Reproductive outcome using a GnRH antagonist (cetrorelix) for luteolysis and follicular synchronization in poor responder IVF/ICSI patients treated with a flexible GnRH antagonist protocol.

To investigate the possible beneficial effect of a new stimulation protocol (termed 'CRASH') on the outcome of poor responder patients, a multicentre, prospective longitudinal study including a total of 36 women undergoing 72 IVF/intracytoplasmic sperm injection (ICSI) cycles with patients serving as their own controls, was conducted. A poor responder patient was defined as a patient with four or fewer oocytes extracted from five or fewer follicles and with a total FSH consumption exceeding 2000 IU in a preceding long agonist down-regulation protocol. The CRASH protocol included 3 mg of the gonadotrophin-releasing hormone (GnRH) antagonist cetrorelix given in the late luteal phase on cycle day 23. Stimulation with recombinant human FSH (rhFSH) started on cycle day 2, followed by a flexible GnRH antagonist protocol. The results showed significantly more follicles (5.4 versus 3.5), oocytes (4.3 versus 2.4) and transferable embryos (1.8 versus 0.8) with the CRASH protocol as compared with the preceding long protocol (P < 0.005 in all cases). The implantation rate and pregnancy rate per transfer was 18.4 and 38.5% respectively, approaching the clinical outcome of normal responder patients. The CRASH protocol thus may constitute an attractive alternative to conventional protocols for low responder patients, improving their clinical outcome.

High ratings of satisfaction with fertility treatment are common: findings from the Copenhagen Multi-centre Psychosocial Infertility (COMPI) Research Programme.

BACKGROUND: The aims were: (i). to identify gender differences in evaluation of medical and patient-centred (psychosocial) care in fertility clinics and (ii). to identify predictors of satisfaction. METHODS: An epidemiological prospective study based on questionnaire responses among all new couples attending five fertility clinics. The response rate at the 12 month follow-up was 87.7% and included a total of 1934 patients. RESULTS: During the follow-up period about two-thirds had achieved a pregnancy and about a third became parents. The participants were satisfied with both the medical and patient-centred (psychosocial) services. There were no sex differences in the evaluation of treatment except that women were more satisfied than men with how the staff had performed their medical examinations. Satisfaction with medical and patient-centred services was positively associated with a treatment-related pregnancy/delivery and the report of marital benefits resulting from the infertility experience. Lower social class was a significant predictor for satisfaction. CONCLUSIONS: Both men and women in fertility treatment had high ratings on medical and patient-centred care. It seemed that satisfaction with the psychosocial services was higher than in earlier studies from other countries.

Patients' attitudes to medical and psychosocial aspects of care in fertility clinics: findings from the Copenhagen Multi-centre Psychosocial Infertility (COMPI) Research Programme.

BACKGROUND: The aims were (i) to identify gender differences in motivations to seek assisted reproduction and gender differences in expectations about medical and psychosocial services and (ii) to examine factors that predict the perceived importance of, and intention to use, psychosocial services among infertile people. METHODS: We conducted an epidemiological study based on questionnaires among all new couples attending five fertility clinics with a response rate of 80.0% and a total of 2250 patients. RESULTS: The vast majority of both men and women considered a high level of medical information and patient-centred care as important. Fewer respondents (women 10.0-20.8%, men 4.1-8.9%) felt that professional psychosocial services were important and/or had the intention to use these services. The main predictor of perceived importance of patient-centred care and professional psychosocial services for both men and women was high infertility-related stress in the marital, personal and social domain. CONCLUSIONS: A supportive attitude from medical staff and the provision of both medical and psychosocial information and support should be integral aspects of medical care in fertility clinics. Although only a minority of the participants perceived professional psychosocial services as important, they should be available for patients whose infertility causes them much strain, especially for patients whose marital relationship suffered much because of infertility.

Maternal serum supplementation in culture medium benefits maturation of immature human oocytes.

This study compared the rates of maturation, fertilization, cleavage and pregnancy among oocytes matured in medium containing either human serum albumin (HSA) or maternal serum. Immature oocytes were obtained from 51 consecutive regularly cycling women <38 years of age. Immature oocytes were aspirated transvaginally on cycle day 8-9 after priming with FSH (Gonal-F 150 IU/day for 3 days, initiated on day 3). Oocytes were matured in Dyrkningsmedie til IVM supplemented with recombinant FSH (rFSH) 0.075 IU/ml and HCG 0.5 IU/ml for 28-30 h. In group I (n = 63 oocytes obtained from the first 23 cycles) the culture medium was supplemented with 2% (w/v) HSA. In group II (n = 74 oocytes obtained from the following 28 cycles) the medium was supplemented with 10% (v/v) heat-inactivated maternal serum. Intracytoplasmic sperm injection (ICSI) was performed on all methaphase II oocytes. Significantly increased rates of maturation 47/74 (63%) vs. 26/63 (41%) (P < 0.05), pregnancy 6/28 (21%) vs. 0/23 (0%) (P < 0.05) and implantation 6/20 (30%) vs. 0/15 (0%) (P < 0.05) were obtained from oocytes matured in culture medium with maternal serum supplementation compared with oocytes matured in medium supplemented with HSA. These results indicate that factors other than albumin in maternal serum play an important role in maturation and subsequent developmental capacity of human oocytes.

[The first 100 early medical abortions]. / De første 100 tidlige medicinske aborter.

Early medical abortion was introduced in Denmark in 1998. This article describes our experiences with the first 100 patients at Herlev University Hospital. The regimen was 600 mg mifepriston (RU486) given orally on day one. All women had an ultrasound examination before RU486 was given in order to ensure an intrauterine pregnancy and a gestationel age of eight weeks or less, and all had a quantitative P-hCG. On day three the patients received 1 mg gemeprost as vagitory as well as a paracetamol/-codein suppository. They were observed in the department for four hours, and were thereafter discharged no matter whether a complete abortion had occurred ot not. On day 14 a new P-hCG was taken. All women in whom the hCG value was not reduced to one half of the initial value or less underwent a new ultrasound examination. All women were given a questionnaire. The effectivity was 96%. Four of 100 women were evacuated: one due to severe vaginal bleeding four hours after application of gemeprost, two because of womiting soon after having taken RU486 and one due to incomplete abortion. Half of the women began to bleed before application of gemeprost, and 91% had bleeding for more than six days. One half had no side effects to mifepristone, the other half had mild nausea. Nine of ten patients were sufficiently relieved of pain without opioids, whereas 10% were insufficiently pain relieved. Eight of ten patients would choose the same method again, in case of a future need for an induced abortion. The reason for not preferring a medical abortion among the remaining 20% was primarily pain. Early medical abortion should be offered to all women referred for induced abortion with a gestational age of eight weeks or less.

[Prophylactic use of prostaglandin synthesis inhibitors in connection with IUD insertion]. / Profylaktisk brug af prostaglandinsyntesehaemmere ved oplaegning af spiral.

In a double-blind, randomized, placebo-controlled study conducted at a contraception clinic, 55 women (three nulliparous) were given either ibuprofen 600 mg or placebo 1-4 hours prior to insertion of IUD, 4-6 hours after insertion of IUD and the following morning. Pain was assessed by ten point Numerical Rating Scales during insertion, in the first 4-6 hours and in the following three days. No benefit of ibuprofen was demonstrated at insertion or at any other time during the first three days. The patients were further randomized to type of IUD: TCu-380A and Nova T (R.). No difference in pain scores was evaluated between these.

PIP: In a double-blind, randomized, placebo-controlled study conducted at a family planning clinic in Herlev, County of Copenhagen, during the period of May 1994 to May 1995, a total of 55 women were randomized in the following 4 groups according to treatment: 1) ibuprofen and the Gyne T 380 IUD, 2) ibuprofen and Nova T IUD, 3) placebo and Gyne T 380 IUD, and 4) placebo and Nova T IUD. All women were given either ibuprofen 600 mg or placebo 1-4 hours prior to insertion of an IUD, 4-6 hours after insertion, and the morning after insertion. Pain was assessed by a 10-point Numerical Rating Scale during insertion, in the first 4-6 hours, and over the following 3 days. The median values of pain intensity for Nova T and Gyne T were 3.0/2.9 at insertion, 1.6/1.9 during the first 4-6 hours, 1.3/1.5 during the first day, 1.1/1.3 the next day, and 1.1/1.1 on the third day after insertion. The median values of pain intensity for the ibuprofen/placebo groups were 3.3/2.5 at insertion, 1.7/1.8 during the first 4-6 hours, 1.4/1.3 during the first day, 1.3/1.1 the next day, and 1.1/1.1 on the third day after insertion. Among the women who had just given birth only 6% had intensity of pain over point 3 after 4-6 hours and none of them had it beyond the first day. 38% had significantly more pain (3) at insertion; this problem could be prevented by local anesthesia. No benefit of ibuprofen was demonstrated at insertion or at any other time during the first three days. The patients were further randomized according to the type of IUD: TCu-380A and Nova T. No difference in pain scores was ascertained between these groups.

[The antiprogesterone preparation mifepristone (RU 486). Should this "abortion pill" be introduced in Denmark?]. / Antiprogesteronpraeparatet mifepriston (RU 486). Bør man indføre denne "abortpille" i Danmark?

The antiprogesterone mifepristone (RU 486) was synthesized in 1980 by Roussel-Uclaf (Paris). Since 1982 several studies have examined the ability of the drug to interrupt early pregnancies. 600 mg of mifepristone given by mouth to pregnant women with an amenorrhea of less than 50 days will lead to vaginal bleeding in more than 97% of the cases. The bleeding will be followed by moderate (menstruation-like) pain, and complete abortion will occur in 75% of the cases. A success rate of 75% is not sufficient for clinical use. The treatment should therefore consist of a combination of mifepristone and prostaglandin. The prostaglandin can be administered either by i.m. injections or as a vaginal suppository given 38-48 hours after the patient has received 600 mg of mifepristone by mouth. Such a combination of mifepristone and prostaglandin results in a complete abortion rate of more than 95%. Pelvic inflammatory disease (P.I.D.) after these abortions is extremely rare (below 0.5%), and other serious side effects are also uncommon. We find that mifepristone in combination with prostaglandin should be offered to Danish women seeking abortion as an alternative to the traditional method of vacuum aspiration.

Serious intestinal complication five years after insertion of a Nova-T.

This report presents a case of sigmoid perforation five years after insertion of a Nova-T. This case illustrates that serious complications of third generation IUDs may occur even after several years of intraabdominal location. An IUD, which has perforated the uterus, cannot be left in the peritoneal cavity. Therefore, removal of a perforated IUD is still a medical indication as recommended by the World Health Organization and IPPF International Medical Advisory Panel Meetings.

[Diagnosis and treatment of women with urinary incontinence at Danish gynecologic departments]. / Diagnostik og behandling af kvinder med urin-inkontinens på danske gynaekologiske afdelinger.

The routine practice in the diagnosis and treatment of urinary incontinence was investigated by means of a questionnaire to which all 32 departments replied. Miction charts were employed routinely in 17 departments and for selected patients in eight departments. Weighing of diapers was employed in 13 departments for all patients investigated for incontinence, but only for selected patients in ten departments. Cystometry was employed in cases of stress-incontinence in 23 departments and in cases of urge-incontinence in 30 departments. As regards the choice of operative treatment, 22 departments stated that they would employ abdominal intervention in cases of anterior suspension defect and vaginal operation in posterior suspension defects. Other departments perferred an abdominal or vaginal approach without employment of guiding miction cysto-urethrography. It is concluded that there are great differences in the routine practices in Danish gynaecological departments in the diagnosis and treatment of utinary incontinence. This appears to be a suitable field for so called reference programmes.

Risk factors and sib correlation in physiological neonatal jaundice.

The effect of a number of explanatory variables on the degree of physiological jaundice in mature infants was evaluated by multiple regression analysis. The sampling was designed so that comparisons could be made between siblings. We found an effect of gestational age, gender, infant nutrition, ABO incompatibility and induction of labour. Taking these factors into account we still found a highly significant correlation between the peak bilirubin levels of siblings. Whether this correlation is genetically or environmentally determined is not clear.

Clinical value of pregnancy-specific beta 1-glycoprotein (SP1) and beta-hCG determination in serum in suspected ectopic pregnancy.

We compared the clinical value of pregnancy-specific beta 1-glycoprotein (SP1) determination in serum by means of a highly sensitive enzyme-linked immunosorbent assay (ELISA) versus that of beta human chorionic gonadotropin (beta-hCG) determination in suspected ectopic pregnancy. The study comprised 58 women admitted consecutively with suspected ectopic pregnancy but without signs warranting immediate surgical intervention. Both SP1 and beta-hCG were found in 11 patients with ectopic pregnancy and in 8 patients with early intra-uterine pregnancy, whereas beta-hCG was detected in 4 and SP1 in 7 of 8 women with a recent abortion. Of 31 women presenting a non-pregnant condition, 2 were positive for both SP1 and beta-hCG. The measurement of SP1 in serum thus appears to be an alternative to beta-hCG measurement when ectopic pregnancy is suspected.

Phenoxybenzamine reduces bladder outlet obstruction in benign prostatic hyperplasia. A urodynamic investigation.

Nine patients with bladder outlet obstruction attributable to benign prostatic hyperplasia were treated with 15 mg of phenoxybenzamine daily. Spontaneous urinary flow, water cystometry, simultaneous pressure-flow-EMG, and the urethral closure pressure profile were measured before and at the end of 4 weeks of treatment with phenoxybenzamine. A significant reduction in residual urine volume and a significant increase in the first sensation and bladder capacity were found. All voiding pressure parameters were significantly reduced and flow rates significantly increased. Urethral closure pressure decreased significantly.

Bladder function after abdominoperineal resection of the rectum for anorectal cancer. Urodynamic investigation before and after operative in a consecutive series.

In a consecutive series of 26 patients (10 men and 16 women) undergoing abdominoperineal resection of the rectum, cystometry and pressure-flow-EMG measurements were made preoperatively and three and 6-12 months after operation. Two patients developed neurogenic bladder paresis (7.7%, 95% c.l. 1-25%). Men with even slight complaints of bladder outlet obstruction preoperatively ran a risk of postoperative aggravation demanding surgery. In women no significant changes in micturition patterns were found. It is concluded that urinary flow measurement and cystometry should be available as minimum screening procedures after abdominoperineal resection of the rectum to detect bladder dysfunction at an early stage.