Limitations of current contraceptives for women

Frontiers in Nonhormonal Male Contraception: The Next Step

Download PDF version of Frontiers in Nonhormonal Male Contraception (1 MB)

Why do we need new contraceptives?

Abortion rates are still high.
In the United States, about 2% of women get an abortion each year, and more than 20% of total pregnancies end in abortion (Elam-Evans et al., 2002 p. 1, 3; The Alan Guttmacher Institute, 2005). Furthermore, the United States has the highest adolescent birth rate in the industrialized world — about four times the European Union average, and more than 10 times the rate in Japan and Korea. In fact, one in five girls has a child by the time she turns 20 (UNICEF International Child Development Centre, 2001). Nearly one million teenage girls become pregnant in the U.S. each year, and 78% of these pregnancies are unintended (The National Campaign to Prevent Teen Pregnancy, 2001).

With the United States disgraced with a teenage pregnancy rate more than twice that of its neighbor to the north, clearly the state of contraceptive technology is not the only problem. Politics, pricing and culture have also limited access to contraceptives that already on the market. A 2004 report calls contraceptive availability in the United States an “unfinished revolution” (Reproductive Health Technologies Project, 2004). Still, even with universal health coverage and consistent support for contraception, other prosperous nations have not completely eliminated the need for abortion — a sign that the search must continue for reliable, foolproof, long-term contraceptives free from frustrating side effects. Western Europe, where 1% of reproductive-age women get abortions each year, probably represents the limit of what can be accomplished with current contraceptives (Henshaw, Singh, & Haas, 1999).

Current contraceptives don’t meet everyone’s needs.
The current contraceptive situation is far from ideal, and this remains true despite its recent improvement. For instance, in the United States, the selection of contraceptives has become more similar to that in Europe with the recent introduction of three new hormonal methods for women: the contraceptive patch, the contraceptive ring, and the Mirena IUS (intrauterine system), the last of which has been in use in Europe for more than a decade. These methods can combine lower peak doses of hormones, more physiologically natural delivery systems, and greater reliability than the traditional Pill. Many hope that these new methods will be appealing to women and that their efficacy will soon bring lower rates of unwanted pregnancies.

However, even at its best, this state of affairs leaves two major groups unserved by the “contraceptive supermarket”: (1) women who experience intolerable side effects from hormonal methods, and (2) men who are too young for vasectomy but want more reliable control over their fertility than condoms can provide. Unfortunately, these are both rather large groups. For example, even among women who don’t have contraindications to the Pill (such as smoking, breastfeeding, or varicose veins), nearly every woman who has used the Pill has experienced weight gain, breast tenderness, or reduced libido. (For details on how the Pill affects libido, click here.)

As for condoms, although they are 98% reliable with perfect use, the real-world yearly pregnancy rate can be as high as 15%, leaving many men wishing for a viable backup method (Hatcher et al., 2004).

There is an even greater need in the developing world.
For most women in the developing world, the contraceptive revolution is not unfinished. Rather, it has yet to arrive. (For statistics, click here.)

Lack of adequate contraception is literally a life and death matter: one woman in seven (or even six) dies in pregnancy or childbirth in Afghanistan, Angola, Malawi, Niger, and Sierra Leone (versus one in 29,800 in Sweden) (Save the Children, 2005). Not only can access to contraception and birth-spacing determine whether a woman will live past her twenties, but a mother’s level of education and her access to family planning services are the factors most strongly associated with the well-being of her children. (For details on the link between education and child mortality, click here.)

Existing contraceptive options fall short.
The existing contraceptive situation represents a massive global burden of morbidity, mortality, and lost opportunities, both in developing and prosperous nations. Politics, war, tradition, and economics all play a role in perpetuating this situation. Despite the overwhelming nature of such forces, a large part of the problem remains a simple lack of effective, affordable, appropriate contraceptive options. A cheap, effective, and user-friendly option could make a tremendous difference even in such an inhospitable global environment.

Before reviewing new methods for men, we will address the uses and limitations of men’s two current options, condoms and vasectomy. (For detailed information on the uses and limitations of current methods for women, click here.)

Uses and Limitations of Current Contraceptive Options for Men

Condoms
Condoms seem a logical choice as a low-cost contraceptive for governments to provide. Condoms are crucial in the fight against the spread of HIV/AIDS, and they can be 98% effective against pregnancy if used properly and consistently. However, they have five main drawbacks:

Many men dislike them because they reduce sensation.
Many women are uncomfortable insisting on condoms if their partners are reluctant to use them.
Condoms are vulnerable to heat damage during transport and storage.
Condoms must be used every time a couple has intercourse, but it is difficult for poor governments to provide an ample and consistent supply to their people (United Nations Population Fund, 2005a). Aid does not fill the gap: in 2003, donor support paid for the equivalent of one condom per year for each man of reproductive age in the developing world. Fewer than half of men surveyed in rural areas of Chad, Guinea, Mali, Mozambique, and Niger knew of a source for obtaining condoms (United Nations Population Fund, 2005b)
In typical rather than perfect use, the yearly pregnancy rate can be up to 15%. Condoms are a crucial part of the "contraceptive supermarket" and of disease prevention, but they alone cannot meet everybody's needs.

Vasectomy (Male sterilization)
Men who know they don’t want any more children can choose male sterilization. Vasectomy is a simple procedure, as only the tiny tube carrying sperm is cut. The testes and penis are not affected, so there is no change in libido, virility, or ejaculation.

For decades, vasectomy has been a safe and highly effective permanent contraceptive, but in recent years it has gotten even more effective and convenient. With the widely available “no-scalpel vasectomy” technique (NSV), vasectomy is a 10- to 15-minute outpatient procedure, and the NSV technique is getting better all the time (Jones, 2003). (For details on vasectomy techniques, including the Vasclip, click here.)

Vasectomy techniques

With this vasectomy technique, doctors access the vas deferens through a small hole poked in the scrotal skin (rather than cutting the skin), meaning no stitches are required. Furthermore, doctors are just beginning to realize that sealing one end of the tube the sperm flow through (“cautery”), rather than just tying it off, makes vasectomy even more reliable than before (Liu & Li, 1993). Men getting vasectomies should insist on cautery and NSV. (View a video of the entire vasectomy procedure.)

Much effort has gone into further improving and simplifying vasectomy. The U.S. FDA recently approved the Vasclip®, a barrette-shaped clip the size of a grain of rice that is snapped onto the vas deferens rather than cutting the tube (VMBC LLC, 2005). It saves some time for the doctor, could theoretically result in less pain and tissue trauma, and might turn out to improve reversibility success rates.

However, the clip has never had to demonstrate long-term contraceptive reliability. As the manufacturer’s website states, “The effectiveness of using the Vasclip for permanent male sterilization has not been evaluated in comparison to standard vasectomy procedures” (VMBC LLC, 2005). The Vasclip was approved under the FDA’s 510(k) program, meaning it had to demonstrate “substantial equivalence” to an existing product — in this case a clip used to ligate blood vessels. This tells us that the Vasclip is safe to have in the body — not that it is an effective contraceptive. No peer-reviewed scientific study has tested its effectiveness.

The manufacturer’s study reports 97.5% infertility at 10 to 14 months and says this is comparable to vasectomy. However, a 2.5% vasectomy failure rate would be only for the least experienced or most poorly trained doctors. An experienced vasectomy doctor usually has one failure per hundreds or even thousands of procedures; yet even some very experienced vasectomy specialists have had high contraceptive failure rates with the Vasclip, possibly due to variations in the thickness of the vas deferens from man to man (Stein, 2004). An informal survey of six experienced vasectomy providers trying the Vasclip finds a range of reliability, from no failures after several dozen procedures to two failures out of four procedures (Lissner, 2005a). Three of the six doctors have stopped using the Vasclip because of failures. The cost of the Vasclip is an additional deterrent, as using the $300 - $500 clip set can double the cost of a vasectomy.

For comprehensive information on vasectomy and vasectomy techniques, see the following sources and references: Labrecque et al., 2004, full text available free online; Schwingl & Guess, 2000; Engender Health, 2004; Planned Parenthood, 2005, and Vasectomy-Information.com.

Vasectomy is easy, inexpensive, and popular: one in six American men over 35 has had one. About 500,000 additional American men get vasectomies each year (National Institutes of Health, 1996). But for men who haven’t finished having children—those men in the 10-20 years between puberty in their early teens and childbearing in their twenties or thirties—vasectomy is not appropriate.

Reversal is not something to count on. In some cases vasectomy can be reversed, but resulting pregnancy rates are as low as 30%, especially when men have had their vasectomy for many years (Schroeder-Printzen, Diemer, & Weidner, 2003). Since vasovasostomy (vasectomy reversal) is a delicate microsurgical procedure, success rates also depend greatly on the skill of the surgeon, and not all men have access to the best of the best (Schwingl & Guess, 2000 p. 927).

For men in developing countries, it can be difficult to receive priority for “elective” microsurgery in health systems overwhelmed by AIDS. The bottom line remains the same: except for a fortunate few, sterilization is permanent and is appropriate only for those who are finished having children.

Next section: Why new male contraceptives in particular? Would men use one?