G. David Adamson

Efficacy of treatment for unexplained infertility

OBJECTIVE To analyze the efficacy and cost-effectiveness of alternative treatments for unexplained infertility. DESIGN Retrospective analysis of 45 published reports. SETTING Clinical practices. PATIENT(S) Couples who met criteria for unexplained infertility. Women with Stage I or Stage II endometriosis were included. INTERVENTION(S) Observation; clomiphene citrate (CC); gonadotropins (hMG); IUI; and GIFT and IVF. MAIN OUTCOME MEASURE(S) Clinical pregnancy rate. RESULT(S) Combined pregnancy rates per initiated cycle, adjusted for study quality, were as follows: no treatment = 1.3%-4.1%; IUI = 3.8%; CC = 5.6%; CC + IUI = 8.3%; hMG = 7.7%; hMG + IUI = 17.1%; IVF = 20.7%; GIFT = 27.0%. The estimated cost per pregnancy was

Surgical treatment of endometriosis-associated infertility: Meta-analysis compared with survival analysis

10,000 for CC + IUI,

The economic impact of assisted reproductive technology: a review of selected developed countries

17,000 for hMG + IUI, and

Improving embryo selection using a computer-automated time-lapse image analysis test plus day 3 morphology: results from a prospective multicenter trial

50,000 for IVF. CONCLUSION(S) Clomiphene citrate + IUI is a cost-effective treatment for unexplained infertility. If this treatment fails, hMG + IUI and assisted reproduction are efficacious therapeutic options.

Endometriosis fertility index: the new, validated endometriosis staging system.

OBJECTIVE Our purpose was to evaluate the role of surgery in the treatment of endometriosis associated with infertility. STUDY DESIGN We used a prospective cohort analysis of pregnancy rates and variables affecting pregnancy rates for surgical, medical, and no treatment. Our studies were combined with those reported by Hughes et al. (Fertil Steril 1993; 59:963-70), and the meta-analysis was expanded to include additional comparisons. Treatment was performed by a single surgeon in a referral reproductive endocrinology and surgery private practice. Results from 579 women with endometriosis and infertility in our study and the meta-analysis of 25 studies by Hughes et al. were examined. Interventions consisted of no treatment, medical treatment, or surgical treatment by laparoscopy or laparotomy. The main outcome measure was pregnancy rates. RESULTS For minimal and mild disease, no treatment, laparoscopy, and laparotomy had equivalent 3-year estimated cumulative life-table pregnancy rates (67% +/- 12%, 68% +/- 4%, and 74% +/- 8%, respectively) that were higher than medical treatment pregnancy rates (Breslow p = 0.003). For moderate and severe disease, all but 11 patients were treated surgically. The 3-year estimated cumulative life-table pregnancy rates were 62% + 6% [corrected] for 120 laparoscopy cases and 44% + 6% [corrected] for 102 laparotomy cases (Breslow p = 0.054). For endometriomas, 48 laparoscopy patients had a 3-year estimated cumulative life-table pregnancy rate of 52% +/- 9% and 52 laparotomy patients had a 3-year estimated cumulative life-table pregnancy rate of 46% +/- 9% (Breslow p = 0.48). For 28 patients with complete cul-de-sac obliteration, the 3-year estimated cumulative life-table pregnancy rates were 30% +/- 14% after laparoscopy and 24% +/- 12% after laparotomy (Breslow p = 0.084). Comparison of our results with the expanded meta-analysis revealed deficiencies in the design of meta-analysis studies and the impact of our using life-table pregnancy rates controlled for factors influencing outcome (survival analysis with fixed covariates) rather than the simple pregnancy rates used in the meta-analysis. Benefits of sophisticated statistical techniques, including propensity scores, to adjust for noncomparability of groups in prospective cohort studies were identified. CONCLUSION Both our study and the meta-analysis show that either no treatment or surgery is superior to medical treatment for minimal and mild endometriosis associated with infertility. For moderate and severe disease, surgery is usually used. In these patients experienced surgeons utilizing good clinical judgment can achieve results at operative laparoscopy at least equivalent to those at laparotomy, even in cases involving endometriomas and complete cul-de-sac obliteration. Prospective randomized trials should be performed to confirm these findings.

Prediction of pregnancy in infertile women based on the American Society for Reproductive Medicine's revised classification of endometriosis

OBJECTIVE To compare regulatory and economic aspects of assisted reproductive technologies (ART) in developed countries. DESIGN Comparative policy and economic analysis. PATIENT(S) Couples undergoing ART treatment in the United States, Canada, United Kingdom, Scandinavia, Japan, and Australia. OUTCOME MEASURE(S) Description of regulatory and financing arrangements, cycle costs, cost-effectiveness ratios, total expenditure, utilization, and price elasticity. RESULT(S) Regulation and financing of ART share few general characteristics in developed countries. The cost of treatment reflects the costliness of the underlying healthcare system rather than the regulatory or funding environment. The cost (in 2006 United States dollars) of a standard IVF cycle ranged from

Laparoscopic endometriosis treatment : is it better ?

12,513 in the United States to

Treatment of uterine fibroids: Current findings withgonadotropin-releasing hormone agonists

3,956 in Japan. The cost per live birth was highest in the United States and United Kingdom (

Subfertility: causes, treatment and outcome

41,132 and

Comparison of CO2 laser laparoscopy with laparotomy for treatment of endometriomata

40,364, respectively) and lowest in Scandinavia and Japan (