Microdissection TESE is superior to conventional TESE in patients with nonobstructive azoospermia caused by Y chromosome microdeletions.

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.

Pregnancy and Birth After a Two-Step PGD: Polar Body Diagnosis for Hemophilia A and Array CGH on Trophectoderm Cells for Chromosomal Aberrations.

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.

Male factors determining the outcome of intracytoplasmic sperm injection with epididymal and testicular spermatozoa.

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.

[Improving treatment outcome by LeukoNorm Cytochemia in patients with multiple, failed IVF or ICSI treatment cycles]. / Verbesserung der Behandlungsergebnisse durch LeukoNorm Cytochemia bei Patientinnen mit mehrfachen, frustranen IVF- oder ICSI-Behandlungszyklen.

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.

[Fertilization of cryopreserved and thawed human oocytes (Cryo-Oo) by injection of spermatozoa (ICSI)--medical management of sterility and case report of a twin pregnancy]. / Fertilisation von kryokonservierten und aufgetauten humanen Oozyten (Kryo-Oo) vermittels Injektion von Spermatozoen (ICSI)--Sterilitätstherapeutisches Management und Kasuistik einer Zwillingsschwangerschaft.

It is reported on a twin pregnancy and parturition of a healthy girl and a healthy boy following the treatment of the mother by intracytoplasmic injection of spermatozoa (ICSI) into cryopreserved and thawed human oocytes (Cryo-Oo). The couple suffered from a primary sterility because of a severe subfertility of the husband and oligomenorrhea with anovulation of the wife. Before the couple contacted our center for the first time, several pretreatments had been carried out, e.g. intrauterine inseminations (IUI) with husband's and donor sperm and one cycle of in vitro fertilization (IVF) with intracytoplasmic sperm injection. This IVF/ICSI-cycle resulted in a tubal pregnancy. It must be noted that the patient showed in each treatment cycle a remarkable tendency to develop ovarian hyperstimulation syndromes (OHSS), even under stimulation with 50 mg clomiphen citrate. In 1997 we started the first treatment cycle for IVF/ICSI with GnIZH-analogues and FSH according to the long protocol. In spite of a low dosage of gonadotropins the patient again developed a impressive multifollicular growth that we decided, together with the couple, only to perform the oocyte retrieval and cryopreserve the collected eggs. For ethic considerations the couple did not consent in the freezing of pronuclear stages. Two months later we performed the transfer-cycle: after thawing of four oocytes, the intracytoplasmic injection of native spermatozoa led to the fertilization of three oocytes and a total of three preimplantation embryos was transferred one day later. Two weeks later the blood level of hCG was 518 IU/ml and an intact twin pregnancy developed. In July 1998, after 36 weeks of gestation, a healthy girl (2540 g) and an healthy boy (2375 g) were delivered by cesarean section. This case report and the experience with further 23 patients (6 pregnancies) demonstrate that ICSI with cryopreserved and thawed oocytes is an effective approach to avoid repetitive oocyte retrievals. The achievable pregnancy rates so far seem to be similar to frozen pronuclear stages, possibly even better. Under the specific regulations of the German Embryo Protection Act (ESchG)--i.e. freezing of embryos not allowed--this technique is worth being pursued with attention.

[Intracytoplasmic injection (ICSI) of cryopreserved testicular spermatozoa (Cryo-TESE): a retrospective study of the first 250 treatment cycles]. / Intrazytoplasmatische Injektion (ICSI) von kryokonservierten testikulären Spermatozoen (Kryo-TESE): Eine retrospektive Analyse der ersten 250 Behandlungszyklen.

It is reported on the results of 250 treatment cycles in which we carried out intracytoplasmic injections (ICSI) with frozen and thawed testicular spermatozoa (cryo-TESE). Up to July 1997 we treated 127 patients, 225 embryo transfers were performed (90%), and an average of 2.3 preimplantation embryos were transferred. This resulted in 53 clinical pregnancies, six patients aborted (11.3%). The pregnancy rate was 21.2% per treatment cycle, 23.5% per embryo transfer, and 41.7% per patient. This so called cumulative pregnancy rate is still about to rise, because 49 out of the 72 non-pregnant patients are still in our ICSI-program. Twenty-two children are born, 2 twins and 1 triplet. All children are healthy and without any major malformations. We conclude from these results that using cryopreserved testicular sperm for ICSI is an effective and successful approach for the treatment of severe testicular insufficiency. In comparison to the use of native testicular sperm with the necessity of repetitive testicular biopsies, cryopreservation is advantageous in many concerns (e.g. logistic, organisatoric and financial) and is therefore recommended for clinical routine.

[Intracytoplasmic injection of epididymal and testicular sperm after failed heterologous insemination]. / Zur intrazytoplasmatischen Injektion von epididymalen und testikulären Spermien nach frustranen heterologen Inseminationen.

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.

[Intracytoplasmic sperm injection (ICSI) after previous failure of heterologous insemination]. / Zur intrazytoplasmatischen Spermieninjektion (ICSI) nach vorausgegangenen frustranen heterologen Inseminationen.

We report on our experiences with 25 married couples that approached us for intracytoplasmatic sperm injection (ICSI) after previous failure of artificial insemination by donor (AID). AID has been carried out in several specialized fertility centers. We traditionally refrain from donor semen procedures. All patients have undergone at least 4 treatment cycles of AID, the maximum was 20. With exception of one all patients have been inseminated after ovarian hyperstimulation according to different protocols (e.g. GnRH-A/FSH, hMG; CC/hMG). Prior to ICSI we have confirmed male subfertility being in all patients of severe grade. All patients have been proven to have ejaculated spermatozoa. We have performed 71 treatment cycles for ICSI so far, 19 patients have become pregnant, 3 have aborted. The pregnancy rate per cycle is 26%, per embryo transfer 30%, and per patient 76%. We think that these results are primarily caused by so far unknown defects in oocytes and their function during fertilization. Besides, we assume psychosomatic causes maybe involved.

[Pregnancy and delivery after in vitro fertilization (IVF) of human ova via intracytoplasmatic sperm injection (ICSI) of testicular sperm (TESE)]. / Schwangerschaft und Geburt nach In-vitro-Fertilisation (IVF) humaner Eizellen vermittels Intrazytoplasmatischer Spermieninjektion (ICSI) testikulärer Spermien (TESE).

This is a report on a pregnancy achieved by in-vitro fertilisation (IVF) with intracytoplasmatic sperm injection (ICSI) after testicular sperm extraction (TESE). Because of a bilateral absence of the ductus deferens, microsurgical epididymal sperm aspiration (MESA) was not possible. This anatomic situation was probably caused by a bilateral herniotom during childhood. The wife became pregnant in the first treatment cycle and meanwhile gave birth to a healthy boy. This case report demonstrates that the ICSI procedure is successful even with testicular spermia and extremely low sperm counts.

[Triplet pregnancy after intracytoplasmatic sperm injection of cryopreserved testicular sperm]. / Drillingsschwangerschaft nach intracytoplasmatischer Spermieninjektion von kryokonservierten testikulären Spermien.

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.

[Pregnancies after in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) of testicular spermatozoa (TESE) from frozen semen]. / Schwangerschaften nach In-vitro-Fertilisation (IVF) und intracytoplasmatischer Spermieninjektion (ICSI) von testikulären Spermatozoen (TESE) aus Kryokonservaten.

This case report describes the possibility of establishing intact pregnancies by using cryopreserved testicular sperm for in-vitro-fertilization (IVF) with intracytoplasmatic sperm injection (ICSI). Because of a bilateral postinflammatory occlusion of the ductus deferens the patient underwent two cycles of IVF without ICSI by using epididymal sperm (MESA), however no fertilization occurred. In a third attempt with ICSI we used testicular sperm (TESE), because epididymal sperm was not detectable any longer. No pregnancy was established. In the forth treatment cycle again IVF/ICSI, now using cryopreserved and thawed testicular sperm. After embryotransfer (ET) of two preimplantation embryos into the uterine cavity, an intact singleton pregnancy was established. Meanwhile 15 further patients concept after IVF/ICSI using frozen and thawed testicular sperm. The German Embryo Protection Act (ESchG) prohibits the intentional fertilisation of more than three oocytes during one treatment cycle or the cryopreservation of human preimplantation embryos. Therefore it is mandatory to extract testicular sperm for every treatment cycle. Cryopreservation of testicular sperm is offering a legal possibility to avoid repeated testicular biopsies and has acceptable success rates for concerning couples.

Two pregnancies after in-vitro fertilization with spermatozoa from alloplastic spermatocoeles.

Two case reports describe successful in-vitro fertilization (IVF) of oocytes of two 28-year-old women with epididymal spermatozoa aspirated from alloplastic spermatocoeles of the husbands. Both men suffered from complete ejaculatory failure, which was caused by paraplegia in the first and by radical surgery of an embryonic carcinoma of the testis in the second. Motile spermatozoa were aspirated in the first case 4 months after implantation of the spermatocoele, and in the second at 1 month. For the first couple, IVF treatment led to a singleton pregnancy; the child has since been born. In the second couple, IVF treatment resulted in a twin pregnancy, with intra-uterine abortion of one gestational sac. The resulting singleton pregnancy is still ongoing.

Prenatal diagnosis by amniocentesis in 82 pregnancies after in vitro fertilization.

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.

[Surgical pelviscopy in treatment of extrauterine pregnancy following in vitro fertilization and spontaneous conception]. / Die operative Pelviskopie in der Behandlung der Extrauteringravidität nach in-vitro-Fertilisation und Spontankonzeption.

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.

Hysteroscopy for gamete intrafallopian transfer (GIFT).

Gamete intrafallopian transfer (GIFT) is performed currently using laparoscopy. We report on a pilot-study from 1.1.1987 to 31.12.1987 and from 1.5.1988 to 30.4.1989, in which we used hysteroscopy instead of laparoscopy for the GIFT-procedure. The entering conditions were: unexplained (idiopathic) infertility, failure of previous treatments, proven fertilization capability of the gametes in at least one IVF attempt, and request of the married couple to dispense with laparoscopy during GIFT procedure. Hysteroscopic GIFT was initially performed on hysterectomy specimens, using the Chorionoskop. Continuous flow CO2 through the fallopian tubes did not result in loss of gametes. Twenty-four treatment cycles were performed in 16 patients. In 19 cycles, gametes were transferred into one tube, and in two cycles they were transferred into both tubes. Four of 16 women conceived: one patient delivered at term, three pregnancies ended in a first trimester abortion. These results demonstrate that the hysteroscopic approach to intrafallopian gamete transfer can be successful. However, the technique is demanding and requires extensive training. We conclude that further improvements of hysteroscopic GIFT are needed.

[Course of pregnancy and labor following in vitro fertilization. A retrospective study of 246 deliveries]. / Zum Schwangerschafts- und Geburtsverlauf nach In-Vitro-Fertilisation (IVF). Eine retrospektive Untersuchung nach 246 Entbindungen.

This record concerns the statistical registration and analysis of the courses and developments having taken place in 246 pregnancies and births after in-vitro-fertilization. The cases were registered retrospectively, the degree of registration being 77.2% approximately; the scientific evaluation was carried out on the basis of the BPE 1987. It can be shown that there is an increased incidence of the EPH-gestosis, the clinically relevant placenta insufficiency syndrome, the intrauterine death of fetus, the abruptio placentae and prematurity. As predisposing factors must primarily be seen and discussed the ovarian hyperstimulation being--in most cases--connected with IVF and the higher age of the patients; it can be supposed that the method of fertilization in vitro itself is of minor importance. Its importance in the pathogenesis of abruptio placentae, however, cannot be exactly evaluated so far. The frequency of multiple pregnancies represents a special problem. Though the rate is lower in the examined group than in comparable--that is due to the limited number of collected oocytes--it should be aimed at a further lowering of multiple pregnancy rates.