Recombinant or urinary follicle-stimulating hormone? A cost-effectiveness analysis derived by particularizing the number needed to treat from a published meta-analysis

Objective: To demonstrate that particularizing pooled results of a meta-analysis can derive incremental cost effectiveness of superovulation with recombinant follicle-stimulating hormones (rFSH) vs. the highly purified urinary form (uFSH) for assisted conception.

Design: A retrospective study.

Setting: An assisted conception unit in the United Kingdom.

Patient(s): One hundred forty-five fresh in vitro fertilization (IVF) and 58 fresh intracytoplasmic sperm injection (ICSI) cycles.

Intervention(s): rFSH vs. uFSH.

Main Outcome Measure(s): Incremental cost-effectiveness (i.e., cost needed to treat, or CNT) and budget-impact analyses of rFSH vs. uFSH.

Result(s): In women less than 30 years old, the clinical pregnancy rate was 37.7% (95% CI 24.8%–52.1%), the particularized number needed to treat (pNNT) was −19, and the cost needed to treat was £5070.51 (£3660.53 to £7619.32). For the 30- to 35-year-old age group, the clinical pregnancy rate was 29.9% (95% CI 20.0%–41.4%), the particularized number needed to treat was −24, and CNT was £7335.59 (£5284.11 to £10,941.22). For the 36- to 40-year-old age group, the clinical pregnancy rate was 30.6.0% (95% CI 19.6%–43.7%), the particularized number needed to treat was −23.0, and the CNT was £8569.67 (£5998.70 to £13,413.24).

Conclusion(s): The CNT and thus the budget impact analyses (the extra number of cycles that can be funded by the CNT) both increase directly with age of the patient, and inversely with the clinical pregnancy rate.     

Laparoscopic management of adnexal masses: a gold standard?

PURPOSE OF REVIEW: To review recent literature on the laparoscopic management of adnexal masses, when this approach may be considered as a gold standard. RECENT FINDINGS: Cyst rupture was recently demonstrated to be a significant prognostic factor in stage I invasive epithelial carcinoma, and it was recommended to restrict the laparoscopic approach to patients with preoperative evidence that the cyst was benign. The laparoscopic approach is still highly controversial in masses suspicious at ultrasound. The limits of the laparoscopic approach are discussed reviewing recent literature and our experience. The laparoscopic management of adnexal masses appears to be safe in most hospitals even in developing countries. This approach is being used with increasing frequency in unusual indications such as newborns, children, adolescents and pregnant women. The learning curve for endoscopic surgery appears to be longer than expected. Many patients with benign adnexal masses, such as ovarian endometrioma, are still treated by laparotomy or with an inadequate endoscopic technique. Several studies have suggested that the stripping technique is a tissue-sparing procedure. SUMMARY: The laparoscopic puncture of malignant ovarian tumours confined to the ovaries is uncommon, and should be avoided whenever possible. The teaching of endoscopy is essential to promote adequate procedures performed according to the principles of microsurgery and to preserve postoperative ovarian physiology.     

Hysteroscopic myomectomy using bipolar energy: a gold standard?

In recent years, hysteroscopic resection has become the treatment of choice for submucous fibroids. Technological advances enabled the use of bipolar resectoscopes, in the same way as new bipolar instruments used in laparoscopy or open surgery. Bipolar systems would be expected to eliminate the risks of hyponatremia and electrical burns. In evaluation studies, bipolar energy used in operative hysteroscopy is as effective in comparison with the unipolar system. However, no clinical study has yet shown increased reliability of bipolar resection to consider their use as a gold standard. Outpatient operative hysteroscopy is now developing rapidly with the introduction of bipolar energy and small-diameter endoscopes. Although the financial impact is unknown, It allows time saving with maximal safety, avoiding cervical dilatation and anesthetic procedures.     

What is the gold standard for intrapartum fetal monitoring?

The health authorities of Stockholm county recently published a Health Technology Assessment report: "Fetal monitoring with computerized STAN analysis during labor - a systematic review" with the aim to ensure that high quality research information on costs, effectiveness and broader impact of health technologies is analysed and presented in the most efficient way for those who use, manage and work in this field. The report claims to analyse available research in relation to ST interval analysis of fetal electrocardiogram (STAN) and concludes that scientific evidence for advantages of the STAN technology for maternal and fetal outcome was insufficient and that clinical use cannot be recommended and should be restricted to research protocols. The Norwegian reference group for fetal surveillance points out that the report suffers from two insufficiencies: selection bias by not providing a complete collection of the evidence for the clinical performance of the STAN technology and, secondly, that it does not provide evidence-based alternative methods.     

Recombinant follicle-stimulating hormone (follitropin alfa) for ovulation induction in Japanese patients with anti-estrogen-ineffective oligo- or anovulatory infertility: results of a phase II dose–response study

Purpose  

To determine the optimal regimen of recombinant human follicle-stimulating hormone (r-hFSH) for ovulation induction (OI) in Japanese women with amenorrhea I or anovulatory infertility.     

First-trimester screening for aneuploidy: research or standard of care?

First-trimester screening for Down syndrome has been proposed as a significant improvement with respect to second-trimester serum screening programs, the current standard of care, because of apparently higher detection rates and an earlier gestational age at diagnosis. First-trimester nuchal translucency on ultrasonography forms the basis of this new form of screening, although studies of its efficacy have yielded widely conflicting results, with detection rates ranging from 29% to 91%. Studies of first-trimester serum screening with measurements of pregnancy-associated plasma protein A and free beta-human chorionic gonadotropin serum concentrations have been much more consistent, with Down syndrome detection rates of 55% to 63% at a 5% false-positive rate. The combination of first-trimester ultrasonographic and serum screening has the potential to yield a Down syndrome detection rate of 80% at a 5% false-positive rate, although this approach has not been adequately studied. There have been no studies performed to date to directly compare the performance of first-trimester and second-trimester methods of screening. Two major trials are underway that will address this issue, one in the United Kingdom and one in the United States. Until the results of these trials are available, the current standard of care with respect to Down syndrome screening should not be changed, and first-trimester screening should remain investigational.     

Second cycle: to hatch or not to hatch?

The objective of this study was to assess the impact of assisted hatching (AH) on pregnancy rate (PR), clinical pregnancy rate (CPR), and implantation rate (IR) after a single failed, fresh, nondonor IVF cycle. Accordingly, we report that patients with one prior implantation failure benefit from AH with improved PR, CPR, and IR in a subsequent cycle.     

Pediatrician attendance at cesarean delivery: necessary or not?

OBJECTIVE: To determine whether it is necessary for a pediatrician to attend all cesarean deliveries. METHODS: We analyzed a database of 17,867 consecutive deliveries to determine the rates of low Apgar scores in the following three groups of patients: those with vaginal delivery, cesarean delivery using regional anesthesia without fetal indication, and cesarean delivery for fetal indications or using general anesthesia. RESULTS: There was a significantly higher rate of low Apgar scores in the fetal indications or general anesthesia group when compared with vaginal deliveries. Specifically, 35 (5.8%) of 596 cesareans for fetal heart rate abnormality or using general anesthesia had 1-minute Apgars under 4 in contrast to 115 of 10,270 (1.1%) of vaginal deliveries. There was no significantly increased risk for low Apgar scores in the group of cesareans using regional anesthesia for nonfetal indications (33 of 2057, 1.6%). Results were similar for Apgar scores under 7 at 5 minutes. CONCLUSION: Because there is no higher incidence of low Apgar scores in cesarean deliveries using regional anesthesia for nonfetal indications compared with vaginal deliveries, there is no convincing need for pediatrician attendance at such deliveries.     

Prader-Willi and Klinefelter syndrome: a coincidence or not?

Prader-Willi syndrome is a complex multisystem disorder characterized by neonatal hypotonia, developmental delay, short stature, obesity, behaviour problems, hypothalamic hypogonadism and characteristic appearance. A number of sex chromosome abnormalities have been reported in children with Prader-Willi syndrome. We report on an infant with a 47, XXY karyotype and Prader-Willi syndrome diagnosed at 2 months of age. He is possibly the youngest to be reported with both Prader-Willi syndrome and Klinefelter syndrome. We have shown that the extra X chromosome causing Klinefelter syndrome is paternal in origin and Prader-Willi syndrome is due to maternal heterodisomy indicating that these two events occurred coincidentally.     

Suspicion for intraabdominal adhesions -- is open laparoscopy the gold standard?

Laparoscopy is used for most surgical procedures in gynaecology. In general complications are rare. However, one of the most critical steps is the initial laparoscopic entry into the peritoneal cavity. According to the literature serious complications occur in approximately 1-2/1 000 cases. Whereas major vascular injuries are mainly recognised immediately, delayed recognition of bowel injuries is frequent. Complication rates of different entry procedures used in gynaecological laparoscopy are similar even in high risk patients (intraperitoneal adhesions, obesity). Utilising an open - instead a closed - entry (either by Veress needle or first trocar) technique or alternativ entry positions are suggested by some authors. This review presents data available in the literature and highlights that open laparoscopy is no gold standard.