Prevalence and Associated Risk Factors for Obesity During Pregnancy Over Time.

Objective: The increasing prevalence of obesity is having an impact on morbidity worldwide. Since young mature women are equally affected by the general increase in weight, the aim of the study was to evaluate the prevalence of obesity together with associated maternal risk factors, complications during pregnancy, and fetal outcomes in a local cohort for the years 2006 and 2011. Study Design: Maternal and fetal records of women who delivered at the University of Würzburg, with a 5-year interval (2006 and 2011) between investigations, were retrospectively analyzed. Descriptive statistics included prevalence of obesity, maternal weight gain, as well as several complications during pregnancy and fetal characteristics. The association between maternal or fetal complications and extent of maternal obesity was analyzed. Results: Our analysis included 2838 mothers with singleton pregnancies who delivered in 2006 (n = 1293) or 2011 (n = 1545) in our department. We found that neither pre-pregnancy body mass index (23.77 ± 4.85 vs. 24.09 ± 5.10 kg/m2, p = 0.25) nor weight gain (14.41 ± 5.77 vs. 14.78 ± 5.65 kg; p = 0.09) increased significantly over time. But the majority of all overweight (71 %) or obese (60.4 %) mothers gained more weight than generally recommended. The prevalence of gestational diabetes, gestational hypertension, and preeclampsia increased significantly and was associated with high pre-pregnancy body mass index, as was delivery by cesarean section. However, obesity was not associated with prolonged pregnancy and did not seem to negatively affect fetal outcome. Conclusion: There is a trend to increasing weight gain during pregnancy, and the majority of mothers, especially those with a high pre-pregnancy body mass index, exceeded the weight gain recommendations. Associated risk factors such as gestational diabetes, hypertension, and delivery by cesarean section are increasing.

Pregnancy and Obstetrical Outcomes in Women Over 40 Years of Age.

Introduction: Delayed childbearing is increasing, and advanced maternal age has been associated with an increased risk of obstetrical complications. The purpose of this study was to evaluate pregnancy outcomes in women with advanced maternal age (≥ 40 years). Methods: Maternal and obstetrical data were collected from the Department of Obstetrics and Gynecology of the University of Wuerzburg for the period from 2006 to 2011. In this retrospective analysis we compared the outcomes for women aged ≥ 40 years (n = 405) with those of three younger subgroups (I: < 30 y; II: 30-34 y; III: 35-39 y). Results: Pregnant women older than 40 years had more chronic diseases such as hypertension, needed medical treatment more frequently and had a higher thrombosis risk. Pregnancy-induced diseases such as gestational diabetes, preeclampsia and pregnancy-associated hypertension occurred more often in women ≥ 40 years of age. Compared to mothers who were younger than 30 years, primiparous women ≥ 40 years had a more than four times higher overall cesarean section rate and four times higher elective cesarean section rate. Furthermore, they required longer hospital stays, both after cesarean section and after vaginal delivery. The preterm birth rate (≤ 32 weeks of gestation) was similar across the different age groups. Conclusions: The outcomes of pregnancy and childbirth and for newborns born to women ≥ 40 years did not vary significantly from those of younger women if the following conditions were met: a) pre-existing chronic diseases were treated medically and dietetically; b) pregnancy-induced morbidity was monitored regularly and controlled medically; c) women attended regular prenatal check-ups; d) a healthy lifestyle was adhered to during pregnancy, and e) delivery occurred in a perinatal center.

[Umbilical Absent and Reverse End-Diastolic Flow Velocity Waveforms Already Present Prior to Viability do not Exclude Long-Term Foetal Surveillance: A Report of Two Cases]. / Langzeitüberwachung nach dopplersonografischem Nachweis eines umbilikalen Null- und Rückflusses vor extrauteriner Lebensfähigkeit - 2 Kasuistiken.

The finding of absent or reverse end-diastolic flow velocities (AREDV) in the umbilical artery already prior to viability corresponds to the most severe end of the clinical spectrum of placental insufficiency. However, there is little or no experience or published literature with regard to perinatal outcome. We report 2 cases in which structurally and chromosomally normal foetuses showed severe early onset retardation but were continuing to grow. These gestations could be prolonged by 62 and 64 days, respectively. Perinatal outcome was good in both following Caesarean section at 32+3 and 31+5 gestational weeks respectively.

[Prognostic factors of perinatal short-term outcome in severe placental insufficiency using Doppler sonography to assess end-diastolic absent and reverse blood flow in umbilical arteries]. / Prognosefaktoren des perinatalen Kurzzeitergebnisses bei schwerer Plazentainsuffizienz mit dopplersonografisch enddiastolischem Null- und Rückfluss in der Art. umbilicalis.

Significant placental insufficiency, indicated by Doppler ultrasound findings of absent or reverse end-diastolic flow velocities (AREDV), is associated with increased morbidity and mortality. Analysis of blood flow in the ductus venosus should assist in early intrauterine recognition of threatened foetuses. 58 high-risk pregnancies with umbilical AREDV were repeatedly examined (n=364). Doppler findings were correlated with neonatal signs of deterioration (ratio of normoblasts to leukocytes, pH, base excess, Apgar score), as well as short-term morbidity [need for intubation, duration of assisted respiration, evidence of respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), necrotising enterocolitis (NEC), intraventricular haemorrhage (IVH grade III+IV)] against the analysis of the blood flow findings (normal or increased pulsitility, absence or reverse end-diastolic flow) in the umbilical arteries (AU), the middle cerebral arteries (ACM) and ductus venosus (DV) relating these to birth weight and the duration of the pregnancy. The median period of observation was 12.8 days, 48% of the foetuses showed an abnormal ductus venosus flow and 26% an absent venous or reverse end-diastolic flow. The median date of delivery was 30 weeks, with a mean birth weight of 816 g. 93% were live births with 12% dying postnatally. Although the criteria for postnatal morbidity (BPD, NEC, IVH III+IV) and mortality did not correlate with changes in arterial and venous Doppler parameters in our group, there was a significant relationship between the normoblast count, known to be a marker of chronic hypoxia. The Apgar 10 minte score, umbilical arterial pH and base excess were correlated with changes in the DV flow curves. Healthy survival started, irrespective of arterial or venous blood flow criteria, from 27+0 weeks of pregnancy. If born between 27.0 and 30+6 weeks, the infants were more likely to be healthy the less the blood flow had been compromised. A birth weight of 590 g (sensitivity 62.5%; specificity 93.5%) and gestational age of 28+5 weeks (sensitivity 87.5%; specificity 90.3%) were shown to be cut-off points between healthy survival and survival with serious neonatal complications.

[Unexpected respiratory distress in the delivery room--a rare differential diagnosis for the obstetrician and neonatologist]. / Unerwartete Atemnot im Kreißsaal--eine seltene Differenzialdiagnose für Geburtshelfer und Neonatologen.

We present the case of a female infant born prematurely at 34 weeks of gestation. Prenatally a midsized ventricular septal defect was diagnosed. Due to marked respiratory distress intubation was attempted but failed, since the tube could not be placed beyond the glottis. Oxygenation could be improved by nasopharyngeal bag ventilation. The clinical course as well as radiographic imaging was suggestive for a complete tracheal agenesis with broncho-oesophageal fistula which was confirmed at autopsy. Tracheal agenesis (TA) is a rare differential diagnosis of postnatal respiratory distress and the obstetrician or neonatologist will regularly be surprised by this malformation. Partial or complete absence of the trachea without associated malformations will be rarely diagnosed antenatally. In the case of the absence of an oesophageal fistula to the remaining airway a congenital high airway obstruction syndrome (CHAOS) ensues, leading to enlarged hyperechogenic lungs, dilated and fluid-filled trachea and bronchi and an absent tracheal flow during foetal breathing. Aetiology of TA is unknown, therapeutic options are limited thus making TA a usually fatal disorder.

Live-born trisomy 22: patient report and review.

Trisomy 22 is a common trisomy in spontaneous abortions. In contrast, live-born trisomy 22 is rarely seen due to severe organ malformations associated with this condition. Here, we report on a male infant with complete, non-mosaic trisomy 22 born at 35 + 5 weeks via caesarean section. Peripheral blood lymphocytes and fibroblasts showed an additional chromosome 22 in all metaphases analyzed (47,XY,+22). In addition, array CGH confirmed complete trisomy 22. The patient's clinical features included dolichocephalus, hypertelorism, flattened nasal bridge, dysplastic ears with preauricular sinuses and tags, medial cleft palate, anal atresia, and coronary hypospadias with scrotum bipartitum. Essential treatment was implemented in close coordination with the parents. The child died 29 days after birth due to respiratory insufficiency and deterioration of renal function. Our patient's history complements other reports illustrating that children with complete trisomy 22 may survive until birth and beyond.

[Acute foeto-foetal transfusion syndrome--case report and review of the literature]. / Akutes fetofetales Transfusionssyndrom--Fallbericht und Literaturübersicht.

The perinatal morbidity and mortality risk in monochorionic twin pregnancies are 3-5-fold increased compared to those of dichorionic twin pregnancies. Partially, this is due to the higher rate of preterm delivery but also to the twin-to-twin transfusion syndrome (TTTS). Caused by unidirectional blood flow via placental anastomoses, the TTTS leads to weight differences of more than 20% between monochorial twins. The blood donor often shows oligohydramnios, whereas the recipient shows polyhydramnios. Lewi et al. demonstrated, in a study with 202 monochorionic twin pregnancies, a 9% rate of severe TTTS. The mortality of this complication is about 90% when untreated. In contrast to the chronic TTTS, little is known about the acute intrapartal one, which is characterised by anaemia and hypovolaemia of the donor and polyglobulia of the recipient without significant weight differences between the two. In most cases, anaemia occurred after normal delivery of the first twin. Still, there are no means or signs for early detection. We describe the case of a 30-year-old primigravida with a monochorionic diamniotic twin pregnancy. During pregnancy, no evidence of TTTS could be detected. At 37 + 1 weeks gestation labour was induced with prostaglandin-containing gel. Both foetuses showed cephalic presentation. The CTG of the first twin showed a conspicuous heart rate. After labour the first twin presented with anaemia and hypovolaemic shock, the APGAR was 2/7/8. The infant's haemoglobin was 13.7 g/dL. After delivery, the second twin with APGAR 10/10/10 showed a haemoglobin of 19.6 g/dL, which is in the upper normal range. Their birth weights differed by merely 10.4%. Acute TTTS is frequently characterised by anaemia and hypovolaemia of the second twin. In our case of a monochorionic twin delivery with acute TTTS the donor was born first. Early diagnosis and neonatal intervention is essential for reducing postnatal morbidity and mortality.

[Sonographic abnormalities of the fetal CNS in the second trimester screening--clarifications according to the new maternity directives]. / Sonografische Auffälligkeiten des fetalen ZNS im Zweittrimesterscreening--Abklärung nach neuen Mutterschaftsrichtlinien.

Malformations of the central nervous system are among the most frequent congenital anomalies. At best, a qualified and standardised screening of the foetal brain is possible between the 18th and the 22nd week. The newly decided modification of the maternity directives envisages an extended screening upon request. This extended screening refers to the central nervous system and the representation of the ventricles, the evaluation of the head shape and the cerebellum and the back. The examination of the foetal brain should be carried out in a structured way. Three axial planes, the transventricular, the transthalamic and the transcerebellar planes, suffice to represent and measure all structures which are of importance for the screening. In case of ventricular anomalies, anomalies of the head shape, anomalies of the cerebellum and irregularities of the dorsal skin outlined in the second screening a further diagnostic procedure should be initiated. This diagnostic work-up should include a detailed neurosonography, a diagnostic evaluation of the organs and eventually further examination in the form of a caryotyping, determination of the infectology or a foetal MRI. The present article offers an overview of possible CNS abnormalities which could be recognised during the second screening according to the extended maternity directives and describes which differential diagnostics should be considered. In detail, anomalies of the head size (microcephaly, macrocephaly), of the head size (brachycephaly, dolichocephaly, cavities of the cranium, banana sign, etc.,), ventricular abnormalities, anomalies of the cerebellum (cerebellum hypoplasia, abnormal cerebellum shape) and abnormalities of the intermediate line and the intracerebral space requirements are discussed.

[Early diagnosis of gestational diabetes by amniotic fluid insulin levels?]. / Frühdiagnose eines Gestationsdiabetes durch die Fruchtwasserinsulinkonzentration?

BACKGROUND: Gestational diabetes mellitus (GDM) occurs in 3-5% of all pregnant women. As there is no general screening in Germany, many cases remain undetected. Maternal as well as foetal morbidity are increased in GDM. The aim of this study was to investigate whether amniotic fluid insulin or C-peptide levels, collected by genetic amniocentesis in early pregnancy, are predictive for gestational diabetes. Patients at risk for developing GDM might be identified and treated very early. PATIENTS AND METHODS: 260 patients having a genetic amniocentesis were included in this prospective trial. Insulin and C-peptide levels were identified in frozen amniotic fluid samples. All patients should undergo an oral glucose tolerance (oGTT) test at 24-28 weeks of gestation. Only cases with normal genetic screening, normal foetal sonomorphology and birth at term were included in this trial. 90 of 260 patients having an amniocentesis underwent the oGTT and fulfilled all inclusion criteria. RESULTS: GDM was diagnosed in 8 patients, in another 6 patients only one glucose level was out of the normal range. Neither amniotic fluid insulin nor C-peptide levels showed significant differences between normal and GDM pregnancies. The insulin and C-peptide levels did not correlate with blood glucose levels or with foetal weight. CONCLUSIONS: In contrast to literature reports, according to these data no relationship between amniotic fluid insulin or C-peptide levels and gestational diabetes can be assumed. Amniotic fluid insulin or C-peptide levels are not predictive for GDM.

[Diseases caused by human papilloma viruses]. / Erkrankungen durch humane Papillomviren.

Human papilloma viruses are responsible for a large number of benign and malignant lesions of the skin. HPV 6 and 11 cause up to 90 % of condylomata. Almost each cervical cancer is associated with HPV. HPV 16 und 18 induce up to 70 % of cervical neoplasias. The vaccination against HPV is internationally implemented and should be applied to young girls aged 12 to 17 according to STIKO criteria. The vaccination may reduce the rate of cervical cancer by 70 % and the rate of cervical intraepithelial neoplasia by 50 %. Many studies demonstrated the efficacy and safetyness of both vaccines. Gardasil (®) offers protection against HPV 6, 11, 16 and 18, Cervarix (®) against HPV 16 and 18. Protection against condylomata is offered by the quadrivalent vaccine in 90 %. The bivalent vaccine has demonstrated type-specific protection against the five most frequent cancer inducing types (16, 18, 31, 33, 45). The production of VLPs is an innovative technology. A comparison of both vaccines, Cervarix (®) and Gardasil (®), showed a higher immunogenicity for Cervarix (®). In Germany the immunization rates are still low comparing to other countries. As a method for secondary prevention of cervical cancer the PAP smear is still an effective method.

[Obstetric management of fetal growth retardation]. / Geburtshilfliches Management bei fetaler Retardierung.

Intrauterine growth restriction (IGUR) can have different etiologies, but placental insufficiency is the clinically most relevant. Fetuses with IUGR have a significantly higher morbidity and mortality than normally grown fetuses of the same gestational age. It is important to distinguish a growth restricted fetus from a normal, small fetus and from a fetus being small because of a disease, e.g., an aneuploidy. This differentiation requires the knowledge of the gestational age and the use of multiple imaging modalities. Serial assessments of fetal growth by ultrasound are necessary to recognize declining growth. Doppler sonography can detect changes in the uteroplacentar and the fetal perfusion. Blood vessels of clinical relevance are the uterine arteries, the umbilical artery, the middle cerebral artery and the ductus venosus. When no fetal anomalies can be detected, fetal growth is parallel to the percentiles and Doppler sonography measurements are normal, IUGR is unlikely. In most IUGR fetuses, a typical sequence of circulatory changes and ultrasound findings can be observed. As there is no evidence-based treatment option for IUGR until now, obstetric management consists in defining the optimal time of delivery. This means weighing the risks of prematurity against the risks of a potentially hostile intrauterine environment.

[Mediastinal large B-cell lymphoma with symptomatic superior vena cava syndrome in a patient with bichorial twin pregnancy in the 26th week of gestation: peri-and postpartal management -- a case report]. / Grosszelliges B-Zell-Lymphom des Mediastinums mit symptomatischer oberer Einflussstauung bei bichorialer Geminigravidität in der 26. SSW: Peri-und postpartales Management -- Ein Fallbericht.

OBJECTIVE: Non-Hodgkin lymphoma (NHL) is rarely observed during pregnancy. The clinical behavior of this malignancy does not differ significantly from that outside of the setting of pregnancy. Antineoplastic chemotherapy is usually given during the second and third trimester. However, irradiation is another therapeutic option. The teratogenic potential limits its use in pregnancy. Finding an appropriate therapeutic management in an emergency setting is therefore difficult. CASE REPORT: In this report, we describe the case of a 31-year-old gravida three, para two, in whom a mediastinal large B-cell lymphoma with symptomatic superior vena cava syndrome was diagnosed in a bichorial twin pregnancy in the 26 (th) week of gestation. After premature delivery by caesarean section at 26 + 0 weeks gestation the patient was immediately submitted to mediastinal irradiation. The clinical symptoms resolved and adjuvant CHOEP-chemotherapy was instituted. Chemotherapy was well tolerated and a partial remission was observed after 4 cycles. The neonatological follow-up was uneventful. DISCUSSION: To our knowledge, this is the first case in the literature of a patient with bichorial twin pregnancy with large cell mediastinal NHL and symptomatic superior vena cava syndrome who underwent irradiation after caesarean section because of life-threatening medical condition.

Impact of three-dimensionally measured endometrial volume on the pregnancy rate after intrauterine insemination.

OBJECTIVE: The success of artificial reproductive techniques not only depends on the quality of oocytes and spermatozoa but also on the receptivity of the endometrium. The aim of this study was to assess the role of endometrial volume measurement by three-dimensional ultrasound in predicting the pregnancy rate (PR) in women receiving controlled ovarian hyperstimulation followed by intrauterine insemination. MATERIAL AND METHODS: 104 patients having intrauterine insemination (IUI) were included in this prospective trial. Ovarian hyperstimulation was performed with gonadotropins in 73 % of patients and with clomiphene citrate (CC) in 27 % of patients. Endometrial thickness, pattern and three-dimensional volume were measured immediately before insemination. RESULTS: In 104 IUI cycles a total of 14 clinical pregnancies were recorded (PR=13.5 %). The endometrial volume was 3.5 ml and was not significantly different in pregnant (4.0 +/- 1.5 ml) from non-pregnant women (3.4 +/- 1.9 ml). In the subgroup of women with an endometrial volume > or = 2 ml and trilaminar endometrium the pregnancy rate was 22 %, significantly higher than that in women without these two criteria (PR 6 %, p < 0.05). The negative predictive value of an endometrial volume < 2 ml for a clinical pregnancy after IUI was 96 %. Endometrial volume and thickness were significantly higher after ovarian hyperstimulation with gonadotropins (3.7 ml and 11.0 mm) than with CC (2.8 ml and 9.5 mm; p < 0.05). CONCLUSIONS: An endometrial volume < 2 ml at the day of insemination is associated with a poor likelihood of pregnancy. Endometrial volume measured by 3D ultrasound is a new objective parameter to predict endometrial receptivity.

[First experiences with human blastocyst culture after IVF/ICSI under the conditions of the German embryo protection law]. / Erste Erfahrungen mit der Blastozystenkultur nach IVF oder ICSI unter den Bedingungen des Deutschen Embryonenschutzgesetzes.

OBJECTIVE: Due to the improvements in human embryo culture in the recent years, it is now possible to transfer embryos five days after oocyte retrieval and IVF or ICSI at the blastocyst stage with favorable implantation rates. In Germany it is illegal to cultivate more than 3 embryos, therefore the selection has to be done at the pronuclear stage. There we report our experiences of human blastocyst culture in a routine IVF/ICSI programme under the conditions of the German Embryo Protection Law. MATERIALS AND METHODS: The data of 100 couples undergoing the IVF-ICSI programme at the University Clinic of Würzburg were analysed prospectively. 14-18 hours after insemination or micro-injection two or three zygotes with the best pronuclear development were selected for further cultivation. Fertilized oocytes were cultured in sequential media and were then transferred into the uterus 5 days after oocyte recovery. The blastocysts were graded from 1-8. RESULTS: In 100 cycles a total of 859 oocytes were collected, of whom 663 were fertilized and reached the pronuclear stage (median fertilization rate 88.9 %). 251 zygotes were selected at the PN stage. 51 % of the selected zygotes achieved the blastocyst stage after 5 days (grade 1-5), 28 % were morulae (grade 6-7) and 21 % of the embryos arrested in their development (grade 8). The clinical pregnancy rate was 26 %. Women who conceived had a significant better development of blastocysts on day 5 (grade 4 versus grade 6, P < 0.01) than those not achieving pregnancy. CONCLUSIONS: In summary, under the current legal conditions in Germany, blastocyst culture cannot improve pregnancy rates as the rate of arrested embryos of over 20 % limits the chances of implantation.

The use of a detailed zygote score after IVF/ICSI to obtain good quality blastocysts: the German experience.

BACKGROUND: Due to improvements in embryo culture, it is now possible to transfer embryos 5 days after oocyte retrieval and IVF/ICSI at the blastocyst stage, giving a better synchronization with the female reproductive tract. In Germany it is illegal to culture more than three embryos. Therefore, there is need for a sufficient selection at the pronuclear (PN) stage to select the best zygotes and exclude those of poor quality. METHODS: A prospective trial was conducted in 168 IVF and ICSI cycles including the size, number and alignment of pronuclei and nucleoli, cytoplasmic halo effect, the presence of vacuoles and granularity of ooplasm. Based on the above criteria, the best zygotes were selected (score <15) for embryo transfer on day 5. Blastocysts were classified in eight grades based on the cleavage speed. RESULTS: A total of 1450 oocytes were collected, of which 1119 reached the pronuclear stage. Of the zygotes (n = 424) selected at the PN stage, 46% achieved the blastocyst stage after 5 days (grade 1-5), 26% the morula stage (grade 6-7) and 28% were arrested (grade 8). The mean zygote score showed a significant positive correlation with the mean blastocyst quality in ICSI, but not in IVF cycles. A cut-off of 15 was calculated for ICSI cycles giving the best discrimination with blastocyst grades (6 versus 7) and number of arrested embryos (23 versus 45%) below and above this cut-off. A total of 33 clinical pregnancies was achieved (20%). Women conceiving had a significantly better mean blastocyst development than those not conceiving. Strong cytoplasmic vacuolization and an extreme or no halo effect had a negative effect on blastocyst development. CONCLUSIONS: The data show that PN stage morphology is related to blastocyst development, but the rate of arrested embryos of almost 30% limits the chance of conception under the conditions of the German Embryo Protection Law.

Semen sample collection in medium enhances the implantation rate following ICSI in patients with severe oligoasthenoteratozoospermia.

Ejaculation in medium increases the proportion of antibody-free spermatozoa in semen samples containing anti-sperm antibodies and thereby enhances the fertilization rate in vitro. The aim of this study was to investigate whether this technique is also beneficial in semen samples with severe oligoasthenoteratozoospermia (OAT) where bacteria and detritus are often present. A prospective randomized controlled trial was carried out to study the results of sperm preparation and fertilization and pregnancy rates after intracytoplasmic sperm injection (ICSI) for OAT. Of the 114 couples (one cycle per couple) studied between 1998 and 2000, 55 men were randomized to have semen collection into sterile dry pots (group A) and the remaining 59 had samples collected into 20 ml HEPES buffered Ham's F-10 medium with 10% human serum albumin (group B). In group B the ejaculates were incubated for 30 min and mixed gently. The samples were then processed by mild centrifugation and washing followed by a mini-swim-up technique. The ejaculates in group A were prepared by the swim-up procedure only. The overall fertilization rate was 71.8% and was similar in groups A (fertilization rate = 66.7%) and B (fertilization rate = 64.3%). In group A, 10/55 clinical pregnancies were recorded (pregnancy rate 18%), with an implantation rate (IR) of 6.9% per embryo. In group B, 16 of 59 patients conceived leading to significantly higher implantation (9.9%, P < 0.001) and clinical pregnancy rates (27%, P < 0.001). It is postulated that the addition of medium before liquefaction could inhibit the binding of bacteria and detritus to the sperm surface and may diminish DNA damage caused by reactive oxygen species, leading to improved efficiency of fertilization. The results demonstrate that the addition of HEPES buffered Ham's F-10 medium to sample collection pots significantly improves the pregnancy rate after ICSI in patients with severe OAT.

Assessment of endocrine status in patients undergoing in-vitro fertilization treatment. Is it necessary?

Endocrine evaluation as a prerequisite for every patient undergoing routine in-vitro fertilization (IVF) and embryo transfer for tubal or male factor infertility is still a matter of debate. The aim of this study was to determine if a full endocrine work-up, including the measurement of androgens, gonadotropins, prolactin and TSH, is conclusive for the subsequent success in IVF/ET. 71 infertile women without known endocrinopathies (e.g., polycystic ovarian disease), who were scheduled to enter the IVF/ET program were studied under strictly standardized conditions during the follicular phase of a natural cycle. Fasting serum concentrations of follicle stimulating hormone, luteinizing hormone, oestradiol, progesterone, prolactin, testosterone (T), dehydroepiandrosterone, 17-OH-progesterone, androstenedione and thyroid stimulating hormone (TSH) were measured using commercially available radioimmunoassays. Ovarian stimulation was performed by a long gonadotrophin-releasing hormone agonist/human menopausal gonadotrophin protocol. The overall clinical pregnancy rate was 15.5% in the first started IVF cycle. While patients who conceived in the first treatment cycle had significantly lower T levels (368 +/- 49 pg/ml) than those who did not (518 +/- 27 pg/ml, p=0.042, Kruskal & Wallis H-test), but the percentage of women with elevated T concentrations was not different. Similarly, TSH concentrations were significantly higher in women with a clinical pregnancy (1.9 +/- 0.2 mU/ml) than in non-pregnant women (1.4 +/- 0.3 mU/ml, p=0.046), but levels were still within the normal range. There were no further significant differences in hormone levels between pregnant and non-pregnant patients. These results do not suggest the measurement of a full hormonal profile in all infertile women before IVF/ET in non-endocrine infertility, taking into account the low likelihood to identify endocrinological disturbances, the considerable cost of endocrine testing and the paucity of therapeutic consequences.

Evaluation of a cut-off value for sperm motility after different hours of incubation to select the suitable reproductive technology (IVF or ICSI).

BACKGROUND: The aim of this study was to enhance the predictability of conventional semen parameters for in-vitro fertilization outcome. The utility of late sperm motility in presence of a cumulus-oocyte complex after different hours of incubation was investigated to predict the outcome of IVF in borderline and normal ejaculates (at least 5 x 10(6) motile sperm). METHODS: The study was done on 52 infertile couples undergoing conventional in-vitro fertilization and embryo transfer. Sperm were prepared by the Percoll cushion centrifugation with swim-down. Cocultures were established by inseminating the cumulus-oocyte complexes with 100000 motile spermatozoa and incubating them for 48 hours. Another 100000 spermatozoa were incubated in culture medium for 48 hours. Sperm motility (WHO a+b) was determined at 0, 4, 24 and 48 hours of incubation. RESULTS: The fertilization rate was 65.5% (42.9-88.1). The conventional semen parameters did not correlate with the fertilization rate. Sperm motility measured after different hours of incubation was found to be significantly positively correlated with the fertilizing ability of sperm in vitro in Spearman's rank correlation test: motility after 0 h (p<0.02), after 4 h (p=0.0025). after 24 h (n.s.) and after 48 h (p=0.0071). Cut-off values for late sperm motility were determined and differences in fertilization rates were calculated for these cut-off values after different hours of incubation. A cut-off value of 20% progressive motile spermatozoa after 48 hours gave the best statistical power (fertilization rate 71.7 vs. 50.2%, p<0.001). Significant differences in the fertilization rates were also observed for a cut-off value of 35% after 24 hours of incubation (70.1 vs. 46.2%, p=0.001) and for a cut-off point of 60% after 4 hours (72.4 vs. 51.5%, p=0.001). CONCLUSIONS: The predictive power of sperm motility after 48 h for fertilization outcome provides support in the decision-making process within the assisted reproduction setting. If less than 20% of sperm are motile after 48 h micromanipulatory techniques should be considered.