Predicting impaired glucose metabolism in women with polycystic ovary syndrome by decision tree modelling.

AIMS/HYPOTHESIS: Polycystic ovary syndrome (PCOS) is a risk factor of type 2 diabetes. Screening for impaired glucose metabolism (IGM) with an OGTT has been recommended, but this is relatively time-consuming and inconvenient. Thus, a strategy that could minimise the need for an OGTT would be beneficial. MATERIALS AND METHODS: Consecutive PCOS patients (n=118) with fasting glucose <6.1 mmol/l were included in the study. Parameters derived from medical history, clinical examination and fasting blood samples were assessed by decision tree modelling for their ability to discriminate women with IGM (2-h OGTT value >/=7.8 mmol/l) from those with NGT. RESULTS: According to the OGTT results, 93 PCOS women had NGT and 25 had IGM. The best decision tree consisted of HOMA-IR, the proinsulin:insulin ratio, proinsulin, 17-OH progesterone and the ratio of luteinising hormone:follicle-stimulating hormone. This tree identified 69 women with NGT. The remaining 49 women included all women with IGM (100% sensitivity, 74% specificity to detect IGM). Pruning this tree to three levels still identified 53 women with NGT (100% sensitivity, 57% specificity to detect IGM). Restricting the data matrix used for tree modelling to medical history and clinical parameters produced a tree using BMI, waist circumference and WHR. Pruning this tree to two levels separated 27 women with NGT (100% sensitivity, 29% specificity to detect IGM). The validity of both trees was tested by a leave-10%-out cross-validation. CONCLUSIONS/INTERPRETATION: Decision trees are useful tools for separating PCOS women with NGT from those with IGM. They can be used for stratifying the metabolic screening of PCOS women, whereby the number of OGTTs can be markedly reduced.

Use of assisted reproductive techniques for treatment of ejaculatory disorders.

Ejaculatory disorders can interfere with the fertility of young adults who suffer from spinal cord injury, have type I diabetes mellitus or have undergone retroperitoneal or intrapelvic operations. Following an overview of causes and treatment of ejaculatory disorders, the data of our centre are presented. From a group of 37 patients with genuine loss of seminal emission, 15 men and their wives were offered a combined treatment of rectal probe electro-ejaculation and artificial reproductive techniques. No serious complications occurred. During 40 cycles with intracorporeal insemination and 11 cycles with extracorporeal fertilization techniques, seven pregnancies were achieved, representing a pregnancy rate of 46% per couple and 14% per cycle for all cycles. Five healthy children were born, all following extracorporeal insemination. The 'take-home baby rate' for this population and for this technique is 45%. In vitro fertilization (IVF) led to one birth, intracytoplasmic sperm injection (ICSI) achieved four live births out of three pregnancies, one being a twin gestation. Since our successes are due to the use of extracorporeal insemination techniques, these are now incorporated in a new, more rational treatment protocol.

[Ambulatory contrast hysterosonography as a possibility for assessing tubal patency]. / Die ambulante Hystero-Kontrast-Sonographie (HKSG) als Möglichkeit zur Kontrolle der Tubendurchgängigkeit.

For the diagnostic evaluation of infertility it is crucial to obtain information on potential abnormalities of the uterus or the fallopian tubes. At present, the following diagnostic methods are available: CO2-pertubation, hysteroscopy, hysterosalpingography (HSG) and chromolaparoscopy (CLP). For the latter procedure, general anaesthesia is required. In a clinical trial 103 patients from our infertility clinic were examined for fallopian tube patency using the contrast agent SH U 454 (Echovist). The new technique hystero-contrast sonography (Hy-Co-Sy) was carried out in an outpatient setting without requiring general anaesthesia. Informed consent was obtain from all patients. A Foley catheter was inserted into the uterine cavity, the balloon was inflated and the contrast medium injected. Distribution of the contrast agent as well as the uterine cavity, the fallopian tubes as well as in the pouch of Douglas was then observed by sonography. In addition to Hy-Co-Sy, 58 patients underwent HSG or CLP. Hy-Co-Sy findings could confirmed by HSG and CLP in 90.6% and 91.6%, respectively. Patients were asked to describe their discomfort on a scale of one to hundred. The average time required for the assessment to tubal patency was 9 minutes. Within 12 months of the Hy-Co-Sy study, 23 out of 60 patients (38.3%) became pregnant. Our study shows that Hy-Co-Sy is a valuable and reliable procedure to assess the uterine cavity and the fallopian tubes in patients undergoing treatment for infertility. The procedure can be performed safely in the office without the need for general anaesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Is there a correlation between tubal occlusions in chronic salpingitis and urogenital chlamydia infections?]. / Gibt es einen Zusammenhang zwischen Tubenverschlüssen bei chronischer Salpingitis und urogenitalen Chlamydieninfektionen?

A prospective study was performed to analyse the relationship between urogenital infections caused by Chlamydia trachomatis and occlusions of the fallopian tubes with histologically confirmed chronic salpingitis and salpingitis isthmica nodosa. 110 infertile patients were tested for C. trachomatis infection. 23 patients with tubal occlusions and histologically confirmed chronic salpingitis (group 1) and eight patients with salpingitis isthmica nodosa (group 2) were compared to 13 patients with tubal occlusions after tuboligation (group 3), and to 66 patients with patent fallopian tubes as demonstrated by laparoscopy or hysterosalpingography (group 4). The prevalence of infections of the endocervix or urethra and the presence of Chlamydia in urine was low in all four groups. However, in groups 1 and 2, the median Chlamydia IgG and IgA serum antibody titres were significantly higher (p < or = 0.0002) than in groups 3 and 4. This result illustrates the association between urogenital infections with Chlamydia and tubal occlusions with histologically documented chronic salpingitis and salpingitis isthmica nodosa.

[Rate of early abortion after in vitro fertilization and embryo transfer]. / Frühstabortrate nach In-vitro-Fertilisation und Embryotransfer.

The high rate of implantation failures in infertile patients after in vitro fertilization must be regarded as the major problem of the kind of treatment. Usually, no information on the development of the embryo can be obtained for the time between embryo replacement and rising beta-hCG levels. Own studies on the early pregnancy factor (EPF) showed a positive reaction few hours following the contact of a fertilized oocyte with the endometrial surface. Therefore, we used the EPF as a marker for the viability of the embryo in 82 patients after in vitro fertilization and embryo transfer. Within two days after embryo transfer the EPF was positive in 52 (63%) patients and negative in 30 (37%) patients. In these women the embryos may have been lost during handling or may have discontinued further development. Between day 3 and day 12 after transfer the EPF turned to negative values in 35 patients--especially between day 6 and 10. These cases must be regarded as true implantation failures. After day 12 following embryo transfer, rising beta-hCG levels could be measured in 17 women (21%), but only in 12 patients (15%) could a growing embryonic sac be detected by ultrasound. From these figures, we may conclude, that about half of the embryos are lost already during the step of embryo transfer and the other half during implantation. Therefore, more attention should be given to the handling of the embryos to increase the pregnancy rate after in vitro fertilization.

[Treatment of fallopian tube pregnancies with prostaglandins]. / Behandlung von Eileiterschwangerschaften mit Prostaglandinen.

In a study, the clinical use of prostaglandin F2 alpha in local and systemic application in women with ectopic pregnancies were studied (1, 9). Two different treatment schedules were defined and applied. In group A, patients with a diagnosed ectopic and beta-HCG level lower than 850 mIU/ml were treated with prostaglandin F2 alpha i.m. injected only. In group B, prostaglandin F2 alpha were injected in the chorionic cavity of the ectopic by laparoscopy after localisation with a thin needle. In spite of prostaglandin F2 alpha treatment, 6 of 30 patients (20.0%) had to be operated by microsurgery because of increasing serum beta-HCG levels. A control of tubal patency 6 month later showed one closed tube only (4.5%). Up to now, 8 spontaneous intrauterine pregnancies occurred in our study groups after successful prostaglandin F2 alpha treatment; one pregnancy was seen in a women with a single fallopian tube. The conserving treatment of one ectopic pregnancy using prostaglandin F2 alpha yields positive results, if serum beta-HCG levels are below 2000 mIU/ml.

[The ovarian hyperstimulation syndrome. Anesthesiologic aspects based on a severe case]. / Das Ovarien-Hyperstimulations-Syndrom (OHS). Anaesthesiologische Gesichtspunkte anhand eines schweren Einzelfalles.

Ovarian hyperstimulation syndrome (OHS) is an iatrogenic syndrome in which induction of ovulation results in a wide spectrum of clinical symptoms and signs and laboratory manifestations. Based on the severity of the symptoms and signs, three degrees of hyperstimulation have been described: mild, moderate and severe. The most severe manifestation, presented in this paper with reference to the case of a 27-year-old woman, takes the form of massive ovarian enlargement with multiple cysts, hemoconcentration and third-space accumulation of fluid in the form of ascites, pleural and pericardial effusion. The full-blown clinical syndrome may be complicated by renal failure and oliguria, hypovolemic shock, thromboembolic episodes, adult respiratory distress syndrome (ARDS) and even death. The pathophysiologic mechanisms responsible for the development of OHS are still not known. The incidence of this iatrogenic syndrome can be reduced by monitoring plasma estradiol and by ultrasonographic evaluation of growing follicles. The anesthesiological aspects of OHS are discussed. A strategy for treatment, based on repeated ultrasonographic examination, clinical and biochemical evaluation, plasma volume replacement, abdominal paracentesis and aspiration puncture of the pleural effusion, is suggested.

[Is microsurgical preserving operation of tubal pregnancy sensible?]. / Ist die mikrochirurgisch-konservierende Operation einer Eileiterschwangerschaft sinnvoll?

During the period from 1976 to 1986, 179 women were operated at the Department of Gynaecology of the University of Düsseldorf. In 112 patients conservative techniques were used to retain the Fallopian tube. Of these 112, a group of 24 patients had a functioning adnexa on only one side at the time of operation. The conceptions of these women were investigated. In 8 of these patients, an intrauterine pregnancy occurred. 6 of these 8 patients had a salpingotomy, 1 woman underwent resection with immediate anastomosis and in another case both Fallopian tubes were treated (left Fallopian tube: reanastomosis status post resection three years earlier, right Fallopian tube: immediate anastomosis). 7 patients had a repeat ectopic pregnancy. Of these cases, direct anastomosis was performed 5 times and salpingotomy twice. 7 patients did not fall pregnant again. The Fallopian tubes of 6 patients were found to be open upon subsequent examination, while only one was found to be closed. One patient could not be followed-up, and one had neither a subsequent examination nor became pregnant again.

Surgical alteration of the mesosalpinx and its influence upon ovarian ovulatory function in the rabbit.

Ovarian ovulatory function as correlated with the production of corpora lutea was studied in 58 rabbits that were subjected to unilateral surgical procedures. Initially, a resection of 50% of the isthmus and 50% (n = 8) or all (n = 8) of the corresponding mesosalpinx was performed. Next, 50% of the ampulla and 50% (n = 7) or all (n = 8) of the corresponding mesosalpinx was resected. Finally, a variable length, either one third, two thirds, or all, of the ampulla (n = 27) was dissected from the adjacent mesosalpinx. After natural copulation of the animals, without administration of gonadotropin, the numbers of corpora lutea on the operated and control sides were counted. A slight but nonsignificant overall reduction in corpora lutea on the operated side was observed. This showed no correlation either to the amount of mesosalpinx resected or the proximity of the surgical procedure to the ovary. Also, no correlation was observed with the length of dissected ampullary part.

Surgical treatment for distal tubal occlusion. A review of 167 cases.

Surgery was performed on 167 patients for distal tubal occlusion. In 143 cases a terminal microsurgical salpingostomy was performed and in 24, a cuff neostomy. The overall intrauterine pregnancy rate was 20.4%, and 16.8% of the patients had live births. The ectopic gestation rate was 1.8%. None of the patients with a cuff neostomy became pregnant.

[Microsurgical reversal of sterilization: experiences and results in 119 cases]. / Sterilisation--Refertilisierung. Erfahrungen und Ergebnisse bei 119 mikrochirurgisch refertilisierten Frauen.

From January 1976 to March 1982 119 microsurgical reversals were performed. Most of these women were not older than 30 years at the time of sterilization. A new partnership was the main reason for a request of reversal. Up to now 69 patients (58,0%) achieved an intrauterine pregnancy. Ectopic pregnancies occurred in 3 women (2,5%). The prognosis of a reversal depends mainly on the remaining length of the fallopian tube and the site of the anastomosis. For isthmo-isthmic anastomoses the intrauterine pregnancy rate was 80%. Due to today's high divorce rates tubal sterilization in women younger than 30 years should be based on a well founded indication. In younger patients only such sterilization techniques should be performed, which offer the highest chances for reversal.

PIP: Between January 1976-March 1982, 119 microsurgical reversals were performed. Most of these women were not older than 30 years at the time of sterilization. A new partnership was the main reason for the request of reversal. Currently, 69 patients (58%) have achieved an intrauterine pregnancy. Ectopic pregnancies have occurred in 3 women (2.5%). The prognosis of a reversal depends mainly on the remaining length of the fallopian tube and the site of the anastomosis. For isthmo-isthmic anastomoses, the intrauterine pregnancy rate was 80%. Due to a high divorce rate prevalent today, tubal sterilization in women younger than 30 years should be based on serious indications. In younger patients, only such sterilization techniques should be used which offer the highest chances for reversal. (author's modified)