Categories
Male contraception

Realizing Quality Families

World Vasectomy Day plan for 2024

            I was walking down the street in Mountain View, California when I noticed a man coming toward me wearing a white T-shirt with small black lettering: “SEEDLESS”. I wonder if he was advertising his vasectomy?

            Vasectomy motivators in Northern Sumatra use humor in their presentations to men about vasectomy. Perhaps they should wear shirts with “KESIP” (Indonesian for “seedless”) on them! From what I can tell, these motivators need all the help they can get, since very few men get vasectomies in Indonesia. However, Indonesian husbands tend to be quite supportive of their wives’ contraceptive choices, even if very few men actually use a male method of birth control.

            Indonesia is a mixture of more than a thousand ethnic groups speaking over 700 languages, living on over 6000 large and small islands. Fortunately, they are united by a single official language, although most Indonesians are multilingual. The motto of their National Family Planning Program is: “Realizing Quality Families”.

            The country has supported family planning for decades. When we visited Bali (another Indonesian island) in 1996, we learned about banjars—the community organizations for a small village or neighborhood. The banjar serves perhaps 1,000 people, and helps its members through thick and thin. Banjar members organize religious ceremonies, dances, weddings and funerals. I was surprised to learn that each banjar also keeps track of every family’s fertility plan; the husband registers if his wife is trying to conceive, is pregnant or if they are using contraception. Although this would be considered an invasion of privacy in the USA, Balinese society does not have a problem with this openness.

            The fertility rate in Bali is a bit above replacement, but is similar to the average for Indonesia. Sumatrans, on the other hand, tend to have larger families, averaging 2.5 children per woman. This is where vasectomy could really be helpful!

            Only a tiny number of men in Indonesia have had vasectomies—just 3 per 1000 men. The vasectomy peak in that country was 30 years ago, with double that number. Unfortunately, this is true globally; the number of vasectomies has declined rather than increased. I am proud that the USA is one of two countries bucking that trend; the other is South Korea.

            I know of two heroes who are working to change this trend—in addition to the vasectomy motivators in Sumatra. One is Dr. Charles Ochieng, whom I met at an international family planning meeting. He performs vasectomies, using the latest techniques, in his native Kenya. Another hero is Dr. Doug Stein, one of the co-founders of World Vasectomy Day (WVD). Trained as a urologist, Stein has limited his practice to male sterilization procedures. Each year he travels to a different country to train doctors there, and together they do a bunch of procedures—on WVD. This year it will be Zambia, November 24th. WVD is not just a day—in fact, they have 9 events scheduled in Zambia, all relating to vasectomy!

            When I was practicing and a patient expressed an interest in being sterilized, I would suggest that vasectomy for her partner was safer and less expensive. I just read another, unfortunate statistic: 1 in 12 women will become pregnant within a decade after tubal ligation. To make things worse, many of these pregnancies will be in a Fallopian tube. A tubal pregnancy can cause serious—even fatal—bleeding.

            I am happy that WVD, Dr. Ochieng and the vasectomy motivators in Sumatra are all promoting vasectomy. They are helping put the responsibility for family planning where more of it belongs—with men.

© Richard Grossman MD, 2024

Categories
Contraception Male contraception

New Contraceptive Methods

            There are three pieces of good news about birth control methods. One is very old, but never really studied, one is brand new and one futuristic.

            I spent some time in Paris studying French when I was in college. I also learned about a male method of birth control from a research assistant for Dr. John Rock. Rock is best known for his work in developing “The Pill”, but he was also interested in other means of limiting fertility. He tested an idea based on the fact that testicles work best if they are cooler than core body temperature. His idea, which was never marketed, was an insulated athletic supporter. It was nicknamed the “Rock Strap”, of course.

            Fast forward 60 years and researchers are still working on this idea. The physiology is clearly effective, but the long-term safety of heating testicles hasn’t been studied. Furthermore, persuading men to wear a warming codpiece doesn’t seem too practical.

            Many governments have recognized that it is safer for women to take “The Pill” than to not use contraception. The relative safety is especially true in places with high maternal mortality—because preventing pregnancy also prevents maternal mortality. Oral contraceptives are available without prescription in over 100 countries—and, thanks to OPill®, now the USA is one of them! The FDA has finally recognized the safety of oral contraceptives.

The manufacturer and nonprofits that worked to make birth control pills available over the counter had several wishes that went along with the approval.  The pill should be available to teens, it should not be too expensive, and that insurance should cover the medication even though it is available over-the-counter. After 20 years of work, they finally got their wishes! The FDA has very strict requirements. One of them is that the pills come with instructions on their proper usage that almost anyone can understand.

            OPill® is a Progestin-Only Pill (POP). Unlike the majority of hormonal contraceptives, it does not have any estrogen. Blood clots, the most serious problems caused by birth control pills, are caused by estrogen; that is one reason the FDA finally gave their approval. There are minor problems with POPs, however, such spotting and needing to take OPill® at the same time of day, every day. Also, the unintended pregnancy rate may be a little higher than pills with estrogen.

            Although I knew that sperm didn’t like heat, I didn’t know that they don’t like iron. An innovative contraceptive that is now the subject of research makes use of that fact. Ovaprene® is a diaphragm-like vaginal insert with a central mesh that is impregnated with an iron compound. Because it is a mesh, it is permeable to blood and cervical mucus, but the iron makes it lethal to sperm. The woman places it in her vagina as her period ends, being careful that her cervix is covered. The insert is left in place until her next period starts. It has the theoretical advantage of being nonhormonal, and providing month-long protection against pregnancy.

            Ovaprene® appears to be ready for human testing. However, it is still years away from commercial availability, so don’t expect to find it in your pharmacy any time soon.

This brings up the challenges of developing a new family planning method. There are many contraceptive ideas that seem great at the start, but wind up in the trash. I know from personal experience. My idea for a rip-stop condom earned a patent (#4,881,553), but lost me a lot of money since no company was interested in buying the idea. This winnowing process explains, in part, why new methods are usually expensive.

©Richard Grossman MD, 2024