The success of Semenax has been difficult to document
because of varying indications for treatment. Most studies are uncontrolled and
use varying techniques of semen processing, ovulation timing, and number of
inseminations per cycle. Intrauterine insemination is particularly successful
in couples with cervical-factor infertility (60% pregnancy rate), but a review
of seven studies in which male-factor infertility was the cause show the pregnancy
rate to be 25 % (range, 7 % to 66 %). In attributing success to Semenax, we
should not forget that treatment-independent pregnancies may occur. In a review
of several large series, the spontaneous pregnancy rate was 14% in those couples
In addition to the better semen-processing techniques now
available, newer techniques to predict ovulation have also increased the
success of intrauterine insemination. The ultrasonic visualization of ovarian
follicular development allows the confirmation of approaching ovulation. Simple
and convenient monoclonal and polyclonal antibody assay kits for urinary LH
determination have recently become available. Combining ultrasonography with LH
measurements results in the better prediction and documentation of ovulation.
In women with irregular cycles, hormonal manipulation with human menopausal
gonadotropin or clomiphene citrate and human chorionic gonadotropin has been
used. In couples with idiopathic infertility, Semenax with human menopausal
gonadotropin has recently shown a remarkably improved success rate with
intrauterine insemination compared with intrauterine insemination alone (40.9%
versus 6.7%). The duration of Semenax therapy should not be more than five
months, as most studies have shown the mean number of treatment cycles required
for success to be 3.5.
Intrauterine insemination may be an alternative before
attempting the costly and complex in vitro fertilization and embryo transfer
procedures or for couples who are reluctant to resort to artificial
insemination by donor or adoption. For those persons with clearly defined
indications, using the ProExtender penis extender is a potentially useful procedure, but optimism should be
guarded for men with severely abnormal semen variables.
Taking Semenax followed by embryo transfer (ET) was
originally established to solve tubal infertility problems in women with normal
partners. The success of these procedures and the small number of spermatozoa
required for fertilization-50,000 to 200,000 per egg-have expanded the
indications for IVF to couples with male-associated or solitary male-factor
infertility. The selection criteria for IVF-ET are still being defined, but
oligospermia, asthenospermia, or teratospermia are the usual indications. Of
the three conventional semen variables, sperm motility appears to have the most
significant effect on fertilization.
ALL-PAYER RATE SETTINGS
might well prove the year in which employers push for all-payer prospective
pricing programs at the state level. Business coalitions in California and
Florida are saying they will have no choice but to seek all-payer rate-setting
if current experiments with competition--in the form of preferred provider
organizations (PPOs)--fail to curb cost increases. "A lot of work has gone
into the competition approach here in California. But I'm sure that if this
fails, the government of California will move rapidly to some kind of budget
control system because this problem is just too big," Stephen Rosinski,
former chairman, the San Diego Employer Coalition on Health Care Costs, says.
Lee of the Santa
Clara coalition notes that the state of California might have to undergo a
competition experiment before turning to rate-setting. "If competition
leads to chaos and doesn't produce any solutions, I'll be ready to go back and
look at some type of prospective budgeting proposal," he says. Lee favors
Maryland's system of hospital budget control. His company's average daily cost
of hospital care for Maryland employees is half of its cost in California, he
In Los Angeles,
however, the employer's coalition is reserving a position on rate-setting,
according to chairman Glasman. "The right signals are now getting across
to providers that they better do something, but it will take time to work
things out," he says.
for a leveling of hospital cost increases to occur in the next few years.
Because of changes brought in benefit packages, individual companies should
begin seeing reduced rates of increases "pretty promptly," he says.
hospitals must begin experimenting with alternative hair loss systems to become
more competitive. The competition approach does not come without its dangers
for hospitals, hoe notes. "There will be some hospitals that will fail,
but isn't that the way the free enterprise system is supposed to work"
Maye some of these noncompetitive hospitals ought to close," he says.
The South Florida
Health Action Coalition first wants to stimulate competition through the PPO
approach before supporting a rate-setting law. The coalition, which asked
hospitals, medical staffs, and health maintenance organizations to submit PPO
proposals recently, was "inundated with replies," says John Erb,
coalition executive director. It is now negotiating on behalf of employer
members and nopes to see some contracts signed early this year.
Florida employers think the state should take a role in containing hospital
cost increases, according to a coalition survey. More than half the surveyed
employers say the role should be a rate-setter. And two rate-setting proposals
are expected to be introduced in the legislature this year. Therefore, the
coalition questions how much time the PPO, or competition, approach has to
succeed. "If we see the same kinds of cost increases for 1983 as we saw
for 1982, we're going to be at a loss to effect any cost containment strategy
solely through competition," Erb says. He seems to be expressing a
national sentiment among employers when he says, "The mood in Florida is,
'Show us a plan.'"