Sleep duration and weight loss among overweight/obese women enrolled in a behavioral weight loss program.

OBJECTIVE: The purpose of this study was to examine whether baseline sleep duration predicts weight loss outcomes in a randomized controlled trial examining a behavioral weight loss (BWL) intervention among overweight and obese (OW/OB) women with urinary incontinence; and whether participation in the BWL intervention is associated with changes in sleep duration. DESIGN: Longitudinal, clinical intervention study of a 6-month BWL program. SUBJECTS: Three hundred sixteen OW/OB women, with urinary incontinence (age: 30-81 years, body mass index (BMI; 25-50 kg m(-2)) enrolled from July 2004-April 2006. MEASUREMENTS: Measured height and weight, self-report measures of demographics, sleep and physical activity. RESULTS: Neither self-reported total sleep time (TST) nor time in bed (TIB) at baseline significantly predicted weight loss outcomes among OW/OB women in a BWL treatment. BWL treatment was successful regardless of how much subjects reported sleeping at baseline, with an average weight loss of 8.19 kg for OW/OB women receiving BWL treatment, versus a weight loss of 1.44 kg in the control condition. Similarly, changes in weight, BMI and incontinence episodes did not significantly predict changes in sleep duration or TIB across the treatment period. CONCLUSION: Although epidemiological and cross-sectional studies support a relationship between short sleep and increased BMI, the present study found no significant relationship between TST or TIB and weight loss for OW/OB women participating in a BWL treatment.

A motivation-focused weight loss maintenance program is an effective alternative to a skill-based approach.

OBJECTIVE: Maintaining weight loss is a major challenge in obesity treatment. Individuals often indicate that waning motivation prompts cessation of effective weight management behaviors. Therefore, a novel weight loss maintenance program that specifically targets motivational factors was evaluated. DESIGN: Overweight women (N=338; 19% African American) with urinary incontinence were randomized to lifestyle obesity treatment or control and followed for 18 months. All participants in lifestyle (N=226) received the same initial 6-month group behavioral obesity treatment and were then randomized to (1) a novel motivation-focused maintenance program (N=113) or (2) a standard skill-based maintenance approach (N=113). MAIN OUTCOME MEASURE: Weight assessed at baseline, 6 and 18 months. RESULTS: Both treatment groups (motivation-focused and skill-based) achieved comparable 18-month weight losses (-5.48% for motivation-focused vs -5.55% in skill-based, P=0.98), and both groups lost significantly more than controls (-1.51%; P=0.0012 in motivation-focused and P=0.0021 in skill-based). CONCLUSIONS: A motivation-focused maintenance program offers an alternative, effective approach to weight maintenance expanding available evidence-based interventions beyond traditional skill-based programs.

Pelvic floor disorders and quality of life in women with self-reported irritable bowel syndrome.

BACKGROUND: Quality of life among women with irritable bowel syndrome may be affected by pelvic floor disorders. AIM: To assess the association of self-reported irritable bowel syndrome with urinary incontinence, pelvic organ prolapse, sexual function and quality of life. METHODS: We analysed data from the Reproductive Risks for Incontinence Study at Kaiser Permanente, a random population-based study of 2109 racially diverse women (mean age = 56). Multivariate analyses assessed the association of irritable bowel syndrome with pelvic floor disorders and quality of life. RESULTS: The prevalence of irritable bowel syndrome was 9.7% (n = 204). Women with irritable bowel had higher adjusted odds of reporting symptomatic pelvic organ prolapse (OR 2.4; 95% CI, 1.4-4.1) and urinary urgency (OR 1.4; 95% CI, 1.0-1.9); greater bother from pelvic organ prolapse (OR 4.3; 95% CI, 1.5-11.9) and faecal incontinence (OR 2.0; 95% CI, 1.3-3.2); greater lifestyle impact from urinary incontinence (OR 2.2; 95% CI, 1.3-3.8); and worse quality of life (P < 0.01). Women with irritable bowel reported more inability to relax and enjoy sexual activity (OR 1.8; 95% CI, 1.3-2.6) and lower ratings for sexual satisfaction (OR 1.8; 95% CI, 1.3-2.5), but no difference in sexual frequency, interest or ability to have an orgasm. CONCLUSIONS: Women with irritable bowel are more likely to report symptomatic pelvic organ prolapse and sexual dysfunction, and report lower quality of life.

Effects of urinary incontinence, comorbidity and race on quality of life outcomes in women.

PURPOSE: We investigated the effects of comorbidity and urinary incontinence on both generic and incontinence specific quality of life outcome measures, and investigated whether the association between urinary incontinence and quality of life varies by race. MATERIALS AND METHODS: Study participants were 2,109 women 40 to 69 years old randomly selected from an urban health maintenance organization and interviewed in person for a study of risk factors for urinary incontinence. The sample was racially diverse consisting of 48% white, 18% black, 17% Hispanic and 16% Asian-American women. In addition to incontinence, reproductive and medical history questionnaires, all participants completed the Medical Outcomes Study Short Form 36, a measure of health related quality of life. All participants with daily and weekly incontinence (29%) completed the Incontinence Impact Questionnaire, an incontinence specific quality of life measure. The health maintenance organization's inpatient and outpatient electronic databases were used to calculate a Charlson comorbidity index score for each participant. ANCOVA was used to produce a model adjusting for sociodemographic variables, comorbidity and incontinence frequency. The same model was run for each of 4 racial groupings to examine differences by race/ethnicity. RESULTS: Urinary incontinence is significantly associated with a decreased quality of life and those with more frequent incontinence have significantly lower quality of life scores. In our model the Charlson score, an objective measure of comorbidity based on hospital and physician records, also has a significant negative impact on quality of life. When comorbidity is controlled, incontinence frequency continues to have a significant negative association with quality of life except among the sickest women. For women with the greatest extent of comorbidity, incontinence frequency is not significantly associated with negative quality of life outcomes. We did not find clear patterns of variation by race. CONCLUSIONS: Urinary incontinence and comorbidity each have an independent and significant role in reducing quality of life outcomes for all but the sickest women.

Urinary incontinence and pelvic floor dysfunction in Asian-American women.

OBJECTIVE: The objective of the study was to describe the prevalence, risk factors, and impact of urinary incontinence and other pelvic floor disorders among Asian-American women. STUDY DESIGN: This was a population-based cohort study of older women randomly selected from age and race strata. RESULTS: Weekly urinary incontinence was reported by 65 of 345 Asian women (18%), with stress and urge incontinence being approximately equally common. In multivariate analysis, higher body mass index (greater than 25 kg/m2) was associated with both stress incontinence (odds ratio 4.90, 95% confidence interval 1.76 to 13.68) and urge incontinence (odds ratio 2.49, 95% confidence interval 1.01 to 6.16) in Asians. Hysterectomy was a significant risk factor for stress incontinence (odds ratio 2.79, 95% confidence interval 1.03 to 7.54). Only 34% of Asian women with weekly urinary incontinence reported ever having sought treatment. Pelvic floor exercises were the most common form of treatment, being used by 29% of Asian women with weekly incontinence. Asians were less likely then white women to report anal incontinence (21% versus 29%, P = .007), although this difference became nonsignificant after adjusting for differences in risk factors. CONCLUSION: Asian women share some risk factors for stress and urge urinary incontinence with white women. Urinary incontinence is associated with anal incontinence among Asian women.

Does weight loss improve incontinence in moderately obese women?

The aim of this study was to evaluate the effect of weight reduction on urinary incontinence in moderately obese women. This prospective cohort study enrolled moderately obese women experiencing four or more incontinence episodes per week. BMI and a 7-day urinary diary were collected at baseline and on the completion of weight reduction. The study included 10 women with a mean (+/-SD) baseline BMI of 38.3 (+/-10.1) kg/m2 and 13 (+/-10) incontinent episodes per week. Participants had a mean BMI reduction of 5.3 (+/-6.2) kg/ m2 (P < 0.03). Among women achieving a weight loss of > or = 5%, 6/6 had > or = 50% reduction in incontinence frequency compared to 1 in 4 women with < 5% weight loss (P < 0.03). Incontinence episodes decreased to 8 (+/-10) per week following weight reduction (P < 0.07). The study demonstrated an association between weight reduction and improved urinary incontinence. Weight reduction should be considered for moderately obese women as part of non-surgical therapy for incontinence.

Cost of pelvic organ prolapse surgery in the United States.

OBJECTIVE: To estimate the annual direct cost to society of pelvic organ prolapse operations in the United States. METHODS: We multiplied the number of pelvic organ prolapse operations identified in the 1997 National Hospital Discharge Survey by national average Medicare reimbursement for physician services and hospitalizations. Although this reimbursement does not estimate the actual cost, it is a proxy for cost, which estimates what society pays for the procedures. RESULTS: In 1997, direct costs of pelvic organ prolapse surgery were 1012 million dollars (95% confidence interval [CI] 775 dollars, 1251 million), including 494 dollars million (49%) for vaginal hysterectomy, 279 million dollars (28%) for cystocele and rectocele repair, and 135 million dollars (13%) for abdominal hysterectomy. Physician services accounted for 29% (298 million dollars) of total costs, and hospitalization accounted for 71% (714 million dollars). Twenty-one percent of pelvic organ prolapse operations included urinary incontinence procedures (218 million dollars). If all operations were reimbursed by non-Medicare sources, the annual estimated cost would increase by 52% to 1543 million dollars. CONCLUSION: The annual direct costs of operations for pelvic organ prolapse are substantial.

Annual direct cost of urinary incontinence.

OBJECTIVE: To estimate the annual direct cost of urinary incontinence in 1995 US dollars. METHODS: Epidemiologically based models using diagnostic and treatment algorithms from published clinical practice guidelines and current disease prevalence data were used to estimate direct costs of urinary incontinence. Prevalence and event probability estimates were obtained from literature sources, national data sets, small surveys, and expert opinion. Average national Medicare reimbursement was used to estimate costs, which were determined separately by gender, age group, and type of incontinence. Sensitivity analyses were performed on all variables. RESULTS: The annual direct cost of urinary incontinence in the United States (in 1995 dollars) was estimated as $16.3 billion, including $12.4 billion (76%) for women and $3.8 billion (24%) for men. Costs for community-dwelling women ($8.6 billion, 69% of costs for women) were greater than for institutionalized women ($3.8 billion, 31%). Costs for women over 65 years of age were more than twice the costs for those under 65 years ($7.6 and $3.6 billion, respectively). The largest cost category was routine care (70% of costs for women), followed by nursing home admissions (14%), treatment (9%), complications (6%), and diagnosis and evaluations (1%). Costs were most sensitive to changes in incontinence prevalence, routine care costs, and institutionalization rates and costs. CONCLUSION: Urinary incontinence is a very costly condition, with annual expenditures similar to other chronic diseases in women.

Measuring cost-effectiveness of surgical procedures.

Our review of CEA of surgical procedures suggests that much of the existing cost analysis literature does not adhere to basic recommended analytic guidelines. However, those authors who specifically planned to perform a CEA analysis met all or nearly all of the methodologic principles (Table 1). Investigators who conduct CEA are strongly encouraged to use the many outstanding methodologic reviews for CEA. An example of threshold analysis was presented by Gray et al in their CEA of laparoscopy versus laparotomy for the treatment of ectopic pregnancy. They calculated that cost per successful treatment would be equal between the two strategies at an initial failure rate of 32% for laparoscopy (compared with their baseline value of 19%). This type of analysis is helpful, in addition to sensitivity analyses, to identify the value of a variable that results in an equal outcome. In the only cost-utility analysis performed on gynecologic surgery, Sculpher studied the trade-offs between a less invasive, less costly procedure (transcervical resection of the endometrium) with a more invasive, more costly, and more effective procedure (abdominal hysterectomy) to treat menorrhagia. Hysterectomy resulted in an incremental cost of 1,500 British pounds per QALY during 2 years of follow-up. This is much less than the range of $30,000 to $100,000 that represents a currently acceptable C/E ratio. Grover et al evaluated the cost-effectiveness of performing a concurrent hysterectomy in women undergoing bilateral salpingo-oophorectomy. They observed that in 45-year-old women, the additional concurrent procedure dominated the alternative strategy of bilateral salpingo-oophorectomy, being both less expensive and increasing average life expectancy. The concurrent hysterectomy strategy also dominated for women aged 55, but both with less cost-savings and gains in life expectancy compared with 45-year-old women. Selecting an appropriate time frame for the analysis is difficult and may dramatically affect the results of the analysis. The time frame should be long enough to measure all clinically relevant costs and benefits. For example, Kung et al compared the cost per cure of stress urinary incontinence of laparoscopic and open Burch procedures. The probability of cure after each procedure was estimated from a retrospective cohort of 62 women with a mean follow-up of 1.2 years for the laparoscopic Burch strategy and 2.7 years in the open Burch strategy. The authors found that the laparoscopic Burch dominated, with lower costs and a higher cure rate. However, the analysis would be more informative with much longer follow-up, because most women who undergo an incontinence procedure have a life expectancy far greater than 1 to 2 years. Ramsey et al performed an economic analysis to assess the long-term costs of behavioral therapy, pharmacotherapy, and surgical therapy used for stress urinary incontinence. They found that in the short-term, behavioral and pharmacotherapy were less costly. However, if life expectancy was equal to or greater than 3.5 years, surgical therapy was least costly. In many articles that evaluate the cost of managing ectopic pregnancy, only short-term costs of the procedures and follow-up visits are considered. Mol et al considered a longer time frame and also included the costs of infertility management based on the future probability of conception correlated with the different management strategies. Selection of an effectiveness measure after surgical intervention is often difficult and controversial. For benign disease, life years or QALYs will be minimally affected by a reasonably safe intervention. In the short-term, utility may be negatively affected by surgery and recovery. In longer-term analyses, these effects will be diluted by time and be negligible. Intermediate measures such as days of hospitalization averted or lives saved are often more appropriate for gynecologic interventions than are longer-term outcomes such as lif

Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities.

CONTEXT: Postmenopausal vaginal bleeding is a common clinical problem. Endovaginal ultrasound (EVUS) is a noninvasive diagnostic test that may help determine which women should undergo endometrial biopsy. OBJECTIVE: To determine the accuracy of EVUS in detecting endometrial disease in postmenopausal women with vaginal bleeding according to hormone replacement use. DATA SOURCES: Literature search of English-language and non-English-language articles published from 1966 through November 1996 using MEDLINE and by a manual search of bibliographies of published articles. STUDY SELECTION: Studies were included if they prospectively collected EVUS measurements of endometrial thickness prior to obtaining endometrial tissue for histologic evaluation in postmenopausal women with vaginal bleeding. Of 85 studies that included data on EVUS and endometrial histology, 35 were included in the meta-analysis and included 5892 women. DATA EXTRACTION: Articles were reviewed and independently selected and abstracted by 2 reviewers. Disagreement was resolved by consensus. DATA SYNTHESIS: The overall summary mean weighted estimates of sensitivity and specificity were calculated for thresholds of endometrial thickness from 3 to 10 mm. Using a 5-mm threshold to define abnormal endometrial thickening, 96% (95% confidence interval [CI], 94%-98%) of women with cancer had an abnormal EVUS result, whereas 92% (95% CI, 90%-93%) of women with endometrial disease (cancer, polyp, or atypical hyperplasia) had an abnormal result. This did not vary by hormone replacement use. However, the number of women with normal histology who had an abnormal EVUS result did vary by hormone replacement use. In women who were not using hormone replacement therapy, 593 (8%) with normal histological findings had an abnormal EVUS result (specificity, 92%; 95% CI, 90%-94%), whereas 1544 (23%) using hormone replacement therapy had an abnormal EVUS result (specificity, 77%; 95% CI, 75%-79%). For a postmenopausal woman with vaginal bleeding with a 10% pretest probability of endometrial cancer, her probability of cancer is 1% following a normal EVUS result. CONCLUSION: Endovaginal ultrasound has a high sensitivity for detecting endometrial cancer and other endometrial disease and can reliably identify postmenopausal women with vaginal bleeding who are highly unlikely to have significant endometrial disease so that endometrial sampling may be unnecessary.

Preoperative staging of cervical carcinoma: phased array coil fast spin-echo versus body coil spin-echo T2-weighted MR imaging.

OBJECTIVE: This study was performed to compare the diagnostic efficacy of MR imaging in the preoperative evaluation of invasive cervical cancer using the pelvic phased array coil in combination with fast spin-echo T2-weighted imaging and the body coil in combination with conventional spin-echo T2-weighted imaging. MATERIALS AND METHODS: Ninety-four women (22-68 years old) with invasive cervical cancer underwent MR imaging (at 1.5 T) using a body coil conventional spin-echo protocol (n = 62) or a phased array coil fast spin-echo protocol (n = 32). Imaging preceded surgery by no more than 5 weeks. MR images were evaluated for tumor size, local stage, and nodal metastasis using surgical pathology as the standard of reference. RESULTS: Overall staging accuracy for the body coil conventional spin-echo protocol (89%) was not significantly different from that of the phased array coil fast spin-echo protocol (91%). Both techniques also achieved similar accuracy in diagnosing parametrial invasion (95% versus 94%) and lymph node metastases (85% versus 91%) and in tumor sizing (correlation coefficient, .93 versus .94). CONCLUSION: In the preoperative staging of cervical carcinoma by MR imaging, both the newer (phased array coil fast spin-echo protocol) and the older (body coil conventional spin-echo protocol) techniques achieved similarly high accuracies in local staging, assessment of parametrial invasion, and evaluation of tumor size. Decreased imaging time and increased image resolution are advantages of the newer technique, although in our series they did not increase staging accuracy.

Hormone replacement therapy and the risk of epithelial ovarian carcinoma: a meta-analysis.

OBJECTIVE: To determine if use of postmenopausal hormone replacement therapy (HRT) increases the risk of invasive epithelial ovarian carcinoma. DATA SOURCES: English-language articles published from January 1966 to June 1997 examining HRT and ovarian cancer were found by using MEDLINE, searching the bibliographies of relevant articles and by consulting experts. STUDY SELECTION: Of 327 articles identified, nine provided data on the risk of invasive cancer among ever-users of HRT and were selected for inclusion by consensus of two independent reviewers. Studies were included if cases were age-matched to controls or results were age-adjusted and if women with bilateral salpingo-oophorectomy were excluded. TABULATION, INTEGRATION, AND RESULTS: Two independent unblinded reviewers abstracted data regarding risk of developing epithelial ovarian carcinoma and use of HRT. A general variance-based, fixed-effects model was used to calculate summary relative risks. Ever-use of HRT was associated with an increased risk of developing invasive epithelial ovarian carcinoma (odds ratio [OR] 1.15; 95% confidence interval [CI] 1.05, 1.27). Use of HRT for more than 10 years was associated with the greatest risk of ovarian cancer (OR 1.27; 95% CI 1.00, 1.61). CONCLUSION: Prolonged use of hormone therapy by postmenopausal women may be associated with an increased risk of developing epithelial carcinoma of the ovary.

Urge incontinence: the patient's perspective.

Urge incontinence has a profound effect on the day-to-day lives of women. The purpose of this study was to identify specific aspects of functioning and well-being affected by urge incontinence or mixed incontinence with a primary urge component. We conducted six focus groups of 65 racially and age diverse, community-dwelling women with urge incontinence. Transcripts of the focus groups were quantitatively analyzed for word use frequency with QSR NUD*IST software. Demographics, symptomatology, and the impact of incontinence on daily activities and feelings were assessed by questionnaire. Participants in the focus groups were on average 62 years of age; 52% were nonwhite, and 26% had a high school or less education. In the three identified broad domains, 52% of domain-related words were associated with feelings, 40% with activities, and 8% with relationships. Frequently identified references were bathroom availability (24%), loss of control (14%), anxiety (11%), and sleep disturbance (10%). Women under the age of 70 compared with older women more commonly identified feeling unattractive and low self-esteem (12% versus 2%, p < 0.007) and adverse effects on dating and sexual activity (45% versus 0%, p < 0.02). The effect of incontinence on quality of life correlated with frequency, nocturia, and pad use (Kendall's tau beta 0.02-0.32, p < 0.05). Urge incontinence affects many quality of life issues and contributes to limitation of activities, loss of control, and negative self-perception. Focus groups of diverse women with urge incontinence symptomatology are useful in understanding these effects.

Radiological evaluation of lymph node metastases in patients with cervical cancer. A meta-analysis.

OBJECTIVE: To apply meta-analysis to compare the utility of lymphangiography (LAG), computed tomography (CT), and magnetic resonance (MR) imaging for the diagnosis of lymph node metastasis in patients with cervical cancer. DATA SOURCES: MEDLINE literature search and manual reviews of article bibliographies. STUDY SELECTION: Studies selected included at least 20 patients with imaging-histologic correlation, described diagnostic criteria for lymph node metastasis, and presented data to allow calculation of contingency tables. DATA EXTRACTION: Independently by 2 investigators, stratified for stage of disease (early vs late) and for lymph node location (pelvic vs para-aortic). DATA SYNTHESIS: Seventeen studies met the inclusion criteria for LAG, 17 for CT, and 10 for MR imaging. Summary receiver operator characteristic analysis showed no significant differences in the overall performance of LAG, CT, and MR imaging. There was, however, a trend toward better performance for MR imaging than for LAG or CT, both globally and when stratified for stage of disease or for lymph node location. Bayesian analysis of clinical utility showed only moderate increases in positive posttest probability of lymph node metastasis for all methods. Negative test results had a greater impact and, depending on the clinical setting, decreased the probability of lymph node metastasis from 15% to 44% (pretest) to 3% to 18% (posttest). CONCLUSIONS: The LAG, CT, and MR imaging perform similarly in the detection of lymph node metastasis from cervical cancer. As CT and MR imaging are less invasive than LAG and also assess local tumor extent, they should be considered the preferred adjuncts to clinical evaluation of invasive cervical cancer.

Comparison of diagnostic studies in the pretreatment evaluation of stage Ib carcinoma of the cervix.

The results of our study highlight the need for change in the pretreatment workup of clinical stage Ib cervical cancer. The routine use of excretory urography, barium enema, cystoscopy,and sigmoidoscopy is not justified. MR evaluation is recommended in patients with lesions larger than 2 cm (the group with the greatest increase in predictive value). Although CT scanning is not recommended for the evaluation of parametrial invasion, both CT scanning and MR imaging provide similar positive and negative posttest probabilities for the evaluation of nodal disease.

Invasive cervical carcinoma: role of MR imaging in pretreatment work-up--cost minimization and diagnostic efficacy analysis.

PURPOSE: To examine the cost and efficacy of diagnostic work-up in patients with invasive cervical cancer. MATERIALS AND METHODS: In 246 patients with invasive cervical cancer, all diagnostic tests performed before treatment were recorded. Patients were divided into two groups: those who underwent magnetic resonance (MR) imaging as the initial study (n = 105) and those who did not (n = 141). A list of 1995 Medicare global payments was used to measure cost. Bayesian analysis (likelihood ratios derived from a literature search) was performed for bladder, rectal, parameterial, and nodal involvement in stage Ib disease. RESULTS: Significantly fewer procedures and fewer invasive studies were performed in the MR imaging group. Net cost savings for the MR imaging group was $401 for all patients and $449 for patients with stage Ib disease. For stage Ib disease, the 0% pretest probability of bladder or rectal invasion does not justify the routine use of barium enema examination, cystoscopy, or proctoscopy. The increase in predictive values for parameterial and nodal disease was highest for MR imaging when tumor size was at least 2 cm. CONCLUSION: Guidelines for the pretreatment work-up of clinical stage Ib cervical cancer need revision. MR imaging should be used as an adjunct to clinical evaluation.

Cervical carcinoma: computed tomography and magnetic resonance imaging for preoperative staging.

OBJECTIVE: To assess the accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of invasive cervical cancer. METHODS: Seventy-nine women with untreated cervical cancer underwent pre-treatment MRI (n = 71) and/or CT (n = 37) within 4 weeks of surgical evaluation. Twenty-nine women had both MRI and CT. Images were evaluated for tumor detection, size, stromal invasion, local extension, and nodal metastases. RESULTS: Tumor size was evaluated accurately by MRI, with a correlation coefficient of 0.93. Magnetic resonance estimates of tumor size were within 0.5 cm of the surgical sample in 64 of 69 women (93%). Magnetic resonance was 88% accurate evaluating the presence of stromal invasion and 78% accurate for depth of stromal invasion. Computed tomography could not evaluate tumor size or stromal invasion because it could not distinguish cancer from the surrounding normal cervical tissue. In evaluating stage of disease, MRI had an accuracy of 90%, compared with 65% for CT (P < .005). Magnetic resonance imaging was more accurate than CT (94 versus 76%, P < .005) in assessing parametrial invasion. Both modalities were comparable in evaluating lymph node metastases (86% each). In determining operative candidates (stage I and minimal IIA), MRI was 94% accurate, compared with 76% for CT (P < .005). CONCLUSION: Compared with CT, MRI offered significantly improved evaluation of tumor size, stromal invasion, and local and regional extent of disease in pre-treatment imaging for cervical cancer.

Therapeutic donor insemination: a prospective randomized trial of fresh versus frozen sperm.

OBJECTIVE: We evaluated the efficacy of fresh versus frozen sperm in therapeutic donor insemination. STUDY DESIGN: Fifty-seven women underwent 72 courses of treatment (a maximum of six therapeutic donor insemination cycles--three fresh and three frozen) totaling 198 cycles. Each woman served as her own control and was prospectively randomized to receive a single, timed insemination of either fresh or frozen sperm. RESULTS: Fecundity was 20.6% for fresh sperm cycles and 9.4% for frozen (p less than 0.03, by chi 2 analysis). Fresh cervical cap insemination fecundity was 20.3%; frozen was 7.8% (p less than 0.03, by chi 2 analysis). Fresh intrauterine insemination fecundity was 21.2%; frozen was 15.8% (p = 0.63, by chi 2 analysis). Fresh 3-month life-table pregnancy rates were 48% +/- 10%; frozen rates were 22% +/- 8% (p = 0.05 by Breslow analysis). Survival analysis with fixed covariates showed a positive association with the use of fresh sperm (p = 0.04). CONCLUSION: Cycle fecundity was significantly greater with fresh sperm in women undergoing cervical cap insemination or intrauterine insemination and in women undergoing only cervical cap insemination. These results have important implications for contemporary management of patients undergoing therapeutic donor insemination with frozen sperm.

Comparison of CO2 laser laparoscopy with laparotomy for treatment of endometriomata.

OBJECTIVE: To assess the effectiveness of laparoscopy versus laparotomy in the treatment of endometriomata. DESIGN: Controlled study using data prospectively tabulated. SETTING: Treatment performed by senior author in a referral reproductive endocrinology and surgery private practice. PATIENTS: One hundred infertile women were diagnosed with endometriomata. INTERVENTION: Forty-eight women were treated with CO2 laser laparoscopy (laparoscopy group) and 52 women were treated with CO2 laser or nonlaser laparotomy (laparotomy group). MAIN OUTCOME MEASURE: The hypothesis that laparoscopy group pregnancy rates (PRs) would be equal to or greater than laparotomy group was formulated before data analysis but after data tabulation. RESULTS: The 1 and 3-year life table estimated cumulative PRs +/- SE were 0.30 +/- 0.07 and 0.52 +/- 0.09 for laparoscopy group and 0.23 +/- 0.06 and 0.46 +/- 0.09 for laparotomy group (Breslow P = 0.48). Monthly fecundity over 3 years was 2.4% for laparoscopy group and 2.0% for laparotomy group. CONCLUSIONS: Laparoscopy with CO2 laser can be a safe and effective modality for treating endometriomata.

Failure of intrauterine insemination in a refractory infertility population.

Intrauterine insemination by itself for multiple and/or severe infertility factors had no benefit over cervical cap with whole ejaculate or coitus in this study. The PRs for IUI and cervical cap with whole ejaculate or coitus were similar and low, suggesting that IUI by itself has limited, if any, utility in enhancing PRs in this type of infertility population. Couples attempting IUI should be advised about the low probability of achieving pregnancy. Ovulation stimulation and/or heterologous donor insemination, IVF, or gamete intrafallopian transfer may be beneficial therapeutic options.