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320 German and 262 Turkish immigrant patients of the gynaecological units of the Virchow Women's Clinic in Berlin were questioned, to compare their knowledge and opinion on menopause and possible cultural influence factors. The results showed that 70% of the migrant vs. 90% of the German women regarded menopause as a normal phase in a women's life and more Turkish than German women (35% vs. 7%) associated complaints with menopause. However the immigrant women knew noticeably less about health risks related to menopause (10% vs. 50%).

Objective: We examined the possible connection between mood state of patients during IVF/ICSI-treatment and pregnancy rate. Which influence does the patient's age and the social support have on the mood state?, Material and Methods: Questionnaires were handed out to 100 patients of our fertility center during an IVF/ICSI-treatment-cycle. We used the standardized Leipziger Stimmungsfragebogen (LSB), a visual analogue-scale for free indication of mood state and the questionnaire for social support (SOZU)., Results: Per oocyte pick up 32 women became pregnant (32.7%), 58 women did not become pregnant (59.2%). Lower rating on the aggressivity-scale showed a tendency (p = 0.085) and higher rating on the balance-scale showed a trend toward higher pregnancy rates. There was no significant relation shown on the visual analogue-scale as well as on the LSB-scales grief, activity and fatigue. There was no correlation between age and mood state or between social support and pregnancy rate., Conclusions: We could not show a significant relation between general mood state and pregnancy rate. Yet there was a tendency concerning certain components of mood. Increasing age of the patient does not have a negative influence on the mood state either. The individual situation and adjustment seem to be decisive.

The legally binding consent of a patient to surgical operations of certain diagnostic measures during hospitalisation is actually guaranteed only in cases where the medical information is oriented to the individual level of understanding of the patient. The real extent of actual knowledge about health relevant aspects is not always known. Immigrant women constitute a large portion of the patients in big German cities. In most clinics the difficulties in communication caused by persistent language barriers are not presently being solved in a satisfactory manner. In light of this situation, it seemed necessary to ascertain the knowledge of German and Turkish women with respect to specifically female bodily functions, contraception, preventative medical examinations and menopause. The study included a total of 320 German and 262 Turkish patients of both gynaecological units at the Virchow Women's Clinic in Berlin during the 1 1/2-year inquiry period (1997/98). The questionnaire we used was laid out in multiple choice format, whereby each question was provided with a list of possible answers (level of significance p < 0.05). Only a small portion of the general female populace (approximately 13% of the study population, 22% of German patients) is well-to-very-well informed about 'specific female bodily functions, anatomy, preventative health care and contraception', and this proportion is even smaller among Turkish female patients (3% of Turkish women surveyed). While the understanding demonstrated by immigrants who possessed strong writing skills in German is nearly as great as that of the German group, the proportion of patients who demonstrated less sophisticated understanding was still twice as high with 32.5% as compared to that of the German group (15%). According to the opinion of approximately one-third of the Turkish immigrants (German women 8.2%) surveyed, there are no (increased) health risks associated with menopause.

Objective: Our purpose was to compare birth complications and fetal outcome in hospitals and birth centers., Method: We retrospectively compared all 801 deliveries between 1992 and 1994 from two free-standing birth centers against 3271 hospital deliveries in Berlin. The hospital collective was selected according to the same risk criteria of the birth centers., Results: The birth center group had significantly fewer medical interventions, with a similar cesarean section rate (3.0% vs. 4.6%, P = 0.057) and occurrence of severe perineal lesions. The episiotomy rate was significantly higher (P < 0.001) in the clinics for first-time and multiple births. The perinatal mortality was not significantly different ( < 0.1 per 1000). One-minute Apgar scores less than 7 were found significantly more often in the birth center group., Conclusion: When birth centers employ thorough risk selection and significant early referral rates to nearby hospitals, there is no evidence of increased maternal or perinatal risk compared to hospital deliveries.

We determined the concentrations of tumour necrosis factor (TNF)-alpha, interleukins (IL)-1 beta, -6, -8 and -1-receptor antagonist (IL-1-ra) and of oestradiol and progesterone in the follicular fluid of 111 women undergoing in-vitro fertilization (IVF) and of six women with ovarian cysts in order to elucidate mid-cycle mechanisms causing dissociation of the follicle wall and local rupture of the ovarian tissue complex. Four stimulation protocols were administered: gonadotrophin releasing hormone agonist/human menopausal gonadotrophin (GnRHa/HMG), clomiphene citrate/HMG (CC/HMG), HMG and follicle-stimulating hormone (FSH). Concentrations of TNF alpha and IL-1 beta were below 15 and 3 pg/ml respectively. IL-6 (median 4.1, 3.5-4.4 pg/ml, 95% CI) was higher after stimulation with FSH (5.6 pg/ml) than with HMG (3.2 pg/ml, P < 0.05) or GnRHa/HMG (3.7 pg/ml, P < 0.05), and after stimulation with CC/HMG (5.5 pg/ml) than with HMG (P < 0.01) or GnRHa/HMG (P < 0.001). IL-8 ranged from 32 to 1241 pg/ml (147, 117-178 pg/ml) and IL-1-ra from < 31 to > 10,000 pg/ml (156, 109-192 pg/ml). Cytokine levels did not correlate to oestradiol or progesterone concentrations. The ovarian cysts contained similar IL-8 (14-540 pg/ml) and IL-1 beta (< 30 pg/ml), but higher IL-6 (13.6-> 500 pg/ml) and lower IL-1-ra concentrations. We assume that IL-6, IL-8 and IL-1-ra are involved in peri-ovulatory cellular interactions. Thus, ovulation appears to be a cytokine-regulated process of an 'inflammation' (IL-6 and IL-8) followed by 'anti-inflammatory' reactions (IL-1-ra).

Secondary side-effects often occur in women undergoing hormonal stimulation treatment with clomiphene citrate. In general 10.4% of women experience hot flushing, 5.5% have complaints caused by enlargement of the ovaries and 3.5% experience central nervous symptoms (nervousness, sleeplessness, headaches, visual disturbances, vertigo). During ovarian stimulation with clomiphene citrate for in-vitro fertilization, a 32 year old patient developed psychotic symptoms, commencing 3 days after initiation of treatment. Hospitalization in the psychiatric ward became necessary when severe formal and rational thought disturbances arose together with perceptory and sensory delusions. Under neuroleptic treatment the symptoms improved. Nevertheless, follow-up psychiatric care on an outpatient basis was deemed necessary. The infertility treatment was continued with human menopausal gonadotrophin stimulation. Psychiatric instability occurred neither at this point nor during the 2 year follow-up observation period. Both an exogenous psychosis (ICD F23.9) as well as the exacerbation of an endogenous psychosis (ICD F29) may be considered for the differential diagnosis. The stimulation with clomiphene citrate in connection with the physical and psychic stress of the infertility therapy can be regarded as the trigger factor. For patients with evidence of psychiatric illness in their case history, ovulation-inducing substances such as clomiphene citrate should be implemented with particular care.

A cytogenetic-cytological study was performed on unfertilized human oocytes (first polar body visible) after intracytoplasmic sperm injection (ICSI) with respect to the rate of prematurely condensed sperm chromosomes (G1-PCC). Out of 163 prepared oocytes derived from 41 ICSI cycles, 133 (approximately 82%) could be analysed successfully. a total of 60 oocytes (45.1%) showed metaphase II chromosomes in the haploid range along with an intact sperm head and 27 oocytes (20.3%) were missing the sperm head, but two of them showed an approximately diploid set of chromosomes; 38 oocytes (28.4%) exhibited the maternal metaphase II chromosomes as well as G1-PCC of the sperm nucleus showing a remarkable variation in the degree of condensation. Ten ICSI cycles (each followed by an embryo transfer) were characterized each by 2-3 oocytes demonstrating G1-PCC. It is concluded that the main cause of failed fertilization after ICSI is the failure of oocyte activation. When the sperm nucleus is able to act with the chromosome condensing factors and the oocyte does not become activated, this will lead to the induction of PCC. Absence of the sperm head might be due to injection or ejection of the spermatozoon in the perivitelline space except for two cases in which fertilization might have occurred. Finally, the observation of both a single chromatin region (n = 6) or two chromatin regions (n = 2) indicated oocyte activation which, however, was followed by developmental arrest.

A retrospective study was carried out to compare the results of in vitro fertilisation (IVF) in 20936 patients with different sperm parameters who underwent IVF in Germany between 1990 and 1993. The study was designed to evaluate prognostic factors for IVF outcome, such as sperm parameters and pre-treatment diagnosis. The percentage of subfertile sperm parameters ( < 10 millions sperm per ml and/or < 30% progressive mobility and/or < 30% normal morphology) increased from 31.4% in 1990 to 51.1% in 1993. The fertilisation rate per puncture varied between 87.9% in patients with normozoospermia and 38.7% in patients with severe oligo-astheno-teratozoospermia (OAT). The fertilisation rate in patients with tubal indication was significantly higher than in patients with male indication and comparable spermatozoa. The pregnancy rate per embryo transfer was 23% in patients with normozoospermia and 13.8% in patients with "severe OAT syndrome" in the IVF semen parameters. On the other hand, patients with male sterility as pre-treatment diagnosis showed significantly higher chances of pregnancy than patients with a tubal factor (24% versus 20%, p < 0.05). Comparing percoll and swim-up preparation techniques, we found significantly higher fertilisation rates in normozoospermia and significantly higher pregnancy rates in subfertile patients after percoll sperm preparation. The results of the study demonstrated that patients with moderate subfertile sperm parameters have good chances of fertilisation and pregnancy following conventional IVE. It seems reasonable to set the boundary at a sperm count of 10 millions sperm/ml with 30% progressive motility and 30% normal morphology. Below these limits intracytoplasmic sperm injection shows better IVF outcome.

We present a case of a 24 year old woman who became pregnant (twins) after human menopausal gonadotrophin (HMG)-induced ovarian stimulation, in-vitro fertilization (IVF) and subsequent embryo transfer. She developed a right internal jugular vein thrombosis as a complication of severe ovarian hyperstimulation syndrome (OHSS) 28 days after embryo transfer. The thrombosis developed in spite of anticoagulation with low-dose heparin. Later a resistance to activated protein C (APC) or Dahlbäck disease was diagnosed. Due to a new test procedure (accelerin inactivation test), the diagnosis was possible even under anticoagulation treatment. The coincidence of hyperstimulation and internal jugular vein thrombosis with the concurrent diagnosis of resistance to APC has not been published previously. The benefit of general screening for resistance to APC before admission to the IVF programme should be weighed. Targeted selection of a group of high-risk women would therefore be made possible.

In order to assess the efficacy and safety of recombinant human follicle stimulating hormone (FSH) in routine clinical use, ovarian stimulation with recombinant human FSH was performed in 71 patients prior to in-vitro fertilization (IVF) without gonadotrophin-releasing hormone (GnRH) analogues in a multicentre, non-comparative study. Human chorionic gonadotrophin (HCG) was administered to 58 patients (81.7%), 15 of whom underwent 19 cycles with an initial dosage of three ampoules daily of recombinant FSH and 43 of whom underwent 152 cycles with four ampoules daily from day 3 onwards. No significant differences were detected between these two groups in all test parameters. The mean duration of treatment was 9.06 and 8.86 days respectively with a mean number of 24.06 and 23.25 vials of recombinant human FSH administered. A mean number of 6.26 and 5.88 oocytes respectively was collected. The number of transferred embryos was 2.4 and 2.2. A clinical pregnancy rate of 23.8% (10 out of 42) per transfer was achieved (30.9 and 20.6% respectively). Local tolerance of s.c. administration was excellent. Mild pain at the injection site was the dominant finding in < 20% of patients. Two cases of ovarian hyperstimulation syndrome were noted. Recombinant human FSH is very attractive to patients because it can be self-administered s.c. and the preparation does not come from a human source. In conclusion, these data support the safety and efficacy of recombinant human FSH in routine use for IVF.

Although the implantation of a human trophoblast cannot be directly observed, in-vitro fertilization permits examination of the factors accompanying the nidation of the trophoblast. Against this background, the question arises: at what point in time does the nidation of the human embryo take place in the endometrium of the uterus? In this study, we investigated 104 pregnancies which had resulted from in-vitro fertilization. The course curves of the HCG serum concentration were drawn up and then set in relation to the course of the pregnancy. By means of a regression analysis, we established the time point at which nidation occurred. In pregnancies carried through to delivery, the implantation happens, on the median, 6.6 days after the follicle puncture. The implantation window lies between 5.9 and 7.5 days (25th to 75th percentile). In the case of abortions, the median is 7,0 days (after follicle puncture), and for extra-uterine pregnancies it is 8.1 days (after follicle puncture). This shows that implantations in pathological pregnancies take place at a larger point in time.

All oocytes from a patient who had undergone four unsuccessful in-vitro fertilization attempts showed neither a polar body nor pronuclei when examined for fertilization. In 19 inseminated oocytes that were spread for karyotypic analysis, one haploid set of metaphase II chromosomes and a remarkable condensed structure were found. Hormonal and morphological criteria implied that the oocytes had been mature at the time of retrieval. Since non-inseminated oocytes contained only one set of metaphase II chromosomes, the condensed structure appeared to represent the sperm chromatin in the state of premature chromosome condensation due to a block in oocyte maturation. Since the first and second polar body, as well as their chromatin, were undetectable in all the patient's oocytes, a rapid maturation to metaphase II before retrieval and prolonged arrest in this state before fertilization, accompanied by degeneration of the first polar body, appear to be responsible for the condition. In accordance with this notion, degenerate spindles (typical of post-ovulatory aged oocytes) and separating chromosomes (probably representing presegregating chromatids) were observed by antitubulin immunofluorescence.

The attendance of fathers in the delivery room to accompany the women giving birth is in Germany quite common. In this study we wanted to compare the results of a questionnaire on feelings, intention an anxiety of attending fathers in an east and west German maternity hospital. Although social acceptance of fathers in the delivery room in the eastern part of Germany is delayed by 10 years (compared to western clinics) the over all impression of attending fathers was similar. We aid find differences concerning the expectations, the way of mental preparing and considerations participating the approaching birth in east and west questionared fathers. The results also showed variable knowledge in respect of pregnancy and birth. We do think that after a time of ("father") experience in the east part of Germany the expression of opinion will adjust.

Meanwhile the attendance of fathers in the labour room is common. From 1. 7. 90-15. 10. 91 510 German fathers were interviewed before and 45' after labour. In comparison a smaller number (n = 56) of fathers were questioned who had decided not to attend. The evaluated data was split in the following three categories: 1. pre-post comparison; 2. "participants" and "non-participants" comparison; 3. special problems. The most mentioned reason for participation (over 85%) was the positive influence on the women. More then 70% of the attendants even wanted to support their wives during complicated delivery and surgical interventions. Approximately 5% of the fathers attending a clinic delivery would then prefer a home delivery because they more or less felt as a substitute to medical personnel. Non participants evidently were anxious due to missing preparation and information about the parturition. Sometimes the women desired no participation of their partners. About 23% of the men decided to attend labour just before birth. Practical recommendations are given and the change in the point of view of the fathers during course of labour is presented in this paper.

Developmental arrest of 111 (approximately 5%) fertilized ova which had formed two pronuclei was observed during a 5-year period of an in-vitro fertilization programme. At least 30 zygotes demonstrated visible pronuclei at 44-66 h after insemination, and 42 zygotes fragmented. Of the 107 prepared zygotes, 97 were informative and revealed that developmental arrest occurred at different stages of the cell cycle: from interphase (n = 48), to transition interphase-prophase (n = 20), to prophase (n = 11), and to metaphase (n = 13). The latter 13 zygotes were characterized by chromosome sets as follows: haploid (n = 2), diploid (n = 6), triploid (n = 1) and tetraploid (n = 4). Another five zygotes demonstrated different numbers of metaphase chromosomes (between 10 and 40), as well as prematurely condensed chromosomes (PCC) as a result of marked asynchrony in pronuclear morphogenesis. A total of 18 zygotes exhibited asynchrony in the morphology of the two pronuclei. It is concluded that abnormal chromosome sets and pronuclear asynchrony might be causes for early developmental arrest.

Nowadays, in vitro fertilisation can be judged as a relatively successful treatment in special cases of sterility. Success cannot be defined only by induction of pregnancy, but must also be taken into consideration the couple's and the "IVF-children's" personal situation. The main problem of IVF is the high multiple rate of nearly 20%, resulting in a higher frequency of preterm deliveries. This leads to higher perinatal mortality and more longterm deficiencies in these children. The women's attitude during pregnancy can be considered to be responsible. From a psychosomatic point of view (the husband's presence during delivery, breast feeding etc.) there are favourable preconditions for the "birth of the family." In most cases, the couples give a contented or good view of their partnership (self-assessment). Nearly 5% of them seem to be "disappointed" after the birth of the baby. The method of IVF is positively assessed from an overall point of view. But only half of the women do not keep this special method of procreation secret.

In order to study psychosomatic considerations of the male IVF patient, three issues were investigated. First, the personality traits of sterile males (n = 180) were recorded. Male IVF patients were found to have largely the same personality traits as the general population although they tended to have more dominant and retentive traits. Second, in examining the specific stress experiences during IVF, the individual treatment steps were ranked as being similarly stressful by both partners. Males felt the waiting periods (fertilization? pregnancy?) to be clearly more unpleasant than the physical aspects of treatment (e.g. masturbation). Third, an individual comparison of sperm parameters taken during the diagnostic phase with those measured during the IVF attempt, showed that density and morphology were significantly different. Some practical recommendations to reduce the stress that men experience during IVF include his presence during the treatment steps that the female must undergo, as well as his participation in a self-help discussion group.

A couple is presented suffering from primary sterility for 20 years and who were selected for an IVF test, since conservative methods failed to induce a pregnancy. The ejaculate of two semen samples revealed exclusively round-headed spermatozoa in each sample. Contrary to this diagnosis, however, asthenoteratozoospermia had been diagnosed in previous investigations and the patient had been treated with tamoxifene. However, no therapy exists for the phenomenon of round-headed spermatozoa, because this defect is genetic of origin and correlates with irreversible infertility.

At our hospital a 32 year old patient with a cystic ovarian had been operated. Because sonography was without pathological findings and the patient showed a sterility type, laparoscopy was indicated. Histological findings showed invasive growth of a tubulopapillary carcinoma. Laparotomy with hysterectomy, bilateral adnexa removal, omentectomy as well as pelvic and para-aortic lymphadenectomy was examined. Histologic and immunohistochemical investigations led to coexistence of ovarian endometroid carcinoma and to an endometrial carcinoma, both tumors being of different antigenicity.

Several questions need to be answered before covering the subject of emotional support and guidance of IVF patients. These include what we actually know about the desire for a child, the emotional characteristics typical of infertility patients and especially of IVF patients, how IVF patients justify their motivations for their desire for a child, cope with the anguish caused by infertility, and how much we know about the stress surrounding IVF treatment. These questions will be discussed in the following article.

During an in-vitro fertilization programme, 320 inseminated oocytes showing neither formation of pronuclei nor cell cleavage were studied cytogenetically. Fourteen of 17 oocytes exhibiting no extrusion of a polar body were characterized by an approximately diploid set of metaphase II chromosomes with four of these oocytes also showing an additional set of prematurely condensed sperm chromosomes of the G1-phase (G1-PCC). These chromosomes were single chromatids. Among 211 oocytes characterized by polar body extrusion, the same type of chromosomes were found in 22, along with metaphase II chromosomes in the haploid range. This phenomenon can be explained by the permanent arrest of the oocytes at metaphase II after sperm penetration, which allows the presence of cytoplasmic chromosome condensing factors to remain, leading to the induction of PCC in the sperm nucleus. In single cases, PCC was also observed in fertilized eggs that had formed two or three pronuclei. In these cases, PCC resulted either from distinct pronuclear asynchrony or interchromosomal asynchrony within the chromosome set.

Developmental arrest of 18 ova (about 5%) of 362 fertilized oocytes showing formation of two pronuclei was observed after in-vitro fertilization. In 7 ova the pronuclei were still visible 40 hrs after insemination. Five ova were degenerated after formation of the pronuclei. Cytological analysis of the ova revealed that the arrest of development had occurred at different stages of the cell cycle (interphase to metaphase of the first mitotic division) with one ovum being characterized by a tetraploid chromosome set. Asynchronous development of the pronuclei, which is obviously a cause of early developmental arrest, was observed in 4 ova. According to our observations we would rather transfer fertilized oocytes after cell cleavage (in the 2- to 6-cell stage) than in the pronuclei stage.

This paper goes into the question as to how greatly mother and father desire an individualised kind of delivery, how this wish is realised, and how it is valued many years later. The basic demand was a safe delivery-safe for both mother and child. For the purpose of analysis and study, 170 women were asked to register their opinion before being admitted to the labour ward, on the following points: for example, presence of the partner, free mobility during the first stage of labour, avoidance of analgesics, positioning the baby on the mother's belly, use of the obstetric chair, rooming-in, breast feeding, etc. Changes in the mother's behaviour during birth, as well as the interaction between mother, child and partner were observed. During the puerperium the delivery was critically assessed by the mother, and her ideas regarding delivery at a future time were recorded. It is possible to show that under the conditions of a safe, monitored birth (uncorrected perinatal mortality 1980-1983 0.71%) the individual wishes of the patients can be met. All mothers whose partners had been present during delivery, assessed this fact positively. Likewise, 100% of the mothers whose baby had been positioned on their belly after birth, considered this to be pleasant. 77% of them actively caressed the newborn in this position. 68% of the mothers talked to the child within the first 15 minutes. 86% kept the newborn for more than an hour in their bed. Of the fathers present during delivery, 55% caressed the newborn, and 50% talked to it within the first 15 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)

During an in vitro fertilization (IVF) program 122 inseminated eggs showing polar body extrusion, but neither formation of pronuclei nor cell cleavage were analysed cytogenetically. Nine of these eggs showed prematurely condensed sperm chromosomes of the G1-phase (G1-PCC) besides the haploid set of maternal metaphase II chromosomes. This phenomenon can be explained by the permanent arrest of the oocytes at metaphase II after sperm penetration and hence the continuing presence of cytoplasmic chromosome condensing factors which lead to the induction of PCC in the sperm nucleus. The overall frequency of this aberrant type of fertilization was calculated to be in the order of 3-4% of all in vitro fertilized eggs.

The in vitro fertilization (IVF) treatment is very stressful for the couple. The emotional tension (waiting, hoping) plays a greater role than the bodily complaints (stimulation, follicle puncture). Sometimes the wish to get a child is very strong and is the motivation for IVF treatment. Psychological investigations show that IVF patients have fewer psychological complaints compared with other sterility patients; in the psychoanalytically oriented Giessen test there are no differences compared with other sterility patients. The aim of a treatment for IVF patients is the individual, medically and psychologically oriented therapy - sometimes involving the renunciation of a further IVF therapy.

The case of a patient with recurrent abortions and one premature deficient birth is described. The underlying condition was an immunocoagulopathy caused by a lupus anticoagulant, leading to a tendency to thrombosis and in pregnancy to abortions, stillbirths, and deficient births. The diagnostic and therapeutic procedure is described and discussed.