[Measurement of gestational sac volume in the first trimester of pregnancy]. / Merení objemu gestacního vácku v I. trimestru gestace.

OBJECTIVE: The aim of our study was to measure the volume of gestational sac and amniotic sac in physiological pregnancies and missed abortion. We wanted to create nomograms for individual weeks of gestation. DESIGN: Retrospective cohort study. SETTING: Institute for the Care of Mother and Child, Prague. METHODS: The study randomized 413 women after spontaneous conception. The patients were divided into two groups: women with physiological pregnancy and childbirth in the period (374), and women with pregnancy terminated by missed abortion. Both groups were performed measurement volume of gestational and amniotic sac in the first trimester of pregnancy. Analysis was performed using 4D View software applications, and volume calculations were performed using VOCAL (Virtual Organ Computer Aided anaLysis). RESULTS: We have created the first in the Czech Republic nomograms volumes of gestational and amniotic sac in physiological pregnancies and missed abortion. We performed a correlation between the size of gestational sac and prosperity pregnancy. CONCLUSION: In our study we found no correlation between the volume of gestational sac and the development of the pregnancy.

Time-lapse cleavage rating predicts human embryo viability.

Chronology of three consecutive mitotic events in human pre-implantation embryos was examined by time-lapse imaging. In zygotes producing well-formed and pregnancy-yielding expanded blastocysts, uniform time-patterning of cleavage clusters (c) and interphases (i) was revealed: i2=11+/-1, i3=15+/-1, i4=23+/-1 h / c2=15+/-5, c3=40+/-10, c4=55+/-15 min. Oppositely, shortened or prolonged durations of one or more cell cycles were strongly predictive of poor implantation and development. Furthermore, trichotomic mitosis was discovered in 17 % of cases - zygotes cleaved into 3 blastomeres and 2-cell embryos into 5-6 cells (instead of normal 2 and 4). During conventional clinical assessment, such embryos are indistinguishable from normal, often considered just-in-course of the next cell cycle. Only detailed time-lapse monitoring paced at 10-minute intervals had proven all these embryos to be absolutely unviable, even in rare cases when they reduced their hypercellularity to normal cell counts via cell-cell fusion. Overall, we demonstrate that time-lapse embryo cleavage rating (ECR) as a standalone diagnostic procedure allows for effective identification of viable early embryos with 90 % specificity, while elimination of good-looking but unviable embryos can be assumed with a specificity of 100 %. Thus, making this non-invasive and contactless approach worth of addition to routine embryo screening in clinical IVF programs.

[Non-invasive monitoring of the timing of early embryo cleavages--objectively measurable predictor of human embryo viability]. / Neinvazívne meranie dlzky bunkového cyklu v prvých dnoch embryonálneho vývoja--objektívne meratel'ný ukazovatel' zivotaschopnosti l'udských embryí.

OBJECTIVE: The evaluation of the developmental abilities of human embryos according to the timing of their early mitotic cleavages. DESIGN: Retrospective study. SETTING: Prague Fertility Centre and Institute for Care of Mother and Child, CAR, Prague. METHODS: The embryos obtained in IVF program were used for further observations and subjected to automated time-lapse monitoring (PrimoVision, Cryo-Innovation, 1 picture/10 min, intermittent white-light illumination) under standard cultivation conditions (37.0 degrees C, 5% CO2 in humid air). Image sequences were digitally recorded for later use. For intravital spindle detection we used polaryzing microscopy (Oosight, Research Instruments) and Hoechst 33342 fluorescent dye for intravital chromatin visualization. A total number of 180 human embryos which gave a vital pregnancies (FHB, fetal heart beat) were analysed retrospectively for timing of early cleavages. In our study, the exact timing of the four interphases (IP) and synchrony of sister cell divisions (ID, interval division) occurring after fertilization were identified and manually recorded. Interphases: IP1 was defined as the period from fertilization till 2 cell stage. IP2 between 2 and 3 cells stages, IP3 between 3 and 5 and IP4 between 5 and 9 cells embryo. INTERVAL DIVISION: ID2 was recorded as a time interval between 3 and 4 cells, ID3 between 5 and 8 cells and ID4 between 9 and 16 cells stage embryos. RESULTS: In the embryos giving viable pregnancies, the durations of IP1 was 20-26 hrs. IP2 was 10-12 hrs, IP3 was 14-16 hrs and IP4 was 20-26 hrs. In these embryos, the sister blastomeres cleaved in a very synchronous manner. The duration of ID1 was recorded to varry from 120 to 210 min. ID2 from 20 to 60 min., ID3 from 120 to 240 min. and ID4 from 230 to 360 min. CONCLUSION: The viable embryos cleave in a very similar time pattern which can be defined and applied as referencial value. Non-invasive monitoring of the timing of early embryo cleavages can be used as an objectively measurable predictor of human embryo.

[The role of three-dimensional ultrasonography in assisted reproduction]. / Vyuzití a význam 3D ultrasonografického vysetrení v asistované reprodukci.

OBJECTIVE: Clarifying the role of three-dimensional transvaginal sonography in diagnosis sterility and assisted reproduction treatment. DESIGN: Review. SETTING: Institute for the Care of Mother and Child, Department of IVF, Charles University, Prague. METHODS: Study of current literature. SUMMARY: With arrised frequency of ovarian, uterus and another pelvic patologies remains the three-dimensional transvaginal sonography in diagnosis of sterility women very actual in the fields of reproductive medicine. Actually the assessment of ovarian reserve belong to the essentials investigations in the diagnosis of primary and secondary sterility at this time. The advance in the three-dimensional transvaginal sonography allows to assess the endometrial volume, echogenity, endometrial vascularity and endometrial receptivity. There is a significant importance of 3D power Doppler angiography by measurement of folicular and ovarian vascularity with three indices (VI, FI, VFI) and provides the calculation of ovarian vascularity from the volume. New Sono-Automatic Volume Calculation (Sono-AVC) software that identifies and quantifies hypoechoic regions within a three-dimensional dataset and provides automatic estimation of their absolute dimensions, mean diameter and volume. An unlimited number of volumes can theoretically be quantified, which makes it an ideal tool for assessment of the ovarian volume and the antral follicle count (AFC) in women undergoing controlled ovarian stimulation.

[Chlamydia trachomatis in men with impaired fertility]. / Chlamydia trachomatis u muzu s poruchou plodnosti.

OBJECTIVE: The objective of the prospective study was to assess whether there exists a relationship between the results of positive laboratory tests for the presence of Chlamydia infection (assessment of the presence of Chlamydia trachomatis in the ejaculate by the DNA amplification method, IgA and IgG antichlamydia antibodies in the ejaculate and serum), an abnormal spermiogram and total number of sexual partners in men from infertile couples examined at the Gynaecological and Obstetric Clinic of the First Medical Faculty, Charles University Prague. DESIGN: Prospective clinical study. SETTING: Department of Gynaec.-Obstet., the 1st Medical Faculty of the Charles University, Prague, Czech Republic--Institut of Clinical Biochemy, the 1st Medical Faculty of Charles University, Prague, Czech Republic. METHOD: 101 men were examined. In all the spermiogram was evaluated according to WHO criteria. Specific antichlamydial antibodies IgA and IgG is serum and the ejaculate were assessed by the ELISA method. Evidence of the DNA portion of Chlamydia trachomatis was provided by the MEIA method. Amplification of DNA by LCR was made on a Thermocycler. By means of an aimed questionnaire the number of all sexual partners was assessed. The men were divided into three groups with 1-5, 6-9 and with 10 or more partners. Patients where Chlamydia infection was detected were treated with Ig Azitromycin and their spermiogram was checked 6-8 weeks after treatment. The results of the examination were tested by the chi square test. RESULTS: An abnormal spermiogram was found in 44 (44%) of the examined subjects. With the increasing number of sexual partners the number of men with pathospermia increased. In none LCR for the presence of Chlamydia trachomatis was positive in the ejaculate. In 15 examined patients IgA antichlamydia antibodies were found in the ejaculate. At the same time in all an abnormal spermiogram was found and 11 (73%) of them had six or more sexual partners. After treatment in 8 (62%) of 13 (two did not attend the check-up) marked improvement of the spermiogram occurred. CONCLUSION: IgA antichlamydial antibodies in the ejaculate proved in 62% of the examined men with an abnormal spermiogram a useful indicator of infection in the genital tract. With the increasing number of sexual partners the number of pathospermias increased.

[Chlamydia trachomatis--a risk for reproductive capacity in women]. / Chlamydia trachomatis--riziko ohrození reprodukcní schopnosti zen.

BACKGROUND: Chlamydia trachomatis is a bacterium which causes in man among others urogenital infections. So far no data were published pertaining to the herd immunity of the population to this infection in the Czech Republic. The objective of the present investigation was to summarize clinical and laboratory results of examined women and to evaluate the assembled data by statistical methods. Special attention was paid to patients examined on account of infertility. METHODS AND RESULTS: 506 women aged 17-50 years (mean age 28 years) were examined. They were divided into five groups (1-cervicitis, 2-pelvic pain, 3-pregnant, 4-sterile, 5-before UPT). Group 4 (sterile) was further subdivided into three categories (4a IVF on account of tubal sterility, 4b IVF on account of non-tubal sterility and 4c others). With regard to the domicile the women were divided into those residing in Prague and those from other towns and rural areas. In all antigenic examinations of smears from the endocervix were made and serological examinations of specific IgA, IgG antichlamydial antibodies. During collection of the smears the appearance of the cervix; discharge, bleeding and pain on examination were evaluated. For statistical evaluation the chi 2 test was used. In 57% of the women from the whole group positive IgG antibodies were detected suggesting a past or present infection. Differences of antigenic or serological positivity between the five different groups were not statistically significant. In category 4a a significantly higher positivity of IgG (2 alpha < 0.001) of antichlamydial antibodies was found (92% patients) than in categories 4b and 4c. 71% women had complaints during examination. The authors did not find a correlation between antigen- and serum positive women indifferent groups and their domicile. CONCLUSIONS: The results provide evidence of a high herd immunity of the population of the Czech Republic to Chlamyata infection. At the same time they prove that post-inflammatory changes caused by Chlamydia trachomatis are the most frequent cause of occlusion of the oviducts and tubal sterility.

[The effect of endometrial infection on embryo implantation in the IVF and ET program]. / Vliv infekce endometria na implantaci embrya v programu IVF + ET.

The results of the IVF and ET programme depend on a number of known and hitherto unknown factors. One of them is implantation of the embryo. Only 10-15% of the embryos transferred into the uterus are implanted. The most important factors affecting implantation are quality of the embryo and receptivity of the endometrium. The receptivity of the endometrium depends on hormonal changes, vascularization of the uterus, infectious environment and other factors. Part of them can be influenced to a certain extent. Infection of the endometrium as the cause of unsuccessful implantation could be resolved by therapeutic administration of antibiotics. The objective of the present work was to prove the possible effect of bacterial contamination of the endometrium on results of IVF + ET programmes. During 1996-1997 120 sterile women included in the IVF + ET programme were examined at the First Gynaecological and Obstetric Clinic (transport system-Pronatal, Prague). In all women the author performed during the cycle preceding the stimulated one (the IVF cycle proper) microabrasion of the endometrium by a method which prevents as much as possible contamination of the specimen by the endocervical flora. A smear from the endocervix and vagina was made. The samples were examined for the presence of aerobic and anaerobic flora, Chlamydiae. The endometrium was evaluated also from the histopathological aspect. Results of the examination of the endometrium: 62% of the specimens were positive on cultivation. Most frequently Pseudomonas spec. and Staph. epidermidis were found. Of 34 women who became pregnant 10 had a positive cultivation (29.4%). Of 86 women where pregnancy was not achieved, cultivation was positive in 64 (74.4%). This difference is statistically significant. The same cultivation finding from the endocervix and endometrium was observed only in 21% patients. From the trial where more than twice as many positive cultivations were recorded in non-conceptive cycles as compared with conceptive ones, the following preliminary conclusions can be drawn: 1. Elimination of endometrial infection has its place in the preparation of patients in the IVF + ET programme. 2. It is advisable to treat with antibiotics a positive cultivation of the endometrium or administer antibiotics prophylactically (62% positive) to all patients during a stimulated IVF cycle.

[Chlamydia trachomatis and its role in female infertility]. / Chlamydia trachomatis a její podíl na neplodnosti zen.

Infertility is a worldwide problem. 15-20% married couples are childless though they want children. The tubal factor is the most frequent cause of female infertility. Chlamydia trachomatis is one of the most frequent pathogenic organisms which cause tubal occlusion. From January 1995 till June 1997 at the 1st Dept. Gynecol. and Obstetric, 1st Fac. of Medicine 327 infertile women were examined divided into three groups (sterile, included in the IVF programme on account of the tubal factor and those included in the programme for other reasons). In all an antigenic examination from the endocervix and serological examination of antichlamydia antibodies was made. In 73 women in the IVF programme by microabrasion of the endometrium material for detection of Chlamydia infection was obtained by PCR. During sampling from the uterine cervix the appearance of the portio uteri, discharge, haemorrhage and pain on examination were evaluated. For statistical evaluation the chi square test was used. In 61% patients anamnestic IGG antibodies were detected suggesting a past or present Chlamydia infection. In women included in the IVF programme on account of the tubal factor there was a significantly higher IgG positivity (92%). Of ten women who suffered from acute chlamydial cervicitis only in one the infection was detected during microabrasion of the endometrium. 65% antigen positive patients had complaints during the examination (discharge, bleeding, pain). The authors discuss the impact of the assembled results from the aspect of impaired fertility of women in the Czech Republic.

[Treatment of chlamydial urogenital infections]. / Lécba chlamydiové urogenitální infekce.

Chlamydia trachomatis is the most frequent sexually transmitted bacterial pathogen in developed countries [3, 12, 13]. The position is similar in the Czech Republic. Depending on the group of examined women active Chlamydia infection varies between 10 and 23%. The increasing incidence of urogenital Chlamydia infections and improving diagnostic possibilities call for adequate treatment. Correct treatment of urogenital infections caused by Chlamydia trachomatis is very important for the prevention of undesirable sequelae of inflammations of the lesser pelvis, subsequent risk of GEU, sterility, prevention of premature delivery and possible infection of the neonate. When starting treatment, selecting a suitable antibiotic and deciding on the therapeutic strategy it is important to select an antibiotic with regard to its efficacy, the epidemiological situation, regional sensitivity of the infectious agent, toxicity and tolerance of the antibiotic, to its bacteriostatic or bactericide action, and last not least, also its price. Despite selection of a suitable antibiotic sometimes treatment fails. For treatment of urogenital chlamydial infections tetracyclin and macrolid antibiotics are recommended or quinolone chemotherapeutic agents of the third generation. Tetracyclines are broad spectrum antibiotics with bacteriostatic action. As to oral forms doxycycline, tetracycline and oxytetracycline are used. The most frequent undesirable effects during treatment are nausea, vomiting, diarrhoea and abdominal pain. Tetracycline antibiotics are contraindicated in children under 8 years, during pregnancy and lactation and in case of sensitivity to this group of drugs. Macrolids are antibiotics with a medium broad antibacterial spectrum with bacteriostatic action. Macrolids of the first generation have a low antibacterial activity. They have a short biological half-life, not always a good tolerance, and serious clinically important drug interactions may develop. The most frequently used preparations of the first generation include erythromycin, josamycina and spiramycin. Macrolids of the second generation, azitromycin, roxitromycin and claritromycin lack the above negative properties. The most frequent undesirable effects after administration of macrolids include nausea and vomiting. Considerable differences were found in particular between different preparations containing erythromycin. Macrolids of the second generation have only slight undesirable gastrointestinal effects. Macrolid antibiotics are contraindicated in case of sensitization to this group, in severe hepatic disorders and great care must be taken in the treatment of pregnant women. Quinolone chemotherapeutic agents of the third generation, ciprofloxacine, enoxacine, ofloxacine and pefloxacine are synthetic drugs with a broad antibacterial spectrum which act on systemic infections. On oral administration they are rapidly absorbed and the blood and tissue concentrations are sufficiently effective. In the treatment of urogenital Chlamydia infections they are useful in the treatment of chronic infections after failure of previous macrolid and tetracycline therapy. The most frequent undesirable side-effects include nausea, vomiting, meteorism, diarrhoea, tinnitus, headache, changes of mood, allergic skin reaction. They are contraindicated in hypersensitivity to quinolone chemotherapeutic preparations, in children and adolescents under 18 years, during pregnancy and lactation. The objective of the present study was to evaluate different therapeutic patterns, their efficacy and tolerance.

[Detection of cadmium and zinc in the blood and follicular fluid in women in the IVF and ET program]. / Detekce kadmia a zinku v krvi a folikulární tekutine zen zarazených do programu IVF + ET.

Scientific and technical development contributed on the one hand greatly to easier living conditions, on the other hand there is however substantially greater danger threatening not only the life of man but also of nature, of the entire living environment. At present the problem of the possible part played by this phenomenon in reproductive disorders is in the foreground. Via the food chain heavy metals, toxic trace elements and polyhalogenic hydrocarbons penetrate into the organism. They accumulate in the organism and thus also in the reproductive tract and may have an impact on fertility. Some elements with a possible negative impact on reproductive health are in such low concentrations in tissues that only contemporary methods of their detection make it possible to map their presence in the organism. They are called trace elements. Toxic ones comprise cadmium, mercury, lead and arsenic. The mechanism of the negative action of cadmium in the organism is most probably due to its competition with the vitally important trace element--zinc. It was therefore the objective of the present investigation to trace the presence of cadmium and zinc in the organism of 100 sterile women included in an IVF programme: in blood and follicular fluid (i.e. in a medium which surrounds the gamete--the oocyte) and to follow up their concentrations in relation to achievement pregnancy. Cadmium and zinc in blood and follicular fluid were assessed on a mass spectrometer with induction bound plasma as the source of ions (ICP-MS), Varian Co. produced in 1994. The assessed mean levels (microgram/l) of cadmium in blood (2.88 s 2.71) and follicular fluid (1.25 s 0.55) in the group of conception cycles did not differ significantly from mean blood levels (2.82 s 2.22) and follicular levels (1.16 s 0.55) of non-conception cycles. The mean zinc levels in blood and follicular fluid did not differ either in the group of conception and non-conception cycles. Very significant are the differences in the blood and follicular fluid levels, the levels in follicular fluid being significantly lower. We may speak of a protective barrier of the oocyte formed by the follicle (probably the cells of the granulosa) against blood. Thus no relationship was found between the cadmium concentration in blood and follicular fluid of women where pregnancy was achieved and non-pregnant women. The possible cause of fertility disorders in conjunction with toxic elements is probably in damage of the granulosa cells and thus their dysfunction as regards production of steroid hormones with full impact on female fertility (hormone disruptors).

[Effect of oocyte transportation (IVF transport) on effectiveness of the IVF and ET program]. / Sledování vlivu transportu oocytu (transportní IVF) na efektivitu programu IVF + ET.

The programme of in vitro fertilization helps at present an ever increasing number of married couples to resolve successfully the problem of sterility. It is however a method pretentions technically, as regards time, material and in particular funds. This applies above all to embryological laboratories. The transport system of the IVF programme makes possible care of patients indicated for sterility treatment by the IVF method in departments without their own embryological laboratory and thus it is possible to include more patients in the programme and save money. In the author's department the first two stages of the IVF programme are implemented, i.e. stimulation of the ovaries and aspiration of follicular fluid. Then this material is taken in a transport box of the K-system Co., Denmark, type G-81E to a centre with full accreditation where the subsequent stages of the IVF programme take place (selection of the oocyte, fertilization, cultivation of embryos and embryo transfer). The transport system has operated now for three years (1995-1997) and at present the authors evaluate the system. The fertility rate and pregnancy rate in individual years was compared and the following conclusions were reached: The fertility rate is significantly (at the 1% level) lower in the transport centre in 1995 and 1996 (47%, 54%) as compared with the other centre the laboratory of which is used by the authors (57%, 61%). In 1997 the difference is no longer significant (63% x 64%). The difference in the pregnancy rate in centres for aspiration and embryo transfer in both centres is insignificant in the years of investigation. It may thus be stated that the oocyte transport does not have a negative influence on the effectiveness of the IVF + ET programme (same pregnancy rate) and thus makes it possible to include a greater and ever increasing number of patients in the IVF programme by making use of reserve capacities of embryological laboratories and thus reduce the total costs of this programme.

[Sactosalpinx, one of the factors affecting the results of in vitro fertilization]. / Sactosalpinx, jeden z faktoru ovlivnující výsledky IVF.

The tubal factor of sterility is nowadays already a classical and also the most frequent indication for including the patient in a programme of in vitro fertilization--embryo transfer (IVF-ET) [3]. Tubal sterility has a multifactorial etiology. The causes include unilateral or bilateral sactosalpinx, distal and proximal obstructions, intraluminal or extramural adhesions. In many patients with damaged oviducts who were included in our IVF programme we recorded repeatedly failures despite an adequate ovarian response to the stimulation by menogonadotropins, uncomplicated collection of oocytes, equal numbers of collected oocytes, similar fertilization and embryo transfer of high standard embrya. In this group of patients sactosalpinx was frequently encountered. Recent investigations assume that the presence of sactosalpinx reduces the implantation rate, pregnancy rate, increases early gestation losses and the incidence of extrauterine pregnancies [12, 5, 14]. In the submitted paper the authors evaluated the possible effect of sactosalpinx on the results of the IVF-ET programme.

[Ultrasonographic hysterosalpingography]. / Ultrazvuková hysterosalpingografie.

The objective of the investigation was to compare US hysterosalpingography with methods currently used to examine tubal patency, i.e. hysterosalpingography and laparoscopy with chromoperturbation. The examination was made in 39 women with the diagnosis of primary or secondary sterility. Consistent with data in the literature, the authors proved a high concordance (86.8%) with reference methods. US HSG is an ambulatory minimally-invasive method of examination of the uterine cavity and patency of the oviducts, which is well tolerated by patients.

[The transport system in the in vitro fertilization program]. / Transportní systém v programu in vitro fertilizace.

The programme of in vitro fertilization helps at present successfully to resolve the problem of sterility in an ever increasing number of married couples. It is, however, a method which is very pretentious from the technical aspect, from the aspect of time and financial demands. Therefore in February 1994 with the Institute for the Care of Mother and Child in Prague-Podolí collaboration in the Transport IVF programme was started. In our clinic the first two stages of the IVF programme are implemented, i.e. stimulation of the ovaries and aspiration of the follicles. The patients of our centre for sterility are included in the programme, if the following indications are present: tubal factor 82%, idiopathic sterility 4%, the remainder being endometriosis, andrological factor and others. The majority of women were in the age group from 30-35 years. Stimulation is most frequently implemented by GnRh analogues and menopausal gonadotropins, aspiration of follicles by the transvaginal route with short analgosedation under so-called semi-ambulatory conditions. The aspirated follicular fluid is immediately stored in a special transport incubator G-812 of K-system Co., Denmark. Within 20 minutes it is taken by the patient's husband to the embryological laboratory of the Institute for the Care of Mother and Child in Prague-Podolí. Between February and December 1994 a total of 69 aspirations in 56 patients were made and 15 pregnancies were achieved. It is 23% pregnancies by transfer.(ABSTRACT TRUNCATED AT 250 WORDS)

[Successful completion of pregnancy in a dialyzed patient]. / Uspesne ukoncené tehotenství u dialyzované pacientky.

The authors describe the first case of a successful pregnancy in the Czech Republic in a patient treated by continuous ambulatory peritoneal dialysis. The 22-year-old patient became pregnant ten months after the onset of treatment by peritoneal dialysis. During pregnancy deterioration of arterial hypertension occurred, deterioration of anaemia and from the 29th week onwards cholestasis gravidarum developed. The development of the foetus was within normal limits. Because of suspected preeclampsia the pregnancy was terminated during the 35th week by Caesarean section. The patient was delivered of a healthy eutrophic boy without any congenital abnormalities.