Why does male contraception still lag so far behind?

World Contraception Day on September 26 provides an opportunity to examine the disparity in contraception options between men and women. Women have access to a wide range of methods, including oral pills, injectables, implants, intrauterine devices and even permanent sterilisation, though access and affordability continue to be major issues in our country. Men, on the other hand, are largely limited to condoms for reversible contraception and vasectomy for permanent contraception.

The biology, anatomy and mechanics of preventing conception create different challenges for men and women. While women's reproduction is governed by a narrow hormonal axis with a single ovum released in most menstrual cycles, men's fertility is organised differently with millions of sperm continuously produced. Suppressing sperm production to zero and allowing fertility to return instantly is a significant challenge for a male contraceptive.

The condom remains the only widely used reversible contraceptive that a man can control directly. Its history dates back 3000 years, evolving from animal intestine and bladder to modern latex condoms that are thinner and stronger. However, condoms depend on correct use during every act of intercourse and their failure rate is higher compared to other methods.

Vasectomy, on the other hand, is a permanent solution where the vas deferens carrying sperm from each testis is interrupted. While modern no-scalpel vasectomy is simpler and does not require abdominal entry, its share of sterilisations in India remains low compared to female sterilisation. Fear of weakness, misconceptions about sexual performance, social expectations and the evolution of family-planning services have contributed to this imbalance.

The reproductive differences between men and women create various obstacles for a male contraceptive. Continuous sperm production, suppressing high local testosterone while preserving enough androgen action elsewhere, and the absence of a mechanical cavity like the uterus in men present significant challenges. Furthermore, there is currently no approved method that allows men to prevent conception after intercourse.

Researchers are exploring various directions to tackle this problem, moving beyond replicating the female pill. A testosterone gel suppresses sperm production while replacing androgen, while a non-hormonal oral drug named YCT-529 interferes with retinoic-acid signalling required for sperm development. Other researchers are investigating compounds that temporarily impair sperm motility and mechanical approaches such as the Reversible Inhibition of Sperm Under Guidance (RISUG) and hydrogel systems like ADAM, which temporarily block the vas deferens.

Although none of these methods have yet become routine, there are several promising routes to explore.