Evaluation of malignant effusions using MR-based T1 mapping.

Our aim was to investigate the diagnostic yield of rapid T1-mapping for the differentiation of malignant and non-malignant effusions in an ex-vivo set up. T1-mapping was performed with a fast modified Look-Locker inversion-recovery (MOLLI) acquisition and a combined turbo spin-echo and inversion-recovery sequence (TMIX) as reference. A total of 13 titrated albumin-solutions as well as 48 samples (29 ascites/pleural effusions from patients with malignancy; 19 from patients without malignancy) were examined. Samples were classified as malignant-positive histology, malignant-negative histology and non-malignant negative histology. In phantom analysis both mapping techniques correlated with albumin-content (MOLLI: r = - 0.97, TMIX: r = - 0.98). MOLLI T1 relaxation times were shorter in malignancy-positive histology fluids (2237 ± 137 ms) than in malignancy-negative histology fluids (2423 ± 357 ms) as well as than in non-malignant-negative histology fluids (2651 ± 139 ms); post hoc test for all intergroup comparisons: < 0.05. ROC analysis for differentiation between malignant and non-malignant effusions (malignant positive histology vs. all other) showed an (AUC) of 0.89 (95% CI 0.77-0.96). T1 mapping allows for non-invasive differentiation of malignant and non-malignant effusions in an ex-vivo set up.

Improving the barrier function of damaged cultured urothelium using chondroitin sulfate.

AIMS: To determine whether glycosaminoglycan (GAG) replenishment is able to improve recovery of a deficient urothelial barrier, chondroitin sulfate (CS) instillations were tested using an in vitro model. Porcine urothelial cells (Ucells) were terminally differentiated in culture conditions to construct a urothelial layer with a functional barrier. This layer was damaged to compromise barrier function to simulate a key characteristic of bladder pain syndrome/interstitial cystitis. The functional effect of subsequent treatment with CS was evaluated. METHODS: Primary porcine Ucells were isolated and cultured on inserts. Differentiation of cells was evaluated with immunohistochemical analysis for the presence of umbrella cells, tight junctions and CS. Transepithelial electrical resistance (TEER) measurements were performed to evaluate barrier function. Protamine was used to simulate mild urothelial damage. CS 0.2% (vol/vol), a GAG, was subsequently instilled in the treatment group. The recovery of barrier function was further evaluated with TEER measurements. The Student t test was used for the analysis of results. RESULTS: After induction of differentiation, the Ucells expressed barrier markers and a functional barrier was established (measured by high TEER). TEER decreased significantly after instillation with protamine. CS instillation improved recovery of TEER significantly measured after 7 hours (84% vs 22% in controls). After 24 hours; however, the TEER was comparable in both experimental groups. CONCLUSION: CS instillation improves the recovery of the urothelial barrier after damage in vitro. This functional experiment shows that CS improves recovery of damaged urothelial function, which supports the hypothesis behind the mechanism of action of GAG-replenishment therapy.

In vitro exposure to Hymenoptera venom and constituents activates discrete ionotropic pathways in mast cells.

Calcium entry is central to the functional processes in mast cells and basophils that contribute to the induction and maintenance of inflammatory responses. Mast cells and basophils express an array of calcium channels, which mediate responses to diverse stimuli triggered by small bioactive molecules, physicochemical stimuli and immunological inputs including antigens and direct immune cell interactions. These cells are also highly responsive to certain venoms (such as Hymenoptera envenomations), which cause histamine secretion, cytokine release and an array of pro-inflammatory functional responses. There are gaps in our understanding of the coupling of venom exposure to specific signaling pathways such as activation of calcium channels. In the present study, we performed a current survey of a model mast cell line selected for its pleiotropic responsiveness to multiple pro-inflammatory inputs. As a heterogenous stimulus, Hymenoptera venom activates multiple classes of conductance at the population level but tend to lead to the measurement of only one type of conductance per cell, despite the cell co-expressing multiple channel types. The data show that ICRAC, IARC, and TRPV-like currents are present in the model mast cell populations and respond to venom exposure. We further assessed individual venom components, specifically secretagogues and arachidonic acid, and identified the conductances associated with these stimuli in mast cells. Single-cell calcium assays and immunofluorescence analysis show that there is heterogeneity of channel expression across the cell population, but this heterogeneity does not explain the apparent selectivity for specific channels in response to exposure to venom as a composite stimulus.

Toxicity data for modeling impacts of oil components in an Arctic ecosystem.

Ecological impact assessment modeling systems are valuable support tools for managing impacts from commercial activities on marine habitats and species. The inclusion of toxic effects modeling in these systems is predicated on the availability and quality of ecotoxicology data. Here we report on a data gathering exercise to obtain toxic effects data on oil compounds for a selection of cold-water marine species of fish and plankton associated with the Barents Sea ecosystem. Effects data were collated from historical and contemporary literature resources for the endpoints mortality, development, growth, bioaccumulation and reproduction. Evaluating the utility and applicability of these data for modeling, we find that data coverage is limited to a sub-set of the required endpoints. There is a need for new experimental studies for zooplankton focused on the endpoints development and bioaccumulation and for larvae and juvenile fish focused on growth and development.

Risk of borderline and invasive ovarian tumours after ovarian stimulation for in vitro fertilization in a large Dutch cohort.

BACKGROUND: Long-term effects of ovarian stimulation for IVF on the risk of ovarian malignancies are unknown. METHODS: We identified a nationwide historic cohort of 19,146 women who received IVF treatment in the Netherlands between 1983 and 1995, and a comparison group of 6006 subfertile women not treated with IVF. In 1997-1999, data on reproductive risk factors were obtained from 65% of women and data on subfertility (treatment) were obtained from the medical records. The incidence of ovarian malignancies (including borderline ovarian tumours) through 2007 was assessed through linkage with disease registries. The risk of ovarian malignancies in the IVF group was compared with risks in the general population and the subfertile comparison group. RESULTS: After a median follow-up of 14.7 years, the risk of borderline ovarian tumours was increased in the IVF group compared with the general population [standardized incidence ratio (SIR) = 1.76; 95% confidence interval (CI) = 1.16-2.56]. The overall SIR for invasive ovarian cancer was not significantly elevated, but increased with longer follow-up after first IVF (P = 0.02); the SIR was 3.54 (95% CI = 1.62-6.72) after 15 years. The risks of borderline ovarian tumours and of all ovarian malignancies combined in the IVF group were significantly increased compared with risks in the subfertile comparison group (hazard ratios = 4.23; 95% CI = 1.25-14.33 and 2.14; 95% CI = 1.07-4.25, respectively, adjusted for age, parity and subfertility cause). CONCLUSIONS: Ovarian stimulation for IVF may increase the risk of ovarian malignancies, especially borderline ovarian tumours. More large cohort studies are needed to confirm these findings and to examine the effect of IVF treatment characteristics.

Registering preprocedure volumetric images with intraprocedure 3-D ultrasound using an ultrasound imaging model.

For many image-guided interventions there exists a need to compute the registration between preprocedure image(s) and the physical space of the intervention. Real-time intraprocedure imaging such as ultrasound (US) can be used to image the region of interest directly and provide valuable anatomical information for computing this registration. Unfortunately, real-time US images often have poor signal-to-noise ratio and suffer from imaging artefacts. Therefore, registration using US images can be challenging and significant preprocessing is often required to make the registrations robust. In this paper we present a novel technique for computing the image-to-physical registration for minimally invasive cardiac interventions using 3-D US. Our technique uses knowledge of the physics of the US imaging process to reduce the amount of preprocessing required on the 3-D US images. To account for the fact that clinical US images normally undergo significant image processing before being exported from the US machine our optimization scheme allows the parameters of the US imaging model to vary. We validated our technique by computing rigid registrations for 12 cardiac US/magnetic resonance imaging (MRI) datasets acquired from six volunteers and two patients. The technique had mean registration errors of 2.1-4.4 mm, and 75% capture ranges of 5-30 mm. We also demonstrate how the same approach can be used for respiratory motion correction: on 15 datasets acquired from five volunteers the registration errors due to respiratory motion were reduced by 45%-92%.

Respiratory motion correction for image-guided cardiac interventions using 3-D echocardiography.

In this paper, we investigate the use of 3-D echocardiography (echo) data for respiratory motion correction of roadmaps in image-guided cardiac interventions. This is made possible by tracking and calibrating the echo probe and registering it to the roadmap coordinate system. We compare two techniques. The first uses only echo-echo registration to predict a motion-correction transformation in roadmap coordinates. The second combines echo-echo registration with a model of the respiratory motion of the heart. Using experiments with cardiac MRI and 3-D echo data acquired from eight volunteers, we demonstrate that the second technique is more robust than the first, resulting in motion-correction transformations that were accurate to within 5mm in 60% of cases, compared to 42% for the echo-only technique, based on subjective visual assessments. Objective validation showed that the model-based technique had an accuracy of 3.3 + or - 1.1mm, compared to 4.1 + or - 2.2mm for the echo only technique. The greater errors of the echo-only technique were mostly found away from the area of echo coverage. The model-based technique was more robust away from this area, and also has significant benefits in terms of computational cost.

Leptospirosis and Goodpasture's syndrome: testing the aetiological hypothesis.

Leptospiral pathogens have a world-wide distribution and cause a spectrum of disease ranging from a mild, influenza-like illness to Weil's disease, which manifests itself in multi-organ failure. Recently, Leptospira-reactive sera from 40 leptospirosis patients were investigated in an ELISA designed to detect antibodies to the human glomerular basement membrane (GBM). The aim was to determine if host-derived leptospiral immunoglobulins cross-react with proteins in the human GBM, so facilitating the development of Goodpasture's syndrome. As all 40 sera were found negative in the anti-GBM ELISA, the hypothesis that, during the immune phase of leptospirosis, patients are at risk of developing Goodpasture's syndrome was not supported. Further work is required to determine if leptospirosis is a risk factor in the development of any other pulmonary-renal syndromes that are associated with auto-immune diseases, such as Wegener's granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome, Behçet's disease, IgA nephropathy and systemic lupus erythematosus.

First Report of Tomato yellow leaf curl virus in Tomato in the Netherlands.

Tomato yellow leaf curl virus (TYLCV) is an economically important virus with tomato (Solanum lycopersicum L.) as its main host. The virus is widely distributed in subtropical areas and is transmitted by the tobacco whitefly (Bemisia tabaci) in a persistent manner. TYLCV has a quarantine status (IIAII) in the European Union (EU directive 2000/29/EC). It was not previously recorded in the Netherlands. In September 2007, symptoms were observed in tomato crops in a few greenhouses located in close proximity from each other in the western part of the Netherlands. Infected plants showed TYLCV-like symptoms, i.e., stunting, leaf curl, and marginal and interveinal chlorosis. Similar symptoms were evoked after grafting symptomatic tips onto healthy tomato seedlings, whereas no viruses were transmitted by mechanical inoculation to herbaceous test plants. Extracted DNA from symptomatic leaves was used in PCR with two sets of primers for universal detection of begomoviruses (1,2). Analysis of the overlapping amplified products revealed the highest identity to isolate TYLCV-Alm (GenBank Accession No. AJ489258) from Almeria, Spain. To amplify the remaining 60% of the virus genome, three additional primer sets were designed: TYLCV965F 5'-GGCAGCCAAGTACGAGAACC-3' and TYLCV1736R 5'-CCACTATCTTCCTCTGCAATCC-3'; TYLCV1598F 5'-TACTTGCGAACAGTGGCTCG-3' and TYLCV2282R 5'-TCCAAATCGATGGCAGATCAG-3'; TYLCV2229F 5'-ATGCGTCGTTGGCAGATTG-3' and TYLCV68R 5'-CAGTGACGTCTGTGGAACCCT-3'. Analysis of the five overlapping PCR products of one isolate revealed a total virus genome of 2,781 nucleotides. The complete sequence of the Netherlands Isolate (GenBank Accession No. FJ439569) showed 99.3% nucleotide identity to isolate TYLCV-Alm (AJ489258), and therefore, the virus was identified as TYLCV-Alm. After the initial identification, a survey was conducted in all tomato crops in a surrounding area of approximately 40 km2. TYLCV was found in 19 of 27 cultivations. The identity of one isolate per cultivation was confirmed by sequence analysis of the products obtained with the Wyatt and Brown primers (2) occasionally in combination with the Deng primers (with 99.1 to 100% and 99.2 to 100% nucleotide identity to the Netherlands isolate [FJ439569], respectively) (1). As many as 25 symptomatic plants were recorded per greenhouse. A subsequent survey of 34 randomly selected tomato growers in other areas of the country revealed no further infections. Results of the sequence analyses and surveys suggested that the outbreak resulted from a single introduction of the virus, whereas the insect vector B. tabaci accounted for local spread. Measures taken to eliminate the virus included the removal and subsequent destruction of infected tomato plants as well as eradication of B. tabaci. No TYLCV infections were found during surveys in 2008, and therefore, it is believed that the virus was eradicated effectively. References: (1) D. Deng et al. Ann. Appl. Biol. 125:327, 1994. (2) S. D. Wyatt and J. K. Brown. Phytopathology 86:1288, 1996.

[Cognitive functions after surgery and stenting for extracranial stenosis of the carotid artery]. / Kognitive Leistungsfähigkeit nach Operation und stentgeschützter Angioplastie einer Karotisstenose.

BACKGROUND: This prospective, controlled, randomised study evaluates differences concerning cognitive functions between carotid endarterectomy (CEA) and stent-protected angioplasty (CAS) as a treatment for symptomatic carotid stenosis. Both techniques include risks whose effect on neuropsychological abilities remains yet unknown. METHODS: Twenty-seven patients suffering from high-grade symptomatic carotid stenosis underwent neuropsychological testing before, 1 month, and 6 months after treatment. After the first testing patients were randomly assigned for CEA (n=10) or CAS (n=17) as treatment. The patients' cognitive functions were compared to those of 13 healthy controls. RESULTS: Whether patients underwent CEA or CAS made no difference in the neuropsychological outcome 4 weeks and 6 months after treatment. Patients always performed worse than the healthy controls. CONCLUSION: Both techniques seem to have no different effect on cognitive functions.

First Report of Tomato chlorotic dwarf viroid in Petunia hybrida from the United States of America.

In November 2005, 13 accessions of Petunia hybrida from the United States of America entered the post-entry quarantine station of the Plant Protection Service in the Netherlands. The plants were inspected and tested for quarantine organisms according to Directives 95/44 and 97/46 of the European Union. No virus and viroid symptoms were observed in the imported plants or in mechanically inoculated plants of Chenopodium quinoa, Nicotiana benthamiana, and N. occidentalis-P1 (3). Testing for pospiviroids by return-polyacrylamide gel electrophoresis (1) and reverse transcriptase-PCR with universal pospiviroid primers Pospi1-RE/FW (2) indicated the presence of pospiviroids in 3 and 11 P. hybrida accessions, respectively. The 196-bp amplicons of six accessions were sequenced. Sequence analysis showed the highest identity for all amplicons to both isolates of Tomato chlorotic dwarf viroid (TCDVd) in NCBI GenBank, Accession Nos. AF162131and AY372399, from Canada and the United States, respectively. Additional RT-PCRs with the Pospi1-RE/FW primers in opposite order and the semi-universal pospiviroid primers Vid-RE/FW (2) for one isolate, followed by sequence analysis, confirmed the identity as TCDVd. The isolate consisted of 359 nucleotides (GenBank Accession No. DQ859013) and showed sequence identities of 98.6 and 96.1% to the Canadian and American tomato isolates of this viroid, respectively. The next highest sequence identity was 90.0% to two accessions of Potato spindle tuber viroid (GenBank Accession Nos. AJ593449 and AY962324). On the basis of these results, the viroid from P. hybrida was identified as TCDVd. To our knowledge, this is the first report of TCDVd in this plant species. Reference: (1) J. W. Roenhorst et al. EPPO Bull. 30:453, 2000. (2) J. Th. J. Verhoeven et al. Eur. J. Plant Pathol. 110:823, 2004. (3) J. Th. J. Verhoeven and J. W. Roenhorst. EPPO Bull. 33:305, 2003.

Surgical repair of aortopulmonary window: thirty-seven years of experience.

An aortopulmonary window (APW) is a communication between the ascending aorta and the pulmonary trunk in the presence of two separate semilunar valves. In order to increase our understanding about the surgical management of this rare lesion and its long-term results, we describe our experience over a 37-year period. Between 1968 and 2005, 18 patients were diagnosed with APW. Seventeen underwent surgical correction. Age at operation ranged from 22 days to 22 years (median, 0.20 years). Follow-up ranged from 2 weeks to 28.6 years (median, 11.0 years). Surgical closure was achieved using a single patch in 7 patients (41.2%) double patch in 4 (23.5%), primary closure in 3 (17.6%), clip in 2 (11.8%), and ligation in 1 (5.9%). Complex APW was present in 8 patients (44.4%). One patient was treated nonsurgically. There were no early or late deaths after surgery. Both primary closure and patch closure gave excellent long-term results. Sporadic postoperative complications were only associated with complex lesions. One patient who was treated conservatively died (of pulmonary hypertension) 21 years after diagnosis. Repair of APW is ideally performed in the first months of life, before irreversible PHT has developed. Various surgical repair techniques in this series of patients gave excellent short-term and long-term results, without significant hemodynamic sequelae.

First Report of Potato virus M and Chrysanthemum stunt viroid in Solanum jasminoides.

In 2005, a plant of the ornamental crop Solanum jasminoides from the Netherlands was submitted for testing on viruses and viroids because of its intended use for propagation. Sap from this plant was mechanically inoculated to the test plant species Chenopodium quinoa, Nicotiana benthamiana, N. hesperis-67A, and N. occidentalis-P1 (3). N. hesperis-67A showed chlorotic local lesions and rugosity followed by vein necrosis, N. occidentalis-P1 showed necrotic local lesions and systemic leaf distortion, and the two other test plant species remained symptomless. Potato virus M (PVM) was identified by double antibody sandwich enzyme-linked immunosorbent assay using leaves from S. jasminoides and N. hesperis-67A. The plant of S. jasminoides was also tested for the presence of viroids by reverse transcriptase-polymerase chain reaction (RT-PCR) with universal pospiviroid primers Pospi1-RE/FW (2). This reaction yielded an amplicon of the expected size of 198 bp. The sequence showed 100% identity to an isolate of Chrysanthemum stunt viroid (CSVd; NCBI GenBank Accession No. AF394453). Subsequently, the complete sequence of our viroid isolate (GenBank Accession No. DQ406591) was determined from the amplicon obtained after RT-PCR using specific primers for the detection of CSVd (1). The viroid isolate from S. jasminoides consisted of 354 nucleotides and showed the highest identity (98.6%) to a chrysanthemum isolate of CSVd (GenBank Accession No. AB055974). Therefore, the viroid was identified as CSVd. To our knowledge, this is the first report of PVM and CSVd in S. jasminoides. Reference: (1) R. Hooftman et al. Acta Hortic. 432:120, 1996. (2) J. Th. J. Verhoeven et al. Eur. J. Plant Pathol. 110:823, 2004. (3) J. Th. J. Verhoeven and J. W. Roenhorst, EPPO Bull. 33:305, 2003.

First Report of Tomato apical stunt viroid in Tomato in Tunisia.

In May 2005, the Plant Protection Service in the Netherlands received two tomato (Lycopersicon esculentum) plant specimens for diagnosis from a protected crop production facility of 2.5 ha near Kebili in Tunisia. Growth of the plants was reduced and leaves were chlorotic and brittle. Ripening of the fruits was delayed and their storage life was reduced from 3 weeks to 1 week. The grower reported that initially only 5% of plants showed symptoms; however, the number of symptomatic plants increased quickly to 100% as a result of increasing temperatures in the production facility. Test plant species Chenopodium quinoa, Datura stramonium, Nicotiana glutinosa, N. hesperis-67A, N. occidentalis-P1, and L. esculentum 'Money-maker' were mechanically inoculated with sap from the affected plants. Symptoms including chlorosis and stunting were observed only on L. esculentum. Reverse transcriptase-polymerase chain reaction (RT-PCR) with universal pospiviroid primers Pospi1-RE/FW (2) yielded amplicons of the expected size (196 bp) for each of the two samples. One of these amplicons was sequenced and showed the highest identity to the four isolates of Tomato apical stunt viroid (TASVd) in the NCBI Gen-Bank. Subsequently, the complete sequence of the Tunisian isolate (Gen-Bank Accession No. DQ144506) was determined by sequencing the am-plicon obtained after RT-PCR using primers developed for the detection of Citrus exocortis viroid (CEVd) (1). The isolate consisted of 363 nucleotides and showed the highest sequence identity (96.7%) to tomato isolates of TASVd from Indonesia and Israel (GenBank Accession Nos. X06390 and AY062121, respectively), 92.6% to a tomato isolate from the Ivory Coast (GenBank Accession No. K00818), and 87.7% to an isolate from Solanum pseudocapsicum (GenBank Accession No. X95293). The next highest sequence identity was 81.5% to an isolate of CEVd (GenBank Accession No. X53716). On the basis of these results, the viroid was identified as TASVd. To our knowledge, this is the first report of TASVd in Tunisia. Reference: (1) N. Önelge. Turkish J. Agric. For. 21:419, 1997. (2) J. Th. J. Verhoeven et al. Eur. J. Plant Pathol. 110:823, 2004.

Two cases of fatal necrosis of the lesser pelvis in patients treated with combined radiotherapy and hyperthermia for cervical carcinoma.

This study reports two cases of fatal necrosis of the lesser pelvis in patients with advanced cervical carcinoma, who had received combined radiotherapy and hyperthermia. The necrosis reached far from the high dose area, in one of the cases even outside the radiation portals. Both patients initially had treatment-related morbidity which responded well to surgical treatment. After a disease-free interval, a rapidly progressive necrosis developed. Necrosis to this extent after combined modality treatment has, to the authors' knowledge, not been described.

Effects of subfertility cause, smoking and body weight on the success rate of IVF.

BACKGROUND: We investigated the separate and combined effects of smoking and body mass index (BMI) on the success rate of IVF for couples with different causes of subfertility. METHODS: The success rate of IVF was examined in 8457 women. Detailed information on reproduction and lifestyle factors was combined with medical record data on IVF treatment. All IVF clinics in The Netherlands participated in this study. The main outcome measures were live birth rate per first cycle of IVF differentiated for the major predictive factors. RESULTS: For male subfertility the delivery rate per cycle was significantly lower than unexplained subfertility, OR of 0.70 (95% CI 0.57-0.86); for tubal pathology, the delivery rate was slightly lower, OR = 0.86 (95% CI 0.70-1.01). Smoking was associated with a significantly lower delivery rate was slightly lower; for OR = 0.72 (95% CI 0.61-0.84) and a significantly higher abortion rate compared to non-smoking delivery rates of 21.4% and 16.4%, respectively (P=0.02). Women with a BMI of > or = 27 kg/m2 had a significantly lower delivery rate, with an OR of 0.67 (95% CI 0.48-0.94), compared with normal weight women (BMI > or = 20 and <27 kg/m2). CONCLUSIONS: Both smoking and overweight unfavourably affect the live birth rate after IVF. The devastating impact of smoking on the live birth rate in IVF treatment is comparable with an increase in female age of >10 years from age 20 to 30 years. Subfertile couples may improve the outcome of IVF treatment by lifestyle changes.

[Methods and results of in-vitro fertilisation in the Netherlands in the years 1983-1994]. / Methoden en resultaten van in-vitrofertilisatie in Nederland in de jaren 1983-1994.

OBJECTIVE: To describe methods and results of in-vitro fertilisation (IVF) treatment during the first 12 years after the introduction of IVF treatment in the Netherlands. Design. Retrospective cohort study. METHOD: A nationwide study was conducted among women who had had their first IVF cycle stimulated with gonadotrophins in 12 IVF centres in the Netherlands in the period 1 January 1983 to 31 December 1994 (n = 8, 184). RESULTS: The subfertility diagnosis related to tubal factors decreased from 70% in 1987 to 25% in 1994. The subfertility diagnosis related to a male factor increased from 8.7% in 1987 to 35.5% in 1994. The mean age at first IVF treatment remained roughly constant. During the introduction of GnRH agonists there was an increase in gonadotrophin dosages, the number of retrieved oocytes, the number of high responders and/or women who experienced an ovarian hyperstimulation syndrome (OHSS). The percentage of deliveries with at least one baby born alive after the first IVF cycle increased from 6% in 1984 to 18% in 1994. The number of live births per 100 transferred embryos increased from 2.5 in 1985 to 12 in 1994. Furthermore, the mean numbers of embryos transferred after the first IVF cycle decreased from 3.2 in 1987 to 2.2 in 1994. The overall success rate - defined as the proportion of women who had at least one child born alive after one or more IVF cycles - for women who had their first IVF treatment between 1983 and 1994 was 37.1%. The percentage of triplets or quadruplets decreased from 8.7 in 1989 to 1.2 in 1994. The percentage of twin deliveries remained about 25. CONCLUSION: The introduction of GnRH agonists and the higher dosages of gonadotrophins led to a higher oocyte harvest. During the first years of IVF treatment there was an increase in the success rate after the first treatment cycle. The overall success rate remained constant after 1991. The risk of developing an OHSS increased whereas the rate of twin deliveries remained constant.