Laparoscopy in women with unexplained infertility: a cost-effectiveness analysis

Cost-effectiveness of second curettage for treatment of low-risk non-metastatic gestational trophoblastic neoplasia

OBJECTIVE

Low-risk non-metastatic gestational trophoblastic neoplasia (GTN) has been treated with single agent chemotherapy, but second curettage is emerging as an alternative strategy with reported cure rates of 40%. We sought to estimate the cost-effectiveness of second curettage as the first line treatment of low-risk GTN.

METHODS

A decision-analytic model was created using TreeAge software to compare costs and outcomes for women with WHO staged low-risk GTN undergoing treatment with 5-day methotrexate (MTX), biweekly pulsed actinomycin-D, or second curettage. Probabilities were derived from the literature. Outcomes of interest included side effects from chemotherapy, need for additional agents, hemorrhage, uterine perforation, and cure rates. Utilities were applied to discounted life expectancy at a rate of 3% to generate quality adjusted life years (QALYs). Sensitivity analyses were then performed in order to assess the robustness of our assumptions.

RESULTS

Of the three treatment arms, MTX was associated with the lowest cost and had similar QALYs to the other studied modalities. Second curettage was associated with 49 additional cures when applied to a theoretic cohort of 1000 women, as well as an additional 83 hemorrhages and 17 uterine perforations. Sensitivity analysis on the cure rate of second curettage revealed that second curettage was not cost-effective over MTX unless its probability of cure was 98%.

CONCLUSION

Our study found 5-day MTX was the cost-effective strategy for treatment of women with low-risk, non-metastatic GTN when compared to second curettage and actinomycin-D. In a carefully selected patient population, second curettage may be an additional treatment strategy.

Fertiloscopy in women with unexplained infertility: Long-term cumulative pregnancy rate

OBJECTIVE

Fertiloscopy is as safe as laparoscopy in literature, but we don't know its relevance in women with unexplained infertility (UI). Our objective was to assess the effects of fertiloscopy procedures on the outcomes of subsequent pregnancy occurrences in patients with UI.

METHODS

Retrospective, single-center study of all patients followed up after fertiloscopy procedures between 2002 and 2007. The occurrence and outcome of pregnancies were studied in the five years following the procedure.

RESULTS

124 fertiloscopies were performed. Pelvic exploration was considered as sufficient in 83.8% of cases, of which no abnormalities were found in 78.2%. Laparoconversions occurred for 19 patients (16.5%). The pregnancy rate at five years was 76.9%. The mean delay for pregnancy occurrence was 10.7 months (±17).

CONCLUSION

The pregnancy rate in our study is similar to that after laparoscopy. Fertiloscopy, a less intrusive procedure, should be considered as a reliable option for the management of patients with UI.

[First line management without IVF of infertility related to endometriosis: Result of medical therapy? Results of ovarian superovulation? Results of intrauterine insemination? CNGOF-HAS Endometriosis Guidelines]

INTRODUCTION

Using the structured methodology of French guidelines (HAS-CNGOF), the aim of this chapter was to formulate good practice points (GPP), in relation to optimal non-ART management of endometriosis related to infertility, based on the best available evidence in the literature.

MATERIALS AND METHODS

This guideline was produced by a group of experts in the field including a thorough systematic search of the literature (from January 1980 to March 2017). Were included only women with endometriosis related to infertility. For each recommendation, a grade (A-D, where A is the highest quality) was assigned based on the strength of the supporting evidence.

RESULTS

Management of endometriosis related to infertility should be multidisciplinary and take account into the pain, the global evaluation of infertile couple and the different phenotypes of endometriotic lesions (good practice point). Hormonal treatment for suppression of ovarian function should not prescribe to improve fertility (grade A). After laproscopy for endometriosis related to infertility, the Endometriosis Fertility Index should be used to counsel patients regarding duration of conventional treatments before undergoing ART (grade C). After laparoscopy surgery for infertile women with AFS/ASRM stage I/II endometriosis or superficial peritoneal endometriosis, controlled ovarian stimulation with or without intrauterine insemination could be used to enhance non-ART pregnancy rate (grade C). Gonadotrophins should be the first line therapy for the stimulation (grade B). The number of cycles before referring ART should not exceed up to 6 cycles (good practice point). No recommendation can be performed for non-ART management of deep infiltrating endometriosis or endometrioma, as suitable evidence is lacking.

DISCUSSION AND CONCLUSION

Non-ART management is a possible option for the management of endometriosis related to infertility. Endometriosis Fertilty Index could be a useful tool for subsequent postoperative fertility management. Controlled ovarian stimulation can be proposed.

Quality indicators for all dimensions of infertility care quality: consensus between professionals and patients

STUDY QUESTION

What is the relative importance of the six dimensions of quality of care according to different stakeholders and can a quality indicator set address all six quality dimensions and incorporate the views from professionals working in different disciplines and from patients?

SUMMARY ANSWER

Safety, effectiveness and patient centeredness were the most important quality dimensions. All six quality dimensions can be assessed with a set of 24 quality indicators, which is face valid and acceptable according to both professionals from different disciplines and patients.

WHAT IS KNOWN ALREADY

To our knowledge, no study has weighted the relative importance of all quality dimensions to infertility care. Additionally, there are very few infertility care-specific quality indicators and no quality indicator set covers all six quality dimensions and incorporated the views of professionals and patients.

STUDY DESIGN, SIZE AND DURATION

A three-round iterative Delphi survey including patients and professionals from four different fields, conducted in two European countries over the course of 2011 and 2012.

PARTICIPANTS/MATERIALS, SETTINGS AND METHODS

Dutch and Belgian gynaecologists, embryologists, counsellors, nurses/midwifes and patients took part (n = 43 in round 1 and finally 30 in round 3). Respondents ranked the six quality dimensions twice for importance and their agreement was evaluated. Furthermore, in round 1, respondents gave suggestions, which were subsequently uniformly formulated as quality indicators. In rounds 2 and 3, respondents rated the quality indicators for preparedness to measure and for importance (relation to quality and prioritization for benchmarking). Providing feedback allowed selecting indicators based on consensus between stakeholder groups. Measurable indicators, important to all stakeholder groups, were selected for each quality dimension.

MAIN RESULTS

All stakeholder groups and most individuals agreed that safety, effectiveness and patient centeredness were the most important quality dimensions. A total of 498 suggestions led to the development of 298 indicators. Professionals were sufficiently prepared to measure 204 of these indicators. Based on importance, 52 (7-15 per dimension; round 2) and finally 24 (4 per dimension; round 3) quality indicators were selected.

LIMITATIONS, REASONS FOR CAUTION

The final quality indicator set does not cover the entire care process, but rather takes a 'sample' of each quality dimension. Although the quality indicators are face valid and acceptable, their psychometric characteristics need to be tested by further research.

WIDER IMPLICATIONS OF THE FINDINGS

Quality management should focus on safety, effectiveness and patient centeredness of care. Clinics can use the quality indicator set to assess all quality dimensions of their care.

Use of laparoscopy in unexplained infertility

OBJECTIVE

The use of laparoscopy in unexplained infertility work-up is still a subject of debate, although laparoscopy remains the gold standard for diagnosis and treatment of several pelvic pathologies. The objective of this study was to assess the rates and types of pelvic pathologies observed during diagnostic laparoscopy, and the pregnancy rate in couples with unexplained infertility following laparoscopy.

STUDY DESIGN

Prospective study, from November 2003 to October 2009, including 114 infertile, spontaneously ovulating women with normal clinical examination, ovarian reserve assessment, pelvic ultrasound scan and patent tubes on hysterosalpingography. Semen analyses were normal according to the World Health Organization criteria. After three cycles of ovulation induction with or without intra-uterine insemination and no pregnancy, women were referred for diagnostic laparoscopy.

RESULTS

Laparoscopy revealed pelvic pathology in 95 patients. Endometriosis, pelvic adhesions and tubal disease were observed and treated in 72, 46 and 24 patients, respectively. Following laparoscopy, bilateral and unilateral tubal patencies were observed in 107 and five patients, respectively. Pregnancy was observed in 77 out of 102 patients who tried to conceive after surgery, 35 of whom conceived using their own tubes.

CONCLUSION

Diagnostic laparoscopy should be strongly considered in unexplained infertility work-up, and tubal efficiency should not be underestimated.

Role of laparohysteroscopy in women with normal pelvic imaging and failed ovulation stimulation with intrauterine insemination

CONTEXT:

Women with primary infertility and no obvious pelvic pathology on clinical evaluation and imaging are either treated empirically or further investigated by laparoscopy.

AIMS:

The role of diagnostic laparoscopy in women who fail to conceive after empirical treatment with ovulation induction and intrauterine insemination was evaluated.

SETTINGS AND DESIGN:

Retrospective study at a private infertility center.

MATERIALS AND METHODS:

A study of patients who underwent diagnostic laparoscopy between 1^st January 2001 and 31^st December 2008 was performed. Those patients who had no detectable pathology based on history, physical examination, and ultrasound and had treatment for three or more cycles in the form of ovulation induction and IUI were included in the study. Moderate and severe male factor infertility and history of any previous surgery were exclusion criteria.

STATISTICAL ANALYSIS USED:

Data were statistically analyzed using Statistics Package for Social Sciences (ver. 16.0; SPSS Inc., Chicago).

RESULTS:

Of the 127 women who underwent diagnostic laparoscopy and hysteroscopy, 87.4% (n = 111) of patients had positive findings. Significant pelvic pathology (moderate endometriosis, pelvic inflammatory disease, and tubal pathology) was seen in 26.8% of cases.

CONCLUSION:

One in four women had significant pelvic pathology where treatment could possibly improve future fertility. Diagnostic laparoscopy has a role in infertile women with no obvious abnormality before they proceed to more aggressive treatments.

Long-term cumulative pregnancy rate in women with unexplained infertility after laparoscopic surgery followed by in vitro fertilization or in vitro fertilization alone

AIMS

Laparoscopy has been performed in women with unexplained infertility, but the recent trend is to commence in vitro fertilization (IVF) without prior laparoscopy. The aim of this study was to determine whether or not laparoscopic surgery is necessary for these patients.

MATERIAL & METHODS

With a diagnosis of unexplained infertility, 51 women underwent laparoscopic surgery followed by IVF (laparoscopy group) and 41 women underwent IVF without prior laparoscopy (IVF group). We reviewed these two groups retrospectively and evaluated the cumulative pregnancy rate.

RESULTS

In the laparoscopy group, 16 of the 51 women became pregnant spontaneously soon after surgery. Twenty-three patients became pregnant with IVF. In the IVF group, 32 patients became pregnant with IVF. Two of the 41 women became pregnant spontaneously while waiting to commence IVF.

CONCLUSION

Laparoscopy should be offered as an option for younger patients who desire spontaneous pregnancy because there was no significant difference of the cumulative pregnancy rate between the groups.