The economics of infertility: developing an infertility managed-care plan

The cost of out-patient culdoscopy compared to in-patient laparoscopy in women with infertility

Diagnostic laparoscopy is a common procedure performed in many hospitals worldwide to investigate infertile women. However, morbidity and cost prevent it being considered a first-line diagnostic tool. If out-patient culdoscopy could replace in-patient laparoscopy then a major component of the cost of investigations could be avoided. We studied ten consecutive infertile patients who had laparoscopy under general anaesthesia and another ten patients who had culdoscopy under local anaesthesia in The One Stop Fertility Clinic (OSFC) in The Royal Free Hospital in London. The costs for each patient from both groups was calculated and compared. We found that out-patient investigation in an OSFC produced a saving of over 350 pounds sterling per case or 28% to the hospital compared with in-patient investigation. Although there were other factors which may influence the costs of out-patient culdoscopy, it did provide noticeable savings to the healthcare system.

Minimally invasive exploration of the female reproductive tract in infertility

Classically, invasive and non-invasive tests are performed to evaluate the causes of infertility. Transvaginal hydrolaparoscopy (THL) allows the exploration of the pelvic structures with a mini-endoscope, using a vaginal needle-guided trocar introduction technique and saline as a distension medium. A first study on 349 patients demonstrated the feasibility of the procedure and gave a high patient satisfaction. Access to the pouch of Douglas was achieved in 330 patients (94.5%) under local anaesthesia and in an ambulatory environment. The mean pain score measured on a visual analogue scale of 10 was 2.7, comparable to the score of mini-hysteroscopy only and significantly lower than the scores of hysterosalpingography with either metal cannula or balloon catheter. A total of 96% of the patients agreed to repeat the procedure under the same circumstances if required. The diagnostic accuracy of the technique was demonstrated in a prospective study, in which two independent endoscopists explored 10 patients with both THL and standard laparoscopy. The inter-observer agreement for ovarian adhesions was 75% for standard laparoscopy and 90% for THL. In addition, in patients with mild endometriosis, more peri-ovarian adhesions were detected with THL than with standard laparoscopy. A multinational survey to evaluate the risk and outcome of bowel injury during THL registered 24 (0.65%) cases in 3667 procedures. In all cases, the diagnosis was made immediately and the treatment was conservative without complications.

Investigation of the infertile couple: a one-stop outpatient endoscopy-based approach

Transvaginal hydrolaparoscopy (THL) is a new culdoscopic technique for exploration of the pelvic cavity that takes advantage of micro-endoscopic technology and uses aquaflotation for inspection of the tubo-ovarian structures. In infertility patients, THL is systematically combined with mini-hysteroscopy, chromopertubation, fimbrioscopy and, when indicated, salpingoscopy. Mini-hysteroscopy in combination with the chromopertubation test allows accurate assessment of the uterine cavity and tubal patency. The transvaginal access combined with the aquaflotation during THL facilitates detailed inspection of the tubo-ovarian structures and detection of subtle pelvic disease. This combined transvaginal endoscopic approach allows complete evaluation of the reproductive tract. THL is better tolerated than hysterosalpingography, less invasive than standard laparoscopy, and can be used safely as a first line investigation of the female partner in a one-stop infertility clinic.

Diagnostic and operative transvaginal hydrolaparoscopy for infertility and pelvic pain

STUDY OBJECTIVE

To review our experience with diagnostic and operative transvaginal hydrolaparoscopy (THL), a procedure that is less invasive than operative laparoscopy.

DESIGN

Prospective, observational cohort study (Canadian Task Force classification II-2).

SETTING

Private institute and university-affiliated hospital.

PATIENTS

Twenty-nine women with infertility and 11 with pelvic pain.

INTERVENTIONS

Diagnostic and operative THL.

MEASUREMENTS AND MAIN RESULTS

Thirty-five (88%) diagnostic THLs were performed in the office and the other five were done in hospital for insurance reasons; all six operative THLs were performed in the office under conscious sedation. The procedure was conclusive (all organs seen) in 37 patients (93%). Based on THL, no further surgical intervention was recommended in 18 (62%) infertile women and 5 (45%) of those with pain. Further surgical intervention was required in 5 (56%) of 9 infertility patients with a previous normal hysterosalpingogram (HSG) and 6 (32%) of 19 infertility patients with no previous HSG.

CONCLUSION

Transvaginal hydrolaparoscopy can be performed in the office with minimal pain, with a conclusive examination anticipated in 93% of cases. The procedure is more accurate than HSG and similar to laparoscopy.

Office hydrolaparoscopy for the diagnosis of endometriosis and tubal infertility

Transvaginal hydrolaparoscopy has been described as an office procedure that is particularly suitable for the diagnosis of endometriosis and adhesions. It is recommended as a first line procedure in patients with infertility. The procedure is performed under local anaesthesia or sedation in an office setting. The abdominal distension is achieved by transvaginal instillation of warm saline using a combined Veress needle-trocar system. The exploration under fluid allows the inspection of the tubo-ovarian structures in their natural position and the easy identification of endometriotic lesions and adhesions in the posterior pelvis. The limitation of the inspection to the posterior pelvis is not a major problem for the diagnosis of endometriosis because exclusively anterior pelvis endometriosis is rare and of doubtful significance in infertility. Transvaginal hydrolaparoscopy can be performed in the office setting in combination with minihysteroscopy, tubal patency test and salpingoscopy, offering major advantages for the diagnosis of pelvic disease in patients with infertility.

Initial evaluation and treatment of infertility in a primary-care setting

Infertility is a condition that primary-care physicians frequently encounter. The infertility work-up necessitates an understanding of the physiology and anatomy of the female and male partners. A systematic work-up can be initiated by a primary-care physician. Infertility problems are stressful for the couple, and initial assessment by their own physician may help them work through the process as well as prepare them if they need to seek the care of a reproductive endocrinologist for further assessment or for assisted reproductive techniques. Infertility services are expensive and are rarely completely covered by many health insurance plans; therefore, a cost-effective evaluation is important. In the managed-care environment, a primary-care physician can begin the investigation and decide which patients require more advanced assessment and treatment. Helping a couple through the stages of an infertility investigation is a professionally rewarding experience.

Coculture of human embryos with buffalo rat liver cells for women with decreased prognosis in in vitro fertilization

OBJECTIVE

The coculture of human embryos with epithelial cells may improve both embryo quality and pregnancy rates. In this current study we tested the efficacy of coculture with the buffalo rat liver cell line on pregnancy rates in women with a potentially poor prognosis for success with in vitro fertilization (previous in vitro fertilization failure, advanced maternal age, increased early follicular follicle-stimulating hormone levels, and anovulation).

STUDY DESIGN

This prospective controlled study evaluated a total of 203 women (135 coculture, 68 controls) undergoing in vitro fertilization. Implantation rates per embryo, clinical pregnancy rates, and continuing/delivered pregnancy rates were analyzed.

RESULTS

Buffalo rat liver cells, which are commercially available, are stable in coculture. Implantation rates (number of sacs with fetal heart motion per embryos transferred) were similar for coculture (19%) and control (18%) embryos. No difference in the rate of continuing/delivered pregnancies per retrieval was noted (17% coculture vs 14% control) in the group with advanced maternal age, but coculture caused a trend toward improved pregnancy rates in the group with ovulatory dysfunction (43% coculture vs 14% control) and the group with previous in vitro fertilization failure (34% coculture vs 28% control).

CONCLUSION

This is the first published controlled study to our knowledge that reports the use of the buffalo rat liver cell coculture for human in vitro fertilization in a large number of patients. Our data support consideration of buffalo rat liver coculture for in vitro fertilization for women with previous in vitro fertilization failure and possibly for patients with oocyte or ovulatory dysfunction.