler's Procedures for Primary Care; Park's Textbook of Preventive and Social Medicine
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