Vishvanath Karande

Prospective randomized trial comparing the outcome and cost of in vitro fertilization with that of a traditional treatment algorithm as first-line therapy for couples with infertility

OBJECTIVE To determine whether IVF or a standard infertility treatment algorithm results in better outcome and/or lower cost when used as first-line therapy for couples with infertility. DESIGN Prospective, randomized clinical study. SETTING University-affiliated infertility clinic. PATIENT(S) Couples with newly diagnosed infertility and no prior treatment. INTERVENTION(S) Couples were randomized to undergo either IVF (group 1, n = 46) or a standard infertility treatment algorithm (group 2, n = 50) as initial therapy for infertility. MAIN OUTCOME MEASURE(S) Pregnancy rates and costs per couple, per month of treatment, and per pregnancy. RESULT(S) Pregnancy rates were higher in group 2 than in group 1. Costs per couple were not statistically different, although a trend toward higher costs was apparent in group 1, reflected by a higher median cost per clinical pregnancy established and a higher cost per month of treatment. Whereas cost differences between the groups diminished over time, pregnancy rates remained the same. CONCLUSION(S) In vitro fertilization currently does not represent an appropriate first-line treatment option for couples with infertility. The use of a standard infertility treatment algorithm results in a higher pregnancy rate and lower cost and therefore should be the preferred treatment approach.

Infertility treatment dropout and insurance coverage

Objective To assess early patient dropout rates during infertility treatment as a potential measure of wasted resources. Methods The study involved multifaceted population cohorts, including a prospectively observed captive health maintenance organization (HMO) population and retrospectively selected preferred provider organization (PPO) patients. One hundred twenty-eight HMO couples were followed prospectively for 6 months. The insurance carrier retroactively selected 96 couples from their PPO population who were believed to be infertility patients. They were matched by date, age, and time of hysterosalpingography to infertility patients in the carriers HMO population. Patients were considered treatment dropouts if they either requested their provider to abandon further work-up or treatment, or if they failed to return for an appointment for 3 months. Results Forty-six of 128 (36%) HMO patients followed prospectively discontinued care within 180 days, with only eight (6.3%) providing defined reasons. Preferred provider organization patients uniformly demonstrated significantly higher dropout rates than HMO patients, a finding already apparent at 60 days (P <.002; odds ratio [OR] 3.67, 95% confidence interval [CI] 1.47–9.97) and 120 days of treatment (P = .002; OR 2.87, 95% CI 1.39–6.06). Among PPO patients, dropout rates were especially pronounced if infertility care was provided by generalists. At billing levels of at least

What is the radiation exposure to patients during a gynecoradiologic procedure

2000, HMO patients also demonstrated less dropout than PPO patients (P <.001; OR 6.14, 95% CI 2.72–14.79), with generalists again demonstrating a significantly larger patient loss than infertility specialists (P <.001; OR 0.18, 95% CI 0.66–0.49). Conclusion Infertility patients demonstrate a surprisingly large early dropout rate, which is significantly larger if patients receive infertility care from generalists rather than specialists. Newly presenting infertility patients should be carefully evaluated, especially in indemnity situations, before expensive diagnostic and therapeutic interventions are ordered.

Role of routine diagnostic laparoscopy in the investigation of infertility.

OBJECTIVE To evaluate the risk of radiation exposure to infertility patients during a gynecoradiologic procedure. DESIGN Retrospective clinical study. SETTING Medical school-affiliated infertility center. PATIENT(S) Three hundred thirty-two consecutive infertility patients undergoing a gynecoradiologic procedure. INTERVENTION(S) Patients underwent a gynecoradiologic procedure as part of their infertility workup and the fluoroscopic exposure time was analyzed. MAIN OUTCOME MEASURE(S) The fluoroscopic exposure (rad time) during gynecoradiologic procedures, including hysterosalpingogram (HSG), selective salpingography, tubal catheterization, and others. RESULT(S) The rad time (mean +/- SD) was 63 +/- 54 seconds for normal HSG (n = 94, range 17 to 404 seconds), 100 +/- 61 seconds for abnormal HSG (n = 53, range 28 to 272 seconds), 111 +/- 57 seconds for unilateral selective salpingography (n = 36, range 31 to 324 seconds), 142 +/- 74 seconds for bilateral selective salpingography (n = 87, range 40 to 430 seconds), 176 +/- 77 seconds for unilateral tubal catheterization (n = 27, range 70 to 342 seconds), and 239 +/- 82 seconds for bilateral tubal catheterization (n = 30, range 110 to 381 seconds). Five patients had other procedures, such as lysis of intrauterine adhesions (n = 2) and resection of an uterine septum (n = 3), for which the rad time was in a range of 180 to 300 seconds. CONCLUSION(S) The radiation exposure of patients during a gynecoradiologic procedure, using previously described standard techniques, is well within established margins of safety.

A rational approach to the management of low responders in in-vitro fertilization.

Over the past two decades, endoscopic evaluation of the pelvis has become an integral part of the infertility workup (1). These procedures are expensive (in the United States), relatively invasive, and associated with potentially serious complications. If performed routinely on all infertile patients, there will be a large number of patients with normal findings or with relatively minor pathology that has no impact on pregnancy rates. The question that merits discussion, therefore, is: When should one perform endoscopy in an infertile patient? This very issue was addressed by Hovav el al. (2). Hovav et al. retrospectively analyzed 206 laparoscopies that were performed over a 2-year period. They analyzed their data based on the patients history and found a significantly higher incidence of normal findings in patients with primary infertility and no risk factor. This was not true in patients with secondary infertility, where the presence or absence of a risk factor did not correlate with the findings at laparoscopy. The authors therefore suggest that patients with primary infertility should undergo laparoscopy only if they have additional risk factors. On the other hand,