Science not Silence!

Thousands of people across Australia rallied together for the 'March for Science' on Earth Day 2017 (Saturday 22nd April) as part of a global movement to defend the vital role science plays in our health, safety, economics and government. Demonstrations were held around the world, from the North Pole to the bottom of the ocean, bringing together anyone who values the important role of science in our lives. Of late, concerns have been raised that new policies and governments are ignoring and denying scientific evidence whilst simultaneously restricting scientists' ability to research and to communicate their findings. 'Alternative facts' are being presented as viable truths in place of real scientific discoveries, and it is time for those who value science to break their silence and come forth to defend science and scientific integrity.

I was unsure what to expect when I headed through Forrest Place in the city centre to join the March for Science in Perth, but was overjoyed to see a large group of people adorned with science-related t-shirts, hats, banners and of course posters and signs. Having not had the opportunity to make one of my own, I was grateful to find that the organisers had a table full of extra signs for attendees and chose a dinosaur-themed sign for myself proclaiming 'Science can do it!'.

Looking around the crowd there were a variety of inventive signs and attire with slogans such as 'The Oceans are Rising and so are We!', ' There is NO Planet B' and 'Make Glaciers Great Again!'. There was even one lady with a fantastic hat decorated creatively with brightly coloured fish!

For people who are under the impression that science is of no interest or importance to them, helpful reminders such as 'Have a Smartphone? Thank a Scientist!' and 'Ever used Antibiotics? Thank Science!' demonstrated how integrated and universal science is in our lives. It was fantastic to see children and families getting involved with the March as the future we fight to secure now will be their future, and it will be their fight.

What really stood out for me was the various speakers the organisers had arranged to talk about their work and the importance of science. The main presenter (or 'MC'!) was Callum Ormonde of UWA, who is currently working on breast cancer research. Callum has gained global recognition after co-authoring a paper in 2015 on research that was awarded The Ig Nobel Prize for Chemistry for partially unboiling an egg. He has since received attention for his 2015 TEDxPerth talk and most recently was named as one of Business news WA 40 under 40 for 2017. As the main presenter, Callum was witty and engaging, effortlessly dealing with minor hiccups such as additional speakers running behind whilst entertaining the gathered crowd with ease.

Another stand out was Lindy Fitzgerald, a Professor of Neurotrauma at Curtain University who was also selected for 'Homeward Bound 2016' - an expedition to Antarctica that, as part of an international leadership and strategy program, was designed to increase the the proportion of women in higher levels of science. Taking part in this program has inspired Lindy to serve as an advocate for broader equity in science and, as a woman scientist myself, her speech was thought-provoking and empowering.

The crowd was also wowed by Professor Lyn Beazley, another neuroscientist and also WA's Chief Scientist from 2006 to 2013. In this role, Lyn acted as a science ambassador, worked closely with industry, and advised governments on science and innovation. She was also at the head of a program to supply primary schools with microscopes and has a personal goal that every Australian child with grow up to learn and love science. Inspiring future generations is essential in ensuring that the importance of scientific research and evidence continues to be upheld and it was wonderful to hear Lyn speak about something she is clearly so passionate about.

This offers just a snapshot of the amazing speakers present at the March for Science in Perth, with many more inspiring the crowd with their research, presenting evidence and explaining the importance of what they do, and how it impacts us all. Across the globe similar demonstrations were taking place, where those who love and appreciate science stood up and refused to be silenced.

For the future of human life and our planet, the application of science must influence policy and guide long-term decision making, and the March for Science demonstrated just how many people are prepared to fight for and defend science.

Will Vasalgel be the breakthrough in male contraception?

There have been no advances in male contraception for over a century, with current options limited to condoms, the withdrawal method or a vasectomy. Despite promising research into male hormonal contraception, trials have had to be halted early due to side effects, and further work is required to reach an acceptable balance between efficacy and safety.

Currently the most promising new research is Vasalgel – a long-acting, non-hormonal contraceptive that works in a similar way as a no-scalpel vasectomy but is thought to be more easily reversible.

How does Vasalgel work?

Sperm is produced in the testes and is transported through tubes called the vas deferens. It is these vas deferens which are clamped, cut or otherwise sealed during a vasectomy, preventing the flow of sperm so that they are reabsorbed by the body. With this new method, Vasalgel is injected into the vas deferens and fills the interior of the tube (lumen) with a soft, semi-permeable gel barrier. Fluid remains able to pass through the tubes, reducing the back-pressure in the epididymis (sperm storage area), however the sperm themselves cannot and are instead reabsorbed by the body.

Image sourced from Parsemus Foundation on the 16^th March 2017 (https://www.parsemusfoundation.org/projects/vasalgel/)

Does Vasalgel work?

Vasalgel was inspired by another polymer contraceptive known as 'reversible inhibition of sperm under guidance' (RISUG) that is currently undergoing advanced clinical trials in India. Some men have been using RISUG for over 15 years but only local men near the study sites are currently eligible for the trial. In addition, any formal reversibility studies have only been performed in animal models thus far, however this process is relatively simple and requires the gel to be 'flushed out' with another polymer.

Vasalgel was developed by the Parsemus Foundation for the rest of the world outside of India. Initial studies in rabbits over 12 months showed no sperm from the second semen sample onwards and a rapid return of sperm flow after the Vasalgel polymer had been flushed out.

In addition, a new study published earlier this year has shown that Vasalgel was 100% effective in trials using rhesus monkeys. 16 adult rhesus macaques received Vasalgel injections, had one week of recovery time and then returned to outdoor housing with between 3-9 breeding females with a successful reproductive history. All of the monkeys in the trial were housed with the females for at least one breeding season, and 7 out of the 16 were housed with breeding females for 2 years.

Following the 1-2 year period, the Vasalgel trial was 100% effective with no reported pregnancies amongst the breeding females. Overall, Vasalgel was very well-tolerated, and placement resulted in minimal complications, which were comparable to monkeys in the control group which had received vasectomies.

Elaine Lissner, executive director of the Parsemus Foundation said "What was important here was that this worked and was safe in animals similar to humans".

What's next?

The promising results of this study warrant further research, including studying the possibility of reversal, which thus far has been successful in rabbits but has not yet been shown in non-human primates.

Lissner and her team have further animal studies planned for this year and hope to start clinical trials in humans next year. There is still a way to go, but if the promising results observed in animal studies are transferable to humans it is possible that Vasalgel will be on the market in the not too distant future.

Additional notes

The Parsemus Foundation is developing Vasalgel as a 'social venture' company, meaning that it makes enough money to stay afloat but not to make large profits, with its mandate being affordable pricing and a wide availability. They rely on public support and donations to drive the development and bring Vasalgel to market with further information available here.

The California National Primate Research Centre (CNPRC) ensures a free-living environment with social groups for the well-being of it's primates.

Will there ever be a hormonal contraception method for men?

Although there are a wide variety of contraceptive options for females to prevent pregnancy, the choices available for men to have control over their fertility have not changed for over a century. These choices either have a lower efficacy, such as condoms or the withdrawal method which have an efficacy rate of 82% and 78% respectively, or are intended to be permanent, such as a vasectomy. Various studies have worked on developing a hormonal contraceptive for men with limited success.

One promising study published in the Journal of Clinical Endocrinology and Metabolism last year described the progress of a male contraceptive injection. The injection contained two hormones: progestogen which acts on the brains pituitary gland and affects sperm production, and testosterone to counteract the testosterone-reducing effects of progestogen.

In the study, 320 healthy males aged 18-45 years that had been in long-term monogamous relationships with females for at least 1 year and had a healthy sperm count of at least 15 million/ml received injections every 8 weeks for over a year. Once the injection had taken affect (sperm count had dropped below 1 million/ml), their partners stopped using other birth control methods.

Semen samples from the participants showed that at 24 weeks the sperm counts of 274 participants had dropped to this level and overall the study showed the injection to be 96% effective, with only 4 pregnancies recorded amongst the partners of 266 participants.

One of the study's authors, Dr Mario Philip Reyes Festin, of the World Health Organisation stated that “The study found it is possible to have a hormonal contraceptive for men that reduces the risk of unplanned pregnancies in the partners of men who use it”.

However, despite the fact that 75% of the participants said they would continue using the injection, 20 men dropped out of the study due to associated side effects. These side effects included mood disorders, acne, muscle pain, increased libido and pain at the injection site, however there was also 1 case of depression, 1 case of an intentional paracetamol overdose and 1 case of an irregular heart rate that were judged to be possibly related to the injection. The trial was eventually discontinued following an evaluation by an external safety review panel who determined that the risks to participants outweighed the potential benefits.

The female oral contraceptive pill (which contains either a combination of oestrogen and progesterone, or solely progesterone) was first launched in 1962 and is widely used across the globe. However, it does have many associated side effects including mood disorders, depression, nausea, breast tenderness, headaches, weight gain, decreased libido and the disruption of the menstrual cycle, as well as increasing your risk of blood clots, heart attacks and stroke.

Despite this, progresses in male hormonal contraceptives are being delayed due to concerns over similar side effects.

Hopefully the developments in non-hormonal male contraception will be more successful and reach the market to allow men to aid their partners and take control of their own fertility.

Contraception use in Australia

According to one national survey, approximately 50% of Australian women experience an unplanned pregnancy during their reproductive lifetime. This is despite the fact that approximately 70% of Australian women are currently using contraception and up to 85% of women have ever used contraception. The majority of these unintended pregnancies result from either not using contraception or using it incorrectly during sex,with only a small proportion resulting from contraceptive failure.
Despite advances in contraception, including an increased variety of high efficacy methods, surveys show that Australia is still lagging behind in its use of contraception compared to the rest of the developed world.

Contraceptive methods used
The oral contraceptive pill has been available in Australia for over 50 years and remains the most popular form of contraception used by Australian women (27-34%), followed by condom use (20-23%). Despite the fact that long-acting reversible contraception (LARC) options including the implant, IUDs and injection all have higher efficacy rates, they are used by very few women in Australia. For example, in the BEACH study of female patients aged 12-54 years who consulted a GP for contraception, 69% of those prescribed were for oral contraception, compared to 15% prescribed for any type of LARC. In addition, in comparison with other developed countries Australia is lagging behind on its use of LARC, with IUD use in Australia at approximately 0.8% compared to 9.8% on average in other developed countries.

Figure 1: Estimates of contraceptive methods used throughout Australia

Interestingly, when the data is broken down by Australian territory, the use of oral contraceptives and condoms are less common in the Northern Territory compared to the other states (Figure 2). In addition, the Northern Territory shows a higher frequency of LARC and sterilisation being used to prevent pregnancy, and has the highest prevalence of current use of contraception at 79%.

Figure 2: Type of contraceptive method by Australian state and territory, 2011

Additionally, the proportion of women who have ever used emergency contraception ranged from 19-27%, with only 0.4% of women reporting that emergency contraception was one of the methods they used to prevent pregnancy. Nonetheless, over-the-counter access to emergency contraception has not decreased the number of unintended pregnancy or abortion rates in Australia. This is likely attributed to lack of knowledge regarding availability without a doctors visit and efficacy beyond 24 hours after unprotected sex.

Contraception use by age
Oral contraception and condoms are the most commonly reported methods of contraception for all age groups except those over 40 years of age, and the proportion of women reporting using these methods declined with increasing age. On the other hand, partner sterilisation increased from the age of 35 years. This is likely due to the changes in family dynamics as older women have finished their families and look to a longer-acting contraceptive method.

Figure 3: Choice of contraceptive methods by age group, 2011

Resources
The data presented in this article represents some of the main findings of the resource from the family planning alliance of NSW which summarises data collated from various surveys on contraception use. For more information and the full report please click here. 

Why more women should switch to long-acting reversible contraception (LARC) methods

Although over two-thirds of Australian women of reproductive age use contraception, it is estimated that over half of Australian women experience an unplanned pregnancy. Currently the most commonly used methods of contraception in Australia are the contraceptive pill (27-34%) and condoms (20-23%), the efficacy of which can be easily affected by human error. Experts suggest that the number of unplanned pregnancies could be reduced if more women used long-acting reversible contraception (LARC) methods, however currently they have one of the lowest uptakes.

Family Planning NSW's 'Reproductive and sexual health in Australia' resource states:

"Very few women used long acting reversible contraception (LARCs) with injectable contraception accounting for 0.9 to 2.1% of contraceptive use with similar proportions of use for the implant (1.1 to 3.6%) and intrauterine contraceptive methods (IUDs) (1.2 to 3.2%).”

Improving the public's understanding of LARCs will not only allow women to have more choices of contraception, but also decrease the risk and rate of unplanned pregnancies.

What are LARCs?
LARCs are the most effective forms of contraception after abstinence and are considered to be on par with sterilisation. Unlike other methods of contraception, human error generally has very little impact on LARCs as they do not require action to prevent pregnancy on a daily basis or prior to each incidence of sexual intercourse. The long-acting nature of LARCs often gives them the tag line 'fit and forget' as once they've been inserted they will be effective for a number of years. LARCs need to be inserted and removed by a doctor, and are fully reversible allowing a quick return to full fertility after removal.

There are three main types of LARC:

Implant

What is it?
The implant is a 4cm plastic rod that is inserted under the skin in your upper arm by your doctor. It continuously releases a synthetic hormone similar to progesterone into the bloodstream and lasts up to three years. Fertility returns very quickly upon removal of the implant by your doctor.

Efficacy
The implant is one of the most effective contraception options available with a rate of 99.95% protection with typical use (how most people use it).

Side effects
Some women may experience dramatic changes to their menstrual cycle, or other hormone-related side effects, and are recommended to trial the implant for three months and discuss issues with a doctor before considering removal.

Intrauterine devices/systems (IUD/IUS)

Early forms of IUD/IUS had a bad reputation, but modern types of IUD/IUS have greatly improved and are an excellent choice for women who have completed their families or younger, childless women. There are two types currently available – hormonal (IUS) and copper (IUD).

Hormonal IUS

What is it?
A small, T-shaped piece of plastic is inserted into the uterus by your doctor, and the attached fine threads protrude through the cervix to assist with removal. The hormonal IUS slowly releases the hormone levonorgestrel (similar to progesterone) for up to 5 years and fertility returns to normal very quickly following removal.

Efficacy
The hormonal IUD has a protection rate of 99.8% for typical use.

Side effects
A small number of women (~5%) may experience an unexpected expulsion of the hormonal IUS. Women can check whether their device is still in place by feeling for the fine threads that protrude through the cervix. The hormonal IUS can also alter a women's menstrual cycle, usually by causing periods to become lighter and less frequent so are particularly useful in women with heavy menstrual bleeding.

Copper IUD

What is it?
A small, T-shaped or U-shaped plastic device wrapped with copper wire is inserted into the uterus by your doctor, and the attached fine threads protrude through the cervix to assist with removal. The copper IUD inhibits the movement of sperm (sperm motility) and also creates an unsuitable environment for implantation. Different types of copper IUD last for up to 5 or 10 years and fertility returns to normal very quickly following removal.

Efficacy
The copper IUD has a protection rate of 99.2% with typical use.

Side effects
A small number of women (~2-3%) may experience an unexpected expulsion of the copper IUD. Women can check whether their device is still in place by feeling for the fine threads that protrude through the cervix. The copper IUD can also alter a women's menstrual cycle, usually by causing periods to become heavier, with up to 50% more bleeding. The copper IUD is a suitable choice for women who cannot, or prefer not to use a hormonal form of contraception.


The 'in-between'

Contraceptive injections

The contraceptive injection falls somewhere between short-term contraceptive methods and LARCs. Contraceptive injections last between 8-13 weeks so require more human input than other LARCs and therefore have a lower efficacy rate. Unlike the implant or IUD/IUS, the injection does not offer an immediate return to fertility.

What is it?
A synthetic hormone similar to progesterone is injected into the buttock or upper arm by a doctor or nurse every 8-13 weeks depending on the type. It takes 7 days to become effective and is not immediately reversible, with women taking up to two years to return to full fertility.

Efficacy
The injection has a protection rate of 94% with typical use.

Side effects
The contraceptive injection effects bone density and is not recommended as a first choice for women under 18 or over 45 years of age. However, this reduction in bone density is reversible after injections are ceased for women in their mid-reproductive years. The injection can also effect a woman's menstrual cycle, with ~50% of women having no bleeding after one year.

Which contraception is right for me?

There is no 'one contraception fits all' approach to preventing pregnancy as a number of factors can affect the individuals choice including:

• Age
• Gender
• Medical History
• Ability (or preference) to use hormones
• Personality/lifestyle

There is a wide variety of contraception choices ensuring that there is something to suit everyone's individual needs. However, the efficacy (or effectiveness) of each contraceptive method differs and should be considered carefully when making your choice. You should discuss your options with your doctor, however tools such as this one from Your Life may help you get started in knowing what might work best for you.

Long-acting reversible contraception
Long-acting reversible contraception (LARC) is considered the to be the most effective form of contraception and is on par with sterilisation. For more information regarding LARCs please see my article: 'Why more women should switch to long-acting reversible contraception (LARC) methods'.

Short-term contraceptive options:
If LARCs are not right for you, there are a number of short-term contraception methods to choose from, although their efficacy is lower than LARC methods.

Contraceptive pills

Family Planning NSW's 'Reproductive and sexual health in Australia' resource states that contraceptive pills are contraception of choice for most Australian women (27-34%). There are two main types of contraceptive pill – the combined pill and the progesterone-only ('mini') pill.

Combined pill

What is it?
The combined contraceptive pill contains synthetic versions of both oestrogen and progesterone. Most combined pill packs contain 21 active pills and 7 inactive or 'placebo' pills which allow a women to menstruate. If a combined pill is missed a woman may have a leeway of up to 24 hours.

Efficacy
Combined pills have an efficacy of 91% with typical use.

Side effects
Gastric upsets such as vomiting and diarrhoea can prevent the pill from working, as can certain medications including some antibiotics. In addition a woman may experience hormone-related side effects, and is at an increased risk of blood clots.

Mini-pill

What is it?
The mini (or progesterone-only) pill contains a synthetic version of progesterone and is a better option for women over the age of 35 years or who smoke. Most combined pill packs contain 28 active pills. The mini pill needs to be taken at the same time every day and is one is missed a woman may only have a leeway of up to 3 hours.

Efficacy
Mini pills have an efficacy of 91% with typical use.

Side effects
Gastric upsets such as vomiting and diarrhoea can prevent the pill from working, as can certain medications including some antibiotics. In addition a woman may experience hormone-related side effects and be at an increased risk of blood clots.

Condoms

What is it?
Condoms are barrier methods of contraception that prevent sperm entering the uterus and also help protect against some sexually transmitted infections (STIs). There are both male and female condoms, however male condoms are far more common. Male condoms are generally made of latex (although latex-free versions are available) and are placed over an erect penis before penetration. A new condom must be used before each incidence of sexual intercourse.

Efficacy
Male condoms have a lower efficacy for typical use at 82%.

Side effects
Some people may experience an allergic reaction to latex condoms and require latex-free versions. Condoms can also weaken or break, be past their expiration date, be forgotten in the heat of the moment or reduce the sensation for the man – all of which contribute to the lower efficacy rate for typical use.

Vaginal ring

What is it?
A soft, plastic ring is inserted by a woman into her vagina and can remain in place for up to 3 weeks before needing replaced. The ring releases low doses of the hormones oestrogen and progestogen, similar to the contraceptive pill.

Efficacy
The vaginal ring has a protection rate of 91% with typical use.

Side effects
The vaginal ring is an alternative delivery system to the contraceptive pill, and may cause hormone-related side effects including bloodclots. In addition, some women may experience vaginal irritation.

Contraceptive diaphragms and caps

What is it?
Diaphragms and caps are dome-shaped barrier devices made of silicone that are inserted into the vagina to prevent sperm from passing through the cervix. They need to be inserted before every incidence of sexual intercourse and should be left in for at least 6 hours after to ensure sperm does not enter the womb. It is often advised to use spermicide (a gel that kills sperm) along with a diaphragm/cap.

Efficacy
The diaphragm/cap has an efficacy rate of ~88%.

Side effects
The diaphragm/cap can be difficult to put in and requires practice to be done correctly. Some women may find them uncomfortable to use. There is also an increased risk of urinary tract infections (UTIs) associated with diaphragms/caps.


Other contraception methods

Other contraception methods include the 'withdrawal' method and 'fertility awareness' and are less effective at preventing pregnancy. The withdrawal method requires the man to withdraw his penis from the vagina prior to ejaculation, however only has a efficacy rate of 78% due to inconsistent successful implementation and the potential for sperm to be present prior to full ejaculation. Likewise, fertility awareness-based techniques such as timing of the cycle or temperature-taking to determine the fertile days and allowing condoms to be used or sex to be abstained from during this time, have an efficacy rate of just 76%.

Emergency contraception

Emergency contraception can be useful in cases where other forms of contraception have failed or were forgotten. The most common forms of emergency contraception are:

• The emergency contraceptive pill (or 'morning after pill') which contains levonorgestrel
• The Copper IUD

Emergency contraception must be taken within 5 days of sexual intercourse, however is most effective the closer to time, particularly if taken within 24 hours of sex.