The Cost-Effectiveness of Salpingectomies for Family Planning in the Prevention of Ovarian Cancer.

OBJECTIVE: Ovarian cancer is the most lethal gynaecologic cancer. Disease prevention may be the only method to reduce the incidence of ovarian cancer. The Society of Gynecologic Oncology advised that salpingectomies may be an appropriate and feasible strategy for ovarian cancer risk reduction. This study conducted an economic evaluation from a societal perspective of bilateral salpingectomies versus conventional sterilization techniques in the prevention of ovarian cancer. STUDY DESIGN: We performed a micro-cost analysis comparing laparoscopic tubal coagulation, tubal clips and bilateral salpingectomies at the Michael Garron Hospital, formerly the Toronto East General Hospital, from 2015 to 2016. A Markov model was used in the cost-effectiveness and cost-utility analyses on these surgical procedures in ovarian cancer prevention. Costs were derived for the number ovarian cancer cases observed per sterilization method, cancer treatment, and associated procedural costs over each cancer patient's lifetime. The number of bilateral salpingectomies required to prevent an additional ovarian cancer case with the recommended treatment was also estimated. RESULTS: Bilateral salpingectomies performed at the Michael Garron Hospital generated savings of $7823 per life-year gained (95% CI $3248-$10 190; incremental cost [ΔC] -$907, incremental effect [ΔE] 0.11 life-years gained) compared with tubal clips and savings of $6315 per life-year gained (95% CI -$6360 to $9342; ΔC -$755, ΔE 0.11 life-years gained) compared with tubal coagulation. Most importantly, for every 150 bilateral salpingectomies performed, one case of ovarian cancer may be prevented. CONCLUSION: Laparoscopic bilateral salpingectomy is the dominant, cost-effective surgical strategy when compared to tubal clips and tubal coagulation to prevent ovarian cancer. Laparoscopic bilateral salpingectomies reduce costs and enhance quality-adjusted life-years relative to the two alternative treatments.

Chlamydia sequelae cost estimates used in current economic evaluations: does one-size-fit-all?

BACKGROUND: Current evidence suggests that chlamydia screening programmes can be cost-effective, conditional on assumptions within mathematical models. We explored differences in cost estimates used in published economic evaluations of chlamydia screening from seven countries (four papers each from UK and the Netherlands, two each from Sweden and Australia, and one each from Ireland, Canada and Denmark). METHODS: From these studies, we extracted management cost estimates for seven major chlamydia sequelae. In order to compare the influence of different sequelae considered in each paper and their corresponding management costs on the total cost per case of untreated chlamydia, we applied reported unit sequelae management costs considered in each paper to a set of untreated infection to sequela progression probabilities. All costs were adjusted to 2013/2014 Great British Pound (GBP) values. RESULTS: Sequelae management costs ranged from £171 to £3635 (pelvic inflammatory disease); £953 to £3615 (ectopic pregnancy); £546 to £6752 (tubal factor infertility); £159 to £3341 (chronic pelvic pain); £22 to £1008 (epididymitis); £11 to £1459 (neonatal conjunctivitis) and £433 to £3992 (neonatal pneumonia). Total cost of sequelae per case of untreated chlamydia ranged from £37 to £412. CONCLUSIONS: There was substantial variation in cost per case of chlamydia sequelae used in published chlamydia screening economic evaluations, which likely arose from different assumptions about disease management pathways and the country perspectives taken. In light of this, when interpreting these studies, the reader should be satisfied that the cost estimates used sufficiently reflect the perspective taken and current disease management for their respective context.

Pre-pregnancy and Early Prenatal Care are Associated with Lower Risk of Ectopic Pregnancy Complications in the Medicaid Population: 2004-08.

BACKGROUND: Ectopic pregnancy causes significant maternal morbidity and mortality. Complications are more common among women with Medicaid or no insurance compared to those with private insurance. It is unknown whether preventive care prior to pregnancy and prenatal care, which are covered by Medicaid, would decrease complications if they were more fully utilised. METHODS: Medicaid claims were used to identify a clinical cohort of women who experienced an ectopic pregnancy during 2004-08 among all female Medicaid enrolees from a large 14-state population, ages 15-44. Diagnosis and procedure codes were used to identify ectopic pregnancies and associated complications. The primary outcomes were complications associated with ectopic pregnancy: blood transfusion, sterilisation, or hospitalisation with length of stay greater than 2 days. Independent variables were documentation of preventive care within 1 year prior to the ectopic pregnancy and prenatal care within 4 months prior. RESULTS: Controlling for race, age, and state of residence, women's risks of any ectopic pregnancy complication were independently higher among those who did not receive any Medicaid-covered preventive care within 1 year before the ectopic pregnancy compared to those who did (RR 1.12, 95% confidence interval (CI) 1.09, 1.16), and among those who did not receive any Medicaid-covered prenatal care within 4 months prior, compared to those who did (RR 1.89, 95% CI 1.83, 1.96). CONCLUSIONS: Pre-pregnancy and prenatal care are independently associated with decreased risk of ectopic pregnancy complications among Medicaid beneficiaries.

Treatment cost evaluation of extrauterine gravidity: a literature review of medical and surgical treatment costs.

BACKGROUND: The diagnosis of extrauterine pregnancy is possible very early giving the patient and doctors treatment options. As the risks and success rate of medical and surgical treatment are similar, the decision is increasingly influenced by cost-effectiveness. OBJECTIVE: The following article systematically reviews the known literature regarding cost, decision criteria and possible follow-up. METHODS: Literature review of extrauterine gravity in combination with cost in the online National Library of Medicine since 1.1.1997 following the PRISMA recommendations. RESULTS: Six articles were identified in which the cost of the laparoscopic versus medical treatment is reviewed. In five articles, the medical treatment was shown to be more cost effective and in the sixth article the costs were found to be equal. The cost saving varies between 18 and 88% depending on the consideration of direct and indirect costs. If indirect expenses are considered, the total sum increases with treatment failures. Failure rates are given as up to 27% depending on the type of failure (surgical or medical). These rates seem to be linked indirectly with the ß-HCG levels. Predictive parameters for the successful medical treatment are missing. CONCLUSIONS: The treatment of small extrauterine gravidities in haemodynamically stable patients (defined by HCG levels <1,500 IU/l) is medically successful and cost-effective. With HCG levels between 1,500 IU/l and 3,000 IU/l, the treatment costs are similar. HCG levels >5,000 IU/l favour the surgical treatment as being more cost-effective. A similar cut-off for the sonographic imaging is missing.

The cost-effectiveness analysis of laparoscopic treatment of ectopic pregnancy: a single-center review of a five-year experience.

PURPOSE: The aim of this study was to investigate the cost-effectiveness of laparoscopic treatment for ectopic pregnancy by comparing the medical expenses and time of hospitalization of laparoscopic and open surgery for ectopic pregnancy in partial area of Shanghai, China. MATERIALS AND METHODS: Clinical data of 762 cases with ectopic pregnancy undergoing surgical treatment (307 cases for laparoscopic surgery and 455 cases for open surgery) were analyzed retrospectively. The clinical information including the medical expenses and time of hospitalization was compared. The patients were divided into three groups according to the treatments of different lesions (lesions resection, conservative laparotomy, and exploration group) and were analyzed. RESULTS: The total hospitalization expenses and the top three single costs including surgery, exams, and medicine expenses were higher in laparoscopic group than in open surgery group. There was no significant difference between the two groups on the total time of hospitalization. The hospital days of preoperation were higher but the postoperative hospital days were lower in laparoscopic group than in open surgery group. Compared with the open surgery treatment, the hospitalization expenses of laparoscopic treatment for ectopic pregnancy increased. There was no significant difference on the total hospitalization days. CONCLUSION: The preoperative waiting period of inpatients increased and the post-operative hospital days reduced in laparoscopic group.

[Cost of medical treatment with methotrexate for ectopic pregnancy. Study comparing medical treatment versus laparoscopy. Experience of Aziza Othmana Hospital]. / Coût du traitement médical par méthotrexate de la grossesse extra utérine. Etude comparative traitement médical versus traitement coeliochirurgical. Expérience de l'Hôpital Aziza Othmana.

BACKGROUND: The ectopic pregnancy can be treated surgically (conservative or radical) or medically. Currently, the choice between medical and surgical treatment is a critical issue. One of the parameters of this choice is the total cost of management. AIM: To compare the cost of the management of ectopic pregnancy by medical treatment (methotrexate, MTX) and coeliochirurgicaux. METHODS: This is a prospective, comparative, nonrandomized,unicentric study, on 39 patients who have ectopic pregnancies treated with MTX versus 16 patients treated by laparoscopic surgery with conservative treatment. This study was collected at the service of Obstetrics and Gynecology Reproductive Medicine Aziza Othmana Hospital (Tunis) for a period of two years. RESULTS: The average cost of hospital stay per patient was 549.38 dt for the MTX group against 268.39 dt for laparoscopic surgery group (p <0.001). There was no statistically significant difference between the two groups. In terms of overall absenteeism, there is no statistically significant difference (16.43 vs 17.5 days). CONCLUSION: The initial treatment with MTX costs more cost than the conservative laparoscopic treatment and this is mainly due to the long period of hospitalization.

Unintended pregnancies in England in 2010: costs to the National Health Service (NHS).

INTRODUCTION: Here we estimate the direct medical costs to the National Health Service (NHS) of unintended pregnancies in 2010 and identify populations at risk for unintended pregnancies. METHODS: The number of unintended pregnancies in England in 2010 was estimated based on the number of induced and spontaneous abortions, live births and ectopic pregnancies reported by the NHS and Office for National Statistics. Direct medical costs associated with these were obtained from the NHS Reference Costs. RESULTS: In 2010, there were an estimated 225,600 unintended pregnancies in England, of which 218,100 were paid for by the NHS. Of these, 155,500 led to induced abortions, 53,900 to births, 7,500 to spontaneous abortions and 1,200 to ectopic pregnancies. These unintended pregnancies cost the NHS £193,200,000 ($299,200,000) in direct medical costs. DISCUSSION: London, the North West and the West Midlands should be targeted in efforts to reduce unintended pregnancies. More specifically, women between the ages of 20 and 34 years produce the greatest costs.

The financial costs to patients of diagnosing and excluding ectopic pregnancy.

OBJECTIVES: Health care costs are one of the greatest challenges in modern medicine. In gynaecology, diagnosing and excluding ectopic pregnancy (EP) has been shown to be a financial burden to health services because it commonly requires multiple investigations and hospital visits. However, the full economic costs are not captured by an analysis of health care costs alone. This study therefore aimed to assess the indirect costs to patients of diagnosing and excluding EP. METHODS: Patients presenting to a Pregnancy Support Centre in a large UK teaching hospital with abdominal pain and/or bleeding and a positive pregnancy test were recruited during the period June 2010-February 2011. Patients were provided with questionnaires to be completed at home and designed to record and quantify costs that they had incurred until a final diagnosis of their condition was made. A cost-description analysis was performed. RESULTS: 52/203 (26%) recruited patients returned completed questionnaires. The mean cost to patients of diagnosing or excluding EP was £135.13±£51.60 (median £20.70). The main cost drivers identified were hospital visits, holiday cancellations, income loss and household help. CONCLUSIONS: Quantification of the indirect costs of diagnosing and excluding EP is challenging because it relies on questionnaire feedback from patients at a time when they have suffered from the emotional impact of pregnancy loss. However, initial estimates suggest that such costs are significant due to diagnostic delays. This further highlights the importance of the development of potential biomarkers of EP to allow prompt diagnosis.

Ovarian pregnancy: a case report in a resource-poor setting.

Ovarian pregnancy is very rare and to our knowledge, no case has been reported in Cameroon. We herein report a case at the Yaounde Central Hospital. It is the case of a 29 years old woman who consulted in emergency for left pelvic pain at 9 weeks of pregnancy. The level of beta human chorionic gonadotropin was 96702 milli-international Units/ milliliter and ultrasound revealed an intra-ovarian gestational sac, an empty uterus and no peritoneal effusion. In the absence of facilities for laparoscopy, an emergency laparotomy was done. We found the non ruptured mass inside the left ovary. The left fallopian tube, the uterus and the right adnexae were normal. We did a successful ovarian dissection and resection of gestational sac. Trophoblastic tissue was found at pathology. Similar symptoms should draw attention of practitioners on the plausibility of ovarian pregnancy.

[Comprehensive analysis of therapeutic methods and effect on cesarean scar pregnancy].

OBJECTIVE: To evaluate the efficacies and medic economic efficiency of therapeutic method for cesarean scar pregnancy (CSP). METHODS: The pertinent literatures on the treatment of CSP were collected and screened by retrieving some Chinese and English databases, such as PubMed, VIP and Wanfang Data. The weighting means and polled standard deviations of operative duration, operative hemorrhage volume, hysterectomy rate, length of stay, medical fees and the time of serum level of beta-human chorionic gonadotropin (ß-HCG) returning to normal were reckoned. RESULTS: Among different therapeutic methods of CSP, curettage duration was shortest in the patients with methotrexate (MTX) injection; operative hemorrhage volume, hysterectomy rate and length of stay were smallest in those with uterine artery embolization; medical fees was least in those with local MTX injection; the time of serum ß-HCG level returning to normal was shortest in those with hysteroscopic and/or laparoscopic operation after MTX injection or uterine artery embolization. CONCLUSION: Curettage after uterine artery embolization offers multiple advantages over therapeutic methods in the treatment of CSP.

Has increased clinical experience with methotrexate reduced the direct costs of medical management of ectopic pregnancy compared to surgery?

BACKGROUND: There is a debate about the cost-efficiency of methotrexate for the management of ectopic pregnancy (EP), especially for patients presenting with serum human chorionic gonadotrophin levels of >1500 IU/L. We hypothesised that further experience with methotrexate, and increased use of guideline-based protocols, has reduced the direct costs of management with methotrexate. METHODS: We conducted a retrospective cost analysis on women treated for EP in a large UK teaching hospital to (1) investigate whether the cost of medical management is less expensive than surgical management for those patients eligible for both treatments and (2) to compare the cost of medical management for women with hCG concentrations 1500-3000 IU/L against those with similar hCG concentrations that elected for surgery. Three distinct treatment groups were identified: (1) those who had initial medical management with methotrexate, (2) those who were eligible for initial medical management but chose surgery ('elected' surgery) and (3) those who initially 'required' surgery and did not meet the eligibility criteria for methotrexate. We calculated the costs from the point of view of the National Health Service (NHS) in the UK. We summarised the cost per study group using the mean, standard deviation, median and range and, to account for the skewed nature of the data, we calculated 95% confidence intervals for differential costs using the nonparametric bootstrap method. RESULTS: Methotrexate was £1179 (CI 819-1550) per patient cheaper than surgery but there were no significant savings with methotrexate in women with hCG >1500 IU/L due to treatment failures. CONCLUSIONS: Our data support an ongoing unmet economic need for better medical treatments for EP with hCG >1500 IU/L.

Economic evaluation of diagnosing and excluding ectopic pregnancy.

BACKGROUND: The diagnosis of ectopic pregnancy in women presenting in early pregnancy is often protracted, relying on costly investigations that are psychologically burdensome to the patient. The aim of this study was to evaluate the financial costs to the health services in Scotland of the current methods used to diagnose and exclude ectopic pregnancy, and compare these with that of a theoretical single diagnostic serum biomarker. METHODS: We conducted a retrospective cost-description analysis (with and without costs of diagnostic laparoscopy) of the health-care costs incurred by all patients presenting to a large Scottish teaching hospital between June and September 2006 with pain and bleeding in early pregnancy, where ectopic pregnancy was not excluded. Additionally, a cost minimization analysis was performed for the costs of current ectopic pregnancy investigations versus those of a theoretical single diagnostic serum biomarker. This included sensitivity analyses where the biomarker was priced at increasing values and assumed to have less than 100% diagnostic sensitivity and specificity. RESULTS: About 175 patients were eligible to be included in the analysis. Forty-seven per cent of patients required more than three visits to diagnose or exclude ectopic pregnancy. The total yearly cost for diagnosing and excluding ectopic pregnancy was 197K pound sterling for the hospital stated, and was estimated to be 1364K pound sterling for Scotland overall. Using a theoretical diagnostic serum biomarker we calculated that we could save health services up to 976K pound sterling (lowest saving 251K pound sterling after subanalysis) every year in Scotland. CONCLUSIONS: Ectopic pregnancy is expensive to diagnose and exclude, and the investigation process is often long and might involve significant psychological morbidity. The development of a single diagnostic serum biomarker would minimize this morbidity and lead to significant savings of up to 1 million pounds per year in Scotland.

Evolución, complicaciones y repercusión económica del embarazo ectópico según algoritmo para su asistencia / Type of onset, complications and economic impact of ectopic pregnancy according to its management

Se realizó un estudio longitudinal, descriptivo, prospectivo en el Servicio de Ginecología del Hospital Universitario Ginecoobstétrico Mariana Grajales, en Santa Clara, Villa Clara, en el período de enero de 2003 a diciembre de 2006, con el objetivo de caracterizar los factores asociados con la evolución y complicaciones del embarazo ectópico, en relación con el itinerario seguido así como la repercusión económica de esta entidad con relación a su manejo. Se incluyeron un total de 583 pacientes con diagnóstico de embarazo ectópico a las que se les aplicó un instrumento en forma de cuestionario aplicado, que incluyó variables directas e indirectas para el análisis y procesamiento estadístico. En los resultados se evidencia un incremento del embarazo ectópico en los últimos años respecto al número de nacimientos (1/48,7, 1/28,7, 1/34,0 y 1/33,3, respectivamente). Los principales factores de riesgo se corresponden con la incidencia en estas pacientes de enfermedad inflamatoria pélvica, 62,7%, seguido del uso de DIU, 40,8%, el tabaquismo 34,4%, y los antecedentes de instrumentación tubárica, 5,3%. La forma de evolución que predominó fue la aguda en 310 pacientes, 53,2%. El 77,6% de las pacientes se diagnosticó presuntamente en la atención primaria de salud y se remitieron hacia la atención hospitalaria donde se confirmó el diagnóstico. El seguimiento de un itinerario correcto repercute en la aparición de un menor número de complicaciones en las pacientes. El coste económico en el seguimiento médico-terapéutico de estas pacientes se ve afectado por la dependencia de la ruta correcta o incorrecta en relación con el itinerario seguido. Las pacientes que acuden con embarazo ectópico complicado requieren la utilización de mayor número de medicamentos y el uso de transfusiones de sangre que incrementan el coste total a 68.959,55 $ MN (AU)

To characterize the factors associated with the type of onset, complications, and economic impact of ectopic pregnancy according to the management of this entity, we performed a longitudinal, descriptive, prospective study in the Gynecology Service of the Mariana Grajales University Gynecology and Obstetrics Hospital in Santa Clara, Villa Clara (Cuba) between January 2003 and December 2006. A total of 583 patients with a diagnosis of ectopic pregnancy were included. Direct and indirect variables were gathered for statistical analysis. The results showed an increase in the number of ectopic pregnancies in relation to the number of births (1/48.7, 1/28.7, 1/34.0 and 1/33.3 respectively). The main risk factors were pelvic inflammatory disease in 62.7%, followed by the use of an intrauterine device in 40.8%, smoking in 34.4%, and tubal procedures in 5.3%. Onset was acute in 310 women (53.2%), while 77.6% received a presumptive diagnosis in primary care and were referred to hospital where the diagnosis was confirmed. Correct management of ectopic pregnancy reduces the number of complications in these patients and modifies the cost of follow-up. Medication and blood transfusion requirements were higher in women with complicated ectopic pregnancy, increasing the total cost to $68, 959.55 MN (AU)

Care pathways for ectopic pregnancy: a population-based cost-effectiveness analysis.

OBJECTIVE: To define care pathways in terms of frequency, costs, and outcomes and to assess their cost-effectiveness. DESIGN: Population-based cost-effectiveness study. SETTING: Auvergne EP registry (France). PATIENT(S): Women (n = 1,664) registered between 1994 and 2003. INTERVENTION(S): Standard diagnosis and treatment of EP. MAIN OUTCOME MEASURE(S): Costs before, during, and after hospitalization were assessed from data concerning medical costs of examinations and treatments. One-year fertility was used for effectiveness assessment. We assessed cost-effectiveness for the healthcare system. RESULT(S): Diagnostic ultrasound (47% of scans were nondiagnostic) was essential for the use of methotrexate as a first-line treatment for subacute EP. Hospital and ambulatory care costs were similar for all surgical-care pathways (diagnostic or nondiagnostic ultrasound scan followed by conservative or radical laparoscopy). Hospital and ambulatory-care costs associated with methotrexate treatment were less than half those for surgical-care pathways. In subacute cases, conservative treatments, and methotrexate in particular, were associated with better fertility at similar or lower cost to salpingectomy for EP for reproductive failure. CONCLUSION(S): Conservative treatments are cost-effective with respect to salpingectomy, when subsequent fertility is at stake. Efforts should be made to increase the frequency of diagnostic ultrasound scans, making it possible to increase methotrexate use and cost-effectiveness.

Cost-effectiveness of presumptively medically treating women at risk for ectopic pregnancy compared with first performing a dilatation and curettage.

OBJECTIVE: To compare the cost and complication rate of two alternative strategies for the diagnosis and medical management of ectopic pregnancy when ultrasound is nondiagnostic. DESIGN: A decision tree was constructed to compare [1] dilatation and curettage (D&C) followed by treatment of all ectopic pregnancies with methotrexate versus [2] empiric treatment of all patients with possible ectopic pregnancies with methotrexate without D&C. SETTING: University setting. PATIENT(S): Ten thousand hypothetical women with nonviable pregnancies and a known incidence of ectopic pregnancy were entered into a computer model. MAIN OUTCOME MEASURE(S): The two approaches were compared with respect to the number of missed ectopic pregnancies, complications, procedures performed, admissions to the hospital, and cost. RESULT(S): The D&C group had 1% more failed managements of ectopic pregnancies and 13.4% fewer patients with a miscarriage undergo a second treatment for resolution. The D&C group had 13.7% fewer complications including 6.3% fewer hospitalizations. D&C costs $173 to $223 more than empiric use of methotrexate per patient. CONCLUSION(S): Empirically treating women at risk for ectopic pregnancy with methotrexate does not reduce complications or save money. In the absence of such savings, the desire to make an accurate and definitive diagnosis, allowing objective prognosis on future fertility and risk of repeat ectopic pregnancy, supports the need to distinguish a miscarriage from ectopic pregnancy before treatment with methotrexate.

[Cost-effectiveness analysis of laparoscopic surgery versus methotrexate: comparison of data recorded in an ectopic pregnancy registry]. / Comparaison coût-effectivité de la coelio-chirurgie versus le traitement médical au méthotrexate à partir du registre des grossesses extra-utérines d'Auvergne.

OBJECTIVES: To compare the cost efficacy ratios of medical therapy (methotrexate - MTX) and laparoscopic surgery for ectopic pregnancy, based on an observational study of effectiveness. MATERIAL AND METHODS: Data were collected by a population register of the Auvergne area. We computed the costs before, during and after hospitalization of women who could be treated either by MTX or laparoscopic surgery. We detailed costs related to the various existing facilities. We considered the entire treatment. RESULTS: One hundred nine cases of ectopic pregnancy were treated by laparoscopic surgery and 46 by MTX. Second-line therapy was required in 3% of women who underwent laparoscopic surgery, and 35% of those given MTX. MTX was found to be less costly (1,342 euros) than laparoscopic surgery (2,113 euros). The efficacy threshold for MTX was 11% (giving a failure rate of 89%). CONCLUSION: MTX is much more cost effective than laparoscopic surgery but the frequent need for second-line treatment must also be assessed.

A refined estimate of the average lifetime cost of pelvic inflammatory disease.

BACKGROUND: The major complications of pelvic inflammatory disease (infertility, ectopic pregnancy, and chronic pelvic pain) are the leading cause of non-HIV sexually transmitted disease morbidity in the United States. GOAL: The goal of the study was to estimate a plausible range for the average lifetime cost of pelvic inflammatory disease (PID) and its major complications in a cohort of U.S. women of reproductive age. STUDY DESIGN: We developed a state-transition computer-based model to simulate the natural history of PID, incorporating the severity of infection, number of recurrent episodes, treatment setting, and the risk over time of major complications. Clinical and cost data were from the published literature. Model outcomes included life expectancy, quality-adjusted life expectancy, and lifetime costs. RESULTS: In a cohort of 100,000 females acquiring PID between 20 and 24 years of age, 8550 ectopic pregnancies, 16,800 cases of infertility, and 18,600 cases of chronic pelvic pain were projected to occur. Assuming a 3% annual discount rate, we found the average per-person lifetime cost to be $2150. Average lifetime costs for women who developed major complications were $6350 for chronic pelvic pain, $6840 for ectopic pregnancy, and $1270 for infertility. The majority of costs (79%) were accrued within 5 years of upper genital tract infection. Results were most sensitive to assumptions about the timing of major complications and the discount rate. CONCLUSION: The average per-person lifetime cost of PID ranges between $1060 and $3180. Future cost-effectiveness analyses of STD screening programs can include this range as a reasonable upper and lower bound. These findings suggest successful PID prevention efforts may avert substantial costs for care providers such as managed care organizations while providing well documented clinical benefits for women in the United States.

Symptom-free women at increased risk of ectopic pregnancy: should we screen?

BACKGROUND: Transvaginal sonography, serum human chorionic gonadotrophin (hCG) measurement, and serum progesterone measurement provide the possibility to screen symptom-free women at increased risk of ectopic pregnancy. The objective of the present study was to evaluate the cost-effectiveness of screening for ectopic pregnancy, by addressing the expected benefits and costs of screening for ectopic pregnancy. METHODS: Screening programs incorporating transvaginal sonography, serum hCG measurement, and serum progesterone measurement were compared with a 'watchful waiting' strategy. Data were extracted from the literature. The strategies were compared on the expected number of prevented tubal ruptures, the expected number of false-positive diagnoses, and expected costs. RESULTS: The cost-effectiveness of screening appeared to be strongly dependent on the prevalence of ectopic pregnancy. At a prevalence of ectopic pregnancy of 6%, a screening program with transvaginal sonography and serum hCG measurement would reduce the number of patients with ruptured ectopic pregnancy from 2.1 to 0.61 per 100 screened women. Screening was expected to cost approximately Euro 933 per prevented tubal rupture, whereas the number of expected false-positive diagnoses was 0.64 per prevented tubal rupture. CONCLUSION: We conclude that screening for ectopic pregnancy reduces the number of patients with tubal rupture, but only at the expense of a large false-positive rate. Although sonography in symptom-free women at risk of ectopic pregnancy might be justified for psychological reasons, the medical and economic benefits of such a policy seem to be limited.

Ectopic pregnancy without therapy despite previous failure with in vitro fertilization and a male partner with an extremely low hypoosmotic swelling test score: case report.

PURPOSE: To record an ectopic pregnancy achieved through natural intercourse despite previous implantation failure following in vitro fertilization-embryo transfer (IVF-ET) with a male partner who had an extremely low hypoosmotic swelling test (HOST) score. METHODS: A hypoosmotic swelling test was performed for the first time on the semen of a male partner who was advised previously that his sperm specimen was perfectly normal. RESULTS: The standard semen parameters except normal morphology with strict criteria were normal. The HOST score was 33%. CONCLUSIONS: The HOST score of 33% was the lowest level recorded in anyone achieving a pregnancy. The fact that it resulted in an ectopic pregnancy in a woman with apparently normal tubes and failure to achieve an intrauterine pregnancy despite transfer of 13 embryos with good morphology may suggest that the low HOST score inhibits the blastocyst from implanting in the uterus rather than from failure to develop a blastocyst from a multi-cell embryo.