Microsurgical epididymal sperm aspiration (MESA) combined with intracytoplasmic sperm injection (ICSI) represents a great advance in the therapy of non-reconstructable obstructive azoospermia. For procedure synchronization, a great number of organizational facilities are needed. Intentional cryopreservation of the aspirate may reduce these problems, therefore the aim of this study was to analyse the amount and quality of aspirate fluid obtained by means of MESA and the quality of the vials after thawing. Furthermore, the available cryopreserved straws were calculated. A total of 93 consecutive MESA procedures were performed and epididymal spermatozoa were obtained in 88 patients. Mean sperm concentration was 40.9 x 10(6) spermatozoa/ml. Global and progressive motility were 24.8 and 7.5% respectively. In one-third of the aspirates, no progressive motile spermatozoa were found. The mean number of straws available was 7.6. In 33 ICSI cycles with frozen-thawed epididymal spermatozoa, a pregnancy rate of 42.4% was achieved. In conclusion, these data show that enough spermatozoa are available for various ICSI cycles following a single MESA procedure in men with non-reconstructable obstructive azoospermia. Furthermore, ICSI with cryopreserved spermatozoa leads to excellent pregnancy rates

Die intrazytoplasmatische Spermatozoen-Injektion (ICSI) mit operativ gewonnenen epididymalen (MESA) oder testikulären (TESE) Spermatozoen führte bei der Hälfte der behandelten Paare (8/15) zu einer Schwangerschaft, fünf gesunde Kinder wurden bisher geboren. Die hohe Fertilisierungs- und Schwangerschaftsrate rechtfertigt bei definierter Indikation den hohen methodischen Aufwand der Behandlung.

Intracytoplasmatic sperm injection (ICSI) of spermatozoa recovered by microsurgical epididymal sperm aspiration (MESA) or from a testicular biopsy specimen (TESE) can be successfully used for establishing pregnancies. The high fertilisation rate of 60% (64 from 107 oocytes) and pregnancy rate (8 from 15 treatment cycles) endorses this treatment if congenital absence of vas deferens or obstructive azoospermia is suspected. Even in case of azoospermia resulting from complete induration of the epididymis or tubular atrophy, spermatozoa could be recovered from the testis by open biopsy in four patients and one pregnancy resulted.

Knapp 20% tubarer Funktionsstörungen betreffen den isthmischen Eileiterabschnitt und die Pars intramuralis tubae. Die Diagnostik der uterusnahen proximalen Tubenverschlüsse ist problematisch. In bis zu einem Drittel der Fälle findet sich bei Wiederholung der Pelviskopie oder Hysterosalpingografie eine freie Passage im intramuralen Tubenabschnitt bei zuvor diagnostiziertem proximalem Tubenverschluß. Sulak et al. berichteten 1987 in einer Studie, daß nur in knapp 40% der Fälle nach Resektion des uterusnahen Tubenanteils wegen eines proximalen Tubenverschlusses ein pathologisch-anatomisches Korrelat im Sinne einer fibrösen Obliteration oder Salpingitis isthmica nodosa nachweisbar war. In allen anderen Fällen fand sich eine normale Anatomie des Tubensegments.

For sensitive assessment of thyroid function a TRH stimulation test using 200 micrograms TRH i.v. was routinely performed in 304 women admitted for evaluation and treatment of infertility. In 37 cases (12.2%) the reaction of TSH 30 min after injection of TRH i.v. was enhanced (by definition of a peak TSH level greater than 25 mIU/l), according to mild or subclinical hypothyroidism. Approximately 14 (14/37 = 37.8%) of these patients were found to have slightly elevated serum PRL values (mean PRL greater than 15 ng/ml). Cycle analysis by means of basal body temperature and evaluation of progesterone and oestradiol values, supplied evidence of luteal phase deficiency in 8 and anovulation in 3 cases. Another group of 11 patients with hypothyroidism involved oligo-/amenorrhoea, hirsutism and hyperandrogenaemia. After treatment with 50-150 micrograms l-thyroxine daily for at least 4 to 6 weeks, elevated PRL values significantly decreased (mean level less than 15 ng/ml, p less than 0.01) in 9 out of 12 patients and testosterone levels slightly decreased in 5 out of 8 patients. An improvement of the cyclical ovarian function could be observed by the significant increase of the average progesterone concentration in the luteal phase. During therapy with l-thyroxine, 4 pregnancies occurred. From these results we conclude, that mild hypothyroidism may cause ovarian insufficiency. Assessment of thyroid function should be mandatory in infertile patients with elevated prolactin levels or chronic anovulation.

During a period of 17 months 61 couples without pathological tubal factors were treated by follicular puncture and gamete intra-Fallopian transfer (GIFT) at the department of Obstretrics and Gynaecology, University of Hamburg. The combination GnRH-antagonist (GnRH-A)/hMG was administered in 69 stimulation cycles. Two different GnRH-A application forms were used (daily intranasal spray/monthly depot injection). In all cases mature oocytes were collected after ovulation induction, and gamete transfer was performed. None of the cycles had to be cancelled. Twenty-two clinical pregnancies were achieved (32% by stimulation cycle). The highest pregnancy rate was observed in the group of cervical infertility (58%), lowest rate in cases of pathological male factors (15%). In addition, pregnancy rate correlated with the number and maturity of transfered oocytes. The combined GnRH-A/hMG stimulation therapy allows for a prolonged active follicular development without the occurrence of endogenous, premature luteinization. Besides a more flexible and effective strategy of ovarian stimulation, the number of follicles/oocytes was L, increased which provided a better condition for GIFT.

During a period of 17 months 61 couples without pathological tubal factors were treated by follicular puncture and gamete intra-Fallopian transfer (GIFT) at the department of Obstretrics and Gynaecology, University of Hamburg. The combination GnRH-antagonist (GnRH-A)/hMG was administered in 69 stimulation cycles. Two different GnRH-A application forms were used (daily intranasal spray/monthly depot injection). In all cases mature oocytes were collected after ovulation induction, and gamete transfer was performed. None of the cycles had to be cancelled. Twenty-two clinical pregnancies were achieved (32% by stimulation cycle). The highest pregnancy rate was observed in the group of cervical infertility (58%), lowest rate in cases of pathological male factors (15%). In addition, pregnancy rate correlated with the number and maturity of transfered oocytes. The combined GnRH-A/hMG stimulation therapy allows for a prolonged active follicular development without the occurrence of endogenous, premature luteinization. Besides a more flexible and effective strategy of ovarian stimulation, the number of follicles/oocytes was L, increased which provided a better condition for GIFT.

Induction of ovulation in patients with functional hypothalamus and pituitary is frequently complicated by unpredictable LH discharge and premature early luteinization. The best response and highest pregnancy rate following hMG-treatment can be achieved in hypogonadotropic patients [1]. Therefore a procedure was developed for selective temporary inhibition of pituitary gonadotropin secretion with the LH/RH-analogue Buserelin [2]. In a clinical study hMG-induced follicular maturation and succeeding fertilization during pharmacologic hypogonadotropism was investigated. In 31 cycles of 26 patients hMG/hCG-stimulation for in-vitro fertilization (IVF) because of a tubal factor was started after pretreatment with Buserelin (1.2 mg/day, nasal spray) had resulted in the absence of endogenous LH-discharge to an estrogen provocation test (group I). The cycles were compared with previous hMG/hCG cycles of the same patients without Buserelin treatment (n = 18, group II) and the total of hMG-treatment cycles for IVF (n = 66, group III).

In patients with functioning hypothalamus and pituitary, ovarian stimulation with exogenous gonadotropins frequently results in an unpredictable ovarian response due to LH surges induced by increasing estrogens. Gonadotropin treatment cycles displaying an endogenous LH-peak rarely result in a pregnancy and in in-vitro fertilization programs the proper timing of follicle puncture is made difficult.

Out of 109 hMG stimulations for in vitro fertilization (IVF) 41 cycles (38%) had to be cancelled because of premature endogenous luteinization. Pretreatment with the LH/RH-agonist Buserelin induces selective pituitary suppression and prevents spontaneous LH-surge during hMG stimulation. The pharmacologic hypogonadotropism allows considerable flexibility with respect to the timing of starting gonadotropin stimulation and ovulation induction. In 74 Buserelin/hMG/IVF-cycles no premature luteinization occurred and all started stimulations yielded in follicular puncture. In addition increased oocyte recovery rate, significant higher fertilization rate and significant better pregnancy rate could be achieved as compared with hMG/IVF-cycles. In conclusion pharmacologic hypogonadotropism by administration of LH/RH-analogue reliably prevents endogenous luteinization and improves gonadotropin stimulation as well as IVF results.

Out of 109 hMG stimulations for in vitro fertilization (IVF) 41 cycles (38%) had to be cancelled because of premature endogenous luteinization. Pretreatment with the LH/RH-agonist Buserelin induces selective pituitary suppression and prevents spontaneous LH-surge during hMG stimulation. The pharmacologic hypogonadotropism allows considerable flexibility with respect to the timing of starting gonadotropin stimulation and ovulation induction. In 74 Buserelin/hMG/IVF-cycles no premature luteinization occurred and all started stimulations yielded in follicular puncture. In addition increased oocyte recovery rate, significant higher fertilization rate and significant better pregnancy rate could be achieved as compared with hMG/IVF-cycles. In conclusion pharmacologic hypogonadotropism by administration of LH/RH-analogue reliably prevents endogenous luteinization and improves gonadotropin stimulation as well as IVF results.