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No clear impact of varicocele treatment on male subfertility
Male subfertility may be related to the presence of varicocele; however, it is not known whether treatment of the varicocele or treatment modality affect subsequent fertility rates. A systematic review has identified 48 studies and compared surgical and radiological treatments with each other and with no treatment. Overall, there is no clear superior treatment modality and it is not certain that treatment has an effect on live birth rate; however, treatment may improve the pregnancy rate. Microscopic subinguinal surgical treatment is possibly more effective and has a lower recurrence rate than other forms of surgical treatment. Robust, larger scale randomised controlled trials (RCTs) are needed to better inform the management of men with varicocele and subfertility.
Cochrane Database Syst Rev 2021;4:CD000479. https://doi.org/10.1002/14651858.cd000479.pub6
Dolutegravir-containing regimens more effective at HIV suppression during pregnancy
Rapid suppression of HIV viral load to undetectable levels is essential during pregnancy to minimise the chance of transmission to the neonate. Historically, studies of new drugs during pregnancy (including antiretroviral therapy) have been minimal due to concerns over adverse effects for neonates. A multicentre RCT conducted in nine countries randomised over 600 women to receive one of two regimens containing dolutegravir (with either tenofovir alafenamide fumarate (TAF) or tenofovir disoproxil fumarate (TDF)) or a more established regimen (efavirenz, emtricitabine, TDF). The TAF+dolutegravir regimen had the lowest composite adverse outcomes and neonatal deaths. Both dolutegravir-containing regimens had superior virological suppression compared with the more established regimen. This study provides robust useful data to help guide the management of women presenting in pregnancy with detectable HIV levels.
Lancet 2021;397:1276–1292. https://doi.org/10.1016/S0140-6736(21)00314-7
Astrodrimer gel may be a useful treatment for bacterial vaginosis
Bacterial vaginosis (BV) is a frequently identified condition that can cause patients distress and frustrate clinicians as there are few reliable treatments. Astrodrimer sodium gel is a novel compound that has recently been licensed to treat BV. A systematic review of RCTs has identified four studies assessing safety and efficacy. Astrodrimer gel appeared to be superior to placebo with regard to all outcomes (including Nugent score, Amsel score, patient-reported symptoms) but these were only assessed at 9–12 and 21–30 days following treatment. There was also an increased rate of candidiasis following astrodrimer treatment. Further study comparing astrodrimer with other available BV treatments would be useful to guide clinicians treating women with BV.
Int J Clin Pract 2021;00:e14165. https://doi.org/10.1111/ijcp.14165
Levonorgestrel IUDs may be effective for emergency contraception
Copper intrauterine devices (IUDs) are the gold standard method of emergency contraception (EC). However, copper IUDs can cause heavier, prolonged and more painful periods which may not be acceptable to many patients. Levonorgestrel (LNG) IUDs may be more acceptable to a greater number of patients due to their effect of reducing blood loss and pain. An RCT compared both types of IUD as a method of EC for 700 women and found the LNG IUD to be non-inferior to the copper IUD at preventing pregnancy. There were important differences between the groups (such as the women in the LNG group being more likely to be using a hormonal contraceptive method already and so having a possibly lower risk of pregnancy) and so a change of practice is not yet recommended by the FSRH Clinical Effectiveness Unit but this may change with future trials.
N Engl J Med 2021;384:335–344. https://www.nejm.org/doi/full/10.1056/NEJMoa2022141
Salpingectomy as safe and efficacious as tubal ligation for female sterilisation
There is increasing evidence that many ovarian cancers originate in the fallopian tubes. Women seeking laparoscopic sterilisation could benefit from salpingectomy as a method of sterilisation rather than tubal ligation as it may have the side effect of reducing ovarian cancer risk. A systematic review of studies comparing tubal ligation and salpingectomy shows no difference in efficacy rates between the methods and no difference in complication rates. As sexual and reproductive healthcare (SRH) clinicians, we should discuss the option of salpingectomy for sterilisation with women and liaise with colleagues in gynaecology to establish pathways for this treatment option.
Am J Obstet Gynecol 2021;224:258–265.e4. https://doi.org/10.1016/j.ajog.2020.09.011
Superior hypogastric plexus block does not reduce post-hysterectomy pain
Pain management for gynaecological procedures is important in order to facilitate rapid discharge from hospital and return to normal life for the patient. An RCT compared superior hypogastric plexus block provided following laparoscopic hysterectomy with no treatment. Patients were blinded to their treatment group and visual analogue score was obtained 2 hours post-operatively. The primary outcome was proportion of patients with a score less than 4. There was no statistically significant difference between groups, although a greater proportion of the treatment group achieved this score. Other options are needed to manage post-gynaecological operation pain.
Obstet Gynecol 2021;137:648–656. https://doi.org/10.1097/AOG.0000000000004329
Men want to use novel male contraception and women will trust them to use it
Male contraception has been in development for the past 70 years. Technological developments have meant that there are increasingly viable male methods on the horizon, but there is an oft-expressed doubt that men would use these methods and that women would trust them. A systematic review examined the acceptability and willingness to use data published over the last 50 years. Studies were too heterogenous to allow meta-analysis; however, there was a consistent group of men and women who reported willingness to use a novel male contraceptive method throughout all of these studies. A validated tool for assessing acceptability of male contraceptive methods would improve reporting consistency in the field and for use following the release of a male method to the market.
J Sex Res 2021; https://doi.org/10.1080/00224499.2021.1905764
Ethics statements
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, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Commissioned; internally peer reviewed.