[Histochemical characterization of endometrial proliferation using AgNOR (nucleolus organizer region)]

Nucleolar organizer regions (NORs) are loops of DNA that transcribe to ribosomal RNA. We used histochemical staining of NORs for 78 sections of endometrial tissue, obtained either from curettage or from hysterectomy specimens (normal endometrium 14, simple hyperplasia 10, complex hyperplasia 18, atypical hyperplasia 8 and adenocarcinoma 28). There was a significant positive correlation between mean AgNOR counts and the degree of hyperplasia. In adenocarcinoma, no significant difference was found between AgNOR counts in tissues of different histologic grades. Our study suggests that AgNOR counts are reliable markers of endometrial proliferation and allow a clear distinction between benign, premalignant and malignant epithelial changes.

[The value of curettage in the assessment of abnormal uterine bleeding]

Current practice of investigating abnormal uterine bleeding via dilatation and curettage is sometimes open to question, and outpatient procedures are emphasised. The therapeutic effect of curettage in normalising menstrual patterns is being discussed. In a prospective study we answered the question of diagnostic and therapeutic effects of curettage. Over a period of 6 months, all patients with curettage treated in our department were investigated (history, risk factors, previous hormonal treatment, preoperative haemoglobin value, type of anaesthesia, complications, histology). Curettages performed for the purpose of abortion, as well as in combination with conisation of the uterine cervix, were not included in the study. 234 curettages were carried out. Clinical indications were as follows: in 29% of the cases recurrent preclimacteric metrorrhagia, in 27% climacteric metrorrhagia, in 24% PMB (postmenopausal bleeding). In 19 cases we found an Hb value lower than 10.5 g%. Risk factors (obesity, hypertension, diabetes mellitus) for endometrial cancer were found in 38% of MB and in 20% of climacteric metrorrhagia. In 9 cases, the histological diagnosis was endometrial cancer (clinical indications: 5 PMB, 3 climacteric metrorrhagia, 1 recurrent preclimacteric metrorrhagia). Our study shows, that the indication for curettage should be applied generously, especially in cases of abnormal postmenopausal and perimenopausal bleeding.

[Surgical correction of uterus abnormalities: experiences with the Tompkins method]

In the last 10 years, 12 abdominal metroplasties (Tompkins) were performed at the 2nd Department of Obstetrics and Gynaecology, Vienna. All patients had a history of at least 2 spontaneous abortions, caused by a deformity of the uterus. The operation according to Tompkins, is technically simple and does not result in a defect in the uterus. There were no intraoperative or postoperative complications. Follow-up was possible in 10 patients, 8 of whom had a persisting wish for a child. 5 of these women became pregnant again, one had an abortion. All children were delivered by elective Caesarean section after the 36th week; the fetal outcome was satisfactory. In our experience, Tompkins' operation is the surgical therapy of choice in habitual abortion cause by Müllerian anomalies.

[Surgery of prolapse and incontinence in Austria--current status and prospects]

In early 1989, we sent a questionnaire to all 89 Departments of Gynaecology in Austria. Questions covered the number and type of gynaecological operations performed, perioperative management, and diagnosis and treatment of descent and urinary incontinence. 90% of questionnaires were returned. We found that currently 2/3 of all hysterectomies and 9/10 operations for descent and incontinence are done vaginally, irrespective of the size of the department. There was no relationship between the frequency of vaginal hysterectomies and the percentage of vaginal operations for descent and incontinence. Suprapubic bladder drainage is used in over 50%, in 85% postoperative screening for urinary tract infection is done routinely, and 53% of departments use prophylactic antibiotics. We conclude, that vaginal hysterectomy is still the method of choice in Austria, and that there is extreme emphasis on vaginal operations for urinary incontinence.

In vitro fertilization with spermatozoa from alloplastic spermatocele

This case report describes successful IVF of oocytes of a 22-year-old female with epididymal spermatozoa aspirated from alloplastic spermatocele of the husband presenting with bilateral congenital absence of the vas deferens. Motile spermatozoa were aspirated from the reservoir 3 months after implantation. Abortion occurred 22 days after embryo replacement.

[Classification and documentation of vulvar changes: organization of a data bank by personal computer]

We developed a simple menu driven database on a personal computer for classification and documentation of vulvar lesions (IBM-PC, dBaseII). Vulvar lesions were classified according to morphological appearance: red, white, dark, ulcer, small tumor (less than 1 cm), large tumor. The data for each category were entered in multiple choice form or as free text and stored in a separate database file. Overlap between categories was observed in vulvar intraepithelial neoplasia, invasive carcinoma and between large and small tumors. For each category an automated table of the frequencies of the different diagnoses is provided, individual patients and variables can easily be accessed through the database query language. We used the database system in the gynecological outpatient clinic of our department during 6 months and were able to document 117 patients with vulvar lesions. In our experience, the database system permits complete documentation according to clinical criteria of all vulvar lesions seen in gynecological practice.

[Hypophyseal suppression and subsequent cycle stimulation: experiences in an in vitro fertilization program]

Gonadotropin releasing hormone (GnRH) agonists can induce a hypogonadotropic state. We studied the effect of a long acting GnRH agonist on pituitary gonadotropin levels, the pattern of serum steroid levels in subsequent cycle stimulation, and whether such a protocol can improve the results of an in-vitro fertilization (IVF) program. 29 patients with tubal factor from our IVF program received 4 mg Decapeptyl CR intramuscularly and were subsequently stimulated with FSH/HMG/HCG (Group I). 35 patients were stimulated according to our standard protocol with HMG/HCG (Group II). After a single injection of Decapeptyl CR, serum levels of LH, FSH and E2 fell to more than half of pretreatment levels. In the subsequent cycle stimulation the gonadotropin dosage was increased threefold compared with the control group. In group I, progesterone levels were significantly higher. Though more oocytes were retrieved in group I, fertilization rates were significantly lower. After Decapeptyl and the subsequent stimulation, we observed short rises in urinary LH in 22/29 patients. In our experience, a single intramuscular injection of Decapeptyl resulted in sufficient pituitary suppression, however, we could not see an improvement in the results after IVF.

[The urethral pressure profile at rest and in stress following diaphragmplasty]

56 women underwent vaginal repair because of primary genuine stress incontinence. Urodynamic investigation was carried out preoperatively and 10.9 (7-13) months after surgery. At follow-up continence was demonstrable in 44/56 patients (79%). Detrusor instability following surgery for stress incontinence was found in 2/56 patients (4%). Vaginal repair failed to rectify stress incontinence in 21% of the patients. In cured patients the postoperative urethral pressure profile at rest remained unchanged, while the postoperative urethral closure pressure profile during stress significantly increased in these patients. In incontinent patients following surgery the urodynamic parameters of both pressure profiles correlated well with the severity of the incontinence.

[Impulse galvanization in postoperative urination disorders]

In this study we examined the therapeutic effect of impulse-galvanization in patients with voiding difficulties after anterior vaginal repair. Patients (n = 56/79) revealing residual urine until the sixth postoperative day were studied. Considering the onset of the first spontaneous micturition and the lack of residual urine no significant difference was found in the group undergoing impulse-galvanization (n = 19) compared to a group without therapy (n = 37). By adjuvant treatment with alpha-sympathicolytics, spasmolytics or tranquilizers patients with impulse-galvanization and the comparative group were found to be without residual urine 11.2 and 13 days after surgery, respectively (p less than 0.001).

[On the problem of the definition of ovarian pregnancy]

We report on a case of true ovarian pregnancy, and discuss the anatomical criteria required for the diagnosis of this rare type of ectopic pregnancy.

Obesity and stress urinary incontinence: significance of indices of relative weight

We analyzed the significance of weight and various indices of relative weight in the assessment of genuine stress incontinence (GSI) in 193 female patients. Body mass index [BMI = weight/(height2)] and the other indices of relative weight [weight/height - weight/(height3)] were not markedly different between patients with GSI and a control group of 43 females without demonstrable incontinence. A markedly increased BMI was found to be correlated with a positive clinical stress test. In addition BMI was significantly higher in patients with a higher maximum urethral pressure. We conclude that although obese women tend to have higher maximum urethral pressures, this advantage disappears in regard to the maximum urethral closure pressure, resulting in a higher prevalence of positive clinical stress test.

[Facilitation of the diagnosis of colpitis in pregnancy: the line test as a quantitative parameter of vaginal discharge]

To define the vaginal discharge in pregnancy with a numeric quantitative parameter and to determine out its pathognomonic importance, the vaginal discharge of 140 pregnant and 33 non pregnant women was examined and the women were asked to indicate the subjective degree of discharge in a visual linear analog scale (Line-test). Pregnant woman marked high Line test values more frequently than non pregnants irrespective of detection of a vaginitis. With increasing gestational age and parity higher Line test values were found irrespective of the frequency of vaginitis. With a cut off level of 80 mm, the specificity of the Line test concerning vaginitis is high below cut-off, the possibility to have vaginitis is increased. The Line test is simple to use and - because of its specificity and sensitivity - has been found useful in evaluating the degree of vaginal discharge.

Wertheim radical hysterectomy 1921-1986: changes in urologic complications

In order to assess the incidence and type of urologic complications associated with Wertheim's radical hysterectomy we studied all 154 patients undergoing radical hysterectomy at our department between 1980 and 1986. More than 2/3 of patients had stage I carcinoma of the cervix, the mean age was 46.9 years (range 27-73 years). Various intraoperative reconstructive procedures were required in 5%. A comparison with the experience of Wertheim (before 1919) and that of a subsequent time period (1952-1967) showed that while the incidence of intraoperative injury to the lower urinary tract remained stable, the incidence of postoperative fistula formation decreased significantly (from 6.4% to 0.6%), possibly due to changes in the operative technique. We conclude that Wertheim's radical hysterectomy now involves only a very low risk of injury to the bladder or to the ureter.

Follicular aspiration for in vitro fertilization: sonographically guided transvaginal versus laparoscopic approach

Laparoscopy is the most commonly used procedure for oocyte retrieval in an in-vitro fertilization (IVF) program. In this study we compared the results of 21 laparoscopic and 21 sonographically guided transvaginal oocyte retrievals using a vaginal probe. Laparoscopically 3.7 and transvaginally 4.8 oocytes per patient were recovered. Overall 6 pregnancies were achieved, giving a pregnancy rate of 14.1% per patient. Vaginal follicular aspiration resulted in a higher oocyte recovery rate. The advantages of the method were a shorter operation time, a superficial anesthesia and, compared to laparoscopy, a less invasive and simpler technique. Therefore this method is now commonly used for routine IVF procedures in our institution.

Relationship between the steroid and prolactin concentration in follicular fluid and the maturation and fertilization of human oocytes

Seventy-eight follicles and their follicular fluid were aspirated from 46 women undergoing in vitro fertilization (IVF) procedures after stimulation of the ovaries with a low-dose human menopausal gonadotropin/human chorionic gonadotropin stimulation regimen. The concentrations of estradiol (E2), progesterone (P), testosterone (T), and prolactin (PRL) were measured in follicular fluid and related to the maturation of the oocyte-corona-cumulus complex (OCCC) and the fertilization of oocytes. Follicles containing mature oocytes had significantly higher follicular fluid E2 and P levels than follicles with intermediate and immature oocytes. A constant decrease in PRL and T values with advancing follicular maturation was observed. Similar results were obtained when the fertilizing ability of the oocytes was examined. The gradual decline in follicular fluid PRL and T levels during follicular development was connected with increasing E2 and P biosynthesis and therefore seems to be an important precondition for normal follicular and oocyte maturation.

[Hormonal pregnancy parameters in the serum following surgery for extrauterine pregnancy]

We did serial determinations of beta-HCG, total-HCG, prolactin, SP-1, and progesterone in maternal serum after operation of an ectopic pregnancy in 38 patients. Prolactin, progesterone and SP-1 rapidly returned to normal values after removal of the ectopic pregnancy. However, the half life of HCG was related to the type of operation: after conservative operation of ectopic pregnancy the half life of HCG was greater than after tubectomy (41.4 +/- 1.9 SEM hours versus 33.4 +/- 2.0 hours), possibly due to lack of complete removal of trophoblast tissue. This fact should be kept in mind when evaluating postoperative HCG levels.

[Effect of serum prolactin on cycle stimulation and fertilization of human oocytes]

During cycle stimulation for in-vitro fertilisation (IVF) some patients develop hyperprolactinaemia. Since prolactin (PRL), being an aromatase inhibitor, can interfere with follicular fluid steroid metabolism, we examined the influence of high serum PRL levels on the endocrine response and fertilisation rate of oocytes. 33 consecutive patients stimulated by hMG/hCG for IVF were included in this study. Two groups of patients were established: Group 1 consisting of 18 patients with serum PRL levels less than or equal to 25 ng/ml, and group 2 containing 15 patients, who developed PRL levels greater than 25 ng/ml during cycle stimulation. The serum oestradiol (E2), progesterone (P) and PRL levels 3, 2 and 1 day before and at the day of follicle puncture were evaluated. The decrease of E2 levels at the day of oocyte retrieval was significantly steeper in group 1. The P levels 2 days before oocyte retrieval were significantly higher in group 1 indicating the onset of preovulatory luteinization. Luteinization after the hCG injection was more effective in group 1 resulting in significantly higher P levels. Fertilisation and cleavage rates were significantly higher in patients with normal PRL levels. High serum PRL levels therefore might indicate an interference in follicular and oocyte development leading to oocytes of inferior quality.

[Decreasing Rhesus serum antibody titer in pregnancy with Rhesus constellation]

Without Rh-IgG prophylaxis the incidence of rhesus sensitisation increases in D-negative women with the number of subsequent pregnancies. However, our case report of a d-negative multipara demonstrates that foetal erythroblastosis does not necessarily occur in a pregnancy with initially high anti-D titres.

Hormonal parameters in follicular fluid and the fertilization rate of in vitro cultured oocytes

Oocytes and matched samples of follicular fluid were obtained from 52 preovulatory follicles aspirated laparoscopically for in vitro fertilization (IVF). Follicular fluid concentrations of estradiol (E2), progesterone (P), testosterone (T), prolactin (HPRL), prostaglandin F2 alpha (PGF2 alpha), prostaglandin E (PGE), protein content, and collagenolytic activity were measured and related to the fertilization rate of oocytes cultured in vitro. High concentrations of P and low levels of T and HPRL were associated with mature, fertilizable oocytes. Levels of PGF2 alpha, PGE, and follicular fluid protein concentrations were similar in both groups. Mean collagenolytic activity was increased in the fertilized oocytes, although no significant difference could be observed. Our data demonstrate a close association between follicular fluid steroid and HPRL concentrations and successful fertilization of oocytes.

[Comparison of vaginosonographic, transabdominal sonographic and laparoscopic follicle puncture for the retrieval of oocytes within the scope of an in vitro fertilization program]

For follicular aspiration and oocyte retrieval for in-vitro-fertilization (IVF) laparoscopy, laparotomy and different ultrasound guided methods like transvesical and transvaginal puncture can be used. Sonographically guided follicular aspiration has become more important because this procedure is less invasive. In this study we compared the results of 28 laparoscopical, 35 transabdominal and 21 transvaginal follicle puncture after successful cycle stimulation. Performing transvaginal puncture 4.7, using laparoscopy 3.4 and performing transvesical puncture 2.0 oocytes per attempt were retrieved. The advantages of transvaginal follicle aspiration were a shorter operation time, a superficial anesthesia and compared to laparoscopy a less invasive and simple technique. Therefore this method is now commonly used for routine IVF procedures in our institution.