Cost-effectiveness modelling of recombinant FSH versus urinary FSH in assisted reproduction techniques in the UK.

BACKGROUND: The purpose of this study was to undertake an economic evaluation to compare the cost-effectiveness of recombinant (r)FSH with urinary (u)FSH for attaining clinical pregnancy with assisted reproduction. METHODS: Mathematical modelling was utilized incorporating a Markovian decision framework and a Monte Carlo simulation. Statistical representations of recurrent events over time were incorporated into a decision analysis involving fresh and frozen cycles in any sequence (after the first fresh embryo transfer cycle) over three successive assisted reproduction attempts. The mean values of transition probabilities were derived from randomized controlled clinical trials and published reports. The distributions of these transition probabilities were agreed upon by a panel of experts. Cost data for procedures and drugs were derived and validated according to the perspectives of the National Health Service and private clinics in the UK. RESULTS: The study involved 5000 Monte-Carlo simulations of treatment on a Markov cohort of 100 000 patients. The total number of pregnancies attained was significantly higher in the rFSH (40 575) compared with the uFSH (37 358) group. The cost per successful pregnancy was significantly lower for rFSH (5906 pounds sterling) compared with uFSH (6060 pounds sterling) and overall, fewer cycles of treatment were required with rFSH to achieve an ongoing pregnancy. The incremental cost-effectiveness ratio is 4148 pounds sterling for each additional clinical pregnancy with rFSH. CONCLUSIONS: In addition to the increased effectiveness of rFSH in ART, this study demonstrated that it is more cost-effective and more efficient than uFSH in attaining an ongoing pregnancy.

Outpatient laparoscopic tubal anastomosis and subsequent fertility.

OBJECTIVE: To determine the reproductive outcome of women who undergo laparoscopic tubal anastomosis. DESIGN: Observational prospective study. SETTING: University-affiliated infertility medical center. PATIENT(S): One hundred two patients seeking reversal of tubal sterilization. INTERVENTION(S): Laparoscopic tubal anastomosis was performed with a one-suture technique. MAIN OUTCOME MEASURE(S): Pregnancy rate. RESULT(S): There were 69 isthmic-isthmic, 16 isthmic-ampullary, 12 cornual-isthmic, and 5 ampullary-ampullary anastomoses. The mean operative time was 71.35 minutes. Eight patients had bilateral tubal obstruction on postoperative hysterosalpingography. Sixty-nine patients (70%) conceived. Sixty-four (65.3%) had ongoing intrauterine pregnancies, 15 (21.7%) had spontaneous abortions, and 5 (7.2%) had ectopic pregnancies. CONCLUSION(S): This study demonstrates that laparoscopic tubal anastomosis can be done safely and successfully on an outpatient basis, reducing costs and postoperative morbidity while accelerating the patient's return to normal activities.

Ovarian stromal echogenicity in women with normal and polycystic ovaries.

Since the widespread use of transvaginal ultrasound to diagnose polycystic ovary syndrome (PCOS), a cardinal feature has been shown to be the presence of a bright, highly echogenic stroma. This is usually assessed subjectively. The objective of this study was to determine whether ovarian stromal echogenicity when measured objectively actually differed between women with polycystic ovaries and those with normal ovaries. A total of 67 women underwent a detailed ultrasound assessment before considering assisted conception treatment. Ovarian morphology was assessed and total ovarian volume, stromal volume, peak stromal blood flow velocity and mean stromal echogenicity were measured. The stromal index (ratio of mean stromal echogenicity to mean echogenicity of the entire ovary) and total stromal echogenicity were also calculated. Ovarian volume, stromal volume, and stromal peak blood flow velocity were all significantly higher in ovaries from women with PCOS. There was no difference in the mean stromal echogenicity, although the stromal index was significantly greater in women with polycystic ovaries. The apparent subjective increase in stromal echogenicity in women with polycystic ovaries, as exemplified by the greater stromal index, is due to a combination of the increased volume of ovarian stroma and the significantly lower mean echogenicity of the entire ovary in these women.

Results of laparoscopic treatments of ovarian endometriomas: laparoscopic ovarian fenestration and coagulation.

OBJECTIVE: To determine the long-term results of laparoscopic fenestration and coagulation of ovarian endometriomas and to compare them with the results of ovarian cystectomy performed by either laparotomy or laparoscopy. DESIGN: Case-control study. SETTING: Two university-affiliated hospitals. PATIENT(S): One hundred fifty-six premenopausal women with ovarian endometriomas of at least 3 cm in diameter (stage 3 and 4 endometriosis, revised American Fertility Society classification). INTERVENTION(S): Laparoscopic ovarian fenestration and coagulation (group 1, 80 patients); laparoscopic ovarian cystectomy (group 2, 23 patients); and ovarian cystectomy by laparotomy and microsurgical technique (group 3, 53 patients). MAIN OUTCOME MEASURE(S): Operative findings, recurrence rate, and cumulative clinical pregnancy rate (PR) over a 36-month follow-up period. RESULT(S): The mean (+/-SD) time to first pregnancy was significantly shorter in group 1 (1.4+/-0.2 years) than in group 2 (2.2+/-0.5 years) or group 3 (2.4+/-0.5 years). The difference between the cumulative clinical PR between the three groups was not statistically significant after 36 months of follow-up. The difference in the recurrence rate among groups 1, 2, and 3 was not statistically significant. CONCLUSION(S): Laparoscopic ovarian fenestration and coagulation of endometriomas leads to faster conception than ovarian cystectomy by laparotomy. Laparoscopic ovarian fenestration and coagulation of endometriomas is associated with cumulative clinical PRs and recurrence rates over 36 months that are similar to those associated with ovarian cystectomy.

Effect of lysoplatelet-activating factor on human sperm fertilizing ability.

OBJECTIVE: To evaluate the penetration rates in the hamster zona-free oocyte sperm penetration assay (SPA) after exposure of spermatozoa to lysoplatelet-activating factor (LPAF) and lysophosphatidyl choline (LPC). DESIGN: Washed human spermatozoa were exposed to 100 microM of LPAF or LPC, followed by the assessment of their fertilizing ability using the SPA. The percentage of penetration, the sperm binding in the SPA, the percentage of motile spermatozoa, and the acrosome reaction rates were quantified. SETTING: Private research and university laboratories. PATIENTS, PARTICIPANTS: Fresh and frozen semen samples from fertile donors with proven fertility were used as well as fresh semen from infertile patients attending a fertility clinic. All the infertile patients had abnormal semen analysis. INTERVENTIONS: Human spermatozoa were incubated for 90 minutes in the presence or absence of LPAF or LPC at 100 microM with 0.3% albumin in Ham's F-10 (GIBCO, Dorval, Quebec, Canada), and their fertilizing ability was evaluated using the SPA. The effect of these lysophospholipids on the percentage of acrosome reaction was evaluated with a fluorescent microscopy technique. RESULTS: The penetration rates of the SPA in male factor increased significantly from 3% +/- 6% with controls to 19% +/- 9% and 34% +/- 22% after incubation with LPC and LPAF, respectively. Sperm-oocyte binding was not significantly increased in this group. Sperm penetration assay penetration rates were also increased in fertile cryopreserved spermatozoa with LPC and LPAF. In this group, the acrosome reaction was significantly increased from 2% +/- 1% in controls to 10% +/- 6% and 8% +/- 3% after incubation with LPC and LPAF, respectively. CONCLUSION: Lysoplatelet-activating factor and LPC independently increased the penetration rate of spermatozoa and the percentage of acrosome reaction. Lysophosphatidylcholine and LPAF may be beneficial in the treatment of spermatozoa with male factor infertility and may increase fertilization rates in IVF.