Is Male Birth Control the Answer to the Unplanned Pregnancy Epidemic?

February 12, 2024 - In an interview with Healthcare Strategies, Stephanie Page, MD, PhD, Co-Director of the University of Washington Medicine Diabetes Institute in Seattle, WA, Robert B. McMillen Professor of Medicine in Lipid Research and head of the Division of Metabolism, Endocrinology, and Nutrition, discussed the continuing global epidemic of unplanned pregnancy.

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Page noted that nearly 50% of all pregnancies worldwide are unplanned, according to estimates from the World Health Organization (WHO). Domestically, that number is similar, with approximately 40–45% of United States pregnancies tracked by the CDC being unintended. Unintended pregnancies have always carried concerns for mothers and their offspring if carried to term.

However, since the reversal of Roe v. Wade by the Supreme Court of the United States (SCOTUS) in the Dobbs v. Jackson Women’s Health Organization case, the concerns around unplanned pregnancies have increased significantly. As abortion rights decisions are turned over to state legislature, many women and birthing individuals find themselves losing or at risk of losing reproductive agency.

The high rate of unintended pregnancy combined with restricted access to abortion care may contribute significantly to multiple health risks. According to data analyzed by the Commonwealth Fund, states with abortion restrictions have higher maternal mortality rates — 62% greater than abortion-access states.

Beyond the risks associated with carrying an unintended or unwanted pregnancy to term, abortion restrictions may drive some individuals to seek illegal abortions. For example, the WHO notes that 50% of all global abortions do not follow the appropriate medical guidelines, contributing to 4.7–13.2% of all maternal deaths. 

Despite the high rate of unintended pregnancy and the risks associated with it, effective and accessible contraceptives can help minimize the number of unintended pregnancies and allow for planned and wanted pregnancies.

Interest in Contraceptives

“Since the reversal of ROE and the Dobbs decision a couple of years ago, several surveys and data points have suggested that interesting contraception has gone up,” Page noted.

For instance, in July 2022, CNN revealed that there was a 300% increase in requests for emergency contraception. More recently, the media outlet noted that the over-the-counter sale of emergency contraceptives increased by 0.63 units per 1,000 women in 2022. 

Additionally, other studies and surveys conducted following the Dobbs decision revealed an increased interest from males in vasectomies, especially among younger men. An article in the American Journal of Men’s Health notes that, on average, 500,000 vasectomies are conducted annually in the US. However, sources like the American Academy of Medical Colleges (AAMC) have reinforced an increased interest in vasectomies in the Dobbs decision. For example, an article by the University of Florida Health explained that in June 2022, vasectomy rates increased by 50%.

Beyond those two types of contraception, more women are looking toward longer-acting contraceptives as the future of reproductive health access remains unclear.

“Lots of data suggests that since the restriction on female reproductive agency, there has been an increased interest in uptake in contraception,” Page added.

Available Male Birth Control Methods

With an increased interest in contraceptive options, there has been a focus on how males, who historically have only had two birth control options, can contribute to pregnancy prevention.

“There are only two methods of birth control available to men, and one of them is not reversible,” said Page, recounting currently available birth control methods.

While vasectomies are a critical type of contraceptive, they are a permanent birth control method. Despite common misconceptions, vasectomies are a non-reversible birth control method.

“A vasectomy in and of itself is not particularly invasive, but a vasectomy reversal is a much bigger deal in terms of the surgical approach and the recovery and so forth,” began Page.

According to Hopkins Medicine, vasectomies are a type of contraception that allows men to continue making semen and ejaculate, but the semen does not contain sperm because the vas deferens is blocked by some means, preventing sperm from traveling from the testicles to the urethra. While sperm are continually produced, they die and are reabsorbed into the body when not released.

There are multiple methods of vasectomy, but the most common are incision and non-scalpel vasectomies. Although vasectomies can be reversal, the procedure is extensive, invasive, and only 85% successful.

Page also notes that vasectomy reversal is rarely covered by insurance, which can be another issue. The average cost of vasectomy reversal is $15,000.

“Condoms are super important. Many couples use them, and they're very important for all aspects of sexual health; we consider those a male method,” Page added. “The biggest downside of condoms is that they have a high failure rate at about 14% and a high discontinuation rate. That's a critical [factor] because if people stop their method and they don't take up a new one, we're back in the same non-contraceptive space.”

Although men do participate in contraception, currently available birth control tools only account for 25% of all contraceptive uses. Men don’t have as many options as women when it comes to contraception.

“We, in the male contraceptive development community, are firm believers, and there's a lot of data about this that if we gave men more options, there would be more uptake. So that's the goal of the field.”

Male Birth Control Development

“I work in the development of hormonal male contraceptive methods,” explained Page. “A pillar of the work we do is based upon the success of female hormonal contraceptives, which, while some women do have some side effects, overall have been an enormous breakthrough for women and are enormously effective.”

Instead of the estrogen and progestin used in female birth control pills, male hormonal birth control uses testosterone and progestin. Testosterone and progestin block the signals from the brain to the testicles that trigger the production of sperm. While blocking the production of sperm, men are receiving enough testosterone to have regular sexual drive.

“The goal is that they feel nothing. They feel all the normal testosterone characteristics. They have normal male facial hair, a low voice, etc. And the only thing that's touched is the production of sperm,” she added.

Page, her team, and other researchers are working on multiple delivery methods for male birth control, including long-acting injections, daily gels, and a pill.

Hormonal Male Contraceptives

“We're further along with the gel in terms of it getting potentially to the market,” noted Page.

One of the primary reasons is that testosterone, given orally, is broken down much faster than oral estrogen, and the alternative of using early modifications of testosterone can be linked to liver toxicity.

Although the development of a male pill is behind, Page notes, “It turns out when we give men a gel, they can absorb the testosterone through their skin well,” comparing it to existing gels used as a hormone replacement therapy for men with low testosterone.

By adding progestin, these gels transform into a form of birth control.

Although someone may assume that men might perceive a daily gel poorly because of the mess and the risk of transfer, Page told Healthcare Strategies that it is not the case.

“We were a little surprised at how the men find it acceptable. They can work it into their routine with showering pretty easily. And, internationally, when asking men about their preferred method of contraceptive delivery, there's a lot of interest in Africa because there's a lot of familiarity with using lotions [and topical treatments] for other sorts of things.”

Non-Hormonal Male Contraceptives

In addition to hormonal contraceptives, some teams are working on a type of vasectomy that is reversible. Instead of severing the vas deferens, the team injects a  proprietary hydrogel into the tube to prevent sperm from traveling out of them or killing them as they escape. Down the line, a sodium bicarbonate solution can be used to dissolve the prior biocompatible polymer and subsequently reverse the vasectomy.

“Then there's a whole other field of developers that are trying to interfere with the production of sperm or the sperm getting to the egg in different ways,” she added. “For sperm to get to the egg in the female reproductive tract, they have to do this highly specialized, fast swimming. So, investigators are trying to interfere with the molecular processes required for that really fast swimming.”

The goal of these alternative methods is to avoid using hormones but effectively interfere with sperm production.

“Those lines of investigation and those trials are behind the hormonal methods because they don't have these years of female hormonal contraceptive work for foundational purposes, but I believe some new agents are coming out, and we're hoping that there'll be clinical trials of some of those non-hormonal methods for men even in 2024.”