[Antibody detection after antepartal rhesus prophylaxis: normal values or sensitization]. / Antikörper-Nachweis nach antepartaler Rhesus-Prophylaxe: Normalfall oder Sensibilisierung?

Antibody screening tests were performed in 29 unsensitized pregnant women after antepartum Rh immune prophylaxis, using the indirect Coombs test (ICT) and a more sensitive ID-microtyping-system (IDM). With the ICT, anti-D antibodies were detected in 85% for at least 4 weeks and at most 8 weeks after immunisation. The maximum titer was 1:8. With the IDM, 97% showed antibodies against 'D' for at least 4 weeks and at most 11 weeks with a maximum of 1:16. The IDM titer was always 1 to 3 steps more sensitive than the ICT. After postpartum Rh immune prophylaxis, anti-D titers were again positive in many of the patients (ICT: 42%; IDM: 60%). In conclusion, it is nearly always possible to measure antibodies against 'D' after antepartum Rh immune prophylaxis and IDM was superior in comparison to ICT. However, maternal isoimmunisation to the rhesus antigen cannot be excluded for sure and patients have then to be controlled. As isoimmunisation could not be confirmed in any of our patients, postpartum Rh immune prophylaxis has to be administered even after detection of an antibody titer against 'D' after antepartum Rh prophylaxis.

[Clinical aspects of prenatal prevention of rhesus incompatibility]. / Klinische Aspekte der antenatalen Rhesus-Prophylaxe.

The postnatal treatment with anti-D immunoglobulin to prevent rhesus sensitization is successful in about 90% of all rhesus-negative mothers at risk. Failures derive mostly from large fetomaternal hemorrhages during the last months of pregnancy. Studies from Canada, Great Britain and Sweden have shown that the injection of an additional dosage of anti-D during the 28th to 34th week of pregnancy results in a further 90% reduction of the failure rate. Although there is only a limited number of cases of hemolytic diseases in the newborn, the cost-effect ratio of this prophylactic treatment calculated for the Federal Republic of Germany shows not only a medical but also an economic benefit.

[Rate of early abortion after in vitro fertilization and embryo transfer]. / Frühstabortrate nach In-vitro-Fertilisation und Embryotransfer.

The high rate of implantation failures in infertile patients after in vitro fertilization must be regarded as the major problem of the kind of treatment. Usually, no information on the development of the embryo can be obtained for the time between embryo replacement and rising beta-hCG levels. Own studies on the early pregnancy factor (EPF) showed a positive reaction few hours following the contact of a fertilized oocyte with the endometrial surface. Therefore, we used the EPF as a marker for the viability of the embryo in 82 patients after in vitro fertilization and embryo transfer. Within two days after embryo transfer the EPF was positive in 52 (63%) patients and negative in 30 (37%) patients. In these women the embryos may have been lost during handling or may have discontinued further development. Between day 3 and day 12 after transfer the EPF turned to negative values in 35 patients--especially between day 6 and 10. These cases must be regarded as true implantation failures. After day 12 following embryo transfer, rising beta-hCG levels could be measured in 17 women (21%), but only in 12 patients (15%) could a growing embryonic sac be detected by ultrasound. From these figures, we may conclude, that about half of the embryos are lost already during the step of embryo transfer and the other half during implantation. Therefore, more attention should be given to the handling of the embryos to increase the pregnancy rate after in vitro fertilization.

[Successful prevention of adhesions using peat and humic acids]. / Erfolgreiche Adhäsionsprophylaxe durch Anwendung von Moor und Huminsäuren.

In order to verify the adhesion preventing capability of peat and peat components, 180 female rats were subjected to therapeutic bathing after standardised lesions had been placed on both uterine horns and the peritoneum of the anterior abdominal wall. From the 3rd and 7th day after surgery, respectively, randomized groups of animals consisting of 20 animals each were bathed in tap water, pure fresh peat, peat solution after pressing, centrifugation and filtration, and a solution of humic acids extracted from peat, all at the same temperature. One week after bathing for three weeks, the rats were relaparotomized, and quality and degree of the adhesions found were documented. Significant less and minor (p less than 0.001) adhesions were found in animals bathed in humic acid solution compared to the animals which had not been bathed at all. Peat solution and fresh peat reduced the formation of adhesions significantly, too, while warm water baths did not show any antiadhesive effect. Our results suggest humic acids to be the most effective component of peat with regard to the prevention of adhesions.

[Immunological factors in extracorporeal fertilization. The role of antibodies against spermatozoa and zona pellucida antigen]. / Immunologische Faktoren bei extrakorporaler Befruchtung. Die Bedeutung von Antikörpern gegen Spermatozoen und Zona-pellucida-Antigen.

Immunologic disturbances must be considered a major cause of unexplained infertility. To evaluate the influence of sperm antibodies (SPAB) and zona pellucida antibodies (ZPAB) on the pregnancy rate, we have screened patients treated by in-vitro fertilization (IVF) and embryo transfer (ET) in the Department of Obstetrics and Gynecology of the School of Medicine, Hannover, for the presence of sperm antibodies and zona pellucida antibodies in the serum, cervical mucus and uterine secretions, and also in the serum and ejaculate of the husbands. After embryo transfer the concentrations of progesterone and beta-hCG in the sera were determined to evaluate the luteal phase and to detect early pregnancy. Among 122 women 11 clinical pregnancies were achieved; 8 of these pregnant women showed negative antibody reactions, while only 3 women with significant positive reactions for SPAB or ZPAB became pregnant. Only one pregnancy occurred in 24 women with high ZPAB titers. In conclusion, determinations of SPAB- and ZPAB-titers in serum and genital secretions are highly recommended in the evaluation of infertile couples.

[Spermatozoal antibodies in cervical mucus and in the luminal fluid of the uterus in sterile patients]. / Spermatozoen-Antikörper im zervikalen Mukus und in der luminalen Flüssigkeit des Uterus bei Sterilitätspatientinnen.

Poor postcoital tests in infertile patients may be due to dysmucurrhoea, low sperm count, or specific antibodies against spermatozoa. Using a latex agglutination test ("Sperm-antibody-slide-test", Fa. Biotec, Hannover), we examined the cervical and uterine secretions of the patients for sperm antibodies. The results showed a close correlation between a positive sperm-antibody-test and a poor postcoital test, especially in those couples with regular sperm quality. Also in cases with normal postcoital tests, positive sperm-antibody titers can be observed. Therefore, the sperm-antibodies may disturb fertilization in infertile patients even without causing immobilization or agglutination of the spermatozoa in the female genital tract fluids. The determination of the spermatozoa-antibody content in the cervical and uterine secretions must be regarded as an improvement in the diagnostic procedure in human infertility.

[Tubal pregnancies: early pregnancy factor, progesterone, beta-HCG and vaginal sonography as differential diagnostic parameters]. / Tubargraviditäten: early pregnancy factor, Progesteron, beta-HCG und Vaginalsonographie als differentialdiagnostische Parameter.

By anamnestic, clinical, biochemical (beta-HCG), and ultrasonographical data, only a portion of ectopic pregnancies can be diagnosed early enough to allow conservative surgery. In the present study, the diagnostic value of the Early Pregnancy Factor (EPF), progesterone, and endosonography was investigated in 142 patients with suspected tubal pregnancy. beta-HCG and Progesterone serum levels had been in the lover range of or below normal values in most cases of tubal pregnancy compared to intrauterine pregnancies. The EPF was found to be negative in 94% of all cases of ectopic or disturbed intrauterine pregnancies, while all these patients showed a positive pregnancy test (HCG). By abdominal ultrasonography, only 73.7% of all tubal pregnancies could be detected, while transvaginal scanning increased the rate of verified diagnoses up to 90.6% of these cases. Our results suggest that EPF measurement and endosonography are valuable supplements for precise and rapid diagnosis of ectopic pregnancies.

[Early abortion rate in sterility patients: early pregnancy factor as a parameter]. / Untersuchungen zur Frühstabortrate bei Sterilitätspatientinnen: EPF als Parameter.

To evaluate the diagnostic value of Early Pregnancy Factor (EPF) measurements in infertile patients, we performed a modified rosette inhibition test in 58 women after follicular stimulation and/or homologous artificial insemination (AIH). The patients were grouped according to the main diagnosis as cervical hostility, poor semen quality, and anovulation. While the overall fertilization rate in our patients was 39.6%, which is considerably lower than in comparable studies of fertile women, the pregnancy rates per EPF positive cycle in the various groups were 25.0%, 30.8%, and 50.5%, respectively. As the process of fertilization can be detected by EPF measurement within 48 h after ovulation, a distinction can be made between failure of fertilization and of implantation. Thus, a valuable diagnostic tool has become available for treatment of infertile patients.

Early pregnancy factor as a marker for the earliest stages of pregnancy in infertile women.

Early pregnancy factor (EPF) is known to be detectable in sera of pregnant women within 24 to 48 h after conception. To examine the incidence of early embryonic loss after hormonal treatment and homologous artificial insemination, we screened the sera of our patients for the presence of EPF by means of a rosette inhibition test. Our results show a considerably lower conception rate as described in appropriate studies on fertile women. If reduced sperm quality is the indication for insemination, the abortion rate in the first 2 weeks of gestation is significantly increased in relation to the rest of our patients. Infertility because of an impaired development of the embryo, especially if repeated EPF-positive cycles do not result in a pregnancy, may be due to chromosomal defects or malformations and a chromosomal analysis is recommended. In patients in whom EPF is never found to be positive, indicating a disorder of conception, we regard IVF/ET to be the treatment of choice.

Influence of luteinizing hormone and prostaglandin F2 alpha on progesterone secretion in superfused bovine luteal tissue slices.

Tissue slices from bovine corpus luteum from Days 12 or 13 of the oestrous cycle were superfused for 8 h, and the progesterone secretion under the influence of prostaglandin F2 alpha (PGF2 alpha) and/or LH was measured. PGF2 alpha at concentrations of 0.28 to 2800 nmol/l medium did not affect the basal progesterone secretion, whereas higher doses (7000 to 28,000 nmol/l) induced a slight increase in hormone secretion. LH, 3.4 nmol/l, caused an increase in the progesterone concentration in superfusates which exceeded the control levels (P less than 0.01). This luteotropic effect of LH was not influenced by simultaneous addition of 28 to 2800 nmol/l PGF2 alpha. PGF2 alpha, 2800 nmol/l, did not inhibit progesterone secretion, when administered together with 0.034 to 34 nmol LH/l. Pre-superfusion with 2800 nmol/l PGF2 alpha had no effect on the LH-stimulated increase in progesterone secretion. It is concluded that in cattle, a direct cellular effect of PGF2 alpha, antagonizing the luteotropic function of LH, may be of less importance than other possible direct and indirect PGF2 alpha actions.

Influence of microsurgical reanastomosis of the fallopian tube on luminal pH and PO2 and on the fertilization rate and embryo development in the rabbit oviduct.

The luminal pH and PO2 were measured in rabbit oviducts to evaluate the influence of microsurgery on the environment within the fallopian tube before and after resection of a 1 cm ampullary portion with subsequent tubal reanastomosis. While the oxygen tension showed no difference between the operated oviduct (56 +/- 16 mmHg, n = 8) and the control side (53 +/- 13 mmHg, n = 8), there was a significant pH decrease in the oviducts after microsurgery (7.94 +/- 0.10, n = 8, versus 7.75 +/- 0.16, n = 8, p less than 0.0025). In the second part of the experiment the operated animals were induced to ovulate by hCG injection, and artificial insemination was performed at the same time. The number of fertilized and unfertilized oocytes and the stages of embryonic development (64 h post hCG) were compared between the operated and control oviducts. From the operated oviducts a lower number of ova were recovered and a lower rate of fertilization was observed. The data indicate that microsurgery of the rabbit fallopian tube does not disturb the luminal oxygen tension but may cause a lower pH. Ultimately a reduced rate of fertilization and impaired early development were observed.

PO2 and pH measurements within the rabbit oviduct following tubal microsurgery: reanastomosis of previously dissected tubes.

Adhesions of the fallopian tube might be a source of generalized infertility. In order to improve the mechanical and functional properties of the oviduct, microsurgical replacement of the affected tubular segments have been applied, however, with contradictory results. In order to improve the situation and gain further information about this problem, catheter microelectrodes for Po2 and pH measurements within the lumen of the fallopian tube have been developed. The validity of the measurements was tested in a series of rabbits (Dutch belt strain, n = 19, 3.5-4.5 kg bw) which have been laparatomized under pentobarbital anesthesia during the oestrus phase. From one side of the oviduct 1 cm was resected and the free ends reanastomosed while the other side served as a control. Six to eight weeks later Po2 and pH values within the oviduct were measured. After another 4-5 weeks ovulation had been induced and artificial insemination performed. 64 hours later the rabbits were sacrificed. The oviducts were isolated and the corpora lutea as well as the ova were collected and examined histologically. The mean Po2 of the oviduct was 53 (+/- 16) mm Hg (mean +/- SD) for the control side and 56 (+/- 13) mm Hg (mean +/- SD) within the anastomosed tubes. The range of values was the same in both groups (n = 8) 34-75 mm Hg. A T-test comparison of the means of the two groups gave p-values which were not significant (p greater than 0.1). Po2 fluctuations with small-fast amplitudes (1 mm Hg) and additional slow-large oscillations (about 20 mm Hg) have been observed similar to the Po2 waves described for muscle and brain. The mean pH value of the oviduct a showed slight, statistically significant pH differences (7.75 reanastomosed side, 7.94 control side) whereby the degree of adhesions was correlated with luminal pH value. In three rabbits the relationship between corpora lutea and fertilized ova was 1:6, 2:9, 3:6 for the reanastomosed side while the control side showed balanced quotients of 4:4, 4:4, 6:6. In two rabbits unfertilized ova have been observed within the reanastomosed tubes where the typical outside layer of mucoproteids was absent while the control side was normal. Nevertheless, within both oviducts a continuous layer of epithelial cells has been observed even after reanastomosis.

[Immuno-elimination and clearance of Rh-positive erythrocytes in Rh-negative volunteers following administration of anti-D-immunoglobulin]. / Immunelimination und Abbau Rh-positiver Erythrozyten in Rh-negativen Versuchspersonen nach Gabe von Anti-D-Immunglobulin.

The prophylactic treatment of Rhesus-negative women to prevent Rhesus-sensitization has been accepted worldwide, although the working mechanism of the anti-D-immunoglobulin is still unknown. We have used Cr-51-labelled red blood cells to investigate the immune clearance of the cells in Rhesus-negative volunteers following injection of anti-D. Intravenous application of anti-D-immunoglobulin resulted in an accelerated elimination of the Rhesus-positive erythrocytes from the peripheral blood in contrast to the intramuscular treatment with the same dosage. But we had not been able to investigate whether the intravenous route might result in a more effective prophylaxis. In result of the application of IgG-anti-D sequestration can be observed in the spleen. This organ seems to be of great importance for the working mechanism of the anti-D-immunoglobulin. On the other hand splenectomized patients showed reduced clearance rates. In these cases the liver may be involved in the elimination of the red blood cells. F(ab')2-fragments, which cannot pass the placental barrier, seemed to be ineffective with respects to immunosuppression. As patients showing the Du-variant can be sensitized against -- D -- they also should receive anti-D-immunoglobulin for prophylaxis.

[New recommendations for the completion of rhesus-immunization prophylaxis with anti-D]. / Neue Empfehlungen zur Durchführung der Rhesusprophylaxe mit Anti-D.

Despite the successful prevention of the Rhesus-isoimmunization in Rhesus-negative mothers after delivery of a Rhesus-positive child by immunoglobulin anti-D injected post partum, some women still get sensitized against the Rhesus-antigen by transplacental haemorrhages occurring during pregnancy or in miscarriages, abortions or ectopic pregnancies. Besides that, failures of the Rhesus-prophylaxis may be caused by large volumes of fetal blood transferred to the maternal circulation - especially in complicated deliveries. We therefore recommend to give immunoglobulin anti-D during pregnancy whenever there is a reported risk of significant transplacental haemorrhages. Further we urge to count the fetal cells in the maternal blood after each delivery to adjust the anti-D-dosage to the volume of the transplacental haemorrhage.

[Alpha fetoprotein and HbF cells in the maternal blood and their modification through amniocentesis]. / Alpha-Fetoprotein und HbF-Zellen im maternen Blut und ihre Beeinflussung durch Amniozentesen.

In 101 patients of the Frauenklinik der Medizinischen Hochschule Hannover we have measured the concentrations of fetal cells and alpha-fetoprotein before and after amniocentesis. There was a significant increase in both parameters corresponding to an arbitrary fetomaternal haemorrhage of 0,05--0,4 ml. AFP seemed to be more reliable than the fetal cell count. The site of placentation was of no influence on the fetomaternal haemorrhage. As less than 0,1 ml rhesus-positive fetal blood is enough to cause isoimmunization in mothers at risk we highly recommend to give immunoglobulin-anti-D to all unsensitized rhesus-negative mothers after amniocentesis.

Immunoprophylactic anti-Rho(D) treatment after mismatched transfusions.

80 cases of anti-Rho(D) treatment after mismatched transfusions are reviewed to compare the intramuscular (i.m.) and intravenous (i.v.) route of treatment. No severe reactions such as renal failure occurred with either method of anti-D treatment. If the Rh-immune globulin is injected i.m., 20 micrograms anti-D per ml red cells are used. For i.v. anti-D administration, 10-12 micrograms anti-D are suggested. The i.v. method of anti-D treatment is recommended for the future. Furthermore, a scheme of treatment for after mismatched transfusions is described.

[Anti-D prophylaxis after abortions and interruptions]. / Anti-D-Prophylaxe bei Aborten und Interruptionen.

In almost every pregnancy feto-maternal transfusions occur. From the 6th week of pregnancy, blood containing Rhesus antigens may be infused into the maternal circulation and cause sensitization. In case of miscarriage, abortion, ectopic pregnancy and cystic mole the chance of fetomaternal transfusion followed by sensitization of the mother is significantly increased. Therefore immunoprophylaxis with anti-D-immunoglobins should be performed in all these cases.

PIP: Rh-sensitization in cases of spontaneous and induced abortions is discussed. In an intact pregnancy, the average volume of fetomaternal transfusion is about .1-.2 ml. Rh antibodies occur in 2% of the cases of Rh-negative mother with Rh-positive child during the first pregnancy and 11-17% during the second pregnancy. The standard Anti-D dosage in such cases is 250-330 mcg, enough to counteract a fetomaternal transfusion of 30 ml. In the case of spontaneous abortions, the average volume of fetomaternal transfusion ranges from .l-1.0 ml. Fetal erythrocytes are found in 5-25% of pregnant women before the 12th week of pregnancy and 12-45% after the 12th week. The risk of Rh-sensitization ranges from 3-10% in cases of spontaneous abortion; the risk increases with the length of pregnancy. Other factors, e.g., parity, age, and the use of oxytocin during subsequent curettage, show no relationship to the volume of fetomaternal transfusion. In the case of induced abortion, the volume of fetomaternal transfusion is generally greater than .1 ml. Fetomaternal transfusions were more frequent in conjunction with salt water instillation than with vacuum aspiration in pregnancies before the 12th-16th week of pregnancy; the opposite was true for induced abortions performed after the 13th week of pregnancy. Fetomaternal transfusion is also possible in cases of ectopic pregnancy and hydatidiform mole. Anti-D prophylaxis should be used in all cases of spontaneous and induced abortion, ectopic pregnancy, and hydatidiform mole, except in cases before the 6th week of pregnancy. The standard dosage of 250-330 mg should be used, except before the 12th week of pregnancy; in this case, 50 mcg has been shown to be sufficient.