[narrator] We're not sure why this shape became the universal symbol of love.
But one leading theory is that it came from the silphium pod,
so valuable across the ancient Mediterranean,
it was printed on the currency of the only place they grew,
the Greek colony Cyrene.
It was exported around the region for all kinds of medical uses
and one in particular.
Soranus of Ephesus, the foremost gynecologist of his time,
advised women to drink silphium juice once a month,
since it not only prevents conception, but also destroys any already existing.
Which means, our modern heart shape may derive from an ancient kind
of morning-after pill.
But for most of human history, birth control was a lot less refined.
There were early condoms made of animal intestines
that were washed and reused.
And diaphragms, early versions,
were just women putting various things up their vaginas:
wool, silk, crushed plants or animal dung,
depending on the available animal.
In Egypt, it was crocodile dung.
In India, dung of the elephant.
We'll never know for sure how well silphium worked,
because it went extinct.
But research into its likely relatives,
like Queen Anne's lace and devil's dung,
suggest it probably manipulated the hormone levels
involved in getting pregnant.
Scientists eventually figured out how to do that in a lab in the 1950s.
And it's how nearly every new type of birth control has worked ever since.
But this method isn't perfect.
Weight gain, depression, acne...
I was just bleeding and bleeding at a low level for months.
I would just, like, cry over, like, things that didn't make any sense.
Cutting a cucumber, and I was like, "Why? Like, "Is this, like--?
This is the worst, like, vegetable I've ever, like, cut up before."
[narrator] It's been over 60 years since we invented hormonal birth control.
Shouldn't it be better by now?
[man 1] This little white tablet is more explosive than dynamite.
Sermons have been preached on it.
Men and women have argued over it.
[man 2] Mary and her team merely explain the pill,
and they nod back, but it's not consent,
because it's their man who decides yes or no.
[woman 1] The doctors themselves may not be well-informed
about the side effects.
[woman 2] It's hard to see what more we could do without using women themselves
as the experimental model.
[narrator] If you have a pet cat,
well, you may remember when she started going into heat...
[yowls]
[narrator] ...as in, when she started ovulating,
producing eggs.
And for those few days when they're fertile,
they really want to mate.
Most female mammals look and act different around the days they're ovulating,
called "estrus," signaling that they want it,
so come and get it.
Female chimpanzees get huge sexual swellings,
goats wag their tails,
and horses wink their vulvas.
But higher primates, like humans, are pretty unique.
We don't show outward signs that it's our fertile few days of the month,
and we're continually receptive to sex, whether we're fertile or not.
Scientists call this concealed ovulation,
and it took them into the 1900s to figure out how it worked...
and how to hack it.
Ovulation mainly involves four hormones,
which rise and fall over the course of a month.
Two of them are released from the brain,
and two come from the ovaries: estrogen and progesterone.
To kick things off, those two brain hormones
send a signal to the ovaries, where roughly a dozen follicles,
each containing a single immature egg,
have been patiently waiting for this moment.
It's winner takes all in the fight over the limited hormone supply,
and the loser follicles die off.
Next, the winning follicle emits lots of estrogen,
which starts to thicken the uterine lining
and opens up the cervix,
which is now coated with a nutrient-filled fluid
that protects any incoming sperm on their journey up to the uterus.
Then the follicle ruptures, releasing the matured egg,
which is snatched up by the nearby Fallopian tube.
The sperm has a short window of time to get to the egg, or it dies off.
But if one gets there, that's fertilization.
The egg keeps traveling down the Fallopian tube to the uterus
as progesterone levels rise,
which close the cervix and turns that fluid into a sticky shield,
blocking any new sperm from getting in.
The progesterone also keeps building up the uterine lining
into a warm, snuggly bed where the egg can stick.
But it's not that warm and snuggly.
It's also a lethal testing ground
that not every fertilized egg can survive.
If a fertilized egg does successfully implant,
that's a pregnancy.
Estrogen and progesterone levels stay high,
and the ovaries won't release more eggs.
But if the fertilized egg is rejected or there never was one,
estrogen and progesterone plummet.
And out comes that lining: your period.
And the cycle reboots.
Hormonal birth control's main cheat
is altering the estrogen and progesterone levels in the body,
so it thinks you're already pregnant.
So, no new eggs are released.
The cervix stays plugged up, and the uterine lining remains thin.
"The pill," released in 1957, was the first form of this hack.
A daily dose of both synthetic estrogen and progesterone,
marketed as Enovid in the US and Enavid in the UK,
but only to treat menstrual problems,
which an unusually large number of women suddenly found they had.
And when the pill hit the market as birth control in the 1960s,
it transformed the world.
More women were able to stay in school and have smaller families,
helping to lift millions out of poverty.
You can see that kind of profound impact in rural Bangladesh,
starting in the 1970s.
Bangladesh had just become a country. It was very poor.
Religiously conservative.
Most Bangladeshi women were practicing female seclusion,
where they would not even go in public.
So, going to a clinic was a big ask of these women.
[narrator] But then in 1978, health workers went door-to-door
in 70 randomly selected villages every two weeks
with an array of birth control options,
including injections, the most popular choice,
because they were discreet, and one shot lasted for months.
Two decades later, the results were transformative.
Compared to an otherwise identical village...
families in a birth control village had more education,
higher incomes, more valuable homes and savings,
and better access to running water.
Those women also had a higher body mass index,
and as a result,
they were 20% more likely to survive into old age.
But the progress hormonal birth control brought women around the world
didn't come without a cost.
Starting with that very first pill.
See, when you take the pill,
it puts those synthetic hormones in your bloodstream,
so they travel all over the place.
The changing hormone levels can cause headaches and nausea,
affect hair growth, and increase water retention,
so you can gain weight.
And these hormones also play a role in regulating sexual desire and emotions,
so you can experience changes to your very sense of self.
And while the risk is extremely small,
estrogen increases the chances that your blood will thicken into a clot,
which can travel to your lungs and block blood flow,
which can be lethal.
And that first pill,
it contained ten times the amount of hormones needed to be effective.
That high dose was primarily tested in Puerto Rico in the '50s,
chosen because it was poor,
and the US government worried about its overpopulation.
The US-appointed governor endorsed a sterilization program.
By 1954, sterilizations had nearly tripled,
the women often coerced.
So, when researchers arrived with a reversible birth control option,
these women took it.
But they didn't know that they were a part of an experiment
until a documentary filmmaker told them decades later.
[interviewer, in Spanish] The women who took those pills
were the first in the world to try them.
Did you know that, doña Maria?
No.
They were experimenting with us,
without us knowing what they were doing.
[narrator, in English] Hundreds of women
faced serious side effects.
At least three died, though it was never investigated.
It took more than ten years, several new formulations,
and millions of women around the world taking birth control pills
for the US Congress to finally hold a hearing on their side effects.
It was called, after one senator read the landmark book,
The Doctors' Case Against the Pill,
by the investigative journalist Barbara Seaman,
who reported women experiencing
heart attacks, strokes, blood clots, and cancer.
Thousands had died or been injured in the US alone.
For the first five days of the hearing,
the all-male panel only invited men to testify.
So, the women, they invited themselves.
An outburst by a group of young women today
temporarily halted the Senate hearing on the safety of the birth control pill.
I'd like to know why is it that scientists and drug companies are perfectly willing
to use women as guinea pigs and experiment testing the high estrogen,
low estrogen content of the pill.
[narrator] The doses of hormones in the pills were lowered
in the following years,
reducing the chance of side effects like headaches, nausea,
excess hair growth and weight gain.
And some new pills were better at reducing cramps and acne,
thanks to new synthetic forms of progesterone.
A lot of potential side effects still remain.
But for hundreds of millions of women around the world,
not getting pregnant is worth making yourself a little sicker.
And just like with those early versions,
women, and sometimes even their doctors,
don't actually know how much sicker they'll get,
because you can't always know until a lot of people start taking a drug.
One of those synthetic forms of progesterone, DRSP,
was a key component in a pill called Yaz,
which was heavily marketed in the 2000s as way more than just birth control.
[announcer on TV] Yaz is the only birth control
proven to treat the emotional
and physical premenstrual symptoms
that are severe enough to impact your life.
It can also help keep your skin clear.
Yaz contains a different kind of hormone that may increase potassium.
[narrator] The ad campaign worked.
For two years, Yaz was the most popular birth control pill
in the United States.
And many young women who didn't need birth control
bought it on its own claims that it made PMS symptoms disappear.
Then reports of side effects started to spread.
From blood clots to organ failure to stroke,
thousands of women say they got sick
after taking a birth control pill called Yaz.
Now under scrutiny
for possibly causing serious health problems.
Using it can increase the risk of dangerous side effects
that may even cause death.
[narrator] Birth control pills roughly triple the risk of getting blood clots...
but studies later found that DRSP can as much as triple that risk.
And while the risk is still small,
it adds up to thousands of women if millions are taking that pill.
As of 2015, the maker of Yaz,
Bayer Pharmaceuticals, has settled nearly 10,000 claims
from women who got blood clots, totaling around $2 billion.
But by that time,
a different type of birth control was growing in popularity: the IUD.
This is the hormonal version.
There's also a different kind, made of copper.
Both types are inserted into the uterus by a doctor,
where it can stay for three to ten years, depending on the brand.
We don't totally know how they work,
but we do know they turn the uterus into a no-sperm zone.
As a foreign object in the uterus,
the IUD causes inflammation,
triggering white blood cells to rush in and eat the sperm.
The hormonal IUD also continuously releases a tiny amount
of synthetic progesterone, so it has a lot of the same effects of the pill,
but with fewer side effects.
The copper IUD doesn't use hormones at all.
Its trick is that copper is sperm kryptonite,
for reasons scientists don't understand.
I love having an IUD.
I don't worry that I forgot to take my pill.
I don't spot. I don't get a period.
I think I've used two tampons in the last seven years.
I decided to get the copper IUD because both my mother and her sister
had estrogen-related breast cancer.
So, I was advised by doctors
to get on a non-hormonal birth control option.
[narrator] The IUD is 99% effective,
in part, because you can just set it and forget it.
In general, birth control gets less effective
the more humans have to remember to do something to make it work,
especially if it's during sex.
Which is why another of the most effective methods is sterilization.
For men, "the snip" is a minor procedure
to cut or clamp the tubes that carry sperm out of the testicles.
For women, "getting your tubes tied" is a more invasive procedure,
which blocks or cuts the Fallopian tubes.
That's actually the most popular form of birth control in the world.
But women usually only get it when they've already had kids.
Meanwhile, the IUD is as effective and can be taken out,
but only 12% of American women using birth control have one.
And that's largely because of a huge class action lawsuit
against one IUD, the Dalkon Shield.
Such a disaster, it was a joke on Saturday Night Live.
If you don't agree that the Dalkon Shield trout lure
is the most amazing trout catching phenomenon you've ever tried,
well, sue us!
[narrator] But it wasn't the fish-bait shape
that caused problems for people who got the Dalkon Shield,
like Loretta Ross.
My first two or three years with it were fine.
But then, I started developing very low-grade infections.
[narrator] She went to an ob-gyn, who said she had an STD.
If I was black and female presenting with an infection,
it had to be an STD, in his opinion.
Even though all the tests were showing up negative.
He just kept searching for something more exotic, more exotic, more exotic.
[narrator] None of the treatments worked, and six months later...
I lapsed into a coma one night.
When I woke up, I had a total hysterectomy.
The first thing that doctor should have done
was remove the Dalkon Shield.
[narrator] It turned out the Dalkon Shield had a design flaw.
Its braided string was too thick,
and it acted like a ladder for bacteria to climb into the uterus.
Within four years of the Dalkon Shield's release,
it was taken off the market.
By that point, it had been inserted into 3.3 million women around the world.
At least 18 died.
Hundreds of thousands of women
sued the maker of the Dalkon Shield, A.H. Robins,
bankrupting the company.
It later came out that Robins officials knew about the wicking problem
six months before the shield went to market.
The IUDs on the market now are extremely safe.
The most common drawback?
Horrible to get put in.
Excruciating pain.
[narrator] Every birth control option has a drawback,
which is why a third of American women have tried five or more kinds.
I started with the pill, and then I went to the ring.
And then I went back to the pill.
Two forms of the pill,
the Nuvaring, um, which was interesting,
but that would come out during sex.
I've been on three different types of the pill.
I tried an IUD. And now I'm getting an arm implant.
[narrator] And a lot of women don't use birth control at all,
even though they don't want to get pregnant.
In one survey of developing countries,
just 5% of women not on birth control said the reason was access.
26% said the reason was side effects.
There is actually a birth control pill that doesn't use hormones.
It was launched as Saheli,
and it's been on the market for almost 30 years.
Its active ingredient is what's called
a "selective estrogen receptor modulator."
Not estrogen,
but a compound that acts on estrogen receptors in the uterus.
So, the estrogen there can't do its job,
building up that warm uterine lining so no fertilized eggs can snuggle in.
Since it doesn't actually affect estrogen levels,
the balance of hormones in your body stays the same.
So there are fewer side effects than hormonal pills.
And you only have to take it once a week.
But good luck getting Saheli outside of India.
That's where it was invented
and went through the large human trials most countries require to market a drug.
And it was one of the lucky ones.
Out of every 5,000 compounds developed in a lab,
only five make it to human trials, and only one of those gets to market.
So finding new ways to deliver the same hormones we already know work
is faster, cheaper, and less risky.
Birth control has sparked thousands of lawsuits,
because mostly healthy women are taking these drugs,
so they're more likely to notice and sue over serious side effects.
There's also little incentive to innovate
since women are buying their products anyway.
The mood swings have been bad.
The nausea has been bad initially, but then you just get used to it, I guess.
Years worth of drama in my life, years worth of medical bills,
drama while I'm traveling,
drama that I have to think about every time I have sex,
every time I get my period.
Why go through that? I guess 'cause condoms suck, but...
[narrator] And there's a huge potential market
the birth control industry has left almost entirely untapped.
I'm not at all satisfied with the options of birth control
for myself as a man because I feel like there aren't enough.
My only option as a guy is to use condoms, uh...
[laughs] ...or to-- or to pull out.
So, really, my only option is to use condoms.
If there was a commercially available male birth control pill,
I would definitely, definitely, at the very least, try it.
[narrator] Scientists figured out how to hack the male reproductive system
decades ago.
And large trials in the 1970s showed some promise.
The perfection of male birth control
seemed right around the corner for decades.
The Chinese have developed what they say
is a safe and effective birth control pill for men.
Medical researchers reported today
they have found a chemical that may hold the key
to a male birth control pill.
International research teams are working on an injectable...
...birth control pill for...
...men are taking part in the first trials of a new form of birth control.
-For men... -Birth control for men...
-Male birth control... -Male birth control pill.
Male birth control may be one step closer to becoming a reality.
[narrator] But it never arrived, since trials were often cut short
because men faced too many side effects.
Side effects that might sound familiar,
like mood swings, acne, and a loss of libido.
When approving a drug, the FDA weighs its risks
against the risks of not taking that drug.
And men, unlike women, don't personally face
the risks that come with pregnancy and childbirth,
like blood clots.
Hormonal birth control might triple a person's risk of blood clots,
but during pregnancy, the risk is double that,
and in the weeks after childbirth, quadruple.
And that was part of Bayer's defense in court documents
in the wake of all those lawsuits.
And it's why Yaz is still on the market,
as are a bunch of other pills using DRSP.
Male birth control just has to meet a higher bar,
so the kind that has the best shot at approval right now
doesn't use hormones.
It's a non-surgical vasectomy.
It works by injecting a gel into that sperm carrying tube,
where it stays, killing sperm as they leave the testicles.
A second shot is in development that would break down the gel.
It's awaiting approval in India...
where early trials have shown it's 98% effective,
has no major side effects
and can last over a decade.
But it hasn't gone through human trials anywhere else,
and drug companies aren't sure
male birth control has a market to make that worth it.
I'll be open to it.
Does that make me less of a man?
I don't know, but I'm open to anything, honestly.
If guys had the option to sort of take that level of responsibility,
like, leveling up from just using a condom,
I think that would make it a fairer conversation.
It takes two people to accidentally get pregnant.
[narrator] A 2002 survey found that 55% of men would be willing
to try even a hormonal male birth control.
But everywhere in the world,
women get their tubes tied more often than men get the snip.
They don't think it's their responsibility.
I would probably personally always want to protect myself.
I have to be responsible for my own shit.
At the end of the day, if something did happen,
the consequences would lay on me.
[narrator] And most women around the world see the consequences
of an unplanned pregnancy as so serious, that the choice is easy.
Which is why in the United States,
more than two-thirds of partnered women use birth control.
It's 68% in El Salvador,
58% in Kenya,
and 80% in China.
But not everyone gets the same choices.
In 1999, it was included in the Congressional Record.
that A. H. Robins had "conspired in the early 1970s
to dump hundreds of thousands
of dangerous, unsterilized contraceptive devices--
unmarketable in the United States-- into the developing world."
Those devices "were Dalkon Shields."
Loretta Ross traveled to one of those places,
apartheid South Africa, and shared her story.
But many women still chose to get one.
There were so few contraceptive options available to them,
they thought that they needed to accept the IUD
because it's what freed them up
for educational and economic opportunities.
And I felt it was tragic.
[narrator] Having a variety of options is just as important as knowing the risks.
That's what made the Bangladesh program so successful.
[Shareen Joshi] What you see in Bangladesh is the commitment
to offer them a full range of services.
Getting a cold storage supply chain for injectables
in a place where there are no roads or fridges, or electricity,
that was a very big deal at that time.
And, you know, the task of recruiting local women
to talk to women about their lives,
their needs, their desires, their aspirations,
was a pretty big commitment.
One thing we in the women's health movement
have never insisted upon
is a perfect contraceptive with no risk.
because every time you put something in your body,
you're changing something.
What we ask is fully informed consent.
We need to determine for ourselves
what risk we're willing to undertake or not.
Not have someone determine that for us, regardless of risk.
[theme music playing]