Biomedical subjects
Publications and source records attributed to K Diedrich.
Vesicovaginal fistulas develop as an early complication following gynaecological operations or as a late complication following irradiation. The waiting period for the surgical closure of the fistula implies social and psychic problems for patients and attending physicians. Three cases report on the exclusive fibrin sealing for closing vesicovaginal fistulas after which continence was re-established.
We performed histological examinations on 75 patients in whom a breast lesion was identified by mammography or clinical examination. We found 35 malignant and 40 benign lesions with an average size of 16 mm. In 57 cases (76%) a lesion was identified preoperatively by the use of ultrasound. Blood flow of sufficient magnitude to be visualized by Colour Coded Doppler was only detectable in 22 cases of which 20 turned out to have a malignant lesion. Thus the detection of blood flow by Colour Coded Doppler in a small breast lesion may be considered as a sign of malignancy. However the absence of such blood flow should not be considered as an indicator of a benign lesion. At the same time we would like to point out that the detection of blood flow is also dependent on technical factors of the equipment used.
The management of a pregnancy complicated by uterus myomatosus remains being controversially discussed. Myomectomy early in pregnancy is opposed by exspectative management with myomectomy subsequent to the post partum period. Therapeutic abortion and exstirpation of the gravid uterus represent only hypothetical but not reasonable alternatives. Complications like ureteral obstruction, sepsis, and torsion of the uterus with subperimetrial bleeding as a cause of fever of unknown origin may occur. Rapid growth of a fibromatous uterus in pregnancy may call for a biopsy. Two cases are presented to demonstrate that with intensive pregnancy surveillance exspectative management is justified and may lead to successful confinement of the pregnancy.
Since 1992 direct injection of a single spermatozoon into the cytoplasm of the oocyte (ICSI) has developed as the treatment of choice in cases of severe male subfertility. The ICSI procedure displays high fertilization and pregnancy rates in cases of extreme oligoasthenoteratozoospermia. In combination with sperm aspiration from the epididymis or sperm retrieval by testicular sperm extraction, fertilization is possible even in cases of azoospermia. To date, a couple of thousand children have been born after ICSI. Despite the criticism about the lack of natural selection while breaking the zona pellucida and the cytoplasmic membrane with the injection pipette, there has been no increased incidence of malformations and chromosomal abnormalities.
We report on 4 cases of ectopic pregnancy with low HCG-levels and lack of clinical symptoms, in which expectant management was performed. Advantages and disadvantages of the procedure are discussed. While one can find a variety of therapeutical concepts in the literature such as conservative medical treatment alone or in combination with laparoscopy or expectant management, we dispose to prefer a fertilization providing gentle operative laparoscopic assessment as the treatment of choice in all cases of ectopic pregnancy. In all 4 cases operative laparoscopy had to be performed after an interval of expectance when the patients displayed sudden severe clinical symptoms.
Ejaculatory disorders can interfere with the fertility of young adults who suffer from spinal cord injury, have type I diabetes mellitus or have undergone retroperitoneal or intrapelvic operations. Following an overview of causes and treatment of ejaculatory disorders, the data of our centre are presented. From a group of 37 patients with genuine loss of seminal emission, 15 men and their wives were offered a combined treatment of rectal probe electro-ejaculation and artificial reproductive techniques. No serious complications occurred. During 40 cycles with intracorporeal insemination and 11 cycles with extracorporeal fertilization techniques, seven pregnancies were achieved, representing a pregnancy rate of 46% per couple and 14% per cycle for all cycles. Five healthy children were born, all following extracorporeal insemination. The 'take-home baby rate' for this population and for this technique is 45%. In vitro fertilization (IVF) led to one birth, intracytoplasmic sperm injection (ICSI) achieved four live births out of three pregnancies, one being a twin gestation. Since our successes are due to the use of extracorporeal insemination techniques, these are now incorporated in a new, more rational treatment protocol.
PURPOSE: The male factor is nowadays one of the major problems in the treatment of infertility. New methods of assisted fertilization such as the intracytoplasmic sperm injection (ICSI) show better fertilization and pregnancy rates than classical IVF. METHOD: In this study, we present a new technique of sperm preparation: the "mini-swim-up." CONCLUSION: This technique, used in conjunction with the ICSI procedure, improves pregnancy and fertility rates in cases of severe oligoasthenoteratozoospermia.
PURPOSE: Direct intracytoplasmic sperm injection (ICSI) is a successful treatment of severe male subfertility. Conventional in vitro fertilization shows poor pregnancy rates especially in cases of severe teratozoospermia. The objective was to determine if severe morphological defects of spermatozoa in oligoasthenoteratozoospermia (OAT) have any impact on the fertilization process in ICSI and if there are any specific morphological characteristics in nonfertilized oocytes after the ICSI procedure. METHODS: Ejaculates and nonfertilized oocytes were investigated by electron microscopy. CONCLUSIONS: The lack of intracytoplasmic sperm-oocyte interaction, not severe sperm defects, displays the most critical role in the fertilization process. Clinical data with fertilization rates of 66% and pregnancy rates of 23.3% confirm the fertilization capacity of severely
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OBJECTIVE: To examine the pituitary response in patients undergoing short-term application of the GnRH antagonist Cetrorelix in the mid-cycle phase for hypophysial suppression of premature LH surges within an IVF-program. DESIGN: Twenty patients suffering from primary or secondary tubal infertility were stimulated with hMG from cycle day 2. From day 7 till ovulation induction Cetrorelix was administered in two different dose regimens (15 patients 3 mg s.c. daily; 5 patients 1 mg s.c. daily). Three hours before ovulation induction a GnRH test was performed using 25 micrograms of native GnRH and the pituitary response examined by measurement of the serum LH concentration after 30 min. RESULTS: Premature LH surges could be avoided in the 3-mg group and in the 1-mg group, respectively. Due to this, none of the cycles had to be cancelled. Oestradiol profiles and ultrasound demonstrated a satisfactory follicular maturation. All patients showed pronounced suppression of the serum LH levels before ovulation induction. The mean increase of serum LH due to the performed GnRH test was 10 mIU/ml for the 3-mg group, while the average maximum in the 1-mg group was about 32.5 mIU/ml. CONCLUSIONS: The pituitary response is preserved by the treatment with the GnRH antagonist Cetrorelix. The extent of suppression of the adenohypophysis, as expressed by the different reactions on GnRH test, can be modulated by the dosage administered. This should allow ovulation induction by GnRH or one of its agonists instead of hCG, which could be beneficial in patients at high risk of Ovarian Hyperstimulation Syndrome (OHSS) and those suffering from Polycystic Ovary Disease (PCOD).
In the period from June 1990 to February 1993, 718 excess pronucleated oocytes from 185 cycles were cryopreserved by using the "open freezing system" in our IVF-programme at the Department of Gynaecology and Hospital of the University of Bonn. 1.5 mol propanediol and 0.1 mol sucrose were used as a cryoprotectant. During this time 287, pronuclear oocytes were thawed; of these 245 survived the freezing process and were classified as intact. The survival rate in this study was 85.4%, though if only one intact pronuclear oocyte was transferred, no pregnancy could be achieved, whereas if two or three pronuclear oocytes were transferred, seven to ten pregnancies resulted, respectively (23.3% and 23.8% pregnancy rates). Eight healthy children have been born to date from four other ongoing pregnancies, one of them is a twin pregnancy.
Within a period of 5 months a serious of 42 small diameter laparoscopies (2 mm) (SDL) were performed with a modified technical approach. 28 (SDL). Procedures were done under general anaesthesia and the findings were controlled by concurrent conventional laparoscopy. In 26 out of 28 patients we could confirm the SDL diagnosis. 14 patients had SDL in analgosedation. Optical information gained by SDL was sufficient and, as experience in handling the system increased, also competitive. The procedures performed in analgosedation were tolerated and highly appreciated (reduced incisional pains, reduced complaints due to pneumoperitoneum). SDL procedures seem to have possible indications in gynaecology.
Morphology of the spermatozoa is one of the major criteria in severe male subfertility. We report on a case of severe Oligoasthenoteratozoospermia in which a triplet pregnancy could be achieved after intracytoplasmic sperm injection (ICSI). After treatment with GnRH-analogues/HMG/HCG seven oocytes of metaphase II could be retrieved and injected. Three of them fertilised and were transferred as four-cell stage embryos after two days. Seven weeks later an intact triplet pregnancy could be detected by ultrasonography. The severe sperm defects in this case were evaluated with the technique of electron microscopy. Ultramorphology of spermatozoa appears to have an important predictive value for fertilisation and pregnancy in classical IVF. Its value for the assisted procreation techniques such as ICSI remains to be investigated.
Detection of ovulation is an essential step in sterility treatment. Determination of the luteinising hormone is the most reliable method, which is generally performed by serum analysis. In this study, we proved the reliability of LH analysis in urine. 44 cycles of 35 volunteers with regular ovulatory cycles were examined. From day 11 on, daily LH measurements were performed on serum and urine. Ovulation was established by ultrasound monitoring of follicular development and/or by progesterone detection in the luteal phase. The sensitivity was 89% for serum analysis and 97.5% for urine analysis. The specificity was 100% for both methods. Hence, LH detection in urine is a reliable and secure method for ovulation determination. As an advantage over serum analysis, it requires less consultations, thereby offering a less expensive and stress reduced treatment.
In order to determine the suitability of new microlaparoscopes of < 2.0 mm diameter for diagnostic laparoscopy, 28 small diameter laparoscopies (SDL) were performed during a 4 month period. These cases were performed under general anaesthesia with immediate follow-up confirmation with conventional laparoscopic equipment (group I). An additional 13 SDL procedures were performed under analgesic sedation plus local anaesthesia and were well tolerated by the patients (group II). For group I, the visualization results were comparable in 27 out of 28 procedures. In group II, patients were highly satisfied and reported less post-procedural discomfort and minimal scar formation due to the smaller access ports. In this study, two different types of microlaparoscopes were used; while both were adequate, the newer high-resolution microlaparoscope delivered an image much more similar to conventional laparoscopy and required little or no change in technique in order to obtain images. This new endoscopic technology, with optical performance comparable to that of conventional laparoscopy, has been demonstrated to be a useful procedure for certain clinical indications.
Luteinizing hormone-releasing hormone (LHRH) plays a crucial role in controlling the ovarian cycle in women. By modification of the molecular structure of this decapeptide, analogues were synthesized with agonistic or antagonistic effects on the gonadotrophic cells of the anterior pituitary gland. The agonists, after an initial stimulatory effect ('flare up'), lead to desensitization of the gonadotrophic cells and a reduction in the number of LHRH receptors on the cell membrane ('down-regulation'), while the antagonists produce an immediate effect by competitive blockade of the LHRH receptors. After administration of LHRH antagonists, the serum levels of FSH and LH decrease within hours. Nevertheless, the adenohypophysis maintains its responsiveness to an LHRH stimulus ('pituitary response') after pretreatment with an antagonist. This different pharmacological mechanism of LHRH antagonists makes possible new approaches to ovarian stimulation and to the therapy of sex steroid dependent diseases. The premature LH surge, the main cause of cancellation during induction of superovulation in assisted reproduction technology (ART) programmes, can be abolished by short term application of an LHRH antagonist associated with a reduced human menopausal gonadotrophin (HMG) requirement for ovarian stimulation. A future approach to ART might be based on the combination of pretreatment with an LHRH antagonist and ovulation induction by native LHRH or an agonist. The severe side effects encountered with early LHRH antagonists, such as anaphylactoid reactions due to histamine release, are almost completely eliminated in modern antagonists, especially Cetrorelix which is presently used clinically in controlled phase II clinical studies.
OBJECTIVE: Applicability of the GnRH-antagonist Cetrorelix within controlled ovarian hyperstimulation (COH) to avoid the premature LH-surge should be examined. METHODS: 35 patients suffering from tubal infertility were stimulated for In Vitro Fertilization (IVF) by human menopausal gonadotrophins (HMG) and concomitant administration of Cetrorelix in different dosages (3 mg, 1 mg, 0,5 mg). RESULTS: No premature LH-surge could be observed. CONCLUSIONS: Short term administration of the GnGR-antagonists avoids the occurrence of a premature LH-surge.