M Rothenaicher’s research while affiliated with Schön Klinik München Schwabing and other places

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.

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.

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.

We report on first experiences with amniocentesis in 63 pregnancies after IVF treatment over a period of 3 years. It is shown, that there is no increased risk through amniocentesis; it does not require special precautions. Above average number of aberrations could be found in amniotic cultures in cases where it could be identified additionally in one parent. It remains to be seen, whether the small number and sterility causes were coincidental or manifest themselves in future, especially, if the sterility concerned can be classified as idiopathic. The occurrence of trisomy 21 in accordance with the frequency is to be expected in the group of persons over 35 years of age and no increased risk through IVF treatment can be found.

Intratubar embryo transfer is a form of sterility treatment, in which the in-vitro-fertilized pre-implantation embryos are transferred into the intact fallopian tube(s). This enables the benefits of in-vitro fertilization (information of the gamete fertilization behavior, specific incubation of dysmature oocytes, reduction of the polyploidy rate, risk of multiple pregnancies) to be combined with those of gamete intrafallopian transfer (GIFT; tubar environment for the further development of the pre-implantation embryos). Intratubar embryo transfer is indicated in cases of sterility that are not due to the fallopian tubes; in addition to idiopathic sterility, particular emphasis is put on a certain form of immunological sterility (antibodies against sperm antigens), which seems to be a special indication for this method. Intratubar embryo transfer demands a two sided approach. It is advisable to collect the oocytes transvaginally, guided by ultrasound, since general anaesthesia maybe dispensed with - if so desired. The embryo transfer itself still requires a pelviscopy, which is only performed once fertilization of the oocyte has been confirmed; which is in contrast to GIFT, in which pelviscopy is an inherent part of each treatment cycle. In spite of this advantage, intratubar embryo transfer is a method, which is associated with a high expenditure. The aim of the study was, to evaluate the success rate when all the alternative, less costly options have been exhausted. Our first results are demonstrating, that intratubar embryo transfer is successful, even as a second line therapy. Therefore the method has a significance in the treatment of sterility, not caused by the tubes and the expenditure, with which it is associated, can be justified.(ABSTRACT TRUNCATED AT 250 WORDS)

Es wird berichtet über erste Erfahrungen mit der Durchführung der Amniozentese bei 63 Schwangerschaften nach IVF in einem Zeitraum von 3 Jahren. Es kann gezeigt werden, daß die Amniozentese zu keiner Risikomehrung führt, besondere Vorsichtsmaßnahmen sind nicht indiziert. Überdurchschnittlich häufig wurden in der Amnionkultur Aberrationen gefunden, die auch bei einem der Elternteile nachzuweisen waren. Es muß offen bleiben, ob sich hierin nur die Zufälligkeit der kleinen Zahl oder auch zukünftig besonders zu berücksichtigende Sterilitätsursachen manifestieren, vor allem bei der sogenannten idiopathischen Sterilität. Das Auftreten einer Trisomie 21 entspricht der zu erwartenden Häufigkeit in der Altersgruppe über 35 Jahren; ein erhöhtes Risiko durch die IVF-Behandlung kann nicht gefunden werden.

Beim intratubaren Embryotransfer handelt es sich um ein Verfahren der Sterilitätstherapie, beim dem die in vitro gezeugten Präimplantationsembryonen in die intakte(n) Tübe(n) verbracht werden. Hierdurch ist es möglich, die Vorteile der In-vitro-Fertilisation {Information über das Fertilisationsverhalten der Gameten, gezielte Inkubation dysmaturer Oozyten. Reduktion der Polyploidierate, Erfassung des Risikos von Mehrlingsschwangerschaften) mil denen des intratubaren Gametentransfers (Tubenmilieu für die Entwicklung der Präimplantationsembryonen) zu verbinden. Die Indikationen für den intratubaren Embryotransfer sind im Bereich der nicht tubar bedingten Sterilität zu sehen; hierbei ist neben der idiopathischen Sterilität vor allem auf eine bestimmte Form der immunologisch bedingten Sterilität hinzuweisen (Antikörper gegen Spermatozoenantigene), für die sich eine spezielle Indikation, abzuzeichnen scheint. Der intratubare Embryotransfer erfordert ein zweizeitiges Vorgehen. Es ist zu empfehlen, die Oozytengewinnung transvaginal, ultraschallkontrolliert vorzunehmen, weil damit-wenn gewünscht - auf eine Narkose verzichtet werden kann. Der Embryotransfer selbst erfordert derzeit die Pelviskopie. Sie. wird aber nur im Falle der nachgewiesenen Fertilisation der Oozyten durchgeführt, womit ein wesentlicher Unterschied zum intratubaren Gametentransfer besteht. Dennoch ist der intratubare Embryotransfer als relativ aufwendiges und belastendes Verfahren zu betrachten. Es war daher Inhalt dieser Untersuchung, festzustellen, ob die Methode auch nach Ausschöpfimg anderer, weniger invasiver Verfahren noch erfolgreich angewendet werden kann. Die vorgelegten Ergebnisse zeigen, daß dem intratubaren Embryotransfer als nachgeordnetem Therapieverfahren eine Bedeutung zukommt und der Einsatz der Methode zu rechtfertigen ist. Darüber hinaus ist festzuhalten, daß gerade innerhalb eines bislang erfolglos therapierten Patientengutes überdurchschnittlich häufig Fertilisationen in vitro ausbleiben, was auf noch nicht näher definierte Gametenfusionsstörungen als Sterilitätsursache hinweist. Die Methode ist als eine Variante der Invitro-Fertilisation zu betrachten, weswegen die Abkürzung IVF/IT-ET (In-vitro-Fertilisation/intratubarer Embryotransfer) vorzuschlagen ist.