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For the zoonotic disease Q fever, serological analysis plays a dominant role in the diagnosis ofCoxiella burnetiiinfection and in pre-screening for past exposure prior to vaccination. A number of studies suggest that assessment ofC. burnetii-specific T-cell IFNγ responses may be a more sensitive tool to assess past exposure. In this study, we assessed the performance of a whole bloodC. burnetiiIFNγ release assay in comparison to serological detection in an area of high Q fever incidence in 2014, up to seven years after initial exposure during the Dutch Q fever outbreak 2007-2010. In a cohort of >1500 individuals from the Dutch outbreak village of Herpen, approximately 60% had mounted IFNγ responses toC. burnetii. This proportion was independent of theCoxiellastrain used for stimulation and much higher than the proportion of individuals scored sero-positive using the serological gold standard immunofluorescence assay. Moreover,C. burnetii-specific IFNγ responses were found to be more durable than antibody responses in two sub-groups of individuals known to have sero-converted as of 2007 or previously reported to the municipality as notified Q fever cases. A novel ready-to-use version of the IFNγ release assay assessed in a subgroup of pre-exposed individuals in 2021 (10-14 years post exposure) proved again to be more sensitive than serology in detecting past exposure. These data demonstrate thatC. burnetii-induced IFNγ release is indeed a more sensitive and durable marker of exposure toC. burnetiithan are serological responses. In combination with a simplified assay version suitable for implementation in routine diagnostic settings, this makes the assessment of IFNγ responses a valuable tool for exposure screening to obtain epidemiological data, and to identify previously exposed individuals in pre-vaccination screens.

Objective women in the Netherlands, with a fetus in breech presentation, are thoroughly counseled to make an informed choice for the mode of delivery. The aim of this study was to assess the influence of counseling techniques on women's choices for the mode of delivery and subsequently to compare fetal and maternal outcomes of vaginal breech birth versus planned caesarean section. Study design we performed an observational prospective study. Data on breech deliveries were prospectively collected. We used ANOVA to identify variables influencing women's choice for the mode of delivery. Setting the obstetric department of the Red Cross Hospital in Beverwijk, the Netherlands. Participants women with a singleton gestation (>37 + 0 weeks) and a fetus in breech presentation were included. Measurements and findings between January 2007 and December 2015 364 women were included. Counseling technique (p =

Purpose: The chance of recurrence of poor fertilization in a second in vitro fertilization (IVF) cycle was assessed. Methods: Total fertilization failure was defined, and the relationship between the fertilization rate and the number of motile sperm cells per milliliter of semen was assessed. Patients with a total fertilization failure or poor fertilization (20% or less of the oocytes fertilized) were divided into three subgroups with different chances of fertilization and were followed in a subsequent IVF cycle. Results: The recurrence rate of total fertilization failure was high in all three groups (45-70%), and poor fertilization frequently occurred in the second cycle (50-75%). Conclusions: Poor fertilization frequently recurs in the second IVF cycle. The use of intracytoplasmic sperm injection could be considered after fertilization of 20% or less of oocytes in the first cycle, irrespective of the number of motile sperm cells per milliliter of semen.

Objective To determine whether age or response to controlled ovarian hyperstimulation (COH) is a better predictor of IVF outcome in women≥40years. Design Retrospective analysis. Setting A transport IVF program. Patient(s) For patients undergoing IVF treatment the correlation between treatment outcome and age and response to COH was analyzed using the data of 2,588 consecutive cycles. Intervention(s) None. Main Outcome Measure(s) Pregnancy. Result(s) The incidence of poor ovarian response rises significantly with increasing age. Analysis of all cycles showed a significant decrease in clinical and ongoing pregnancy rate for women≥40years. Analysis of cycles with a good ovarian response showed no statistically significant differences for these parameters between women≥40years and those younger. A logistic regression analysis on pregnancy showed that ovarian response contributes more to the prediction of pregnancy than age. Conclusion(s) Patients aged≥40years with a good response to COH have a good prognosis for IVF treatment. The age limit for acceptance of patients should not be set at 40years. Instead, the response to COH can be used to predict candidates likely to have a successful IVF outcome.

The results of in-vitro fertilization (IVF) treatments carried out in a university IVF centre are compared with those obtained following 15-40 min transportation of oocytes from a transport IVF clinic to the central IVF laboratory of the university centre. Moreover, treatment results following monitoring of ovarian stimulation in satellite clinics, combined with ovum retrieval at the transport clinic and transport of oocytes to the central IVF laboratory, are described. In a total of 5540 IVF treatment cycles, 24-26% of viable pregnancies per embryo transfer were found in the three groups. Comparison of results, obtained with the three different treatment modalities, showed no negative influences of transporting oocytes from transport clinic to IVF laboratory and of monitoring ovarian stimulation in satellite clinics. It is concluded that decentralization of the clinical phase of IVF treatment is possible. This leads to a more optimal use of existing laboratory facilities in large urban areas. It is stressed that good communication between satellite clinic, transport clinic and IVF laboratory is necessary for a decentralized IVF programme. To obtain good quality assurance, both the satellite clinic and the transport clinic must adhere to the same protocol.

The objective of this study was to determine the emissions of dust and pathogens, especially Coxiella burnetii (C. burnetii), from goat houses in the Netherlands. The study was conducted in two houses for milking goats. Furthermore, emissions of ammonia, odor, and greenhouse gases (methane and nitrous oxide) and the contribution of the different dust sources to airborne dust were determined.

The validity of the cumulative pregnancy rate (CPR) calculated by life-table approach, obtained in a transport in-vitro fertilization (IVF) programme, was tested by the determination of possible influence of selective drop-out of patients with a poor treatment prognosis. A cohort of 1211 patients who had a first IVF cycle was followed, and the CPR after three IVF cycles was assessed. First cycles of patients who discontinued treatment after failed IVF, and of those who did not achieve a pregnancy but proceeded to a subsequent cycle, were compared for fertilization rate and for occurrence of prognosticators of poor treatment outcome: oocyte yield < or =2, and replacement of

Objective To investigate whether the incidence and obstetric outcome of triplet pregnancies after IVF treatment justify strict limitation of the number of embryos to be replaced to two. Design Retrospective analysis. Setting A transport IVF program. Patient(s) All patients who had more than one embryo replaced. Intervention(s) None. Main Outcome Measure(s) Obstetric outcome, pregnancy. Result(s) High-order pregnancies occurred in 24 cases (23 triplets and 1 quadruplet). Three patients opted for selective embryo reduction (12.5%). Three triplet pregnancies spontaneously reduced to twins. Comparison of 18 triplets, reaching at least 20 weeks' gestation, with 54 twin pregnancies shows a higher perinatal mortality in the triplet group, causing 6 out of 18 patients to be confronted with at least one perinatal death. Triplets were born at a lower gestational age, had a lower birth weight, and a higher hospital admission rate of longer duration. Replacement of two, three, or four embryos did not lead to differences in pregnancy rates in the population studied. When a pregnancy occurred after replacement of three embryos, the risk of having a triplet pregnancy was 7.5%. Conclusion(s) The obstetric outcome of triplet pregnancies in our population indicates that triplet pregnancies after IVF treatment have to be prevented. Selective embryo reduction is acceptable for few patients only and can therefore not be seen as a solution. Replacement of three embryos results in triplet pregnancy in an unacceptably high percentage. Replacement of two embryos only gives acceptable IVF results and is the method chosen in the IVF program in Rotterdam to prevent triplet pregnancies. Fertil Steril ® 1997;67:290-5

TABLE OF CONTENTSIntroduction 345Materials and methods 346Ovarian hyperstimulation syndrome 346Adnexal torsion 349Complications of the transvaginal procedure 349Ectopic pregnancy 350Conclusion 351References 351Four different major clinical complications wereidentified in a retrospective analysis of 2495 in-vitrofertilization (IVF) cycles resulting in oocyte retrieval.The severe form of ovarian hyperstimulation syndrome(OHSS) occurred in 18 patients, giving a prevalence forthis complication of 0.7%. Seven (39%) of these 18 pa-tients had previously been diagnosed as having polycys-tic ovaries. Eleven patients were admitted withmoderate OHSS. Adnexal torsion was diagnosed in twopatients. Ovariectomy was considered necessary inboth cases. Complications of the transvaginal pro-cedure occurred in seven cases (0.3%): one patient hadan acute appendicitis with puncture holes in the appen-dix, six patients were admitted shortly after oocyte re-trieval with a pelvic inflammatory disease. Of the 624pregnancies obtained, 13 were ectopic, giving an ec-topic pregnancy rate of 2.1%. It is concluded that seri-ous clinical complications of IVF treatment are rare.However, patients should be counselled for the occur-rence of serious procedure-related complications be-fore entering an IVF programme.Key words: clinical complications/ectopic pregnancy/IVF/OHSSIntroductionIn-vitro fertilization (IVF) treatment is an elective pro-cedure. Clinical complications caused by the procedure aretherefore always iatrogenic. Although complications arereported to occur infrequently, counselling of patients onpossible complications of IVF treatment is necessary be-fore informed consent can be obtained. The incidence ofcomplications appears to differ between programmes andcould depend on various factors such as methods used forovarian stimulation, criteria used for cancellation of cycles,and techniques used for follicle aspiration and embryotransfer. Therefore, it seems advisable to inform patientsabout the incidence of clinical complications in the actualIVF programme they are about to join. To obtain data con-cerning the incidence of clinical complications leading tohospital admission in our transport IVF programme at theZuiderziekenhuis, Rotterdam, The Netherlands, a retro-spective analysis was carried out. In the population studied,four different major complications were identified: ovarianhyperstimulation syndrome (OHSS), adnexal torsion,pelvic inflammatory disease (PID) and ectopic pregnancy.The occurrence of high-order pregnancies is not discussedhere since this will be the subject of a separate paper. De-tailed reports have been published elsewhere on the occur-rence of a hepatitis-B infection related to the IVFlaboratory procedure (van Os et al., 1991). Psychologicalcomplications resulting from procedure-related stress ordisappointing treatment results can occur in IVF treatment.Although this aspect certainly needs attention, psychologi-cal reactions were not a subject of this study. Publicationson assisted reproduction that include information concern-ing complications are reviewed, and the findings of ourretrospective study are compared with these reports.

Objective To investigate the feasibility of IVF treatment with minimal monitoring during ovarian hyperstimulation. Design Retrospective analysis and prospective study with real-time control group. Setting Transport IVF program with transport clinic and satellite clinics. Patients One hundred consecutive IVF cycles monitored at a transport clinic and 100 concurrent consecutive cycles monitored at satellite clinics, using the same stimulation-monitoring protocol and resulting in oocyte aspiration, are compared retrospectively for the number of ultrasound (US) measurements carried out during monitoring and for results of IVF treatment. No patient selection took place. After introduction of a minimal monitoring protocol at a transport clinic, a prospective study was started comparing 100 minimal monitoring cycles at a transport clinic with 100 concurrent conventional monitoring cycles at satellite clinics, all resulting in oocyte aspiration. Patients entered the retrospective or prospective study only once. In all cases the same laboratory facility was used. Monitoring of ovarian hyperstimulation was done with US measurements only. Cycles were canceled for impending ovarian hyperstimulation syndrome (OHSS) when >35 follicles were seen to develop during hyperstimulation. Results Retrospective analysis shows no difference for the average number of US measurements at transport and satellite clinics (2.8±0.9 and 3.0±1.0; mean±SD). No differences were found in the number of ongoing pregnancies obtained in the two groups: 22 and 18, respectively. One case of severe OHSS occurred in the satellite clinic group. Introduction of minimal monitoring at the transport clinic gives a significant reduction of the average number of US measurements at the transport clinic compared with satellite clinics, where conventional monitoring continued to be used (1.5±0.8 versus 2.8±0.9). Ongoing pregnancies at transport and satellite clinics numbered 33 and 26, respectively. In both groups one patient developed severe OHSS. Sixty-two percent of cycles at the transport clinic were monitored with one US measurement only. No cancellations for impending OHSS occurred during the study period. Conclusion A large group of patients need only one US measurement during monitoring of ovarian hyperstimulation. Minimal monitoring gives a useful further simplification of the clinical phase of IVF treatment, without adverse effects on treatment outcome and incidence of OHSS.