SEARCHLIGHT Navigating the Global Medical Network Of Sexual Health Issues for Sexual Health Matters

Mr Ibrahim Bolaji, MD, FRCPI, FRCOG.
Consultant Obstetrician and Gynaecologist, Diana Princess of Wales Hospital, Grimsby, DN3 2BA
Honorary Senior Clinical lecturer, Section of Reproductive and Developmental Medicine, University of Sheffield.

You are welcome to this column in Sexual Health Matters that will regularly navigate the medical world to flag recent development in Sexual Health issues. There will be opportunity to take par in regular problem based searchlight medical exercises. The columnist welcomes regular feedback from readers through the feedback email. Enjoy your reading.

Unsafe sex: fifty excuses for not using condom: Mombasa Phenomenon

Participant observations were conducted over a period of 2 months in the bars, discos, shebeens, and guesthouses of Mombasa, Kenya, where many of the sexual transactions are initiated. This is to explore the reasons why men who have sex with sex workers in Kenya refuse to use condoms in order to develop potential interventions that might help to overcome these barriers.
Thomsen et al found 1, following analysis of the participant observations, at least 50 reasons for not using a condom, which were grouped into six categories: condoms are not pleasurable, condoms are defective, condoms are harmful, condoms are unnecessary, condoms are too hard to use, and external forces prohibit using condoms.
Some of the reasons men say they do not use condoms would be difficult to change directly, whilst others are the result of gaps in knowledge and have not been impacted through better communication strategies. Finally, some of the reasons for not using condoms, such as men’s weaknesses, and the loss of pleasure, could possibly be addressed through the introduction of female controlled devices. However, the most important conclusion of this paper is that men who pay for sex do so because it is pleasurable and many men do not find the male condom pleasurable. Therefore, messages targeted at men who have sex with sex workers may not be 100% successful if they only emphasise the benefits of condom use as disease control.

1Thomsen S, Stalker M and Toroitich-Ruto C.
Fifty ways to leave your rubber: how men in Mombasa rationalise unsafe sex. Sex Transm Infect 2004; 80:466-468.

Recreational Viagra use and Sexual risk behaviours

A cross sectional pilot study 1 was conducted using behavioural measures including Viagra (sildenafil) use assessed by a 3 month recall. The aim is to identify bivariate correlates of recreational (non-prescription) Viagra use among men who have sex with men (MSM) attending a popular sex resort for men located in the southern United States. Given the potential for Viagra use to foster greater friction during sex (owing to enlarged erection size), and prolonged sex, the recreational use of this substance warrants investigation in the context of STI risk.
Ninety–one percent of the study population (N=164) completed a self administered questionnaire. Men resided in 14 states, most of which were located in the southern United States. Their average age was 40 years. Most (93%) men self identified as white. The median annual income interval was $25 000 to $50 000. One sixth (16.7%) reported being HIV positive. 16% reported using non-prescription Viagra. Age (p = 0.41), income (p = 0.32), and HIV serostatus (p = 0.85) were not associated with Viagra use. Of men recently using ecstasy during sex, 35% reported Viagra use compared to 13% among those not using ecstasy (p = 0.01). Of men recently using cocaine during sex, 37% reported Viagra use compared to 13% among those not using cocaine (p = 0.009). Use of "poppers" approached, but did not achieve, statistical significance as a correlate
of Viagra use (p = 0.06). Recent frequency of unprotected anal sex (p = 0.79), fisting (p = 0.10), rimming (p = 0.64), and having five or more sex partners (p = 0.09) were not associated with Viagra use.

It is concluded that recreational Viagra use was relatively common among men, regardless of age or HIV serostatus. Viagra use was associated with men’s substance abuse behaviours rather than their sexual risk behaviours.

1Crosby R and DiClemente R J.
Use of recreational Viagra among men having sex with men. Sex Transm Infect 2004; 80:466-468.

Elective single versus double-embryo transfer in artificial reproductive technology-effects on preterm and multiple births

The high incidence of multiple births, which relates to the number of embryos transferred in in-vitro fertilization (IVF), is responsible for the increased risks of premature birth and perinatal death. Thurin et al1 performed a randomized, multicentre trial to assess the equivalence of two approaches to IVF with respect to the rates of pregnancy that result in at least one live birth and to compare associated rates of multiple gestation. Women less than 36 years of age who had at least two good-quality embryos were randomly assigned either to undergo transfer of a single fresh embryo and, if there was no live birth, subsequent transfer of a single frozen-and-thawed embryo, or to undergo a single transfer of two fresh embryos. Equivalence was defined as a difference of no more than 10 percentage points in the rates of pregnancy resulting in at least one live birth.
Pregnancy resulting in at least one live birth occurred in 142 of 331 women (42.9 percent) in the double-embryo-transfer group as compared with 128 of 330 women (38.8 percent) in the single-embryo-transfer group (difference, 4.1 percentage points; 95 percent confidence interval, –3.4 to 11.6 percentage points); rates of multiple births were 33.1 percent and 0.8 percent, respectively (P<0.001). These results do not demonstrate equivalence of the two approaches in rates of live births, but they do indicate that any reduction in the rate of live births with the transfer of single embryos is unlikely to exceed 11.6 percentage points.
This study concludes that in women under 36 years of age, transferring one fresh embryo and then, if needed, one frozen-and-thawed embryo dramatically reduces the rate of multiple births while achieving a rate of live births that is not substantially lower than the rate that is achievable with a double-embryo transfer.

1Thurin Ann, Hausken Jon, Hillensjö Torbjörn et al. Elective Single-embryo Transfer versus Double-embryo Transfer in In-Vitro Fertilization.
New England Journal of Medicine 2004:351(23):2392-2402.

Diastolic blood pressure in pregnancy, birth weight and perinatal mortality: any relationship?

A recent prospective study1 involving 15 maternity units in one London Health Region, 1988-2000 investigated the relationship of diastolic blood pressure in pregnancy with birth weight and perinatal mortality.
The participants included 210 814 first singleton births of babies weighing more than 200g among mothers with no hypertension before 20 weeks' gestation and without proteinuria, delivering between 24 and 43 weeks' gestation.
The mean (SD) birth weight of babies born to mothers with no hypertension before 20 weeks' gestation or proteinuria was 3282 g (545 g) and there were 1335 perinatal deaths, compared with 94 perinatal deaths among women with proteinuria or a history of hypertension. Diastolic blood pressure at booking for antenatal checks was progressively higher from weeks 34 to 40 of gestation. The birth weight of babies being delivered after 34 weeks was highest for highest recorded maternal diastolic blood pressures of between 70 and 80 mm Hg and lower for blood pressures outside this range. Both low and high diastolic blood pressures were associated with statistically significantly higher perinatal mortality. Using a linear quadratic model, 94 of 825 (11.4%) perinatal deaths could be attributed to mothers having blood pressure differing from the optimal blood pressure (82.7 mm Hg) predicted by the fitted model. Most of these excess deaths occurred with blood pressures below the optimal value. This study concludes that both low and high diastolic blood pressures in women during pregnancy are associated with small babies and high perinatal mortality.

1Steer PJ, Little PM, Kold-Jensen T, Chapple J, Elliott P.
Maternal blood pressure in pregnancy, birth weight, and perinatal mortality in first births: prospective study.
BMJ 2004; 329:1312

The effects of Lactobacillus on Postantibiotic Candidiasis.

Pirotta et al 1 in a randomised, placebo controlled, double blind, factorial 2x2 trial involving 50 general practices and 16 pharmacies in Melbourne, Australia, investigated whether oral or vaginal lactobacillus can prevent vulvovaginitis after antibiotic treatment.
The study population involved non-pregnant women aged 18-50 years who required a short course of oral antibiotics for a non-gynaecological infection: 278 were enrolled in the study, and results were available for 235. Lactobacillus preparations were taken orally or vaginally, or both, from enrolment until four days after completion of their antibiotic course. The outcome measures were: participants’ reports of symptoms of post-antibiotic vulvovaginitis, with microbiological evidence of candidiasis provided by a self obtained vaginal swab.
Fifty five (23% (95% CI, 18%-29%)) women developed post-antibiotic vulvovaginitis. Compared with placebo, the odds ratio for developing post-antibiotic vulvovaginitis with oral lactobacillus was 1.06 (95% CI 0.58 to 1.94) and with vaginal lactobacillus 1.38 (0.75 to 2.54). Compliance with antibiotics and interventions was high. The trial was terminated after the second interim analysis because of lack of effect of the interventions. Given the data at this time, the chances of detecting a significant reduction in vulvovaginitis with oral or vaginal lactobacillus treatment were less than 0.032 and 0.0006 respectively if the trial proceeded to full enrolment. In conclusion, the use of oral or vaginal forms of lactobacillus to prevent post-antibiotic vulvovaginitis is not supported by these results. Further research is required to investigate the pathogenesis of post-antibiotic vulvovaginitis and interaction with lactobacillus.

1Pirotta M , Gunn J , Chondros P , Grover S , O'Malley P , Hurley S, Suzanne Garland.
Effect of lactobacillus in preventing post-antibiotic vulvovaginal candidiasis: a randomised controlled trial.
BMJ 2004; 329:548.

Antenatal pelvic floor exercise reduces duration of second stage of labour

Randomised controlled trial of pelvic floor muscle training during pregnancy involving 301 healthy nulliparous women randomly allocated to a training group (148) or a control group (153) was carried out by Salvesen and Siv 1. The training group undergo a structured training programme with exercises for the pelvic floor muscles between the 20th and 36th week of pregnancy. The main objective is to examine a possible effect on labour of training the muscles of the pelvic floor during pregnancy.
The main outcome measures were the duration of the second stage of labour and number of deliveries lasting longer than 60 minutes of active pushing among women with spontaneous start of labour after 37 weeks of pregnancy with a singleton fetus in cephalic position.
The patients randomised to pelvic floor muscle training had a lower rate of prolonged second stage labour (24%, 95% CI 16% - 33%; 22 out of 105 women were at risk (undelivered) at 60 minutes in the survival analysis) than women allocated to no training (38% (37/109), 28% to 47%). The duration of the second stage was not significantly shorter (40 minutes v 45 minutes, P = 0. 06). It is concluded that a structured training programme for the pelvic floor muscles is associated with fewer cases of active pushing in the second stage of labour lasting longer than 60 minutes.

1 Salvesen Kjell and Mørkved Siv.
Randomised controlled trial of pelvic floor muscle training during pregnancy. BMJ 2004; 329:378-380.

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