PubMed · 7286725
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K Imieliński. 1981. [Sexual interaction dysfunctions].. https://pubmed.ncbi.nlm.nih.gov/7286725/
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The cardiovascular response to coitus and the risk of an acute cardiac event related to sexual activity is of clinical importance, especially now that effective pharmacologic treatment of male erectile dysfunction permits older men to resume active sex lives. Early studies by Masters and Johnson of young subjects engaging in coitus in laboratory settings reported that heart rates and systolic blood pressures were at near maximum exercise levels. Subsequent data from studies by Hellerstein and Friedman and by Stein in men with coronary artery disease, using ambulatory electrocardiographic recordings during coitus at home, demonstrated significantly lower heart rate and blood pressure responses to coitus. The associated myocardial oxygen demand of coitus in these men was found to in the range of moderate activities, often achieved or exceeded during their workday. The cardiovascular risk of coitus was addressed in the recent ONSET study in which myocardial infarction (MI) patients were interviewed shortly after their MI about potential triggering activities or events. Coitus was noted to represent a very low absolute risk of being a trigger for MI, but had an increased relative risk of 2.5 for the subjects in their study. Sexual intercourse will, in most men, represent only a moderate "stress" on the heart in terms of the responses that impact on myocardial oxygen requirement (heart rates, and systolic blood pressure). In patients with coronary artery atherosclerosis, coitus, compared with vigorous physical activity and intense emotional responses, represents a small risk of triggering an acute MI.
The cardiovascular tolerance for sex has largely been equated with physical activity, yet sexual arousal plays a major role. Exercise testing is useful, primarily for evaluating functional capacity, which reflects the extent of physical conditioning and the limitation imposed by symptoms of angina, dyspnea, and fatigue. Exercise testing, which is useful for evaluating functional capacity in sedentary patients, is generally unnecessary in physically active patients. Exercise testing, with or without radionuclide imaging, is of limited value in assessing the risk of future cardiovascular events-a limitation shared by all diagnostic tests, including coronary angiography. The absolute risks of coition-induced myocardial infarction (MI) or death are extremely low-on the order of 2 chances per million per hour in healthy middle-aged individuals or 20 chances per million per hour in "high-risk" patients with ischemic heart disease. This is equivalent to an annual risk of 1. 01% and 1.2%, respectively. Sex is a comparatively weak precipitant of acute coronary events, accounting for only 0.5-1.0% of all such events. The cardiovascular tolerance for sex in an individual can be characterized by the "functional reserve," that is, the extent to which the cardiovascular response to sex-measured by the heart rate, blood pressure, and oxygen consumption-encroaches on the peak response to exercise. Cardiovascular symptoms during sex rarely occur in patients who do not experience similar symptoms during exercise testing at a level equivalent to 6 METS.
BACKGROUND: Although intra-uterine insemination (IUI) is widely used, however its effectiveness remains a matter of debate. Although IUI is less invasive and expensive than IVF or GIFT, it should only be applied if the probability of conception is improved significantly as compared to the natural chance of conceiving. To increase the number of available oocytes at the site of fertilization, controlled ovarian hyperstimulation (COH) can be applied in conjunction with IUI. Uncontrolled studies suggest a beneficial effect of COH in combination with IUI, also when a male factor is present. To be able to draw firm conclusions whether IUI and/or COH improve the probability of conception, several comparisons should be performed in randomized controlled trials (RCTs). OBJECTIVES: To determine for male subfertility whether intrauterine insemination (IUI) improves the probability of conception compared with timed intercourse and whether the addition of controlled ovarian hyperstimulation influences the results. SEARCH STRATEGY: 1. The specialist database of the Cochrane Menstrual Disorders and Subfertility Group. 2. Medline search. 3. Embase search. 4. DDFU search. 5. BIOSIS search. 6. SCIsearch. 7. Manual searching of references mentioned in the obtained studies. 8. Personal communication and write letters to experts (14) in the field. 9. Abstracts of The American Society for Reproductive Medicine and European Society for Human Reproduction and Embryology Meetings. When important information is lacking from the original publications the authors will be contacted. SELECTION CRITERIA: Randomized controlled trials only. DATA COLLECTION AND ANALYSIS: Independently by the first 2 authors: 1. Trial design characteristics. 2. Baseline characteristics of participants. 3. Types of intervention. 4. Outcomes where pregnancy is the outcome of main interest. Number of multiple pregnancies and number of cycles with ovarian hyperstimulation syndrome (OHSS) are secondary outcomes. Analysis of agreement between the two observers was determined for the following items: inclusion or exclusion of a trial, method of randomization, definition of male subfertility, design of the trial, number of pregnancies and completed cycles. Sensitivity analysis is performed. MAIN RESULTS: Seventeen trials fulfilled the selection criteria for this review and were included. Four trials are pending. Crude agreement concerning inclusion or exclusion of trials occurred for 41 of 43 (95%) trials reviewed (kappa 0.90). The included trials comprised 3,662 completed cycles. In natural cycles intrauterine insemination (IUI) significantly improved the probability of conception compared with timed intercourse (TI) (combined odds ratio with 95% confidence intervals: 2.43, 1.54 - 3.83). In cycles with controlled ovarian hyperstimulation (COH) IUI significantly improved the probability of conception also compared with TI (combined odds ratio with 95% confidence intervals: 2.14, 1.30 - 3.51). Despite clinical heterogeneity, these results are based on strong evidence. Intrauterine insemination in cycles with COH improved the probability of conception compared with IUI in natural cycles but significance was not reached (combined odds ratio with 95% confidence intervals: 1.79, 0.98 - 3.25). Comparing IUI in COH-cycles with TI in natural cycles the first treatment modality significantly improved the probability of conception (combined odds ratio with 95% confidence intervals: 6.23, 2.35 - 16.52). REVIEWER'S CONCLUSIONS: Intra-uterine insemination offers couples with male subfertility benefit over timed intercourse, both in natural cycles and in cycles with COH. In the case of a severe semen defect (with more than 1 million motile sperm after semen preparation and no triple sperm defect) IUI in natural cycles should be the treatment of first choice. The value of COH need to be further investigated in RCTs. Mild ovarian hyperstimulation with gonadotrophins is advised in cases with less sever