[Infertility treatment before assisted reproductive techniques]

The prevalence of infertility has increased in recent years, but the medical services to treat these problems are not available for most of the affected couples. The prognosis for fertility is important in order to determine the therapeutic capacity of each service, and to select the couples that could be treated at a primary level, or to send them to more advanced levels of reproductive technology. In practice, the infertility is treated in primary medical levels and the assisted reproductive technology is available only to a limited sector of the poblation. In general, the managed-care plans do not compensate directly for infertility treatments, but they are indirectly paying some therapeutic procedures for fertility.

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.

Dependence of the in-vitro fertilization capacity of the oocyte on perifollicular flow in the preovulatory period of unstimulated cycles

BACKGROUND

One method to economize on monitoring cycles for IVF and improving its outcome is follicular selection. The purpose of our study was to determine whether quantitative indices of perifollicular blood flow allow the prediction which follicles contain a fertilizable oocyte and which do not.

METHODS

This prospective study included 178 unstimulated cycles for IVF in patients treated for tubal infertility, endometriosis and unknown causes of infertility that ended with follicular aspiration. All male partners had a normal spermiogram. Cycles were monitored using ultrasound folliculometry and estimation of serum estradiol concentrations. On the day of hCG administration (day 0), day +1 and prior to follicular aspiration (day +2), perifollicular blood flow was measured using color and pulsed Doppler. The pulsatility index (PI), resistance index (RI) and peak systolic velocity (PSV) between the group in which fertilization occurred (group A) and that in which no fertilization occurred (group B) were compared. Student's t-test and ANOVA were used for statistical analysis.

RESULTS

The oocyte recovery rate was 71.5% and the fertilization rate 74.8%. Comparison of RI and PI between group A (N = 95) and group B (N = 32) revealed a decline in PI and RI after hCG administration in both groups. Only on day 0 was PI in group A significantly lower than that in group B. The difference in RI and PSV between the two groups was not statistically significant. ANOVA showed that there was no significant difference in serial Doppler measurements between the two groups.

CONCLUSION

We confirmed an increased perifollicular blood flow in the preovulatory period. Quantitative indices of perifollicular blood flow are of limited value as parameters for cycle monitoring and decision-making in unstimulated cycles for IVF.

Evaluation of the couple with infertility in a managed care environment

The classic infertility evaluation is a costly experience for many couples. In the new era of managed care, it may be possible to perform a targeted evaluation that, while significantly lowering the total cost, will not impair our ability to correctly diagnose the cause of a couple's infertility. When combined with algorithms for streamlined treatment, it may be possible to significantly reduce the cost for the diagnosis and treatment of infertility.

Cost-effective treatment for the couple with infertility

Although the evaluation of cost-effective approaches to infertility treatment remains in its infancy, several important principles have emerged from the initial studies in this field. Currently, in treating couples with infertility without tubal disease or severe male-factor infertility, the most cost-effective approach is to start with IUI or superovulation-IUI treatments before resorting to IVF procedures. The woman's age and number of sperm present for insemination are significant factors influencing cost-effectiveness. The influence of certain diagnoses on the cost-effectiveness of infertility treatments requires further study. Even when accounting for the costs associated with multiple gestations and premature deliveries, the cost of IVF decreases within the range of other cost-effective medical procedures and decreases to less than the willingness to pay for these procedures. Indeed, for patients with severe tubal disease, IVF has been found to be more cost-effective than surgical repair. The cost-effectiveness of IVF will likely improve as success rates show continued improvements over the course of time. In addition, usefulness of embryo selection and practices to reduce the likelihood of high-order multiple pregnancies, without reductions in pregnancy rates, will significantly impact cost-effectiveness. The exclusion of infertility treatments from insurance plans is unfortunate and accentuates the importance of physicians understanding the economics of infertility treatment with costs that are often passed directly to the patient. The erroneous economic policies and judgments that have led to inequities in access to infertility health care should not be tolerated.

Exclusions of infertility treatment in the aftermath of Bragdon v. Abbott

This article analyzes the Supreme Court's decision in Bragdon v. Abbott to determine whether the Court's reading of ADA necessarily leads to the conclusion that a group health plan's or insurer's exclusion or limitation of coverage with respect to infertility is prohibited by ADA. The authors conclude that it may be advisable for plans to perform at least minimal actuarial calculations with respect to the current or anticipated costs of covering infertility treatments prior to adopting any exclusions or limitations of coverage.

Seeking coverage for infertility. Insurers should offer reasonable services to help couples achieve pregnancy

One of every eight U.S. couples will seek treatment for infertility at some point in the child-bearing years. Infertility affects both men and women of every racial, religious, ethnic, and socioeconomic group. For most of these couples, access to infertility treatment will be denied either because they don't have medical insurance, or because the coverage that they have severely limits infertility coverage.

Direct medical cost of pelvic inflammatory disease and its sequelae: decreasing, but still substantial

OBJECTIVE

To estimate direct medical costs and average lifetime cost per case of pelvic inflammatory disease (PID).

METHODS

We estimated the direct medical expenditures for PID and its three major sequelae (chronic pelvic pain, ectopic pregnancy, and infertility) and determined the average lifetime cost of a case of PID and its sequelae. We analyzed 3 years of claims data of privately insured individuals to determine costs, and 3 years of national survey data to determine number of cases of PID, chronic pelvic pain, and ectopic pregnancy. We developed a probability model to determine the average lifetime cost of a case of PID.

RESULTS

Direct medical expenditures for PID and its sequelae were estimated at $1.88 billion in 1998: $1.06 billion for PID, $166 million for chronic pelvic pain, $295 million for ectopic pregnancy, and $360 million for infertility associated with PID. The expected lifetime cost of a case of PID was $1167 in 1998 dollars. The majority of those costs ($843 per case) represent care for acute PID rather than diagnosis and treatment of sequelae. Approximately 73% of cases will not accrue costs beyond the treatment of acute PID.

CONCLUSION

The direct medical cost of PID is still substantial. The majority of PID related costs are incurred in the treatment of acute PID. Because most PID-related costs arise in the first year from treatment of acute PID infection, strategies that prevent PID are likely to be cost-effective within a single year.

The economics of optimal health and productivity in the commercial dairy

Dairy production practices are changing; in order to remain viable, producers must optimise the health and productivity of dairy herds in economic terms. Health care is important in economic terms because disease can substantially reduce the productivity of individual animals. Preventive disease control programmes can thus result in economic gains for the dairy producer. The author describes new approaches to preventing postpartum diseases and dealing with fertility problems which can result from these diseases. Other aspects of dairy production are also changing, employing new technologies where these are judged to be profitable. Innovations include: the use of bovine somatotropin; systematic breeding/culling programmes; new mathematical modelling techniques to determine optimum feed composition and to define optimal growth levels for accelerated heifer-rearing programmes; the use of computers to collect, store and analyse data on animal production and health; and semen selection programmes. Increasing awareness of bio-security is also vital, not least because of the large investment present in dairy herds. Whatever practices are employed, they must offer economic returns to producers that compete with alternative uses of capital. Optimal levels of disease control must be determined for a particular production situation, taking into account not only the economic health of the producer, but also the well-being of the animals.

Resection of uterine septum using gynaecoradiological techniques

This paper presents further refinements in our technique for the resection of uterine septum. Fourteen patients [infertility (n = 9) and recurrent miscarriages (n = 5)] underwent in-office resection of a uterine septum under fluoroscopic control. The main outcome measure was complete resection of uterine septum. Resections were carried out using either hysteroscopic scissors in combination with a specially designed uterine balloon catheter, or microlaparoscopy scissors in conjunction with a cervical cannula. In all patients the septum was successfully resected without any intra-operative complications. We conclude that ambulatory gynaecoradiological resection of uterine septa is a safe and simple procedure. It avoids utilization of expensive operating room time, general anaesthesia, and some complications associated with hysteroscopic resection, such as fluid retention and electrolyte imbalance.

Diagnosis of subtle ovulation disorders in subfertile women with regular menstrual cycles: cost-effective clinical practice?

Serial monitoring by plasma progesterone measurement is advised in the literature for fertility work-up, to detect ovulation disturbances in women presenting with regular menstrual cycles. Three strategies to diagnose such 'subtle ovulation disorders' (SOD, defined as anovulation, inadequately timed ovulation or ovulation of a follicle of reduced size in regularly cycling women) were evaluated, in order to investigate costs of such a diagnosis. On the basis of a 'maximal', an 'ultrasound-only', and a 'preselection' strategy, total medical costs and costs including non-medical costs were calculated for each SOD diagnosis. A 'maximal' diagnostic strategy resulted in a total medical cost of ECU 9057 per diagnosis (including non-medical costs ECU 12,787); an 'ultrasound-only' strategy in ECU 4520 (ECU 6791) per diagnosis. By use of a 'preselection' strategy, 4.25% of the women were found to have an SOD, at a cost of ECU 3036 (ECU 6868) for each diagnosis. As the real significance of SOD diagnosis for the prognosis of the patient to become pregnant without treatment remains unclear, and as no randomized trials on treatment effectiveness have as yet been undertaken, it is questionable whether this approach is worthwhile.

Infertility: from a personal to a public health problem

The inability to conceive a child is most often viewed as a private matter, but public health perspectives and skills can contribute greatly to our knowledge about infertility, and the development of effective and rational public policy for prevention, access to health care, and regulation of new technologies. We offer a primer of public health aspects of infertility in an effort to encourage the broad spectrum of public health professionals to become more knowledgeable about these topics and join in the national debate about preventive strategies, cost-benefit assessment, resource allocation, and ethics.

Pelvic inflammatory disease. From diagnosis to prevention

Pelvic inflammatory disease (PID) refers to infection of the uterus, fallopian tubes, and adjacent pelvic structures that is not associated with surgery or pregnancy. PID causes major medical, social, and economic problems worldwide. Long-term sequelae, most notably tubal factor infertility and ectopic pregnancy, are common and extremely costly to the healthcare system. The most important causative micro-organisms are Chlamydia trachomatis, Neisseria gonorrhoeae, and micro-organisms associated with bacterial vaginosis. The clinical spectrum of PID ranges from subclinical endometritis to severe salpingitis, pyosalpinx, tubo-ovarian abscess, pelvic peritonitis, and perihepatitis. Clinical diagnosis of PID has limitations. The clinical diagnostic criteria are insensitive and nonspecific, and false-positive and false-negative diagnosis is common; however, direct visual diagnosis is not always feasible, requires general anesthesia, and is costly. More research is needed of noninvasive diagnosis of PID. Current treatment guidelines call for broad-spectrum antimicrobial coverage. Screening for asymptomatic chlamydial infection is the mainstay of prevention of PID. Emerging evidence from randomized controlled trials provides strong evidence that intervention with selective screening for chlamydial infection effectively reduces the incidence of PID.

Recombinant follicle-stimulating hormone: new biotechnology for infertility

The frequency of infertility in developed countries is approximately 8-10%. New drugs are available for assisted reproduction techniques. Two recombinant follicle-stimulating hormone (FSH) products, follitropin-beta (Follistim in the United States, Puregon in Europe) and follitropin-alpha (Gonal-F), join compounds derived through transfecting nonhuman cell lines with genetic material capable of replicating identical amino acid sequences to human compounds. The cell line used for recombinant (r)-FSH production is the Chinese hamster ovary (CHO). Previously, the only agents that showed benefit in controlled ovulatory stimulation were derived from the urine of menopausal women. Those compounds contain additional substances, such as urinary proteins and various amounts of luteininzing hormone. The amino acid sequence of r-FSH is identical to that of human FSH, but the two recombinant products exist in many different isoforms and differ from each other and from human FSH due to varied carbohydrate side chains. Due to variation in the carbohydrate side chains, follitropin-beta in solution has a higher pH than urine-derived FSH, which enhances receptor affinity and therefore is a greater inducer of folliculogenesis. Follitropin-beta does not cause endogenous production of anti-CHO or anti-FSH antibodies, and is well tolerated.

The economic cost of infertility-related services: an examination of the Massachusetts infertility insurance mandate

OBJECTIVE

To examine the costs and outcomes of infertility-related services in Massachusetts during a time of expanded use of assisted reproductive technology (ART).

DESIGN

Cost data were obtained from the Massachusetts Department of Insurance Rate-Setting Commission and 9 large group insurance plans for the period 1986-1993. Utilization and success rates of ART were examined, and the cost per live delivery with the use of ART in 1993 was estimated.

SETTING

The state of Massachusetts, in which access to infertility-related services has been mandated by law since 1989.

PATIENT(S)

The study population consisted of 8 large health maintenance organization plans and the Blue Cross/Blue Shield indemnity plan.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Per capita infertility-related expenditures, infertility-related expenditures as a percentage of total expenditures, live deliveries per initiated ART cycle, and cost per live delivery.

RESULT(S)

Expenditures for infertility services increased at a rate similar to or slower than inflation during the years 1988-1992. Increases were slowest in health maintenance organizations, probably as a result of provider arrangements. Infertility services accounted for 0.41% of total expenditures within the indemnity plan in 1993 (approximately $1.71 per contract-month). Examination of ART utilization showed no evidence of overutilization by patients with a low chance of success. The cost per live delivery with the use of ART in 1993 was $59,484.

CONCLUSION(S)

Mandated infertility coverage was associated with increased use of ART but not with excessive increases in consumer cost for infertility insurance coverage.

Conception failure in swine: importance of the sex ratio of a female's birth litter and tests of other factors

Failure of gilts and sows to conceive when they are mated is a potentially serious economic cost for swine producers. In Exp. 1, we determined that anogenital distance of newborn gilts is related to the proportion of males in the litter (P < .001). Gilts from litters with more males have larger anogenital distances (mean = 8.0 +/- .2 mm); those from litters with low proportions of males have smaller anogenital distances (mean = 5.7 +/- .1 mm). In Exp. 2, we examined the effect of birth litter sex ratio of sows and gilts on reproductive performance using a 13-yr database of breeding and litter data. Gilts that failed to become pregnant on the first breeding attempt came from litters with significantly higher proportions of males than gilts that successfully conceived on the first breeding attempt. Overall, female swine were significantly more likely to exhibit lower rates of successful breeding during their first four breeding attempts if they had been born in a male-biased litter. These results have implications for swine producers deciding which gilts to keep and which to market. Given the higher probability of reproductive problems for gilts from litters of 12 or more pigs with 67% or more males, these females should likely become market hogs. Sow's age, mode of insemination, and the number of insemination attempts at an estrus period, but not season, can affect successful breeding.

[Cost effective media in vaginal ultrasound uterus and fallopian tube diagnosis]

AIM

The recent development of hysterocontrastsonography (HyCoSy) for assessing tubal patency may provide an alternative to current methods, which are either invasive (laparoscopy and dye) or involve exposure to radiation and require a radiology department (hysterosalpingography).

METHOD

Following the introduction of an intrauterine balloon catheter, the contrast agent (Echovist) is slowly injected into the cavity and tracked using ultrasound as it passes through the tubes. The technique is well tolerated as an outpatient method, and takes about 15 to 20 minutes to perform.

RESULTS

In a clinical trial with infertile women we compared the results of HyCoSy to laparoscopy and dye. In 90 out of 108 tubes investigated the results agreed-equivalent to a sensitivity of 88% and a specificity of 82%. Three false negative findings on the one hand and 15 false positive findings on the other represent a negative predictive value of 96% and a positive predictive value of 58%. In approximately 50% of patients, this outpatient procedure caused little or no pain, and in 40%, moderate pain. Only a small part of the investigated group (8%) complained about serious discomfort; in two cases (3%) the procedure was discontinued because of pain.

CONCLUSION

HyCoSy is a reliable and simple method to provide preliminary information about tubal patency. It may be carried out at an early stage of the algorithm to investigate the infertile couple, and may so lead to more rapid and efficient treatment.

[Sexually transmitted diseases and female sterility at the University Hospital Center of Dakar: management and prevention]

It is a retrospective study supporting 82 cases continued series of feminine sterility and which objective is to evaluate the nursing management quality of genital infection in exploration and treatment of sterility. Women mean age is 26 years old, sterility is most primary frequently (68%) and from fallopian origin (80%). Followers examinations have been asked: vaginal taking (100%), urines cytobacteriology examination (56%), syphilis serology (23%), chlamydia serology (57%), mycoplasma serology (03%). Genital infection have been diagnosed in 75% of cases, in 33% of cases positive Chlamydia serology was found. Three molecules have been used principally in treatment: cyclines 50%, imidazoles derived 47%, lactamines 15%. The upper cost of diagnostic and treatments produce a wishest of prevention which based is the tracking and the precocious treatment of STD.

There's a big niche market for infertility care

A lucrative niche remains in a market increasingly dominated by managed care and cost containment. Many infertile women are willing to pay just about any price for infertility products, usually not covered by their insurers, writes Pamela Moore, managing editor of Healthcare Advertising Review.