Withdrawal Method Efficacy: What the Research Actually Shows (Episode 575)

Full Transcript: Episode 575

Lisa Hendrickson-Jack:

This is the Fertility Friday Podcast, episode number 575.

So today we are diving right into the controversy. We’re going to go into the question of whether or not withdrawal is legit. And the reason that we’re going here today is because a recent study came out. I find I think they did an interesting job. I think their study design was pretty interesting as well. And it’s just not that often that we get new research on withdrawal. So that and that’s one of the issues with the method as we’ll get into. So without further ado, let’s go ahead and get into the topic of withdrawal.

So I would say one of the biggest issues with withdrawal is that it’s really not considered to be an actual method of birth control. I think a lot of people think that it’s not. For instance, for myself, I’ve been working in this field for the better part of the last 20 years and so I’ve worked with many, many women, and when we get into the question of what birth control methods they’re using, what they’ve used before, many, many women and couples will kind of under their breath be like, “Well, we use withdrawal,” and they kind of like hang their heads, like this dirty little secret that they’re doing this and, you know, “We’re not supposed to but we’re using it.” And I feel like we need to just talk about it, because at the end of the day, a large percentage of people are using it. The percentage of people who use withdrawal is a lot higher than what you would think. And not everybody uses it as their primary or only birth control method. Many couples use withdrawal in conjunction with other methods. So, you may have a couple who uses condoms and they also withdraw. They are on the birth control pill and they also withdraw or they have an IUD and he also withdraws or whatever the case. And then some couples use withdrawal just by itself as the birth control method. And regardless of your personal opinion about withdrawal, it’s really important to understand what the research says or doesn’t say about it. So we kind of put our personal ideas aside and figure out what’s really there.

I would say that one of the biggest challenges with withdrawal is that we don’t really have a lot of data on the perfect use efficacy because there are some questions that arise in the research. And that’s why we’re going through this paper today. So for example, in The Fifth Vital Sign and Real Food for Fertility, when we talk about withdrawal and we look at what the research has to say, the research is not always that clear because the question — the big question — is, is there sperm in a man’s pre-ejaculatory fluid or not? That’s the question. So theoretically there shouldn’t be sperm in there because if we look at the anatomy, the pre-ejaculatory fluid is released through the Cowper’s gland and technically there shouldn’t really be any sperm in there, unless there was some sperm already hanging out in the urethra or something like that. But when we look at the research, there are studies that have shown that some men seem to leak sperm into their pre-ejaculatory fluid. What’s interesting about those studies is that it leaves me with questions. So if the studies are showing that some men have some sperm in the pre-ejaculatory fluid, well, how much sperm? Is it enough to theoretically cause a pregnancy? Is this really a risk factor? And what then are the implications for the perfect use efficacy?

So I would say with a lot of methods, we can get a clearer picture on perfect use and typical use because there’s a lot of studies that are done. But one of the things I always say is that withdrawal is free and available to everybody. So there’s no pharmaceutical incentive to do large-scale studies on these men to find out if withdrawal is truly effective. And so one of the challenges when we do look at research in this area is that the sample sizes are often very small. How much can you really glean from a study of like 22 people or something like that? We would need the bigger scale study, but who’s paying for that? There’s just no financial incentive here. But fortunately, we have this research paper that we’re going to go into today. And if you’re wanting to have a read through the research paper and everything, fertilityfriday.com/575 is where you will find the information.

So, in this particular study, again, we still have a small sample size. You can kind of think of it as a pilot study. 24 participants, average age 27 years old. And there’s a few things in the study that I think are really interesting. I just stated some of the challenges with research around this area. And one of the things that I think separates this study from some of the other research before is that they’re trying to answer some of the questions that were not necessarily answered. So when you look at some of the previous research, you see like some men had sperm in the pre-ejaculate and some didn’t, but they don’t necessarily explain how the semen was collected. So you don’t know if it was that they legit had sperm in their ejaculate or if there were other factors that could theoretically have led to that. What if they weren’t urinating between each collection? What if their instructions weren’t clear? And so there’s some question there — if you’re not clear on how everything was collected, could it have been that it was from a faulty collection method, or could it have been that it was actually leaking sperm from that area? And were there any health conditions or any existing conditions that were correlated in those men that had sperm in their ejaculate or not? And also, how much sperm was in there? Is it enough to actually be causing a pregnancy, or is it just such a minimal amount that it’s negligible?

So, these are questions that weren’t necessarily answered in some of the prior research in this area. And in this particular study, they actually took a lot of that into consideration and outlined a pretty detailed study procedure to try to minimize it.

So what they did is they defined what they called a significant pregnancy risk as if there was greater than 1 million sperm per milliliter. And if you remember a few episodes ago, when we were talking about the male hormonal contraceptive options, this was one of the similar barometers where they were saying if there’s less than a million sperm per milliliter, the chances of pregnancy are very, very unlikely. They also identified something else where even if they looked at that concentration, they had a secondary factor that if there was a total motile sperm count of greater than 3 million, that that would also present a risk of pregnancy. So they looked at these two factors. So they’re saying, what’s the concentration, and then what’s the total motile sperm count?

Now what’s interesting about that is that when I look at fertility research — this was something that I talked about in Real Food for Fertility in the sperm chapter — total motile sperm count is most highly correlated with successful pregnancy. So the higher the total motile sperm count, what that means in layman’s terms is, if you look at a man’s ejaculate, not all the sperm is going to be moving. So that’s where we get the motility — the motility is the percentage of sperm that are moving. And they can look at the progressive motility, that’s the percentage of sperm that are actually moving forward, not just moving in one spot. So there’s different factors. So the percentage of sperm that are moving, but also the total amount. And so the higher the count is great, but the higher the total motile sperm — the total number of sperm that have good motility — that number is highly, highly correlated with pregnancy. So the higher that number, the more likely conception is to occur.

So it’s interesting that they chose that marker as a secondary marker to say, okay, so when we look at the sperm, we’re going to look at if there’s any sperm in the pre-ejaculate, but we’re also going to look at how much. And we’re going to say if the concentration is greater than 1 million per milliliter, then that’s a risk of pregnancy. But we’re also going to look at the total motile sperm count. And if it’s less than 3 million in total, then we know that there’s a very low risk of pregnancy. And this is talking about the sperm in the pre-ejaculate itself.

So in addition to this, they did a couple of things. They had each male contribute three samples. And they gave them very specific instructions. So they were to urinate first to clear the urethra of any sperm that might have been in there before. And then they gave very specific instructions for how to collect the pre-ejaculate to make sure that they’re not accidentally getting true ejaculate. So they gave them detailed instructions, and I think for anyone who’s like a data nerd like myself who’s looked at the previous studies and is looking at this information, these are things that other studies previous to this one weren’t necessarily as clear about. Which leaves you questioning — is it really that these men had this amount in there, or was it that there was faulty collection? So I feel like it doesn’t make it perfect, but it certainly gives you the sense that these researchers are trying to kind of get to the bottom of this and they’re being a lot more specific with their instructions so that they can set it up hopefully to get more accurate data.

So that’s a little bit of the background about the study. Now in terms of what they found, what they found is also very interesting. So they had these two different measures, and ultimately if we look at the bottom line, none of the men in the study had a significant risk of pregnancy. So based on the first factor, they said a small percentage of these men had some sperm in the pre-ejaculate, but none of them had enough — like the total motile sperm count — to actually likely result in a pregnancy.

So if I kind of read through what their results were: only seven samples, so 10% of the samples, met the primary outcome with sperm concentrations higher than 1 million per milliliter. So there were seven samples — 10% — that actually did have sperm in the pre-ejaculate and it was of a greater concentration than 1 million per milliliter. However, no pre-ejaculate samples met the secondary outcome of total motile sperm count of greater than 3 million, given the small pre-ejaculate volumes. So because pre-ejaculate isn’t the full ejaculate, there wasn’t more than that 3 million total motile sperm count in any of the samples that did contain sperm. And that is significant and very interesting. So again, this answers that question that was lingering in my mind from the previous studies — well, how much was in there? Was it enough to trigger a pregnancy? So what they’re saying is there’s a very, very low chance that could even happen because there’s just such a small quantity.

And interesting — there was data that is in line with the other studies. So some of the other studies on pre-ejaculate, this question of is there sperm in the pre-ejaculate, could withdrawal be effective — you would have the majority of participants with no sperm in the pre-ejaculate. So that was pretty consistent across the other studies, but there would always be like a small percentage of men who had sperm in the pre-ejaculate. And then what the other studies suggested was that the men who had the sperm in the ejaculate always did versus the men who didn’t never did. But in this study, because they had each person, each male, submit three samples, it says among the six participants with sperm-containing pre-ejaculate, five provided sperm-containing pre-ejaculate samples inconsistently. Only one participant consistently had sperm-containing pre-ejaculate. So this study showed different results to the other one because they said that it wasn’t just so straightforward that the men who did always did and the men who didn’t always didn’t. The men who did sometimes did. And it didn’t mean that they always did because they took these multiple samples.

So what do we do with this information, right? What is the purpose of this? How does this help us? When they were kind of setting the groundwork for the study and kind of sharing the background information, the researchers shared an interesting stat. They said that a 2016 study revealed that 7% of reproductive age women solely relied on withdrawal, and 18.8% of unmarried men reported sole reliance on withdrawal. So what they’re saying is what I was saying at the beginning — a higher percentage of people use withdrawal than you think. And it’s literally a dirty little secret that a lot of couples use. And if we’re wanting to support couples who use this method, we can’t just write it off and say it just doesn’t work and don’t ever talk about it.

What I found is that if couples are going to use it, they’re going to use it. So you may as well provide them with information. That’s one of the reasons why I share information about perfect use or correct use withdrawal — so that we have at least some information about it, because a lot of couples are using it but they’ve never been told about how to use it correctly because it’s largely thought of as a non-method without any possible benefit.

And I think part of the reason the researchers — I’m certainly always curious about their motivations for doing it, but based on what I’ve read in the study — it would appear to me that the researchers are looking at this because it’s an area where the research is lacking. They’re looking at the stats and acknowledging that a higher percentage of people use withdrawal than we’d like to admit. And I think that they’re kind of calling out clinicians because they’re saying more people are using it than you think. And if you don’t provide accurate information, then you’re not helping your patients.

So they say this study is one of the first to introduce specific collection instructions to simulate perfect use withdrawal and perfect collection. And so that’s one of the key points the researchers are making — previously, we didn’t really know how they were collecting the semen. So we didn’t really know if their results were accurate. But this time they made an effort to simulate perfect use withdrawal.

So when I talk about perfect use withdrawal, it’s — you would make sure to have your partner urinate prior to any sexual activity, because if there was previous sexual activity that day, there could be sperm in the urethra and then that could be kind of preloading that ejaculate. So we want to make sure that you’re starting with a clean slate, so to speak. And then obviously the penis has to be withdrawn from the vagina before any type of ejaculation takes place.

So they’re trying to say, okay, if we simulate this perfect use scenario, then we’re getting a more accurate view of how much sperm theoretically is actually in the pre-ejaculate. So they go on to say most participants did not have sperm in their pre-ejaculate. So 78.3% of the participants did not have any sperm in the pre-ejaculate. Only 10% of all of the samples they took contained sperm concentrations that could confer significant clinical pregnancy risk. So they’re saying 10% of the samples contained greater than 1 million sperm per milliliter. But remember that when they looked at the second factor as well, even though that was the case, none of the samples had a total motile sperm count of greater than 3 million per milliliter. So they’re saying therefore this widely used but underreported method can and does reduce pregnancy risk if used correctly and consistently, since sperm does not exist in sufficient numbers in pre-ejaculate even when present. So that’s coming from them. That’s what they said.

And they go on to say clinician counseling should better reflect this assessment of pregnancy risk. Withdrawal should be destigmatized as a contraceptive method. And then they go on to make some interesting suggestions. So again, I always say, well, there’s no money to be made in withdrawal. But then they go on to suggest that the development of a mass-producible test for pre-ejaculate sperm identification could help to improve that efficacy. Because what they’re saying is if they can mass-produce like an at-home test for semen to see how much sperm is actually in the pre-ejaculate, then that could be an avenue to increase the effectiveness. And ironically, that could also be an avenue for funding. If there are companies making money from selling test kits that allow men to test their pre-ejaculate — the percentage of sperm in the pre-ejaculate fluid — then that could be a market that opens up and that could be a place where more research could happen in this area, because then all of a sudden there’s a financial benefit. And when there’s a financial benefit, research seems to start coming out of the woodwork.

So that is interesting as well, because that’s certainly something I hadn’t considered. But maybe in the future this will be the thing where they are selling these at-home kits for men to test the pre-ejaculate. There are already home kits to test semen analysis and things like that, and so this could be an area. So I thought that was a really interesting way to end it.

But in terms of what this means — if we look at everything in context — I would say that it certainly shows this research is really interesting. They did the study a little bit differently than previous ones. They looked at some of the questions that were lingering from some of the previous research. And so I think the overall data — like what do we do with this information, where do we go from here — well, I think that it shows that withdrawal is an actual method. And the perfect use efficacy, we still need a lot more research on that, but it could theoretically be decent.

With that said, as I always say, if withdrawal is your method, then if he fails to withdraw, there’s no method, right? And there’s debate on the typical use effectiveness rate, but it’s typically listed as about 20%. In Real Food for Fertility, I shared data from a research study that showed typical use effectiveness rates anywhere from 78 to 90%. So depending on the source that you’re looking at, the typical use failure rate ranges anywhere from like 12% to 20% failure. So the typical use is not good. Arguably, if we treat it like a non-method and provide no instruction of how to do it, then chances are people aren’t going to be using it as correctly.

So it’s still controversial. It’s still going to remain controversial. And certainly I am not suggesting that this should be your primary method or anything like that, but I live in the real world. I work with a lot of clients who use this. And I think it’s very useful to be able to provide some evidence-based information and to kind of put our pitchforks down and look at it, because if people are going to use it anyways, they may as well get instructions.

So I thought it was interesting that the researchers are calling for clinicians to be like, okay, stop just giving these blanket statements that are not evidence-based. Stop just saying it doesn’t work. Let’s look at what the research has to actually say. Let’s acknowledge that it’s a method even if you don’t like it, and even if the typical use isn’t as high. Let’s see what the data is really saying.

So I think that that is certainly interesting. And I’m curious to know if additional research is going to come out. I’m curious to know if there’s going to start to be a burgeoning field where companies are selling at-home pre-ejaculate test strips or whatever. So I guess we’ll just kind of have to wait and see on that one.

But certainly for anyone who’s listening who has used withdrawal in the past or is using it and is nervous about it, even though you’re still using it — I think the more data and information that we have, the more informed you can be. And like I said, a lot of my clients use withdrawal in conjunction with other methods. And I think that is certainly something I can get behind. Because if you are using fertility awareness and you’re having sex during that fertile window, protected sex, then any way that you can improve that efficacy is helpful. So if you were using a diaphragm or a cervical cap and your partner is also withdrawing, of course, using those two methods together is going to increase the overall efficacy of either one alone.

And so I do think that it’s worthwhile to have this conversation, because what I’ve learned as well is that everyone has different preferences and everyone’s relationships are different. So you may have a certain preference — maybe in your relationship you use condoms, you’re happy with it, your partner’s happy with it. I’ve worked with many couples who don’t like condoms and whose partner doesn’t want to use it or they don’t like it or whatever. And so every relationship is different. Every person is different. Everyone has their own preferences. This is a very personal, intimate conversation. And so at the end of the day, it’s useful to be able to provide options and allow your clients to choose what is going to work best for them, and to suspend personal judgment as much as humanly possible so that they can really find what’s going to work best in their relationship.