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The human leukocyte antigen (HLA) genes are cell-surface proteins, essential for immune cell interaction. HLA-G is known for their high immunosuppressive effect and its potential as predictive marker in breast cancer. However, nothing is known about the HLA-J and its immunosuppressive, prognostic and predictive features, as it is assumed to be a "pseudogene" by in silico sequence interpretation. HLA-J, ESR1, ERBB2, KRT5 and KRT20 mRNA expression were analysed in 29 fresh frozen breast cancer biopsies and their corresponding resectates obtained from patients treated with neoadjuvant chemotherapy (NACT). mRNA was analysed with gene specific TaqMan-based Primer/Probe sets and normalized to Calmodulin 2. All breast cancer samples did express HLA-J and frequently increased HLA-J mRNA levels after NACT. HLA-J mRNA was significantly associated with overexpression of the ESR1 mRNA status (Spearman ρ 0,5679; p = 0.0090) and KRT5 mRNA (Spearman ρ 0,6121; p = 0.0041) in breast cancer core biopsies and dominated in luminal B subtype. Kaplan Meier analysis revealed that an increase of HLA-J mRNA expression after NACT had worse progression free survival (p = 0,0096), indicating a counterreaction of tumor tissues presumably to prevent elimination by enhanced immune infiltration induced by NACT. This counterreaction is associated with worse prognosis. To our knowledge this is the first study identifying HLA-J as a new predictive marker in breast cancer being involved in immune evasion mechanisms.Humane Leukozyten-Antigene (HLA) sind Proteine auf der Zelloberfläche, die essenziell für die Immunzellinteraktion sind. HLA-G ist für seine hohe immunosuppressive Wirkung sowie als potenzieller prädikativer Marker für Brustkrebs bekannt. Dagegen ist kaum etwas über HLA-J und seine immunosuppressiven, prognostischen und prädiktiven Eigenschaften bekannt, da es basierend auf In-silico-Sequenzanalysen als „Pseudogen“ interpretiert wurde. Die Expression von HLA-J, ESR1, ERBB2, KRT5 und KRT20 mRNA wurde in 29 frisch gefrorenen Brustkrebsbiopsien analysiert und mit den klinisch-pathologischen Daten von Patientinnen, welche mit neoadjuvanter Chemotherapie behandelt wurden, verglichen. Die mRNA-Expression wurde mit genspezifischen TaqMan-basierten Primer/Probe-Sets analysiert und auf Calmodulin 2 normalisiert. Alle Gewebeproben von Patientinnen mit Brustkrebs exprimierten HLA-J, und der HLA-J-mRNA-Spiegel war nach NACT oft erhöht. In den Brustkrebsstanzbiopsien war die HLA-J-mRNA-Expression signifikant mit der Überexpression von ESR1-mRNA (Spearmans ρ 0,5679; p = 0,0090) und KRT5-mRNA (Spearmans ρ 0,6121; p = 0,0041) assoziiert und dominierte im Luminal-B-Subtyp. Die Kaplan-Meier-Analyse zeigte, dass ein Anstieg der HLA-J-mRNA-Expression nach NACT mit einem schlechteren progressionsfreien Überleben einhergeht (p = 0,0096), womöglich als Gegenreaktion des Tumorgewebes, um eine Eliminierung durch tumorinfiltrierende Lymphozyten, welche durch eine NACT induziert wurden, zu verhindern. Diese Gegenreaktion ist mit einer schlechteren Prognose assoziiert. Soweit uns bekannt, handelt es sich hierbei um die erste Studie, die HLA-J als neuen prädiktiven Marker im Brustkrebs identifiziert hat und möglicherweise zur Immunevasion beiträgt.

Recurrent miscarriages are associated with strong distress in patients. In this paper, we describe - based on the S1 guideline of the German Society for Gynecology and Obstetrics (DGGG) - the evidence-based diagnostic and therapeutic options in patients with recurrent miscarriages.

Purpose Official guideline of the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (ÖGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). The aim of this guideline was to standardize the diagnosis and treatment of couples with recurrent miscarriage (RM). Recommendations were based on the current literature and the views of the involved committee members. Methods Based on the current literature, the committee members developed the statements and recommendations of this guideline in a formalized process which included DELPHI rounds and a formal consensus meeting. Recommendations Recommendations for the diagnosis and treatment of patients with RM were compiled based on the international literature. Specific established risk factors such as chromosomal, anatomical, endocrine, hemostatic, psychological, infectious and immunological disorders were taken into consideration.

On August 1, 2013, the German Patent and Trademark Office issued a patent for the "Non-embryo-destructive extraction of pluripotent embryonic stem cells, stem cells obtained by this process and their uses" (DE 10 2004 062 184 B4). The patent document describes a non-embryo-destructive process to harvest embryonic stem cells from the inner cell mass (ICM) during the blastocyst development stage. The patent application was filed with the German Patent Office in Munich on December 23, 2004 and the patent claim was published in 2006. The patent was granted on August 1, 2013. Processing the patent application was a lengthy affair due to the fact that, for a long time, the prevailing opinion in Germany was that genetic screening of embryos (preimplantation genetic diagnosis) was prohibited under the German Embryo Protection Act (ESchG). A ruling by the German Federal Court in 2010 proved this opinion to be false. Animal studies have provided the evidence that the described procedure is technically feasible; healthy offspring were born after stem cells were harvested from the blastocyst and stored. We report here on a technique for the non-embryo-destructive extraction of pluripotent embryonic stem cells together with potential future applications for stem cells harvested in this manner.Am 1. August 2013 wurde vom Deutschen Patent- und Markenamt das Patent für die Patentschrift „Embryonenerhaltende Gewinnung pluripotenter embryonaler Stammzellen, derart gewonnene Stammzellen und Verwendung derselben“ (DE 10 2004 062 184 B4) erteilt. Das vorliegende Patent beschreibt ein Verfahren zur embryonenerhaltenden Gewinnung embryonaler Stammzellen aus der inneren Zellmasse (ICM) im Entwicklungsstadium der Blastocyste. Es wurde am 23. 12. 2004 beim Deutschen Patentamt in München angemeldet und 2006 als Patentanspruch offengelegt, also veröffentlicht. Rechtswirksam erteilt wurde das Patent am 1. 8. 2013. Die lange Bearbeitungsfrist ergab sich u. a. dadurch, dass in Deutschland lange Zeit die Meinung vorherrschte, dass genetische Untersuchungen am Embryo (Präimplantationsdiagnostik) nach dem Embryonenschutzgesetz (ESchG) verboten seien, was sich erst nach einem Urteil des Bundesgerichtshof im Jahre 2010 als unzutreffend erwies. Der Nachweis, dass das dargestellte Verfahren auch technisch umsetzbar ist, erfolgte im Tierversuch, nach Stammzellasservation wurde aus den Blastozysten eine gesunde Nachkommenschaft geboren. Im Artikel werden die Techniken der embryonenerhaltenden Gewinnung pluripotenter embryonaler Stammzellen beschrieben und die potenziellen Möglichkeiten einer Anwendung aufgezeigt.

Purpose: Official guideline coordinated and published by the German Society of Gynecology and Obstetrics (DGGG). Aim of the guideline was to standardize the diagnosis and treatment of patients with recurrent miscarriage (RM). Recommendations were proposed, based on the current national and international literature and the experience of the involved physicians. Consistent definitions, objective assessments and standardized therapy were applied. Methods: Members of the different involved societies developed a consensus in an informal process based on the current literature. The consensus was subsequently approved by the heads of the scientific societies. Recommendations: Recommendations for the diagnosis and treatment of patients with RM were compiled which took the importance of established risk factors such as chromosomal, anatomical, endocrine, hemostatic, psychological, infectious and immunological disorders into consideration.

Nonobstructive azoospermia is caused in up to 10% by microdeletions of the Y chromosome in the azoospermia factor (AZF) region, which is divided into three nonoverlapping areas (AZFa, AZFb and AZFc). In 25 male patients with AZF microdeletions, the results of two different techniques for surgical sperm retrieval (SR), conventional multilocular TESE and microdissection TESE, were studied retrospectively over a period of 19 years. Conventional multilocular TESE was carried out in 11 patients and microdissection TESE in 14 patients. Successful SR was possible only in patients with isolated AZFc microdeletions, so only the 20 patients with AZFc microdeletions alone were taken into account for the comparison of the both operative techniques. The sperm detection rate for conventional multilocular TESE was 25%, the sperm detection for microdissection TESE was significantly higher with 67%. In all patients, a histological examination of the testicular tissue was carried out, which showed a mixed picture, but Sertoli-cell-only syndrome in most cases. FSH was no prognostic marker for successful SR. In two of six couples performing an intracytoplasmic sperm injection until now, a pregnancy occurred.

Granulocyte colony-stimulating factor (G-CSF) belongs to the family of colony-stimulating factors (CSF). As the name suggests, it was initially identified as being able to target and influence granulopoiesis, but was soon shown to be a ubiquitous growth factor, with synthesis and receptors, such as the related granulocyte macrophage colony-stimulating factor (GM-CSF), which is found in a wide variety of tissue types, including the organs and cell populations involved in reproduction. It must now be assumed that both G-CSF and GM-CSF control, or play a role in controlling, key processes in oocyte and sperm maturation, endometrial receptivity, implantation, and embryo and fetal development, possibly extending to birth. The following article offers an overview of the current findings with regard to animal experimental studies, initial clinical applications in reproductive medicine, and potential risks.

Reparaturmechanismen fruher Embryonen in vitro In vitro kultivierte Embryonen bzw. Blastozysten zeigen eine hohe Aneuploidierate. Es liegen Belege vor, dass v. a. Mosaikbildungen durch Selbstreparaturmechanismen korrigiert werden konnen. Diese Mechanismen scheinen in erster Linie im Embryo selbst, also genomisch, angelegt zu sein. Daruber hinaus scheint es auch eine Beeinflussung durch externe Faktoren zu geben, v. a. Zytokine und Wachstumsfaktoren, die maternaler Herkunft sind und vermutlich auch noch nach der Implantation, also in der Schwangerschaft wirken.

Antithrombin (AT) deficiency is a rare hereditary thrombophilia with a mean prevalence of 0.02 % in the general population, associated with a more than ten-fold increased risk of venous thromboembolism (VTE). Within this multicenter retrospective clinical analysis, female patients with inherited AT deficiency were evaluated concerning the type of inheritance and extent of AT deficiency, medical treatment during pregnancy and postpartally, VTE risk as well as maternal and neonatal outcome. Statistical analysis was performed with SPPS for Windows (19.0). A total of 18 pregnancies in 7 patients were evaluated, including 11 healthy newborns ≥37th gestational weeks (gw), one small for gestational age premature infant (25th gw), two late-pregnancy losses (21st and 28th gw) and four early miscarriages. Despite low molecular weight heparin (LMWH) administration, three VTE occurred during pregnancy and one postpartally. Several adverse pregnancy outcomes occurred including fetal and neonatal death, as well as severe maternal neurologic disorders occurred. Patients with substitution of AT during pregnancy in addition to LMWH showed the best maternal and neonatal outcome. Close monitoring with appropriate anticoagulant treatment including surveillance of AT levels might help to optimize maternal and fetal outcome in patients with hereditary AT deficiency.

In 1–5 % of patients during childbearing years recurrent miscarriages (RM) occur. There are established risk factors like anatomical, endocrine and hemostatic disorders as well as immunological changes in the maternal immune system. Nevertheless, further elucidation of the pathogenesis remains a matter of debate. In addition, there are no standardized immunological treatment strategies. Recent studies indicate possible effects of tumor necrosis factor α blocker and granulocyte-colony stimulating factor (G-CSF) concerning live birth rate (LBR) in RM patients. Therefore, we performed a retrospective cohort study in patients undergoing assisted reproductive treatment (ART) with known RM analysing the possible benefits of G-CSF application. From January 2002 to December 2010, 127 patients (199 cylces) with RM (at least 2 early miscarriages) 49 (72 cycles) receiving G-CSF and 78 (127 cycles) controls receiving either no medication (subgroup 1) or Cortisone, intravenous immunoglobulins or low molecular weight heparin (subgroup 2) undergoing ART for in vitro fertilisation/intracytoplasmic sperm injection were analysed. G-CSF was administered weekly once (34 Mill) in 11 patients, 38 patients received 2 × 13 Mill G-CSF per week until the 12th week of gestation. Statistical analysis was performed with SPSS for Windows (19.0), p < 0.05 significant. The mean age of the study population was 37.3 ± 4.4 years (mean ± standard deviation) and differed not significantly between patients and subgroups. However, the number of early miscarriages was significantly higher in the G-CSF group as compared to the subgroups (G-CSF 2.67 ± 1.27, subgroup 1 0.85 ± 0.91, subgroup 2 0.64 ± 0.74) and RM patients receiving G-CSF had significantly more often a late embryo transfer (day 5) (G-CSF 36.7 %, subgroup 1 12.1 %, subgroup 2 8.9 %). The LBR of patients and the subgroups differed significantly (G-CSF 32 %, subgroup 1 13 %, subgroup 2 14 %). Side effects were present in less than 10 % of patients, consisting of irritation at the injection side, slight leukocytosis, rise of the temperature (

Recent developments in reproductive medicine address oocyte morphology, sperm analysis and embryo selection. However, in a subgroup of infertile couples, it is the embryo implantation process that is disrupted. Diagnostic tools to identify patients at risk of implantation failure are limited and therapeutic options are far away from being established. In this review we focus on selected possible causes and treatments of failed implantation. Reproductive surgery allows a proper first step diagnosis and therapy of recurrent implantation failure (RIF). Possible anatomical malformations and associated diseases with treatment options are mentioned. Diagnostic procedures in patients often focus on defining gene polymorphisms (like hereditary thrombophilia and p53) and determinants of endometrial receptivity including endometrial gene expression profiles. Although significant differences in gene expression have been identified, the study populations are quite small, some of the data conflicting and clinical significance has yet to be proven. Implantation requires a close interaction between the fetal trophoblast and the maternal endometrium with natural killer cells (NK cells) playing a main part at the feto-maternal interface during early pregnancy. Therefore this review also focuses on NK cell receptor expression and new immunomodulatory treatment options like G-CSF in RIF patients.

Although recurrent miscarriage (RM) affects only 1-3% of couples, it has a major influence on the wellbeing and psychosocial status of patients. Therefore, research into improved diagnosis and development of new treatment strategies is essential. In this review, we summarize current concepts on diagnosis and treatment in RM, drawing upon research reports and international guidelines to provide insights into the pathophysiology of pregnancy disrupted by repeated miscarriage. Anatomical malformations, infectious diseases, endocrine disorders, autoimmune defects as well as acquired and inherited thrombophilia are established risk factors in RM. In addition, our recent findings indicate an impact on miscarriage incidence of glycoproteins such as glycodelin, and nuclear hormone receptors such as the peroxisome proliferator-activated receptors (PPARs). Significantly reduced glycodelin expression is associated with miscarriage, whereas up-regulation of PPARs appears to compensate for either the activated immune response or the disturbed cytotrophoblast differentiation in RM patients. There is also evidence that circulating placental microparticles are increased in a subgroup of RM patients, indicating an acquired procoagulant state even outside pregnancy. Treatment strategies like aspirin and low molecular weight heparin (LMWH) are standard medications in RM, although only a few placebo-controlled trials have proven their benefit in respect to live birth rate. There is emerging evidence that new treatment options, including drugs like TNFalpha inhibitors and granulocyte colony-stimulating factor (G-CSF) might be beneficial in some cases of RM. However, larger clinical trials must be completed to further prove or disprove benefits of these drugs in the treatment of RM patients.

During a period of 8 years, 1,079 intracytoplasmic sperm injection (ICSI) procedures with aspirated epididymal or testicular spermatozoa were performed. Epididymal spermatozoa were used in 172 cycles and testicular spermatozoa or spermatids in 907 cycles. Multiple biopsies were obtained from at least two different locations in the testes. Retrieved spermatozoa were used after cryopreservation (frozen) or immediately after aspiration (fresh). Three hundred patients had obstructive azoospermia (OA) or ejaculation failure. In 414 cases, azoospermia was caused by impaired spermatogenesis resulting from maldescended testes, chemotherapy/radiotherapy, or by Sertoli-cell-only syndrome, genetic disorders or unknown aetiology. Transfer rates, pregnancy rates and birth rates per ICSI cycle showed no statistically significant differences between testicular and epididymal spermatozoa in men with OA (28% average birth rates in both cases). However, birth rates differed significantly with regard to the status of spermatogenesis. Treatment of men with nonobstructive azoospermia (NOA) resulted in a birth rate of 19% per cycle. In all patient groups, there was no difference in the birth rates achieved with fresh and cryopreserved spermatozoa. While testicular volume, follicle-stimulating hormone level and age of the male patient are no statistically significant prognostic factors, the underlying cause of azoospermia is the most important factor determining the outcome of ICSI with epididymal and testicular spermatozoa. The pregnancy rate is lower in NOA patients than in those with OA.

Introduction: Male infertility caused by azoospermia due to non-reconstructable obstruction or non-obstructive azoospermia can be treated by microsurgical epididymal aspiration (MESA) or testicular sperm extraction (TESE) followed by an intracytoplasmatic spermatozoa injection (ICSI). Material and Methods: From 9/93 to 6/01, we carried out 1,025 ICSI procedures with aspirated epididymal or testicular sperms in 684 cases. 163 ICSI cycles were performed with epididymal sperms and 862 ICSI cycles with testicular sperms or spermatids. The TESE was carried out by open biopsy, frequently in a multilocular technique. The aspirated spermatozoas were used after cryopreservation (frozen) or immediately after aspiration (fresh). Results: 538 patients had obstructive azoospermia or ejaculation failure. In 487 cases the underlying cause of azoospermia was an impaired spermatogenesis, following maldescensus testis, chemotherapy, radiotherapy, or caused by Sertoli-cell-only syndrome, a genetic disorder or an unknown etiology. The transfer rates, pregnancy rates and birth rates per ICSI cycle showed no statistically significant differences between testicular and epididymal sperms in the cases of seminal obstruction (28% average birth rates in both cases). However, highly significant was the difference in birth rates with regard to the underlying cause of infertility. In contrast, in treating non-obstructive azoospermia we observed a birth rate of 19% per cycle. In all patient groups the birth rate with fresh spermatozoas did not differ from those with cryopreserved spermatozoa. 40% of patients after multilocular TESE showed clinical signs of testicular lesion. Conclusion: The underlying cause of azoospermia is the most important factor for the outcome of ICSI using epididymal and testicular sperms. In cases of non-obstructive azoospermia, the pregnancy rate is low compared with the results in cases of obstructive azoospermia. There is no difference between fresh and cryopreserved sperms. TESE with ICSI is the most efficient treatment of azoospermia caused by hypergonadotropic hypogonadism. The morbidity of the TESE procedure is highly relevant and must be considered if this technique is indicated.

Objective To systematically review the reporting of MII (MII) oocyte development after xenotransplantation of human ovarian tissue. Design Systematic review in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Setting Not applicable. Patient(s) Not applicable. Intervention(s) Formation of MII oocytes after xenotransplantation of human ovarian tissue. Main Outcome Measure(s) Any outcome reported in Pubmed. Result(s) Six publications were identified that report on formation of MII oocytes after xenotransplantation of human ovarian tissue. Conclusion(s) Xenografting of human ovarian tissue has proved to be a useful model for examining ovarian function and follicle development in vivo. With human follicles that have matured through xenografting, the possibility of cancer transmission and relapse can also be eliminated, because cancer cells are not able to penetrate the zona pellucida. The reported studies have demonstrated that xenografted ovarian tissue from a range of species, including humans, can produce antral follicles that contain mature (MII) oocytes, and it has been shown that mice oocytes have the potential to give rise to live young. Although some ethical questions remain unresolved, xenotransplantation may be a promising method for restoring fertility. This review furthermore describes the value of xenotransplantation as a tool in reproductive biology and discusses the ethical and potential safety issues regarding ovarian tissue xenotransplantation as a means of recovering fertility.

OBJECTIVE The aim of these studies was to investigate whether the leucocytic ultrafiltrate LeukoNorm Cytochemia, which is approved for the treatment of immunologically-based recurrent spontaneous abortions (RSA), improves treatment results in patients with repetitive IVF or ICSI failures. MATERIAL AND METHODS Included in this study were patients with 3 embryo transfers, with at least 8 morphologically good-looking embryos of the categories a and b, and no conception. Excluded were patients with accompanying endocrine disorders, uterine malformations, and those exhibiting the presence of an antiphospholipid syndrome and of further autoantibody syndromes (e.g. antinuclear antibodies [ANA]). The patients were treated in three prospective, randomized studies. The studies differed with respect to the frequency and timing of the administration of LeukoNorm Cytochemia. RESULTS Pregnancy rates in each of the study protocols were generally higher than in the normal treatment group. Because of the small number of patients (study I: 10 patients), the differences were not always significant. The results of study III, which is still ongoing and in which LeukoNorm Cytochemia has been given on 5 consecutive days starting with the day of oocyte retrieval, are more significant. In the treatment group of study III the pregnancy rate was 55% as opposed to a rate of 21.2% in the non-treatment group. CONCLUSIONS The administration of LeukoNorm Cytochemia can significantly improve treatment results in patients with repetitive IVF or ICSI failures. Currently the most favourable results are observed with a dosage of 1 unit/10 kg on 5 consecutive days, starting with the day of oocyte retrieval. These results imply that, in the IVF or ICSI programmes, there exists a group of patients with disturbances in the embryo-maternal dialogue, and therefore no conceptions. Furthermore, the results demonstrate that the administration of LeukoNorm Cytochemia can improve the implantation rate of transferred embryos in these patients. We conclude that growth factors and cytokines synthesized and secreted by leucocytes have an important influence on embryonic implantation and growth.

Objective: Intracytoplasmatic sperm injection (ICSI) has improved fertilization and pregnancy rates in assisted reproduction programs. We studied the fertilization of cryopreserved oocytes with ICSI. Methods: A long protocol (GnRH analogues/FSH, hMG) was generally used for ovarian stimulation. Oocytes from 57 patients were cryopreserved using modified standard freezing and thawing protocols. 16 patients became pregnant after the first treatment cycle with native oocytes so that 31 remained for ICSI with cryopreserved oocytes. 38 cycles with cryopreserved oocytes were carried out in 26 of these patients. Results: After thawing 24 of 161 oocytes (15%) were degenerated. The degeneration rate after ICSI was a further 13%. Thus the total degeneration rate was higher than that with pronuclear stages (28% vs. 22%). 36 embryo transfers resulted in 7 clinical pregnancies. One pregnancy ended in spontaneous abortion, 2 in the delivery of healthy twins, and 4 are ongoing. Conclusion: Fertilization of cryopreserved oocytes by ICSI is associated with a good fertilization rate (48%) and a good pregnancy rate (24% per thawing cycle). The procedure is indicated if freezing of embryos or pronuclear stages is not an option. Furthermore, it appears to be a potential alternative for young patients scheduled for chemotherapy or radiation therapy.

We report on our experiences with intracytoplasmic injection (ICSI) of epididymal and testicular spermatozoa (MESA, TESE) from azoospermic men whose wives had previously failed to become pregnant after several cycles of artificial insemination by donor (AID); because we do not perform AID treatment in our clinic, all these treatments were carried out in other fertility centers as well as the female diagnostic of sterility. In 3 husbands we could not find any testicular spermatozoa or spermatids, leaving 15 women under treatment. Of these 15 women, 9 became pregnant. This accounts for a pregnancy rate per patient of 60%. We believe that functional defects of the oocytes and somatizing psychological problems concerning AID are predominantly responsible for these results and that both problems can be overcome by ICSI. Besides, these results demonstrate that ICSI/MESA and ICSI/TESE are effective approaches in the treatment of azoospermic men and that using cryopreserved spermatozoa is not disadvantageous in the outcome of ICSI.

Objective: To demonstrate that a PGD program can be successfully established after the 2011 verdict of the German Bundestag concerning PGD. Material and Method: Eight years previously, the couple had had a daughter who suffered from clinically manifest hemophilia A due to an unbalanced X-inactivation, as well as microdeletion syndrome resulting in severe physical and mental disability. The couple wished to have a second child but refused the idea of a “trial” pregnancy. Given the indications for both, it was necessary to carry out polar body diagnosis (PBD) to rule out hemophilia A and, during the same cycle, a subsequent PGD on the blastocysts to rule out genetic aberrations. The PBD and PGD (trophectoderm biopsy, TEB) were performed after high-dosage ovarian stimulation and ICSI fertilization of the oocytes. A blastocyst was successfully transferred on day 6. Results: The patient conceived immediately. The pregnancy developed normally and the patient gave birth to a girl in the 40th week of pregnancy. Post-natal examinations showed that the baby is free from hemophilia A and is developing normally both physically and mentally. Conclusion: Establishment of a PGD program is now possible after legalization of PGD in Germany. It is possible to apply two investigative techniques in a single treatment cycle if multifactorial diagnosis is required.

In 220 consecutive patients with non-obstructive azoospermia, sperm retrieval was attempted by a combination of conventional and microdissection testicular sperm extraction (TESE). For sperm retrieval, 2-3 conventional biopsies were performed followed by a microdissection TESE in cases of negative conventional biopsies. During the surgery, the vasculature of the testis was assessed using the operative microscope, and the location of positive biopsies was registered in relation to the blood supply. The overall sperm retrieval rate was 58.2%. From the initial conventional biopsies, sperm could be retrieved in 46.8% of the patients. With microdissection TESE, sperm could be retrieved from an additional 11.4% of the patients. The further use of microdissection TESE improved the sperm retrieval rate significantly (P=0.017). No significant accumulation of positive biopsies was found towards the rete testis or the main testicular vessels.

For the first time we report on an intact and ongoing triplet pregnancy after intracytoplasmatic sperm injection of cryopreserved testicular sperm. Indication was azoospermia due to hypergonadotropic hypogonadism. The patient conceived in the third treatment cycle after 25 treatment cycles with donor sperm that had been carried out without success in two other treatment centers.

Antiphospholipid syndrome (APS) is a multisystemic disorder of coagulation-causing thrombosis in the arterial and venous system as well as pregnancy-related complications such as miscarriage, stillbirth, preterm delivery and pre-eclampsia. The disease is characterized by the autoimmune production of antibodies against phospholipid, a substance found in the cell membrane. We here report the case of a patient with four second trimester miscarriages, who apart from a heterozygous plasminogen activator-inhibitor-1 mutation, had no risk factors explaining her condition. In the subsequent pregnancy she was therefore put on low-molecular-weight heparin, aspirin and granulocyte colony-stimulating factor. Antiphospholipid antibodies (APL), which had been negative before gestation, increased and remained high throughout pregnancy, thus suggesting a pregnancy-induced or -aggravated APS. The patient was kept on the above-mentioned medication and delivered a healthy male baby by Caesarean section after an otherwise uneventful pregnancy. Thus, in order to diagnose and treat pregnancy-triggered APS in patients with unexplained recurrent miscarriage, screening for APL should also be performed at several time points after conception.

Sir, As early as the year 2000, we reported on the use of granulocyte colony-stimulating factor (G-CSF) for IVF patients who failed to become pregnant after repeated embryo transfers (Wurfel, 2000; Wurfel, 2003). At that time, we administered 300 µg of Molgramostin in a single dose on the day of the embryo transfer. The pregnancy rate of patients treated with transfer on day 2 (average two embryos) was almost 43% compared with almost 20% in the placebo group. The study by Scarpellini et al. (2009) now reports on continuous administration of G-CSF, evidently without any identifiable negative effects on the infants. Given this, we decided to run a pilot study to investigate whether continuous administration of G-CSF to patients with RIF (repetitive implantation failure) would be beneficial or not. However, the initial criterion—patients' failure to conceive after repeated IVF or ICSI treatments—appeared to us to be too vague. Taking the publication by Hiby et al. (2008) as a basis we initially performed killer-cell immunglobulin-like receptor (KIR) typing on patients with more than five unsuccessful IVF treatments or embryo transfers. Only patients who lacked the three activating receptors were accepted for the study; also included were patients suffering from long-term unexplained sterility (average 6.8 years) and lacking the three activating KIR genes. Groups overlapped to some extent as cases of unexplained sterility had often undergone (unsuccessful) IVF treatment. The incidence of three lacking receptors (2 DS 1, 2 DS 3 and 3 DS 5) was very high in the group examined, at 78%. In addition, it was noted that patients lacked not only the three named activating receptors but also further receptors, so that in general the group was shown to lack five to seven receptors including the above-mentioned three activating receptors. We performed IVF and ICSI treatment on the defined group with the target of a day 5 transfer. Patients received 13 million units of GranocyteTM (Lanogrostim) every 3 days in addition to the usual luteal support. In cases where insufficient numbers of fertilized oocytes were available, the transfer was performed on day 2 (particularly in cases of ovarian insufficiency). Results for d + 5: Exclusively transfer of two blastocysts/morulae or compacted morulae Number of patients 40 Number of treatment cycles 42 Clinical pregnancies (excluding biochemical) 31 of which abortions (clinical) 12 Pregnancy rate per treatment cycle/embryo transfer 73.8% Abortion rate (clinical pregnancies) 38.7% View it in a separate window Results for transfer d + 2 (also including patients with significant ovarian insufficiency) Number of patients 19 Number of treatment cycles 19 Clinical pregnancies 8 of which abortion (clinical) 3 Pregnancy rate per embryo transfer 42% Abortion rate 37.5% View it in a separate window The group we selected and defined certainly had a very poor prognosis. The pregnancy rates achieved were extraordinarily high both in the day 5 transfers and the day 2 transfers. However, the rate of clinical abortions is also high (biochemical pregnancies were ignored). In the meantime, we have also conducted a further pilot study in which G-CSF was administered to patients with a history of multiple unsuccessful IVF treatments or unexplained sterility, who had no KIR defects. The results were very poor, with pregnancy rates currently below 10% per embryo transfer. We conclude from this that the use of G-CSF is an extremely promising additional method of treatment in cases where defects in materno-embryonic implantation communication can be shown. This applies in particular to KIR defects and, in this, particularly to the lack of the three activating receptors as described by Hiby et al. Where such defects were not present, results of G-CSF treatment were disappointing. On the basis of the results of these pilot studies, we are currently planning a prospective randomized double-blind study under the initial criteria given above.

We report on the outcome of 82 amniocenteses (AC) carried out during pregnancies after in vitro fertilization (IVF) from 1-1-1985 to 31-12-1989. The main indication for amniocentesis was a maternal age of greater than or equal to 35 years. In 48 cases, we found an anterior placenta and assumed that this was related to the position in which the uterine embryo transfer was performed. In six pregnancies, we found an abnormal karyotype, including two cases of trisomy 21; the two couples decided for abortion. Four aberrations in the fetal karyotypes were also present in either the mother or the father, the resulting children are healthy. The further course of pregnancies after IVF and AC was characterized by a higher incidence of toxemia, uterine bleeding before the 28th week of gestation, abruptio placentae, and premature deliveries, when compared to the course of pregnancies after spontaneous conception. We believe that these occurrences were not caused by AC, as the incidence was higher in all our pregnancies after IVF (without AC) and has also been reported in pregnancies after ovarian hyperstimulation without IVF. Therefore, we see no reason to renounce AC after IVF. However, the special risks inherent in pregnancies after IVF must always be discussed with the couple.

Die Konversion von Cholesterol zu Pregnenolon gilt als der wichtigste und zugleich limitierende Schritt der Steroidsynthese. Steroltragerprotein-2 (SCP2) oder nichtspezifisches Lipidtransferprotein (nsL-TP) ist ein intrazellulares Protein, das fur den pr-a und transmitochondrialen Cholesteroltransport und damit die mitochondriale Pregnenolonsynthese von wesentlicher Bedeutung ist. In den Leydig-Zellen der Ratte kann die Pregnenolonsynthese durch LH und LH-RH stimuliert werden, dabei kommt es nur unter LH zu charakteristischen Veranderungen der intrazellularen SCP2-Konzentrationen. Dies bedeutet, daβ die Pregnenolonsynthese uber zwei verschiedene Wege reguliert werden kann. Ziel dieser Untersuchung war festzustellen, ob es auch im humanen Corpus luteum einen derartigen «zweiten Weg» der Steroidsynthese gibt. Anhand von humanen Lutealzellen, die bei Follikelpunktionen anfielen und kultiviert wurden, konnten wir zeigen, dass (humanes) LH/hCG auch im humanen Corpus luteum die Pregnenolonsynthese erhoht und es dabei zu charakteristischen Umverteilungen von SCP2 sowie einer Aktivitatssteigerung der 7-Dehydrocholesterol-Reduktase, eines Markerenzyms fur SCP2, kommt. LH-RH zeigt an humanen Lutealzellen hingegen keinerlei Effekte, so dass im humanen Corpus luteum kein «zweiter Weg» der Steroidsynthese nachzuweisen ist.

Zwischen der Schilddrusen- und der Ovarialfunktion bestehen Interferenzen, weswegen sich Funktionstorungen der Schilddruse auf das Zyklusgeschehen auswirken konnen. Bislang, sind Interferenzen in drei

Human chorionic gonadotropin (hCG) exerts a clinically apparent negative feedback on the secretion of human thyroid-stimulating hormone (hTSH) in pregnancy, and the two have cross-reactivity for the TSH receptor in membrane preparations of the thyroid. We examined whether hTSH, in turn, has an influence on the secretion and synthesis of hCG in short-term cultures of human placenta at term. A dose- and time-dependent decrease in the extracellular hCG concentration caused by hTSH was demonstrated. To examine whether hTSH inhibits de novo synthesis of hCG or decreases hCG depletion, we determined the amount of hCG secreted and the size of the intracellular pool by using an enzyme immunoassay. By incorporating a radiolabeled amino acid in the hCG molecule, we measured the amount of hCG synthesized de novo. We concluded that hTSH acts by decreasing the rate of de novo synthesis of placental hCG.

We report on our experience with surgical pelviscopy in the treatment of ectopic pregnancies after in-vitro fertilisation and, in comparison, during spontaneous cycles and during cycles with ovarian hyperstimulations and IUI. From 1.1. 1988 to 31.12.1990, 54 patients underwent this operation, 25 of these having undergone the IVF programme. All IVF patients had an extensive history of tubal sterility. Therefore, we found difficult anatomic conditions during the operation in most cases. Furthermore, the special conditions of the IVF treatment itself (e.g., multiple transfer of embryos into the uterus) caused a higher incidence of complicated situations (one triple ectopic, three ovarian ectopic pregnancies and one simultaneous pregnancy). Firstly, our experience leads to the conclusion, that surgical pelviscopy can be used for management of more complicate problems and can be regarded, so far, as an alternative to laparotomy. Secondly, laparotomy should not be replaced by pelviscopy in difficult situations (e.g., ovarian ectopics pregnancies). Surgical pelviscopy reduces the trauma of treatment, a consideration, which is very important especially for IVF patients. Because of the extraordinary problems related to ectopic pregnancies after IVF, we are at present sceptical about the use of other methods (e.g., instillation of prostaglandins or methotrexate) for these patients. Subsequently, 19 patients in the IVF group conceived with an intrauterine pregnancy after repeated IVF treatment. In the second group, 8 spontaneous intrauterine conceptions have occurred since.

In order to improve the ovarian response to exogenous gonadotropins and to reduce the risk of the ovarian hyperstimulation syndrome and of multiple pregnancies, human menopausal gonadotropin (hMG) was administered by continuous pulsatile subcutaneous (s.c.) infusion via a portable pump. The effectiveness of pulsatile hMG treatment was first demonstrated in a control group comprising 7 females with regular ovulatory cycles, who underwent gonadotropin ovarian superovulation and subsequent IVF/GIFT procedures for tubal or male factor. All pulsatile s.c. hMG cycles were ovulatory and one clinical pregnancy was achieved. In this group, ovarian response was similar following intramuscular (i.m.) and pulsatile s.c. hMG therapy, with a marked reduction of preovulatory serum levels of oestradiol in the pulsatile s.c. hMG cycles. In a prospective study, 11 patients with overt polycystic ovary syndrome (PCO) who failed to ovulate in response to clomiphene, received i.m. hMG ovarian superovulation treatment in 19 cycles and pulsatile s.c. hMG in 21 cycles. Following i.m. hMG treatment, only 10 cycles were ovulatory; 7 cycles had to be cancelled for impending ovarian hyperstimulation syndrome. Following pulsatile s.c. hMG treatment, 15 cycles were ovulatory, only 3 treatment cycles had to be disrupted for multifollicular ovarian response. Both modes of treatment were similar in terms of requirement of hMG ampoules, number of preovulatory follicles, preovulatory serum levels of oestradiol and duration of the preovulatory oestradiol rise. The total duration of hMG treatment was significantly increased following pulsatile s.c. hMG. It is concluded, that in overt PCO syndrome, continuous pulsatile s.c. administration of hMG is an effective method to induce follicular maturation and to achieve ovulations.(ABSTRACT TRUNCATED AT 250 WORDS)