Once a month in the south of Brittany, a small group of men gather to debate the comparative merits of jerry-rigging jockstraps out of bras and children’s socks versus making them from scratch. The group called Thomas Boulou – which roughly translates as “warm balls” – are advocates of an unusual form of contraception they call “the thermal method”.
This do-it-yourself approach involves lifting the testicles until they rest slightly south of the inguinal canal – the passage in the abdominal wall that lies just above the scrotum in men. The scrotal sac – now resembling a deflated party balloon – is then thumbed through a narrow hole sewn into a pair of homemade pants, preventing the testicles from hanging naturally outside of the body.
Wince-inducing as it may be, the goal of the thermal method is relatively simple. By wearing the DIY underwear for 15 hours a day, members of Thomas Boulou hope to increase the temperature of their testicles by a couple of degrees, dramatically reducing their sperm count and rendering themselves temporarily infertile. The jockstrap, one website advocating the method notes, also doubles-up as a handy swimming costume.
Although only practised by a handful of adherents, if the thermal method ever caught on – and earned the approval of the medical world – it would boost the number of male contraceptive methods out there by a full 50 per cent. Right now, men who wish to control their own fertility have two options: condoms or vasectomy. And both – like any form of contraception – have significant limitations.
Women, on the other hand, have a veritable smorgasbord of contraceptive options: pills, injections, caps, intrauterine devices, implants, sterilisation and spermicidal sponges, to name just a few. This range of options is one of the reasons why women bear a disproportionate part of the contraceptive burden in most couples.
But for the people working to bring the first new male contraceptive to the market since medical vasectomy became common after the Second World War, it’s not just about spreading the contraceptive load between partners. They take one look at the 85 million unplanned pregnancies that happen every year and see a huge demand for contraceptives that don’t currently exist. Filling this gap would help give women more control over their financial and medical lives, and may prevent some of the 25 million unsafe abortions performed worldwide each year.
Now, the slow-moving world of male contraceptives might be starting to catch up – with a handful of different male contraceptives currently under development. Researchers are trialling hormone gels, pills and injections as well as companies trying new ways to block sperm from leaving the body. The race to close the contraceptive gap is back on.
For most of medical history, the study of fertility has centred on female bodies. The oldest Egyptian medical text – the Kahun Medical Papyrus – dates from 1,800 BCE and discusses fertility, pregnancy and gynaecological aches and pains. “Gynaecology a very old discipline – we have been studying female reproductive bodies for hundreds of years – but for the male reproductive body we just didn't know that much,” says Miriam Klemm at the Berlin Institute of Technology, who is writing a PhD thesis on the development of male contraceptives. The burden of controlling fertility has historically fallen squarely on the shoulders of women.
Ancient contraceptives included pessaries – bronze discs that were inserted into the vagina to block sperm from reaching the cervix. By the turn of the twentieth century, condoms made out of animal, silk or linen had become by far the most popular contraceptive – though these were then superseded by rubber and, by the 30s, latex versions.
But it would be the combined oral contraceptive pill – popularised as “the pill” – that would really kick start the contraceptive revolution. The first reversible, widely-available hormonal contraception, the pill was certified as a contraceptive by the US Food and Drugs Administration (FDA) in 1960. By 1967 nearly 13 million women were using the pill around the world. That same year, Time dedicated its cover to the revolutionary tablet.
The pill also prompted discussions about male contraceptives, says Klemm. Early versions of the pill contained much higher doses of hormones than the versions we have today, and were linked to blood clots and strokes. In the first clinical trials, on women in Puerto Rico, 17 per cent reported significant unpleasant side effects and one woman died of congestive heart failure. In 1961, the first reports of pill-related deaths started making headlines. Worried about the safety of the drug, Norway banned its sale in 1962.
“There was all this cultural, societal negotiation about the pill and if it was a safe product,” says Klemm. In the West, feminists were arguing that the pill was unsafe for women and men should share the contraceptive burden. “It could not be that we had this unsafe product for women and basically nothing else,” she says.
Elsewhere in the world, particularly in places such as India and China, countries were looking to contraceptives to control burgeoning populations. “From their perspective they needed more choices – they needed to address the other half of the population,” Klemm says. The pill had proved the case for hormone-based reversible contraception, but it barely scratched the surface of the need for better birth control.
In the 70s, the National Institutes of Health (NIH) in the US started to experiment with hormonal male birth control. Male volunteers were injected with the steroid testosterone enanthate – commonly used to treat people with low levels of testosterone – which was shown to reduce sperm concentration to very low levels.
In the 90s, the World Health Organisation wanted to see how well the approach would work as a form of contraception and so recruited 271 couples in seven different countries for a trial. Just over half of those couples used weekly testosterone enanthate injections as their only form of contraception, with 119 couples finishing the 12-month trial. There was only one pregnancy during the entire process. A slightly larger second study confirmed that steroid injections could reach the same level of effectiveness as female contraceptives.
But in medicine, a trial isn’t worth much unless you can convince pharmaceutical companies that they might like to turn your experiment into a widely-used and profitable drug. By the early 2000s a couple of drug companies were thinking about doing exactly that. In 2003 the Dutch firm Organon teamed up with the German counterpart Schering to trial progestogen implants and testosterone injections. Most of the men in the trial had dramatically reduced sperm counts and recovered normal fertility after stopping the treatment, but there were also concerning reports about side effects including mood swings, reduced sex drive and acne.
“That was a peak in the field – the early heydays of the hormone approach,” says Klemm. But the optimism didn’t last long. In 2006, Schering was bought by the pharmaceutical giant Bayer and a year later Organon was bought by the US firm Schering-Plough – a separate enterprise from the Dutch Schering. Both firms dropped the research into male contraceptives. The dream of a better birth control for men was dead, for now.
As research into male birth control entered its dark ages, the centre of research started to shift away from Europe and back towards the US. There, a researcher by the name of Diana Blithe – now program director for contraception development at the NIH National Institute of Child Health and Human Development – had just finished research on ella, an emergency contraceptive pill that worked up to five days after sex and was approved by the FDA in 2010.
Blithe’s next focus was a male contraceptive. Since 2005, the NIH has been working on a gel that delivers two hormones: progestin, to shut down testosterone in the testes, and testosterone to make sure the blood levels of the hormones don’t dip too low. Lowering the level of testosterone in the testes is key to halting sperm production, but lower blood levels too much and men lose their ability to ejaculate or get an erection, so the goal is to keep testosterone levels in a constant middle ground.
One advantage of a gel over a pill is that testosterone absorbed through the skin will stay in the bloodstream for longer. “If you take a testosterone pill it is cleared too rapidly and you have to take it many times a day – maybe three times a day,” Blithe says. Although other researchers are trialling hormone pills, this gel is currently the furthest along hormone-based male contraceptive study.
Since November 2018, Blithe has been recruiting couples to trial the gel as their only form of contraception. In total, she hopes to recruit 420 couples across nine cities worldwide, including Edinburgh and Manchester in the UK as well as others in Sweden, Italy, Kenya and Chile and the US. “We're going to have a lot of different types of people who are using that, who will give us feedback on how they liked it or didn't,” Blithe says.
She has no illusions about the path ahead. Developing drugs is slow and tricky at the best of times – and these problems are magnified in the chronically underfunded world of male contraceptives. “Unlike, say, cancer patients who are willing to tolerate side effects because of the alternative, we're treating healthy individuals so we can't disrupt or do something that would be permanent or damaging.”
But male contraceptive studies also present an unusual problem. Usually the effectiveness of a drug is measured in the person taking it – but in this the case the drug is taken by a man and its effectiveness is measured in a woman. “It's an incredibly unusual situation,” Blithe says. Women taking some versions of the pill increase their risk of conditions such as blood clots, but this is balanced by the risk that pregnancy would present to their health. In this study, the risk is borne by the man. “His benefit is what happens as a couple or with his partner as oppose to a direct health benefit to him.”
John Reynolds-Wright, a clinician and researcher at the University of Edinburgh is helping run the NIH trial in the UK. He points towards studies in China and South Africa which indicate that men would be willing to take hormonal birth control. “People are drawn to what’s already familiar to them,” he says, so it’s no wonder that people are uncertain about male birth control.
He’s already started recruitment for the NIH trial and is getting interest from people in their early twenties to those in their late thirties – a sizeable range given that the trial requires female participants to be aged between 18 and 34. The men will use the gel – spreading a teaspoon of the liquid onto a shoulder every day – for a year, although the total study time is closer to two years. “Once we have a variety of tools available to men that will allow them to be more engaged in reproductive health and take more responsibility over their reproductive health,” Reynolds-Wright says.
Others are opting for non-hormonal approaches to male birth control. Virginia-based startup Contraline is exploring a kind of reversible vasectomy that involves injecting a gel into the tube that transports sperm away from the testes. The firm, which is preparing to clear its technology with the FDA and start clinical trials, says that the gel is designed to last for years but will be reversible. At the moment, vasectomies are only reversible in 75 per cent of men who have a reversal within three years of their initial operation, after which point the chances of reversal drop precipitously.
At the University of Dundee in Scotland, Christopher Barratt is part of a team that has won a $900,000 (£700,000) grant from the Bill and Melinda Gates Foundation to screen existing chemicals to understand their impact on male fertility. Barratt started by studying sperm samples from infertile men to understand how defects in their sperm stop them from getting into eggs, and plans to try and identify drugs that can cause the same sperm changes in fertile men.
Despite these different approaches to male birth control, Blithe says that she doesn’t regard these other researchers as competitors. “I think you’ll increase the user population of contraceptives overall, but I don’t think it’s a zero-sum game where she’ll stop using it because he’s using it instead,” she says. Klemm agrees. She says that it might just be the case that one breakthrough is enough to spark interest in male contraceptives across the industry – after which we’ll see a range of approaches come to the market.
For Blithe, the number of unplanned pregnancies – which currently hovers at around 40 per cent of all pregnancies – is evidence enough that there is vast demand for male contraceptives that just isn’t being met. “It drives me that we don’t have as many options as we need,” she says. “Everyone benefits when they have options for controlling their reproductive life. Everyone wants to have control.”
This article is part of our in-depth series investigating how technology is changing love, sex and relationships.
From keeping an intimate secret from the internet to the battle to destroy super gonorrhoea, we'll explore the technologies and ideas changing how we all live and love – for better or worse.
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– Inside the strange world of China's romantic video games
– Inside the disgustingly gloopy fight against super-gonorrhoea
– Why it's so difficult keeping your unborn child a secret from the internet
This article was originally published by WIRED UK
