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Campelia GD, Adashi EY, Amory JK. Shared risk and shared responsibility: the ethics of male contraceptives. Andrology 2024. [PMID: 38639014 DOI: 10.1111/andr.13649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Efforts to develop reversible male contraceptives analogous to female oral contraceptives are underway and may be introduced in the next decade. The advent of novel male contraceptives provides an opportunity for an ethical reformulation of the contraceptive paradigm given the relational, rather than individual, nature of sexual relationships, and family planning. For individuals in any sexual relationship that could result in pregnancy, issues of reproductive autonomy, freedom, equality in reproductive decision-making and risks-both of side effects and of unintended pregnancies-are significant. Historically, however, women have been attributed the greatest responsibilities simultaneously with the most restrictions on their freedom of choice and access to reproductive care. OBJECTIVES In this paper, we extend our prior "shared risk" model of male contraception to one of "shared risk and responsibility" to ethically inform this discourse. CONCLUSIONS This updated framework more fully captures the complexity of this novel technology and may be of use to regulatory and legal agencies grappling with an intervention that poses medical risks to the member of the relationship who does not face risks of becoming pregnant.
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Affiliation(s)
| | - Eli Y Adashi
- Department of Medical Science, Former Dean of Medicine and Biological Sciences, Brown University, Providence, Rhode Island, USA
| | - John K Amory
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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Nguyen BT. The demand for male contraception: Estimating the potential market for users of novel male contraceptive methods using United States National Survey of Family Growth data. Contraception 2024:110438. [PMID: 38555051 DOI: 10.1016/j.contraception.2024.110438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/07/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE To estimate the potential market for novel male contraceptives (NMCs) using United States National Survey of Family Growth (NSFG) data, 2015-2017. STUDY DESIGN We described the market for NMCs via secondary analysis of the 2015-2017 NSFG's weighted male respondent data, utilizing surrogate markers for contraceptive switching (NSFG) and contraceptive discontinuation data from the Contraceptive CHOICE project. Potential NMC users included men relying on: (1) no methods or less effective methods but who reported that they would be "very upset" if they got someone pregnant, (2) permanent methods but who reported that they might still want more children, (3) a female partner's method that she might discontinue in the next year, (4) a male method even when his partner uses her own contraceptive. RESULTS Of 3340 respondents-representing 55,890,830 sexually active, reproductive-age men-23.2% used no contraception at last intercourse, 15.8% condoms, 5.1% withdrawal, and 5.1% vasectomy. Among respondents relying solely on condoms, withdrawal, or no method, 19.7%, 3.8%, and 4.4% would be "very upset" if they got someone pregnant. For permanent contraceptive users, 17.3%-20.5% wanted another child. For men reliant on their partner's long-acting reversible or combined hormonal contraceptive, 12-17% and 45-51% of partners might discontinue their method. These data conservatively suggest that 13% or more than 7 million men would potentially use NMCs, rising to 15.5 million with less restrictive contraceptive switching criteria. CONCLUSION Adjusting for pregnancy attitudes and likelihood of contraceptive switching, a substantial portion (between 7-15.5 million) of reproductive age men in the US are potential NMC users. IMPLICATIONS The population of potential novel male contraceptive users extends beyond just users of condoms, withdrawal and vasectomy and should include couples practicing dual-partner contraception and female partners using contraceptive methods that they may become dissatisfied with and discontinue.
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Affiliation(s)
- Brian T Nguyen
- Department of Obstetrics and Gynecology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States; Department of Obstetrics and Gynecology, Los Angeles General Medical Center, Los Angeles, CA, United States.
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Hoover AT, Shattuck D, Andes KL. Vasectomy provider decision-making balancing autonomy and non-maleficence: qualitative interviews with providers. Gates Open Res 2023; 7:132. [PMID: 38352125 PMCID: PMC10861492 DOI: 10.12688/gatesopenres.15036.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 02/16/2024] Open
Abstract
Background Male sterilization, or vasectomy, is 99.9% effective at preventing pregnancy with less than a 2% risk of complications. Despite the high efficacy, low risk, low cost, and gender equity benefits of vasectomy, just 2% of women reported that they and their partners relied on vasectomy as their contraceptive method globally in 2019. Health care providers can be both a facilitator and a barrier in men's health generally, and may be in vasectomy provision as well. This study sought to describe the decision-making rationales of experienced vasectomy providers when evaluating patient candidacy in complex cases. Methods Fifteen vasectomy providers belonging to the global Vasectomy Network google group from seven countries participated in online interviews using a semi-structured in-depth interview guide. Providers were asked about their vasectomy training, their reasons for vasectomy provision, challenging cases they have faced, and approaches used to manage challenging cases. Vignettes were used to further elicit decision-making rationale. Thematic analysis was conducted using MAXQDA20. Results Provider decision-making was predicated on ensuring patients were well-informed, able to consent, and certain about their choice to have a vasectomy. Once those foundational conditions were met, providers filtered patient characteristics through their training, laws and policies, sociocultural norms, experience, and peer influence to produce a cost-benefit breakdown. Based on the cost-benefit analysis, providers determined whether to weigh autonomy or non-maleficence more heavily when determining vasectomy patient candidacy. Conclusions Despite clinical best practices that promote prioritizing patient autonomy over non-maleficence, some providers continued to weigh non-maleficence over autonomy in vasectomy patient candidacy evaluations. Non-maleficence was particularly prioritized in cases providers deemed to be at higher risk of regret. The findings of this study suggest vasectomy provider training should emphasize evidence-based best practices in shared decision-making and patient-centered care to facilitate vasectomy provision that honors patient autonomy and rights.
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Affiliation(s)
- Alison T. Hoover
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, 30322, USA
| | - Dominick Shattuck
- Center for Communication, and Department of Health Behavior and Society at the Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, 21205, USA
| | - Karen L. Andes
- Department of Behavioral and Social Sciences, Brown University, Providence, Rhode Island, 02903, USA
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Wang C, Meriggiola MC, Amory JK, Barratt CLR, Behre HM, Bremner WJ, Ferlin A, Honig S, Kopa Z, Lo K, Nieschlag E, Page ST, Sandlow J, Sitruk-Ware R, Swerdloff RS, Wu FCW, Goulis DG. Practice and development of male contraception: European Academy of Andrology and American Society of Andrology guidelines. Andrology 2023. [PMID: 37727884 DOI: 10.1111/andr.13525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUNDS Despite a wide spectrum of contraceptive methods for women, the unintended pregnancy rate remains high (45% in the US), with 50% resulting in abortion. Currently, 20% of global contraceptive use is male-directed, with a wide variation among countries due to limited availability and lack of efficacy. Worldwide studies indicate that >50% of men would opt to use a reversible method, and 90% of women would rely on their partner to use a contraceptive. Additional reasons for novel male contraceptive methods to be available include the increased life expectancy, sharing the reproductive risks among partners, social issues, the lack of pharma industry involvement and the lack of opinion makers advocating for male contraception. AIM The present guidelines aim to review the status regarding male contraception, the current state of the art to support the clinical practice, recommend minimal requirements for new male contraceptive development and provide and grade updated, evidence-based recommendations from the European Society of Andrology (EAA) and the American Society of Andrology (ASA). METHODS An expert panel of academicians appointed by the EAA and the ASA generated a consensus guideline according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system. RESULTS Sixty evidence-based and graded recommendations were produced on couple-centered communication, behaviors, barrier methods, semen analysis and contraceptive efficacy, physical agents, surgical methods, actions before initiating male contraception, hormonal methods, non-hormonal methods, vaccines, and social and ethical considerations. CONCLUSION As gender roles transform and gender equity is established in relationships, the male contribution to family planning must be facilitated. Efficient and safe male-directed methods must be evaluated and introduced into clinical practice, preferably reversible, either hormonal or non-hormonal. From a future perspective, identifying new hormonal combinations, suitable testicular targets, and emerging vas occlusion methods will produce novel molecules and products for male contraception.
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Affiliation(s)
- Christina Wang
- Division of Endocrinology, Department of Medicine and Clinical and Translational Science Institute, The Lundquist Insitute and Harbor-UCLA Medical Center, Torrance, California, USA
| | - Maria Cristina Meriggiola
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - John K Amory
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Christopher L R Barratt
- Division of Systems and Cellular Medicine, Medical School, Ninewells Hospital, University of Dundee, Dundee, Scotland
| | - Hermann M Behre
- Center for Reproductive Medicine and Andrology, University Medicine Halle, Halle, Germany
| | - William J Bremner
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Alberto Ferlin
- Unit of Andrology and Reproductive Medicine, Department of Medicine, University of Padova, Padova, Italy
| | - Stanton Honig
- Division of Reproductive and Sexual Medicine, Department of Urology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Zsolt Kopa
- Department of Urology, Andrology Centre, Semmelweis University, Budapest, Hungary
| | - Kirk Lo
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Eberhard Nieschlag
- Center of Reproductive Medicine and Andrology, University Hospital, Münster, Germany
| | - Stephanie T Page
- Division of Metabolism, Endocrinology and Nutrition, UW Medicine Diabetes Institute, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jay Sandlow
- Department of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Regine Sitruk-Ware
- Center for Biomedical Research, Population Council, New York, New York, USA
| | - Ronald S Swerdloff
- Division of Endocrinology, Department of Medicine, The Lundquist Institute and Harbor-UCLA Medical Center, Torrance, California, USA
| | - Frederick C W Wu
- Division of Endocrinology, Diabetes and Gastroenterology, Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Dimitrios G Goulis
- First Department of Obstetrics and Gynecology, Unit of Reproductive Endocrinology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Nieschlag E, Nieschlag S. Why we need more methods for male contraception. Andrology 2023; 11:421-424. [PMID: 36415925 DOI: 10.1111/andr.13343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/29/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022]
Abstract
The US Supreme Court decision against abortion has once again triggered the call for male contraception. However, in addition to existing methods, there are further reasons why pharmacological reversible easy-to-use male contraception should be available. Green activists and environmentalists have to recognize that overpopulation consume resources. Medical progress results in increasing life expectancy and must be combined with contraception. Sharing the risks of contraception among partners and "Reproductive Autonomy for All" are ethical issues. The resistance of the pharmacological industry to becoming partners in male contraception must be overcome by public financial subsidies and popular demand.
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Affiliation(s)
- Eberhard Nieschlag
- Centre of Reproductive Medicine and Andrology, University Hospitals Münster, Münster, Germany
| | - Susan Nieschlag
- Centre of Reproductive Medicine and Andrology, University Hospitals Münster, Münster, Germany
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Page ST, Amory JK. The world needs better male contraceptives: What is taking so long? FASEB J 2022; 36:e22658. [PMID: 36370122 DOI: 10.1096/fj.202201258r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/11/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Abstract
Forty percent of US pregnancies are unintended despite currently available contraceptives. A substantial number of men use the currently available methods of male contraception, condoms and vasectomy, and a large majority would be interested in novel forms of male contraception if available. Research into male contraception has been ongoing for more than 50 years, with hormonal contraceptives nearing clinical utility and non-hormonal methods hopefully becoming available, albeit with a longer time frame. However, uncertainly regarding benchmarks for the efficacy and safety of male contraception continue to be an issue with development and regulatory approval. In addition, pharmaceutical industry support is minimal with the NIH and Foundations being the main research funders. Given the continuing high rates of unintended pregnancy, many of which are now occurring in areas with extremely restricted access to legal abortion, additional focus and investment in male contraceptive development is imperative.
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Affiliation(s)
- Stephanie T Page
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - John K Amory
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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Sheridan T, Gómez-Torres P, Vera Cruz G, Martínez-Pérez GZ. A global grounded theory exploration of investigators' perspectives on male hormonal contraceptive development and acceptability. Glob Public Health 2022; 17:3760-3772. [PMID: 35901059 DOI: 10.1080/17441692.2022.2102201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
While best practices have been proposed on how to engage men in family planning (FP), the limited options of male hormonal contraceptives (MHC) are a barrier to reaching men as clients of FP programs. The lack of alternative MHC is preventing the global health community from providing holistic reproductive healthcare. A qualitative grounded theory study was conducted in 2020 to explore MHC experts' perceptions around the development and theoretical acceptability of MHCs. Individual in-depth interviews were conducted with 15 key informants. The informants cited evidence that there is a demand for MHC. The inability to access this data by the pharmaceutical industry was acknowledged. Many informants expressed concern of the possibility for MHC to increase male power in a predominantly patriarchal world. To most informants, at least for the initial introduction of MHC, fertility sharing is something that will largely happen among couples alone rather than individually. There is proven demand among women and men for MHC, however industries may still be reluctant to invest. Effort is needed by the sexual and reproductive health and rights community to include male engagement in FP and to advocate for the development and use of MHC as a tool for women's empowerment.
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Affiliation(s)
- Taylor Sheridan
- The Barcelona Institute for Global Health Foundation (ISGlobal), Barcelona, Spain
| | - Piedad Gómez-Torres
- Department of Physiatrics and Nursing, University of Zaragoza, Zaragoza, Spain
| | - Germano Vera Cruz
- Department of Psychology, UR 7273 CRP-CPO, University of Picardie Jules Verne, Amiens, France
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Abstract
Rates of unplanned pregnancies are high and stagnant globally, burdening women, families and the environment. Local limitations placed upon contraceptive access and abortion services exacerbate global disparities for women. Despite survey data suggesting men and their partners are eager for expanded male contraceptive options, efforts to develop such agents have been stymied by a paucity of monetary investment. Modern male hormonal contraception, like female hormonal methods, relies upon exogenous progestins to suppress the hypothalamic-pituitary-gonadal axis, in turn suppressing testicular testosterone production and sperm maturation. Addition of an androgen augments gonadotropin suppression, more effectively suppressing spermatogenesis in men, and provides androgenic support for male physiology. Previous contraceptive efficacy studies in couples have shown that hormonal male methods are effective and reversible. Recent efforts have been directed at addressing potential user and regulatory concerns by utilizing novel steroids and varied routes of hormone delivery. Provision of effective contraceptive options for men and women is an urgent public health need. Recognizing and addressing the gaps in our contraceptive options and engaging men in family planning will help reduce rates of unplanned pregnancies in the coming decades.
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Affiliation(s)
- Stephanie T. Page
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, United States
- *Correspondence: Stephanie T. Page,
| | - Diana Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Christina Wang
- Clinical and Translational Science Institute at the Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, United States
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Abstract
BACKGROUND The advent of new methods of male contraception would increase contraceptive options for men and women and advance male contraceptive agency. Pharmaceutical R&D for male contraception has been dormant since the 1990s. The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) has supported a contraceptive development program since 1969 and supports most ongoing hormonal male contraceptive development. Nonhormonal methods are in earlier stages of development. CONTENT Several hormonal male contraceptive agents have entered clinical trials. Novel single agent products being evaluated include dimethandrolone undecanoate, 11β-methyl-nortestosterone dodecylcarbonate, and 7α-methyl-19-nortestosterone. A contraceptive efficacy trial of Nestorone®/testosterone gel is underway. Potential nonhormonal methods are at preclinical stages of development. Many nonhormonal male contraceptive targets that affect sperm production, sperm function, or sperm transport have been identified. SUMMARY NICHD supports development of reversible male contraceptive agents. Other organizations such as the World Health Organization, the Population Council, and the Male Contraception Initiative are pursuing male contraceptive development, but industry involvement remains limited.
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Affiliation(s)
- Jill E Long
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
- Correspondence: Dr. Jill Long, 6710B Rockledge Drive, Room 3243, Bethesda, MD 20892, USA.
| | - Min S Lee
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Diana L Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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