Chlorinated hydrocarbon content of fetal and maternal body tissues and fluids in full term pregnant women: a comparison of Germany versus Tanzania

Chlorinated hydrocarbons are distributed worldwide and due to their lipophilic properties and chemical stability they accumulate in the foodchain. The concentrations of 19 different chlorinated hydrocarbons (hexachlorohexane (HCH), DDT and various metabolites and nine different polychlorinated phenyl (PCB) congeners were detected in various body tissues and fluids (maternal and fetal serum, adipose tissue, placenta, amniotic fluid) of full term pregnant women from Germany and Tanzania. Great variation of total toxin burden and toxin distribution within the different body compartments was found. This was in part due to local differences of exposure to some of the chlorinated hydrocarbons. Comparing samples from Germany and Tanzania, typical distribution patterns reflected the specific economic situation of the two countries with a high burden of insecticides (DDT and Dieldrin) in the agricultural country and high levels of constituents of industrial products (hexachlorobenzene (HCB) and PCBs) in Germany. Different chlorinated hydrocarbons seem to show different distribution patterns in body tissues, probably due to their chemical structure, the lipid content of the compartment and the overall toxin burden of the individual. A 10 to 100 fold accumulation of chlorinated hydrocarbons was observed in maternal adipose tissue compared with the other compartments. The concentrations of certain toxins in fetal cord serum and placenta were higher than in maternal serum.

Indications for in-vitro fertilization and results

During the last few years, many healthy children have been born after in vitro fertilization and embryo transfer, fulfilling the wish for a child for many couples who had often nearly given up hope. Because of in vitro fertilization and other related methods developed subsequently (gamete intra-Fallopian transfer, intratubal embryo transfer), progress in the diagnosis and treatment of involuntary childlessness took place and has helped many patients. Furthermore, by dealing with these methods, new knowledge about ovarian function, fertilization and early embryonic development could be gained. This has also led to better treatment of childless couples. Despite the broad diagnostic and therapeutic possibilities of reproductive medicine, its limits must also be taken into account. These limitations have been recognized early by physicians and scientists dealing with this subject and also by society. Guidelines and laws have been drawn up which now give a clear framework.

The effect of 17 alpha-hydroxyprogesterone caproate/oestradiol valerate on the development and outcome of early pregnancies following in vitro fertilization and embryo transfer: a prospective and randomized controlled trial

A prospective and randomized study was performed to investigate the effect of supportive hormones on the development and outcome of early pregnancies following in vitro fertilization and embryo transfer. Immediately after pregnancies were confirmed endocrinologically on day 15 after oocyte collection, 17 alpha-hydroxyprogesterone caproate and oestradiol valerate (PC/EV) was administered to half of the patients in a randomly controlled trial. One group received supportive treatment until the twelfth week of gestation, whereas the other group received no treatment at all. Both groups were followed up by measurements of serum levels of human chorionic gonadotrophin (HCG), oestradiol and progesterone every three days until day 35, when a first ultrasound examination was carried out to confirm fetal vitality. Subsequently, pregnancies were monitored sonographically at regular intervals. In cases of miscarriage, dilatation and curettage was performed and histology analysed. A total of 120 pregnant patients entered the study: 55 of them received hormone treatment and 65 patients were controls. Within the treatment group 48 (89%) clinically ongoing pregnancies were observed, five (9%) miscarriages occurred after the seventh week of gestation and one preclinical pregnancy was noted. In the control group, 38 (59%) ongoing pregnancies were observed, nine (14%) miscarriages occurred and 17 (27%) preclinical pregnancies were recorded. Two ectopic pregnancies, one in each group, were excluded from evaluation. A significantly higher percentage of pregnancies were intact at 7 weeks of gestation after treatment with PC/EV (p less than or equal to 0.01).

Cryopreservation of rabbit zygotes

Rabbit embryos at the pronuclear stage (n = 480) were frozen using a mixture of propanediol and sucrose. The survival rate was 71% according to their morphological features shortly after thawing. The viability rate after 5 days of culture was 10% according to the number of embryos that reached the blastocyst stage, while the rate of formation of blastocysts from freshly collected and cultured pronuclear embryos was higher (59%). The implantation rate was higher (24%) if the frozen/thawed zygotes were directly transferred to foster mothers after 2-4 hours of culture, whereas with zygotes cultured for 24 hours (4 to 8-cell stages) the implantation rate was poor (4%). Both rates were low compared with the implantation rate (52%) achieved with freshly collected and directly transferred pronucleate embryos.

Indications and outcomes of assisted reproduction

Since 1978 many healthy children have been born after in vitro fertilization and embryo transfer, fulfilling the wishes of many previously childless couples. In vitro fertilization and subsequently developed methods (GIFT, intratubal embryo transfer) have contributed to progress in the diagnosis and treatment of unwanted childlessness. Furthermore these techniques have improved knowledge of ovarian function, fertilization and early embryo development.

[Incidence and type of premenstrual symptoms in relation to experienced infertility: a comparative study]

Using the symptomatological criteria of "Late Luteal Dysphoric Disorder" according to DSM-III-R, the frequency and type of premenstrual symptoms were investigated in a group of 405 infertile women (participants in an in-vitro-fertilisation programme at the University of Bonn) and a control group of 101 female medical students. 84% of both groups of women reported premenstrual psychological and/or physical changes. 52% of the infertile patients and 42% of the students fulfilled the symptomatological criteria of late luteal dysphoric disorder. Comparing both groups, it was found, that infertile women reported significantly more often mood lability, anger/irritability, anxiety/tension and loss of interest.

[Intrauterine pregnancy with uterine myoma after downregulation with GnRH analogs]

GnRH analogues are widely used for the reduction of uterine fibroids. This case report describes the therapy of a 27-year-old woman, whose uterus had a diameter of about 13 cm. After 7 injections of Zoladex Depot (ICI Pharma, Heidelberg, Germany), the uterus was reduced to normal size carrying dorsally a myoma of the same size. After only 7 weeks of medroxyprogesterone acetate (5 mg twice daily, Clinofem, Upjohn, Heppenheim, Germany) the uterus had grown again, so that therapy was changed to Zoladex Depot for another 3 months. On the 27th day of the first spontaneous cycle, the patient ovulated and conceived. Up to the 29th week of gestation (Aug '91), the foetal growth and development was normal, the uterus was normal in size, a childhead sized myoma being situated unproblematically behind the foetus.

Determination of TNF alpha, interferon alpha, interleukin 2 and reactivity in the leucocyte migration inhibition test in breast cancer patients

To date, the results concerning the prognostic importance of parameters of cell-mediated immunity in breast cancer patients are very contradictory; moreover, in most of them the results are hardly comparable due to methodological differences and heterogeneous groups of patients. In 123 patients with nonmetastatic breast carcinoma TNF alpha, INF alpha, IL 2 and reactivity in the leucocyte migration inhibition test (LMI-Test) against autologous tumor tissue were determined and the results correlated with the clinical course of the disease up to a maximum of 108 months. In breast cancer patients TNF alpha-serum levels were significantly (p less than 0.05) elevated compared to healthy controls. We also found that patients with progressive disease had higher levels than patients without recurrences. There were no differences concerning the IL-2 and IFN alpha serum levels between cancer patients and controls, nor did we find a correlation with the clinical course of the disease. In 38% of all breast cancer patients examined, a MIF production against tumor tissue could be demonstrated in the LMI-test. There was no difference concerning the LMI-reactivity between the groups of lymph-node negative and positive patients, but the observation that those patients with an unfavourable clinical course respond more frequently with an enhanced macrophage migration and rarely with migration inhibition was considered of notable prognostic significance. According to these results, it is possible that determination of TNF alpha and delayed type hypersensitivity reaction against tumor tissue in the LMI-test is of clinical value for the determination of risk groups.

Transvaginal intratubal embryo transfer: a new treatment of male infertility

Intratubal embryo transfer is a new method in the treatment of human infertility. Following transvaginal sonographic oocyte retrieval, in-vitro fertilization (IVF) is performed and embryos are transferred into the Fallopian tube transvaginally. In comparison with gamete intra-Fallopian transfer (GIFT), fertilization under in vitro conditions offers the advantage that the success of the fertilization process can be examined. Therefore, this method can give important diagnostic information, especially in cases of poor sperm quality or unexplained infertility. After fertilization in vitro and transfer into the tube, embryonic development occurs in the physiological milieu of the oviduct. Transvaginal intratubal embryo transfer was performed in 95 patients with male factor infertility. In 29 cases (31%), a pregnancy was achieved. One abortion, but no ectopic pregnancy was observed. This method combines the advantages of IVF and GIFT and offers a successful procedure for the treatment of infertility.

Cellular sensitization against sperm and seminal antigens in women

In 13 healthy women and 6 virgins the cellular sensitization against sperm and seminal plasma antigens was demonstrated by an indirect lymphokin assay, the leucocyte migration inhibition test (LMI-test) using the following preparations: "washed" spermatozoa, seminal plasma and spermatozoa of the supernatant prepared with the "swim-up" technique. In both groups of women a cellular sensitization against sperm and seminal plasma antigens could be observed. Further, a dose dependent correlation was found in that way, that increasing concentrations of spermatozoa lead to an increased inhibition of macrophage migration. In virgins cellular sensitization against seminal plasma proteins did not differ from non-virgins, only the percentage of significant reactions in the LMI-Test was reduced. As low sperm concentrations (1 million ml-1), which represent best the physiological situation in the uterus, induced an enhanced migrations of macrophages the enhancement of macrophage migration is considered as physiological cellular sensitization of females against sperm-associated antigens.

Cellular sensitization against spermatic and seminal plasma antigens in women after intrauterine insemination

Using an indirect lymphokine-assay, the leucocyte-migration-inhibition-test (LMI-test), the cellular sensitization of fertile and infertile patients before and after homologous and heterologous intrauterine insemination (IUI) was investigated. In this assay several preparations of spermatozoa ("washed"-, "swim-up"- and "pellet"-spermatozoa) in different concentrations (1, 5 and 10 x 10(6) sperms/ml culture medium) and seminal plasma were tested as antigen. In all investigated groups a cellular immune response against spermatic antigen was demonstrable and seemed to be dose dependent. In contrast to fertile women who reacted with an enhancement of the macrophage migration for low concentrations the same concentration of antigen induced an inhibition of macrophage migration in fertile patients. For high concentrations of spermatic antigens there was a difference in the intensity of cell-mediated immune response between fertile and infertile women. Since infertile patients demonstrated an increased level of cell-mediated immune response it is possible that infertility may be caused by this altered immunological reaction. This response changes after multiple IUI-treatment and that change might be caused by the high concentration of spermatic antigens as there was a difference in the intensity of cell-mediated immune response between fertile and infertile women. Since infertile patients demonstrated an increased level of cell-mediated immune response it is possible that infertility may be caused by this altered immunological reaction. This response changes after multiple IUI-treatment and that change might be caused by the high concentration of spermatozoa. The immunological response of infertile patients seems to be similar in those receiving husband and donor IUI.

[Chemosensitivity studies with soft agar culture systems in ovarian cancer]

Since 1982, chemosensitivity studies have been conducted in our laboratory with 181 tumour samples from 132 woman patients suffering from carcinoma of the ovaries, using the colony test and capillary assays. Colonisation rates were 67% and assay rates between 60 and 47%; in 36 cases the in vitro result was compared with the course of the disease observed in vivo. Whereas in 11 of 12 patients it was possible to correctly assess chemoresistance (in vitro growth inhibition less than or equal to 49%) pretherapeutically, chemosensitivity (growth inhibition greater than or equal to 50%) proved more difficult to confirm, 15 predictions being true and 9 false. To assess the prognostic significance of the test results, survival curves were calculated from the data of 33 patients. With a p-value of 0.49, the courses of disease of "in vitro resistant" and "in vitro sensitive" patients differed only slightly from one another. We can conclude from our experiments, that an important indication for performing the colony test in ovarian carcinoma should always be assumed in patients with a poor prognosis, e.g. in women having a large postoperative residual tumour. If, in such cases, the possibility of chemosensitivity testing via the colony test is considered, this examination may offer the chance of sparing the patient additional strain due to the side effects of a treatment with cytostatics if the latter is most likely to be of no significant use.

Accumulation of pollutants in the genital tract of sterility patients

In order to assess the burden of environmental pollutants in the genital tract, 12 different chlorinated hydrocarbons were determined in 152 samples of follicular, seminal and cervical fluids from sterility patients in the in vitro fertilization programme at the Centre for Obstetrics and Gynaecology of the University of Bonn. The lowest concentrations were found in the follicular fluids of patients who eventually became pregnant by in vitro fertilization. Higher concentrations were found in patients with sterility of unknown origin. Concentrations in the cervical secretion were up to twenty times higher than those in the seminal or follicular fluids. The results show that considerable concentrations of chlorinated hydrocarbons may be present in parts of the reproductive system, and that these compounds accumulate in the reception zone for spermatozoa. Certain pollutants therefore probably contribute to infertility.

Significance of cumulus oophorus in in-vitro fertilization and oocyte viability and fertility

Fertilization and cleavage rates of human cumulus-intact oocytes incubated in vitro for 36-48 h with normal spermatozoa tended to be higher than those which were cumulus-denuded (73 versus 68%; 68 versus 56%, respectively); however, the difference was not significant. Nor were these differences significant when using sperm samples of various qualities (normozoospermic samples: 75 versus 70% fertilized oocytes; asthenozoospermic: 66 versus 64%; oligozoospermic: 64 versus 56%; oligoasthenozoospermic: 35 versus 33%). The beneficial effect of the human cumulus oophorus on the binding of human spermatozoa to denuded hamster oocytes and on head decondensation of human spermatozoa observed after 2 h of incubation (9.3 versus 7.0 bound spermatozoa per oocyte, P less than 0.05; 0.5 versus 0.3 decondensed sperm heads per oocyte, P less than 0.02) disappeared after 6 h. A protective effect of the cumulus oophorus on hamster oocytes preincubated in medium containing 50% human preovulatory follicular fluid was observed in the sperm penetration assay (fertilization rate of cumulus-intact: cumulus-denuded oocytes, 26 versus 13%, P less than 0.05) and confirmed using fluorescein diacetate stain (cumulus-intact oocytes: 86 versus 100% vitality, non-significant; cumulus-denuded oocytes: 64 versus 100%, P less than 0.01). These data suggest the accelerating effect of the human cumulus oophorus on fertilization in its early stages. Furthermore, the cumulus plays an important part in protecting the oocyte against adverse environmental influences.

[Effect of sequential embryo transfer on pregnancy following in vitro fertilization]

In this study, the influence of sequential embryo transfers in an in-vitro fertilisation programme was examined. After in-vitro fertilisation, a maximum of 6 fertilised oocytes were cultured. In cases with more than 6 fertilised oocytes, the rest was cryopreserved in the pronucleus stage. At day 2 after an oocytes retrieval, three embryos with the best morphological appearance were replaced and the remaining embryos (1-3) were cultured for further 3 days. At day 5 after oocytes collection, second a embryo transfer was performed, if one of these embryos had reached the blastocyst stage. In a total of 106 patients, 40 pregnancies (38%) could be observed. No statistical difference in the pregnancy rate could be seen between the group with a second embryo transfer (n = 38; 42%) and the group without second transfer (n = 68; 35%). The incidence of multiple pregnancy was not statistically different between both group and no high-rank multiple pregnancy (greater than Triplete) were observed. Out of 300 cultured embryos, only 59 embryos (17%) reached the blastocyst stage. In the group, in which a second embryo transfer was performed, 22 patients received one blastocyst and 13 patients two blastocysts during the second transfer. The second transfer did not have a significant effect on the pregnancy rate in this series. The most important factor for the induction of pregnancy seems to be the quality of the embryos transferred on day 2 following oocyte retrieval.

The comparison of early follicular and midluteal administration of long-acting gonadotropin-releasing hormone agonist

Long-acting GnRH-a (D-Trp6 microcapsules, 3.2 mg) was intramuscularly injected, either in early follicular phase (group A) or midluteal phase (group B). Two hundred sixteen cycles were randomly allocated. Ovarian suppression was significantly more prompt in group B. Follicle cysts were diagnosed in 19% and 16% of groups A and B, respectively; their appearance and regression were significantly more rapid in group B cycles. More ampules of human menopausal gonadotropin were needed in group B. The number of oocytes retrieved was not significantly different between the groups. However, in group A more mature oocytes and more embryos with good morphology were achieved in the patients. Cancellation rate was 2.8% in groups A and B. Pregnancy rate and outcome were similar in both groups.

Preliminary results on transvaginal tubal embryo stage transfer (TV-TEST) without ultrasound guidance

IVF procedures have been increasingly used in male subfertility for both therapeutic and diagnostic purposes. As we assume a positive influence of the tubal milieu on the early embryonal development, any therapy should aim at intratubal embryo transfer. In this respect, only invasive techniques such as laparoscopy or laparotomy have been available hitherto (Asch et al., 1986; Balmaceda et al., 1988; Diedrich et al., 1989). Transvaginal intra-tubal embryo stage transfer (TV-TEST) was performed in 15 patients. After stimulation with clomiphene/HMG, HMG or GnRHA/HMG, patients with a follicle size of 18 mm were given 10000 IU HCG. Thirty six hours later, the transvaginal oocyte retrieval was performed without anaesthesia. Altogether, 109 oocytes were recovered. A fertilization rate of 30.3% yielded 33 embryos. Forty-eight hours after oocyte retrieval, the TV-TEST was performed without anaesthesia, in the course of which a maximum of three embryos in the 2- to 8-cell stage were transferred into one tube. Six of these patients are now pregnant.

Establishment of pregnancy related to embryo transfer techniques after in-vitro fertilization

The success rate of embryo transfers is not influenced by the choice of the catheter or the position of the patient during embryo transfer. The quality of embryos seems to be the crucial factor for the establishment of pregnancy and the transfer of more than one embryo (so-called multiple transfer) increases the pregnancy rate. Embryo transfer under general anaesthesia does not improve the pregnancy rate significantly. Intratubal embryo transfer in patients with normal Fallopian tubes seems to be promising, especially in cases of andrological infertility.

Polychlorinated biphenyls: the occurrence of the main congeners in follicular and sperm fluids

We have studied the presence of polychlorinated biphenyls in human body fluids associated with reproduction. Since the polychlorinated biphenyls represent a family of compounds, 3 of the main congeners of this family were selected for this study. The distribution of these 3 congeners was investigated in 37 specimens of follicular fluid and in 16 specimens of sperm fluid. Both fluids showed a similar, low contamination with total polychlorinated biphenyls (ca. 10 micrograms/kg on average), but it was evident that the follicular fluids preferentially accumulated the more highly chlorinated components. This finding must be taken into account when interpreting the concentration levels of the main congeners in relation to total pollution and the toxic potential of polychlorinated biphenyls.

[Pregnancy and labor in acute intermittent porphyria]

We report on the pregnancy and delivery of a 33-year old nullipara suffering from acute intermittent porphyria. Despite high risk of mortality and exacerbation of the disease, no complications occurred, since basic therapeutic principles were followed.

[Pregnancy following transvaginal intra-tubal embryo transfer (TV-TEST)]

It is a preliminary report on 2 pregnancies after transvaginal intra fallopian tubal embryo stage transfer (TV-TEST) in male factor infertility. Method and indications are discussed.

[Initial results with intratubal embryo transfer]

The intratubal transfer of pronucleus or early cleavage stage embryos (2-8-cell stage) is a new method in the treatment of human infertility. Following transvaginal sonographic oocyte retrieval in vitro fertilization is performed and the fertilized (pronucleus-stage) or embryos are transferred into the tube by laparoscopy. In comparison to GIFT (intratubal gamete transfer) fertilization under in vitro conditions offers the advantage that the success of the fertilization process can be examined. Therefore, this method can give important diagnostic information - especially in cases of poor sperm quality or unexplained infertility. After fertilization in vitro and transfer into the tube the embryone development occurs in the physiological milieu of the oviduct. Up to now the new procedure was performed in 40 patients with male factor or unexplained infertility. In 11 cases (28%) a pregnancy could be achieved. One abortion, but no ectopic pregnancy was observed. No difference in the pregnancy rates could be observed between the transfer of pronucleus stage and the early cleavage stage embryos. This method combines the advantage of IVF and GIFT and offers a successful procedure for the treatment of infertility.

[Comparison of a long-acting and short-acting GnRH analog in combination with gonadotropins in in vitro fertilization under various indications]

The occurrence of a premature luteinizing hormone (LH)-surge during gonadotropin stimulation for in-vitro fertilization leads to cancellation of the cycle. Moreover, insufficient follicular maturation is often caused by elevated basal gonadotropin levels. Therefore the gonadotropin releasing hormone (GnRH) agonist, D-TRP6-LHRH, was applied to patients exhibiting premature LH-surges, hyperandrogenemia or incipient premature menopause. 119 cycles were treated, using a long-acting versus a short-acting GnRH agonistic analogue. In protocol 1, patients received daily subcutaneous injections of 100-500 micrograms of a short-acting compound. In protocol 2, a long-acting bolus of 3.2 mg was given intramuscularly. Concomitant human gonadotropin (HMG) stimulation started in protocol 1 after clinical and biochemical evidence of pituitary suppression and in protocol 2 after a fixed suppression interval of 14 days. In protocol 1 higher estrogen levels were reached with more oocytes harvested. The pregnancy rate per transfer was increased from 3.5% to 18%, with most pregnancies occurring with protocol 2. The cancellation rate of 13.4% was mainly due to insufficient follicular development in patients, in whom premature menopause was suspected. Hyper-androgenemic patients with an elevated LH/FSH-ratio exhibited the best follicular recruitment with the highest pregnancy rate of 25% per transfer. Thus combined GnRH-agonist/gonadotropin stimulation offers a causal treatment for patients susceptible to premature LH-surges and for hyperandrogenemic patients.

Fertilization of human oocytes in capillary tubes with very small numbers of spermatozoa

Human oocytes can be fertilized with high rates of success under in-vitro conditions even if only low numbers of spermatozoa are used. A culture system has been developed in which fertilization is performed in haematocrit capillary tubes (length 75 mm; i.d. 0.8-0.9 mm). Oocytes were fertilized in 5-10 microliters of different sperm suspensions containing a total of 500, 1000, 2000 and 4000 spermatozoa per oocyte (0.1-0.4 x 10(6) spermatozoa/ml). Oocytes were obtained from 10 patients participating in an in-vitro fertilization programme; of these, 32 oocytes were fertilized in capillary tubes and 32 oocytes were cultured using standard methods (1 ml culture medium in tissue culture tubes; 0.1-0.2 x 10(6) spermatozoa/ml). The overall fertilization rate of oocytes cultured in tissue culture tubes was 78% (25/32) and the fertilization rates in capillary tubes using 4000, 2000, 1000 or 500 spermatozoa per oocyte were 71% (5/7), 86% (6/7), 60% (6/10) and 50% (4/8), respectively. The fertilization rate of mature oocytes was higher compared with immature oocytes when fertilization was performed in culture tubes (83 and 63%) or in capillary tubes (74 and 44%). Fertilization in capillary tubes using a 10 microliter of oocyte and spermatozoa suspension compared to 5 microliters seemed to provide better culture conditions, resulting in higher fertilization and cleavage rates. These preliminary results indicate that fertilization of human oocytes under in-vitro conditions can be achieved even with very low numbers of spermatozoa.

Successful embryo transfer of cryopreserved and in-vitro fertilized rabbit oocytes

In-vitro fertilization experiments with frozen/thawed rabbit oocytes were performed to develop an effective technique to be used for the in-vitro fertilization of cryopreserved human oocytes. Ovulatory oocytes, collected from the oviduct of virgin does 13 h after induction of ovulation by HCG injection, were cryopreserved slowly to -30 degrees C and plunged directly into liquid nitrogen. A mixture of 1.5 M 1,3-propanediol and 0.1 M sucrose was used as a cryoprotectant. After thawing, the oocytes were incubated with in-vitro capacitated sperm for 5 h in defined Brackett's medium. Fertilized ova were cultured for an additional 20 h until the 4-to-8-cell stage was reached. These embryos were transferred to pseudopregnant recipient rabbits which were 'asynchronous' in the sense that they had been given an injection of HCG 30, 24 and 18 h before starting to do the embryo transfer. A 32% survival rate of frozen/thawed oocytes was achieved. The fertilization rate was 74% (181/264) in this study. A total of 53 embryos was transferred to the oviducts of six recipients of three different asynchronicity and four young were born. The highest implantation rate (including resorptions) of 18% could be achieved in this investigation by using -6 h asynchronous recipients, while the overall implantation rate was 9.4%.

[Intra-tubal embryo transfer. A new therapy in andrologic sterility]

The intratubal transfer of pronucleus or early cleavage stage embryos (2-8-cell stage) is a new method in the treatment of human infertility. Following transvaginal sonographic oocyte retrieval, in vitro fertilization is performed and the fertilized oocyte pronucleus-stage or embryos are transferred into the tube by laparoscopy. By comparison to GIFT (intratubal gamete transfer), fertilization under in vitro conditions offers the advantage that the success of the fertilization process can be examined. Therefore, this method can give important diagnostic information--especially in cases of poor sperm quality or unexplained infertility. After fertilization in vitro and transfer into the tube the embryonic development occurs in the physiological milieu of the oviduct. Up until the present, the new procedure was performed in 40 patients with male factor or unexplained infertility. In 11 cases (28%) a pregnancy could be achieved. One abortion, but no ectopic pregnancy was observed. No difference in the pregnancy rates could be observed between the transfer of pronucleus stage and the early cleavage stage embryos. This method combines the advantages of IVF and GIFT and offers a successful procedure for the treatment of infertility.

The effect of general anaesthesia on the success of embryo transfer following human in-vitro fertilization

In this study the effect of general anaesthesia on the success of embryo transfer was investigated. Between January and August 1986, in a preliminary trial using general anaesthesia for embryo replacement (sodium thiopentone and alfentanyl), the overall pregnancy rate was 36% (n = 86), compared to 21% in a group of matched controls without anaesthesia (n = 131). Following the preliminary study in a larger series of patients between August 1986 and December 1987, all embryo transfers were performed using general anaesthesia. In a total of 795 embryo replacements the pregnancy rate was 19%. This was neither significantly different from the overall pregnancy rate of the non-anaesthetic controls of the preliminary study (21%), nor from a group of 603 patients who received embryo replacement without anaesthesia between June 1984 and December 1985. The results of this study indicate no obviously adverse effect of the anaesthesia on the induction of pregnancy. The results of the preliminary study even indicate a beneficial effect of anaesthesia on the pregnancy rate. However, to assess accurately the effect of general anaesthesia, a large prospective randomized study is needed. The type of anaesthesia used in this study, however, may be useful in cases of difficult transfer procedures, due to psychological stress to the patient, or technical/mechanical problems during the embryo transfer procedure.

Acrosomal proteinase activity of human spermatozoa and relation of results to semen quality

An assay for measuring the acrosomal proteinase activity of human spermatozoa with the use of a microscope slide coated with a thin layer of gelatin as a protein substrate was developed and applied to study the semen of 82 males from infertile couples and 15 normal donors. Acrosomal protease activity is indicated by a clear area of proteolyzed gelatin (halo) about the sperm head. Probit analysis revealed two populations divided at a halo diameter of 14 microns. The patient samples were grouped according to semen quality. The mean proteinase activity for most of the infertile groups was significantly below the control and more of the infertile men had a halo diameter less than 14 microns. Decreased activity was also found in 37% of patients with normal semen analysis. It is concluded that low acrosomal proteinase activity is associated with infertility. This reliable, inexpensive and rapid assay may prove to be helpful as an adjunct to semen analysis in the infertility work-up.

Ovarian stimulation using pure FSH in an in-vitro fertilization programme

The therapeutic efficacy of stimulating ovarian follicular development by pure urinary FSH in an IVF programme was determined and compared with results of other therapeutic regimens. Forty-three patients selected for extracorporeal fertilization were treated with pure FSH after stimulation with clomiphene or HMG had proved to be unsuccessful. Treatment had to be discontinued in five patients before follicular puncture, and embryo transfer was performed in 32, of whom seven conceived. FSH stimulation evidently creates favourable conditions for in-vitro fertilization in patients with impaired follicular maturation following conventional stimulation with clomiphene or HMG. Levels of oestradiol, progesterone and androstenedione were measured in follicular fluid, and high progesterone concentrations were correlated with mature oocytes. The increased ratios of progesterone/androstenedione and progesterone/oestradiol in follicles containing mature oocytes are due to the onset of luteinization of mature follicles as a consequence of HCG administration.

Transvaginal sonographically guided oocyte retrieval for in-vitro fertilization

Between December 1986 and November 1987, 588 transvaginal sonographically guided oocyte retrievals using a vaginal transducer were performed for in-vitro fertilization. All follicles were accessible. No complication occurred except for one case of pelviperitonitis in a patient with preoperatively diagnosed sactosalpinx. Because this technique is safe, non-invasive and can be performed without general anaesthesia, eggs were also retrieved from patients despite poor hormonal values and endogenous LH surge. In all, clinical pregnancies were diagnosed in 85 patients. Pregnancy rates per embryo transfer, oocyte retrieval and stimulated cycle, respectively, were 19.0, 14.5 and 12.0%. The advantages of the transvaginal technique compared with laparoscopically guided and with other sonographically guided techniques of oocyte retrieval are obvious, e.g. no general anaesthesia, in general all follicles accessible, very low complication rates, little discomfort to patient, less time and fewer staff. Therefore, this technique seems to be the method of choice. Laparoscopically guided oocyte retrieval is only indicated when a laparoscopic screening of pelvic organs or a gamete intra-Fallopian transfer are to be performed simultaneously.

Combined GnRH-agonist/gonadotrophin stimulation for in-vitro fertilization

The occurrence of a premature luteinizing hormone (LH) surge during gonadotrophin stimulation for in-vitro fertilization leads to cancellation of the cycle. Moreover, insufficient follicular maturation is often caused by elevated basal gonadotrophin levels. Therefore, the gonadotrophin-releasing hormone (GnRH) agonist, D-Trp-6-LHRH, was applied to patients exhibiting premature LH surges, hyperandrogenaemia or incipient premature menopause. A total of 119 cycles were treated using a long-acting versus a short-acting GnRH agonistic analogue. In protocol 1, patients received daily s.c. injections of 100-500 micrograms of a short-acting compound. In protocol 2, a long-acting bolus of 3.2 mg was given i.m. Concomitant human gonadotrophin stimulation was started in protocol 1 after clinical and biochemical evidence of pituitary suppression and in protocol 2 after a fixed suppression interval of 14 days. In protocol 1, higher oestrogen levels were reached with more oocytes harvested. The pregnancy rate per transfer was increased from 3.5 to 18%, with most pregnancies occurring with protocol 1. The cancellation rate of 13.4% was mainly due to insufficient follicular development in patients in whom premature menopause was suspected. Hyperandrogenaemic patients with an elevated LH/FSH ratio exhibited the best follicular recruitment with the highest pregnancy rate of 25% per transfer. Thus, combined GnRH-agonist/gonadotrophin stimulation offers a causal treatment for patients susceptible to premature LH surges and for hyperandrogenaemic patients.

[Transvaginal, ultrasound-controlled follicle puncture]

Between December 1986 and November 1987, 588 transvaginal sonographically-guided oocyte retrievals, using a vaginal transducer, were performed for in vitro fertilization at the University of Bonn. All follicles were accessible. No complication occurred except one case of pelviperitonitis in a patient with preoperatively diagnosed sactosalpinx. Because this technique is safe, non-invasive, and performable without general anaesthesia, we also retrieved eggs in patients despite poor hormonal values and endogenous LH-surge. In all, clinical pregnancies were diagnosed in 85 patients. Pregnancy rates per embryo transfer, oocyte retrieval and stimulated cycle, respectively were 19.0%, 14.5% and 12.0%. The advantages of the transvaginal technique, using a vaginal transducer compared with the laparoscopically-guided as well as with other sonographically-guided techniques of oocyte retrieval, are obvious (possibly without general anaesthesia, in general all follicles are accessible, very low complication rates, low discomfort to patient, and less amount of time and staff). Therefore, this technique seems to be the method of first choice. A laparoscopically-guided oocyte retrieval is only indicated, when a laparoscopic screening of pelvic organs or a gamete intrafallopian transfer are to be performed simultaneously.

[Tolerance of intraoperative, intraperitoneal chemotherapy in advanced gynecologic malignancies]

Assuming that cells and portions of tumor may remain in the abdominal cavity after surgery to reduce tumor size in cases of ovarian carcinoma, and that a change in cell kinetics could result in accelerated growth in the event of a recurrence, 23 patients with advanced tumors were given local (intraperitoneal) treatment intraoperatively. The treatment consisted of 15 mg Mitomycin C or 30 or 40 mg of Mitoxantron, in 1000 ml normal saline. Since the observation time was so short, the tolerance and side effects of this form of treatment were of primary interest, rather than remission quotas and survival times. The principal abdominal complaints included two subileus conditions which responded well to therapy and the problem of postoperative nausea. Four patients reacted to the treatment described with temperatures of over 38 degrees C. Chemical changes detected in the laboratory included 18 cases of leukopenia, which in one case reached WHO Grade 4. Intermittent changes in liver values and electrolytes were observed in isolated cases. Wound-healing impairments occurred in three cases. In one of them, a patient who sustained a prolapse of the small intestine with tumor growth into the abdominal wall, reoperation was necessary. Taken overall, the side effects of the intraoperative, intraperitoneal cytostatic therapy were acceptable. In view of the courses observed and with the idea of employing a form of therapy to combat aggressive growth of tumor cells remaining after surgery, it appears justified to continue with this form of treatment.

[Immunocytochemical detection of the estrogen receptor and lectin binding sites in tumor cell colonies growing in vitro]

Since it became clear that tumor cell colonies growing in soft agar are closely related to embryonic tumor cells, it has been possible to examine, with the aid of immunohistochemical methods, the behavior of estrogen receptors (ER) and lectin binding sites on those tumor components which determine malignant growth. With this aim in mind, 14 breast cancers, four ovarian cancers, and one corpus cancer with ER concentrations known from DCC studies were cultured in a colony assay. Using immunohistochemical techniques it was possible, after preparing permanent cultures, to demonstrate the estrogen receptors and lectin binding sites on the tumor cell colonies cultured in vitro.

Ovarian stimulation for in-vitro fertilization

In-vitro fertilization (IVF) and embryo transfer has become an accepted clinical method for the treatment of sterility. Different types of ovarian stimulation have been used successfully. The therapeutic principles behind the stimulation treatment in an IVF programme are the same as those applied in the treatment of normal and hypogonadotrophic ovarian insufficiency. These include clomiphene therapy with subsequent HCG administration, combined clomiphene/HMG administration and stimulation with HMG alone, followed by HCG. A new approach to the stimulation of follicular development and oocyte maturation is the use of pure FSH and GnRH analogues. The principal indications, results, advantages and disadvantages of these different schemes of ovarian stimulation for oocyte retrieval are discussed.

Glass wool column filtration of human semen: relation to swim-up procedure and outcome of IVF

The number and viability of spermatozoa recovered by glass wool column filtration and a swim-up procedure were compared using different types of ejaculates, such as normal, asthenozoospermic and very viscous oligozoospermic semen. The filtration procedure resulted in significantly (P less than 0.01) higher recovery of viable spermatozoa than the swim-up procedure from all types of ejaculates studied. Further, the spermatozoa from 50 (78.1%) of the 64 ejaculates filtered through glass wool column fertilized at least one intact human egg in an in-vitro fertilization (IVF) procedure. It is concluded that glass wool column filtration is superior to the swim-up procedure since it yields a higher recovery of viable spermatozoa that are potentially fertile. Therefore, the glass wool column filtration procedure used to prepare spermatozoa may be of benefit for IVF, intra-uterine insemination, in-vitro fertilization and GIFT (gamete intra-Fallopian transfer), especially in cases of poor quality semen.

Cryopreservation of human oocytes

Three different methods were used for freezing human excess oocytes (320 frozen, 205 thawed) in our IVF programme and the results of these methods were compared. A high fertilization rate (75%) could be achieved after thawing, using 1,2 propanediol as a cryoprotectant. Polyploidy rates of 20% and 40% were observed using DMSO and 1,2-propanediol as cryoprotectants, respectively. Using the ultracooling method, the survival rate was poor (4%).

Elevated levels of CA-125 in serum of patients suffering from ovarian hyperstimulation syndrome

Elevated levels of CA-125, an antigen expressed by malignant ovarian tissue, have been found in women who developed OHSS in response to treatment with exogenous gonadotropins for IVF. In contrast, CA-125 concentrations in women who were treated with an identical regimen but who did not show signs of OHSS remained in the normal range. We conclude that the expression of CA-125 is not restricted to neoplastic ovarian tissue but can also occur as a consequence of supraphysiologic stimulation of the ovary with exogenous gonadotropins.