My teenage nephew came to visit last summer, and I asked him if there was anything he needed from the drug store. “Uh, condoms?” he said. It was easier to ask liberal Aunt Val than Grandma, who is raising him. We hopped in the car. At the local Walgreens, we found the display and we lingered, picking packages up and putting them back. “Wow, there’s a lot of choices,” he enthused, exchanging a rainbow of colors for a fruit-flavored variety pack. I bit my tongue to keep from pointing out that we were seeing a lot of packaging but only a single type of latex device, vulnerable to misuse and rupture. I was determined to focus on the positive, making our shopping excursion as normal and playful as possible—to make condom buying (and wearing) an absolutely ordinary thing to do. For 20 years, ever since the HIV epidemic swelled to global proportions, aunts, parents, schools, public health agencies, and governments around the planet have been trying to do the same thing: indelibly pair condoms and sex. Condoms are the best thing we have going for prevention of sexually transmitted diseases.
Unfortunately, all the focus on HIV and condoms has drawn attention away from another reality: from a contraceptive standpoint condoms are mediocre at best. While the top tier of female birth control methods (IUDs and implants) have an annual pregnancy risk as low as 1 in 1,000, the annual risk for a couple using condoms is closer to 1 in 5. Multiply that by almost 40 years of female fertility! Reliance on condoms is one of the reasons that 1 in 3 American women has had an abortion by the time she hits menopause.
Photo credit courosa, cc.
As my nephew and I stood in line at the cash register, I thought about how proud I was that even with a challenging home situation and only a grandmother to guide him, he was taking responsibility for himself. Then I thought, “I wish he had better options—like something we could count on!” Thanks to some determined researchers and funders, my wish may come true in time to give my nephew real choices as he moves into adulthood. In contrast to the frustrating options at the pharmacy, an array of promising possibilities can be found in various stages of research around the globe. Here are some of the top contenders.
Clean Sheets Pill
(London, Oxford) Dr. Nnaemeka Amobi and his team are researching a hormone-free method that has been dubbed the “clean sheets pill” because it decreases or eliminates semen emission while leaving intact the sensation of ejaculation and the pleasure of male orgasm. The pill works by relaxing just the muscles in the vas deferens that normally propel sperm-containing semen forward and out. Without the forward propulsion, circular muscle contractions essentially close down the passage. Reducing or eliminating emission of semen not only prevents pregnancy, it also decreases the spread of semen-born diseases, including HIV. The hope is that this medication can be delivered via pills that men take before sex—much like Viagra.
RISUG
(Kharagpur) More than 250 men have undergone a procedure named RISUG, which stands for reversible inhibition of sperm under guidance, that researchers hope will provide a cheaper and more reversible alternative to vasectomy. A liquid polymer is injected into the vas deferens, where it provides contraception for up to ten years. In the duct, the positively charged polymer reportedly acts almost like a magnet, reacting with the negative electrical charge on the membranes of passing sperm and rendering them infertile. In research with rats and primates, fertility has been restored by a noninvasive procedure that removes the polymer. Human clinical trials of RISUG are moving forward slowly in India.
Vasalgel
(San Francisco) Inspired by RISUG, a similar polymer, dubbed Vasalgel, is under development in the United States, with rabbit research now underway to meet FDA standards and primate studies planned. Over 18,000 men and women have signed up to receive information about clinical trials, expected to begin in 2014.
Vasalgel. Photo credit Parsemus Foundation, used with permission.
Ultrasound
(Chapel Hill) Therapeutic ultrasound is a common sports medicine treatment for injured joints and muscles. A brief massage of the testes with the same instruments has been shown to reduce sperm count in both animals and humans. Doctors have long known that heating the testes even to body temperature reduces fertility, and we know that therapeutic ultrasound produces a deep warmth. But for reasons that are unclear, the contraceptive effect of ultrasound is ten times that of heat alone. Depending on the level of exposure, contraceptive duration ranges from six weeks to permanent. One major challenge at this point is to find a treatment regimen that is either reliably reversible or reliably permanent. Of the two, use as a nonsurgical vasectomy option is more likely.
Gamendazole
(Kansas City) Potential contraceptives are sometimes discovered as side effects of other medications, and gamendazole derives from a cancer treatment that by chance was noted to decrease male fertility. Research shows that the drug works by interrupting sperm maturation. Men taking gamendazole produce and release normal quantities of sperm, but the sperm are “nonfunctional.” In mating studies of rats, the drug achieved 100 percent infertility and was fully reversible. Research with monkeys looks promising.
Adjudin
(New York) Like gamendazole, adjudin is an analogue of a cancer drug, lonidamine. It works the same way, causing sperm to be released when they are immature. For lonidamine, the gap between a contraceptive dose and a toxic dose is small, making the drug too dangerous to give to healthy people. But researchers at the Population Council were able to create a related compound that is taken up only by the precise receptors in the testes where it is needed for contraception. This dramatically reduces the needed dose. Two remaining drawbacks to adjudin are that it can be administered only by injection, and its effect is short-lived. Researchers are working to devise a version that doesn’t require frequent injections.
JQ1
(Waco, Boston) JQ1 is related to some familiar drugs, Valium and Xanax, but it has a very different effect. Instead of bringing on sleep or reducing anxiety, it blocks production of a protein in the testes that is essential to sperm growth. In mice that are given JQ1, the number of sperm takes a nose dive, and those that are produced don’t swim very well, which makes the mice infertile. Sex drive remains unaltered, and after the drug is stopped, sperm production rapidly returns to normal.
Testosterone and Progestin
Photo credit Peilin Tan, cc.
(Beijing, Los Angeles, Seattle) If injected or absorbed through the skin, testosterone alters hormonal messaging and reduces production of sperm. When combined with a progestogen and rubbed on in gel form, a daily application has effectively suppressed sperm concentration in almost 90 percent of men, with few side effects. Current research, which builds in part on work done at the University of Washington and UCLA, is exploring the best combination of testosterone and progestin, and how such a combination can be delivered to provide long-acting birth control.
With such a variety of options (and more) in the works, it seems like something new for men should be just around the corner. But much of the research is progressing at a snail’s pace due in part to regulatory barriers and lack of funding. Contraceptives get used by young healthy people, which means that the bar for safety and efficacy is much higher than for many other drugs. A cancer treatment might be welcomed if it has a 70 percent success rate and makes your hair fall out. Needless to say, either of these is a non-starter for a new contraceptive. The high bar (and the corresponding high risk of liability) makes drug companies and even philanthropists wary of investing in contraception—which has to be almost 100 percent effective and side effect free to be a success.
Will any of these options make it to market in the next five years? That depends in part on whether drug companies, nonprofit research funders, and public health experts think we’re ready. Do men really want to take responsibility for contraception? Will women trust them to do so? Those questions are the focus of Part III in this series.
Thanks to S. Minden for her expert editing eye on this series.
Sleeping Realities
Where do you get your low numbers for condom effectiveness? I’ve always heard that condoms have a 99%+ effectiveness rate, better than all other methods of birth control when used correctly. Sure, if you forget to put it on, that’s a “failure,” or if you put it on backwards or poke a hole in it. But it doesn’t take too much effort to learn how to do it well. All it takes is people not being embarrassed to talk about it.
I’m suspicious of anything that says “Side-effect free.” Women have been putting up with side-effects from “Safe” birth control methods for decades. Of course, it’s better than being pregnant, but still, losing your quality of life isn’t cool either.
With reproduction being only second to survival in our list of powerful biological urges, it’s no wonder birth control is so hard to do. I’m hopeful we’ll find better solutions as well!
Charity
Condoms are 99% effective if used correctly, because they can still rip or leak or something. So if my partner and I have sex once every 3 days, that means we have sex about 122 times a year. If condoms are only effective 99 times out of 100 (at best), that means that my partner essentially has a 1 in 1 chance of getting pregnant every year, depending on when she ovulates.
And that 99% figure is the optimal effectiveness. In reality, they’re never that effective.
At any rate – I’m glad to see all of these alternatives emerging; it just makes me sad that pretty much none of it is currently available =(
Scout
Actually, birth control failure rates are always calculated per year of typical use. So if the failure rate for condoms is 12% (which is what I was taught), it means that 12% of people who rely on condoms will get pregnant within a year. <a href="http://goaskalice.columbia.edu/explanation-condom-failure-rates"See here for more.
Valerie Tarico
Thanks. You are absolutely right about how the failure rates are calculated for typical use. (How many couples relying on the method for one year get pregnant?). The reference that is considered most definitive is the medical school textbook, Contraceptive Technology, which is now in its 20th Edition, so the stats keep getting updated as new research comes in. Here is the link: http://www.contraceptivetechnology.org/CTFailureTable.pdf . The most current estimate for the condom failure rate is 18 percent.
Tiana
Unfortunately that is incorrect.. I read up about all the statistics and condoms are not for preventing pregnancy.. They are for preventing std’s. Birth Control is for preventing pregnancy.. Honestly condoms break quite often..
Valerie Tarico
The low numbers for condom effectiveness come from the medical text, Contraceptive Technologies, now in it’s 20th Edition and considered the most definitive source available. The number you mention 99% is probably an estimate of perfect use, though even then it is higher than the best data available would suggest. Perfect use is like asking, How fast can cars stop if you have a robot pushing the pedal at the precisely optimal moment and in the precisely optimal way? What would be the pregnancy rate if you had robots putting on the condoms at precisely the right moment in precisely the right way every time a couple had sex? This question ignores what engineers call “human factors.” Condom use is highly sensitive to a variety of human factors, and as a consequence the typical use failure rate is 18 percent, meaning eighteen percent of couples using this method for a year will experience an unintended pregnancy. The reason long acting methods like IUD’s and implants are so much more effective is that they take human error out of the equation. With an IUD or implant, the perfect use rate and typical use rate are identical.
Valerie Tarico
Forgot the link: http://www.contraceptivetechnology.org/CTFailureTable.pdf
Aaron Hamlin
Unfortunately, there’s a lot of confusion over contraceptive pregnancy rates. When you hear about a pregnancy rate (important terminology–not failure or effectiveness rate), they’re talking about the probability of at least one pregnancy for a couple over the course of a year. This data is collected via survey sampling.
For the condom, its typical-use pregnancy rate (more important than the perfect-use rate), is 17.4%. While we tend not to extrapolate survey data to the individual level, for convenience we must. So, we say, the probability of at least one pregnancy for a couple under typical conditions over a year is 17.4%. Typical use means you may not use it correctly every time or sometimes don’t use it at all; it’s the average in-practice use including all of the sample–perfect and imperfect users alike.
Now for over time.
Let’s assume a lifetime of condom use under typical conditions. Let’s say that’s 20 years of fertility. Here, we have to assume independence of years, and use the average rate to be able to do anything. It’ll get us in the neighborhood. So we take 1-(1-.174)^20. And you get a number near 1 (probability of at least one pregnancy). The expected value (average total number of kids) is over 3 (but not one every year as suggested above). Now, that number is going to be tons higher if you don’t use anything of course. But over three is still pretty high for unplanned pregnancies (i.e. not the pregnancies you want).
Even when you’re talking smaller typical-use pregnancy rates (like the pill), over time, the probability of at least one pregnancy can be unacceptable 1-(1-.087)^20 = 84%. Expected kids (unplanned) for 20 years is under 2. Start looking at these numbers, and you see why something like Implanon (typical pregnancy rate = .05%) Lifetime: 1-(1-.0005)^20 = <1%. Expected pregnancies over 20 years: ~0. Pretty awesome odds. And that's why those small numbers matter. It's not overkill at all. Time substantially increases your odds of an unplanned pregnancy. Note, however, that this effect IS NOT simply adding.
It is true that Implanon and some other hormonal methods can have some unpleasant side effects for some women despite the methods' impressive pregnancy rates. Of course unplanned pregnancy is a pretty nasty side effect in itself. But that's why Vasalgel is so awesome. It seems to promise those awesomely low pregnancy rates without the side effects. Plus, this is one of the few times the male can step up and take control of his fertility.
To go a little further on why Vasalgel is so awesome, know what makes a contraceptive awesome. These are good factors:
1. Typical use rate = perfect use rate (check)
2. No/minimal side effects (check)
3. Long term and reversible (check)
4. Doesn't interrupt sex (check)
5. Super cheap (check).
When Vasalgel finally goes to market, it will have immense impact far beyond any contraceptive that has come before it (including the pill and condom). But because it's super cheap and long-term, no for-profit company is interested in it.
Fortunately, however, a nonprofit is. And you should donate to them to help this happen. This is probably the best donation you'll ever make: Parsemus Foundation
Derek
Aaron was starting to un-wrap some of the probabilities that explain unplanned pregnancies based on rate information. One fact to consider in support of the real benefits of effective male contraceptives is that probabilities ratios against undesired outcomes multiply, so that if men and women combine methods, a probability of 2 undesired outcomes in 100 outings (typical for female methods) combined with a male method also with a probability of 2 undesired outcomes in 100 outings, results in a probability of 4 undesired outcomes in 10,000 outings. That is a vanishingly small probability of an undesired outcome compared to using any one method alone, even considering that improvements in contraceptives may come over time. When new male contraceptives become available, I expect men and women will combine them for the better control it offers them.
Erika Temple
I would have liked to use your article for a psychology assignment but it lacks sufficient research. There are no sources to the facts stated. I am disappointed that this is the only article featuring Vasalgel in it.
Serena Larkin
Hi, Erika. Thanks for your interest in the topic. Much of the information the author cites is hyperlinked in the text of the article. Are those links not working for you? If you have specific questions, it’s possible Valerie could answer them or direct you to someone who can. I’ll leave her to that…. Thanks for reading.
Valerie Tarico
I do hope that the links in the article worked for you. In case not, the Parsemus Foundation is the primary funder of research on Vasalgel. Here is their page on the topic: http://www.parsemusfoundation.org/vasalgel-home/