Revisiting the Withdrawal (Pull-Out) Method

Anyone who has spent years working in the health and medical field has lived to see many accepted practices turn on their heads. There are countless examples of policy reversals. In fact, some medical researchers claim that nearly half of all medical practices may be in error, meaning they are not always “evidence-based.” Medical reversal is a term referring to situations where current practice is found to be no better than placebo in well-designed clinical trials. In reproductive and women’s health, we have seen at least five significant reversals in the past few decades:

• Annual pelvic-gynecological exams are no longer recommended for most women
• Breast cancer, once treated routinely by radical mastectomy is no longer the default approach
• Women aged 40-49 used to be advised to do mammograms every 1-2 years. Research no longer supports this benefit.
• The use of long-term hormone replacement therapy (HRT) once recommended for menopausal women for protecting the brain, heart, and bones- is today considered more risky than beneficial.
• For decades the IUD was considered inappropriate for women who had not yet given birth to two children. Today, the method is enjoying newfound acceptance.

In this spirit of renewed scientific inquiry, the following article revisits evidence for the oldest method of human contraception, the withdrawal or pull-out method. It will summarize the research about what we know about semen, pre-cum with semen, and the efficacy of withdrawal. We will see how medical and cultural attitudes have shaped medical practice. We will see how and why this method has been delegitimized for more than fifty years by health professionals. The goal of re-examining the science and research evidence is to help our clients make informed choices about their sexual health and behavior.

In an era in which more and more people oppose hormonal contraception, it behooves us to examine our attitudes and assumptions towards a method that might be safer and more effective than previously thought.

** Research references and other articles are included within the blue hyperlinks.

Anatomy and physiology

The scrotum is designed to enable temperature regulation and allow optimal conditions for producing sperm and allowing for its maturation and retention in the scrotum and the testicles. A supportive environment means 0.37 degrees (Celsius) lower than the rest of the body. When body heat changes, the scrotum shrinks and knows automatically how to regulate its temperature. If the out-of-body temperature is particularly cold, the testicles shrink and move closer to the body. When body temperature is high, for instance during sexual arousal, the testicles are pulled away from the body. This mechanism regulates the scrotal thermostat and continuously maintains the necessary temperature for the production and development of sperm.

Pre-ejaculate fluid (PEF) is a natural substance that is discharged (not produced) from the penis during sexual arousal, usually before orgasm and ejaculation. The liquid also serves as a natural lubricant during intercourse. Although PEF comes from the Cowper’s gland (unlike the semen that comes from the testicles), it may contain traces of live sperm. But it is doubtful that this could lead to pregnancy. Some researchers believe that this is a “cross-contamination” from semen residue that may remain in the urethra from a previous sexual encounter since both the PEF and the seminal fluid pass through the urethra.

Although the chance of pregnancy is relatively low, official figures claim that 22 percent of people who use the method may experience pregnancy at some point (CDC).

With any ejaculation, whether by masturbation or penetration during sexual intercourse, there is the possibility of sperm remaining in the urethra. There are even those who claim that some men always have semen in the urethra. But we don’t know who they are! (WIKI).

Since these findings are way too contradictory, it makes sense that professionals have generally advised people to take the conservative approach, and distrust the method.

The “branding” of stigma

In the 1930s (USA), the cultural attitude towards withdrawal as unreliable was generally promoted by physicians and medical textbooks. Fast forward thirty years and this assumption was reinforced by Masters and Johnson, in their landmark book Human Sexual Response which was the bible text on human sexuality for several decades. In their book, the authors claimed that there are ‘large numbers of active spermatozoa in the pre-ejaculatory secretion’. However, they were unable to produce any data to substantiate that claim (Masters & Johnson, 1966).

The following is a summary of the meager research literature which attempts to clarify the presence of semen in pre-cum, (and to use this information to assess the risks in using withdrawal as contraception).

1. In 1993- A U.S. study looked at samples of pre-ejaculate fluid among men who were HIV+ and compared them to men who were not HIV+. The virus was found in most of the PEF, but few if any sperm cells were found. Moreover, the sperm cells that were found were almost motionless. The authors noted (relevant in 1993) that: “According to the World Health Organization, a man is considered infertile when he has less than 5 million sperm cells/ml in his ejaculation fluid”. So in the case of pre-ejaculate samples with some sperm, the number of viable sperm that could reach the fallopian tube (where the egg waits for the sperm) could not be more than a few thousand. Thus, the probability of pregnancy is very low if not remote.
2. In 2003, a small Israeli study found no sperm present in PEF while sperm was found in the ejaculate fluid!). The authors conclude that pregnancy from PEF is not possible.
3. In 2009, the withdrawal method’s legitimacy was evaluated following an article printed in the journal Contraception by the Guttmacher Institute (USA) stating the method’s effectiveness was similar to that of condoms (between 80-85%). The article received extensive press coverage and changed the attitude from one of “it is better than nothing” to “its efficacy is similar to condoms.” The authors conclude: “Consistent dual use of withdrawal in conjunction with hormonal, barrier or other methods could constitute an effective contraceptive strategy…Dismissing withdrawal as a legitimate contraceptive method is counterproductive for the prevention of pregnancy and also discourages academic inquiry into this frequently used and reasonably effective method.”
4. In 2010- the life expectancy of sperm in the post-ejaculation urine of fertile men was examined in 10 healthy men who gave pre-ejaculation samples and urine samples before and after ejaculation. The samples were taken twice: within half an hour and within 11 hours of the ejaculation. Sperm was tested for quality, vitality, and motility. No sperm was found before the ejaculation. The average concentration was 50 million sperm cells to 25.8 ml. After half an hour, 60% of the net samples contained sperm cells (M. s), but it is unclear how many. After five hours, the presence of semen could not be found. The conclusion: additional research is needed to verify the findings.
5. In 2010, A study tested 40 PEF and ejaculation fluid samples from 27 subjects. In 11/27 (41%) of the men, sperm was found in PEF, and in 10 subjects (37%) motile sperm was found. The samples were collected in IVF units, adjacent to a lab. An interesting trend was found: some of the men gave samples several times and the researchers discovered that either sperm was present in specific men’s PEF or it was not present at all. The authors explain the phenomenon by suggesting that some of the men may have given their PEF samples mixed with ejaculation fluid because they were embarrassed to submit a sample with so little PEF. From the data presented, none of the 40 samples contained a minimum amount of volume (>2%/ml) and only 2 samples in 40 demonstrated a motility level that could be defined as “fertile” (>50% moderate). Although this latter detail was not included in the text summary of the article, it raises doubts about whether PEF can lead to an actual pregnancy.
6. In 2016, a Thai study looked for the presence of sperm in the PEF of healthy men. It concluded that in a sample of 42 healthy men, sperm was found in 16% of the samples. But the study abstract does not mention how much time elapsed between delivery of the specimen until the microscopic examination nor does it contain data about the amount of viable sperm found in the 16%. Therefore, we cannot reach any practical conclusion.
7. In 2012 and again in 2019, the International Family Planning Association (IPPF) published on their website a Facts and myths sheet about the withdrawal method, claiming that PEF may contain sperm from a previous ejaculation but the amounts so small that they would lead to a faint risk of pregnancy (several hundred sperm cells). The authors further recommended that a man urinate after ejaculation and wipe the penis in order to remove semen residue before the next sexual contact. They cited a typical effectiveness of about 80%. The method is recommended for couples who are willing to take a calculated risk.
8. In 2019, Jen Schwartz published an article in Scientific American which summarized the results of previous studies on withdrawal. The author indicates that perfect use of the method yields 95-96% efficacy while imperfect, typical use, is only 70-80% effective. For example, if men are intoxicated by alcohol, then their response time is slower, therefore reducing efficacy. Schwartz rightly emphasizes that there is a shocking lack of research into this method’s efficacy. She concludes from her own investigation that “Pre-ejaculate fluid itself does not contain sperm—or maybe it does occasionally, but perhaps it gets contaminated with sperm that has “leaked” from elsewhere… She asks important questions that research still needs to confirm: “Even if there is sperm in pre-ejaculate, can they swim? Are all of their parts intact? If sperm is present in pre-ejaculate, and they are simply “leftovers” from the last ejaculation, then where might they be “leaking” from, as the literature suggests??

Conclusions

Withdrawal is the oldest method of contraception in human history and also the most common, natural, and accessible. In the Western world, many contraceptive user surveys show that when people report that they are not using any contraceptive method, they are in fact using the withdrawal strategy. And yet the stigma of “pulling-out” is so culturally embedded that it is not perceived as a legitimate contraceptive method! It is indeed surprising that in the nearly 150 years of human fertility research so little attention has been directed towards clarifying the efficacy of this approach. While one can find over 5 million internet links about sperm survival inside a woman’s body, there are almost no links about sperm survival in a man’s body. The answer seems obvious enough. It is likely because research on this method does not translate into economic gain for anyone, namely the pharmaceutical industry.

The prevailing approach supports the fact that the statistical efficacy of withdrawal is similar to that of the condom (Perfect use is 96-97% and actual use is 80-85%). Therefore there is no reason to disregard one method over the other.

Some organizations (IPPF, PP) suggest that withdrawal can be effective in preventing pregnancy- in fact, withdrawal or pulling out is very close in efficacy to the condom (CDC) and even though the condom is far from being close to 100% effective, it is never disregarded as a viable option.

Regarding pre-cum and its fertility potential, it is worth noting that the current standard set by the W.H.O considers 15 million sperm per ml- as the lowest reference limit for sperm being able to fertilize an egg. Therefore, the risk of pregnancy from pre-cum is minuscule. Researchers who have been developing and testing male birth control methods since the 1970’s- seem to concur that a man’s sperm count doesn’t need to be lowered to zero—a count of around 1 million sperm per milliliter of ejaculate is low enough to count as contraception because statistically, none of those 1 million sperm will reach the egg.

Lastly, it is surprising to learn that none of the studies mention the temperature factor. Sperm cannot survive very long inside the male reproductive tract because it is too warm. The testicles are designed to stay at about 35 degrees Celsius (95 degrees Fahrenheit), which is a few degrees lower than average body temperature. If testicle temperature rises above that, sperm are damaged and immobilized. It is not a coincidence that male reproductive anatomy is completely external to the body and that is what explains why it takes virtually seconds from the time sperm leave the testicle until the time of ejaculation through the urethra/penis. Additionally, we know that during the fertile days of the menstrual cycle, basal body temperature is lower than for all other days of the cycle. This could indeed explain an evolutionary mechanism by which sperm can survive for 3-5 days in a woman’s body.

In conclusion, the withdrawal method is safe, relatively effective, has no harmful side effects, and does not require a doctor’s prescription.

Suggested guidelines for withdrawal

The following guidelines are recommended only for couples who can comply with the conditions and rules:

1. The method should only be used by couples in a serious, long-term relationship. The method cannot expect to reach high efficacy in casual or new relationships.
2. The spouse must have experience and confidence in controlling their ejaculation, while sober!
3. Withdrawal can be combined with other methods during the fertile window. It is not a stand-alone method, so at this time, two methods should be used simultaneously e.g. barriers such as condom or diaphragm together with withdrawal, or spermicide with withdrawal.
4. The method is safe only if a minimum of four hours have elapsed between the man’s last ejaculation and current penetration. “The last ejaculation” can also refer to masturbation. Masturbation should be avoided for four hours, to reduce the possibility of pre-cum being present during the next act of intercourse. In addition, the man needs to urinate and wash his penis between two acts of ejaculation or intercourse. These measures will seriously decrease the probability that PEF containing semen could reach the uterus or fallopian tubes. The acidity of urine also greatly reduces the movement of sperm.
5. The man must make sure that his ejaculation fluid does not touch anywhere near the vulva when he pulls out. Women are known to have conceived on days when their fertile secretions “suck up” semen near the vulva without penetration.
6. Withdrawal is a male method of contraception and its success depends 100% on the man. So female partners need to pay attention to their cycles and their emotional needs before deciding to rely on this method. In the end, both partners must agree and weigh in on how this method can enhance or diminish pleasure and sexual experience.