The creeping Pearl: Why has the rate of contraceptive failure increased in clinical trials of combined hormonal contraceptive pills?

Contraception. 2013 Nov;88(5):604-10. doi: 10.1016/j.contraception.2013.04.001. Epub 2013 Apr 11.


Background: Despite several drawbacks, the Pearl Index continues to be the most widely used statistical measure of contraceptive failure. However, Pearl indices reported in studies of newer hormonal contraceptives appear to be increasing.

Study design: We searched PubMed and Medical Intelligence Solutions databases for prospective trials evaluating oral contraceptive (OC) efficacy to examine potential factors that could contribute to increasing Pearl indices.

Results: Numerous potential factors were identified, including an increased rate of failures of newer OCs, deficiencies in methods of calculating contraceptive failure rates, differences in study design and changes in patient populations resulting in increased rates of contraceptive failures due to the inappropriate or inconsistent use of the method.

Conclusions: The two most likely important contributors to the increase in Pearl indices are more frequent pregnancy testing with more sensitive tests and less adherent study populations. Because study populations appear to be increasingly representative of the likely actual users once the product is marketed, we can expect to see even higher failure rates in ongoing and future studies. This result poses challenges for companies and regulatory agencies.

Keywords: Contraceptive efficacy; Contraceptive study design; Hormonal contraceptives.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Adult
  • Algorithms
  • Biomedical Research
  • Clinical Trials as Topic*
  • Contraception Behavior
  • Contraceptives, Oral, Combined* / administration & dosage
  • Contraceptives, Oral, Combined* / pharmacokinetics
  • Contraceptives, Oral, Hormonal* / administration & dosage
  • Contraceptives, Oral, Hormonal* / pharmacokinetics
  • Embryo Loss / epidemiology
  • Female
  • Humans
  • Medication Adherence
  • Pregnancy
  • Pregnancy Tests
  • Pregnancy, Unplanned*
  • Research Design


  • Contraceptives, Oral, Combined
  • Contraceptives, Oral, Hormonal