A one-year experience with a capitated health care plan for infertility.

OBJECTIVE: To report on a one-year experience participating in a capitated healthcare plan for infertility. DESIGN: Prospective study. SETTING: University population. PATIENT(S): Reproductive-age women 15 to 50 years. INTERVENTION(S): The first-generation Lewin infertility algorithm and CATHI software were used to negotiate infertility services under a capitated arrangement for $0.50 per member per month. The following reports our experience for the fiscal year 1997. MAIN OUTCOME MEASURE(S): Infertility services rendered, pregnancy rate, cost of services, collection rates. RESULT(S): Five thousand forty-six women representing 39,689 member months generated 39 new and 198 return visits. Thirty-two percent of the patients required three visits or less; six patients generated 22% of the visits. Fifty-one percent listed infertility as one of their chief complaints; 31% had mixed diagnoses. Eight (7.6%) patients required surgery, 11 (10.5%) patients underwent either IVF or GIFT cycles. Total charges submitted were $176,636; the amount assigned to specialty care was $135,277, and to IVF/GIFT, $33,433. Total capitated payments, including copayments, was $126,256 under the reproductive medicine agreement and $32,891 under the infertility rider. This resulted in a 71% gross collections rate. CONCLUSION(S): This study indicates that entering into a capitated health care plan to provide an infertility benefit can produce a successful result.

Objective markers of condom failure.

BACKGROUND: Studies of condom efficacy rely on self-reported behavior. Objective markers of exposure to semen may provide a more valid assessment of condom failure and failure to use condoms. GOALS OF THIS STUDY: To compare three semen biomarkers: acid phosphatase (AP) activity, prostate specific antigen (PSA), and the human seminal plasma antigen (MHS-5). STUDY DESIGN: Twenty women were intravaginally inoculated with six measured, increasingly larger amounts of their partners' semen. Vaginal fluid was collected by the participant using swabs and tested. RESULTS: Background levels of PSA were low (0.00-1.25 ng/ml), background levels of AP were variable (0-350 U/l), and all preinoculation samples were negative for MHS-5. All postinoculation samples were positive for PSA, 64 of 117 (55%) for AP, and 14 of 120 (12%) for MHS-5. CONCLUSION: The PSA immunoassay was the best semen biomarker under these sampling and testing conditions.

PIP: Objective markers of exposure to semen provide a more valid assessment of condom failure and failure to use condoms than self-reports. The present study evaluated three of the assays commonly used in forensic medicine for detecting semen exposure: acid phosphatase (AP) activity, prostate specific antigen (PSA), and the human seminal plasma antigen (MHS-5). 20 US women were intravaginally inoculated with 6 measured, increasingly larger amounts of their partners' semen. Vaginal fluid was collected with swabs by study participants and tested for the three markers. Before semen inoculation, PSA levels were consistently low (median, 0.11 ng/ml; range, 0-1.25 ng/ml) while those of AP were highly variable (median, 13.4 U/l; range, 0-350 U/l); all preinoculation samples were negative for MHS-5. The median PSA concentration increased consistently with increasing volumes of semen, while median AP and MHS-5 levels showed an inconsistent pattern. All 120 swabs obtained after intravaginal inoculation with semen were positive for PSA, 64 (55%) were positive for AP, and 14 (12%) were positive for MHS-5. These findings indicate that self-sampling of vaginal secretions followed by the PSA immunoassay represents a simple, accurate marker of semen exposure. Because the PSA assay is available in most hospital laboratories for prostate cancer screening, the methodology used in the present study is suitable for widespread application.

Multifetal pregnancy reduction.

Higher-order multiple pregnancy is associated with significant maternal and fetal complications. Multifetal pregnancy reduction is one option for women with a higher-order multiple pregnancy. Various aspects of multifetal pregnancy reduction are discussed, including the background, options, risks, benefits, techniques, results, and appropriate physical and psychosocial support.

Identification of early pregnancy landmarks by transvaginal sonography: analysis by logistic regression.

OBJECTIVE: To assess the feasibility of logistic regression analysis for determining the gestational ages at which detection of early pregnancy landmarks first can be observed. DESIGN: Retrospective analysis. SETTING: University-based tertiary care clinic. PATIENT(S): Eighty-two women with viable singleton pregnancies in whom ovulation had been achieved by an injection of hCG. INTERVENTION(S): Two hundred fifteen transvaginal sonographic scans. MAIN OUTCOME MEASURE(S): Logistic regression was used to estimate the probability of detection of sonographic findings as a function of gestational age. RESULT(S): We found that the likelihood of visualization of a gestational sac or fetal heart motion could be represented accurately by logistic equations. Gestational age at which there was 95% probability of visualization was 35.5 days for the gestational sac and 44.5 days for fetal cardiac activity. The probability of detecting fetal cardiac activity was 95% when the mean gestational sac diameter was 1.6 cm and was 99% at 1.9 cm. CONCLUSION(S): The sonographic appearances of developmental landmarks in early pregnancy occurs within well-defined gestational time periods, and the probabilities for visualization can be closely approximated using a logistic model. Our results suggest that the number of sonographic examinations required to document infertility treatment success can be minimized by surveillance at standardized gestational ages.

How convergence of research paradigms can improve research on diagnostic judgment.

The author's purpose is to urge the constructive convergence of two current judgment and decision-making research paradigms. He shows why the heuristics-and-biases approach and the lens-model approach should be placed in the context of two very different metatheories, the coherence metatheory and the correspondence metatheory. The differences between the two research paradigms thus become apparent; they speak to different problems and appeal to different criteria for evaluating performance. Bringing the two into a constructive relationship to one another, however, will not only double the store of knowledge regarding diagnostic judgment and decision making, but also enhance efforts to achieve a cumulative discipline. Isolating these research paradigms from one another--as is done now--stifles theoretical generality, fragments knowledge, and confuses medical decision makers. An example of how convergence can be achieved is provided.

Variations in immunoglobulins and IgA subclasses of human uterine cervical secretions around the time of ovulation.

The quantity and subclass distribution of IgA produced by the human uterine cervix may have a significant impact on the defence against sexually transmitted diseases as well as the regulation of fertility. Cervical mucus was obtained from 15 normal ovulating women around the time of ovulation. The total amounts of secreted IgA (including IgA1 and IgA2), IgG, and IgM were determined by ELISA. IgA was detected at high levels in all samples of cervical mucus. When ovulation was ascertained by daily urinary luteinizing hormone testing, IgA production was maximal 2-3 days before ovulation. Equal proportions of IgA1 and IgA2 were detected in cervical mucus, and 80% of the IgA occurred in the polymeric forms. The increased levels of IgA, the ratios of IgA1 to IgA2, and the predominance of polymeric IgA indicate that much of the IgA in human uterine cervical fluid originates from local production.

The effect of routine breast examination on serum prolactin levels.

OBJECTIVE: To evaluate the effect of a routine breast examination on serum PRL levels. DESIGN: Prospective clinical study. SETTING: University-based reproductive endocrinology unit. PATIENTS: Eleven nonlactating, euprolactinemic women of reproductive age with a history of regular menstrual cycles and currently taking no medications. INTERVENTIONS: Breast examination using standard technique. MAIN OUTCOME MEASURE: Changes in serum PRL levels after breast examination. RESULTS: Baseline PRL levels ranged from 3.64 to 19.23 ng/mL (mean 7.17 ng/mL; conversion factor to SI unit, 1.00). There were no significant increases in PRL levels after breast examination, with mean PRL levels after 15, 30, and 45 minutes of 6.59, 6.84, and 6.45 ng/mL, respectively. CONCLUSION: Routine breast examination does not alter acutely serum PRL levels in normal women.

Multifetal reduction of high-order multiple pregnancy: comparison of obstetrical outcome with nonreduced twin gestations.

OBJECTIVE: To compare the obstetric outcomes of twin pregnancies obtained as a result of multifetal pregnancy reduction to those in which pregnancy reduction had not been used. DESIGN: Retrospective analysis. SETTING: University-based tertiary care infertility clinic. PATIENTS: Seventy-four twin pregnancies continuing beyond 10 weeks. Of these, 32 gestations had undergone reduction to twins at 10 weeks. MAIN OUTCOME MEASURES: Gestational age at delivery, birth weights, pregnancy complications. RESULTS: All pregnancies advanced beyond 20 weeks gestation. The mean gestational age at delivery of the reduction group was 33.8 versus 35.7 weeks in the nonreduced group; only 25% of reduced pregnancies reached 37 weeks compared with 57.9% of nonreduced twins. The mean fetal birth weights of the two groups differed significantly (reduced: 2,038 g, nonreduced: 2512 g). The gestational age at delivery in patients reduced from triplets was significantly greater than in pregnancies reduced from quadruplets or higher. Multiple regression analysis revealed that for a given gestational age at delivery, a history of pregnancy reduction was associated with decreased birth weight. CONCLUSION: These data suggest that multifetal pregnancy reduction does not reverse completely the decreased gestational age and impaired fetal growth associated with high-order multiple pregnancy. Furthermore, fetal growth of reduced pregnancies seems to be impaired independent of the gestational age at which delivery occurs.

Effect of estrogen/progestin administration on the ovarian response to gonadotropins: a randomized, prospective study.

The findings of our study indicate that women pretreated with E/progestin demonstrate increased gonadotropin requirements when undergoing ovulation induction. Whether this treatment has a significant effect on the outcome of ovulation induction in patients receiving gonadotropins remains to be established.

Hormonal treatment of functional ovarian cysts: a randomized, prospective study.

Estrogen (E)/progestin therapy for functional ovarian cysts is widely used in clinical practice, but the efficacy of this treatment has not been determined in controlled trials. In this study, we examined the effect of E/progestin administration in a group of infertility patients enrolled in a program of ovulation induction who had cysts identified by transvaginal sonography. Patients were randomized to receive either norethindrone 1 mg/mestranol 0.05 mg/d (group A, n = 24) or no treatment (group B, n = 24) for up to 6 weeks. Patients were re-evaluated by sonography at 3, 6, and 9 weeks after entry into the protocol. The ages, mean cyst diameters, and proportions of patients having received gonadotropins in the previous menstrual cycle were not significantly different among the two groups. All patients who had a sonographic abnormality persisting for 9 weeks were surgically explored and found to have pathological cysts. The rate of disappearance of functional ovarian cysts was not affected by E/progestin treatment.

Performance anxiety during infertility treatment: effect on semen quality.

The requirement to obtain a semen sample at a specific time for an infertility treatment procedure has potential to produce considerable performance anxiety. This study was designed to evaluate the semen quality of men participating in infertility treatments associated with heightened performance anxiety. The most recent pretreatment semen analysis and the infertility treatment semen analysis, as well as the first and last procedure semen analyses, were compared using paired t-tests for 77 patients undergoing assisted reproductive technology procedures and 121 patients undergoing intrauterine insemination. No significant differences were noted in either of these groups of patients. However, in men with total motile sperm counts of less than 40 million, semen parameters improved significantly in the procedure semen analyses. Thus, participation in infertility treatments associated with performance anxiety does not appear to be detrimental to semen quality, and in certain groups of patients semen quality may improve.

Improving clinical judgement.

Before carrying out any action, whether it is concerned with professional life or with humdrum everyday routine, one has always to choose between at least two alternatives: to act or not to act. Decisions are always based upon information, and it is clear that this information should be of the best quality possible and that it should also be used in the most efficient way possible. Judgement analysis helps to improve the reliability of clinical decisions, in practice as well as in the management of clinical trials.

On evaluating the severity of depression: an experimental study of psychiatrists.

This study extends earlier work on the evaluation of depression by general physicians, and compares the results obtained with that group with those from a group of experienced psychiatrists. Differences within each group were larger than those between them. In neither group were individuals able to describe their own diagnostic processes with great accuracy, but psychiatrists were, as expected, somewhat more consistent than general physicians. They became even more so when allowed to select their own cues; of which, however, they made use of a smaller number. These tended to be of a specific rather than (as with the physicians) of a general nature.

An experimental study of the clinical judgment of general physicians in evaluating and prescribing for depression.

Fifteen general physicians were given profiles of symptom combinations representing 80 depressed patients. They were asked to judge the severity of the disorder and to prescribe. There were two phases to the experiment, the formal structure of both being the same. In the first phase, all physicians based their judgments only on the cues of the Hamilton Depression scale; in the second, each physician defined his own cues. Multivariate regression analysis was applied to the observations. Agreement between the judges was low. Most had a more complex policy, in regard to both judgment of the severity of the depression and prescribing, when selecting their own cues than when restricted to textbook variables, but used it more consistently. The observations have important implications for training and research in psychiatry and in psychopharmacology.

Computer graphics as an aid to learning.

Departing from the traditional model for teaching and learning, this article deals with the problem of teaching and learning the effective application of knowledge already acquired. To this end, a model for the process of exercising judgment was outlined, and the results of an empirical study of judgmental learning were employed to show the inadequacy of the traditional outcome feedback procedures. Computer graphics techniques were used to provide new forms of information to the learner; the results are promising for the rapid learning of a task that would otherwise be difficult to learn.