Selection and evaluation of empirical research in technology assessment

Intra-uterine insemination versus fallopian tube sperm perfusion for non-tubal infertility

BACKGROUND

Controlled ovarian hyperstimulation (COH) combined with intrauterine insemination (IUI) is commonly offered to couples with subfertility that does not involve the fallopian tubes. Another method is fallopian tube sperm perfusion (FSP). This technique ensures the presence of higher sperm densities in the fallopian tubes at the time of ovulation than does standard IUI. The aim of this review was to determine whether FSP and IUI differ in improving the probability of conception.

OBJECTIVES

To investigate whether pregnancy and live birth outcomes differ between fallopian tube sperm perfusion and intrauterine insemination in the treatment of non-tubal subfertility.

SEARCH STRATEGY

We searched the Menstrual Disorders and Subfertility Group Trials Register (October 2008), MEDLINE (January 1966 to October 2008), and EMBASE (January 1988 to October 2008). Abstracts of the American Society for Reproductive Medicine (1987 to 2008) and European Society for Human Reproduction and Embryology (1987 to 2008) meetings were searched using the same key or text words.

SELECTION CRITERIA

Only truly randomised controlled studies comparing FSP with IUI were included in this review. Couples with non-tubal subfertility who have been trying to conceive for at least one year were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials for inclusion based on the quality of the studies.

MAIN RESULTS

Eight studies involving 595 couples were included in the meta-analysis. Only one study reported the live birth rate and there was no evidence of a difference between FSP and IUI (OR 1.2, 95% CI 0.39 to 3.5). There was no evidence of a difference between FSP and IUI for clinical pregnancy per couple (OR 1.2, 95% CI 0.79 to 1.7). A subgroup analysis which included couples with unexplained subfertility only (n = 239) did not report any difference between FSP and IUI (OR 1.6, 95% CI 0.89 to 2.8).

AUTHORS' CONCLUSIONS

For non-tubal subfertility, the results indicate no clear benefit for FSP over IUI. Therefore the advice offered to subfertile couples regarding the comparative use of FSP versus IUI in the treatment of non-tubal subfertility should reflect this.

Intrauterine insemination versus fallopian tube sperm perfusion for non tubal infertility

BACKGROUND

Controlled ovarian hyperstimulation (COH) together with intrauterine insemination (IUI) is commonly offered to couples with infertility factors not involving the fallopian tubes. Intrauterine insemination gained its popularity because it is simple, non-invasive and cost-effective technique. Another simple non invasive method was introduced called fallopian tube sperm perfusion (FSP). This technique was developed to ensure the presence of higher sperm densities in the fallopian tubes at the time of ovulation than standard IUI provides. Fallopian tube sperm perfusion is based on pressure injection of 4 ml of sperm suspension with attempt of sealing of the cervix to prevent semen reflux. The IUI technique on the other hand is based on intrauterine injection of 0.5 ml of sperm suspension without flushing the tubes. A number of randomised controlled trials have been published comparing the efficacy of FSP with standard IUI. There were considerable variations in the results. The aim of this review was to determine whether outcomes differ between FSP and IUI in improving the probability of conception.

OBJECTIVES

To investigate whether outcomes differ between fallopian tube sperm perfusion and intrauterine insemination in the treatment of non tubal subfertility resulting in pregnancies and live births.

SEARCH STRATEGY

We searched the Menstrual Disorders & Subfertility Group trials register (24 March 2003), MEDLINE (January 1966 to July 2003) and EMBASE (January 1988 to July 2003). Abstracts of the American Society for Reproductive Medicine (1987 to 2003) and European Society for Human Reproduction and Embryology (1987 to 2003) meetings were searched with the same key- or text words.

SELECTION CRITERIA

Only randomised controlled studies comparing fallopian tube sperm perfusion with intrauterine insemination were included in this review. The method of allocation was assessed to determine whether each study was truly randomised or pseudo-randomised. Only first period data of cross-over trials were included for analysis. Couples who have been trying to conceive for at least one year were included but only when the female partner had patent tubes.

DATA COLLECTION AND ANALYSIS

Two independent reviewers (AC and MJ) selected the trials for inclusion based on the quality of the studies.

MAIN RESULTS

Overall six studies involving 474 couples were included in the meta-analysis. Only one study assessed live birth rates (OR 1.17, 95% CI 0.39 3.53). The results for pregnancy rate per couple were statistically significant with FSP showing higher pregnancy rates (OR 1.85, 95% CI 1.23 to 2.79 using the odds ratio with the fixed effect model. To check the results the random effect model was used, which gave a wider confidence interval which crossed the line of no significance (OR 1.76, 95% CI 0.77 to 4.05). As a result, these outcomes should be interpreted with caution. Subgroup analysis revealed that couples suffering from unexplained subfertility benefit from FSP over IUI, resulting in significantly higher pregnancy rates (OR 2.88, 95% CI 1.73 to 4.78). Excluding studies which used the Foley catheter for tubal perfusion resulted in a significant difference favouring FSP for all indications (OR 2.42, 95% CI 1.54 to 3.80).

REVIEWERS' CONCLUSIONS

FSP may be more effective for non-tubal subfertility, but the significant heterogeneity should be taken into account. As a result no advice based on the meta-analysis could be given for the treatment of non-tubal subfertility. Subgroup analysis, which did not show evidence of statistical heterogeneity, suggested that couples with unexplained infertility may benefit from FSP over IUI in terms of higher pregnancy rates. FSP may therefore be advised in couples with unexplained subfertility. Results suggested the possibility of differential effectiveness of FSP depending on catheter choice.

Methodological characteristics and quality of alcohol treatment outcome studies, 1970-98: an expanded evaluation

AIMS

To examine the methodological quality of the research literature examining treatment for alcohol use disorders.

DESIGN

In total, 701 studies first reported between 1970 and 1998 were evaluated with a scoring system covering 19 areas of research quality.

FINDINGS

Methodological quality improved from a score of 8.2 out of a possible 28.5 in the 1970s, to 10.6 in the 1990s. Strengths included reporting the initial number of participants and conducting follow-ups of 12 months or longer. Although the percentage of studies with adequate power also increased overall, the average statistical power of comparative studies to detect a medium-sized treatment effect was low (0.54).

CONCLUSIONS

Areas with room for improvement include: ensuring that follow-up data are collected when respondents are not under the influence of alcohol, testing for differential dropout among treatment groups with respect to participant background characteristics, reporting the number of individuals being treated in the programs from which samples are drawn, noting the reliability and validity of measures used and conducting process analyses to examine potential mechanisms underlying treatment effects.

Methodological approaches of health technology assessment

In this era of evolving health care systems throughout the world, technology remains the substance of health care. Medical informatics comprises a growing contribution to the technologies used in the delivery and management of health care. Diverse, evolving technologies include artificial neural networks, computer-assisted surgery, computer-based patient records, hospital information systems, and more. Decision-makers increasingly demand well-founded information to determine whether or how to develop these technologies, allow them on the market, acquire them, use them, pay for their use, and more. The development and wider use of health technology assessment (HTA) reflects this demand. While HTA offers systematic, well-founded approaches for determining the value of medical informatics technologies, HTA must continue to adapt and refine its methods in response to these evolving technologies. This paper provides a basic overview of HTA principles and methods.

Alcoholism treatment outcome studies, 1980-1992: methodological characteristics and quality

We examine the methodological characteristics and provision of study information in 339 alcoholism treatment outcome studies reported between 1980 and 1992. We consider factors in four methodological domains: sampling and description of patients, specification of treatments, outcome variable assessment and follow-up, and treatment effect estimates; we also consider the methodological quality of the studies. Although methodological quality has improved over time, there remains room for improvement. Of special concern is the low statistical power of many studies. Multiple treatment group studies had an average .54 probability of detecting a treatment effect of medium size.

Biological effects of cosmetic talc

A review of the literature reveals two primary issues: (1) a weak, but not causal, association of hygienic use of cosmetic talc and ovarian cancer; (2) lung changes in animals exposed to talc aerosol concentrations that resulted in lung overload. The evidentiary weight of the most significant of the epidemiological and laboratory studies and their biological significance for human risk assessment are briefly discussed. Publications describing granulomatous lesions attributed to talc on surgical gloves, and consequences of accidental inhalation of baby powder by infants are also reviewed. The literature reviewed does not provide any convincing evidence that pure cosmetic talc, when used as intended, presents a health risk to the human consumer.

Clinical practice guidelines: from methodological to practical issues

The main goal of clinical practice guidelines is to help clinical decision by practitioners, who can not integrate in their daily practice all the published data concerning new technologies and knowledge. Guidelines also have growing applications in the ethical, legal, socio-economic, public policy and health care funding fields. This article describes the various methodologies that have been proposed to develop guidelines. These methods rely to varying degrees on formal methods of analysis of scientific evidence and expert opinions. Then a step by step process is described, that should ensure a rigorous, feasible and explicit guideline development and lead to valid and applicable recommendations. In order for guidelines to be used, they have to be efficiently implemented. Respective efficiency and justification of educational and coercive methods of implementation are discussed.

Technology assessment of anesthesia monitors

This essay argues that optimal utilization of anesthesia monitors requires careful technology assessment. This careful assessment is important because monitors may produce spurious or uninterpretable values, or they may damage patients. In addition, resources should be spent only for truly beneficial devices. The types of evidence that this essay describes for use in technology assessment include questions concerning data reliability, data interpretability, and data outcome. Considerable evidence bearing on technology assessment has already been amassed. I propose synthesizing this evidence by meta-analysis. Additional primary studies of technology assessment are also needed.

Environmental tobacco smoke: current assessment and future directions

Scientific information on environmental tobacco smoke (ETS) is critically reviewed. Key areas addressed are: differences in chemical composition between mainstream smoke, sidestream smoke, and ETS; techniques for measurement of ETS; epidemiology; in vitro and in vivo toxicology; and chamber and field studies of perceptual or physiological effects. Questions concerning estimation of ETS exposure, suitability of various biomarkers, calculation of lifetime dose, control of confounding variables, use of meta-analysis, and the relationship between ETS concentrations and human responses all emphasize the need for additional research in order to assess potential effects of ETS on health or comfort.