Tax credits, insurance, and in vitro fertilization in the U.S. military health care system.

The FAMILY Act, an income tax credit for infertility treatments, was introduced into the U.S. Senate on May 12, 2011. We estimated the costs and utilization of in vitro fertilization (IVF) in the military if infertility treatment became a tax credit or TRICARE benefit. We surveyed 7 military treatment facilities (MTFs) that offer IVF, with a 100% response rate. We first modeled the impact of the FAMILY Act on the MTFs. We then assessed the impact and costs of a TRICARE benefit for IVF. In 2009, MTFs performed 810 IVF cycles with average patient charges of $4961 and estimated pharmacy costs of $2K per cycle. With implementation of the FAMILY Act, we estimate an increase in IVF demand at the MTFs to 1165 annual cycles. With a TRICARE benefit, estimated demand would increase to 6,924 annual IVF cycles. MTF pharmacy costs would increase to $7.3 annually. TRICARE medical and pharmacy costs would exceed $24.4 million and $6.5 million, respectively. In conclusion, if the FAMILY Act becomes law, demand for IVF at MTFs will increase 29%, with a 50% decrease in patient medical expenses after tax credits. MTF pharmacy costs will rise, and additional staffing will be required to meet the demand. If IVF becomes a TRICARE benefit, demand for IVF will increase at least 2-fold. Current MTFs would be unable to absorb the increased demand, leading to increased TRICARE treatment costs at civilian centers.

Diminished ovarian reserve in the United States assisted reproductive technology population: diagnostic trends among 181,536 cycles from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System.

OBJECTIVE: To evaluate trends in diminished ovarian reserve (DOR) assignment in the Society for Assisted Reproductive Technology (SART) Clinic Outcomes Reporting System database and to evaluate its accuracy in predicting poor ovarian response (POR) as defined in European Society of Human Reproduction and Embryology's Bologna criteria (2011). DESIGN: Retrospective cohort study. SETTING: Not applicable. PATIENT(S): A total of 181,536 fresh, autologous ART cycles reported to SART by U.S. clinics in 2004 and 2011 (earliest and most recent available reporting years). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): DOR assignment was the primary exposure. POR, defined as cycle cancellation for poor response or less than 4 oocytes retrieved after conventional gonadotropin stimulation (>149 IU FSH daily), was the primary outcome. Secondary outcomes were live birth and number of oocytes retrieved. DOR prevalence, power of DOR and FSH (

Single-donor and double-donor sperm intrauterine insemination cycles: does double intrauterine insemination increase clinical pregnancy rates?

OBJECTIVE: To compare the pregnancy outcomes in the setting of a single- vs. double-donor sperm intrauterine insemination (IUI) treatment cycle. DESIGN: Retrospective cohort study. SETTING: Large, private assisted reproductive technology practice. PATIENT(S): Donor sperm IUI recipients. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Clinical pregnancy. RESULT(S): There were 2,486 double and 673 single-donor sperm IUI cycles. The two groups were similar for age, body mass index, and the number of prior cycles. The clinical pregnancy rates were similar between the two groups (single: 16.4% vs. double: 13.6%). In univariate regression analysis, age, total motile sperm, and diminished ovarian reserve (DOR) were associated with pregnancy. Generalized estimating equation models accounting for repeated measures, age, DOR and total motile sperm and the interactions of these factors demonstrated that single and double IUI had similar odds of pregnancy (odds ratio 1.12; 95% confidence interval, 0.96-1.44). Pregnancy rates remained similar between the two groups in matched comparison and other subgroup analyses. CONCLUSION(S): Single and double-donor IUI cycles had similar clinical pregnancy rates. This large data set did not demonstrate a benefit to routine double IUI in donor sperm cycles.

Progesterone luteal support after ovulation induction and intrauterine insemination: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of luteal phase P support after ovulation induction IUI. DESIGN: A systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Undergoing ovulation induction IUI. INTERVENTION(S): Any form of exogenous P in ovulation induction IUI cycles. MAIN OUTCOME MEASURE(S): Clinical pregnancy and live birth. RESULT(S): Five trials were identified that met inclusion criteria and comprised 1,298 patients undergoing 1,938 cycles. Clinical pregnancy (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.15-1.98) and live birth (OR 2.11, 95% CI 1.21-3.67) were more likely in P-supplemented patients. These findings persisted in analyses evaluating per IUI cycle, per patient, and first cycle only data. In subgroup analysis, patients receiving gonadotropins for ovulation induction had the most increase in clinical pregnancy with P support (OR 1.77, 95% CI 1.20-2.6). Conversely, patients receiving clomiphene citrate (CC) for ovulation induction showed no difference in clinical pregnancy with P support (OR 0.89, 95% CI 0.47-1.67). CONCLUSION(S): Progesterone luteal phase support may be of benefit to patients undergoing ovulation induction with gonadotropins in IUI cycles. Progesterone support did not benefit patients undergoing ovulation induction with CC, suggesting a potential difference in endogenous luteal phase function depending on the method of ovulation induction.

Raynaud's phenomenon of the nipple.

BACKGROUND: Raynaud's phenomenon is a well-described pathologic state in which there is episodic vasospasm followed by vasodilation. It is described most commonly in the digits but also has been shown to affect the nipple vasculature. Raynaud's phenomenon of the nipple may result in discontinuation of breastfeeding secondary to pain and disruption of the maternal-infant bonding process. CASES: We present the cases of two patients with painful breastfeeding associated with color changes of the nipple. Owing to a clinical presentation similar to fungal infections, the patients were treated repeatedly with antifungals before the correct diagnosis was made. Symptoms resolved with a course of nifedipine. CONCLUSION: Increased awareness in the obstetric field will lead to appropriate diagnoses, earlier treatment and relief, and more successful breastfeeding experiences.