Contraception - Chemical Methods / Hormonal Contraception / Emergency / Morning After Pill

Emergency Contraception (Plan B / Morning After Pill)

“Emergency Contraception” is receiving a huge publicity push from the American College of Obstetricians and Gynecologists. 

In March, 2002, ACOG President Thomas Purdon sent a mailing to all ACOG members which urged them to make EC patient education a top priority, and which even included sample prescriptions and a sample letter to the local pharmacies urging them to stock the product.

In the US Congress, the Emergency Contraceptive Education Act has been introduced to educate health care providers and the general public about EC.   

College health centers are encouraged to provide EC.  EC will be marketed to college students in college newspapers and with male pinup posters. 

What is this product that is receiving all the attention?  How does it work?  Are there issues of concern for those who believe in the sanctity of human life from conception?  The following discussion will attempt to give some answers to these questions.

 

What is Emergency Contraception?

Emergency Contraception is a general term for estrogen and/or progesterone type (progestin) medications used in high doses within 3 days of unprotected intercourse for the purpose of decreasing the expected pregnancy rate.

There are 2 FDA approved products marketed as EC: “Preven,” and “Plan B.”

The medications contain the same hormones used in standard birth control pills.  However the single day’s dose is much higher that a single day’s dose of a combination birth control pill.  For instance, Preven contains 10 times the daily dose of estrogen found in a low dose combined oral contraceptive (Levlite), and 10 times the daily dose of progestin as well. 

Plan B contains only one hormone, a progestin, in a dose 15 times higher than the single day’s dose of the birth control pill Levlite.

Is Emergency Contraception effective?

It is generally agreed that given 100 women with a single unprotected sexual exposure in the midcycle week, 8 will become pregnant.  Using Preven, 2 will become pregnant.  Using Plan B, 1 will become pregnant.  Thus, the medicine is effective in preventing ongoing pregnancy

(Plan B probably will become the standard, since it has less associated nausea, due to no estrogen component, and it is more effective.)  The method is not effective if used more than 3 days after the unprotected exposure, and is more effective the sooner after exposure it is used.

What are indicated situation for use of EC?

The EC advocates suggest EC should be used if sex was unprotected, the condom broke, the diaphragm slipped, birth control pills were missed, rape occurred, the female condom or the IUD was out of place, or any similar possible situation where unwanted conception might occur.

How does EC work?

In 12 articles reviewed, all authors unanimously agreed, “We do not know for sure the mechanism by which EC reduces the expected pregnancy rate.”  Theories abound. Facts are scarce.  Here are three known facts: 

l.  If the EC is taken before ovulation, it has been shown to delay ovulation by 2 to 3 days in some cases.  That may give time for the sperm to die before the ovulation actually occurs.  This would be contraception.  (Most women, especially in these situations, do not know if they have ovulated or not.)  

2.  Progestins thicken the cervical mucus, greatly hindering sperm transport to the tubes. But sperm gets to the tubes within 5 minutes of intercourse, so EC taken at that time is already too late to prevent conception. 

3.  Endometrial change six days after the EC ingestion (that would be the time of implantation is debatable.  Some studies have shown a degree of what could be called an immature or confused secretory pattern, other studies have shown that the pattern is within normal limits.  Whether the “confused” pattern would lead to implantation difficulties is a matter of conjecture, and is not possible to prove with current technology.  In other words, whether this effect constitutes an abortifacient effect is not known.

Other theories on how the EC works include interference with sperm activity in the tube, or interference with the conception process, interference with corpus luteum progesterone production, somehow affecting development or implantation of the blastocyst.  But the bottom line is the same as the top line, “We do not know for sure the mechanism by which EC reduces the expected pregnancy rate.”

The ACOG, the official voice for women’s healthcare, insists that EC does not abort a pregnancy.  The reason they can be so dogmatic about this is that ACOG has defined pregnancy as “beginning with implantation.”  They are correct in saying that there is no evidence that EC disrupts an implanted pregnancy (which happens six days after conception).  ACOG argues that a fertilized egg in a test tube is not a pregnancy.  There are multiplied thousands of fertilized eggs in frozen storage.

From a sanctity of human life standpoint, the error in their argument is this:  The important point is not when “pregnancy” begins.  The crucial question is “when does human life begin?”  And no one seriously disputes that human life begins with the union of egg and sperm. They only dispute the value of that life. 

One’s conclusion on EC use will be governed by his/her view of the value of earliest life, the fertilized human egg.

A Suggested Position on EC 

Not knowing exactly how EC works, what should we recommend about its use?   Plan B results in 1 pregnancy rather than the expected 8 pregnancies. The seven preventions out of the eight expected pregnancies are accomplished by an unknown mechanism

Some (the women who have NOT ovulated before EC is given) are accomplished by delay of ovulation.  This would be contraception. 

The remainder are accomplished by an unknown post ovulatory action.  This might be pre-fertilization effect, OR it might be post fertilization effect (which involves the destruction of a developing embryonic human being, i.e., abortifacient action.)  There is no data to prove or disprove either mechanism. 

Thus we would conclude that there is a very high probability that EC works part of the time by abortifacient activity. 

On this basis we do not recommend the use of EC.

 

Other Considerations Related to EC Use 

As noted above, the daily dose of levonorgestrel (the progestin in Plan B) is 15 times the daily dose of a standard low dose combined birth control pill (Levlite). 

Would this very high dose adversely affect a developing embryo?  “ACOG Practice Patterns” of October, l996, notes 48 cases of women who continued their pregnancies after EC “failed.” Two infants had only minor abnormalities, but one was born with no left kidney.  Is this kidney defect related to EC, or is it just happenstance?  No one knows.  But if a doctor has given EC which “fails,” and the pregnant woman asks if her baby might be adversely affected, the doctor cannot give her reassurance that all will be well. 

The patient was only seeking prevention.  Now she may well feel pressured to seek abortion.  No pro-life doctor would want to put a patient in that position. And, realistically, she may seek a lawyer’s opinion.  No physician would want to put his patient or himself in that position.   [AAPLOG]

 

STATEMENT OF THE AMERICAN ASSOCIATION OF PRO-LIFE OBSTETRICIANS AND GYNECOLOGISTS (AAPLOG) on JAMA Emergency Contraception Study

Holland, MI – Research released on 5 January 2005 fails to support the contention of those who advocate over-the-counter (OTC) status for the emergency contraceptive Plan B. The rationale these advocates advanced for OTC status was that it would cut the unintended pregnancy rate and abortion rate in half.
   
A study of 2,117 young women ages 15 to 24, reported in the 5 January 2005 Journal of the American Medical Association (JAMA), demonstrated that providing young women with non-prescription access to emergency contraception (EC) did not lead to any decrease in the pregnancy rate.

Even women provided with an advance supply of EC did not have a decreased pregnancy rate, despite being almost twice as likely to use it

There was not even the slightest trend toward a decrease in pregnancy rates, let alone anything approaching a 50% decrease. (See TR Raine et al, Direct Access to Emergency Contraception Through Pharmacies and Effect on Unintended Pregnancy and STIs, JAMA, 2005; 293:54-62, at www.jama.com.)
    
The study demonstrates that ready availability of EC does not lead to a reduction in unintended pregnancies, despite erroneous claims to the contrary by some EC proponents.

These new data clearly add to the existing body of evidence that easy access to emergency contraception is not associated with a decrease in unintended pregnancy or abortion.

A study in Scotland with nearly 18,000 women given advance provision of EC demonstrated no decrease in abortion rate over a 28 month period. (See A Glaiser et al, Advanced Provision of Emergency Contraception Does Not Reduce Abortion Rates, Contraception 2004;69:361-366, at www.contraceptionjournal.org.)

The JAMA study demonstrates that those who claimed that easy access to EC would decrease unintended pregnancy were incorrect: easy access to EC has not decreased unintended pregnancy rates in real world settings, providing no rationale for making this hormonal preparation available OTC.

American College of Obstetricians and Gynecologists (ACOG) president Vivian Dickerson has stated that "FDA leaders bear significant responsibility for a public health failure to reduce these [unintended pregnancy and abortion] rates if they fail to consider sound scientific evidence." (ACOG press release Statement of Vivian M. Dickerson, MD, President, The American College of Obstetricians and Gynecologists on JAMA Emergency Contraception Study, January 5, 2005).

Given the accumulating sound scientific evidence that OTC access to EC doesn't impact unintended pregnancy or abortion rates, this accusation is simply reckless rhetoric and political grandstanding. Further, to continue to claim that OTC access will cut unintended pregnancy rates and abortions in half, when sound scientific evidence exists to the contrary, is to betray public trust.

Addendum: Within days after the FDA approved  Plan B  for over-the-counter (OTC) distribution, EC supporters have retracted their amazing claims of 50% decreased abortion rates. They now say tha

t the number will be minuscule…