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Supplemental zinc and folic acid—no effect on pregnancy rate or semen quality
There have been mixed reports of the effect of supplemental zinc and folic acid consumption on the quality of semen, as both are essential for spermatogenesis. A 2017 meta-analysis concluded that large-scale prospective trials were needed. This multicentre, double-blind, placebo-controlled randomised trial enrolled more than 2000 couples seeking fertility treatment and evaluated live birth rate and a variety of semen analysis parameters. There was no difference in live birth rate or semen parameters between study groups. Supplementation with zinc and folic acid cannot be recommended for those undergoing fertility treatment.
JAMA 2020;323(1):35–48.
Telehealth interventions can improve obstetric outcomes and deliver contraception and medical abortion services
The coronavirus outbreak has necessitated many services moving partially or wholly to telemedicine models of delivery. Clinicians may be concerned about the evidence for safety and efficacy underpinning some of these changes. This systematic review of telehealth interventions in obstetrics and gynaecology has found that telemedicine is as effective and safe as face-to-face care for the provision of medical abortion. Likewise, it presents the evidence for sustained (and possibly improved) oral contraceptive use when provided through telehealth.
Obstet Gynecol 2020;135:371–82.
Long-acting injectable antiretroviral combination is non-inferior to oral treatment for suppression of HIV-1
Development of long-acting antiretrovirals is a key objective in HIV treatment as this can improve adherence to treatment and maintain viral suppression. This phase III open-label study randomised patients to receive injectable long-acting antiretrovirals monthly following initial suppression with oral treatment or to continue on oral treatment. The injectable group reported high satisfaction with this method and non-inferior viral suppression. However, injection site reactions were common, which may affect acceptability and thus adherence when brought to market.
N Engl J Med 2020; 382:1124–1135.
Oral GnRH antagonists may be useful in management of heavy menstrual bleeding
Heavy menstrual bleeding (HMB) affects many women and can be a source of misery and embarrassment. In this pair of double-blinded randomised placebo-controlled trials, elagolix, an oral gonadotrophin-releasing hormone (GnRH) antagonist, was given with and without dual hormone replacement therapy (HRT, as ‘add-back’) versus placebo. Perhaps unsurprisingly, reduction in menstrual blood flow was achieved in both active arms of the study; however, side effects from add-back HRT and hypo-oestrogenic side effects were present. This study does not present a radical change to treatment options for HMB, but the option for an oral GnRH antagonist will be a welcome alternative for patients who are needle-phobic or intolerant of injectable GnRH.
N Engl J Med 2020; 382:328–340.
High rates of rectal Chlamydia trachomatis among women with vaginal infection
Standard testing practice in the UK when screening for Chlamydia trachomatis (CT) in cis-gendered women is to perform nucleic acid amplification testing at the vaginal site only. This prospective epidemiological study sought to determine the rate of spontaneous clearance of CT from vaginal and rectal sites. It found that women infected only vaginally or only rectally were much more likely to spontaneously clear CT than those who were infected at both sites; however, the numbers in these groups were small. Of interest, 76% of women who were initially only tested vaginally were subsequently found to have rectal CT. It may be time that we offer rectal screening routinely for female patients.
doi: 10.1136/sextrans-2019–054 267
More research to guide pain management in second trimester abortion
Medical and surgical methods of abortion are widely recognised to cause pain, and that this pain increases in line with gestational age. Strategies to mitigate pain are necessary to improve the patient experience, but the evidence to support a particular strategy is limited. A systematic review of evidence for second trimester medical and surgical abortion found that studies were limited and heterogenous in nature. However, effective strategies included regional anaesthesia and non-steroidal anti-inflammatory drugs for medical abortion and deep sedation or general anaesthesia for second trimester abortion. Further research is warranted, with a particular focus on strategies that may be deliverable in resource-limited settings.
BJOG 2020 https://doi.org/10.1111/1471-0528.16212
Micronised progesterone vaginal rings demonstrate safety and efficacy similar to copper IUD in postpartum women choosing to breast feed
The progesterone-releasing vaginal ring (PVR) (releasing 10 mg progesterone per day for 3 months) is available for use in some countries for breastfeeding women for contraception. A study of 1-year use of the PVR showed that the period of amenorrhoea following delivery could be extended for many women, support longer periods of breast feeding and give comparable contraceptive efficacy to a copper intrauterine device (IUD). The study did show significantly higher levels of expulsion of the ring than the copper IUD. While the PVR may be suitable for some women, particularly those who desire a user-controlled method, postpartum intrauterine contraception may be superior for long-term method continuation.
Second trimester medical abortion may be effectively self-managed with remote support
Following the coronavirus outbreak, many services in the UK restructured to provide telemedicine abortion care, and in Scotland, legislation and policy was amended to allow home medical abortion up to 11 weeks and 6 days of gestation. A retrospective cohort analysis of self-managed medical abortion between 13 and 24 weeks of gestation in several South American countries found high rates of successful abortion (76%), low rates of complications, and no cases of death, transfusion or hysterectomy. These women were supported by feminist organisations that supplied information online and by telephone, and offered remote support before, during and after abortion treatment. This study adds to the evidence that, with adequate support, women can self-manage medical abortion well beyond 10 weeks of gestation and indeed beyond the first trimester.
Footnotes
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Provenance and peer review Commissioned; internally peer reviewed.