Publications by authors named "Cordula Schippert"

33 Publications

Cognitive function in association with high estradiol levels resulting from fertility treatment.

Horm Behav 2021 Feb 11;130:104951. Epub 2021 Feb 11.

Department of Applied Psychology, Zurich University for Applied Sciences (ZHAW), Zürich, Switzerland. Electronic address:

The putative association between hormones and cognitive performance is controversial. While there is evidence that estradiol plays a neuroprotective role, hormone treatment has not been shown to improve cognitive performance. Current research is flawed by the evaluation of combined hormonal effects throughout the menstrual cycle or in the menopausal transition. The stimulation phase of a fertility treatment offers a unique model to study the effect of estradiol on cognitive function. This quasi-experimental observational study is based on data from 44 women receiving IVF in Zurich, Switzerland. We assessed visuospatial working memory, attention, cognitive bias, and hormone levels at the beginning and at the end of the stimulation phase of ovarian superstimulation as part of a fertility treatment. In addition to inter-individual differences, we examined intra-individual change over time (within-subject effects). The substantial increases in estradiol levels resulting from fertility treatment did not relate to any considerable change in cognitive functioning. As the tests applied represent a broad variety of cognitive functions on different levels of complexity and with various brain regions involved, we can conclude that estradiol does not show a significant short-term effect on cognitive function.
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http://dx.doi.org/10.1016/j.yhbeh.2021.104951DOI Listing
February 2021

Reproductive capacity and recurrence of disease after surgery for moderate and severe endometriosis - a retrospective single center analysis.

BMC Womens Health 2020 07 13;20(1):144. Epub 2020 Jul 13.

Department of Obstetrics and Gynaecology, Hanover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.

Background: Endometriosis can be associated with considerable pain and sterility. After surgical excision of moderate or severe endometriosis lesions, the rate of recurrence reaches up to 67%. The objective of this retrospective study was to establish the recurrence and pregnancy rates following surgical resection of stage III/IV endometriosis lesions. Indications for operation were endometriosis symptoms, sonographic findings and/or infertility.

Methods: A total of 456 patients who underwent stage III/IV endometriosis surgery between 2004 and 2014 were sent a questionnaire relating to their postoperative medical treatment, pregnancies, relief of symptoms and recurrence. Responses of 206 patients (45.2%) and their clinical data were analysed for this study.

Results: A total of 66.5% (N = 137) of patients had stage III disease, and 33.5% (N = 69) had stage IV disease. The average age was 37 years (17-59). A total of 63.1% (N = 130) of surgeries were performed by laparoscopy, 21.8% (N = 45) were performed by laparotomy and 15% (N = 31) were performed by conversion. Complete resection of endometriosis lesions was achieved in 90.8% of patients (N = 187). After surgery, 48.5% (N = 100) of the women did not receive hormonal treatment; the main reason was the desire for children in 53%. Complete or partial relief in complaints was achieved in 93.2% (N = 192). The rate of recurrence was 21.8% (N = 45). The statistically significant factors that was associated with a higher risk to develop recurrence was an age < 35 (p < 0.005). After surgery, 65.8% (79/120) of patients who wished to have children became pregnant. There was a statistically significant association among a higher postoperative pregnancy rate and age < 35 (p < 0.003) in multivariate logistic regression analysis and laparoscopic surgical access in univariate logistic regression analysis (p < 0.01).

Conclusion: We assessed the high percentage of complete or partial relief of symptoms of 93.2%, the high postoperative pregnancy rate of 65.8% and the low rate of recurrence of 21.8% compared to international literature to be very encouraging for women suffering from moderate and severe endometriosis. Though laparoscopy is considered the 'gold standard'of endometriosis surgery, laparotomy still may be indicated in patients with extensive endometriosis especially to preserve reproductive function.
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http://dx.doi.org/10.1186/s12905-020-01016-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358195PMC
July 2020

Effects of six month personalized endurance training on work ability in middle-aged sedentary women: a secondary analysis of a randomized controlled trial.

J Occup Med Toxicol 2020 6;15. Epub 2020 May 6.

1Institute of Sports Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.

Background: To test the effects of guided endurance training on work ability in middle-aged female hospital workers of various occupations.

Methods: We randomized 265 healthy, sedentary, middle-aged women (45-65 years) to an endurance training group (EG 210 min/week) or a wait-list control group (CG). At baseline and at 6-month follow-up, we assessed work ability (Work Ability Index [WAI]), physical activity (Freiburger activity questionnaire) and peak oxygen uptake (VO) by cardiopulmonary exercise testing. To examine the influence of baseline work ability, participants were divided into poor-moderate (WAI 1, 7-36 points,  = 83), good (WAI 2, 37-43 points,  = 136) and excellent (WAI 3, 44-49 points,  = 46) WAI subgroups.

Results: Cardiorespiratory fitness improved significantly after 6 months in the EG but not in the CG. The WAI total score increased significantly in the EG (38.3 ± 5.0 to 39.8 ± 4.9 points) but not in the CG (39.4 ± 4.7 to 39.3 ± 4.9 points), with a significant difference between groups ( < 0.01). In the EG, only the poor-moderate subgroup (WAI 1, 33.0 ± 2.9 to 36.6 ± 4.8 points,  < 0.05) increased the WAI total score, with this increase being significantly higher compared to the good (WAI 2, 40.2 ± 2.1 to, 40.4 ± 3.7 points) and excellent (WAI 3, 45.6 ± 1.5 to 45.7 ± 1.8 points) subgroup.

Conclusions: A 6-month guided exercise training intervention significantly increases cardiorespiratory fitness with concomitant improvements in work ability in middle-aged previously sedentary hospital employees. Women with low baseline work ability seem to particularly benefit from the intervention, which implies that similar interventions may be particularly beneficial for this group of individuals.

Trial Registration: German Clinical Trails Register Identifier: DRKS00005159. Registered 25 September 2013.
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http://dx.doi.org/10.1186/s12995-020-00261-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201966PMC
May 2020

Associations Between Natural Physiological and Supraphysiological Estradiol Levels and Stress Perception.

Front Psychol 2019 11;10:1296. Epub 2019 Jun 11.

Centre of Competence in Aerospace Biomedical Science & Technology, Lucerne University of Applied Sciences and Arts, Lucerne, Switzerland.

Stress is a risk factor for impaired general, mental, and reproductive health. The role of physiological and supraphysiological estradiol concentrations in stress perception and stress processing is less well understood. We, therefore, conducted a prospective observational study to investigate the association between estradiol, stress perception, and stress-related cognitive performance within serial measurements either during the natural menstrual cycle or during fertility treatment, where estradiol levels are strongly above the physiological level of a natural cycle, and consequently, represent a good model to study dose-dependent effects of estradiol. Data from 44 women receiving fertilization (IVF) at the Department of Reproductive Endocrinology in Zurich, Switzerland was compared to data from 88 women with measurements during their natural menstrual cycle. The German version of the Perceived Stress Questionnaire (PSQ) and the Cognitive Bias Test (CBT), in which cognitive performance is tested under time stress were used to evaluate subjective and functional aspects of stress. Estradiol levels were investigated at four different time points during the menstrual cycle and at two different time points during a fertility treatment. Cycle phases were associated with PSQ worry and cognitive bias in normally cycling women, but different phases of fertility treatment were not associated with subjectively perceived stress and stress-related cognitive bias. PSQ lack of joy and PSQ demands related to CBT in women receiving fertility treatment but not in women with a normal menstrual cycle. Only strong changes of the estradiol level during fertility treatment were weakly associated with CBT, but not with subjectively experienced stress. Our research emphasizes the multidimensional character of stress and the necessity to adjust stress research to the complex nature of stress perception and processing. Infertility is associated with an increased psychological burden in patients. However, not all phases of the process to overcome infertility do significantly increase patient stress levels. Also, research on the psychological burden of infertility should consider that stress may vary during the different phases of fertility treatment. ClinicalTrials.gov # NCT02098668.
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http://dx.doi.org/10.3389/fpsyg.2019.01296DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6579809PMC
June 2019

Sequence Variants in TBX6 Are Associated with Disorders of the Müllerian Ducts: An Update.

Sex Dev 2019 9;13(1):35-40. Epub 2019 Feb 9.

Müllerian anomalies comprise the Mayer-Rokitansky-Küster-Hauser syndrome as well as fusion defects of the müllerian ducts. Recurrent micro-aberrations like deletions in 16p11.2 encompassing TBX6 were found to be causative in these patients. TBX6 encodes a transcription factor which plays a role in paraxial mesoderm differentiation/specification. In previous studies, we and other groups found possibly pathogenic variants in TBX6 in patients with müllerian anomalies. Since we suggested TBX6 as a strong candidate, we performed sequential analysis of the TBX6 gene in additional 125 patients with müllerian anomalies, and 2 possibly pathogenic missense variants and 1 nonsense substitution in TBX6 in 4/125 patients were found. The missense variant c.484G>A, which we have described in a previous study, was reidentified but with no higher frequency as in our controls. We detected 3 possibly pathogenic variants in TBX6 and could show that the variant c.484G>A is not causative for disorders of the müllerian ducts in the non-Finnish European population. In summary, we present increasing evidence for association of variants in TBX6 with malformations of the müllerian ducts.
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http://dx.doi.org/10.1159/000496819DOI Listing
August 2019

Sequence Variants in TBX6 Are Associated with Disorders of the Müllerian Ducts: An Update.

Sex Dev 2019 9;13(1):35-40. Epub 2019 Feb 9.

Müllerian anomalies comprise the Mayer-Rokitansky-Küster-Hauser syndrome as well as fusion defects of the müllerian ducts. Recurrent micro-aberrations like deletions in 16p11.2 encompassing TBX6 were found to be causative in these patients. TBX6 encodes a transcription factor which plays a role in paraxial mesoderm differentiation/specification. In previous studies, we and other groups found possibly pathogenic variants in TBX6 in patients with müllerian anomalies. Since we suggested TBX6 as a strong candidate, we performed sequential analysis of the TBX6 gene in additional 125 patients with müllerian anomalies, and 2 possibly pathogenic missense variants and 1 nonsense substitution in TBX6 in 4/125 patients were found. The missense variant c.484G>A, which we have described in a previous study, was reidentified but with no higher frequency as in our controls. We detected 3 possibly pathogenic variants in TBX6 and could show that the variant c.484G>A is not causative for disorders of the müllerian ducts in the non-Finnish European population. In summary, we present increasing evidence for association of variants in TBX6 with malformations of the müllerian ducts.
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http://dx.doi.org/10.1159/000496819DOI Listing
August 2019

Peri- and postoperative management and outcomes of morbidly obese patients (BMI > 40 kg/m) with gynaecological disease.

Arch Gynecol Obstet 2018 05 10;297(5):1221-1233. Epub 2018 Mar 10.

Department of Obstetrics and Gynaecology, Hanover Medical School, Carl-Neuberg-Strasse 1, 30625, Hanover, Germany.

Introduction: For the last two decades, obesity rates have been increasing in both developed and developing countries, with the number of obese women roughly doubling during this period (Stevens et al. in Popul Health Metr 10(1):33, 2012). Obesity represents one of the biggest epidemics of the 21st century. The aim of this retrospective study is to characterise the outcomes of gynaecologic surgeries in cases of extremely obese women with a body mass index (BMI) over 40 kg/m.

Methods: This study is a retrospective case control study in a single-centre setting. Our clinical database was searched for gynaecological operations performed on morbidly obese patients (BMI > 40 kg/m) between 2009 and 2014 in the Department of Gynaecology and Obstetrics at Hannover Medical School. We matched these results with random patients of normal body weight who had similar surgical procedures and diseases.

Results: We included 97 obese patients in our case group and 99 patients in the control group. We found an association between a strongly elevated BMI and peri- and postoperative morbidity. Both intraoperative and postoperative complications are significantly increased in morbid obesity with a BMI over > 40 kg/m. We observed intraoperative complications in 55.6% and postoperative complications in 50.5% of patients with extreme obesity. In contrast, the complication rate in the control group with a normal BMI was 11% intraoperatively (p = 0.0001) and 3% postoperatively (p = 0.0001). The data showed that perioperative and postoperative morbidity could be reduced by laparoscopic surgery in many cases, with a significant lower rate of difficulties with closing the wound, a significant shorter duration of surgery and a significant lower rate of infections combined with a significant lower reoperation rate and shorter hospital stay. In gynaecological-oncological diseases, we could demonstrate a reduced radicality during the operative procedure due to extreme obesity.

Discussion: Dealing with the growing number of obese patients is essential, because the problems emerging from obesity are manifold for the treating hospitals as well as the general health system. For this high-risk patient group, it is indispensable to obtain a thorough overview of the patient's overall situation preoperatively to ensure good perioperative care and complications management.
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http://dx.doi.org/10.1007/s00404-018-4735-3DOI Listing
May 2018

Lack of Associations between Female Hormone Levels and Visuospatial Working Memory, Divided Attention and Cognitive Bias across Two Consecutive Menstrual Cycles.

Front Behav Neurosci 2017 4;11:120. Epub 2017 Jul 4.

Department of Applied Psychology, Zurich University for Applied Sciences (ZHAW)Zurich, Switzerland.

Interpretation of observational studies on associations between prefrontal cognitive functioning and hormone levels across the female menstrual cycle is complicated due to small sample sizes and poor replicability. This observational multisite study comprised data of = 88 menstruating women from Hannover, Germany, and Zurich, Switzerland, assessed during a first cycle and = 68 re-assessed during a second cycle to rule out practice effects and false-positive chance findings. We assessed visuospatial working memory, attention, cognitive bias and hormone levels at four consecutive time-points across both cycles. In addition to inter-individual differences we examined intra-individual change over time (i.e., within-subject effects). Estrogen, progesterone and testosterone did not relate to inter-individual differences in cognitive functioning. There was a significant negative association between intra-individual change in progesterone and change in working memory from pre-ovulatory to mid-luteal phase during the first cycle, but that association did not replicate in the second cycle. Intra-individual change in testosterone related negatively to change in cognitive bias from menstrual to pre-ovulatory as well as from pre-ovulatory to mid-luteal phase in the first cycle, but these associations did not replicate in the second cycle. There is no consistent association between women's hormone levels, in particular estrogen and progesterone, and attention, working memory and cognitive bias. That is, anecdotal findings observed during the first cycle did not replicate in the second cycle, suggesting that these are false-positives attributable to random variation and systematic biases such as practice effects. Due to methodological limitations, positive findings in the published literature must be interpreted with reservation.
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http://dx.doi.org/10.3389/fnbeh.2017.00120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5495858PMC
July 2017

Negative affect is unrelated to fluctuations in hormone levels across the menstrual cycle: Evidence from a multisite observational study across two successive cycles.

J Psychosom Res 2017 08 25;99:21-27. Epub 2017 May 25.

Department of Reproductive Endocrinology, University Hospital Zürich, Switzerland.

Background: Female sex hormones may play a crucial role in the occurrence of cycle-related mood disorders. However, the literature is inconsistent and methodologically stringent observational studies on the relationship between sex hormones and negative affect are lacking.

Methods: In this longitudinal multisite study from Hannover, Germany, and Zurich, Switzerland, we examined oestrogen, progesterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone serum levels in association with negative affect as measured with the Positive and Negative Affect Schedule (PANAS). Negative affect and hormone assays were collected at four consecutive time points comprising menstrual, pre-ovulatory, mid-luteal and premenstrual phase across two cycles (n=87 and n=67 for the first and second cycles). The Beck Depression Inventory (BDI) was assessed once prior to the first cycle and included as a secondary measure.

Results: Mean negative affect scores did not significantly fluctuate across both cycles and there was in particular no symptom increase premenstrually. No sex hormone consistently related to repeated measures of negative affect across two consecutive cycles. The BDI sum-score assessed at baseline was not related to hormone levels across the first cycle.

Conclusions: This is the first multisite longitudinal study on the association between negative affect and sex hormone levels encompassing two consecutive menstrual cycles. Negative affect did not fluctuate across the cycle and there was no direct and uniform association between sex hormones and self-reported negative affect. These findings suggest that moderators such as personality traits and epigenetics should be considered in future research.
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http://dx.doi.org/10.1016/j.jpsychores.2017.05.018DOI Listing
August 2017

Ultrasound versus Clinical Examination to Estimate Fetal Weight at Term.

Geburtshilfe Frauenheilkd 2017 Mar;77(3):276-283

Hanover Medical School, Department of Gynecology and Obstetrics, Hanover, Germany.

At term, fetal weight estimation is an important factor for decisions about the delivery mode and the timing of labor induction. This study aimed to compare the accuracy of abdominal palpation with that of ultrasound performed by different examiners to estimate fetal weight. The study investigated whether differences in the examiners' training affected fetal weight estimates. The accuracy of the weight estimates made for fetuses with extreme birth weights was also evaluated. Finally, the accuracy of Johnson's method and of Insler and Bernstein's formula for estimating fetal weight were compared with the other two methods. This prospective study included singleton pregnancies between 37 weeks of gestation and 12 days post-term planned for vaginal delivery or cesarean section. Ultrasound and abdominal palpation using Leopold's maneuvers were performed by examiners with different levels of professional experience. Fetal weight was additionally estimated using Insler and Bernstein's formula and Johnson's method. Statistical analysis calculated the accuracy of fetal weight estimates for the different examiners and the four methods. A total of 204 women were included in the analysis. Trained ultrasound examiners were most accurate when estimating fetal weight compared with all other examiners. The comparison of all four methods showed that fetal weight was assessed most accurately with ultrasound. No learning curve could be established. BMI and advanced gestational age affected the accuracy of the estimated weight. The analysis showed that a greater deviation between estimated weight and actual weight occurred with all four methods for fetuses at either end of the extremes of fetal weight, i.e., with very low or very high birth weights. Fetal weight should be estimated using ultrasound. A good ultrasound training is essential.
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http://dx.doi.org/10.1055/s-0043-102406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5383430PMC
March 2017

Neonatal and Maternal Short-Term Outcome Parameters in Instrument-Assisted Vaginal Delivery Compared to Second Stage Cesarean Section in Labour: A Retrospective 11-Year Analysis.

Gynecol Obstet Invest 2018 22;83(1):90-98. Epub 2017 Feb 22.

Medical School of Hanover, Departement of Gynecology and Obstetrics, Hanover, Germany.

Background: This study is aimed at comparing the neonatal and maternal short-term outcomes after instrumental-assisted vaginal delivery and cesarean section (CS) in labour.

Methods: This retrospective study over a period of 11 years included singleton pregnancies above 34 + 0 gestational weeks, giving birth either by instrumental-assisted delivery or CS in labour. Maternal and neonatal outcome parameters were analysed using t test or linear regression.

Results: A total of 1,971/2,571 deliveries were included for analysis: 149 forceps-, 393 vacuum-assisted deliveries and 1,420 CS in labour. Regarding maternal outcome, the rate of severe anaemia and hemorrhage in women who delivered by CS in labour was lower than in instrumental-assisted delivery. Analysis of neonatal outcome parameters showed a lower cord pH <7.20 in CS; however, 5-min Apgar score and the need for intervention did not differ with the mode of delivery. The mode of anaesthesia affected the neonatal recovery rate. Subanalysis within instrumental deliveries showed reduced rates of vaginal tears, but higher rates of episiotomy in forceps-assisted deliveries. Except for higher rates of cephalhaematomas after ventouse, no differences were detected regarding further neonatal outcome measures.

Conclusion: Assuming that indication and application is correct, vaginal instrumental-assisted delivery can be considered as an alternative delivery mode to second stage CS in labour.
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http://dx.doi.org/10.1159/000458524DOI Listing
July 2018

Gestational diabetes mellitus: an evaluation of gynecologists' knowledge of guidelines and counseling behavior.

Arch Gynecol Obstet 2016 11 10;294(6):1209-1217. Epub 2016 Aug 10.

Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.

Purpose: Knowledge of risks, adequate pre- and post-partum care, and counseling is essential to reduce short- and long-term consequences for women with gestational diabetes mellitus (GDM) and their offspring. Our study explored the current GDM guideline knowledge and practiced patient counseling of private gynecologists in Germany.

Methods: A survey assessing the GDM guidelines and patient counseling was mailed to 775 practicing gynecologists. We evaluated the knowledge of maternal and offspring disease risks, counseling practice, and guideline awareness. Descriptive statistics were used to analyze the responses and Chi-Square or Fisher exact test to explore differences between groups.

Results: Of the 418 private gynecologists (54.1 % response rate) who responded, the majority was aware of obesity and GDM in the previous pregnancy as risk factors for GDM. To a lesser extent, risk factors like recurrent miscarriages and stillbirth were recalled. Eighty percent stated that GDM was associated with a higher risk for the development for hypertension and 96 % with type 2 diabetes in the mother. Respondents with knowledge of the current GDM guidelines were more often aware of the development of chronic diseases, counseled patients more frequently, and performed post-partum glucose screenings more regularly compared with private gynecologists with no knowledge of the guidelines.

Conclusions: The majority of participants incorporated recent recommendations into their practice patterns for GDM. Providing private gynecologists with additional training may further improve care for women with GDM-affected pregnancies.
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http://dx.doi.org/10.1007/s00404-016-4161-3DOI Listing
November 2016

The Benefit of Baseline Staging-Risk Assessment of Distant Breast Cancer Metastases by Tumor Stage.

Anticancer Res 2016 09;36(9):4909-14

Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany

Background: Despite recommendations of international societies, use of baseline staging in breast cancer varies considerably. We retrospectively analyzed the prevalence of metastases in each pTN stage to estimate the benefit of staging.

Patients And Methods: The prevalence of metastases at primary diagnosis (M1) and in the first year after diagnosis (M112) was determined in 2,906 patients.

Results: The prevalence of M1 was 0.95% [95% confidence interval (CI)=0.53-1.70%] in pT1pN0, 2.17% (95% CI=1.00-4.64) in pT1pN1 and 1.53% (95% CI=0.78-2.99%) in pT2pN0. The prevalence of M112 was 2.17% (95% CI=1.47-3.18%) in pT1pN0 and 3.25% in pathological stage IIA (upper confidence bound 5.14%). In pT2pN1 the prevalence of M1 and M112 was 3.49% (95% CI=1.96-6.14%) and 6.35% (95% CI=4.15-9.60%), respectively. Results for stage pT3pN0 and higher were inconclusive.

Conclusion: Baseline staging can be safely abandoned in pathological stage I and IIA. Individual decisions should be made for pT2pN1. Staging is recommended in stages of pT3pN0 or higher.
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http://dx.doi.org/10.21873/anticanres.11056DOI Listing
September 2016

Clinical diagnosis and therapy of uterine scar defects after caesarean section in non-pregnant women.

Arch Gynecol Obstet 2015 Jun 17;291(6):1417-23. Epub 2014 Dec 17.

Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.

Purpose: Caesarean delivery (c-section) scar dehiscences may cause bleeding abnormalities, e.g. postmenstrual spotting, dysmenorrhea and abdominal pain, secondary sterility and at worst peripartum uterine rupture. The purpose of this study was firstly to identify the correlation of women's complaints after c-section with scar-related clinical symptoms. Secondly, the effects of corrective surgery on preoperatively existing complaints were analysed and assessed in the patient population of our clinic.

Methods: We present data of a retrospective study of 13 premenopausal, non-pregnant women with symptomatic c-section scars. In 9 out of 13 patients, a microsurgical uterus reconstruction was performed by mini-laparotomy. The postoperative changes of scar-associated symptoms were assessed by a questionnaire as earliest as 4 months after surgery (N = 5).

Results: The c-section scar was visualised by transvaginal sonography in 12 out of 13 women by a typical U- or V-shaped hypoechoic or anechoic fluid accumulation in the region of former uterotomy and in all 13 patients by hysteroscopy. Bleeding disorders were often accompanied by dysmenorrhea/abdominal pain (38.5%, N = 5) and secondary sterility (46.2%, N = 6). Blood residues in the scar pouch and bleeding disorders/postmenstrual spotting were found in 30.8% of patients (N = 4) and combined with secondary sterility in 38.5% of patients (N = 5). Reconstructive surgeries resulted in discontinuation of bleeding disorders in all women and a pregnancy in three out of five patients (60%) with secondary sterility.

Conclusion: Clinical symptoms, e.g. "bleeding disorders" like postmenstrual spotting, "pain/dysmenorrhea" and "secondary sterility" could be specific indicators for the diagnosis of uterine dehiscence after c-section. Scar dehiscences can be diagnosed by obtaining the patients medical history and asking for typical symptoms followed by vaginal sonography and diagnostic hysteroscopy. If a c-section scar defect is confirmed, microsurgical uterus reconstruction can stop postmenstrual spotting, reduce abdominal pain/dysmenorrhea and improve fertility.
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http://dx.doi.org/10.1007/s00404-014-3582-0DOI Listing
June 2015

Preeclampsia and long-term risk of cardiovascular disease: what do obstetrician-gynecologists know?

BMC Pregnancy Childbirth 2013 Mar 9;13:61. Epub 2013 Mar 9.

Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Str, 1, Hannover, 30625, Germany.

Background: Preeclampsia (PE), a hypertensive disorder of pregnancy affects 2-8% of women and is associated with increased cardiovascular disease (CVD) risk later in life. There is little information about the knowledge of obstetrician-gynecologists in German outpatient care setting regarding the future health risk of PE and knowledge of the current guidelines on treatment and counseling patients post PE. This study aimed to assess whether obstetrician-gynecologists are aware of PE's association with maternal long-term adverse outcomes and providing appropriate counseling.

Methods: A random sample of 500 obstetrician-gynecologists in the federal state of Lower Saxony was mailed a survey and a reminder with a second copy of the survey. The questionnaire elicited both personal information, and knowledge on future disease risks, e.g. cardiovascular disease (CVD) and current guidelines as well as on counseling practice. Descriptive analysis was used to analyze the responses.

Results: A total of 212 obstetrician-gynecologists (42.4%) responded to the questionnaire. A large proportion of physicians stated that PE was associated with a higher risk for the development for hypertension (86.6%), stroke (78.5%) and kidney disease (78.0%). Of the participants 75.8% reported that women after PE have a shorter life expectancy. Respondents with knowledge of the current guidelines of the German Association of Obstetrics and Gynecology concerning follow up and risk management of PE (45.2%) were more often aware of the development of CVD and stroke and counseled patients on self -blood-pressure measurement, meaning and long-term-risks of PE and attached importance to family history of PE compared to physicians with no knowledge of the guidelines.

Conclusion: Although the majority of obstetrician-gynecologists were aware of higher CVD risk after PE, weaknesses exist in the follow up care and counseling of these patients. These deficiencies would be amendable to directed educational activities to improve the implementation of current guidelines.
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http://dx.doi.org/10.1186/1471-2393-13-61DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3605330PMC
March 2013

Mitomycin C in combination with vinorelbine in anthracycline- and/or taxane-pretreated patients with metastatic breast cancer.

Onkologie 2012 13;35(9):500-4. Epub 2012 Aug 13.

Klinik für Frauenheilkunde und Geburtshilfe, Medizinische Hochschule Hannover, Germany.

Background: Patients with metastatic breast cancer (MBC) with disease progression after anthracycline-and/or taxane-containing therapy need an effective drug regimen with low toxicity. Mitomycin C (MMC) and vinorelbine (VNR) are suitable candidates for combination therapy in the second-/third-line treatment of MBC. This study evaluates the safety and efficacy of an MMC/VNR combination chemotherapy in pretreated patients with MBC.

Patients And Methods: In a phase II trial, patients with anthracycline-and/or taxane-pretreated MBC were treated with MMC 8 mg/m(2) (day 1) and VNR 25 mg/m(2) (days 1 and 8) every 4 weeks for up to 6 cycles or until disease progression.

Results: In 51 eligible patients, 13 (26%) partial remissions (PRs), 20 (39%) stable diseases (SDs) and 18 (35%) progressive diseases (PDs) were observed. The median progression-free survival (PFS) was 5.0 months. The main grade 3/4 toxicities were neutrocytopenia (41%), granulocytopenia (37%), and thrombocytopenia (4%). Other hematological and non-hematological toxicities were mostly mild.

Conclusion: The combination of MMC and VNR is an effective and relatively well-tolerated regimen for anthracycline- and/or taxane-pretreated patients with MBC and is suitable for outpatient therapy.
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http://dx.doi.org/10.1159/000341839DOI Listing
March 2013

Diagnostic challenges of hemihematocolpos and dysmenorrhea in adolescents: obstructed hemivagina, didelphys or bicornuate uterus and renal aplasia is a rare female genital malformation.

Arch Gynecol Obstet 2012 Sep 5;286(3):785-91. Epub 2012 Jun 5.

Department of Obstetrics, Gynecology and Reproductive Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.

Objectives: To develop a clear diagnostic and therapeutic strategy for adolescents presenting with abdominal pain and vaginal tumor caused by congenital female genital anomalies, such as blind hemivagina and uterine anomalies, as the lack of the correct diagnosis of the underlying anatomical genitourinary malformation frequently leads to destructive surgical procedures.

Methods: Retrospective study, study group: patients with double/bicornuate uterus, blind hemivagina and hematocolpos (n = 13), controls: patients with uterine malformation and complete vertical vaginal septum (n = 11), analysis for: menarche, age at onset of symptoms, type of malformation, symptoms leading to admission and diagnostic/surgical techniques applied.

Results: Median age at diagnosis study group 19.85 (SD ± 6.23, range 13-23 years) versus controls 26.09 years (SD ± 7.44, 16-36 years); predominance of imperforated hemivagina: 69.2 % right-sided versus 30.8 % left-sided septum; renal agenesis ipsilateral to imperforate hemivagina 100 % study group versus 9.1 % controls; 84.6 % previous surgical interventions in the study group, such as partial removal of the septum and re-obliteration, unilateral salpingo-ovarectomy and vaginal drainage of pyometra. We used a single transvaginal surgical procedure, including removal of the obstructed vaginal septum and marsupialization of the blind hemivagina.

Conclusions: A diagnostic and therapeutic algorithm for young women presenting with progressive dysmenorrhea and abdominal pain and/or vaginal tumor reduces destructive interventions.
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http://dx.doi.org/10.1007/s00404-012-2392-5DOI Listing
September 2012

The cost efficiency of HPV vaccines is significantly underestimated due to omission of conisation-associated prematurity with neonatal mortality and morbidity.

Hum Vaccin Immunother 2012 Feb 1;8(2):243-51. Epub 2012 Feb 1.

University Women's Hospital, Hannover Medical School, Hannover, Germany.

Introduction: Cervical intraepithelial neoplasia (CIN) represents the precursor of invasive cervical cancer and is associated with human papillomavirus infection (HPV) against which two vaccines have been approved in the last years. Standard treatments of high-grade CIN are conisation procedures, which are associated with an increased risk of subsequent pregnancy complications like premature delivery and possible subsequent life-long disability. HPV vaccination has therefore the potential to decrease neonatal morbidity and mortality. This has not been taken into account in published cost-effectiveness models.

Material And Methods: We calculated the possible reduction rate of conisations for different vaccination strategies for Germany. Using this rate, we computed the reduction of conisation-associated preterm deliveries, life-long disability and neonatal death due to prematurity. The number of life-years saved (LYS) and gain in quality-adjusted life-years (QALYs) was estimated. The incremental costs per LYS / additional QALY were calculated.

Results: The reduction of conisation procedures was highest in scenario I (vaccination coverage 90% prior to HPV exposition) with about 50%. The costs per LYS or additional QALY were lowest in scenario I, II and III with 45,101 € or 43,505-47,855 € and rose up to 60,544 € or 58,401-64,240 € in scenario V (50% vaccinated prior to sexual activity + additional 20% catch-up at a mean age of 20 y).

Conclusion: Regarding the HPV 16 / 18 vaccines as "vaccines against conisation-related neonatal morbidity and mortality" alone, they already have the potential to be cost-effective. This effect adds up to reduction of cervical cancer cases and decreased costs of screening for CIN. Further studies on cost-effectiveness of HPV vaccination should take the significant amount of neonatal morbidity and mortality into account.
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http://dx.doi.org/10.4161/hv.18519DOI Listing
February 2012

Aromatase inhibitors as solely treatment in postmenopausal breast cancer patients.

Breast J 2012 Mar-Apr;18(2):145-50. Epub 2011 Dec 16.

University Women's Clinic, Hanover Medical School, Hanover, Germany.

Several studies evaluating the clinical effectiveness of endocrine therapy alone in breast cancer patients aged 70 years or older reported comparable survival rates to conventional surgical therapy, although the incidence of local recurrences was higher. Primary endocrine therapy is therefore only recommended as an alternative approach in elderly woman with estrogen receptor positive tumors who are deemed inoperable or who refuse surgery. We report our experience with aromatase inhibitors as primary endocrine therapy for estrogen receptor positive breast cancer in postmenopausal woman who are impaired by other diseases, refuse surgery or are of old age. Fifty-six patients with fifty-seven ER+ operable breast cancers who refused surgery, were judged ineligible for surgery because of comorbidity, or were of old age were treated with endocrine therapy using aromatase inhibitors only. Digital mammography and high-end breast ultrasound were used to assess tumor sizes. The mean age of the patients was 74 years (range 52-102 years). All patients suffered from breast cancer. The mean follow-up interval was 40 months (range 5-92 months). Seven patients (12%) achieved complete clinical remission, 31 (57%) partial response giving an overall objective response rate of 69%. In addition, seven (12%) patients showed stable disease, giving a clinical benefit rate (complete remission + partial response + stable disease rate) of 81%. Eleven patients (19%) progressed after an initial partial response or stable disease. Only one patient (2%) progressed on endocrine therapy within the first months. Eventually, 22 (39%) patients underwent surgery after informed consent to achieve better local tumor control. Primary endocrine therapy with aromatase inhibitors may offer an effective and safe alternative to surgery giving a high local control rate in postmenopausal women who refuse surgery, who are judged ineligible for surgery, or are of old age.
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http://dx.doi.org/10.1111/j.1524-4741.2011.01203.xDOI Listing
August 2012

Treatment of high grade cervical intraepithelial neoplasia by photodynamic therapy using hexylaminolevulinate may be costeffective compared to conisation procedures due to decreased pregnancy-related morbidity.

Lasers Surg Med 2011 Sep;43(7):713-20

University Women's Hospital, Hannover Medical School, Hannover, Germany.

Background And Objectives: Standard treatments of high-grade Cervical intraepithelial neoplasia (CIN) are conisation procedures. Theses methods have proven effectiveness but are associated with an increased risk of subsequent pregnancy complications. Recently, photodynamic therapy (PDT) of CIN using hexylaminolevulinate (HAL) may represent an alternative treatment without the risk of cervical insufficiency or scaring. This study aims to evaluate the economical aspect of CIN treatment including associated pregnancy complications by comparing both methods.

Materials And Methods: We developed model treatment pathways for both conisation procedures and PDT using HAL. Thereafter, we calculated total costs for both treatment pathways including necessary re-treatments or alternative treatments. The estimated impact of conisation-related cervical insufficiency, prematurity, perinatal morbidity and life-long disability were determined. The total additional costs per conisation due to perinatal morbidity were calculated.

Results: The total cost of treatment for CIN with a conisation procedure alone was 1,473 €, whereas the PDT procedure alone accounted for 1,386 €, based of assumptions of a 50% re-PDT rate, a 70% response rate and costs of 500 € for the PDT intervention itself. We computed 71, 144 and 545 newborns born prematurely due to conisation procedures <28, between 28 and <32 and between 32 and <37 weeks of gestation, leading to 18, 24 and 65 cases of severe, moderate and mild life-long disability. The attributable additional amount of maternofetal morbidity discounted by 3% for 7 years was 573 € per conisation. The total costs for a conisation therefore added up to 2,046 €, the total costs per treatment with PDT given the above-mentioned assumptions were 1,558 €.

Conclusion: For Germany, PDT has the potential to be a cost-effective treatment for high-grade CIN compared to conisation procedure. Most important, the increased perinatal morbidity, perinatal mortality and associated costs after conisation procedures are significant and may be reduced by the implementation of PDT in CIN treatment.
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http://dx.doi.org/10.1002/lsm.21072DOI Listing
September 2011

The risk of ectopic pregnancy following tubal reconstructive microsurgery and assisted reproductive technology procedures.

Arch Gynecol Obstet 2012 Mar 24;285(3):863-71. Epub 2011 Sep 24.

Division of Reproductive Medicine, Department of Gynecology and Obstetrics, Medical School of Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.

Purpose: The incidence of ectopic pregnancy (EP) in the general population is 2%, whereas the EP rate following assisted reproductive technologies (ART) is between 2.1 and 11%. EP is also an adverse effect of tubal surgery with incidences up to 40% depending on the type, location, and severity of tubal disease and the surgical procedure.

Methods: This paper looks at the incidence of EP following tubal reconstructive microsurgery, analyzes risk factors for EP following own 1,295 ART cycles and looks on the incidence of EP in 128,314 pregnancies following ART according to the presence or absence of tubal infertility using data from the German IVF Registry (DIR).

Results: In our clinic, the EP rate following resterilization was 6.7%. In the presence of acquired tubal disease, the EP rate following adhesiolysis, salpingostomy, salpingoneostomy, fimbrioplasty, and anastomosis was 7.9%. The EP rate following ART in our clinic was 5.6%. Previous abdominal surgeries, microsurgical procedures, hydro-/sactosalpinges, salpingitis, salpingitis isthmica nodosa, and periadnexal adhesions showed a significant positive correlation with EP as outcome. Data of DIR demonstrate a significantly increased incidence of EP in the presence of tubal pathology. The highest EP rate related to all clinical pregnancies was 4.5% (95% CI 3.0-6.0) in smoking women <30 years with tubal pathology following IVF.

Conclusions: In the presence of tubal infertility, the incidence of EP following ART and tubal microsurgery are approximately comparable with each other and higher than in women without tubal infertility. The success of infertility surgery depends on a careful selection of appropriate patients.
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http://dx.doi.org/10.1007/s00404-011-2092-6DOI Listing
March 2012

Is there still a role for reconstructive microsurgery in tubal infertility?

Curr Opin Obstet Gynecol 2011 Jun;23(3):200-5

Division of Reproductive Medicine, Department of Gynecology and Obstetrics, Medical School of Hannover, Germany.

Purpose Of Review: To review the current role of tubal reconstructive surgery in the era of assisted reproductive techniques (ARTs).

Recent Findings: After tubal reconstructive surgery, couples may have unlimited attempts to conceive naturally. Operative risks are low; the risk for ectopic pregnancy after surgery is 4-10%. ART is associated with a number of potential complications: severe ovarian hyperstimulation syndrome (0.25-2%), multiple pregnancies (up to 25%), a higher rate of major malformations and stillbirths, and ectopic pregnancy (1-13%). Birth rates following ART differ between 19 and 35%, depending on different laws governing the fertilization of a limited number of oocytes and the number of embryos transferred. Resterilization is a main indication for microsurgery with resulting pregnancy rates up to 84%. Salpingostomy and dense adhesiolysis have the lowest success rates (term pregnancy rates: 3-65%). Proximal tubal obstructions can be successfully treated by tubocornual anastomosis. Hydrosalpinges should be removed prior to in-vitro fertilization if they cannot be reconstructed. ART is recommended for patients older than 37-38 years, for women with severe tubal pathology, after repeated ectopic pregnancies, and in case of male infertility.

Summary: Tubal reconstructive surgery still plays a role in infertility treatment. ART has not replaced microsurgery routinely as first-line treatment for tubal infertility.
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http://dx.doi.org/10.1097/GCO.0b013e328345522aDOI Listing
June 2011

The First Description of Docetaxel-Induced Recall Inflammatory Skin Reaction After Previous Drug Extravasation.

Ann Pharmacother 2011 Feb;45(2):e11

Tjoung-Won Park-Simon MD, Professor, Assistant Medical Director, Department of Gynaecology and Obstetrics, Hannover Medical School.

Objective: To describe a cutaneous recall soft tissue injury at the site of previous extravasation of docetaxel.

Case Summary: A 65-year-old white female with an invasive ductal carcinoma of the right breast was treated with carboplatin AUC 2 and docetaxel 30 mg/m(2) weekly via a peripheral vein access. During the 14th cycle, drug extravasation of docetaxel occurred in the left antecubital fossa characterized by a mild erythema without edema. A severe erythema developed in the former area of extravasation after the 15th cycle of carboplatin/docetaxel. The recall dermatitis continued to exacerbate after each course of systemic docetaxel chemotherapy and finally led to termination of this therapy.

Discussion: In general, extravasation of docetaxel causes only mild local skin reactions without further necessity of intervention. For pegylated liposomal doxorubicin and paclitaxel, inflammatory recall phenomena at sites of previous drug extravasation are rare and often occur as single events following administration of the same cytotoxic drug. According to the Naranjo probability scale, the administration of docetaxel in this case probably led to the cutaneous soft tissue injury as a result of extravasation.

Conclusions: Caution is needed after an episode of docetaxel extravasation. Even after a therapy interruption of several weeks, resumption of chemotherapy with docetaxel might lead to recrudescence of the inflammatory skin reaction.
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http://dx.doi.org/10.1345/aph.1P440DOI Listing
February 2011

Recurrent aberrations identified by array-CGH in patients with Mayer-Rokitansky-Küster-Hauser syndrome.

Fertil Steril 2011 Apr 24;95(5):1589-94. Epub 2010 Aug 24.

Institut für Humangenetik, Westfälische Wilhelms-Universität, Münster, Germany.

Objective: To identify genetic causes of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome.

Design: Prospective laboratory study.

Setting: University hospital.

Patient(s): Fifty-six patients with MRKH syndrome.

Intervention(s): Identification of microdeletions and -duplications in a group of 48 MRKH patients by array-CGH. Results obtained by array-CGH were confirmed by RT-qPCR. Sequential analysis of two candidate genes LHX1 and HNF1B in a group of 56 MRKH patients.

Main Outcome Measure(s): Identification of chromosomal regions and genes (recurrent and private) associated with MRKH syndrome.

Result(s): We could delineate three definitively relevant regions (1q21.1, 17q12, and 22q11.21) and suggest that LHX1 und HNF1B are candidate genes for MRKH syndrome, because we identified recurrent deletions affecting these genes and a possible causative missense mutation in LHX1.

Conclusion(s): Our findings suggest that different chromosomal regions are associated with MRKH syndrome.
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http://dx.doi.org/10.1016/j.fertnstert.2010.07.1062DOI Listing
April 2011

Perioperative complications in conventional and microsurgical abdominal myomectomy.

Arch Gynecol Obstet 2011 Jul 1;284(1):137-44. Epub 2010 Aug 1.

Department of Obstetrics and Gynecology, Medical Center, University of Muenster, Münster, Germany.

Purpose: It has become evident that laparoscopic myomectomy is limited by size, number and location of fibroids. Myomectomy performed by laparotomy can be technically challenging and the surgical benefits have to be weighed against associated risks and impairing fertile potential, especially in multiple and large fibroids that may be positioned close to the cavity. Our aim was to evaluate the effect of microsurgical myomectomy technique on perioperative morbidity in premenopausal women.

Methods: This retrospective study included 228 patients with symptomatic uterine fibroids and/or infertility undergoing myomectomy by laparotomy. As much as 156 patients were treated by standardized microsurgical technique and 72 patients by conventional myomectomy. The following data were recorded and analysed: postoperative haemoglobin, haemoglobin decrease, rate of blood transfusion, and number, size and location of myomas.

Results: In 228 patients, seven complications occurred (abdominal wall haematoma, bowel and colon injury, transient ileus). The transfusion rate was 1.3%. Microsurgical technique was associated with a smaller haemoglobin decrease compared to conventional myomectomy (1.77 vs. 2.38 g/dl; P = 0.007). Microsurgical technique correlated inversely with haemoglobin decrease (P < 0.001). Haemoglobin decrease correlated positively with myoma number (P < 0.001), size of myoma (P < 0.001) and the opening of the cavum uteri (P = 0.014).

Conclusions: In this large series of abdominal myomectomies, procedure-related morbidity, mainly perioperative blood loss, was amongst the lowest reported when microsurgical techniques were used. In patients with multiple, large or deep intramural fibroids who desire future pregnancies, the use of microsurgical techniques may decrease intraoperative blood loss and perioperative morbidity.
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http://dx.doi.org/10.1007/s00404-010-1622-yDOI Listing
July 2011

Organ-preserving and reconstructive microsurgery of the fallopian tubes in tubal infertility: still an alternative to in vitro fertilization (IVF).

J Reconstr Microsurg 2010 Jul 1;26(5):317-23. Epub 2010 Mar 1.

Department of Gynecology and Obstetrics, Division of Reproductive Medicine, Medical School of Hannover, Hannover, Germany.

Tubal infertility mostly results from infections. Conception only is possible through complex treatments (in vitro fertilization or surgery). Success cannot be guaranteed, even after repeated treatments. Unfortunately, many couples are not informed about the prospect for success of tubal reconstruction. Problems of in vitro fertilization are low pregnancy and birth rates of 28.4% and <20% respectively (Germany) and the high number of multiple pregnancies (21%). In this retrospective study 462 women with acquired tubal infertility and further 127 women after previous sterilization underwent microsurgical treatment (microsurgical adhesiolysis, anastomosis, fimbrioplasty, salpingostomy, and refertilization due to former sterilization). The main outcome measures are the pregnancy and birth rates following the microsurgical procedure. Pregnancy and birth rates of 43.4% and 29.2%, respectively, were higher than the outcomes post-single in vitro fertilization (abortion: 6.4%, extrauterine pregnancy: 7.9%). When reversal of sterilization was performed, pregnancy and birth rates were higher at 73% and 50.6%, respectively (abortion: 15.7%, extrauterine pregnancy: 6.7%). The advantages of reconstructive microsurgery over in vitro fertilization include the ideally permanent restoration of woman's ability to conceive naturally (repeated pregnancies are possible without further therapy), a high postoperative birth rate overall, and avoidance of multiple births. It is advisable to inform the patient about the objective possibility of reconstructive tubal surgery.
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http://dx.doi.org/10.1055/s-0030-1249315DOI Listing
July 2010

Preimplantation genetic diagnosis (polar body biopsy) and trisomy 21.

Hum Reprod 2010 Apr 26;25(4):1081-2. Epub 2010 Jan 26.

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http://dx.doi.org/10.1093/humrep/dep462DOI Listing
April 2010

Reconstructive, organ-preserving microsurgery in tubal infertility: still an alternative to in vitro fertilization.

Fertil Steril 2010 Mar 26;93(4):1359-61. Epub 2009 Sep 26.

Department of Obstetrics and Gynecology, Division of Reproductive Medicine, OE 6410, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.

In this retrospective study, we observed a total of 553 patients with tubal infertility who underwent microsurgical reconstructive surgery of the fallopian tubes (including adhesiolysis, anastomosis, fimbrioplasty, salpingostomy, and refertilization after former sterilization). The pregnancy (43.4%) and birth (29.2%) rates after microsurgery for acquired tubal damages (abortion: 6.4%; ectopic pregnancy: 7.9%) were higher than after single in vitro fertilization (28.4% and <20%, respectively; data from German IVF register). The pregnancy (73%) and birth (50.6%) rates after the reversal of sterilization also were higher (abortion: 15.7%; ectopic pregnancy: 6.7%). The advantages of reconstructive microsurgery over in vitro fertilization include the ideally permanent restoration of a woman's ability to conceive naturally in every cycle that she ovulates, a high postoperative birth rate overall, and avoidance of multiple births.
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http://dx.doi.org/10.1016/j.fertnstert.2009.08.017DOI Listing
March 2010

Onset of labour: women's experiences and midwives' assessments in relation to first stage duration.

Arch Gynecol Obstet 2009 Dec 13;280(6):899-905. Epub 2009 Mar 13.

Department of Obstetrics, Gynaecology and Reproductive Medicine, Hannover Medical School, Germany.

Aim: The study aimed to assess the time of labour onset and its symptoms as perceived by women in labour and midwives, and the relationship between these and first stage duration.

Methods: A longitudinal cohort study of women with a singleton pregnancy in cephalic presentation was performed in 41 maternity units. The sample comprised 1,170 women, 611 nulliparae (np) and 559 multiparae (mp), who answered two standardized questions on the onset of labour and selected the applicable symptoms of labour onset from a list of eight. A multivariate Cox regression model was computed covering further perinatal factors.

Results: The median durations of the first stage of labour as assessed by the women themselves were 11 (np) and 6.5 h (mp), and as assessed by the midwives 7 (np) and 4 h (mp). Median time intervals between the start of labour onset symptoms as perceived by the women concerned and the midwives' diagnoses varied greatly: the shortest related to watery fluid loss (np = 1.5 h, mp = 0.0 h), the longest to alterations in sleep patterns (np = 11.5 h, mp = 4.5 h). Irregular pain, watery fluid loss and the time between self-diagnosed and professionally diagnosed onset of labour were just as closely associated with the duration of the first stage of labour as perinatal factors. Significant perinatal factors were induction with oxytocin, herbal remedies and PROM.

Conclusions: The perceptions of women in labour are as important as perinatal factors in determining the duration of the first stage of labour and should be taken into account in intrapartum care.
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http://dx.doi.org/10.1007/s00404-009-0990-7DOI Listing
December 2009