P–728 Can in couples with unexplained infertility the use of a prediction model to triage assisted reproduction technology save costs?

Study question

Can in couples with unexplained infertility a prognosis-tailored management strategy, that delays treatment if natural conception prospects are good, reduce costs without affecting live-birth rate?

Summary answer

In couples with unexplained infertility, use of a prognostic tool for natural conception followed by expectant management in good-prognosis couples is cost-effective.

What is known already

Few countries have guidelines for the assessment of the likelihood of natural conception to determine access to publicly funded ART. In the Netherlands and New-Zealand, couples with unexplained infertility who have a good prognosis for natural conception are encouraged to delay starting ART. However, the cost-effectiveness of this prognosis-tailored treatment strategy has not been determined.

Study design, size, duration

We studied couples with unexplained infertility to compare a prognosis-tailored strategy to care-as-usual. In the prognosis-tailored strategy, couples were assessed using Hunault’s prediction model. In good-prognosis couples (12-months natural conception >40%), outcomes without ART were modelled by censoring observations after start of ART. We then assumed that poor-prognosis couples (<40% natural conception) were treated, while good-prognosis couples delayed the start of treatment for 12 months. Data for the care-as-usual model were based on real observations.

Participants/materials, setting, methods

We studied 272 couples with unexplained infertility. Costs of in vitro fertilisation (IVF) and intra-uterine insemination (IUI) were calculated based on the out-of-pocket costs and Australian Medicare costs. In a cost-effectiveness model, we compared costs and effects of both strategies.

Main results and the role of chance

The prognostic model classified 272 couples with unexplained infertility as favourable (N = 107 (39.3%) or unfavourable prognosis (N = 165 (60.7%)) for natural conception. In the prognosis-tailored strategy, the cumulative live-birth rate was 71.1% (95% CI 64.7% - 76.4%) while the number of ART cycles was 393 (353 IVF; 40 IUI). In care-as-usual strategy, the cumulative conception rate leading to live-birth for the cohort of 272 couples, who underwent a total of 398 IVF cycles and 48 IUI cycles, was 72.1% (95% CI 65.7% - 77.4%). Mean time to conception leading to live birth was 388 days in the prognosis-tailored strategy and 419 days in the care-as-usual strategy.

This translated for the 272 couples into potential savings of 45 IVF cycles and eight IUI cycles, which cost a total of AUD$ 125,817 for out-of-pocket and AUD$ 264,497 for Australian Medicare. The average cost savings per couple was AUD$ 1,435 (out-of-pocket AUD$ 463 per couple and Australian Medicare AUD$ 962 per couple). The incremental cost-effectiveness ratio, which was calculated as the total costs per additional live-births, was AUD$ 143,497 per additional live birth.

Limitations, reasons for caution

This study was limited to couples at a single IVF clinic. The modelling was also based on several key assumptions, particularly the number of fresh and frozen embryo transfer cycles for each couple.

Wider implications of the findings: Our results show that in couples with unexplained infertility the use of a prognostic model guiding the start of an IVF-treatment reduces costs without compromising live birth rates.

Trial registration number

Not applicable

Effect of clomiphene citrate on endometrial thickness, ovulation, pregnancy and live birth in anovulatory women: systematic review and meta-analysis

OBJECTIVES

To compare the impact of clomiphene citrate (CC) vs other drug regimens on mid-cycle endometrial thickness (EMT), ovulation, pregnancy and live birth rates in women with World Health Organization (WHO) group II ovulatory disorders.

METHODS

We searched MEDLINE, EMBASE, Scopus, Web of Science, The Cochrane Central Register of Clinical Trials (CENTRAL) and the non-MEDLINE subset of PubMed from inception to December 2016 and cross-checked references of relevant articles. We included only randomized controlled trials (RCTs) comparing CC used alone vs other drug regimens for ovulation induction in women with WHO group II anovulation. Outcomes were mid-cycle EMT, ovulation, pregnancy and live birth rates. We pooled weighted mean differences (WMD) with 95% confidence intervals (CI) for continuous variables (EMT) and risk ratios (RR) with 95% CI for binary variables (ovulation, pregnancy and live birth rates).

RESULTS

We retrieved 1718 articles of which 33 RCTs (4349 women, 7210 ovulation induction cycles) were included. In 15 RCTs that compared CC with letrozole, EMT was lower in the CC group (1957 women, 3892 cycles; WMD, -1.39; 95% CI, -2.27 to -0.51; I²  = 100%), ovulation rates after CC and letrozole were comparable (1710 women, 3217 cycles; RR, 0.97; 95% CI, 0.90-1.04; I²  = 47%), while CC led to a lower pregnancy rate (1957 women, 3892 cycles; RR, 0.78; 95% CI, 0.63-0.95; I²  = 43%) and a lower live birth rate (RR, 0.70; 95% CI, 0.49-0.98; I²  = 35%). In two RCTs that compared CC with CC plus metformin, EMT, ovulation and pregnancy rates were comparable (101 women, 140 cycles; WMD, -0.23; 95% CI, -0.92 to 0.45; I²  = 78%; RR, 0.84; 95% CI, 0.67-1.06; I²  = 0%; and RR, 0.79; 95% CI, 0.33-1.87; I²  = 0%). In three studies that compared CC with CC plus N-acetyl cysteine (NAC), EMT was lower in the CC group (340 women, 300 cycles; WMD, -1.51; 95% CI, -1.98 to -1.04; I²  = 45%). In two studies that compared CC with CC + nitric oxide (NO) donor, EMT was lower in the CC group (120 women, 304 cycles; WMD, -1.75; 95% CI, -2.08 to -1.41; I²  = 0%). Compared with CC plus NO donor or NAC, CC showed statistically significant lower ovulation and pregnancy rates. Compared with tamoxifen in three studies, CC showed a tendency towards lower EMT (571 women, 844 cycles; WMD, -1.34; 95% CI, -2.70 to 0.01; I²  = 96%) with comparable ovulation and pregnancy rates.

CONCLUSIONS

In women with WHO group II ovulatory disorders, ovulation induction with CC might result in lower EMT than other ovulation induction regimens. Whether the lower EMT caused the lower pregnancy and live birth rates remains to be elucidated. Letrozole seems to be beneficial for these women. However, our findings should be interpreted with caution as the quality of evidence was very low. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

A study of some factors affecting the dissolution rate enhancement of sulfamethoxazole by crystallization in aqueous surfactant solutions

Effects of crystallization of poorly water soluble sulfamethoxazole in aqueous surfactants solutions on its in vitro dissolution rates were investigated. Marked enhancement was observed. Infrared spectra studies on the prepared crystals indicated polymorphic changes. Some factors affecting the dissolution rate enhancement of crystals prepared in the presence of surfactant namely, the type of the dissolution apparatus, the method of preparation, the type of surfactant, the concentration of surfactant, and washing and soaking of the crystals, were studied. The results of the different effects and possible mechanisms involved are discussed.

Serum levels of procaine in human after peri-oral injections

Doses of procaine for dental purposes have been assessed previously as a result of studies of circulating blood levels of procaine after injection of the drug at body sites other than the mouth. This paper reports results of a study of circulating procaine levels in ten healthy volunteers who received 1.8 ml injections of 2% procaine hydrochloride at a defined peri-oral site. General dental practice conditions were simulated as closely as possible. In addition, procaine pharmacokinetics following peri-oral administration were studied. The serum concentration-time data were found to obey the one-compartment open model adequately with first-order absorption and elimination rates.

Factorial design of experiment for stability studies in the development of a tablet formulation

The stability of chlorpromazine hydrochloride in some hypothetical tablet formulations was evaluated through a fractional factorial design of the type N = 2(6-3). The factors studied were the type of filler (X1), lubricant (X2), binder (X3), disintegrant (X4), the absence or presence of light ( X5 ) and/or humidity ( X6 ). Statistical analysis of the stability data allowed the derivation of a regression equation which determined the magnitude and direction of change of each factor level to optimize drug stability. The significance of the factors could be arranged in the following order: X5 greater than X2 greater than X3 greater than X6 greater than X1. The effects of X4 and the two-factor interaction X2X3 were found to be insignificant. The best multi-component excipient mixture was evaluated on the basis of the information deduced from the factorial design.

Effect of some selected salts and non-ionic surfactants on the antimicrobial activity of nalidixic acid

The effect of different concentrations of some selected salts, namely, sodium chloride, potassium chloride, ammonium chloride, monosodium dihydrogen phosphate, calcium chloride, dibasic sodium phosphate, sodium sulphate, aluminium chloride and sodium citrate on the antimicrobial activity of nalidixic acid was investigated. It was found that all the salts tested, except aluminium chloride and sodium citrate, exert no antimicrobial activity. The effect of 10% non-ionic surface active agents, namely, Myrj 51, 52, 59, Brij 35, 58, 98, Tween 20, 40, 60, and 80 on the antimicrobial activity of nalidixic acid was studied. The results indicated that the activity of nalidixic acid was decreased in the presence of these surfactants. Furthermore, the effect of different concentrations of sodium chloride on the antimicrobial activity of nalidixic acid-surfactants systems was reported.

Evaluation of marketed and formulated furosemide tablets

Five commercial brands of furosemide tablets were evaluated using the official and non-official tests of U.S.P. XIX. These tests include: uniformity of weight, hardness, friability and disintegration time. The results obtained showed that most of these brands failed to attain the U.S.P. requirements. The inclusion of different surface active agents in some of the new suggested formulae was proposed for improving the poor properties of such commercial furosemide tablets. In addition to the above quality control tests, dissolution rate studies of the new formulated tablets were carried out. The addition of 11.4% dioctyl sodium sulphosuccinate increased the dissolution rate up to 48.5% after 60 min. On the other hand, the same concentration of sodium lauryl sulphate caused complete tablet dissolution within 45 min. The effect of a higher concentration of sodium lauryl sulphate on the dissolution rate of furosemide has also been examined.

Comparative dissolution rate studies of commercial furosemide tablets

Five commercial brands of furosemide tablets from different manufacturers, namely, S, F, Ls, L and Fr were elected for this study. The dissolution rate studies of these brands demonstrated vast differences in drug release characteristics. Only two batches of Fr and one batch of F brands fulfilled the U.S.P. dissolution test, while the other failed to meet the requirements of this test. The dissolution rate studies of different batches the same commercial brand showed a larger interlot variation within certain brands. These interlot variations were by far smaller than the dissolution rate differences between the different brands. Studies on the drug content for each furosemide brand showed a great variation between the brands and also within the different batches of the same brand.

Rapid and micro high-pressure liquid chromatographic determination of chloramphenicol in plasma

A high-pressure liquid chromatographic method was developed for chloramphenicol in plasma. Plasma samples were deproteinized with 2.5 volumes of acetonitrile, and the supernates were chromatographed on a reversed-phase column, using acidified ethanol-water as the mobile phase and UV spectrophotometry for detection. The sensitivity for accurate quantitation of chloramphenicol was about 2.5 microgram/ml in plasma, and concentrations as low as 0.5 microgram/ml could be detected. Only about 8 min is needed for each sample. This method is specific, rapid, and sufficiently sensitive and may be useful for clinical monitoring.

Rapid and micro high-pressure liquid chromatographic method for simultaneous determination of procainamide and N-acetylprocainamide in plasma

A rapid and simple high-pressure liquid chromatographic method was developed for the simultaneous determination of plasma levels of procainamide and its major metabolite, N-acetonitrile, and the supernate was chromatographed on a cation-exchange column. The assay can be carried out on as little as 20 microliter of plasma and requires only about 7 min for each sample. No interference was found in plasma samples from cardiac patients receiving procainamide. This method is simple, fast, and useful for routine therapeutic monitoring and for pharmacokinetic studies procainamide and its metabolite.

Simple and rapid high-pressure liquid chromatographic simultaneous determination of aspirin, salicylic acid, and salicyluric acid in plasma

A rapid and sensitive high-pressure liquid chromatographic assay was developed for aspirin, salicylic acid, and salicyluric acid in plasma. The procedure involves the solvent extraction of these compounds from plasma and separation using a reversed-phase column eluted by acidified aqueous acetonitrile. Small quantitites of aspirin can be assayed directly in the presence of a large quantity of salicylic acid. The assay is also free from blank interference.

High-performance liquid-chromatographic determination theophylline in plasma

A high-performance liquid-chromatographic method is reported for monitoring theophylline in plasma. Samples are deproteinized with 2.5 volumes of acetonitrile and the supernates chromatographed on a reversed-phase column. Absorption at 275 nm is monitored. One can accurately measure 1.5 mg of theophylline per liter, in as little as 10 microliter of plasma, and only about 7 min is required per sample. No interference was found in plasma samples from asthmatic patients. This method is particularly useful for routine therapeutic monitoring of both pediatric and adult patients.

Simple, rapid and micro high-pressure liquid chromatographic determination of endogenous "true" creatinine in plasma, serum, and urine

Previously published methods for endogenous creatinine levels in plasma, serum, or urine lack specificity or are subject to interferences from endogenous or exogenous substances. The developed simple, rapid, and specific high-pressure liquid chromatographic method includes the novel deproteinization and extraction of 1 volume of plasma or serum with 2.5 volumes of acetonitrile and also of 1 volume of urine with 40 volumes of a 20% water-80% acetonitrile solution. An aliquot of the supernate is then injected directly into the chromatograph. A cation-exchange column and acidified (0.02% of 85% phosphoric acid) 0.1 M ammonium phosphate solution as the mobile phase, with a flow rate of 2 ml/min, were used. Creatinine, with a retention time of 3.8 min, was monitored via its UV absorption at 215 nm. Both peak heigh and integrated area methods of quantitation yielded the same results. Several methods were employed to show that the "suspected" creatinine peak from plasma samples was due entirely to the "true" creatinine. No interference was found in samples obtained from normal and renal patients. The day-to-day variation in the detector response was small. Each assay requires only about 5 min for completion. Ten microliters of plasma or serum or 1 microliter of urine is sufficient for analysis.

High-performance liquid-chromatographic determination theophylline in plasma

A high-performance liquid-chromatographic method is reported for monitoring theophylline in plasma. Samples are deproteinized with 2.5 volumes of acetonitrile and the supernates chromatographed on a reversed-phase column. Absorption at 275 nm is monitored. One can accurately measure 1.5 mg of theophylline per liter, in as little as 10 microliter of plasma, and only about 7 min is required per sample. No interference was found in plasma samples from asthmatic patients. This method is particularly useful for routine therapeutic monitoring of both pediatric and adult patients.

High-pressure liquid-chromatographic method for determination of gentamicin in plasma

A rapid, specific method for measuring gentamicin in plasma by high-pressure liquid chromatography was developed. After deproteinization, gentamicin in the supernate was dansylated and extracted into ethyl acetate. The organic extract was chromatographed on a microparticulate reversed-phase column, which was eluted with aqueous acetonitrile. Use of the dansyl derivative enables fluorometry, for more sensitive quantitation. Various factors that could affect the assay sensitivity were investigated. With 0.2-ml plasma samples, the method can accurately measure as little as 1 mg of gentamicin per liter. We encountered no interferences from plasma supplemented with various drugs or plasma of patients who were on therapy with other drugs. This method can also separate gentamicin C1 from C1a and C2, all of which are present in various ratios in commercial dosage forms. This method is also applicable to gentamicin determination in urine.

High pressure liquid chromatographic determination of sulfisoxazole in plasma

A high pressure liquid chromatographic method for the separation and quantitative determination of sulfisoxazole in plasma was developed. Plasma samples were vortex-mixed with acetonitrile and centrifuged to obtain clear supernatant solutions. The supernate was chromatographed on a reverse phase column using acidified aqueous ethanol as mobile phase to effect separation. The separated components were detected by UV absorption at 280 nm and the peak height measurement was used for quantitative determination. This assay is simple and rapid. Each assay takes less than 8 minutes to complete and can be carried out on as little as 10 microliter plasma samples to accurately measure 2.0 microgram/ml of sulfisoxazole in plasma. This method can be used for an efficient monitoring of sulfisoxazole in plasma during the chemotherapy of bacterial infections, and also for the bioavailability study of the drug from dosage forms.

High-pressure liquid-chromatographic method for determination of gentamicin in plasma

A rapid, specific method for measuring gentamicin in plasma by high-pressure liquid chromatography was developed. After deproteinization, gentamicin in the supernate was dansylated and extracted into ethyl acetate. The organic extract was chromatographed on a microparticulate reversed-phase column, which was eluted with aqueous acetonitrile. Use of the dansyl derivative enables fluorometry, for more sensitive quantitation. Various factors that could affect the assay sensitivity were investigated. With 0.2-ml plasma samples, the method can accurately measure as little as 1 mg of gentamicin per liter. We encountered no interferences from plasma supplemented with various drugs or plasma of patients who were on therapy with other drugs. This method can also separate gentamicin C1 from C1a and C2, all of which are present in various ratios in commercial dosage forms. This method is also applicable to gentamicin determination in urine.