Contraception: The need for a new contraceptive revolution

Since the approval of the first contraceptive pill on May 11, 1960, contraceptive methods have been flourishing – although some drawbacks have been identified such as the risk of thromboembolic disease related to the use of ethinyl estradiol (EE) as well as the potential cardiovascular risks in women who smoke after age 35.

However, the needs remain enormous, although women can now choose between a variety of combined oral contraceptives containing less and less EE, progestin-only pills, implants, vaginal rings, patches, and intrauterine devices/intrauterine systems. The first reason is the population growth, especially in developing countries, where many young women at reproductive age live. According to the UN Division of Population, the world population is growing, to reach 9.2 billion (2.3–36.4) in 2075 vs. 6.4 billion presently and stabilize thereafter [1]. These previsions are certainly largely speculative because they depend on the projected fertility rate which may decrease significantly in the future (the so-called ‘second demographic transition’), particularly if the trend for later pregnancies is confirmed. However, the need for further research is clear since, although fertility control is the key of economic progress, a very large number of women do not have access to contraception. Presently 60% of women at age of reproduction are using a contraceptive method: 20% in Africa, 70% in Europe, 69% in China and 66% in Latin America.

Another important point to consider is that the need for new methods is also important in the Western world where the rate of unwanted pregnancy remains too high, reaching one-third of pregnancies in some countries. This explains the high number of abortions which does not decrease (e.g. 220 000 every year in France) despite the availability of multiple methods of contraception and the free access to these methods, sometimes without prescription, in France. The reasons for this too high rate of unwanted pregnancies are multiple and involve poor education on contraceptive methods, eventual lack of compliance because of side-effects, and the need for daily compliance. The search for new methods is therefore mandatory, in order to design techniques that are easy to use, long-acting, and devoid of adverse events.

Finally, the pharmaceutical industry seems to have somehow lost interest in this area, where many methods already exist and where the return on investment requires aggressive marketing and the struggle for a reasonable price in the face of national policies of reimbursements. In the last years new pills have been approved, although not very different from the previous ones.

We therefore need better availability of contraceptive devices, at the lowest possible price, where they are needed, and, at the same time, renewal of techniques in order to improve the choice offered to women.

More research is needed, but the new avenues remain questionable. Male contraception, although progressing with the excellent results obtained with progestin implants associated with testosterone substitution, still remains a very low priority for the pharmaceutical industry. All the excellent ideas formulated at conferences since 1970s have remained theoretical; few concepts, if any, have been able to reach clinical use. Last but not least, the recent meeting organized by the respected Institute of Medicine (2004) provided a blueprint for research involving the use of new genomics and proteomics technologies; however, their conclusion still looks very much like science fiction.

This editorial calls for new research involving basic and clinical studies, investigating the crucial genes and proteins involved in ovarian physiology and spermatogenic function. We certainly hope that new genomic studies using analysis of single nucleotide polymorphisms will help us in this endeavor.