By Laura Santhanam

Polina Lishko will tell you she began studying reproductive biology accidentally. But her deep-seated interest in what ignites the body’s bioelectrical signals has opened up new possibilities for how to address infertility and introduce new options for contraception.

Tens of millions of women use some form of birth control in the United States. In 2019, the number of unintended pregnancies hit an all-time low, yet still accounted for 45 percent of all pregnancies, according to the Brookings Institution. Reproductive health experts say that the figure could rise as people lose their health insurance — a trend that was already unfolding before the COVID-19 pandemic forced tens of millions of Americans out of work, severing them from their livelihood and insurance coverage when they needed both the most.

“Having more safe, effective options available for preventing pregnancy is always a good thing,” said Dr. Sarah Prager, a professor who directs the Family Planning Division within the University of Washington’s Department of Obstetrics and Gynecology.

For Ukranian-born Lishko, the brain’s electrical circuits were always fascinating. Lishko, the child of chemists, trained as a physiologist and neuroscientist, studying how bioelectricity sparks neurons into action and the ways our brains work. In 2006, she began to explore how electricity propels sperm cells toward the ovum, or egg, during human reproduction.

Like most cells, sperm is powered by mitochondria, the protein-packed energy storehouse. Cells tap into that energy by breaking down the bonds that hold together molecules of adenosine triphosphate. When that happens, the results can mean muscles contract and nerve impulses flash.

So what if you could turn off the electrical currents that sperm need to tap into those storehouses, she wondered. Could compounds and chemicals, converted into a medication, flip the switch and stop sperm from swimming?

Some tools already exist, but Lishko has found that it is possible to control sperm by manipulating the cell’s access to its mitochondria, illuminating the potential for different purposes. For example, niclosamide is an ointment used to treat tapeworm infestations that has been approved by the Food and Drug Administration. The World Health Organization has long recognized the drug as safe to take with no side effects because it doesn’t absorb into the bloodstream, Lishko said. But in the course of her research, she realized that this ointment overwhelms a sperm cell’s ability to spark bioelectricity and tap into its mitochondria, essentially starving the cell before it reaches the egg. Thanks to Lishko’s work, this product is being explored as a possible contraceptive.

In addition to being the foundation for possible non-hormonal, unisex or male-specific birth control, her research could also potentially be used to spur fertility by directing electrical currents to coax sperm on a successful journey to the egg’s surface.

In science, she said, you often find yourself fumbling to open a “black box,” like how to control bioelectrical signals. When you develop a tool or technique to open the box “you give humanity this picture of what’s inside and this is how it works,” Lishko said.

Birth control has been practiced for millennia, and much of the time, the onus has been on women to prevent pregnancy if they did not wish to bear a child. Since the approval of “the pill” 60 years ago, many women have endured side effects from hormone-based medications, such as depression, intense migraines and loss of bone density, and some are at risk for certain types of cancer and cannot take hormone therapies. But Lishko’s research shows there could be other options for men beyond condoms or vasectomies.

Her work is part of a growing effort to better understand and expand choices for contraception — both hormonal and non-hormonal. But the “research is still very gendered,” said Dr. Sarah Prager, a professor who directs the Family Planning Division within the University of Washington’s Department of Obstetrics and Gynecology. That bias plays out not only in the health care system, but in the research pipeline, perpetuating a lack of options. For years, that has been compounded by medical complaints from women being undervalued, Prager said.

“There’s a lot of gender-disparity that leads to what gets funded and what doesn’t get funded,” she said.

For years, Lishko’s lab struggled to find enough funding to tackle these questions. So when her phone rang in late summer and the voice on the other end said Lishko had been named a 2020 MacArthur Fellow, which comes with a $625,000 award over five years, she thought it was a prank.

“I was in disbelief,” she said.

The MacArthur Foundation chose Lishko, an associate professor in the Department of Molecular and Cell Biology at the University of California, Berkeley, and this year’s 20 other fellows from a wide range of fields because they “show exceptional creativity in their work and the prospect for still more in the future.”

For years, Lishko had applied for federal funding to make her work possible only to be rejected. This award was a huge boost for her studies. Beyond contraception and fertility, Lishko is also exploring the relationship between menopause and diseases like Alzheimer’s.

Access to reproductive health

The Food and Drug Administration first approved a progesterone pill for contraceptive use in 1960. Within a few years, millions of Americans had adopted this method of family planning. Today, a quarter of contraceptive users rely on the pill to prevent unwanted pregnancy, according to the Guttmacher Institute, making it the most popular method of contraception, compared to 22 percent who rely on a spermicidal ointment, another 15 percent who use male condoms and 12 percent who implant IUDs.

“There’s a large population of women who would like to try something different, but there’s nothing on the market yet,” Lishko said.

The market potential for Lishko’s research is being studied, and prototypes are in development. It remains unclear how effective these means might be in preventing unintended pregnancy, Lishko said. There’s also the question of whether men would choose to take birth control medication. Within a year of starting hormonal birth control, roughly 40 percent of women quit, Lishko said, highlighting the need for more choices.

Humans are complex creatures, and there is no one-size-fits-all model for contraception, Prager said. People also demand a lot from their birth control. Aside from controlling one’s ability to get pregnant, people also rely on some contraceptives to regulate acne, migraines and make menstrual cycles more predictable and less painful.

Even a modest increase in copays and cost could make contraception prohibitively expensive for some in the U.S., increasing the risk of unwanted pregnancies. Some studies have suggested one in three Latina women and one out of four Black women of reproductive age could not afford to pay more than $10 for birth control, said Mara Gandal-Powers, who directs research and policy on birth control access and serves as senior counsel for the National Women’s Law Center.

“People shouldn’t have to be making the choice between putting food on the table and paying their utilities and keeping a roof over their head and getting the health care they need,” Gandal-Powers said.

Even for people who have insurance, low-cost birth control may be under threat. While the Affordable Care Act contains a mandate that says insurance must cover contraception, a July 8 decision by the Supreme Court said employers could be exempted for religious reasons. Further legal challenges to the law could continue to erode or eliminate protections in states that don’t have separate provisions.

Newly confirmed Supreme Court Justice Amy Coney Barrett is expected to solidify a right-leaning block of the Supreme Court for years to come. Though she rarely tipped her hand during her confirmation hearing, her record suggests she is opposed to expanded access to contraception. In 2012, Barrett signed onto a letter that rebuked the Affordable Care Act.

“The simple fact is that the Obama administration is compelling religious people and institutions who are employers to purchase a health insurance contract that provides abortion-inducing drugs, contraception, and sterilization,” the letter, titled “Unacceptable,” said.

The issue came into sharper focus on Nov. 10 when the Supreme Court heard arguments in California v. Texas, which questions the constitutionality of the Affordable Care Act and could potentially overturn the law that insures an estimated 21.1 million Americans.

During those arguments, Chief Justice John Roberts and Justice Brett Kavanaugh made comments that seemed to suggest they did not think the law needed to be gutted. But if that happens, contraceptive policy will be a “confusing patchwork” like before the Affordable Care Act was passed, Gandal-Powers said. Thirty states and the District of Columbia would continue to protect contraceptive coverage. Fifteen states plus D.C. protect people from cost-sharing. People may no longer reflexively know if their insurance covers their contraception since companies would not be compelled to do so nationwide. Instead, people would have to know what mandates are in place where they live and how those would apply to covering contraception.

Melanie Israel, a research associate with the Heritage Foundation’s DeVos Center for Religion and Civil Society, argues that those mandates don’t do enough to lower costs or encourage competition and compel people to pay for things they may not want or need.

“Americans want to have a plan that’s going to meet their needs but also reflects their values,” Israel said. In fact, most Americans do not have an issue with the use of contraception, according to a 2016 Pew Research Center poll. it found that just 4 percent of U.S. adults said contraception use was “morally wrong.”

To Lishko, empowering people and women in particular to be “in charge of their fertility” can prevent more burdensome measures in the event of an unintended pregnancy.

“It’s always good to create a situation where an abortion pill is not needed in the first place,” she said.