Sign up
Healthed-White-on-Blue

Sexual health

shutterstock_1350420863
Dr Linda Calabresi
Clinical Articles iconClinical Articles

Fish-oil for future fathers

Prospective fathers might consider taking fish-oil supplements to improve their fertility, new research suggests.Danish researchers conducted the study into the reproductive function among over 1500 young men (aged 18-19 years) from the general population. They compared parameters such as total sperm count and motility, as well as serum hormone levels including testosterone and FSH among those men who had reportedly taken fish oil supplements regularly over the past three months with those who didn’t.

Expert/s: Dr Linda Calabresi
pregnancy
Prof Sarah Robertson
Clinical Articles iconClinical Articles

Bushfire smoke and pregnancy – the risks

Smoke haze from Australia’s catastrophic bushfires is continuing to affect many parts of the country.

Expert/s: Prof Sarah Robertson, Prof Louise Hull
HIV Overwhelming the enemy from the start
University of Montreal
Clinical Articles iconClinical Articles

HIV: Overwhelming the enemy from the start

Great strides have been made in terms of public health campaigns to reduce the spread of HIV, and the development of antiretrovirals to stop people living with the condition from developing AIDS. However, medical interventions to cure or vaccinate against the condition have so far proved elusive.Researchers from the Montreal Clinical Research Institute may have made a crucial first step in this direction. Their recent research, outlined recently in the journal Cell Reports, focuses on boosting the levels of ‘plasmacytoid dendritic cells’ (PDCs) in the earliest stages of HIV infection.

Expert/s: University of Montreal
The problem with fertility apps
Jessica Grieger
Clinical Articles iconClinical Articles

The problem with fertility apps

In years gone by, women would rely on the calendar on the wall to work out when their next menstrual cycle might occur. They would look to physical signs to tell them when they might be ovulating, and therefore when they’d be most likely to fall pregnant.More recently, we’ve seen the proliferation of mobile phone applications helping women track their current cycle, predict their next cycle, and work out when the best time is to try for a baby.There are more than 400 fertility apps available, and over 100 million women worldwide are using them.The personalisation and convenience of apps makes them empowering and attractive. But they require some caution in their use.

Expert/s: Jessica Grieger, Prof Robert Norman
Improving male fertility – a missed opportunity
Dr Linda Calabresi
Clinical Articles iconClinical Articles

Improving male fertility – a missed opportunity

Lack of knowledge and lack of opportunity are two key reasons why Australian GPs aren’t counselling men about how to improve their fertility.According to a survey of over 300 practising GPs, the vast majority (90%) did not feel confident in their knowledge about modifiable risk factors that affect male fertility.And when the researchers got specific, it appeared there was greater awareness of the potential of STIs and smoking to cause fertility problems than a number of other factors such as obesity, undernutrition and poor diet, paternal age and diabetes.

Expert/s: Dr Linda Calabresi
Help for LGBTI patients
Dr Linda Calabresi
Clinical Articles iconClinical Articles

Help for LGBTI patients

Here is a useful resource for those GPs who have patients who are struggling with issues related to their sexuality and need more specifically tailored support.Even though there is much more awareness and openness about different sexual orientations, it is likely GPs will appreciate the support of this free counselling and referral service developed for people who are LGBTI.

Expert/s: Dr Linda Calabresi
shutterstock_1712255008
A/Prof Ken Sikaris
Clinical Articles iconClinical Articles

So you think you understand pregnancy tests?

Less than 40 years ago pregnancy was typically diagnosed by history and examination alone. While clinical skills always remain useful, there have been major advances in pregnancy testing that have been both clinically and medicolegally important. Like all diagnostic testing, pregnancy tests are not infallible, and it is very helpful for clinicians to understand their strengths and weaknesses.

Expert/s: A/Prof Ken Sikaris
shutterstock_1024338388
Prof Deborah Bateson
Clinical Articles iconClinical Articles

An app to prevent pregnancy? Don’t count on it

Fertility awareness apps are being championed as a new approach to contraception. In reality, while the technology may be new, women have been predicting the fertile days in their menstrual cycles to prevent pregnancy for a very long time.But the growth of the “femtech” industry, alongside a seemingly growing wave of younger women looking to move away from hormonal methods of contraception, has led to a renewed interest.

Expert/s: Prof Deborah Bateson
shutterstock_1456138835
Dr Linda Calabresi
Clinical Articles iconClinical Articles

WHO can take what contraceptive

The World Health Organisation (WHO) has developed an app that is sure to prove valuable to health professionals who manage sexual and reproductive health as part of their clinical practice.The ‘Medical eligibility criteria for contraceptive use’ app will help clinicians recommend safe, effective and acceptable contraception methods for women with medical conditions or particular characteristics that require individual consideration.

Expert/s: Dr Linda Calabresi
shutterstock_174165935
Dr Linda Calabresi
Clinical Articles iconClinical Articles

Anal cancer and HPV infection

Anal cancer is a neglected disease.Whether through shame and embarrassment, or self-diagnosis of a haemorrhoid, late presentations are not uncommon and have an overall five-year survival of only 65%. It is an important disease which is potentially preventable but, whether the measure is research time and money, media coverage or the allocation of a coloured ribbon, anal cancer has not received the attention it deserves.Before discussing who gets anal cancer, why they get it, how we might prevent it and the efforts being taken to do so, the anatomy and terminology need to be established and understood.
  • Gentle traction placed on the buttocks will reveal perianal lesions (those falling within 5 cm of the anal opening) however anal canal lesions will be visualised incompletely or not at all by means of this manoeuvre. This is vitally important to appreciate because accurate description of location has direct clinical relevance. Anal canal cancers are more aggressive and require chemoradiation, while perianal cancers behave more like skin cancers and wide excision is usually appropriate.
  • The anal canal has three zones – colorectal, transformation and lower canal. The transformation zone, centred on the dentate line, is where the glandular epithelium of the rectum meets the squamous epithelium of the lower canal, and is analogous to that in the cervix. It may encompass several centimetres, have poorly demarcated margins and is characterised by ongoing squamous metaplasia and constant replacement of glandular epithelium.
The transformation zone is where most anal canal cancers arise.

Who gets anal cancer?

While it is a rare disease in the general community (1–1.5/100,000), several sub-populations have very high rates of anal cancer:
  • HIV-positive men who have sex with men
  • Other HIV-positive individuals (male and female)
  • HIV-negative men who have sex with men
  • Organ transplant recipients
  • Women with a history of HPV-related vulval/vaginal/ cervical cancer or pre-cancer
About 95% of anal cancers are caused by HPV and the great majority of these are caused by HPV 16. HPV is a sexually transmitted infection and anal intercourse an efficient means of HPV transmission; however, anal intercourse is not a prerequisite for anal HPV infection.Anal HPV infection is common in both sexes (whether or not anal intercourse is reported) but most anal infections are transient.Anal cancer is a rare outcome associated with persistence of the virus and with other co-factors, such as smoking and immunosuppression.

Is prevention of anal cancer possible?

VaccinationAustralia was the first country in the world to commence an organised HPV vaccination program, starting with girls and young women in 2007 and extending to school-aged boys in 2013.While vaccine efficacy for the prevention of anal cancer is anticipated to be similar to that for cervical cancer, proof of it will take longer to demonstrate. Unlike cervical cancer, the incidence of anal cancer continues to increase into old age and therefore the benefits of vaccination may take decades to become apparent.Screening for pre-cancerDigital anorectal examination (DARE) is currently recommended to detect the earliest anal cancers. In addition, some centres screen for anal pre-cancer using a model based on the multiple similarities which exist between cervical and anal cancer, namely the same virus infecting the same type of transformation zone, leading to development of the same precancerous, high-grade squamous intraepithelial lesion (HSIL) which can be detected cytologically.These commonalities translate, in the setting of anal cancer screening, to a process involving anal cytology, possibly anal HPV testing and high-resolution anoscopy (akin to colposcopy), followed by biopsy.Despite these correlations between cervical and anal HPV infection and the plausibility of similar screening protocols being applicable in both settings, a screening program for anal cancer has not been as widely implemented as may have been expected.Why is this?-Near-universality of HPV infection in men who have sex with men limits the effectiveness of HPV testing in triage.-Not enough is known about the natural history of anal HSIL and it is likely to differ in significant ways from cervical cancer. In gay men, for example, high-grade lesions appear to be quite common and a proportion may regress without treatment.-There is no accepted treatment for patients with biopsy-diagnosed anal HSIL. While the entire transformation zone of the cervix can be excised with few sequelae, this is not possible in the anal canal and there is no reliable evidence for any other interventions currently used.

Summary

At this stage neither HPV testing or anal cytology can be recommended as routine screening procedures for anal cancer and pre-cancer.Until certain key questions are answered, at-risk patients should be identified, reviewed annually by DARE and managed accordingly.Vaccination is worth offering to those in at-risk groups and is safe and effective in the immunosuppressed. - General Practice Pathology is a regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs. The authors provide this editorial free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.
Expert/s: Dr Linda Calabresi
shutterstock_1077329474
Dr Amanda Henry
Clinical Articles iconClinical Articles

Health Check: How Long Should I Wait Between Pregnancies?

Women often wonder what the “right” length of time is after giving birth before getting pregnant again. A recent Canadian study suggests 12-18 months between pregnancies is ideal for most women.But the period between pregnancies, and whether a shorter or longer period poses risks, is still contested, especially when it comes to other factors such as a mother’s age. It’s important to remember that in high-income countries most pregnancies go well regardless of the gap in between.

What is short and long

The time between the end of the first pregnancy and the conception of the next is known as the interpregnancy interval. A short interpregnancy interval is usually defined as less than 18 months to two years. The definition of a long interpregnancy interval varies – with more than two, three or five years all used in different studies.Most studies look at the difference every six months in the interpregnancy interval makes. This means we can see whether there are different risks between a very short period in between (less than six months) versus just a short period (less than 18 months).Most subsequent pregnancies, particularly in high-income countries like Australia, go well regardless of the gap. In the recent Canadian study, the risk of mothers having a severe complication varied between about one in 400 to about one in 100 depending on the interpregnancy interval and the mother’s age.The risk of stillbirth or a severe baby complication varied from just under 2% to about 3%. So overall, at least 97% of babies and 99% of mothers did not have a major issue.Some differences in risk of pregnancy complications do seem to be related to the interpregnancy interval. Studies of the next pregnancy after a birth show that:

What about other factors?

How much of the differences in complications are due to the period between pregnancies versus other factors such as a mother’s age is still contested. On the one hand, there are biological reasons why a short or a long period in between pregnancies could lead to complications.If the gap is too short, mothers may not have had time to recover from the physical stressors of pregnancy and breastfeeding, such as pregnancy weight gain and reduced vitamin and mineral reserves. They may also not have completely recovered emotionally from the previous birth experience and demands of parenthood.If the period between pregnancies is quite long, the body’s helpful adaptations to the previous pregnancy, such as changes in the uterus that are thought to improve the efficiency of labour, might be lost.However, many women who tend to have a short interpregnancy interval also have characteristics that make them more at risk of pregnancy complications to start with – such as being younger or less educated.Studies do attempt to control for these factors. The recent Canadian study took into account the number of previous children, smoking and the previous pregnancy outcomes, among other things. Even so, they concluded that risks of complications were modestly increased with a lower-than-six-month interpregnancy period for older women (over 35 years) compared to a 12-24-month period.Other studies, however, including a 2014 West Australian paper comparing different pregnancies in the same women, have found little evidence of an effect of a short interpregnancy interval.

So, what’s the verdict?

Based on 1990s and early 2000s data, the World Health Organisation recommends an interpregnancy interval of at least 24 months. The more recent studies would suggest that this is overly restrictive in high-resource countries like Australia.Although there may be modestly increased risks to mother and baby of a very short gap (under six months), the absolute risks appear small. For most women, particularly those in good health with a previously uncomplicated pregnancy and birth, their wishes about family spacing should be the major focus of decision-making.In the case of pregnancy after miscarriage, there appears even less need for restrictive recommendations. A 2017 review of more than 1 million pregnancies found that, compared to an interpregnancy interval of six to 12 months or over 12 months, an interpregnancy interval of less than six months had a lower risk of miscarriage and preterm birth, and did not increase the rate of pre-eclampsia or small babies.So, once women feel ready to try again for pregnancy after miscarriage, they can safely be encouraged to do so.
Expert/s: Dr Amanda Henry
shutterstock_331750409
Dr Linda Calabresi
Clinical Articles iconClinical Articles

Intellectual Disability More Likely with Some ART

Australian research has found an increased risk of intellectual disability with some forms of Assisted Reproductive Technology (ART).The WA study published in Pediatrics found that one in 48 children conceived using ART were diagnosed with an intellectual disability, compared with only one in 59 children conceived naturally.And the risk was even greater for certain subgroups within the ART cohort.“The risk was more than doubled for those born very preterm, for severe [intellectual disability] and after intracytoplasmic sperm injection (ICSI) treatments,” said the researchers from the Telethon Kids Institute.To conduct the study, researchers analysed population registers of over 200,000 live births occurring between 1994 and 2002 in Western Australia and examined data on ART and diagnoses of intellectual disability occurring within eight years of follow-up.The fact that the study findings were based on analyses of statistics from almost 20 years ago was acknowledged by the authors, especially since ART practices have changed greatly since then.“Our study included children born from 1994 to 2002 when multiple embryo transfer was common practice in Western Australia,” they said. This increased the likelihood of a multiple pregnancy and preterm birth.However even when the analyses are restricted to singleton births the small increased risk of intellectual disability persisted but was not as great.The link between ICSI-conceived children and intellectual disability was also of interest. At the time, this technique was restricted to couples with severe male-factor subfertility and was often associated with older aged males.“Genetic abnormalities occur more frequently in men who are infertile, so ICSI (which bypasses natural selection barriers) may allow for the transmission of chromosomal anomalies in the offspring,” the authors said.According to the study, one in 32 children conceived using ICSI were diagnosed with an intellectual disability.ICSI is now used more broadly, prompting concerns.As lead author, Dr Michele Hansen said, “[ICSI] is currently used in 63 per cent of treatment cycles.”“Our findings show an urgent need for more recent data to establish whether the increased risks of intellectual disability seen in children conceived using ICSI are solely related to severe male subfertility and older paternal age, or if there are other risks associated with the technique itself.”Overall the study findings provide supportive evidence for Australia’s current IVF policy of single embryo transfer unlike many other countries where multiple embryo transfers are still routinely performed.The researchers also point out the study has implications for the use of ICSI, or more exactly restricting the use of ICSI and recognising the increased risk of genetic anomalies that might occur in children conceived in this way.“These couples may opt to use preimplantation genetic testing to maximise the transfer of chromosomally normal embryos,” they suggest. 

Reference

Hansen M, Greenop KR, Bourke J, Baynam G, Hart RJ, Leonard H. Intellectual Disability in Children Conceived Using Assisted Reproductive Technology. Pediatrics. 2018; 142(6): e20181269. DOI 10.1542/peds.2018-1269
Expert/s: Dr Linda Calabresi

Education by clinicians, for clinicians

Get the app

Site

Company

Connect

Legal

Discover

Healthed

CPD platform