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Withdrawal (also called coitus interruptus) means withdrawing the penis from the vagina immediately before ejaculationso that all the ejaculate is deposited out­side. Its alternative names include ’being careful’, looking after the wife’, ’pulling lout’, ’getting off at Redfern’ (if you live in NSW - if you live in other states substi­tute the station before your capital city terminus for ’Redfern’) and no doubt many other indelicate colloquialisms. It’s claimed that withdrawal is the oldest method of contraception. It is referred to in the Talmud as ’threshing inside and winnowing outside’ and is the only method of contraception mentioned in the Bible. Onan was instructed by his father Judah to sleep with his brother’s widow Tamar so that his brother may have de­scendants. But Onan, knowing that the children would not be his brother’s, chose let his semen spill on the ground whenever he had intercourse with Tamar, and for this he was slain by Jehovah (Genesis 38:4-10).

This has been interpreted as ’the sin of Onan’. ’Spilling the seed in coitus’ was condemned by St Augustine, St Hubert and many later Christian teachers. However, the method became widely used in the eighteenth and nineteenth centuries and is thought to be responsible for the trend to smaller families in Europe over that time. It is still popular in many Medi­terranean countries, where the know-how is handed down from father to son.

How effective is withdrawal? Failure rates of 8 to 17 per hundred woman-years have been reported. It can be very effec­tive if the man has good control and can withdraw in time, so that all the ejaculate is deposited well away from the entrance of the vagina. Some couples report using it from mar­riage to the menopause without a single unplanned pregnancy. Most failures are put down to faulty technique or incon­sistent use.

Many people believe that withdrawal can’t work because there may be sperm in the pre-ejaculatory lubricating fluid. This seems to be very unlikely, though it is difficult to study, as you can imagine. However, several studies over the past 40 years have reported no sperm or insuffi­cient for fertilisation in the pre-ejaculate.

It’s almost impossible to know how many couples are using withdrawal. A survey in England in 1949 found that about half of all couples studied used this method.

Advantages of withdrawal

• It is free, and you never run out of supplies.

• There are no adverse effects on health.

• It can be very effective for those who are good at it.

Disadvantages of withdrawal

• Some couples find that intercourse is unsatisfying without ejaculation in the vagina.

• It is forbidden by some religions.

• Women, who generally have the big­gest stake in contraception, may be anxious during intercourse in case the man doesn’t withdraw in time.

Coitus interruptus is generally overlooked in discussions about contraception. It can be a very handy back-up or emergency method.

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Advantages of fertility awareness

• There are no known side-effects.

• It is highly effective if coitus is confined to the second infertile phase.

• The method is acceptable to most reli­gious doctrines.

• Once you’ve been taught the method, there’s no follow-up or further expense.

• It allows you to understand your repro­ductive cycle better, which may help you to conceive when you want to.

• Many couples find that the co-opera­tion needed strengthens their relation­ship. Many also discover a new joy in non-coital sexual gratification.

Disadvantages of fertility awareness

• Some women find it hard to observe and interpret the changes.

• Regular daily observations are essential. Some busy women find this difficult.

• There may be conflict and frustration during periods of abstinence.

• Frequent travel by one or other partner may make it difficult to co-ordinate sexual activity and periodic abstinence.

Fertility awareness in the future

Researchers are working on more accurate means of identifying the fertile and non-fertile phases. These include:

• a digital readout thermometer w built-in microcomputer, which works out whether or not your BBT indicates fertility and tells you, day by day, when you must abstain

• devices that women can use to mead the hormone content of their urine orsaliva

• ultrasound machines that eventually may become as cheap as pocket calculators. We could plug them into our television sets and use them to monitor ovulation. This might sound like science fiction, but it’s not so long that most of us thought we’d never learn to use computers, so anything’s possible.

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The temperature method

Most women can reliably detect when ovulation has occurred by measuring basal body temperature (BBT). A temperature rise of 0.2-0.6°C that is sustained for three days is pretty good evidence that you’ve ovulated.

BBT must be taken each morning after waking, before getting out of bed and be­fore eating, drinking or smoking. It doesn’t matter whether you put the thermometer in your vagina or under your tongue (the armpit is less reliable) as long as you always use the same place and leave it in place for at least three minutes before reading. Because the temperature rise is small, special BBT thermometers are avail­able (from pharmacies). These have an amplified scale to make it easier to read small changes. You can buy special charts for recording BBT or make your own with graph paper.

The second infertile phase begins when BBT has been consistently raised for three days. This is playing very safe with ovum survival. If intercourse is confined to the second (post-ovulatory) fertile phase, the method has a very low failure rate (two or less pregnancies per hundred woman-years). The only thing that could go wrong would be a mild infection or anything else that can raise your BBT for three mornings in a row before ovulation.

Mucus methods

You can learn to detect the rhythmic changes in your cervical mucus by noting its amount and appearance, what it feels like, and how damp or dry your vulva feels. The different names for mucus methods refer to different ways of ob­serving these changes. For example, the Billings method concentrates mainly on appearance and changes in sensation of moisture or dryness at the vulva: other teachers emphasise how the mucus feels.

The first infertile phase lasts from the first day of menstruation until the first ob­servation of a change in the mucus. The Billings method advises against inter­course during menstruation (when the blood makes it impossible to assess mu­cus characteristics), and after menstrua­tion suggests intercourse no more than every second night during the first infer­tile phase, to prevent confusion between mucus and semen.

During the fertile phase the mucus be­comes increasingly copious, clear, watery and stretchy. Thesecond infertile phase begins three days after the mucus becomes thick, sticky and opaque. This method also plays very safewith ovum survival.

Some teachers advise confining intercourse to the evenings during the first fertile phase in case the mucus pattern changes to fertile during the night. If you didn’t notice the change, intercourse in the morning could lead to pregnancy. Also, when you’re on your feet during the day, cervical secretions travel down the vagina to the vulva, so that in the evening you have a better chance to observe char­acteristic features of the mucus. After the post-ovulatory mucus change, intercourse can be at any time.

There may be some practical problems with observing vaginal mucus and its changes.

• Discharge from inflammation of the vagina or cervix could make it hard to recognize fertile mucus.

• Semen and vaginal lubricating fluid of sexual arousal could be mistaken for fertile mucus.

• You can’t detect mucus changes during menstruation. If your cycle is short, this may mean that you can’t define the be­ginning of the fertile phase.

Symptothermal methods

These combine BBT and mucus observa­tions. Some teachers include feeling the ’cervix. Some women can detect that as

ovulation approaches their cervix feels softer, larger, higher in the vagina and the external os is more lax. The more changes you note, the less likely you are to make a mistake about when you’re fertile.

Though most teachers advise absti­nence from sexual intercourse during the fertile phase, this doesn’t mean that you can’t express your love physically or satisfy each other sexually. There are hundreds of ways to make love without ejaculation into the vagina. In the textbooks this is given the grand name of’non-coital sexual gratifi­cation’. Some couples choose to use con­doms, a cervical barrier or withdrawal during the fertile phase.

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Knowing the survival time of sperm and ovum, we can work out that the fertile period may extend from seven days before until 24 hours after ovulation. Each cycle has two infertile phases: the first phase lasts from the first day of menstruation until about seven days before ovulation and the second infertile phase lasts from 24 hours after ovulation until the first day of the next menstruation. You can use this knowledge to assess when you are fertile by noting various changes in your body during the menstrual cycle and knowing what these changes mean.

• Changes in cervical mucus and the cervix tell you that the fertile period has begun and that ovulation is approaching.

• A rise in basal body temperature pi further changes in cervical mucus tell you that ovulation has occurred and that the second infertile phase has begun.

There are thus several ways you can use fertility awareness, depending on which changes you concentrate on and observe in your body. These methods are known as the rhythm (calendar), the temperature, the mucus (ovulation, Billings) and the symptothermal (combines mucus am temperature) methods.

The rhythm (calendar) method

The rhythm of your menstrual cycles is observed to calculate your most likely time of fertility, based on the knowledge that ovulation usually occurs around two weeks before the next period starts. But because even women with the most regular cycles can sometimes ovulate early or late, the rhythm method got a bad reputation for its high failure rate. Now that we have more reliable methods of fertility aware­ness, the rhythm method is no longer recommended. However, just for the rec­ord I’ll describe how the calculation was done.

• First, the length of menstrual cycles was rioted for a minimum of six months. For women whose cycles varied widely, observation of 12 cycles was advised.

• From the length of the shortest cycle during the observation period 20 days were subtracted. This marked the first day of the fertile phase by allowing 14-16 days for the length of time after ovulation plus 6-4 days for sperm sur­vival time.

• Eleven days were subtracted from the longest cycle (which allowed for the shortest time from ovulation to men­struation) to find the last day of the fertile phase.

Thus, for example, if your cycle varied from 27 to 30 days, the time of absti­nence would be from the 7th to the 19th days, but if your cycle varied from 21 to 35 days you would need to avoid coitus for 24 days from the first day of men­struation. This amount of abstinence is not acceptable to many couples.

If you intend to use temperature, mucus or cervical changes, it’s best to learn the method from a teacher properly trained to observe and interpret these signs.

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The ovum

The ovum m the past it was thought that the ovum I could be fertilised for up to 24 hours after ovulation, but recent research indicates that its survival time is closer to 12 hours. Thus the most favourable condition for fertilisation would be to have sperm wait­ing in the tube when the ovum is re­leased. We ovulate on one day only of the cycle, even if more than one ovum is re­leased (as happens in cases of non-iden­tical multiple pregnancy). If an ovum isn’t fertilised, it dies and conception is impos­sible during the rest of the cycle.

Cervical mucus

The characteristics of ’fertile mucus’ - copious in amount, clear, watery, slippery and stretchy - are at a peak just before ovulation. Soon (within 24 hours) after ovulation, progesterone from the corpus luteum changes the mu­cus, making it thick and sticky. Cervical mucus influenced by progesterone does not allow sperm to pass through the cervical canal.

The cervix

At the beginning of a cycle the cervix feels firm and its opening into the vagina (ex­ternal os) feels tightly closed. As ovulation approaches, the cervix feels softer and wider and the os becomes lax enough to admit a fingertip. After ovulation the cer­vix soon returns to its firm state with a closed os. Some women also notice that their cervix is closer to the vaginal open­ing at the beginning of the cycle and after ovulation, and further from it during the fertile period before ovulation.

Because changes in the cervix may be hard to compare from day to day, it is recommended that you combine feeling the cervix with observing the cervical mu­cus and/or keeping a temperature chart.

Body temperature

We have already seen that one of the effects of progesterone from the corpus luteum is to cause a rise of 0.2-0.6°C in basal body temperature.

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It’s been known for centuries that women are not fertile throughout the entire men­strual cycle. The awkward term ’periodic abstinence’ means keeping semen out of the vagina when fertilisation could occur; various methods are used to know when you are fertile so that you will know when to avoid any sexual activity that could result in pregnancy. This is often called ’natural family planning’ because no chemicals or devices are used and the method involves an understanding of the nature of your reproductive cycle. I don’t believe that it’s really ’natural’ to avoid sexual intercourse deliberately when there is a possibility you will conceive. Lacta­tion is nature’s only way of delaying the next conception. I prefer the term ’fertility awareness’.

Over the centuries every part of the cycle has been claimed to be either the fertile or the ’safe’ time, but because most of these were wrong (as we now know) the method gained a poor reputation for reliability. It is only since the 1950s that there has been convincing evidence, based on sound re­search, that certain changes in women’s bodies during the menstrual cycle reflect what’s happening in our ovaries, particu­larly hormone production and ovulation. We can observe and interpret these changes to predict and identify when we are fertile in the cycle. But first we must know some important facts concerning sperm, ova and the effects of ovarian hormones on body temperature, cervical mucus and the cervix.

Sperm

The quality of sperm vary in regard to the time they will survive, their ability to swim (motility) and their ability to fertilise the ovum. This variation exists between men and between individual sperm within the same man’s semen. From the point of view of preventing pregnancy we must as­sume that all semen contains some sperm of the ’very best’ quality.

As you can imagine, it is very difficult to study sperm survival after an ejacula­tion into a woman’s genital tract. Most of our knowledge comes from post-coital tests and from IVF (in-vitro fertilisation) studies. The important factors that seem to influence sperm sur­vival after ejaculation are:

• the condition of the cervical mucus in the vagina and in the cervical canal

• conditions in the uterus and tubes. Without fertile cervical mucus sperm can­not pass through the cervical canal and die quickly in the vagina. Studies of sperm survival in women wearing cervical bar­riers (and thus there is no cervical mucus in the vagina) reveal that no live sperm have been found in the vagina three hours after ejaculation and in most cases all were dead after one hour.

Once sperm have entered fertile cervi­cal mucus they can survive on average three to four days. However, the fact that women have conceived when they have had no coitus for seven days (in one case nine days) before the known time of ovu­lation shows that some vigorous sperm can survive for longer in the right conditions.

Most sperm are motile when they are ejaculated but must undergo further changes before they are able, to fertilise the ovum. These changes normally occur they pass through the cervical, uterine and tubal fluids that have been produced under the influence of oestrogen. Note, however, that in these days of assisted conception technologies, ejaculated sperm are also able to fertilise eggs in the test tube.

In humans it would seem that after ejaculation a reservoir of sperm can remain in fertile cervical mucus for some days, from where they move in relays through the uterus and then on to the tube. This explains how fertilisation can sometimes happen up to a week after the last sexual intercourse. The average ejaculate contains around 200 million sperm. Most of the ejaculate is wasted in the vagina, but if 1 per cent of it enters fertile cervical mucus and if 1 per cent of the sperm in this fraction were иthe ’best quality’, a pregnancy could result up to a week later.

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You’ll be advised how to use these when you are fitted. Here are my tips.

• When you first get your diaphragm or cap, spend half an hour putting it in, checking its position and taking it out. If you don’t get the knack, go back to your doctor or clinic in case you’re not on the right track. Practice until you can do the job easily and confidently. Then you won’t be tempted to leave the device in the cupboard.

• You can wear a diaphragm with the dome facing up or down. Caps should be worn with the hollow side fitting over the cervix.

• After insertion, always check that your cervix is covered by the device.

• If you’re living with your partner I suggest putting your cervical barrier in regularly at the same time each day. Around the same time next day take it out, wash it, and put it back in. Thus you’re wearing it just about all the time.

• You can take the diaphragm out earlier, as long as it’s three hours or more since ejaculation.

• Diaphragms left in for more than a couple of days develop an odd, un­pleasant odour. A daily wash with plain soap and water seems to pre­vent this. There have been reports of toxic shock associated with dia­phragms being left in place for more than 36 hours. Daily washing re­duces the risk of this rare event.

• Continuous use during menstrua­tion is not recommended. If you have sex during a period, remove your cap or diaphragm as soon as convenient after three hours.

• Cervical barriers provide effective contraception without spermicide, but if you choose to use it:

1 put spermicide only on the side facing the cervix. Don’t put any on the rim; it may interfere with suction attachment of a cap or cause a diaphragm to slip

2limit the amount of spermicide so that it won’t spill over the rim when the barrier is in place

3 there’s no need to put extra sper­micide in your vagina before sex (if the barrier is inserted in ad­vance) or if sex is repeated.

• The device will be most reliable if you use it every time you have intercourse.

• If you suspect that your barrier may have slipped out of place during use, consult a doctor or family plan­ning clinic within 48 hours to see if ’morning-after’ contraception is advisable.

• When not in use, wash and dry the barrier, wrap in cloth or tissue and store in its container in a cool place.

• The size of your cervical barrier should be checked after pregnancy and delivery, if you lose or gain more than 3 kg, or if you or your partner can feel it when it’s in place.

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The advantages of cervical barriers

• They are effective if used correctly every time you have intercourse.

• There are no side-effects unless you’re allergic to rubber (plastic diaphragms are available) or to spermicide if you use it.

• They are an immediately reversible form of contraception.

• They are cheap, after the initial outlay. A diaphragm lasts for several years with care. Cost is increased if used with spermicide.

• The barrier can be inserted at any time and worn more or less all the time, so that its use need not interfere with sex­ual arousal.

• They are good if you need contracep­tion only occasionally or for short peri­ods now and then. Some women use a diaphragm or cap during their fertile period if they are relying on fertility awareness for contraception.

• They do offer some protection against those STDs that affect the cervix, or that enter the upper reproductive tract through the cervix (for example, cervi­cal wart virus infection, gonorrhoea and chlamydia).

• Some women use a diaphragm if they have sex during menstruation to save soiling the sheets. It will hold an hour or so of average menstrual flow without any spilling over.

Disadvantages of cervical barriers

• They must be fitted by someone trained to do so.

• Some women don’t like putting any­thing into the vagina.

• Not every woman is anatomically suit­ed to the available range of shapes and sizes.

• Some women have problems with in­serting the diaphragm or cap.

• If the barrier is not put in until sexual foreplay has begun, insertion may dis­turb progress and spontaneity.

• Some women find that the rim of a dia­phragm presses against and irritates the urethra, causing urinary symptoms. Use of a cap may solve this problem.

• Occasionally the suction of the rim of a cap may lead to ulceration of the va­ginal lining.

• Rarely, cervical barriers have been as­sociated with toxic shock syndrome.

• Barriers in their plastic storage con­tainers are rather too bulky for the aver­age pocket or purse: thus they are usually not on hand for the unpredicted sexual encounter. But then there are always Marie Stopes’s makeshifts or Casanova’s half a lemon - better than nothing!

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How effective are cervical barriers?

It’s difficult to give a firm answer. Results of studies have been highly variable, ranging from almost none to more than 20 pregnancies per hundred woman-years. As usual, there are less failures with longer use (practice makes perfect), with older women and in women who want no more children. Success is dependent on correct and consistent use.

Types available

Each type of diaphragm and cap available comes in a range of sizes and must be fitted by someone with knowledge and training, usually a doctor or nurse.

The diaphragm fits into the groove be­hind the pubic bone and is held in place by the muscles in the vaginal wall. It forms an inner ’roof that covers the cervix. It not only stops the semen from reaching the cervix but keeps cervical mucus from reaching the semen and providing a ’track’ along which sperm can swim into the cervical canal. Diaphragms provide for differences in anatomy and muscle tone of the vagina with a choice of three different types of spring in the rim.

Cervical caps are thimble-shaped and fit over the cervix, staying in place by suc­tion of the rim around the cervix. Such a cap is only suitable for a woman who has a long cervix that will fit far enough into the cap to maintain suction.

The vault cap (Dumas cap) is placed over the cervix and attaches itself to the surrounding vaginal wall (vaginal vault) by suction. It is suitable for a woman with a short cervix. The Vimule cap is a combi­nation of cervical and vault cap, which hugs the cervix and attaches to the vaginal vault by suction.

In Australia diaphragms are much more popular and easy to get than caps. You would probably have to go to a specialist in contraception, such as an FPA clinic, to be fitted and supplied with a cap.

The ’Today’ sponge, an intravaginal device marketed recently in the USA, is not a cervical barrier but a carrier for spermicide.

Fitting cervical barriers

This involves a pelvic examination to as­sess the size and shape of your cervix, the depth of your vagina and the tone of its muscles. Several sizes may be tried until the right fit is found. You will then be shown how to insert the barrier and how o check that it is properly in place. You should be given a chance to practice in­sertion, and have your skill checked. Some providers prefer you to use other contra­ception until you’ve had a chance to practice in the more relaxed atmosphere of home, and to return at a later date wear­ing the barrier for checking of its position and size. If you have difficulty with inser­tion, plastic introducer rods are available for some barriers.

The best posture for insertion is either squatting or standing with one foot raised onto a chair or the toilet seat. The actions and direction of insertion are similar to those of putting in a tampon.

A properly fitted diaphragm rests snug­ly behind the pubic bone. Because the va­gina has no touch sensation beyond 2 cm from the entrance, a cervical barrier that is correctly fitted and placed can’t be felt. If you can feel it, it’s probably too big or out of place. If your partner can feel the rim of a diaphragm, it’s probably too small.

Should spermicides be used?

For many years the use of additional sper­micide has been recommended with cer­vical barriers. Spermicide adds greatly to the cost and complexity of the method, and its necessity has now been ques­tioned. There have not been enough stud­ies to give a firm answer on whether caps or diaphragms work better with or with­out spermicide.

At present studies on the efficacy of diaphragms and caps with and without spermicide are proceeding in several centres in Australia and the United King­dom, but results haven’t yet been report­ed. Until more information is available, I believe that the use of spermicide is a matter of choice.

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Some people don’t like the term ’cervical barrier’, claiming that the word ’barrier’ has a negative value and shouldn’t be used in association with sexual intercourse, which is concerned (we hope) with close­ness. The alternative suggested ’intra-vaginal occlusive devices (or pessaries)’ seems rather a mouthful to me and equal­ly off-putting, so I shall use ’cervical bar­riers’ to refer to the various types of intravaginal diaphragms and cervical caps. I believe the term is apt, as diaphragms and caps act as mechanical barriers that prevent sperm from mixing with cervical mucus and entering the cervical canal.

History of cervical barriers

Like condoms, cervical barriers have a colourful history that goes back for thou­sands of years. Many early cervical barriers incorporated something to act as a spermi­cide. The ancient Egyptians left descrip­tions on papyrus of a contraceptive pessary made of crocodile dung and honey. Women in the court of Louis XIV placed wads of cotton waste in their cleavage be­fore dinner. At the end of the evening the wad, by this time well soaked with wine, was transferred to the vagina. Casanova is reputed to have given his partners a squeezed half lemon to cover the cervix. And Mae West used a pink satin rose petal!

The first rubber diaphragm appeared late in the nineteenth century and later evolved into a thinner, more pliable latex device with a flat steel watch-spring built into its rim. This became known as the Dutch cap because of its popularity with advocates of contraception in The Netherlands.

Attitudes to cervical barriers

Cervical barriers have never had easy acceptance. Those who opposed contra­ception in any form denounced the dia­phragm even more loudly than condoms and withdrawal. Women controlling their own fertility - what was the world coming to! The first doctor to publish a book for the public about cervical barriers (The Wife’s Handbook, 1887) was struck off the

British Medical Register. Marie Stopes, the British firebrand advocate of cervical bar­riers, was involved in a court action for pornography for her efforts to provide information. Bitter controversy also raged in the USA. However, after 1920 dia­phragms and caps gradually became more available for those who dared and knew where to get them.

During the Second World War all rub­ber manufacturing was diverted to the war effort, and cervical barriers became un­obtainable. As recently as 1943 Marie Stopes recommended (as wartime emer­gency make-shifts) sponges, powder puffs or plugs of wool soaked in oil, soapsuds or vinegar, and even a child’s rubber ball cut in halves.

After the war cervical barriers were widely recommended by family planning providers, and reached peak popularity at the end of the 1950s, being used by about 12 per cent of Family Planning Associa­tion clients in the UK. With the advent of the Pill and IUDs in the 1960s, caps and diaphragms came to be considered an old-fashioned, bothersome method. This is not surprising: instructions for their use had become so complicated, compared with the ease of the newer methods, as to put off all but the most stalwart.

Since about 1980 cervical barriers have had a bit of a ’comeback’. Women dissat­isfied with other methods or worried by ’scare’ reports of possible side-effects of hormones and IUDs have given the dia­phragm or cap a try and found it easier than they had imagined. Simplified in­structions for their use have helped make cervical barriers more acceptable.

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