Safety and efficacy of percutaneous injection of polyurethane elastomer (MPU) plugs for vas occlusion in man

Update on Novel Hormonal and Nonhormonal Male Contraceptive Development

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.

Male contraception-a topic with many facets

In addition to the scientific issues associated with male contraception, there are a variety of other concerns that must be addressed before new male contraceptives reach the market. Cultural attitudes toward contraception will play a role both in the acceptability of any contraceptive and in compliance and usage. Delivery methods must also be considered; different methods are favored depending on the social context. Prevention of sexually transmitted diseases by a combined contraceptive/microbicidal treatment is a laudable goal, and may enhance public acceptance of a male contraceptive. This review is the result of a workshop that was convened to address these topics.

Male contraception

Currently approved male-directed contraceptive methods include condoms and vas occlusion. Vas occlusion is very effective but is intended to be non-reversible. Condoms have a relatively high failure rate, at least partially due to compliance problems and are not accepted by many couples. The only other male-oriented methods in clinical trials utilize the administration of testosterone alone or its combination with another gonadotropin-suppressing agent such as a progestin or a gonadotropin-releasing hormone antagonist. Studies published in the 1990s demonstrated that a testosterone-containing hormonal contraceptive method suppressed spermatogenesis to azoospermia in most men and severe oligozoospermia in the remaining. The contraceptive efficacy after treatment with testosterone alone was comparable to that of female hormonal methods. Having proven that reversible male contraception is a reality, present trials are attempting to identify the best androgen delivery system and the most effective androgen plus progestin preparation. It is likely that the first marketed male hormonal contraceptive method will be a long-acting (injectable or implant) combination of an androgen plus a progestin. Research is continuing to identify other target areas for male contraceptive development, including agents with post-testicular and epididymal sites of action.

The relationship between the vas volume and the anatomic size of the vas deferens

The anatomic sizes of 210 vas segments from 107 volunteers of vasectomy were measured by computerized image graphic technique with microphotography. The mean equivalent-round, outer and inner diameters of the vas were 2.17 +/- 0.20 mm and 0.56 +/- 0.08 mm, respectively. The calculated thickness of vas wall was 0.81 +/- 0.21 mm. The maximal volumes of 124 vas segments (1 cm in length) were tested by injecting colored solution into vas lumen until vas rupture. The mean rupture volume of 1 cm vas lumen was 0.05 +/- 0.007 mL. A significant influence of the thickness of vas wall (p < 0.05) and body height (p < 0.05) on the rupture volume was noticed in stepwise regression analysis. A tunnel-like rupturing pattern was observed in morphological observation. The obtained rupture volume provides a security line in determining the injection volume of occlusive material or the size of the implanted contraceptive device.

Male contraception

With the powerful tools of molecular investigation, the last decade has witnessed the most remarkable scientific advance in our history, yet no new leads for male contraception have been forthcoming. All the likely methods of male contraception discussed above were derived from relatively 'old' physiological principles or serendipitous observations. The increasing gap between fundamental research (in the control of mammalian spermatogenesis) and the lack of clinical application are a testament to the low public funding priority afforded to male reproduction and the unwillingness of the pharmaceutical industry to invest in male reproductive research and development. Yet amidst such an unfavourable setting and with very limited support, it is heartening to note that the prospects of introducing a new systemic method for male contraception into the market by the end of this millenium has been greatly enhanced. Thus the results of recent studies have confirmed the contraceptive efficacy of sex steroid-induced oligozoospermia and unexpectedly revealed an ethnically distinct pattern of susceptibility to the hormonal suppression of spermatogenesis. Thus, Asian men are more responsive than are caucasian, and long-acting testosterone esters now being tested in that most densely populated part of the world may well hasten the large-scale application of this method. This is probably the most effective way to correct the misconceptions that men are unwilling or disinterested in sharing in family planning options with their partners. Together with the increased acceptance of novel non-surgical and reversible methods of vas deferens occlusion and the availability of improved non-latex condoms, the currently unfulfilled contraceptive needs of millions of men can be increasingly met in future years. The consequent increase in overall contraceptive prevalence could well make the telling difference between demographic catastrophe and maintaining good quality existence. Politicians, scientists and industrialists need to wake up to their responsibilities and the opportunities offered by this untapped resource and market potential.

Sterilization

Sterilization is accepted as a permanent method of contraception by many couples in the world. Female sterilization is more widely used than male sterilization, but the latter is used by many couples in developed countries. The most widely used methods for female sterilization are simple tubal ligation, electrocautery of the fallopian tubes, and occlusion of the tubes by Hulka or Filshie clips or Falope rings. These procedures may be carried out either by minilaparotomy or by laparoscopy, under local anaesthesia. Sterilization may be performed immediately following pregnancy, or as an interval operation. The effectiveness of female sterilization is high, with failure rates of about 1-2 per 1000 procedures. Immediate complications are few and minor, while there appear to be no serious, long-term adverse effects. It is possible that there is a protective effect against ovarian cancer. Potential new technologies for female sterilization include the use of chemicals, such as quinacrine, for transcervical tubal occlusion, and hysteroscopic methods. Male sterilization is more simple and can readily be performed under local anaesthesia. A new technique originating in China, the no-scalpel technique, has made the procedure even more simple and produces fewer complications such as haematoma. It is possible that the direct injection of plug-forming material into the vas may render the procedure more reversible. Concerns about possible adverse effects of vasectomy on cardiovascular diseases and testicular cancer largely have been dispelled, but a possible weak association between vasectomy and prostatic cancer continues to be studied.

Intravasal injection of formed-in-place medical grade silicone rubber for vas occlusion

This paper describes two consecutive studies: a volume study and an efficacy study. The volume study determined the appropriated volume of Medical Grade Silicone Rubber (MSR) needed to achieve complete occlusion of the vas deferens. This was done by in-vitro testing of 130 human vas specimens containing plugs of MSR formed in vivo. The volume of MSR needed to occlude the vas was 0.1531 +/- 0.0059 ml injected by five to six turns of the applicator handwheel. There was a correlation between MSR volume, weight, and the number of turns of the applicator handwheel. An influence of body height upon the volume and weight of the MSR was also observed. An oval shaped clamp (15 mm long) was more effective in producing secure vas occlusion than was a round clamp (10 mm long). The mean outer diameter of the vas specimens was 1.80 +/0 0.15 mm, and the mean maximum dilated inner diameter was 0.93 +/- 0.11 mm. The efficacy study was a clinical trial to compare MSR was occlusion (using an oval 15 mm clamp and the appropriate volume derived from the volume study, n = 58) with no-scalpel vasectomy as the standard procedure (n = 64). The azoospermia rate following MSR vas occlusion was not significantly different from that following no-scalpel vasectomy, and was achieved in 3-6 months.