Stimulating an immune response? Oral sex is associated with less endometritis.

Secondary analysis of the PID Evaluation and Clinical Health (PEACH) data suggests that among women presenting with signs and symptoms of pelvic inflammatory disease (PID), those who reported oral sex were less likely to have endometritis (adjusted odds ratio [OR] 0.5 [0.3-0.8]) than those who did not report oral sex. Adaptive immunity requires antigenic priming of the lymphatic system. As lymphatic tissue is abundant in the oropharynx, oral sex could lead to effective immune stimulation and prevent PID. To determine whether oral sex could be a protective factor for PID the relationship between self-reported oral sex and endometritis was analysed among 619 women with clinically suspected PID who participated in the PEACH study. Nearly one quarter of participants reported oral sex in the past four weeks. These women also reported a higher number of sexual partners, a new partner within the past four weeks and a higher frequency of sexual intercourse (all P < 0.03). They were more likely to smoke (P < 0.0001), drink alcohol (P < 0.004) and use recreational drugs (P < 0.02). Participants reporting oral sex were significantly less likely to be black or to have a positive test for Neisseria gonorrhoeae (7.8% versus 21.6%, P = 0.001). Women who disclosed oral sex were significantly less likely to have endometritis after adjusting for race, number of partners, recent new partner, smoking, alcohol use and drug use (adjusted OR 0.5 [0.3-0.8]). This is the first paper showing a negative association between oral sex and endometritis. This may be mediated by a protective immune response in the genital tract following priming in the oropharynx. This hypothesis needs to be tested in further studies.

Do sexual health staff know what patients want from services?

Although the 'patient provider partnership' is now supposed to be an integral part of modern clinical care, an assumption is often made by clinicians that they know what patients want from health services. Sexual health care is no different. In order to investigate the accuracy of this supposition, a survey was undertaken in February 2009 of all staff members working in the Department of Reproductive and Sexual Health (doctors, nurses and administrative staff) in Enfield. They were asked to predict what their patients' priorities were when accessing sexual health services. The results showed that nurses were the most accurate at anticipating what patients most valued, by correctly predicting their top three priorities (confidentiality, speed of service and rapid test results). Doctors were the least accurate and only predicted one of the top three patient priorities. These results are now being used locally to ensure that all members of the multidisciplinary team have input into the development of clinic guidelines and service design.

What do patients want most from sexual health services?

Changes to sexual health clinics have recently been driven by government waiting time targets. However, patients' needs and expectations should be equally important when making service alterations. This study sought to determine what patients valued most when attending an integrated sexual health clinic. During February 2009, 252 patients attending a sexual health clinic in outer London completed an anonymous questionnaire. The questionnaire asked for their views on different aspects of sexual health care. The results showed that the most highly valued aspects of care were confidentiality (18.47% of points allocated) followed by speed of service (13.1%) and rapid test results (12.12%). These aspects were more important than being seen within 48 hours (7.78%), technical expertise (6.26%) or other patient-centred aspects of care. These findings, which represent patients' views, have important implications for service design.

Using standard primipara method to compare the quality of maternity care in Cairo and London.

SUMMARY: There is no universally agreed definition of quality of care (QoC). However, we assumed that the QoC in a London teaching hospital is high and could be used as a benchmark QoC with which to compare the practice in Cairo. We aim to highlight differences in the frequency of adverse outcomes attributable to differences in the QoC between two maternity teaching hospitals in Cairo and London, in low risk, standard primiparae (SP) delivered in 1999. In Ain Shams Maternity Hospital in Cairo and St Mary's Maternity Hospital in London, the caesarean section rate was 9.1% and 22.5%, respectively (OR = 0.34, p < 0.0001); the instrumental delivery rate was 4.1% and 26.8%, respectively (OR = 0.12, p < 0.0001), and the induction of labour (IOL) rate was 1.1% and 16.7%, respectively (OR = 0.06, p < 0.0001). Third degree perineal tears occurred in 0.3% and 8.2%, of the vaginal deliveries (OR = 0.14, p = 0.002) and the still birth rate was 0.78% and 0.1%, (OR = 7.96, p < 0.01) in the Cairo and London hospitals, respectively. This is the first time the SP method has been used to compare similar institutions in developed and developing countries. Intervention rates were significantly higher at St Mary's and so was the improved fetal outcome. A trade-off of improved fetal outcomes for more interventions is difficult to establish. Residual differences in case mix and patient preferences may explain some of the results.

Questioning the value of screening for gonorrhoea in symptomless heterosexual men.

These two papers discuss whether gonorrhoea screening of asymptomatic heterosexual men with no contact history should continue in UK genitourinary medicine clinics. Currently, most clinics routinely test all attenders. This requires an estimated 330,000 tests annually to detect 915 positives (1 in 361). The benefits to these patients are uncertain but the costs are huge and could fund currently unprovided services such as oral contraceptive provision or HIV testing before terminations of pregnancy. However stopping testing would deny individuals the reassurance they seek, prevent early detection of outbreaks and fail to detect carriers who go on to cause morbidity in their partners. On this view, the availability of non-invasive tests should be used to widen screening.

Test Not Talk screening for asymptomatic men.

This audit reviews the first year's experience within a rapid comprehensive sexually transmitted infection (STI) and HIV screening for asymptomatic men in a small-integrated sexual health clinic in outer London. Men requesting STI/HIV screening only were offered symptom self-assessment, blood tests for syphilis and HIV, and first void urine tests for chlamydia and gonorrhoea. Of 468 available appointments, 337 were made (72%) and 303 were kept (80%). Of the 303 attendances, 264 (87%) were first-ever attendances. Of the 303 men seen, 295 (97.4%) underwent chlamydia and gonorrhoea testing, while 246 (80.9%) were tested for syphilis and HIV. No new HIV diagnoses were made. One patient was diagnosed with late latent syphilis and one had asymptomatic gonorrhoea, while 20 (6.6%) diagnoses of chlamydia were made. We believe that Test Not Talk clinics offer a good approach to rapid screening of asymptomatic men and to meet their sexual health needs.

Vitamin A and causes of maternal mortality: association and biological plausibility.

OBJECTIVE: To review the association between major causes of maternal mortality and vitamin A, trying to determine if these associations are causal in nature, and to highlight possible biological pathways that may explain vitamin A effects. DESIGN: Literature review, observational studies and clinical trials. The strength of association was determined by applying Bradford Hill criteria of causality. RESULTS: In a vitamin A deficient population, vitamin A is essential for adequate treatment of anaemia. While vitamin A does not seem to be capable of preventing uterine atony, obstetric or surgical trauma, which are important causes of haemorrhage, it might be capable of preventing or decreasing coagulopathy. Possible effects on the placenta as regards implantation, site and size are not clear. As regards pregnancy-related infections, vitamin A supplementation can improve wound healing by decreasing fibrosis and increasing transforming growth factor-beta (TFG-beta). It can increase resistance to infection by increasing mucosal integrity, increasing surface immunoglobulin A (sIgA) and enhancing adequate neutrophil function. If infection occurs, vitamin A can act as an immune enhancer, increasing the adequacy of natural killer (NK) cells and increasing antibody production. beta-carotene in its provitamin form can act as an antioxidant by decreasing endothelial cell damage (the pathognomonic feature of pre-eclampsia) and promote the vasodilator effect of nitric oxide that might bring about a better outcome of toxaemia in pregnancy. It is unlikely that vitamin A or beta-carotene has an effect on obstructed labour. CONCLUSIONS: Plausible biomedical pathways can only be constructed for obstetric haemorrhage, anaemia in pregnancy, hypertension in pregnancy and pregnancy-related infections. A 40% reduction in the maternal mortality ratio, as observed in Nepal, is unlikely to be solely explained through the aforementioned pathways.

Observed versus expected obstetric complications: an assessment of coverage of obstetric care in developing countries.

The objective of this study was to evaluate access to obstetric care in a rural district in East Africa using easily collected and evaluated data and avoiding expensive field surveys, complicated study design or statistical methods. The number of observed obstetric complications occurring during 12 months in a rural East African district hospital (the only institution with surgical facilities and access to blood transfusion in the district) were compared to the number of expected complications the district should 'generate'. Of the expected > 10000 deliveries < 25% took place in the district hospital. The place of confinement for the other deliveries was not determined. As compared to the total number of expected conditions within the study district < 25% of the breech and < 45% twin deliveries took part in the district hospital and < 10% of pregnancies complicated by placental abruptions and < 5% of the pregnancies complicated by placenta praevia were managed in the district hospital. Comparing the number of serious pregnancy complications which were managed in the hospital to the total expected number for a particular region allows a simple assessment of the accessibility of obstetric care. This ratio might be more useful when evaluating obstetric care than traditional parameters as it stresses the importance of accessibility of care for the whole community.

PIP: A simple, rapid method for evaluating accessibility of obstetric care was applied to maternity register data from Rusape General Hospital in Zimbabwe's Makoni district in 1987. The number of observed obstetric complications in a 12-month period in this rural district hospital was compared with the number of expected complications for the district. The district hospital is the only facility equipped for surgical intervention, intensive obstetric or neonatal care, and blood transfusion. A complete set of data was available for 2147 (98.5%) of the 2178 total births. Under 25% of the expectable minimum of 10,000 deliveries occurred in the district hospital. Compared to the total number of expected obstetric conditions in the district, less than 25% of breech and 45% of twin deliveries were managed at the district hospital, as were under 10% of pregnancies complicated by placental abruption and 5% of those with placenta previa. Overall, these findings indicate that only 5-10% of women in need of essential emergency care in this East African district are receiving the care required.

Transvaginal three-dimensional ultrasound: reproducibility of ovarian and endometrial volume measurements.

OBJECTIVE: To assess the reproducibility of ovarian and endometrial volume measurements obtained using transvaginal three-dimensional (3D) ultrasound (US). DESIGN: Prospective clinical study. SETTING: A tertiary referral center for assisted reproduction. PATIENTS: Forty women undergoing ovarian stimulation for IVF-ET using the long protocol of GnRH agonist. INTERVENTION: Three observers independently measured 20 stored ovarian scanned volumes and 20 endometrial volumes. Also, ovarian volume was calculated from three diameters obtained by two-dimensional (2D) US. MAIN OUTCOME MEASURE: Analysis of variance, the paired Student's t-test, and calculation of intraclass and interclass correlation coefficients were used for statistical analysis. RESULTS: Three-dimensional ovarian volume measurements were not significantly different from ovarian volume calculated from three diameters (7.98 versus 7.58 mL). The mean endometrial volume measurement was 3.56 mL. The intraobserver coefficient of variation for both ovarian and endometrial volume was 8%. The interobserver coefficient of variation was 9% for ovarian volume and 11% for endometrial volume. Intraclass and interclass correlation coefficients were 0.95 and 0.95 for ovarian volume and 0.90 and 0.82, respectively, for endometrial volume. CONCLUSION: Transvaginal 3D US produces highly reproducible ovarian and endometrial volume measurements.

Elective cryopreservation of all embryos in women at risk of developing ovarian hyperstimulation syndrome may not prevent the condition but reduces the live birth rate.

OBJECTIVE: Our goal was to evaluate the use of elective cryopreservation of all embryos to prevent the development of ovarian hyperstimulation syndrome in patients at risk while undergoing in vitro fertilization treatment. DESIGN: We analyzed 117 treatment cycles in which the serum E2 concentration on the day of hCG administration was > 10,000 pM and in whom > or = 15 oocytes were retrieved at ultrasound-directed follicle aspiration. The incidence of ovarian hyperstimulation syndrome, pregnancy, and live birth in 65 patients who had elective cryopreservation of all embryos and 52 patients who had fresh embryo transfer were compared. Independent t test and chi-square test (with Yates' correction) was used as appropriate. RESULTS: The clinical pregnancy (35 vs 17%; P < 0.03) and the live birth (27 vs 12%; P < 0.05) rates in patients receiving fresh embryo transfer was significantly higher than in those who had elective cryopreservation of all embryos. The incidence of moderate and severe ovarian hyperstimulation syndrome was similar in both groups (3.8 and 6.2%). CONCLUSIONS: Elective cryopreservation of all embryos does not reliably protect against the development of ovarian hyperstimulation syndrome but may reduce the clinical pregnancy and live birth rate.

Outcome of frozen embryo replacement cycles following elective cryopreservation of all embryos in women at risk of developing ovarian hyperstimulation syndrome.

AIM: Our aim was to compare the outcome in subsequent frozen embryo replacement cycles in four groups of patients who had elective cryopreservation of all their embryos because they were considered to be at increased risk of developing severe ovarian hyperstimulation syndrome. DESIGN: Sixty-two (91%) of 68 IVF cycles (68 patients) in which elective cryopreservation of all embryos was performed were analyzed. All patients continued on the GnRH agonist, buserelin, after oocyte recovery until the onset of vaginal bleeding. Frozen embryo replacement occurred in a hormone replacement cycle that started either on day 3 of the withdrawal bleed (group I; N = 15) or after serum estradiol levels had fallen to < 100 pmol/L (group II; N = 16). The other patients commenced a frozen embryo replacement cycle several months later in either a hormone replacement (group III; N = 15) or a natural (group IV; N = 16) cycle. RESULTS: Two patients developed severe ovarian hyperstimulation syndrome. There were no significant differences among the four groups regarding demographic variables, the dose of hMG used, and the clinical outcome. There was a higher but not significantly different clinical pregnancy rate in group I (26.7%), compared to group II (12.5%), group III (13.3%), and group IV (18.8%). CONCLUSIONS: Several options exist for the timing and protocol used for frozen embryo replacement in patients who had elective cryopreservation for the prevention of ovarian hyperstimulation syndrome, none of which was found to be clearly superior in this observational report.

Success of intrauterine insemination using cryopreserved donor sperm is related to the age of the woman and the number of preovulatory follicles.

OBJECTIVE: Our objective was to assess parameters associated with a successful outcome of intrauterine insemination (IUI) using cryopreserved donor sperm. DESIGN: We analyzed 750 consecutive donor IUI cycles undertaken by 363 women in an assisted conception clinic. The main outcome measure was clinical pregnancy. RESULTS: IUI was performed in 94.7% of the 750 IUI treatment cycles commenced and 180 clinical pregnancies occurred. The clinical pregnancy rate per cycle was 26.4%. The rate was significantly related to the patient's age (30.5% for age < or = 35 years and 18.1% for age > 35 years; P < 0.006) and whether there was one or more than one preovulatory follicles [20.9, 34.4, and 31.5% for one, two, and three or four follicles with a mean diameter of 14 or more mm at the time of human chorionic gonadotropin (hCG) administration; P = 0.006]. Two to four preovulatory follicles were present in 12.6% of the natural cycles, 43.6% of clomiphene citrate or tamoxifen, and 59.9% of gonadotropin stimulated cycles. The difference in the number of preovulatory follicles between stimulated and unstimulated cycles was highly significant (P < 0.0001). Pregnancy rates were 29.9% in gonadotropin-stimulated cycles, 23.6% in clomiphene citrate- or tamoxifen-stimulated cycles, 23.6% in clomiphene and 20.1% in unstimulated cycles. The difference in pregnancy rates between gonadotropin-stimulated and natural cycles was significant (P = 0.038). Cycle fecundity rates were not significantly affected by the number of previous treatment cycles, duration of infertility, gravidity and parity of the patient, presence of a spontaneous luteinizing hormone (LH) surge before the administration of hCG, or number of motile sperm in the insemination specimen. CONCLUSIONS: Success of IUI using cryopreserved donor sperm is related to the age of the women and whether there is one or more than one preovulatory follicles.

Blood flow changes in the intraovarian arteries during the periovulatory period: relationship to the time of day.

Intraovarian blood flow was assessed by transvaginal color and pulsed Doppler ultrasound prospectively in six women during the periovulatory period. All patients had regular ovulatory menstrual cycles and a mid-luteal serum progesterone level consistent with spontaneous ovulation in the preceding cycle. Each patient underwent serial transvaginal ultrasound examination and Doppler assessment of blood flow in the ovarian stroma and in the wall of the dominant follicle or corpus luteum. When the mean follicular diameter was > 16 mm or day -2 from the estimated day of ovulation was reached, patients were scanned at 6-h intervals at 06.00, 12.00, 18.00 and 24.00 until follicular rupture, to investigate the presence of circadian rhythms. The pulsatility index (PI) and the maximum peak systolic blood flow velocity (Vmax) were calculated as Doppler indices of impedance to blood flow and velocity, respectively. A venous blood sample was taken at each visit for subsequent hormonal analysis. There was no significant circadian fluctuation in either mean follicular Vmax or mean follicular PI before or after the luteinizing hormone (LH) surge. Similarly, mean Vmax and mean PI in the non-dominant ovarian stroma did not show any significant fluctuation over the same periods. The mean PI in the dominant ovarian stroma showed daily fluctuations with the highest values occurring most commonly at 06.00 and the nadir in the afternoon and late evening. This fluctuation was the reverse of the circadian variation previously demonstrated in the uterine artery. However, in contrast to the uterine artery, comparison between the mean PI values in the dominant ovarian stroma at 06.00 and 18.00 only approached significance after the LH surge. The dominant ovarian stroma Vmax tended to rise during the day, although the differences between 06.00 and 18.00 were also not significant. Although there are fluctuations in Doppler blood flow indices in the dominant ovarian stroma, further studies are necessary to demonstrate whether this represents a significant circadian rhythm.

Assessment of uterine artery blood flow on the day of human chorionic gonadotropin administration by transvaginal color Doppler ultrasound in an in vitro fertilization program.

OBJECTIVE: To assess whether measurement of uterine artery blood flow impedance (the pulsatility index) as determined by transvaginal color Doppler ultrasound on the day of hCG administration in patients undergoing IVF can predict pregnancy and implantation rates. DESIGN: Prospective observational study of women undergoing IVF. SETTING: A tertiary referral center for assisted reproduction. PATIENTS: One hundred thirty-five patients undergoing 139 IVF cycles. INTERVENTION: Transvaginal color Doppler assessment of uterine artery pulsatility index on the day of administration of hCG. MAIN OUTCOME MEASURES: Mean pulsatility index of the left and right uterine arteries, pregnancy rate, and embryo implantation rate. RESULTS: The patients were grouped into pregnant and nonpregnant groups and according to whether the pulsatility index was low (1.00 to 1.99), medium (2.00 to 2.99), or high (> or = 3.00). The pregnancy rates were 13.8%, 34.7%, and 14.3% for the low, medium, and high pulsatility index groups, respectively, and were not significantly different. The implantation rates for the same groups were 10.7%, 16.3%, and 5.4%, respectively. The implantation rate for all the patients with pulsatility index < 3.00 (and especially 2.00 to 2.99) was significantly higher than the high pulsatility index group. CONCLUSIONS: The study suggests that the measurement of uterine artery pulsatility index on the day of hCG predicts subsequent implantation rates. It may allow the administration of hCG to be deferred until uterine artery pulsatility index falls to < 3.00, which may result in improved implantation rates.

Transvaginal three-dimensional ultrasound: accuracy of follicular volume measurements.

OBJECTIVES: To evaluate the accuracy of three-dimensional (3-D) ultrasound (US) follicular volume measurements. DESIGN: Prospective clinical study. SETTING: A tertiary referral center for assisted reproduction. PATIENTS: Twenty-five patients undergoing ovarian stimulation for IVF-ET using the long protocol of GnRH agonist. INTERVENTION: Transvaginal two-dimensional (2-D) and 3-D ovarian scan performed immediately before US-directed follicle aspiration. MAIN OUTCOME MEASURES: The volume of follicular fluid aspirated was compared with the corresponding volume of the follicle measured by 3-D US and with the conventional 2-D US volume measurement calculated using the formula pi/6 (D1 x D2 x D3). Limits of agreement and 95% confidence intervals were calculated and systematic bias between the methods was analyzed. RESULTS: The limits of agreement between the volume of follicular aspirate and follicular volume determined by US were +0.96 to -0.43 mL for 3-D measurements and +3.47 to -2.42 mL for 2-D measurements. CONCLUSIONS: The true volume of ovarian follicles, within the clinically useful range for IVF-ET cycles, is measured more accurately by a 3-D US system than by 2-D US techniques.