Hat die In-vitro-Maturation eine Zukunft?

Recent increases in knowledge in reproductive medicine have led to the development of a wide range of methods of assisted reproduction (ART) that can be applied in various infertility situations. Ovarian hyperstimulation with gonadotrophins represents a standardized and highly efficient treatment option to induce polyfollicular development for obtaining numerous oocytes in order to guarantee acceptable pregnancy rates. However, this technique is associated with side effects and disadvantages which has motivated a search for new solutions for infertility treatment. The concept of in-vitro maturation (IM) aims at aspirating immature cumulus-enclosed oocytes at the germinal vesicle stage (GV) from small antral follicles in order to support maturation from the GV stage to the fertilizable metaphase 2 stage (M2) in vitro. At present IVM represents a simple and cost-effective technique and preliminary data suggest that IVM appears to be a safe method. As the development time of clinical IVM is relatively short and pregnancy rates are generally lower, this technique still cannot be equally compared to conventional IVF treatment. However, IVM possesses a great developmental potential for the future.     

Hysterektomie – vaginal, abdominal oder laparoskopisch assistiert?

Hysterectomy is one of the most common gynaecologic operations. Different methods of hysterectomy exist, including abdominal, vaginal, laparoscopy-assisted vaginal (LAVH), and total or supracervical laparoscopic operation. The most common way to perform a hysterectomy is still the abdominal approach, but many studies have proven that vaginal hysterectomy is a less invasive method with the fastest convalescence. Conditions frequently given as contraindications for vaginal hysterectomy have been disproven as such, and it has been shown that even large uteri can be removed vaginally. LAVH is recommended for patients with previous pelvic surgery or additional abdominal problems or for patients with indications for adnectomy. Abdominal hysterectomy usually has no advantages and should be performed for special indications only.     

Neue Ansätze bei der Prävention des ovariellen Überstimulationssyndroms

Severe ovarian hyperstimulation syndrome (OHSS) is a rare and potentially life-threatening complication of ovarian stimulation for IVF. The crucial issue about OHSS is prevention, rather than treatment. One factor to preventing OHSS is recognition of risk factors. Among risk factors such as polycystic ovarian syndrome (PCOS), rapidly rising serum estradiol levels during ovarian stimulation, and previous episodes of OHSS, the number of preovulatory follicles has been shown to have the highest sensitivity and specificity to identify the patients with subsequent development of OHSS. More recently, follicle-stimulating hormone (FSH) receptor polymorphisms and anti-muellerian hormone (AMH) have been suggested to be predictive in the development of the disease, but existing data are conflicting or insufficient. As none of the available clinical algorithms will identify all patients at risk of OHSS, future IVF treatment regimen should routinely employ means that reduce the incidence of the syndrome (GnRH-antagonist protocols, mild stimulation). However, no modification to current ovarian stimulation regimen will be 100% effective in preventing severe OHSS, therefore OHSS prevention by replacing the ovulation-inducing trigger of human chorionic gonadotropin (hCG) with a bolus dose of GnRH-agonist has recently attained great interest. Further novel concepts in OHSS incidence reduction, such as coasting with antagonist, reduced dose of hCG, administration of a VEGF receptor antagonist after oocyte pick-up, and luteal phase antagonist administration will selectively be discussed in this literature review.     

Komplikationen der assistierten Reproduktion

Zusammenfassung Das ovarielle überstimulationssyndrom (OHSS) ist die h?ufigste Komplikation der assistierten Reproduktion. Da eine kausale Therapie derzeit nicht bekannt ist, liegt der bedeutendste therapeutische Ansatz in der Pr?vention. Die Selektion von Risikokollektiven, individuelle ovarielle Stimulation bei Risikopatientinnen mit engem Zyklusmonitoring (Ultraschall, E2-Serumspiegel) und die situationsgerechte Dosisanpassung des hMG in Verbindung mit risikoadaptierter Ovulationsinduktion, ggf. Kryokonservierung von Pronukleusstadien, k?nnen das Risiko für die Entwicklung eines OHSS deutlich reduzieren. Die Behandlung des OHSS besteht im wesentlichen in symptomatischen Ma?nahmen, die sich in erster Linie auf die Vermeidung einer H?mokonzentration mit dem Risiko einer Thromboembolie konzentrieren. Hier kommt dem frühzeitigen Erkennen der H?mokonzentration mit entsprechender umgehender ad?quater Flüssigkeitssubstitution eine Schlüsselfunktion zu. Gleichzeitig sich entwickelnde Pleuraergüsse, Aszites und eine ?demneigung dürfen den Kliniker nicht auf eine falsche F?hrte führen und, wie h?ufig beobachtet zu einer Flüssigkeitrestriktion veranlassen. Eine ad?quate Thromboseprophylaxe sowie die Unterstützung der Nierenfunktion ggf. mit Dopamin sind wichtige Begleitma?nahmen. Stieldrehung einer Adnexe, inflammatorische Prozesse nach transvaginaler Follikelpunktion und unmittelbare postoperative Blutungskomplikationen sind sehr selten. Die klinischen Bilder sind zumeist eindeutig, sehr charakteristisch und bedürfen einer umgehenden Intervention. Die Laparoskopie erm?glicht eine schnelle, wenig invasive Diagnostik, dennoch sollte der Kontakt mit dem Zentrum, das die assistierte reproduktive Technik durchgeführt hat, bei dem geringsten Verdacht auf eine Komplikation gesucht werden.     

Small-diameter laparoscopy (SDL) using a microlaparoscope

Purpose: To determine the ability of new sub-2.0-mm-diameter microlaparoscopes to be used for diagnostic laparoscopy, 28 small-diameter laparoscopies (SDL) were performed during a 4-month-period. Methods: These cases were performed under general anesthesia, with immediate follow-up confirmation with conventional laparoscopic equipment. An additional 13 SDL procedures were performed under analgosedation plus local anesthesia and were well tolerated by the patients. Results: For the cases performed with conventional laparoscopic control, the visualization results were comparable in 27 of 28 procedures. In the nongeneral anesthesia SDL group, patients were highly satisfied and reported less post-procedural discomfort and minimal scar formation due to the smaller access ports. In this study, two types of microlaparoscopes were used. Conclusions: While both were adequate, the newer high-resolution microlaparoscope delivered an image much more similar to that which conventional laparoscopy and required little or no change in technique in order to obtain images. With the advent of this new endoscope technology with optics performance comparable to that of conventional laparoscopes, SDL has demonstrated to be a useful procedure for certain clinical indications.     

Ovarian abscess and heterotopic triplet pregnancy: two complications after IVF in one patient

A patient is reported, who suffered from ovarian abscess after ovarian puncture of a functional ovarian cyst. The cyst has developed after administration of a GnRH agonist depot preparation in the preceeding luteal phase. She was planned to be stimulated for IVF according to the long luteal protocol. The abscess was removed by laparoscopy, and stimulation started two months later after administration of two further GnRH against depot preparations. The patient got pregnant after embryo transfer of three embryos, and a heterotopic triplet pregnancy, with intrauterine twins and a tubal singleton was established. Bilateral salpingectomy was performed, because of bilateral haematosalpinx and previously described bilateral tubal occlusion. The further pregnancy was uncomplicated. Accepted: 27 March 1999     

Medical treatment of uterine fibroids with the LHRH antagonist: Cetrorelix

A depot preparation of the LHRH-antagonist Cetrorelix was used for the preoperative treatment of 20 premenopausal women with symptomatic uterine fibroids to undergo surgery. In an open, prospective and randomised study, 60 mg of this depot preparation were administered i.m. at the second day of cycle. Patients were randomised for a second dosage of 60 mg or 30 mg to be injected on day 21 or day 28 of treatment according to the degree of estradiols' suppression (< 50 pg/mL). The operation was carried out after six or eight weeks of treatment according to the timing of second dosages administration. Weekly transvaginal sonography as well as MRI before and after Cetrorelix treatment were performed for fibroids volume assessment; 16 patients showed satisfactory suppression of gonadotrophins and sexual steroids. No flare up effect was to be observed. In this group of patients the maximum reduction in fibroids size was of 33.5% at the end of treatment. After 14 days of treatment the reduction was of 31.3%. Within the group of good responders (reduction of fibroids size > 20%) the volume of the biggest fibroid after 14 days of treatment was of 56.7% of the initial assessment. Although MRI showed minor mean shrinkage rates of only 25.4% of the initial volume, these differences in comparison to transvaginal sonography were not statistically significant. The avoidance of any flare up phenomenon by the LHRH-antagonist may explain this fast reduction in size. The basic advantages of this treatment modality are the reduction of treatment time with a fast restoration of the ovarian function. The rate of poor responders may be reduced by improving the galenic preparation.     

Development of a New Fixed Functional Appliance for Treatment of Skeletal Class II Malocclusion First Report

Developed under interdisciplinary cooperation, the Functional Mandibular Advancer (FMA) is a new, rigid and fixed appliance for sagittal correction of the intermaxillary jaw relationship in adolescents and young adults. The appliance is non-dependent on patient compliance and is aimed at providing an alternative to the Herbst and MARA appliances. A number of designs, all based on the mechanical principle of the inclined plane combined with guide pins and allowing reactivation, were developed. The version of the appliance providing the best technical advantages was developed to the stage of practical application in patients.