Physical barriers, Withdrawal, and Spermicide
By Sophie Knapp I B.S. M.S.
Reviewed by Emily Reeves I PhD. CNS.
A low-effort and highly affordable form of natural birth control is using a physical barrier every time you have intercourse to block sperm from reaching the egg. Many of us will choose to combine this method with the sympto-thermal method so that sex on fertile days is not off the table and skin-to-skin intimacy is on the table for most of the month. Commercially available physical barriers include condoms, spermicides, cervical sponges, cervical caps, and diaphragms. There is a lot to know about each of these methods, so please make sure to talk with your healthcare provider and read and follow product instructions thoroughly. Though many of these methods are statistically less effective than taking hormonal birth control, their efficacy can be improved if you are diligent about using them as directed and if combined with another method they can be on par with hormonal birth control.11
Male condoms
If used as instructed, male condoms are 98% effective.13 There are 3 types of condoms available in the US (latex, natural membrane and synthetic) with latex being the most popular, and though some protect against STIs better than others, all are equally effective for preventing pregnancy. Many couples prefer condoms because they can make intercourse less stressful (mostly for females) by making men less sensitive and therefore less prone to premature ejaculation. They are also discrete to have on hand and can be minimally disruptive to put on in the moment compared to other barrier options.13
Troubleshooting
Many couples do not use condoms because they can be difficult to bring up using with a partner, embarrassing to buy, and/or diminish pleasure by disrupting the transition from foreplay to intercourse; however, if these are the reasons a couple is avoiding condom use, with a bit of work, these obstacles can be overcome. If one or another reason is holding you back, we recommend examining the reasons why, and see if that’s a story you and/or your partner are willing to rewrite. Can you both identify why the issues are present and work to reframe your perspectives in a healthy way? Try viewing a conversation with a partner about condoms as an opportunity to deepen the relationship by approaching and working through the uncomfortable topic together. The experience will likely intensify the bond between the two of you and make you even more comfortable with one another. Perhaps there are ways to minimize the interruption putting on a condom can create: maybe you can get creative and find ways that the process can actually enhance foreplay and the overall experience.
Though some disadvantages with condoms can be overcome, others are less surmountable. For some men, it’s difficult to find a proper fit, making them much less effective and outright uncomfortable.13 Others find that they minimize sensitivity too much, rendering them unable to maintain an erection or find any pleasure in the experience at all.13 If this is the case, the use of the withdrawal method, spermicide, and/or the use of an alternative barrier could be satisfactory alternatives.13
Withdrawal Method
The withdrawal method is exactly what it sounds like: the man withdraws his penis from his partner’s vagina just before ejaculation. Though this method is roughly 78% effective,12 using it in addition to another method can be a sufficient strategy to avoid pregnancy. Based on its 22% failure rate, we advise against relying on this method in isolation. Instead either combine pulling out with other barriers, or use it if you choose to have unprotected sex on days that cycle tracking/fertility monitoring indicates a chance of pregnancy, especially if you don’t have any other barrier methods available.
Diaphrams
If used perfectly every time, the chance of becoming pregnant with diaphragm use is 6%, and even with human error, they are 88% effective when used in conjunction with spermicides.9 Diaphragms can be difficult for some folks to obtain as they need to be fitted to each individual by a healthcare professional, and they need to be re-fitted after a woman has given birth. Though there are now “one size fits all” products commercially available, there is a lack of research around how well they work compared to their professionally fitted counterparts.14 Some women encounter contraindications for using diaphragms including significant pelvic relaxation that prevents the device from staying in place, frequent urinary tract infections, a history of toxic shock syndrome, issues around inserting it including physical and emotional discomfort and allergies. Some women are allergic to one or more of the possible materials diaphragms are made out of.14 Although there are alternatives, there is little evidence to demonstrate if all materials are created equal in preventing pregnancy. Additionally, many women are allergic to the most commonly used spermicides, and without using spermicide, it is tough to say how effective diaphragm use is at all as there is limited research.14 Diaphragms may be inconvenient for some couples as spermicide must be applied no more than one hour prior to intercourse and be replaced between each instance of intercourse.14
Female Condoms
If neither partner has a latex allergy, female condoms can be a good alternative barrier method. They are similar to male condoms but with a larger opening and one ring at either end instead of just one. The smaller ring serves as a tool to assist with insertion and anchors up against the cervix. Sometimes this end of the condom contains a sponge with or without spermicide, which combines two barrier methods to further decrease the likelihood of fertilization. The other ring lies outside of the vagina, which can be off putting to both partners or just the opposite. Perhaps the visual takes some getting used to, but the outer ring of the female condom can actually stimulate the clitoris and enhance the female experience during intercourse. According to the CDC, female condoms are 79% effective at preventing pregnancy, though it is unclear how that stat changes with or without the use of spermicide.9
Cervical Caps
Cervical caps vary in efficacy depending on whether or not a woman has given birth. Prior to birthing, they are 13-16% effective at preventing pregnancy, and following birth, they are 23-32% effective.14 Shaped like a sailor’s hat and made of silicone, these caps are loaded with spermicide and work similarly to diaphragms by holding spermicide against the cervix to destroy sperm. This method relies on spermicide to create a “barrier” as the cap itself is not a reliable one. Following intercourse, cervical caps must remain inserted for at least 6 hours to be considered effective. Silicone is non allergenic, potentially making caps a good alternative to latex products. Another advantage to the cap is that it can be inserted for over 24 hours, so planning ahead could prevent unwanted interruptions at the time of intercourse. One disadvantage to cervical caps is that a prescription is required to purchase them, so they require a consultation with a healthcare provider.
Sponges
The efficacy of sponges, like cervical caps, is attributed to added spermicide.14 In order to activate the spermicide that comes in these polyurethane foam discs we call sponges, they must be wetted with water and inserted up against the cervix. Unfortunately, this process could disrupt the moment and potentially dampen your experience if it was not prematurely inserted. However, potential inconvenience associated with the logistics of sponge insertion can be avoided with some foresight. Placement of the sponge can occur up to 24 hours prior to intercourse and can be worn for up to 30 hours total.15 As the timing indicates, sponges must be worn for at least 6 hours following intercourse to be effective, but during that first 24 hours, a woman can have intercourse as many times as she’d like!14 Similar to cervical caps, the sponge’s efficacy decreases following childbirth. Prior to, they prevent 88% of pregnancy, and following childbirth, they are 76% effective at prevention.9 Until the end of 2019, the Today Sponge was the only contraceptive sponge available in the US. The COVID 19 pandemic has ceased all production of the Today Sponge, and it’s unclear if and when their manufacturing overseas in India will resume.16
Spermicides
As previously mentioned, spermicides are often used in conjunction with alternative barrier methods, but vaginal spermicide can also be used on its own. The most commonly used spermicide, with barriers and alone, is nonoxynol-9, and it works by immobilizing and deactivating sperm.14 Though this spermicide is effective, it commonly causes vaginal irritation, urinary tract infections and yeast infections.14 A new prescription spermicide, just approved in 2020 called Phexxi, is a vaginal pH regulator gel.14 It works by lowering vaginal pH to 3.5-4.5 creating an environment in which sperm cannot survive.8 The gel can be applied as soon as one hour before intercourse, so with some planning, it can be a non-interruptive option. Additionally, this is an appealing choice as studies indicate that it may actually decrease the incidence of urinary tract and yeast infections from baseline instead of raising rates like other spermicides can. Keep in mind that you will need to go through a healthcare professional to get a prescription for it, which may prevent access to the product for some.
References:
- Contraception. https://www.cdc.gov/reproductivehealth/contraception/index.htm. Published August 13, 2020. Accessed March 16, 2021.
- WebMD – Better information. Better health. https://www.webmd.com/sex/birth-control/birth-control-pills. Updated December 2020. Accessed April 6, 2021.
- Center for Drug Evaluation. Research. Information about the risk of blood clots in women taking drospirenone. Published 2019. Accessed April 20, 2021.
- Zethraeus N, Dreber A, Ranehill E, et al. A first-choice combined oral contraceptive influences general well-being in healthy women: a double-blind, randomized, placebo-controlled trial. Fertil Steril. 2017;107(5):1238-1245.
- Weschler T. Taking Charge of Your Fertility, 10th Anniversary Edition: The Definitive Guide to Natural Birth Control, Pregnancy Achievement, and Reproductive Health. Harper Collins; 2006.
- Guida M, Tommaselli GA, Palomba S, et al. Efficacy of methods for determining ovulation in a natural family planning program. Fertil Steril. 1999;72(5):900-904.
- Mansour D, Inki P, Gemzell-Danielsson K. Efficacy of contraceptive methods: A review of the literature. Eur J Contracept Reprod Health Care. 2010;15(1):4-16.
- Frank-Herrmann P, Heil J, Gnoth C, et al. The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple’s sexual behaviour during the fertile time: a prospective longitudinal study. Human Reproduction. 2007;22(5):1310-1319. doi:10.1093/humrep/dem003
- Centers for Disease Control and Prevention: Effectiveness of family planning methods. http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/PDF/Contraceptive_methods_508.pdf. Accessed April 6, 2021.
- Bigelow JL, Dunson DB, Stanford JB, Ecochard R, Gnoth C, Colombo B. Mucus observations in the fertile window: a better predictor of conception than timing of intercourse. Hum Reprod. 2004;19(4):889-892.
- Barrier methods of birth control: Spermicide, condom, sponge, diaphragm, and cervical cap. https://www.acog.org/womens-health/faqs/barrier-methods-of-birth-control-spermicide-condom-sponge-diaphragm-and-cervical-cap. Accessed April 6, 2021.
- Pull Out Method (Withdrawal). https://www.webmd.com/sex/birth-control/pull-out-withdrawal. Accessed April 6, 2021.
- Warner L Steiner M Stone. UpToDate. https://www.uptodate.com/contents/male-condoms?search=Male%20Condoms&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Accessed February 9, 2021.
- Bartz D. Pericoital contraception: Diaphragm, cervical cap, spermicides, and sponge. UpToDate. https://www.uptodate.com/contents/diaphragm-cervical-cap-and-sponge. Published September 11, 2020. Accessed April 6, 2021.
- Stacey D, LMHC. Should you use the Today Sponge? https://www.verywellhealth.com/the-today-sponge-906820. Accessed April 6, 2021.
- Mehta BH. OTC Product: Today Sponge. J Am Pharm Assoc . 2006;46(2):304.
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