Observe World Contraception Day

            Recently I responded to a blog that was decrying the lack of male contraception. I wish I had better news on that front, but there is good news about women’s birth control.

            In response to the question: “Why do women have to take the hit of contraception?” I wrote that I am a retired male OB-GYN who has had a vasectomy. I believe in contraception for men! The blog”s author only listed two male methods: condom and vasectomy. She apparently didn’t know about withdrawal.

            In the 1980s I practiced in Puerto Rico where people typically had large families. Often women had several children close together, then went a decade or more without modern contraception and without a pregnancy. When I inquired about birth control, some women replied “My husband takes care of me.” My wonderful nurse/translator told me that the couple was using withdrawal. Currently the Puerto Rican Total Fertility Rate is an incredibly low 1.1: most women on the crowded island are having only one child! Although withdrawal statistics show a high failure rate, this method seems to work well for some couples.

            What makes it easier to halt female fertility rather than men’s? Remember from that 8th grade sex talk that women usually create one egg a month? Men make a thousand sperm every second! Egg production depends on a woman’s hormones working in an amazing, well-balanced sequence. It is fairly easy to disrupt the sequence with tiny amounts of exogenous hormones, as with the birth control pill.

            In 1963 I met an assistant of Dr. John Rock, one of the developers of “the pill”. She told me that another of Rock’s projects was nicknamed “the Rock Strap”. Insulated briefs for men raised testicular temperature high enough to stop sperm production. Research along these lines is still ongoing in France.

            The good news is that there are 4 new contraceptive methods for women. One is a hormonal IUD that is a little smaller and has less levonorgestrel than others, but is still effective for 5 years. It has a very low failure rate similar to other LARCs (Long Acting Reversible Contraceptives)–less than 1% per year. Kyleena® is similar to Mirena®, the first hormonal IUD, but may be better tolerated by some women because of its smaller size.

            Currently, nonoxynol-9 is the most common agent used in vaginal spermicides. While the vagina is acidic and hostile to sperm, alkaline cervical mucus helps guide them as they swim toward fertilization. Phexxi, a new spermicide, is a “Vaginal pH Regulator” that is 90+% effective in preventing pregnancy. It also acts as a lubricant and may increase sexual satisfaction, but is expensive if you don’t have insurance.

            Contraceptive diaphragms have been around longer than a century. They have none of the side effects of hormonal contraception, but their failure rate is higher. Although most diaphragms require fitting, Caya® is available in just one size and fits most women. It should be used with a spermicidal jelly or cream, like any other diaphragm. People with latex allergy can use it since it is made from silicone rubber. A Caya® costs about $85 and should last for years.

            All IUDs currently available in the USA are “T” shaped. Most women tolerate them well, but some don’t. A novel IUD, Ballerine®, provides an alternative. Unique in design, a soft, springy strand in spherical shape has 17 tiny copper balls strung on it. The Ballerine® is straight in its inserter, then curls up to conform to the uterine cavity. It has been well received for a number of years in Europe and other countries where it has been used by over 94,000 women. Like other LARCs, fewer than one woman in 100 will conceive with Ballerine®, and its complication rate is low. Although not available yet in the USA, its manufacturer is planning to start the approval process soon.

            Annovera® is a hormonal contraceptive vaginal ring that lasts a whole year. After it has been in place for 21 days, the user removes it for a week to bring on her period. It has two drawbacks: the cost, for someone who doesn’t have insurance, is about $2000! Also, the failure rate is higher than a LARC, although better than “the pill”.

            With new contraceptive methods there is more choice–for women, at least. Please observe World Contraception Day, September 26th, whose purpose “…is to improve awareness of contraception and to enable young people to make informed choices on their sexual and reproductive health.”

© Richard Grossman MD, 2020


Catch a Glimpse of Kenya

Image from The Hunter Legacy Film, courtesy of Hunter Sykes

            Years ago I met Dr. Rhodes Moicombo in the little African country, Swaziland (now “Eswatini”). When he learned about my interests, he told me how he had promoted family planning in Kenya.

            Right after medical school, Moicombo worked in a rural area of Kenya that had never had modern healthcare. He understood that he needed to win the respect of his future patients so came up with an idea. Knowing how much Kenyans prize children, he planned a demonstration of his medical skill using the kids. He set up shop under a large tree in the center of town and gave kids candy-flavored worm medicine. Parents were amazed and delighted the next day to find worms in their children’s poop!

            After Moicombo had established trust with his worm medicine, he started talking with the mothers about the advantages of family planning. I don’t know what methods were available to women then, but overall Kenya has been successful in lowering its fertility rate in the past half century.

            Back in the 1960s Kenya was one of the fastest growing countries in the world, with a Total Fertility Rate (the number of children that a woman bore) of about 8. Although much lower now, the TFR is still high at just over 3 children.

            Kenya had their census last year and we are just starting ours. A subscriber to Population Matters!, David Zarembka, has lived in Kenya for many years and his wife is Kenyan. Some of his recent blogs treat the results of the 2019 census.

            There are problems in getting accurate census data in any country, so it’s not surprising that the Kenyan 2009 census was marked by some “irregularities”. One of the purposes of a census is to allocate government funds. Knowing this, some enumerators (census workers) in the 2009 Kenyan census “padded” the numbers, so their region would get more money. There may have been a million “ghost” people who didn’t really exist! The Kenyan government made changes to prevent this sort of fraud in 2019. Enumerators came from outside the community, and a local “elder” accompanied each. The result of last year’s census was significantly lower than expected. There were 47.5 million Kenyans on the night of August 24, 2019.

            Zarembka is optimistic that Kenya’s growth rate is slowing. He writes: “As I look around Kenya… I notice that very few teenagers are now giving birth – one of the prerequisites for a fall in the birth rate.”

           It will be interesting to see what the USA 2020 census will bring. We know that our country’s TFR is less than replacement, but our population will continue to grow due to population momentum and immigration. Even in the USA there are difficulties in getting an accurate count, since there are some groups who want to go under the radar—undocumented migrants are an example.

            Kenya is an example of what can be done to slow population growth. Moicombo was a pioneer in introducing family planning in one area, and recently I met another innovator. Dr. Charles Ochieng is a general physician in Nairobi whose passion is providing vasectomy care. He even offered to do his father’s vasectomy for free, but was turned down. His father already has 7 children with his new wife!

            Because I’m limiting my travel due to concern about climate change, I’ll probably never visit Kenya. However, I just watched a wonderful movie, The Hunter Legacy; perhaps some of you saw it at the Durango Independent Film Festival. In addition to world-class pictures of the beautiful people, scenery and wildlife, it tells important stories. Because of rapidly increasing population, especially in the past, humans have destroyed much of the wildlife. Hundreds of animals were killed in the past to make room for settlements. We have plowed much of the wildlife habitat into agricultural fields and ­­­­­­­poachers continue to the slaughter the animals.

            The Hunter Legacy demonstrates ways of protecting wildlife using armed guards, aerial surveillance and fences to keep animals away from settlements. It also stresses the importance of slowing population growth with family planning and education.

            The movie is about J.A. Hunter, a Scot who lived up to his name as a professional hunter, cleared the land of wildlife for human settlement. The film says this about Mr. Hunter: “J.A. Hunter lived for more than 50 years in East Africa. During that time, he shifted from a focus on hunting towards a belief in conservation as concerns about wildlife populations intensified.”

            The film was made by Hunter Sykes, who lives in Durango. You can view the film at:

© Richard Grossman MD, 2020