The stepwise development of an interactive web-based sex education programme for subfertile couples: the Pleasure & Pregnancy programme.

STUDY QUESTION: Can we develop a web-based sex education programme (programme running in a web browser) that addresses the needs of subfertile couples who are advised expectant management for at least 6 months? SUMMARY ANSWER: The 'Pleasure & Pregnancy' programme addresses couples' needs, is likely to improve couples' sexual functioning, and is subsequently hypothesised to improve the chance of natural pregnancy. WHAT IS KNOWN ALREADY: According to professional guidelines (e.g. the Netherlands and UK) couples with unexplained subfertility and a good chance of natural pregnancy, should be advised at least 6 months of expectant management. Adherence to expectant management is challenging as couples and gynaecologist prefer a more active approach. Targeting sexuality may be useful as subfertility is a risk factor for decreased sexual functioning. STUDY DESIGN, SIZE, DURATION: A novel programme was developed according to the three steps of the Medical Research Councils' (MRC) framework. First, relevant literature was explored. Second, an interdisciplinary expert panel developed a theory (based on a systematic literature review and patient interviews) on how the chance of natural conception can be improved. Third, the expected process and outcomes were modelled. PARTICIPANTS/MATERIALS, SETTING, METHODS: Two licenced clinical sexologists, two gynaecologists, a clinical embryologist and two midwife-researchers, all from Belgium and the Netherlands, proposed components for the sex education programme. PubMed was searched systematically for randomised controlled trials (RCTs) evaluating the proposed components in different patient populations. The needs of 12 heterosexual Dutch or Belgian couples who were advised expectant management were explored with in-depth interviews. The content and delivery characteristics of the novel programme were described in detail with the aid of 'Intervention Taxonomy'. To model the outcomes, a protocol for an RCT was designed, registered and submitted for publication. MAIN RESULTS AND THE ROLE OF CHANCE: To help maintain or improve sexual functioning, mainly pleasure, and hence increase pregnancy rates, the web-based Pleasure & Pregnancy programme contains a combination of psychosexual education and couple communication, mindfulness and sensate focus exercises. Information on the biology of conception and interaction with fertility clinic staff and peers were added based on couples' needs to increase potential acceptability. LIMITATIONS AND REASON FOR CAUTION: This paper outlines the development phase of a sex education programme according to the MRC-framework. Whether the Pleasure & Pregnancy programme actually is acceptable, improves sexual functioning, increases pregnancy rates and is cost-effective remains to be determined. WIDER IMPLICATIONS OF THE FINDINGS: No previous interactive web-based sex education programme has aimed to increase the natural pregnancy rate of subfertile couples by targeting their sexual pleasure. The Pleasure & Pregnancy programme addresses couples' needs and its effect on sexual functioning and pregnancy rate is plausible but remains to be demonstrated by an RCT which is currently ongoing. STUDY FUNDING/COMPETING INTEREST(S): Funding was provided by The Netherlands Organisation for Health Research and Development (ZonMw), Flanders Research Foundation and the University of Amsterdam. C.B.L. is editor-in-chief of Human Reproductionbut was blinded to all parts of the peer review process. The remaining authors have no conflict of interest to report. TRIAL REGISTRATION NUMBER: Not applicable.

The effects of tibolone on vaginal blood flow, sexual desire and arousability in postmenopausal women.

AIMS: To compare the effects of 3 months' tibolone treatment with the effects of placebo on sexual function (in particular, vaginal blood flow, and sexual desire and arousability) and climacteric symptoms in postmenopausal women. METHODS: A randomized, double-blind, cross-over study was conducted in 38 postmenopausal women who received tibolone 2.5 mg/day and placebo. Vaginal blood flow during erotic stimulation by fantasy and film was measured using a vaginal photoplethysmograph and subjects completed sexual function questionnaires and daily diaries. RESULTS: Tibolone significantly increased baseline vaginal pulse amplitude (VPA) levels compared with placebo. There were significant treatment differences in VPA in favor of tibolone during fantasy periods but not during erotic film stimulation. Tibolone was associated with significant increases in sexual desire, and the frequency of arousability and of sexual fantasies compared with those with placebo. Vaginal lubrication was significantly improved on tibolone. Twenty-five of 38 (66%) subjects correctly guessed when they were on active treatment. Tibolone was well tolerated. CONCLUSIONS: Tibolone was associated with significant improvements in sexual function in postmenopausal women, reflecting both its estrogenic and androgenic properties. There were significantly greater increases in vaginal blood flow with tibolone in response to erotic fantasy but not film, suggesting two possible pathways of female sexual response.

Profile and opinions of the female Persona user in The Netherlands.

OBJECTIVES: The primary objective of this study was to investigate the profile of the Dutch Persona user and her opinion about this relatively new way of natural birth control. The results of the study were used to draw conclusions for the suitability for Persona as a contraceptive method. METHOD: Data from 137 users of the device were obtained from structured questionnaires. RESULTS: The 'Persona woman' is typically in a steady relationship, highly educated and has an above-average income. She wants to have a contraceptive method with no side-effects and desires children in the future. She is therefore looking for information about her own cycle. It is remarkable that one in four women uses the system to help in planning a pregnancy instead of avoiding one. CONCLUSIONS: Persona seems to be a welcome alternative for natural family planning and for couples who have no absolute negative attitude towards a(nother) child, but want to postpone their first pregnancy or to space pregnancies. The method is not reliable enough to be used as the only contraceptive method when a couple absolutely wants to prevent a pregnancy. Another conclusion that can be drawn is that the method improves fertility awareness.

Abortion service in Amsterdam: deciding and coping in a liberal system.

OBJECTIVES: The Netherlands have liberal abortion laws and contraceptives are easily available. In the AMC, a service protocol is designed to facilitate decision-making. In this context, the following questions arise: Do our abortion clients know what went wrong with their contraceptive behavior? Did they decide for more effective contraception afterwards? How did they feel about their own decision and about our services, which include obligatory counselling? STUDY DESIGN: A questionnaire was sent to 23 consecutive clients, who were willing to cooperate. The questionnaire consisted of a scale with 26 items and two open-ended essay-questions. RESULTS: The response rate was 45% (11 complete questionnaires). Seven women had used contraceptives, six knew what had gone wrong, five had decided to improve their contraception, four women had not used contraceptives, out of which two decided to start, seven women found the abortion decision difficult, seven women (not the same) were content with their decision, and one of them felt bereaved. The four who were not, on the whole, content with their decision felt bereaved. Eight appreciated our services, ten had used the essay-questions to tell their own story. One woman explicitly regretted her decision and would have liked more intensive counselling. CONCLUSIONS: Our system does not yet function as it should. The reasons may be psychological (unexplored ambivalence), sociocultural (difficulties in using effective contraception) and cognitive (some women were very young and not adequately informed). On a methodological level, we conclude that open-ended questions on these subjects generate more accurate and subtle information.

The role of the sexologist in urology.

Most urological problems have sexual sequelae. The majority of unexplained urological symptoms have a psychosexual background, many urological interventions have sexual consequences and the urologist is often confronted with patients having sexual dysfunctions. For the urologist it is therefore necessary to learn basic sexological skills and to implement cooperaration with specialists in sexual medicine in daily urological practice in order to prevent somatization of psychosexual problems, to provide effective care and to improve patient compliance.

Hormones and sexuality in postmenopausal women: a psychophysiological study.

Sexual function, including vaginal atrophy, and hormonal status, were studied in 42 naturally postmenopausal women. Vaginal pulse amplitude and subjective sexual responses during self-induced erotic fantasy and during erotic films were compared with responses of a small number of premenopausal women. As predicted, vaginal atrophy was related to estrogens but not to complaints of vaginal dryness and dyspareunia. No significant relationship was found between hormones and sexual function. Unexpectedly, most of the few correlations that did reach significance involved prolactin. The fact that prolactin was negatively associated with sexual desire, sexual arousal and vaginal lubrication during sexual activity, suggests that psychosocial factors are more important than hormone levels in postmenopausal sexual function. Comparisons with a number of premenopausal women revealed that although postmenopausal women displayed lower vaginal pulse amplitude responses prior to erotic stimulation than the premenopausal women, this difference disappeared during subsequent erotic stimulation. We argued that this finding can be interpreted as being supportive of the notion that complaints of vaginal dryness and dyspareunia should not be attributed to vaginal atrophy associated with menopause. Rather, vaginal dryness and dyspareunia seem to reflect sexual arousal problems.

Sex, hormones and the brain.

The human sexual response is a complicated biopsychosocial phenomenon in which internal and external stimuli are modulated by the central and peripheral nervous system, resulting in a cascade of biochemical, hormonal and circulatory changes that lead to cognitive and physical sexual arousal. In this article, current knowledge of the relationships between central processes, mediated by neuropeptides and neurotransmitters, and the hypothalamo-pituitary-gonadal axis is explored. Hormonal aspects of sexual arousability and sexual excitement are mainly related to androgens. The possible influences of hormonal therapies such as hormonal contraception and perimenopausal hormone substitution are described. The main conclusion is that clinicians should be aware of possible sexual problems resulting from changes in circulating sex hormone binding globulin and free testosterone in men and women due to endogenous or exogenous hormonal changes.

Focal vulvitis: a psychosexual problem for which surgery is not the answer.

In the last decade focal vulvitis has been identified as a distinct syndrome, characterized by unexplained burning vulvar pain and superficial dyspareunia. A 'Woodruff perineoplasty' has been recommended as a treatment method. A research project was conducted, investigating the long-term results of surgical treatment and the etiology of focal vulvitis. Results showed that the great majority of women continued to suffer from focal vulvitis after the operation, which leads to the conclusion that the procedure should be abandoned. Retrospective data revealed several immediate causes of mechanical and chemical irritation of the vulva. All women exhibited 'inadequate sexual behavior': having intercourse without a sufficient amount of lubrication and/or in the presence of hypertonia of the pelvic floor. Psychosexual processes were further characterized by deterioration of sexual and general well-being, resulting in lack of libido and depression, which contributed considerably to the problem. An integrated approach to treatment is recommended, which incorporates protection of the vulvar skin, relaxation of pelvic muscles and sexological treatment of the psychosexual and relational aspects.

Visual stimulation facilitates penile responses to vibration in men with and without erectile disorder.

This study compared reflexogenic and psychogenic penile responses in men with and without erectile disorder. It was hypothesized that men with psychogenic erectile dysfunction respond minimally to vibrotactile stimulation. An enhancement of penile responses was expected when vibration was combined with erotic film. Patients were 50 men with psychogenic erectile dysfunction, 45 men with organic erectile dysfunction, and 50 sexually functional men. The combination of film and vibration resulted in stronger penile responses than the stimuli presented separately. Men with psychogenic erectile dysfunction and sexually functional men did not differ in responses to film and film-and-vibration conditions. As predicted, responses of the 2 groups were different in the vibration condition. Interpretations are provided in terms of attention and appraisal. The findings are relevant to the development of psychophysiological diagnostic procedures.

Choices and changes in contraceptive behaviour; the role of information sources.

One of the factors contributing to the fact that contraceptive behaviour in The Netherlands is more effective then in most other countries seems to be that Dutch women are very well informed about all aspects of contraception as a result of formal and informal education at school, in the families and by the media. In a population based survey more than 4500 women were followed during 5 consecutive years by means of a yearly questionnaire about contraceptive behaviour, choices and trends. With regards to information sources it is concluded that the general practitioner, who plays a central role as provider of contraceptive services, is viewed as the most important and reliable source of information. On the other hand Dutch women in general view their contraceptive choices as their own, they do not feel that they are very much influenced by the opinions of their physicians, who in general do not have a normative, patronizing and/or moralizing attitude regarding sexuality and contraception.

PIP: Between 1989 and 1993, a cohort of more than 4500 women, 15-49 years old, living in the Netherlands were interviewed on family planning, contraceptive use, sexual behavior, attitudes, use of services, sources of information, and reasons for changes in behavior and/or contraceptive status. The media, public opinions, and attitudes of health care authorities have affected contraceptive behavior. For example, IUD use fell during the 1980s and early 1990s (1980-1993, from about 14 to 2.8%) due to adverse publicity and the continued belief by women and health care providers that IUDs increase the risk of pelvic inflammatory disease and ectopic pregnancy. 86-89% of women believed that they themselves decided which contraceptive to use. The leading information source for all contraceptive methods but condoms was the general practitioner (66-80%). In fact, the women rated the information from the general practitioner to be the best for all methods (92-98%). The general practitioner was perceived not to have a normative, patronizing, or moralizing attitude towards sexuality and contraception. More and more women, particularly teenagers, were adopting the Dutch method of simultaneous contraceptive and condom use to prevent unwanted pregnancy and transmission of sexually transmitted diseases, including HIV. The female condom, Femidom, was introduced in the Netherlands in January 1993. By March-April 1993, just 22% of the women had never heard of Femidom. 86% of condom users had heard of it, while just 74% of women who used no contraception had heard of it. Just 3 women used it regularly and 8 women used it sometimes.

Validation of a psychophysiological waking erectile assessment (WEA) for the diagnosis of male erectile disorder.

OBJECTIVE: The aim of the present study was to evaluate a psychophysiological waking erectile assessment (WEA). WEA was designed to elicit penile responses using visual and vibrotactile stimuli and cognitive tasks (distraction and monitoring of erections). METHODS: One hundred consecutive patients with erectile dysfunction and a control group of 50 sexually functional males were examined. Clinical decision analysis, including a receiver operating characteristic (ROC) analysis, was used to determine the accuracy of WEA in predicting independent diagnostic classifications. RESULTS: Fifty percent of the patients were independently diagnosed as having pure psychogenic impotence. In 45 percent of the patients an organic factor was found. Discrimination was best in three (out of 7) WEA conditions in which film was combined with vibration. This combination of conditions resulted in a test sensitivity of 81 percent, and predictive values positive (the probability of "no organic involvement" given a penile response greater than 12 mm) ranging from 66 to 95 percent. About one third of the patients with pure psychogenic erectile dysfunction had an average response of more than 30 mm to the three conditions combining vibration and film. None of the patients with organic involvement exceeded this 30 mm criterion. Thus, the predictive value positive reached its maximum of 100 percent. CONCLUSIONS: The results suggest that WEA is an appropriate initial screening procedure, and that it is of particular value in the detection of psychogenic cases.

The way we train the clinical eye through slides.

Inspection is an important clinical skill. It is remarkable that in basic medical education this skill is not specially trained. To remedy this, we have developed a method of instruction at Groningen University Hospital to train inspection. We give an outline of the method and provide examples of dialogue.