I Got Pregnant After Taking The Morning After Pill

Photographed by Ashley Armitage
The first time I took the emergency contraception pill (or morning after pill, as it’s more commonly known in the UK) I was 16 years old and in school uniform. Since then, I have taken it five or six times, mostly at my own expense and always as a precaution in emergencies rather than as a contraceptive method in and of itself, which is exactly how the NHS says we are supposed to use it. 
My relationship with contraception is complex. I’ve struggled with the mental health side effects of the contraceptive pill and my body rejected the coil first time around. The result for me has been that the morning after pill has played a more significant role in my life than for many of my friends. It was my safety net — until one day, after a condom failed, it didn’t catch me. 
To say that I was surprised to learn I was pregnant after taking it last year would be an understatement. Statistically, I was in the two in every 100 women who get pregnant after using a condom, and then the one in 20 women who get pregnant after taking the morning after pill (Levonelle) within 24 hours of having unprotected sex. In any other context, I would have felt exceptional.
In the UK, since 2001 the morning after pill has been available without prescription in pharmacies. There are two main types: levonorgestrel (known by its brand name Levonelle in the UK and Plan B in the US), which was the first to be invented, and ulipristal acetate (known as ellaOne in the UK), which was more recently introduced. 

I was in the two in 100 women who get pregnant after using a condom, and then the one in 20 women who get pregnant after taking the morning after pill.

The main difference between the two is that ellaOne can be taken up to five days after unprotected sex, whereas Levonelle’s window is shorter (three days). According to the NHS guidelines on emergency contraception, this is because they work by delaying ovulation, which "is triggered by rising levels of a hormone called luteinising hormone (LH). Levonelle appears not to be effective after levels of LH start to rise. EllaOne continues to be effective a little later in the cycle."
In both cases, though, the pill is much more likely to work if taken in the first 24 hours after unprotected sex, and becomes less effective as time passes. You probably already know this, as it’s drilled into us all from a very young age. Taken according to these guidelines, manufacturers say that morning after pills are 95% effective.
Yet when I told friends and colleagues about my experience, I was surprised by how many people told me that the morning after pill hadn’t worked for them or someone they know. 
Hannah* is a 35-year-old psychology postgraduate student. She got pregnant after taking a morning after pill, which she bought in a pharmacy. "I was astounded as despite knowing the statistics, no one explained the contexts in which the morning after pill could fail to work," she explains. "I didn’t find out the mechanism through which it works until researching after the fact, and had I known it was tied to ovulation, I probably wouldn’t have bought it, because the timing wasn’t right." 

The morning after pill is much more likely to work if taken in the first 24 hours after unprotected sex, and becomes less effective as time passes.

The problem here is that there are no official statistics for exactly how many women this has happened to. Part of the reason is that it’s almost impossible to determine if they are skewed by women who have taken a morning after pill but would not have got pregnant otherwise. Samuelle Yohou, associate medical manager at HRA Pharma, says that "not everyone who has unprotected sex will fall pregnant but statistically 55 in 1,000 will". According to Samuelle, taking ellaOne reduces this number to nine in 1,000.
But this statistic is cast into doubt by the Faculty of Sexual and Reproductive Health (FSRH) guidelines. They say: "If 1% of all women receiving a particular method of emergency contraception (EC) within 72 hours of unprotected sexual intercourse (UPSI) at any time in the cycle become pregnant, the overall pregnancy rate is quoted as 1%. However, for a significant proportion of the women included in the study, UPSI would not have occurred during the fertile period and they would not have become pregnant in any case." 
Roughly translated, this means that if a woman has already begun to ovulate when she has unprotected sex, no morning after pill will work because an egg has already been released. Dr Jane Dickson, vice president of the FSRH explains why this is: "The main mechanism of action of oral emergency contraception is to postpone ovulation so that sperm in the genital tract will be dead when ovulation occurs [...] but it is thought to have no action once ovulation has already occurred."
This information is included in the leaflet that comes with ellaOne, which states: "Emergency contraception can delay ovulation within a given menstrual cycle, but it will not stop you from becoming pregnant if you have unprotected sex again." Confusingly, it also says that "you can take the tablet at any time in your cycle" but at no point does it state that the stage of your cycle you’re in could have an impact on efficacy. 
That said, the leaflet does state: "Emergency contraception is not effective in every case. Of 100 women who take this medicine approximately 2 will become pregnant." But if you didn’t read the small print or know how it works, it’s easy to see how you might be caught out by not knowing that your proximity to ovulation will affect things. 
In my case, it’s a fact of which I was completely unaware until after I got pregnant. Assuming I was just ignorant, I asked friends and colleagues if they knew about it, and the answer was a resounding "no". 
According to Dr Dickson, "guidelines on emergency contraception recommend that, when making a choice between emergency contraception methods, individual women need to know that the risk of pregnancy depends on the timing of intercourse relative to ovulation." 
She adds that "the only method that will work reliably is an emergency copper intrauterine device (IUD)," and that because of this, "women should be made aware by the provider of oral emergency contraception that a copper IUD is the most effective option." 
As it turns out, a copper IUD is not only more effective at preventing an unplanned pregnancy (99.9%), but the window for taking it is longer. "It can be inserted up to five days after the first unprotected intercourse in a natural menstrual cycle, or up to five days after the earliest likely date of ovulation (whichever is later)."
When I took the morning after pill in the pharmacy's consultation room last year, I wasn’t asked where I was in my cycle (which I know with relative accuracy thanks to my tracking app, Clue) and no one told me that perhaps a copper IUD would be more effective. That’s not to say it would have changed my decision, but it is definitely not information that was volunteered at the time by the person selling me the pill. 
Hannah had the same experience. "At no point was I made aware of any alternatives with greater effectiveness," she tells me. Of course, pharmacies themselves are unable to fit an IUD, but shouldn’t women be at least made aware of other, more effective options? 

There is no reason why these pills can't be offered over the counter in the same way – and at a similar cost – as drugs like paracetamol and ibuprofen.

Clare Murphy, British Pregnancy Advisory Service
"It left me wondering why I was kept in the dark. Was it so the pharmaceutical industry could keep making millions out of the product by not deterring women who aren’t eligible from taking it?" Hannah adds.  
Clare Murphy, director of external affairs for the British Pregnancy Advisory Service (BPAS), notes that the morning after pill "costs pennies to produce" but is sold "at a high mark-up". Just Say Non!, a campaign run by BPAS calling on major retailers to reduce the cost of emergency contraception pills, succeeded in bringing down the price for consumers to around £15.99 (from £25.99 previously). However, it also highlighted that the profit margins for retailers are still much higher than they need to be. For many people, £15.99 is still no small sum. 
Of course, while a method of long-acting reversible contraception (LARC) like the IUD may be cheaper for the NHS in the long run, there’s no getting away from the fact that it isn’t comfortable or viable for some women. 
Clare passionately advocates for morning after pills to be more readily available. She says: "There is no reason why these pills can’t be offered over the counter in the same way – and at a similar cost – as drugs like paracetamol and ibuprofen."  
"Morning after pills are safe and effective, if not as effective as regular methods, and women should make use of them as and when they need to," she says. What remains evident is that women taking the morning after pill need more clarity on when and how it is most effective.
According to quality standards published by the National Institute for Health and Care Excellence (NICE): "Women asking for emergency contraception are told that an IUD is more effective than an oral method." This is at odds with both mine and Hannah’s experiences, and suggests that these guidelines may not always be enforced. When pressed, a representative from NICE confirmed that the body has not looked into emergency contraception as part of its technology appraisal process, which perhaps explains the discrepancy. 
All of this made me wonder whether there are other factors that can interfere with the efficacy of morning after pills. Julia Hogan, the nurse lead for contraception and sexual health at Marie Stopes, tells me that a woman's body mass index (BMI) and interactions with other prescribed medications can also have an impact.
"If a woman has a BMI of over 26, or weighs over 70kg, it is advised to give a double dose for Levonelle," she tells me. For ellaOne, this increases to a BMI of 30 or more and 80kg. As a woman who has a BMI of over 30, this is information that – again – takes me by surprise. When I was sold the morning after pill, nobody took my weight or mentioned that it could potentially be a problem. Ditto any medications I might have been taking. "Asthmatics taking steroids, for example, cannot use ellaOne."
Many women who take the morning after pill are, as I was, likely to be stressed out after finding themselves in the position of dealing with a potential pregnancy. And we can’t forget that some will be victims of rape or sexual abuse, who are already experiencing huge amounts of emotional distress. Can we really expect them to be across all of the attendant issues with emergency contraception while they may be going through a difficult time? Should we expect that of them?
There is no doubt that the invention of emergency contraception changed the game for women’s rights and gave us more ownership and control over our bodies and what happens to them. This does not mean, however, that we should be expected to assume responsibility for the entire reproductive process. 
Government statistics reveal that in 2018, 45% of pregnancies in the UK were classified as "unplanned". Of course, many of these pregnancies are happy ones, but it is surprising that so many women are getting pregnant "by accident", given the contraceptive methods to which British people have access.
As with any conversation worth having, it is clear that this is incredibly complex. It is also clear that as a woman, being aware of what stage of your cycle you’re at when you’re having sex is important, even if – or especially if – pregnancy is not something you're seeking out. At the end of the day though, women can’t make informed choices about contraception – emergency or otherwise – if they aren’t given all the information. 
* Some names have been changed to protect identities.
If you have any concerns or queries about your contraception or emergency contraception, please contact your GP right away.

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