Generalisierter Krampfanfall während der Anlage einer axillären Plexusblockade

Die Anaesthesiologie - Eine junge Patientin erleidet während der Anlage einer axillären Plexusblockade einen generalisierten Krampfanfall. Die Mechanismen, im Wesentlichen die vermutlich...     

An online survey of specialists’ opinion on first line management options for unexplained subfertility

The recent National Institute for Health and Care Excellence (NICE) guideline on Fertility (2012) suggests that IVF should be offered to couples with unexplained subfertility after 2 years of expectant management. The evidence on which these recommendations are based is not robust and there is a lack of agreement among specialists regarding the management of unexplained subfertility. We conducted an online survey among fertility specialists to find out the general consensus regarding the management of these couples. An e-mail questionnaire was sent to 420 reproductive medicine clinicians and 136 (32.38%) replied. Only 16% said they would always recommend IVF as the first line management for these couples, irrespective of age and duration of infertility. Of those surveyed, 39% agreed to the new NICE proposal, 33% agreed partly and 25% did not agree at all. A total of 27% of the respondents said they would definitely change their practice according to the NICE proposal but 30% said they would not; 29% said they might change their policy while the rest were unsure. This survey confirms the ongoing clinical uncertainty among fertility specialists in managing couples with unexplained subfertility.     

Induced regeneration of endometrium following curettage for abortion: a comparative study

A significant increase in endometrial thickness and volume wasobserved in 30 patients given oestrogen and progestin supplementationfollowing curettage for first trimester abortions, comparedwith 30 women who received no treatment. This indicates an enhancedregeneration of the endometrium following treatment. The abilityto induce this response, creating a space between the intra-cavitysurface area a short time after abortion, may theoreticallybe suggested as preventative treatment to reduce the risk ofintrauterine adhesions.     

Involvement of growth factors in the pathophysiology of polycystic ovary syndrome.

The etiology of polycystic ovary syndrome (PCOS) has not yet been fully elucidated but involves a disruption of normal ovarian function and multisystem sequelae. A combination of abnormally functioning genes whose expression is influenced by environmental, extra-ovarian factors determines the symptoms. Growth factors are heavily involved in the pathophysiology, either contributing to or as a consequence of the arrested development of follicles, abnormal steroidogenesis and hyperinsulinemia. Hyperactivity of a--transforming growth factor (TGFa) and epidermal growth factor (EGF) may block stimulation of aromatase and attenuate apoptosis of follicles and other factors may interface with the insulin-like growth factor (IGF) system preventing arrested follicles from becoming atretic and preventing the selection of a dominant follicle. IGF-binding protein concentrations are decreased by insulin, freeing biologically active IGF-I which augments the action of luteinizing hormone (LH) by inducing LH receptors, hyperactivating the enzymes P450c17a and 17,20 lyase resulting in hyperandrogenism. Growth hormone itself may be involved in the pathophysiology, as in normoinsulinemic PCOS patients it is hypersecreted and its actions on growth factors and their binding proteins are similar to those of insulin.     

Factors determining early pregnancy loss in singleton and multiple implantations

BACKGROUND: The incidence of first trimester pregnancy loss is much lower in IVF twin pregnancies than in IVF singleton pregnancies. The objective of this study was to determine which embryonic and maternal factors contribute to this finding. METHODS: Retrospective data analysis of the outcome of 1593 pregnancies after day 3 double-embryo transfer (DET) after IVF or ICSI treatment. RESULTS: Of 1148 single implantations at 6 weeks, 936 (81.5%) were ongoing pregnancies. Of 445 multiple implantations at 6 weeks, 354 (79.6%) were ongoing multiple pregnancies, 80 (17.9%) were ongoing singleton pregnancies and 11 (2.5%) ended in a spontaneous abortion. Total pregnancy loss was 18.5 and 2.5% (P < 0.001) in singleton and twin gestations, respectively. Loss per gestational sac was 18.5 and 11.46% (P < 0.001), respectively. Determinants contributing to the continuation of gestation beyond 6 weeks were young maternal age, possibility to cryopreserve embryos and short GnRH agonist flare-up stimulation protocol. Whereas factors promoting multiple implantation at 6 weeks of gestation were young maternal age, high cumulative embryo score (CES), male infertility, long stimulation protocol and thick endometrium. CONCLUSIONS: Although multiple implantation at 6 weeks is predominantly determined by (morphological) embryo quality, the continuation of pregnancy beyond 6 weeks becomes more dependent on the combination of genetic and developmental potential of the embryo(s) and an optimal uterine milieu.     

Non-response to ovarian stimulation in normogonadotrophic, normogonadal women: a clinical sign of impending onset of ovarian failure pre- empting the rise in basal follicle stimulating hormone levels

The most important aspect of diminished ovarian reserve is the associated decline in reproductive potential. Assessment of ovarian reserve is mainly based on measurement of early follicular phase follicle stimulating hormone (FSH) concentration. The objective of this study was to report the identification of a group of 12 infertile women initially diagnosed as having unexplained or anovulatory infertility, who had a normal baseline hormonal profile and did not respond to repeated ovarian stimulation with gonadotrophins. All developed ovarian failure within a relatively short time span. Non-response to ovarian stimulation was defined by failure to achieve development of follicles >12 mm and failure to raise oestradiol concentration >350 pmol/l in two successive cycles of human menopausal gonadotrophin (HMG) doses of up to five ampoules per day for 5-8 days. Within a mean of 9 months following the failed attempts of ovarian stimulation the mean day 3 FSH concentrations rose from 5.4 +/- 2.7 IU/l to 53.5 +/- 19.7 IU/l. In these patients, day 3 FSH concentration failed to indicate the low ovarian reserve manifested only by lack of clinical response to treatment with gonadotrophins which was the first sign of impending ovarian failure. We conclude that women with normal early follicular phase serum FSH concentrations who do not respond to ovarian stimulation by HMG are at risk of developing ovarian failure within several months.      

A family history of twinning in relation to multiple implantation

BACKGROUND: A familial basis for dizygotic twinning is known for multipleovulation. However, for multiple implantation this remains unclear.In IVF/intracytoplasmic sperm injection (ICSI) ‘multipleovulation’ is artificially induced. If multiple implantationis not hereditary, the incidences of twins in families of patientswith single and multiple implantation after IVF/ICSI with doubleembryo transfer (DET) should be comparable. METHODS: A questionnaire study was conducted among patients with intrauterine pregnancy at 6 weeks of gestation, after IVF/ICSI treatmentwith DET 3 days after oocyte retrieval. RESULTS: There were 940 patients who gave their informed consent. Forwomen with single implantation (Group A), the incidence of oneand of multiple twins among the family was 27.2 and 15.5%, respectively.For women with multiple implantation (Group B), this incidencewas 29.5 and 17.8%, respectively, P = 0.424. The incidence ofone and of multiple twins among first degree relatives was 10.6and 1.1% in Group A; for Group B this was 8.7 and 1.9%, P =0.469. Multivariate regression analysis also did not reveal‘twins in family’ or ‘twins in first degree’as an associated variable for multiple implantation at 6 weeks. CONCLUSIONS: Incidences of twins in families of patients with single implantationand patients with multiple implantation after IVF/ICSI are comparable.Our data do not support the concept that multiple implantationis hereditary.     

Further considerations on natural or mild hyperstimulation cycles for intrauterine insemination treatment: effects on pregnancy and multiple pregnancy rates

BACKGROUND: The high iatrogenic multiple pregnancy rate associated with intrauterine insemination (IUI) in hyperstimulated cycles is becoming less acceptable. Therefore we investigated data from an earlier prospective trial with regard to the specific question of whether the application of mild hyperstimulation in IUI cycles could be an alternative strategy for obtaining acceptable pregnancy rates while preventing a high multiple pregnancy rate, compared with natural cycles for IUI. METHODS: Pregnancy outcome of 310 natural and 334 mildly hyperstimulated cycles for IUI in 171 couples with unexplained or mild male factor subfertility was analysed on a patient level with random coefficient models. RESULTS: Pregnancy rates were similar: 35 and 39.8% per couple in the natural and mildly hyperstimulated cycles respectively (P = 0.60). Multiple pregnancies, all twin pregnancies, were conceived significantly more frequently in the mild hyperstimulation group (27% of the pregnancies) than in the natural cycle group (4% of the pregnancies) (P = 0.01). All multiple pregnancies in the hyperstimulation group were conceived in multifollicular cycles. Multifollicular development was strongly associated with the application of mild hyperstimulation only (odds ratio 21.14, 95% confidence interval 8.15-54.79). CONCLUSION: The application of a mild hyperstimulation protocol as an alternative to a standard hyperstimulation protocol for IUI does not result in higher pregnancy rates than IUI in the natural cycle, while at the same time multiple pregnancies cannot be avoided. Therefore, there is no place for the use of gonadotrophins in IUI treatment.     

碱性磷酸酶-抗碱性磷酸酶铅沉淀技术及其优化

本文介绍了用以显示碱性磷酸酶活性的铅沉淀法的碱性磷酸酶-抗碱性磷酸酶(APA-AP)免疫组织化学技术,以及使用计算机图像处理进行显微光密度测量确定的该技术理想反应条件.其条件是:孵育液硝酸铅浓度为3mmol/L,底物浓度1.96～31.36mmol/L,pH值7～9;APAAP浓度1:50;一级抗体、第一和第二桥抗体的浓度分别为1:1 000、1:100和1:200。讨论了APAAP-铅沉淀技术的某些优点。