Klaus Diedrich’s research while affiliated with Universitätsklinikum Schleswig - Holstein and other places

This review article includes a brief historical outline of the developments in reproductive medicine in the last decades, presents the current state of reproductive medicine and provides a view into the future. Only at the end of the 1970s could women with bilateral fallopian tube blockage be helped to fulfil their desire to have children. From 1993 onwards an effective method for treatment of male subfertility could be found with intracytoplasmic sperm injection (ICSI). In most cases three embryos were transferred into the uterus The pregnancy rate was no more than 20% in the early years of assisted reproduction. As ovulation was exclusively triggered with human chorionic gonadotropin (HCG), there was a risk of ovarian hyperstimulation with formation of ovarian cysts and ascites. Nowadays, many women with infertility and, in some cases men with azoospermia can be helped with reproductive medical treatment. In most cases only one embryo is placed in the uterus. The pregnancy rate per embryo transfer is around 31%. Severe hyperstimulation occurs in less than 1% of all cases of treatment. Around 12 million people worldwide now owe their lives to assisted reproductive technologies (ART). Despite all the advances we still know little about the fundamentals of embryology and reproduction. The failure of in vitro fertilization (IVF) or ICSI treatment is still more likely than success. The chances of success of assisted reproduction must be improved by further scientific studies and further prospective randomized controlled trials with hard outcome parameters are also necessary.

After the so-called long protocol using gonadotropin-releasing hormone (GnRH) agonists had been the gold standard in controlled ovarian stimulation until the turn of the millennium, the market launch of peptide GnRH antagonists heralded a new era in the treatment of involuntarily childless couples. The fact that GnRH antagonists are only used when there is a risk of a premature luteinizing hormone (LH) surge, i.e., premature ovulation, led to a significant shortening of the stimulation time and the necessary amount of gonadotropins to be administered. Additionally, this treatment modality reduced the risk of higher-grade ovarian hyperstimulation syndrome (OHSS). Since the 1920s over 80% of all treatments worldwide have been carried out according to the multiple dose antagonist protocol developed in Bonn and Lübeck. The introduction of the peptide GnRH antagonists was a real game changer. Since the introduction of elagolix on the US market, and of relugolix and linzagolix on the US and European markets, substances have become available that can be administered orally as non-peptide GnRH antagonists. These preparations have become established in the treatment of uterine leiomyoma and endometriosis. Consequently, controlled ovarian stimulation appears to be the next possible area of application; however, published experiences to date are still sparse. The question arises as to whether these new small molecules can have the same effectiveness in preventing premature luteinization or the same efficiency in the treatment with methods of assisted reproduction as the peptidic representatives of this group of substances.

While fertility-preservation measures in the case of oncological diseases in young people are now widely accepted, the desire for pregnancy in patients with breast cancer is still met with reservations. The question arises of the influence of pregnancy and the associated high sex steroid concentrations on disease-free and overall survival. Two current studies have now produced very encouraging results. The POSITIVE (Pregnancy Outcome and Safety of Interrupting Therapy for Women with Endocrine-Responsive Breast Cancer) study with results of 516 women who had received endocrine therapy for at least 18 months and then took a break to achieve pregnancy showed a relapse rate of 8.9% over 3 years compared to 9.2% in the control group; 74% of patients achieved the desired pregnancy and 64% experienced at least one birth. A total of 368 children were born in this study; 40% of the patients had received treatment using assisted reproduction methods. Furthermore, a large retrospective study also found no significant differences in disease-free survival in the group of young patients with mutations in the BRCA genes. On the contrary, the affected patients who became pregnant even had better overall survival. Based on these study results, there is no reason to deny young women with breast cancer their desire to have a child.

This review article contains a historical outline of the developments in reproductive medicine in the last decades, presents the current state of reproductive medicine and provides a view into the future. Until the end of the 1970s women with bilateral fallopian tube blockages could not be helped in fulfilling the desire to have children. Until the early 1990s it was not possible to offer reproductive medical aid to couples with male subfertility. Usually, three embryos were introduced into the uterus. The pregnancy rate was no more than 20% in the early years of assisted reproduction. As ovulation was triggered exclusively by human chorionic gonadotropin (HCG), there was a risk of ovarian hyperstimulation. Nowadays, many women with infertility and, in some cases, men with azoospermia can be helped with reproductive medical treatment. In most cases only one embryo is placed in the uterus. The pregnancy rate per transfer is around 31%. Severe hyperstimulation occurs in less than 1% of all treatments. Around 10 million people worldwide now owe their lives to assisted reproductive technologies (ART). Despite all the advances in this field, little is still known about the fundamentals of embryology and reproduction. Failure of in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment is still more likely than successful treatment. Because of the relatively low success rate of ART, more and more additional examinations and treatments (so-called add-ons) have been developed in recent years. These are intended to increase the chances of success and thus the pregnancy rate; however, further development of these technologies will be necessary in the future. Further prospective randomized controlled trials with hard outcome parameters, such as a continuous pregnancy rate with the birth of a healthy child, are still required.

Introduction For years, generations of medical students have complained that practice-oriented learning is neglected in medical studies. Further training assistants also complain about limited opportunities to learn subject-specific practical activities. Material and techniques We are presenting a pilot project at the University Women’s Hospital in Homburg, in which medical students complete an endoscopic hands-on course as part of the block internship gynaecology and obstetrics. During the course the students perform classic skills training and hand–eye coordination exercises and learn the first steps in endoscopic suturing (suture and rows of knots). The training concepts used can be implemented on simple boxing trainers and can therefore also be reproduced in clinics or in a private setting. Outcome Altogether, 73 medical students did participate in the laparoscopy course. We were able to prove that the knotting time for a simple knot can be reduced from an average of 247 s to 40 s (80%) after completing our training programme. Based on the evaluation sheet that the students filled out after the course, we found a very-high acceptance for surgical simulation training within the student cohort. Discussion Practical surgical exercises can complement the curriculum well and, as we can show with our work, are rated very positively by the students. For students in higher semesters, such practical courses can also provide an insight into the respective subject area and thus counteract the lack of skilled workers in surgical subjects. The practical year should not be the first contact with these practical courses, as at this timepoint a certain favoured subject has often already being chosen by the students.

Endometriosis is one of the most common gynecologic diseases. Women with endometriosis display with subfertility per se. Inflammatory reactions in the pelvis and endometriomas/endometriotic cysts damage the ovaries and reduce the quality of egg cells. Miscarriage rates are elevated. Precision surgery and assisted reproductive techniques (ART; in vitro fertilization/intracytoplasmic sperm injection [IVF/ICSI]) are the predominant therapeutic strategies to improve the chance of conceiving. By better understanding the pathophysiology of endometriosis, less invasive medical treatment options are to be expected in the future.

Although reproductive medical treatment has become the standard in gynecology over the past few decades, there are still significant knowledge gaps. Less than 50% of treatments lead to the desired result, a pregnancy. Therefore, many additional examinations and treatments (so-called add-ons) have been developed, which are offered to couples with an unfulfilled desire to have children in order to possibly improve the treatment results. To date, however, there is no evidence of benefits in terms of pregnancy and live birth rates for the vast majority of these add-ons. This overview article highlights the various add-ons available for patients, oocytes, embryos, and sperm based on the current study situation.