I'm Back For the Dick Jokes

And Venereal Pests

It’s been a jammed packed few weeks since I’ve written. I now have two Freshman (one in college, one in high school, both on tennis teams), Barrack Obama made a dick joke at the Democratic National Convention, JD Vance suggested Great Aunt Ida is the solution to everyone’s childcare problems, and Donald Trump rambled about bacon and wind and schools that are doing gender reassignment surgery at recess.

He's also gone back and forth on his views about abortion and IVF. In recent weeks he’s said six-week bans were too early and that he’d vote for the Florida ballot initiative that protects abortion rights before saying he supports the 6-week ban entirely and would never vote to get rid of it. He’s also said that he will not only protect IVF, but the government would pay for it. (Wait, isn’t that socialized medicine?)

Contrary to media reports, this isn’t classic flip-flopping, and it certainly is brilliant stategery. He clearly has dementia and does not know what he’s saying moment to moment. Recently, he admitted that he lost the 2020 election “by a whisker,” which is pissing off even the most loyal insurrectionists and likely causing his lawyers to break into a cold sweat. (I’m assuming the argument that he was acting in his official capacity as President requires him to have believed he won the election and was officially saving the country from a coup.)

The media is doing a particularly—and possibly purposely—poor job of highlighting his incoherence. Their treating him like a legitimate candidate with policy ideas and even editing his rants to make them look more like real sentences. I’m writing this hours before the Presidential Debate, but we all know there will be a total double standard in how the candidates are judged. She has to be at her prosecutorial finest without being seen as shrill or bitchy, and he has to be able to put together one or two sentences at a 4th grade level.

I hope his lack of mental capacity is on full display. In rallies lately he’s been slurring his speech, using the wrong words, and messing up everyone’s name (just ask Leon Musk). I still hold on to the never-proven theory that late-stage syphilis is to blame for his inability to speak. If only he’d had access to the new at-home syphilis test thirty years ago (see story below), we might all have been spared.

Fallopian Follies: Failure Rates for Tubal Ligation

There’s widespread agreement that using the most effective method of contraception possible is vital in the post-Roe era. Historically, there’s also been widespread agreement that the gold standard method of birth control from an efficacy perspective is surgical sterilization. It’s a structural fix. If you close or even remove the semen-superhighway, there’s no way you can get pregnant ever again. Right?

Maybe not.

A new study says we might be overestimating just how good a contraceptive method tubal ligation is. In fact, the study’s analyses suggest that getting your tubes tied may be less effective than the contraceptive implant or even the IUD.

The study’s authors looked at data from the National Survey of Family Growth (NSFG) collected at intervals between 2002 and 2015. (There are newer editions of the NSFG, but they weren’t included because some of the data needed for these analyses were not made public for those years.) The NSFG asks couples to recall their contraceptive use over a period of time and whether they experienced a pregnancy during that time. This data is used to calculate the effectiveness of many contraceptive methods. For this analysis, the authors looked at people who answered “yes” to the question “Have you ever had both of your tubes tied, cut, or removed? This procedure is often called a tubal ligation or tubal sterilization.”

In the 2013-2015 wave of the survey, the analyses found that an estimated 2.9% of women who underwent a tubal sterilization procedure got pregnant within the first 12 months after the procedure and that 8.4% percent got pregnant within 10 years. The 12-month estimated rate of pregnancy was higher for women under 25 (3.9%) and those 26-24 (3.3%). There were no pregnancies among tube-tied women over 35.

In contrast fewer than 1% of users of contraceptive implants or IUDs get pregnant within the first year of use and this stays the same for the life of the device. (The implant lasts three years while IUDs last anywhere between three and ten years.)

The study can’t answer the mechanics of how pregnancy is happening post-procedure, and I really want to know. Is the closed section of highway fusing back together in the middle of the night? Are egg and sperm finding a way to rendezvous on a side road?

The lead author’s best guess is that there may be microscopic gaps where the tube is tied off or clipped that are big enough to allow for sperm to get through: “Both eggs and sperm are very small, and all it takes is one egg and one sperm to connect.” (That’s not entirely true: the one sperm that gets in needs a few thousand of its friends to break a hole in the outer layer of the egg first, but even 1,000 sperm don’t need much room to maneuver.) Interestingly, most of the post-tubal-ligation pregnancies that they saw in the study were not ectopic, meaning the gap would have to be big enough not just for the lucky sperm and its buddies to get in, but for the fertilized egg to make its way back to the uterus.

There are different ways to close the fallopian tubes. The authors point to tubal occlusion with a Filshie clip and fulguration as potential methods, but the data did not show which procedure was used. The effectiveness rates are different in different waves of the study, with first year rates of pregnancy ranging from 1.2%-2.9% and five-year rates of pregnancy ranging from 1.5%-4.9%. The trends were not linear, so it doesn’t seem like surgical methods or Filshie clips just got better over time.

I’m not a surgeon, but I watch a lot of Grey’s Anatomy and know that surgical techniques go in and out of style as new things are invented (all Grey’s fan know about the Whipple). I wonder if these data are reflecting which techniques work better and last longer. 

I also wonder if we’re going to start seeing these rates drop as more surgeons choose to remove the fallopian tubes entirely. As I’ve told you many times, I’ve been fallopian-tube-free since 2017. I wasn’t planning on having my tubes tied, but the surgeon who had to go in at 3 am to take out a dead ovary and the cyst that killed it made the offer on the grounds that it provided both birth control and protection against ovarian cancer. Some experts are advocating that all female sterilization should follow this lead and simply remove the tubes. The authors of this study agree that bilateral total salpingectomy (the fancy name for taking them both out) will likely be more effective than older surgical methods but note that we don’t have the data to prove that yet.

More real-life research is likely needed before we demote surgical sterilization on our classic contraceptive effectiveness pyramids, but anyone counseling patients on their birth control options should keep this study in mind. The contraceptive implant seems to be angling for that gold standard status and with good reason; it requires only a simple office procedure to place it in the arm, it can be removed if you change your mind about pregnancy, and it’s more than 99% effective.

Test for Syphilis in the Privacy of Your Own Home

There’s a debate among medical historians as to whether syphilis first emerged as a sexually transmitted infection around 3,000 B.C. in South-Western Asia, was brought from Africa by slave traders in the 1300s, or can be blamed entirely on Christopher Columbus and his crew in 1492 (okay 1493, they needed time to get home and bone). We do know that the French Army of Charles VIII is blamed for a big outbreak of the disease in Italy in 1495 because Italian doctors vividly described what they saw: “generalized eruption consisting of pustules, more terrifying than leprosy and elephantiasis.” We also know that in the early days of this ‘lues venera’ (French for ‘venereal pest’) most people mistook it for leprosy.

If only they’d had an easy at-home test to put their minds at ease. Well, not really at ease because the syphilis of the late 1400s appears to have been more deadly than it is today, and antibiotics hadn’t yet been invented. Still, I see a big sepia-colored battle scene as the start of a great ad campaign for First to Know, an at-home syphilis test that recently got FDA approval.

Syphilis is a bacterial STI that causes sores, known as chancres, on the penis, scrotum, vulva, vagina, or anus. It can be passed to another person through contact with the sores during oral, anal, or vaginal sex. It can also be passed from a pregnant person to their baby during pregnancy or childbirth.

Ideally, a health care provider diagnoses the infection by swabbing the sores, but chancres go away on their own, and many people never realized they had one. This is why syphilis screening for people without sores or symptoms—especially pregnant women—is also important.

Screening relies on a series of blood tests. The first test looks for certain antibodies in the blood. A negative result on this test usually rules out an active syphilis infection. People who test positive need to have a second blood test to confirm the diagnosis. If that test is also positive, their health care provider will start treatment.

Until now, these blood tests were most often given in a health care provider’s office, though you could buy a test that would allow you to collect blood at home and send it to a lab for analysis.

First to Know is the first test done entirely at home. Users prick their finger and put a drop of blood on a test strip. Results are available in 15 minutes. Those who have a negative result and have no symptoms do not need to follow up. Those who test positive need to see a health care provider for a second test that can confirm the diagnosis. Those who have symptoms should get go to health care provider regardless of what the test says. (In truth, if you have symptoms, you should go to a health care provider before even bothering to test. They’ll know better which STIs to test for.) Users who have had syphilis in the past should know that they may test positive despite having already been successfully treated. If this happens, see a health care provider.

Modern syphilis trends are as fascinating as its ancient history. The STI was nearly eradicated in the United States in 1957 before rebounding, and this pattern repeated itself every 10 years or so for decades. In the early 2000s, syphilis elimination was in reach, but that has changed dramatically. The number of cases rose 80% between 2018 and 2022 alone, and the number of infants born with syphilis is up a whopping 183% since 2018.  

Syphilis sores will go away on their own, but if not treated the infection can progress to more advanced stages. Late-stage syphilis—which can occur anywhere from two years to more than twenty years after infection—can lead to gradual blindness, hearing loss, delusions, paralysis, vertigo, and perhaps poor performances in presidential debates.