Why does male contraception still lag so far behind?

World Contraception Day on September 26 offers an opportunity to look closely at a part of family planning that receives very little attention: contraception for men. The key question here is why the range of methods available to men and women remains so different.Women today have options including oral pills, injectables, implants, intrauterine devices and permanent sterilisation, though access and affordability to safe and reliable contraception in our country continues to remain a major challenge. For men, the practical choices are still largely limited to condoms for reversible contraception and vasectomy for permanent contraception. Male and female reproduction are governed by the same broad hormonal axis, yet the biology, anatomy and mechanics of preventing conception create very different problems. Understanding those differences helps explain why a male equivalent of the pill has remained elusive.The condomThe condom remains the only widely used reversible contraceptive that a man can control directly. Its history stretches 3,000 years since animal intestine and bladder were used as penile sheaths, while linen coverings appeared in Europe partly as protection against syphilis. The major technological leap came in the 19th century, when Charles Goodyear’s vulcanisation of rubber made durable condoms suitable for mass production. Latex, introduced in the 1920s, made them thinner and stronger. Even today, however, condoms depend on correct use during every act of intercourse. Pregnancy occurs in about 2% of users over a year with perfect use, but the failure rate rises to around 13% with typical use; perceived reduction in pleasure can also affect consistent use. Yet the condom has an advantage that no pill, implant, IUD or sterilisation procedure can reproduce: it also reduces transmission of many sexually transmitted infections. Any future male contraceptive would therefore supplement, rather than make the condom obsolete.Vasectomy’s reversalAt the permanent end of the spectrum is vasectomy, in which the vas deferens carrying sperm from each testis is interrupted. Modern no-scalpel vasectomy is technically simpler than female sterilisation and does not require entry into the abdominal cavity. India, however, offers an unusual historical contrast. Vasectomy once accounted for most sterilisations, but coercive mass sterilisation drives during 1975–77 produced a lasting backlash. Its share fell from 65.1% of sterilisations during 1971–75 to only 14.8% during 1981–85. The imbalance remains pronounced. National Family Health Survey-6 (NFHS-5) reported female sterilisation in 36.5% in women, while male sterilisation stood at only 0.5%. Fear of weakness, misconceptions about sexual performance, social expectations and the way family-planning services evolved have all contributed. The paradox is that the less invasive permanent procedure is now used far less often.Why the gap?The first difficulty is reproductive arithmetic. In most menstrual cycles, a woman releases a single ovum. Hormonal pills can therefore suppress a relatively discrete event ‘ovulation’ while also thickening cervical mucus. Male fertility is organised differently. The testes continuously produce millions of sperm every day, and merely reducing their number is not enough. A useful male contraceptive has to suppress sperm production to zero, sustain that effect reliably, and then allow fertility to return instantly. The hormonal route is also delicate. Suppressing luteinising hormone (LH) and follicle-stimulating hormone (FSH) can reduce sperm production, but it also lowers testosterone inside the testes. Researchers must therefore suppress the high local testosterone needed for spermatogenesis while preserving enough androgen action elsewhere for secondary sexual function, muscle and bone.Time and anatomy add further obstacles. A complete cycle of human sperm production takes about 74 days, so neither suppression nor recovery is immediate. Women also have a mechanical target: the uterus can be reached through the cervix, allowing an intrauterine device (IUD) to sit locally for years. Men have no equivalent cavity. The two vas deferens can be blocked, but a reversible blockage must later reopen without scarring or damage, which is a harder problem than permanent vasectomy. There is another asymmetry after intercourse. Following unprotected sex or contraceptive failure, a woman can use a emergency pill within a 144 hours, or in suitable circumstances have a copper IUD inserted. At present, there is no approved method that a man himself can use after intercourse to prevent conception. His contraceptive decision therefore has to be made largely before, or during, intercourse.What comes next?Researchers are now attacking the problem from several directions rather than trying to reproduce the female pill exactly. A Nestorone-testosterone gel suppresses sperm production while replacing androgen; recent trial data showed that more than 80% of participants reached the target level of sperm suppression within 12 weeks. YCT-529 (YCT refers to YourChoice Therapeutics; ‘529’ is the compound’s numerical development identifier rather than an abbreviation) takes a different route. It is a non-hormonal oral drug that interferes with retinoic-acid signalling required for sperm development; its first human study found single doses generally well tolerated, and further repeat-dose studies have followed.Other researchers are investigating compounds that temporarily impair sperm motility, raising the possibility of an on-demand method. Mechanical approaches are progressing too. India’s Reversible Inhibition of Sperm Under Guidance (RISUG) uses an injectable polymer within the vas deferens, while hydrogel systems such as ADAM (an injectable hydrogel designed to temporarily block the vas deferens) seek to create temporary vas blockage. None has yet become a routine contraceptive, but the field now has several plausible routes rather than a single experimental idea.The broader pictureIt is important, however, to understand that the lack of options for men go beyond biological difficulties. Historically, the burden of contraception has largely fallen upon women; India reflects this pattern even today. Decades of research and significant amounts in funding have gone towards the development of contraception for women; far less time and money has been spent researching options for men. There are about 11 contraceptive methods available to women today and while this may, at first glace, seem to offer a wide range of options, it also means that the bulk of the financial, medical and practical burden of preventing pregnancy falls solely on women, leaving men out of the equation.Pharmaceutical companies have shown limited interest because development has seemed difficult and the market uncertain. Even when developments have occurred, they have sometimes stalled. A notable case occurred in 2016, when Hermann Behre and colleagues reported in The Journal of Clinical Endocrinology & Metabolism, a 320-man trial of injectable testosterone and norethisterone (mimics progesterone). The additional testosterone was meant to send a signal to the brain to shut down testosterone production due to already sufficient levels. As a result, sperm production would also drop significantly, rendering the men temporarily sterile. Although efficacy was about 96%, injections were stopped after adverse events including acne, mood disorders and depression. Critics have pointed out that similar side effects and more, including abdominal pain and heavy menstrual bleeding have been recognised with female hormonal contraceptives that are still in use: essentially women have lived with such side-effects for years, as the price to pay while opting for contraception, but they were deemed too serious in men for the trial to continue.This strengthens the ethical case for sustained investment in safer male methods and more equitable sharing of contraceptive risks and responsibilities.Why choice mattersWhy does this matter? It matters because contraceptive choice is also reproductive agency. In a society such as ours where the burden of preventing a pregnancy falls indiscriminately on women but where her subsequent reproductive choices and autonomy over her body are governed by men and families, this becomes even more significant. Biologically, men do not currently possess the option of a regular contraceptive pill or any ability to prevent a pregnancy after unprotected sexual intercourse; their main reversible tool remains the condom. A safe male pill or long-acting reversible method would add, not subtract, choices. Giving both partners independent preventive options could reduce unintended pregnancies, spread responsibility more evenly and make family planning less dependent on the contraceptive options of one gender.(Dr. C. Aravinda is an academic and public health physician. The views expressed are personal. aravindaaiimsjr10@hotmail.com)