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THE COMING BIRTH-CONTROL REVOLUTION  
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Katherine J. Wu
April 3, 2024
The Atlantic
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_ An abundance of new methods for men could transform women’s
contraception too. _

, Illustration by Joanne Imperio / The Atlantic. Source: SSPL /
Getty.

 

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Within the next couple of decades, a new generation of contraceptives
could hit the American market. One, a pill that prevents certain
cells from accessing vitamin A
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might be able to limit fertility without flooding the body with
hormones; another is an injection that temporarily blocks
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reproductive plumbing. The method that’s furthest along in trials is
a topical gel
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to induce temporary infertility when smeared daily on the shoulders
and upper arms—without affecting mood or libido. “Overall, we
don’t have any serious adverse events at all,” Christina Wang, a
contraceptive researcher at the Lundquist Institute in California, and
one of the developers of the gel, told me.

This coming slew of treatments will be notable not only for their
imaginative delivery methods, but for their target audience: men. For
decades, men hoping to manage their fertility have been limited to
just two imperfect options—condoms or vasectomies. But in recent
years, researchers have taken massive steps toward developing simple,
convenient, and effective contraceptive options for men with virtually
zero side effects. Soon, women may not be forced to bear nearly the
entire burden of preventing pregnancy.

But the coming innovations won’t just be about expanding the menu of
options for men. Better male contraception wouldn’t be on the way if
not for the many scientific paths that female contraception has paved.
Now women’s birth control—much of which still comes with plenty of
irksome, sometimes risky, side effects—seems due for some kickbacks.
True, the logistics of keeping an egg from exiting an ovary don’t
completely overlap with the mechanics of keeping sperm out of the
female reproductive tract. But in principle, “there are a lot of
similarities,” Diana Blithe, the chief of the NIH’s Contraceptive
Development Program, told me, which means one can easily inform the
other. With an eye on what’s now being accomplished for male
contraception, researchers may soon be able to deliver to women new
forms of birth control that aren’t just more tolerable, but also
more on-demand, less invasive, or even usable on male and female
reproductive systems alike.

In the six-plus decades since the debut of the birth-control pill, the
list of contraceptive choices for women has lengthened impressively.
People can opt for barrier methods, or choose among pills, patches,
and implants; they can receive injections a few times a year, or
select an intrauterine device that can last up to 10 years. “We have
so many options, it’s almost like you’re in a cereal aisle,” Amy
Alspaugh, a nurse and reproductive-health researcher at the University
of Tennessee at Knoxville, told me.

Many methods are also ever-improving: IUDs, implants, and injections
now have longer lifespans and are easier to insert and remove; doses
of hormonal contraception have dramatically decreased. “We used to
give basically like a horse dose of estrogen and progestin,”
Alspaugh told me. “Now we give the lowest dose that we know we can
give and still have it be effective,” in order to minimize side
effects. Some researchers have been exploring new ways to deliver
contraception
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or even microchip
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that might allow women to remotely tune their birth control. (The
latter idea has raised privacy concerns galore.) The Population
Council, an NGO based in New York, has been working on a multipurpose
vaginal ring
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addition to preventing pregnancy, release an antiviral to protect
women against HIV, Régine Sitruk-Ware, a reproductive endocrinologist
and contraception researcher at the nonprofit, told me.

By and large, though, the changes to female contraception have been
incremental—more ingredient swaps than whole new recipes.
Categorically, “we’ve had the same offerings for pretty much 30
years now,” Heather Vahdat, the executive director of the Male
Contraceptive Initiative, told me. And plenty of women remain
dissatisfied with the inconveniences and risks that come with the
choices at hand. Some experience weight gain, acne, or nasty mood
swings, or worry about the risk of stroke that can come with
hormone-based pills. Others balk at the often-painful placement
process for IUDs. Manually inserting a device into the lower abdomen
probably wouldn’t be acceptable in other contexts without
anesthesia, and yet, for women’s contraception, “we’ve
socialized that into something acceptable,” Brian Nguyen, an ob-gyn
and contraception researcher at the University of Southern California,
told me. Nonhormonal methods such as condoms, diaphragms, and
spermicide are easy to come by, but generally less effective than
hormonal ones. They can also come with their own side effects
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And women could certainly benefit from a greater variety of on-demand
methods, Vahdat told me—contraception for _when_ you have sex,
“not just in case you have sex”—that would save them the trouble
of weathering side effects all month, year, or decade long.

Over the years, some researchers have argued that significant
inconveniences and side effects are acceptable for female
contraception. Women, after all, are weighing those costs against
pregnancy, itself a risky condition that can come with
life-threatening complications; men, meanwhile, take contraception to
prevent pregnancy in someone else. I asked Vahdat whether the typical
side-effect profile of currently available female contraceptives would
pass muster in any of the male methods in trials. “Based on
history,” she told me, “I think that it would not.” Several
other experts agreed. In 2011, a worldwide trial for an injectable
hormonal contraceptive for men was halted when an independent
safety-review committee determined that the drug’s side effects
“outweighed the potential benefits
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The side effects in question included mood swings and depression, both
of which are frequently experienced by women on birth control. And
yet, most of the participants who stuck with the study said that they
wanted to keep using the injection
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In recent years, Nguyen has heard more and more of the men in
contraceptive trials cite their female partners’ negative
experiences with birth control as reason for their participation.
“Many think of risk to their partner as a risk themselves,” he
said.

Still, the strict standards for the tolerability of male birth control
could raise the floor for female methods too. Such crossover advances
are already in the works. Researchers took care to formulate the
topical contraceptive for men with a dose of natural testosterone,
alongside progestin, the active ingredient that halts sperm
production; the idea, experts told me, is to better recapitulate
what’s naturally seen in men’s bodies, to minimize unnecessary
side effects. Many female hormonal contraceptives, meanwhile, rely on
a synthetic compound called ethinylestradiol that incompletely mimics
the estrogen women’s bodies make—and appears to raise the risk of
blood clots. The Population Council is now working on another vaginal
ring
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replaces ethinylestradiol with hormones better matched to female
biology.

Other conveniences may be trickier to translate. For example,
researchers hope to someday offer men a more easily reversible
vasectomy, in which a dissolvable or removable hydrogel is inserted
into the vas deferens. But experts told me that temporarily stopping
up the fallopian tubes is simply harder. Plus, whereas sperm are
churned out constantly, eggs are released for fertilization on a cycle
that can be tricky to measure and predict—which can make side
effects frustratingly tough to control too, Nguyen told me. Targeted
interventions are also more easily delivered to the testes than the
ovaries. And their success is easier to verify: Men have long been
able to check their own sperm count with a device that’s similar to
an at-home COVID test, but no parallel exists for women, Wang told me.
And because sperm take months to produce, male hormonal contraceptives
might be more forgiving to users who miss a day of treatment—unlike
many pills designed for women, which tend to be less flexible,
Mitchell Creinin, a contraceptive researcher at UC Davis Health, told
me.

The difficulty of wrangling eggs, though, doesn’t have to mean
limiting options for women. Conception can’t happen unless egg and
sperm actually meet—which means that just about any drug designed to
waylay the functionality or motility of sperm could play a role in the
female reproductive tract. The options go way beyond spermicide: The
Population Council is working on a product that will modify the
vagina’s acidity to stop sperm from swimming properly, Sitruk-Ware
told me. And Deborah Anderson, an immunologist and reproductive-health
researcher at Boston University, has been working on a dissolvable
film imbued with sperm-blocking antibodies
[[link removed](23)00139-4/fulltext] that
can be placed into the vagina before sex, and seems to persist at high
enough levels to provide contraception for 24 to 48 hours, she told
me. A couple of drugs being trialed for men could even someday be
marketed to women in some form—among them,
a sperm-motility-blocking drug
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might be deployable in the female reproductive tract too.

With all the attention now being paid to men’s contraceptive
preferences, some researchers worry that women’s needs will fall
even further to the wayside. Jeffrey Jensen, a contraception
researcher at Oregon Health & Science University, told me that even
as grants
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male methods continue to be green-lighted
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his team has had to pause work on some female-contraceptive projects
because of lack of funding in recent years. “Policy makers think
that we’ve checked the box and that we can move on,” he said. And
Sitruk-Ware said that, although researchers had at one point started
developing a topical contraceptive gel for women, “donors were more
interested in the gel for men.”

Still, the arrival of male contraception is unlikely to dampen
women’s enthusiasm for using their own methods, Allison Merz, an
ob-gyn at UC San Francisco, told me. If anything, when those
ultrasafe, ultra-effective products for men come to market, they’ll
ignite more discussions over female contraception—and inspire more
questions about why convenience and tolerability weren’t prioritized
for women from the start.

_KATHERINE J. WU is a staff writer at The Atlantic. She holds a
Ph.D. in microbiology from Harvard University. Before joining The
Atlantic in 2021, she was a science and health reporter for The New
York Times focused on COVID-19. She won a Schmidt Award for
Excellence in Science Communication in 2022, a Science in Society
journalism award in 2021, and the Evert Clark/Seth Payne Award for
Young Science Journalists in 2020. At The Atlantic, she covers
science._

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* Inequality
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