title: The creeping Pearl: Why has the rate of contraceptive failure increased in clinical trials of combined hormonal contraceptive pills?
abstract: 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.
  
  
  METHODS
  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.
authors.affiliation: Office of Population Research, Princeton University, Princeton, NJ 08544; The Hull York Medical School, Hull, England HU6 7RX.
authors.forename: James
authors.initials: J
authors.lastname: Trussell
authors.forename: David
authors.initials: D
authors.lastname: Portman
mesh_terms: D000328:Adult; D000465:Algorithms; D035843:Biomedical Research; D002986:Clinical Trials as Topic; D003268:Contraception Behavior; D003277:Contraceptives, Oral, Combined / Q000008:administration & dosage / Q000493:pharmacokinetics; D003278:Contraceptives, Oral, Hormonal / Q000008:administration & dosage / Q000493:pharmacokinetics; D020964:Embryo Loss / Q000453:epidemiology; D005260:Female; D006801:Humans; D055118:Medication Adherence; D011247:Pregnancy; D011258:Pregnancy Tests; D049168:Pregnancy, Unplanned; D012107:Research Design
chemical_list: D003277:Contraceptives, Oral, Combined; D003278:Contraceptives, Oral, Hormonal
keywords: Contraceptive efficacy; Contraceptive study design; Hormonal contraceptives