A possible improvement

Here in Belgium, despite having the best contraceptive coverage in Europe, there still is undoubtedly room for improvement. There are still 20,000 abortions per year, and 45% of them occur following contraceptive failure caused by improper use, or by the inefficiency of the contraceptive method.

It is regrettable that the contraceptive burden rests primarily on women, who are the ones suffering the consequences of contraceptive failure. Moreover, the choice of male contraception should always go hand in hand with the empowerment of men, which involves, among other things, the generalization of emotional and sexual education in schools and other settings, but also by strengthening access to female contraceptive methods.

However, male contraception today remains limited to inefficient techniques or methods such as the withdrawal method or condoms. The latter, which is often described as restrictive, nonetheless remains the only contraception that also protects against STDs and HIV-AIDS. Another option is a vasectomy, which is effective but difficult to reverse. Although many hormonal and non-hormonal contraceptive options for men have been explored and proven to be effective, there continues to be poor uptake in comparison to female contraceptive options.

Today in Belgium, the younger generations are questioning female hormonal contraceptive methods, with demands for "natural" methods increasing and those of vasectomies even more, as some men want to be able to manage their contraception.

Finally, the third and fourth generation pill crisis and the #MeToo movement have led to a demand for the rebalancing of the contraceptive load within heterosexual couples. Other voices such as renowned researchers have also been vocal in their call for access to reliable, reversible and affordable male contraceptive methods. It is undeniable that male contraception is gaining increasing interest. In addition, improving access to it would improve birth control and couples' reproductive health as well as allow men to control their fertility and reduce the number of unplanned pregnancies. Yet to date, there is no male contraceptive drug with marketing authorization.

A public health issue

For 30 years it has been said: The male contraceptive pill is for tomorrow! Despite countless Phase 2 studies that have proven the effectiveness of hormonal male contraception, and although a few doctors prescribe it in France, its development remains blocked. Uncomfortable routes of administration (injections, implants, etc.), institutional obstacles, gender stereotypes about virility and the reluctance of the pharmaceutical industry that claims it won't be profitable, prevent Phase 3 studies that would lead to commercialization.

Non-hormonal alternatives exist, including male thermal contraception which was developed in the 1990s by a French team. It is based on artificial cryptorchidism, in other words, the artificial raising of the testicles to the base of the groin. It is a simple, non-drug required, reversible and effective method, but like other forms of male contraception, it is sorely lacking in evaluation studies. Recently, this experimental technique has been adopted by groups of men concerned with controlling their fertility, but also eager to share the contraceptive burden with their partners.

Encouraging contraceptive diversity 

In Belgium, the internet, social networks, the media, and committed men and women have shed light on this technique, which has contributed to a regular increase in requests for information and use in young men between 20 and 35 years old. However, although protocols for the medical management of thermal contraception have been published and training exists in France, our health professionals are not educated in this method and the staff in this sector are not equipped to direct the public effectively.

Faced with this growing increase in demands, whose leitmotif is mainly that of sharing the contraceptive onus, we caregivers believe that these are legitimate and take responsibility in responding to them. The information available on the internet must be medically supervised (side effects, precautions for use, monitoring, etc.); to leave these couples and men to cope with what they find would be irresponsible.

In view of these observations and in agreement with first and second-line organizations in lifelong education and health promotion, we ask for active public policies in favor of male contraception and contraceptive diversity: political support and academic research and evaluation of methods, training of caregivers in contraceptive diversity, generalization of EVRAS and teaching of a comprehensive approach to sexual and reproductive health, accessibility of vasectomy in the first line of health care (family planning center, medical centers, etc.), promotion of new male contraceptive methods and the involvement of the pharmaceutical sector in their marketing.

Society evolves, and history has repeatedly shown that civil society can be the driver of significant change in the way we live our lives.

*Dr Daniel Murillo is the deputy head of gynecology at the CHU Saint-Pierre in Brussels and Caroline Watillon is a coordinator in the access to global health sector.

**This article was translated with permission from its authors.