Male Contraception: Where Are We Going and Where Have We
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View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Edinburgh Research Explorer Edinburgh Research Explorer Male Contraception: Where are we going and where have we been? Citation for published version: Reynolds-Wright, J & Anderson, R 2019, 'Male Contraception: Where are we going and where have we been?', BMJ Sexual & Reproductive Health. https://doi.org/10.1136/bmjsrh-2019-200395 Digital Object Identifier (DOI): 10.1136/bmjsrh-2019-200395 Link: Link to publication record in Edinburgh Research Explorer Document Version: Publisher's PDF, also known as Version of record Published In: BMJ Sexual & Reproductive Health General rights Copyright for the publications made accessible via the Edinburgh Research Explorer is retained by the author(s) and / or other copyright owners and it is a condition of accessing these publications that users recognise and abide by the legal requirements associated with these rights. Take down policy The University of Edinburgh has made every reasonable effort to ensure that Edinburgh Research Explorer content complies with UK legislation. If you believe that the public display of this file breaches copyright please contact [email protected] providing details, and we will remove access to the work immediately and investigate your claim. Download date: 11. May. 2020 Review BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2019-200395 on 19 September 2019. Downloaded from Male contraception: where are we going and where have we been? John Joseph Reynolds-Wright, Richard A Anderson MRC Centre for Reproductive ABSTRACT Key messages Health, The Queen’s Medical Progress in developing new reversible male Research Institute, University of contraception has been slow. While the Edinburgh, Edinburgh, UK ► Development of male hormonal hormonal approach has been clearly shown contraception has been delayed by Correspondence to to be capable of providing effective and multiple factors, but new clinical trials Dr John Joseph Reynolds-Wright, reversible contraception, there remains no MRC Centre for Reproductive are closer than ever to bringing viable product available. Currently, trials of a self- Health, The Queen’s Medical products to market. administered gel combination of testosterone Research Institute, University ► With new technologies, new potential of Edinburgh, Edinburgh EH16 and the progestogen Nestorone® are under non-hormonal targets for male 4TJ, UK; john. reynolds- wright@ way, complementing the largely injectable nhs. net contraception have been discovered. methods previously investigated. Novel long- ► Developing a greater range of male Received 8 May 2019 acting steroids with both androgenic and methods is vital to providing holistic Revised 13 August 2019 progestogenic activity are also in early clinical reproductive healthcare. Accepted 30 August 2019 trials. The non-hormonal approach offers potential advantages, with potential sites of action on spermatogenesis, and sperm Protected by copyright. maturation in the epididymis or at the vas, but horizon and may start coming to market remains in preclinical testing. Surveys indicate the in the medium term. willingness of men, and their partners, to use a new male method, but they continue to lack that THE LIFE COURSE OF A SPERM opportunity. Spermatogenesis begins in the brain. The hypothalamus secretes gonadotro- INTRODUCTION phin-releasing hormone (GnRH), which The Faculty of Sexual and Reproduc- in turn stimulates the anterior pituitary tive Healthcare vision statement1 focuses to release luteinising hormone (LH) and on patient experience, specifically that follicle stimulating hormone (FSH). These patients should have access to the full range hormones then act on the Leydig and http://jfprhc.bmj.com/ of contraceptive options. For men, these Sertoli cells within the testis. options are currently limited to condoms Leydig cells produce testosterone, and vasectomy. Both these methods have which is secreted into the bloodstream. their positives—condoms continue to Serum testosterone supports a wide range play a vital role in infection prevention of male functions and is a key compo- and are a widely used, easily accessible nent of the negative feedback loop that method of contraception; likewise, vasec- controls GnRH and gonadotrophin on October 10, 2019 at University of Edinburgh. tomy is a highly effective permanent production. Testicular levels of testos- method of contraception. However, they terone are approximately 40 times higher 2 are not sufficient for many sexually active than in blood and support Sertoli cells in men who wish to have control over their their role in spermatogenesis. © Author(s) (or their fertility, and for their partners who wish After release from Sertoli cells (‘spermi- employer(s)) 2019. Re-use to share the burden of contraception. We ation’), sperm progress through the semi- permitted under CC BY. know that sterilisation and condoms are niferous tubules and into the epididymis Published by BMJ. not sufficient for women to control their for storage, concentration and maturation To cite: Reynolds-Wright JJ, fertility, and having a greater breadth of to functional sperm. Finally, at the point Anderson RA. BMJ Sex Reprod of ejaculation, sperm are transferred Health Published Online First: contraceptive tools allows more couples [please include Day Month to have better reproductive control. This from the epididymis via the vas deferens Year]. doi:10.1136/ review will help clinicians to understand to the urethra and then out of the body bmjsrh-2019-200395 the male contraceptives that are on the (figure 1). Reynolds-Wright JJ, Anderson RA. BMJ Sex Reprod Health 2019;0:1–7. doi:10.1136/bmjsrh-2019-200395 1 Review BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2019-200395 on 19 September 2019. Downloaded from history of male contraception will hopefully answer this question. The quest to develop new forms of male contracep- tion started at more or less the same time as the devel- opment of female hormonal contraceptive methods, but has taken a very different course. The culture shift that took place in the wake of the phenomenon of the hormonal contraceptive pill for women3 in 1965 led to the creation of the WHO Special Programme of Research, Development and Research Training in Human Reproduction (WHO-HRP).3 Within the WHO-HRP a task force for developing methods of male fertility regulation was developed. This iden- tified possible modalities for male contraceptives through basic science research projects and multi- centre landmark clinical trials of testosterone alone and in combination with progestogens.3 The task force also focused efforts on the development and promo- tion of no-scalpel vasectomy, which has become the predominant technique globally, and gossypol, which was planned as a reversible contraceptive but unfortu- nately had to be abandoned due to issues with toxicity and irreversibility.3 Over approximately a decade from the mid-1980s, the task force developed new esters of testosterone with the hope that they would be developed by Protected by copyright. industry partners for use in treatment of hypogo- Figure 1 The hypothalamic-pituitary-testicular axis and its role in nadal patients and as male contraceptives. However, spermatogenesis. CCBY 4.0 Licence – John Reynolds-Wright. Image this did not come to fruition, for reasons including accessible via https://flic.kr/p/2hgvk5V6A. FSH, follicle stimulating concerns in industry about security of patents, possi- hormone; GnRH, gonadotrophin-releasing hormone; LH, luteinising bility of litigation, perception of a ‘small market’ and hormone. competition with their existing female contraceptives. Nevertheless, landmark contraceptive efficacy studies Potential novel male contraceptives can be divided were conducted at this time using weekly injections of into those based on a hormonal approach, acting testosterone enanthate. The first of these demonstrated via gonadotrophin suppression, and non-hormonal that most men (70%) became azoospermic when administered 200 mg/week of testosterone enanthate, methods. Hormonal strategies for male contracep- http://jfprhc.bmj.com/ tion involve the hypothalamic-pituitary-testicular and couples then used this as their exclusive method (HPT) axis, using exogenous testosterone in combina- of contraception for 12 months. This proved to be a highly effective contraceptive, with only 0.8 pregnan- tion with progestogen to drive the negative feedback 4 response and suppress GnRH, FSH and LH. Exoge- cies per 100 person-years of exposure. A second study nous replacement of testosterone prevents hypogo- extended this to ask ‘how low does a sperm count nadal side effects from HPT axis suppression but is not need to go?’, and used 3 million/mL as the cut-off for entry to the efficacy phase. This increased the response delivered at high enough concentrations to support on October 10, 2019 at University of Edinburgh. spermatogenesis directly. Non-hormonal methods can rate (92% of men achieved sperm counts below this act at any point during spermatogenesis or can target threshold and entered the efficacy phase), and again excellent efficacy was demonstrated with a Pearl Index sperm maturation, detachment, motility or transport 5 out of the testis. This includes physical methods of of 1.4 (95% CI 0.4 to 3.7). Although a Pearl Index infiltration of the vas with a dissolvable compound to of 8.1 (95% CI 2.2 to 20.7) was achieved even in block or damage sperm during their movement along