Emergency contraception

michael.asciak@parlament.mt

The issue on the “morning after” pill is one such issue. One sometimes finds many assertions made even by doctors, who do not state all the medical facts. For example, the issue when pregnancy starts is often defined in textbooks of the Anglo-Saxon language as starting at nidation, that is when the embryo embeds into the uterine wall. Now every doctor worth his salt knows that human life starts when there is fertilization. Nidation can occur a week to 10 days after fertilization. Of course the best thing is to be careful and not get pregnant in the first place! As I teach my students, it is best to practise the ABC, in that order, of safe sex. A for Abstinence, B for Be careful who you sleep with and after these comes C, for the use of Contraceptives both to avoid sexually transmitted disease and to avoid an unwanted pregnancy.

It is possible to slip up emotionally and sleep with the wrong guy at the wrong time, make a mistaken calculation in your contraceptive use or to just be plain drunk, or throw caution to the wind and have sex with someone you do not really want to have children with! In the modern world the answer to this is emergency contraception within the next three to five days. There are numerous possibilities for this. Insert an IUD device which causes the uterus lining to abort any fertilized embryo, or take one of two tablets in single form. The first is Ulipristal which also causes the uterine lining to abort or prevent nidation of any embryo there may be. The second pill is made of a progesterone hormone in a high dose called Levonorgestrel (1.5 mg) with or without oestrogen. This normally works by preventing ovulation if it has not yet taken place and possibly fertilization if this has not yet taken place. If ovulation has however occurred, there is much academic contention about the possibility of this causing the prevention of nidation in the uterus and therefore aborting the embryo.

Today, neither pill is available over the counter without a prescription, and that is the way things should remain as the physiology and pharmacology of use and complications of a medical and moral kind are complex and legion, and so are the side-effects. A doctor is also not allowed to write a prescription for these pills especially if they are going to be used as an abortifacient as this would be illegal. However there are certain times when a doctor could feel that if ovulation has not yet taken place, and this can be ascertained by a two-minute over-the-counter test, circumstances may warrant the use of Levonorgestrel to prevent ovulation and/or fertilization. One such case is rape! Although high dose Levonorgestrel is not available for sale in Malta, a low dose variety (200 micrograms) is available as an oral contraceptive pill and also as a uterus-implanted five-year contraceptive device. Doctors often combine the oral intake of these low dose pills to form the equivalent of the high dose Levonorgestrel in order to prevent ovulation and therefore pregnancy. Since this frequently happens, and it is no great secret either, I think it is time to call a spade a spade and allow the high dose Levonorgestrel to be available for doctors’ prescription as well, on condition that in its indication, it is not used post-ovulation. There is no possibility of policing this, as is the actual case now, and therefore doctors should be given the choice to use it responsibly. If there is evidence of irresponsible use, then one should be held legally accountable. After all, one has to be able to use one’s conscience and, in the final analysis, it is between oneself and God. Ulipristal use and prescription should however remain illegal.

One should keep in mind that in the final distillate here, there is the issue of when human life begins. This is established by anatomy and embryology to be at fertilization of the egg by the sperm. Once human life exists, then we ought to respect it. Using the measure of the golden rule, one should do to others as one wishes to be done by. The rest is futile language.