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PURPOSE: The aim of the study was to assess cytogenetic and embryoscopic characteristics in subsequent miscarriages of spontaneous pregnancy losses (SPL) and recurrent pregnancy losses (RPL). METHODS: A retrospective cohort of 75 women was affected by repeated pregnancy loss. Of those, 34 had SPL, 24 primary RPL, and 17 secondary RPL. Ploidy status and morphology was analyzed by transcervical embryoscopic examination of the embryo and cytogenetic analysis of the chorionic villi in subsequent miscarriages. RESULTS: Similar rates of recurrent ploidy status were observed between first and second miscarriage in SPL and RPL (82.4% recurrent ploidy status in SPL, p > 0.999; 73% recurrent ploidy status in RPL, p = 0.227). No difference was found regarding recurrent abnormal morphology between SPL and RPL (p = 0.092). However, secondary RPL resulted significantly more often in recurrent abnormal morphology compared to primary RPL (p = 0.004). CONCLUSIONS: High rates of recurrent normal/abnormal karyotypes were observed in all groups with a majority of embryos presenting with recurrent abnormal morphology. Secondary RPL presented significantly more often with recurrent abnormal morphology compared to primary RPL. These findings offer prognostic information for the affected patient and might impact treatment choice.

Hysteroscopy has become an integral part of infertility workup, a modality to treat intrauterine pathologies and a vital tool in evaluation of patients of recurrent implantation failure. Newer advances in various hysteroscopes, associated instruments and devices have expanded the procedures done successfully by hysteroscopy. There are more unexplored indications, where hysteroscopy can be successfully employed. Further evaluation is needed to assess the role of hysteroscopy in procedures like embryo transfer. With continued emergence of newer instruments and techniques, the prospects for improvement seem unlimited.

Einleitung: Monoamniote Zwillinge zahlen zu den Hochrisikoschwangerschaften. Diskordante Fehlbildungen sind dabei selten. In nur wenigen Fallen wurde bisher eine diskordante Exenzephalie beschrieben. Die transzervikale Embryoskopie kann nach verhaltenem Abort in monoamnioten Zwillingen zur erweiterten Diagnostik unmittelbar vor der Abort-Curettage eingesetzt werden. Fallbericht: 35-jahrige G1/P0 in der 12. Schwangerschaftswoche. Monoamniote Zwillingsschwangerschaft mit diskordanter Exenzephalie und verhaltenem Abort diagnostiziert an 11+2 SSW. Eine transzervikale Embryoskopie wurde direkt vor der Abortcurettage durchgefuhrt und identifizierte die Exenzephalie und zusatzlich einen Nabelschnurknoten der beiden Feten als mogliche Ursache fur den Abort. Diskussion: In unserem Fallbeispiel fuhrte die transzervikale Embryoskopie zu der Diagnose eines Nabelschnurknotens nach missed abortion bei monoamnioten Zwllingen. Des Weiteren konnte eine diskordante Exenzephalie mittels Embryoskopie dargestellt werden. Bei stumpfer Eroffnung der Fruchthohle stellt die transzervikale Embryoskopie ein nur geringes zusatzliches Operationsrisiko im Rahmen einer Abortcurettage dar. Sie sollte jedoch nur auf ausdrucklichen Wunsch der Patientin nach erweiterter Diagnostik durchgefuhrt werden. Fazit: Die transzervikale Embryoskopie kann als zusatzliches diagnostisches Mittel nach missed abortion bei monoamnioten Zwillingen im Rahmen der Abortcurettage durchgefuhrt werden. Jedoch sollte vorher eine ausfuhrliche Nutzen-Risiko Analyse gemeinsam mit der Patientin erfolgen.

The most probable cause of an anembryonic gestation is an abnormal karyotype. The analysis of 59 cases of missed abortion with anembrionia prior to 12 weeks of gestation after spontaneous conception and the assisted reproductive technologies (ART) was carried out. Patients were divided into two groups: those pregnant after natural conception and those with pregnancies after the ART programs. Upon embryoscopy and direct chorion biopsy, samples were sent for karyotyping. High frequency of normal karyotypes of chorion was found: 28.6% and 44.7%, respectively.

High incidence of missed abortion induces to search for its causes. Apart from genetic and anatomic uterine factors, the state of the decidual endometrium and implantation zone of chorionic structures of the gestational sac are of particular interest. Direct visualization of the intact decidual endometrium is possible with embryoscopy, however, there is lack of presented data of normal and pathological signs of the endometrium during pregnancy. This paper describes the changes of the endometrium in missed abortion obtained by hysteroscopy in 160 women with nonprogressive pregnancy after ART protocols. High incidence of vascular disorders is determined, namely perivascular hemorrhage (70%), thrombosis of small-caliber endometrial vessels (36.9%), necrosis of the decidual endometrium and areas of the endometrium ejection beyond the implantation zone as a source of vaginal bleeding (10%). In addition, a high incidence of capsular decidual membrane defects are detected, namely, dystrophy, thinning and necrosis (60.6%).

Embryoscopy and fetoscopy are techniques that render the developing embryo/fetus and its environment accessible to the "outside" world, which includes diagnosis and, potentially, therapy. Embryocopy and fetoscopy, sometimes referred to as embryofetoscopy, uses high-resolution fiber optic equipment for direct visualization of the embryo/fetus. This has been used to identify developmental milestones from weeks 4 to 8 after conception. With this technique, it has been possible to identify anomalies and confirm those previously diagnosed by ultrasound. Its application has generally included the first and early second trimester of pregnancy for prenatal diagnosis in continuing pregnancies. In addition, fetal blood sampling has also been successfully performed experimentally with this technology, extending its potential applications into the realm of fetal therapy. Future applications for embryofetoscopy include therapeutic interventions such as gene or cell therapy at a time when the embryo is immunologically tolerant. This article focuses on the importance of embryoscopy and fetoscopy (embryofetoscopy) to perinatal medicine and its potential contributions to the concept of fetal therapy.

To demonstrate the efficacy of first-trimester needle embryofetoscopy (or embryoscopy) for prenatal diagnosis in a continuing pregnancy.A patient at risk for giving birth to an infant with Robert's syndrome was referred for prenatal diagnosis at 12 weeks of gestation.Transabdominal embryoscopy and amniocentesis were performed. Direct visualization of the embryo was achieved and no gross limb or facial abnormalities were seen. Chromosome studies of the amniotic fluid revealed a normal male 46, XY. Special studies with C-banding and DAPI techniques revealed no evidence of premature separation of centromeres. Two- and three-dimensional ultrasound also demonstrated no gross limb or facial abnormalities.This case confirms the efficacy of embryoscopy as a simple and relatively low-risk approach to first-trimester diagnosis for continuing pregnancies.

Objectives Conjoined twins are rare. High-quality imaging techniques are essential for proper first-trimester diagnosis. Technological development leads to new imaging techniques such as 3-dimensional virtual embryoscopy. The aim of this review was to explore imaging techniques used in the first-trimester diagnosis of conjoined twins and provide a systematic diagnostic table for making this diagnosis. Design A PubMed literature search was performed using the terms ultrasound, Doppler, MRI, and CT combined with first-trimester and conjoined twins. Three recent cases at our department are reviewed and examined additionally using 3-dimensional virtual embryoscopy. Results The different types of conjoined twins are summarized in a table for practical use during ultrasound examination. In evaluating conjoined twins, 2-dimensional ultrasound is the criterion standard. Three-dimensional and Doppler ultrasounds add anatomical and prognostic information. Virtual embryoscopy imaging reveals additional findings in our 3 cases not seen with routine 2-dimensionalultrasound examination. Conclusions Each case of conjoined twins is unique and should be evaluated with the best possible imaging techniques. Three-dimensional and Doppler ultrasound should be added to the systematic diagnostic evaluation of conjoined twins. Virtual embryoscopy imaging may contribute to earlier, more appropriate counseling and management of these pregnancies. Conclusions Target Audience: Obstetricians and gynecologists, family physicians Conclusions Learning Objectives: After completing this CME activity, physicians should be better able to differentiate between the different types of conjoined twins and their prognosis, compare the different imaging techniques used for the evaluation of conjoined twins to decide whether additional diagnostic imaging techniques are useful in an individual case, and evaluate complex cases, such as conjoined twins, using new imaging techniques.

On the basis of prenatal identification of a cleft lip by embryoscopy, a case of van der Woude syndrome was diagnosed at 11 menstrual weeks, allowing for early termination of pregnancy. The potential of embryoscopy to detect minor malformations in early pregnancy is discussed from both the technical and the ethical point of view.

Time-lapse (TL) embryo monitoring is the latest technology that is proposed for embryo evaluation and selection for transfer. TL technology enables us to collect significantly more information about the in vitro development of the embryos that can be obtained through the daily-once evaluation under the light microscope. In addition, the embryos do not need to be removed from the culture environment for this. The extra morphokinetic information and the undisturbed culture conditions could both be beneficial for the cultured embryo cohort. Many morphokinetic parameters have been tested in relation to variety of laboratory (e.g. blastocyst development) and clinical (implantation and live-birth rate) outcomes. Most of these studies are retrospective in nature and suffer from methodological problems (heterogeneous patient population, culture conditions not standardized, and small sample size). Several groups attempted to build algorithms, however, have not yet been confirmed externally as attempts so far could not reproduce the expected predictive abilities. Therefore, these algorithms cannot be universally accepted. The latest algorithm proposed for embryo selection was developed based on data from 24 clinics using local stimulation and laboratory procedures. It groups embryos into five categories (KIDScore) based on in and out of range kinetic events. The algorithm was tested in subsets of patients using various fertilization methods or culture conditions and its predictive ability remained the same. The authors, therefore, feel comfortable to recommend it for routine use in any laboratory using TL technology. There is, however, still limited prospective, randomized trial data testing the algorithms. This article reviews TL technology, retrospective and prospective reports on various morphokinetic parameters, and the benefits and shortcomings of currently available algorithms.

SUMMARY The introduction of transabdominal fiberoptic thin-gauge visualization of the embryo or fetus in the first trimester allows an earlier diagnosis of congenital anomalies currently beyond the resolution of ultrasound. In addition, it has the true potential of providing access to the fetal circulation at an early age, an accomplishment that would have enormous diagnostic and therapeutic implications. In the second and third trimester, operative fetoscopic techniques promise to open a new frontier in the diagnosis and management of fetal surgical and medical conditions.

Embryoscopy is a new technique that allows direct visualization of the embryo/fetus as early as the first trimester. A rigid fiberoptic endoscope is passed transcervically into the extracoelomic cavity and has been utilized to identify developmental milestones from weeks 4 to 8 following conception. All major external and internal structures develop during this period. With this technique, it is possible to both identify anomalies and confirm those diagnosed by ultrasound. Fetal blood sampling has also been preformed utilizing this technology and has established the feasibility of access to the human embryonic circulation. Future applications for embryoscopy include first-trimester prenatal diagnosis and therapeutic interventions such as gene or cell therapy at a time when the embryo is immunologically tolerant.

Advancing technology has made the fetus and its environment even more accessible to prenatal diagnosis and treatment. The current approach to prenatal diagnosis relies mainly on the use of high-resolution ultrasonography. However, as attempts are made to conduct antenatal diagnoses earlier in gestation, the limits of ultrasonography are approached. Embryoscopy allows for direct visualization of the first-trimester fetus with a fiberoptic endoscope. A customized side channel enables the operator to pass a variety of diagnostic tools and gain access into the fetal circulation. The further development and refinement of this technology are expected to change early prenatal diagnosis and treatment considerably. The potential contribution of this technique to perinatal medicine is readily apparent when it is placed in historic context. Undoubtedly, many ethical, legal, and regulatory questions will have to be addressed before the full potential of embryoscopy is realized. The responsibility for the judicious use of this powerful technology for prenatal intervention will have to be shared by the scientific community and a well-informed public.

Two cases of conjoined twins were diagnosed during first-trimester endovaginal ultrasound and were confirmed by embryoscopy performed prior to the termination of pregnancy. An early and accurate diagnosis of this anomaly, obtained by the combined use of ultrasound and endoscopy, may enable adequate counselling and an earlier termination of pregnancy associated with minimal maternal risks.

The strong light sources used in fetoscopy and embryoscopy may cause eye injuries to the fetus. To circumvent this potential hazard, we have successfully used an infrared light source and infrared video camera to perform 'night vision' fetoscopy in a fetal lamb model.