Long-term follow-up of laparoscopic electrocautery of the ovaries versus ovulation induction with recombinant FSH in clomiphene citrate-resistant women with polycystic ovary syndrome: an economic evaluation.

BACKGROUND: Laparoscopic electrocautery of the ovaries and ovulation induction with gonadotrophins are both second line treatments for women with clomiphene citrate-resistant polycystic ovary syndrome (PCOS). Long-term follow-up after electrocautery versus ovulation induction with gonadotrophins has demonstrated at least comparable chances for a first live born child with a reduced need for ovulation induction or assisted reproduction treatment and increased chances for a second live born child. In this study, we report on the long-term economic consequences of both treatment modalities. METHODS: Between February 1998 and October 2001, we performed a multi-centre randomized controlled trial (RCT) comparing a strategy of laparoscopic electrocautery of the ovaries, followed by clomiphene citrate and gonadotrophins when anovulation persisted, and a strategy of ovulation induction with gonadotrophins in women with clomiphene citrate-resistant PCOS. Eight to twelve years after randomization we performed a follow-up study on reproductive outcome in these women and the fertility treatments they had needed including data on direct medical costs of pregnancy and delivery. Clinical data included number of treatment cycles, live births, miscarriages, ectopic pregnancies and multiple pregnancies. We calculated mean costs per woman after randomization until the first live birth. Confidence intervals (CIs) were estimated by bootstrapping. RESULTS: We obtained data for an economic analysis on 159 of the 168 randomized women (95%). In total, 71 of 83 women (86%) allocated to the electrocautery strategy and 69 of 85 women (81%) allocated to the gonadotrophin strategy had at least one live birth. Given the equivalence between the two treatment strategies in terms of a first live birth-the primary outcome measure-our analysis focused on the cost difference between the two strategies within a mean follow-up time of 8-12 years. The mean costs per first live birth after randomization were €11 176 (95% CI: €9689-€12 549) for the electrocautery group and €14 423 (95% CI: €12 239-€16 606) for the recombinant FSH group, resulting in significantly lower costs (P < 0.05) per first live birth for women allocated to the electrocautery group (mean difference €3247; 95% CI: €650-€5814). CONCLUSION: In women with clomiphene-resistant PCOS, laparoscopic electrocautery of the ovaries results in significantly lower costs per live birth than ovulation induction with gonadotrophins for an at least equal effectiveness.

The value of additional carpal box radiographs in suspected scaphoid fracture.

RATIONALE AND OBJECTIVES: Carpal Box (CB) radiographs, transverse and longitudinal, produce elongated and magnified views of the carpus. These radiographs can be used after carpal injury, in addition to conventional scaphoid x-rays. In this study, the use of CB radiographs was evaluated in patients with possible scaphoid fracture. METHODS: Seventy-one consecutive patients who presented at the First Aid department from May 1994 to May 1995 were included. All patients were examined for scaphoid fracture after a fall on the out-stretched hand. If a scaphoid fracture was seen on the scaphoid x-rays, patients were immobilized. If the x-rays remained negative or dubious for fracture, additional transverse and longitudinal CB radiographs were obtained. If CB radiographs remained negative or inconclusive, patients were referred for three-phase bone scintigraphy. The results of independent and masked judgment by three different observers were used for an inter- and intraobserver analysis. RESULTS: Twenty of 71 patients initially showed a scaphoid fracture on the conventional scaphoid x-rays, 41 were negative, and 10 inconclusive. All 41 negative patients remained negative on CB radiograph; however, the bone scintigraphy was positive for scaphoid fracture in 11 patients and in 9 patients a hot spot elsewhere in the carpus was found. Of the 10 patients with inconclusive x-rays, 2 showed a clear fracture of the scaphoid on CB radiograph, 5 were negative, and 3 remained inconclusive. The agreement between observers, calculated in kappa values, was highest in CB radiographs. CONCLUSIONS: In the diagnosis of scaphoid fracture, Carpal Box radiography is of limited value in patients with clinically suspected scaphoid fracture. In two of 10 patients with initial dubious scaphoid x-ray, bone scintigraphy can be avoided. Furthermore, the reliability of the interpretation of the radiographs is increased by additional Carpal Box radiography.