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Without ongoing education, our knowledge about birth control is frozen in time. In The State of Your Birth Control, Lifehacker follows the history of contraception in the U.S. and explains what everyone needs to know about their options, recent medical advancements, and legal access. Follow the complete series here.

People have sex without adequate protection for all kinds of reasons—your protection failed, you did not have any protection on you, you thought another form of protection would cover you, your partner lied about protection, you did not think you could get pregnant because you are breastfeeding or not having a period, you did not consent to the sex, or you changed your mind on wanting to get pregnant after the sex. However it happened, the result is the same. Penetrative sex, and in rare cases non-penetrative sex between someone who produces sperm and someone with a uterus means there is a chance of a pregnancy, and so now you’re in the market for some emergency contraception.

What is emergency contraception?

Simply, emergency contraception, or EC, is any procedure or medication that prevents pregnancy from taking place after sex. It does not reverse a pregnancy, and it is not an abortion pill. Emergency contraception does not affect your future fertility, or your ability to get pregnant in the future.

How can you prevent pregnancy after having sex? Well, imagine a stopwatch that starts the moment the sperm in question enters the world in any way where it might make contact with your vagina. Sperm are determined MFers who have been known to live for, not kidding, five days inside your cervix and uterus. But until they meet an egg, and that egg implants in your uterus, you are not pregnant. Think back to that stopwatch—you have until it hits 120 hours to take a form of emergency contraception. (If you want a quick rundown of your options based on how long it’s been since you had unprotected sex, use this tool from Planned Parenthood.)

There’s a catch, though: depending on the method, your body, prescriptions you’re on, and where you are in a menstrual cycle, emergency contraception may not always work. So it’s important to know that the sooner you take emergency contraception during those five days, the more likely you are to be able to prevent a pregnancy.

What are my options for emergency contraception?

There are three kinds of emergency contraception. First, you may have heard of pills you can take in the five days after any sperm-related incidents. The brand names probably you know them by are Plan B and Ella—Plan B is levonorgestrel, and Ella (which styles itself “ella,” in lowercase) is ulipristal. There are other brands of levonorgestrel like Take Action, My Way, Option 2, Preventeza, AfterPill, My Choice, Aftera, and EContra. These drugs work by stopping your ovaries from releasing an egg, and without an egg, those sperm are just on a long, pointless journey to nowhere. Levonorgestrel pills reduce pregnancy risk by 81-90%, and ulipristal reduces it by 97%. That sounds great, but there are some strong caveats we’ll discuss below.

A second kind of emergency contraception is to get an IUD implanted in that five-day window, specifically the copper IUD Paragard, or the hormonal IUDs Mirena or Liletta. The efficacy rate of this method is exceptional, up to 99%, at any time in your ovulation cycle. IUDs are a safe and fantastically reliable method of birth control that lasts for years, and can be removed at any time if you decide you want to get pregnant.

But let’s be honest, an IUD insertion is still a procedure that can be expensive and that you have to get done right away (Planned Parenthood will work to prioritize getting you in when it’s for emergency contraception), and the procedure has been known to be painful for some folks. Additionally, copper IUDs can sometimes make periods more painful or heavier. For this reason, the recent addition of Mirena and Liletta as an option is welcome, as these hormonal IUDs often have the side effect of less bleeding and period symptoms.

The last way is not usually recommended, but we’ll mention it for completeness: There is a protocol to use standard birth control pills as emergency contraception, which is called the Yuzpe method. It uses combination pills (which use both progesterone and estrogen, and are the more common type of birith control pills), of which there are hundreds of brands and types, and each one is used a little differently for emergency contraception. The Yuzpe method has a lower efficacy rate than Plan B, Ella, and the IUD—around 75%—and there can be a lot of side effects, like vomiting. So while it’s technically one of your options, it’s nowhere near as good as the others.

EC pills may not work for everyone

Plan B and Ella are the most promoted forms of emergency contraception– they’re non-invasive and inexpensive, but there are a number of instances where they’re not the best option.

First, if you’ve started ovulating, neither Plan B or Ella may work. Ella can work a little closer to ovulation, which is why it’s often a better choice. It’s often hard to know when you’re ovulating, so using a calculator can help you estimate (it’s typically two weeks after the start of your last period). Because of this timing issue, taking the pills as soon as possible is key.

Medications can also interact with oral ECs. If you’re on certain antibiotics like Rifampin, some HIV meds, anti-seizure meds, St. John’s wort, or an antifungal called griseofulvin, Plan B and Ella might not work as well. In those instances, you might consider an IUD even though it’s more of a hassle to get one placed in time.

And then there is one other, major issue that impacts effectiveness for many people: weight and BMI.

Your weight may affect how well EC pills work

For Plan B and other levonorgestrel pills, the recommended weight threshold by Planned Parenthood and some other organizations is 165lbs. For Ella, it’s 194lbs, or 30 BMI. (Both are FDA-approved for use in people of any weight, so these are not hard limits.) The efficacy of these pills may drop when you’re above that weight threshold.

It’s unclear how much the efficacy drops, but at least one study suggests it may be as much as 50% less effective. (And before you ask: Taking a double dose is not recommended.) In yet another failing of the industrial health complex towards sexual health, people with uteruses, and fat people, the best advisory for people over the weight threshold is to forget the pills and get an IUD.

We spoke to Kelly Cleland, executive director of the American Society for Emergency Contraception, for advice. “The best advice we can give right now if you weigh more than 194 lbs is to take ella or have a copper IUD inserted,” she says. While advocating for more research in this underfunded area, Cleland noted: “If we look at a map of abortion restrictions across this country, and a map of the proportion of people with BMI over 30, there’s a lot of correlation. More effective emergency contraception options are even more critical in those settings.”

To be absolutely clear: The pills are potentially less effective for a heavier person than a lighter one, but they can still be effective preventing a pregnancy, and are much more effective than doing nothing. If this is the only option available to you, it’s worth taking.

What to consider while choosing a method of emergency contraception

You have three good options in front of you: an IUD that almost certainly will prevent pregnancy, and two kinds of pills that may prevent pregnancy. On numbers alone, IUDs are more effective, so in theory they’d be the slam-dunk option. That said, a pill is a much more convenient, low-stakes, less expensive option, and an IUD is a long-term commitment, so it’s not an easy equation.

According to Cleland, if you’re choosing a pill, “ella is more effective for anyone because it works closer to the time of ovulation than Plan B, so if you can get it, we recommend ella as the first-line option among emergency contraceptive pills.” She noted that while Plan B is available on pharmacy shelves without a prescription, ella is sometimes harder to obtain—but that all things being equal, ella has a higher efficacy rate, higher weight range, and works closer to ovulation.

It’s also important to think about what you would do if the EC fails. That may mean you need to factor in the local restrictions around abortion when deciding how much risk you’re willing to take, particularly if you, like the average person in America, happen to be over 30 BMI or 194lbs. Cleland put it starkly: “So much depends on the context that you’re in and the stakes of preventing pregnancy for each individual. If you live in Texas and preventing pregnancy is an urgent priority, an IUD is the most effective option so it may be your best choice.”

How much does emergency contraception cost and where do you get it?

The Affordable Care Act requires insurance plans under the ACA pay for emergency contraception, even if you haven’t met your deductible. Your Plan B and Ella are covered if you obtained insurance from the Healthcare.gov exchange or Medicaid, and they are still likely to be covered under most insurance plans otherwise. To find out, call the number on the back of your insurance card. If you don’t have insurance, many states, counties, and even cities have funding programs that can help, and calling your local women’s health clinic, like Planned Parenthood, will help you find out those options.

If all other options fail, levonorgestrel (Plan B) pills range from $25-$55 and can be bought over the counter in almost any pharmacy. You may need to ask the pharmacist for it, and it might be locked up, but you do not need a prescription or to offer your ID. If a pharmacist gives you a problem trying to obtain it, because some laws allow them to utilize a religious objection, they generally have to give you information regarding where you can get it, or ask another pharmacist to step in. No matter how mortified you are (and you shouldn’t be!) this is a good time to call in the calvary, like a mouthy friend, and get a manager involved because embarrassment shouldn’t result in an unwanted pregnancy.

To obtain Ella, on the other hand, you’ll need a prescription and around $50. But there are ways to get a prescription quickly. First, see if the Planned Parenthood app is available in your state and consider other online options like Nurx or PRJKT RUBY. Your physician or ob/gyn can prescribe it, and a local Planned Parenthood office can, too—often without a visit. In some states, the pharmacist can prescribe it. It is covered by Medicare and ACA insurance plans and is likely covered by your private insurance, as well.

Your insurance will likely also cover your IUD, which is great news, because they’re expensive, often running $1,000 or more. Like the pills, your clinic will have information on discount programs and health initiatives that can bring the cost down to zero, so don’t let cost be a factor to calling. Remember, an unplanned pregnancy is so much more expensive, and clinic staff are trained to help you figure this out.

Don’t forget the follow-up pregnancy test

If you took Plan B, Ella, or any other EC pill, the thing so often not mentioned is the importance of follow-up pregnancy testing. These pills are not a bulletproof vest. Take a pregnancy test two to three weeks after the emergency contraception. In fact, when you take the emergency contraception, set a reminder on your calendar or phone to take the test. Buy the test while you’re at the drugstore getting your Plan B or Ella.

Please do not take this advice lightly, because if you do still get pregnant, you have options, but in half of U.S. states, those options are very limited and on a very tight timetable. I became pregnant after taking Ella. Take the test.

How to prepare for your future sexual health

Fun fact: You do not have to be pregnant to have Ella or Plan B on hand. You can buy it well ahead of time, and insurance should still cover it. The shelf life on them is pretty fantastic: four years for Plan B, and three years for Ella. Because you want to take them as soon as possible after sex, having them in the house is a pro move.

Cleland gave a more urgent warning: “ella has been on the market in the U.S. since 2010, but it is vastly underutilized. Many healthcare providers don’t know about ella, and only 10-12% of pharmacies keep it in stock ready to prescribe that day.” Pharmacies will order it for you, but time is precious. Ordering it ahead of time means it’s in your bathroom cabinet when you need it.

You can order Ella right now by going to any of these online pharmacies:

You can order Plan B or follow-up pregnancy tests on Amazon.



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