[Oocyte donation after the bioethics law. Medical, ethical and legal implications drawn form a series of 300 cases at the Tenon hospital]

This is the perfect example of the problems which are the consequences of the actual medicine. We carried out an ovocyte donation study at the Tenon Hospital, in Paris, between 1994 and 1999 involving 177 cryopreserved thawed embryo transfers among 300 recipients. This study enables us to stress the ethical difficulties posed by the so called bioethical laws of 1994. Simultaneously two consequences became clearly evident: a paucity of donors, and the necessity to only transfer frozen embryos due to decree of 1996 upon sanitary security that imposes the quarantine of embryos for six months. On the other hand, the use of this method has yielded important new information regarding embryo implantation and the importance of ovocyte quality that is closely correlated to donor age.

[Therapeutic management of ovarian dystrophy and insufficiency in abortion disorders: recent data]

Many reports suggested that the high rate of miscarriage in women with polycystic ovaries may be due to increased urine and/or plasma LH concentration. In fact, with the exception of pulsatile GnRH, any treatment likely to increase the plasma LH level results in unchanged or rather low miscarriage rates. Conversely, a reduction in this rate by GnRH agonists is not conclusive. Excess weight may also increase the risk of miscarriage. In women with incipient ovarian failure, the miscarriage rate is mainly linked to age. No stimulation has been found to be effective in these patients. There is a need for more extensive evaluation in GnRH analog microdoses, recombinant FSH and GnRH antagonists. Oocyte donations from younger women are difficult to obtain because of the lack of donors in France.

The influence of psychological factors on the outcome of the fertilization step of in vitro fertilization

Our objective was to determine whether psychological factors have an influence on the outcome of the fertilization step of in vitro fertilization (IVF) trials. The design was a prospective cohort study. We studied 48 women and 32 of their spouses. Each subject was assessed psychologically on the day before oocyte retrieval (OR) with the Child Project Questionnaire (CPQ) and the Ways of Coping Checklist. In addition, the State-Trait Anxiety Inventory was filled in by subjects 2 days before OR, and the State form was completed again for 6 additional days. The outcome measure was the success of the fertilization step. Logistic regression analysis was used to test the influence of psychological factors while taking into account the effect of medical and sociodemographic variables. The following variables were found to be statistically significant predictors of fertilization: normal sperm; tubal lesions or occlusion; women's factor II of the CPQ, i.e. Perception of Marital Harmony in the Project to Conceive a Child. We conclude that, even when the influence of biomedical variables is taken into account, the women's Perception of Marital Harmony in the Project to Conceive a Child, is a statistically significant predictor of the success of the fertilization step of IVF.

[Can we define the indications for oocyte donation?]

The outline of oocyte donation's indications is defined in France by the law of the 29 july 1994. A great number of situations do not pose any problem with regard to this principles: gonadal dysgenesis, premature ovarian failure, ovariectomy, castration following chimiotherapy or radiotherapy. However, others indications drive us progressively outside legal limits. What is the normal age of physiological menopause? Which threshold to justify oocyte donation for low responders? Is oocyte donation an alternative for other treatments failures? Ovocyte donation for genetic reason presents a risk of eugenic drift. Answering these questions is uneasy, though it is urgent for our patients to offer them a better uniformity.

[Oocyte donation: psychological and sociological aspects, the clinician's viewpoint]

Among the treatment for medical assisted procreation, oocyte donation presents the more complex implications on psycho-sociological aspects. French law of the 29th July 1994, tries to prevent risk for the principal actors of oocyte donation, but has created new problems: 1) the shortage of donors lengthens the waiting list and reduces the succes's chance, 2) the absence of uniformitybetween different countries opens the door to an international market of the oocyte. Medical progress give new possibilities for situations that presented no problem in the past, for instance, pregnancies after menopause. Natural markers are questionned, it is too soon to conclude and to mesure all the consequences of our treatment on the well-being of the child, the recipient's couple, and the donor.

[Clinical use of recombinant gonadotropins (FSH, LH, hCG)]

The production of recombinant gonadotropins is independent of urine collection. They have a high specific activity and a better batch to batch consistency than urinary gonadotropins. In our IVF programme 62 normo-ovulatory patients less than 38 years old, with tubal or idiopathic infertility and normal sperm, were treated by r-FSH and randomized into four groups : with or without LHRH agonist, step-up or step-down stimulation. The overall results were higher in the agonist groups, but did not reveal any significant difference between step-up and step-down stimulation.

[Oocyte donation -- embryo donation]

From 1993 to 1995, 82 donors have permitted the retrieval of 810 oocytes allowing to obtain 411 embryos. 95 receiving couples have been included : 30 obtained a pregnancy, 7 abandoned and 38 are waiting for a transfer. The rate of pregnancies by transfer is superior to the one observed with the transfer of frozen embryos (40.5% versus 27%).

[Oocyte fertilizability and embryo development in poor responders]

Oocyte quality (atresia, immaturity), fertilizability, the incidence of abnormal fertilization (parthenogenesis, triploidy) and embryo development (rate of division and morphology) are similar in poor and normal responders. Only, the small number of available embryos (0.9/patient vs 4.4) penalize these patients.

[Influence of infertility etiology and follicular stimulation protocols on pregnancy outcomes by in vitro fertilization]

During a retrospective study on 152 singles pregnancies obtained by in vitro fecondation at Tenon hospital, and followed in this department between January 1990 and December 1994, we have studied the influence of the IVF (tubal origin, masculine or idiopathic) and the type of stimulation (human menopausal gonadotrophin: hMG or follicle stimulating hormone: FSH) on the weight of the newborn and the pathologies that occurred during the pregnancy. No difference in the antecedents has been found in the different group of patients. This study shows a significative difference (p < 0.001) of the newborn's weight when the indication of IVF is tubal origin or masculine. Also, in all IVF indications, the weight is significantly (p < 0.01) higher after a follicular stimulation by FSH versus hMG. For the pregnancy pathologies, no significative difference has been noted, although arterial hypertension, fetal growth retardation and gestational diabetes appear to be more frequent in the group of women who had stimulation by hMG.

Psychological aspects in anonymous and non-anonymous oocyte donation

A study, in which 110 patients were screened by a psychoanalyst, included 69 recipients who chose non-anonymous oocyte donation, i.e. they received oocytes from a known donor, most frequently a sister or a close relative. Another 41 recipients received anonymous oocytes, but had to bring a donor. Psychological motivations for either choice are reported, and significant topics such as attitudes towards confidentiality and links to the child are compared. No specific psychopathology is reported at this stage. An additional study on children born by these techniques is ongoing.

[Hyperstimulation for in vitro fertilization with the "step-down" technique. Preliminary results from a prospective randomized study with and without LHRH agonists]

Twenty six normo-ovulatory patients < 38 years with tubal or idiopathic infertility and normal sperm were treated for IVF by FSH +/- hMG and randomized into four groups: with and without LHRH agonist, "step-up" or "step-down" stimulation. In the step down protocol, after 4 days with 4 amps plasmatic FSH reached its top level, then decreased. Despite reduction to only two amps, estradiol continued to increase in all the 5 women without agonist, whereas 3/7 with the long protocol were considered as low responders and stopped. The fertilization/cleavage rate was 69.2% in step-down and 45.7% in step-up (p < 0.04) with the short protocol, and respectively 65.6% and 41.9% (p < 0.03) with the long one. The pregnancy rate was equivalent in all groups.

Is there an indication for embryo reduction?

The selective reduction of embryos in multiple pregnancies poses numerous medical, technical, ethical and psycho-social problems. In a retrospective study, we analysed nine hundred and twenty-two pregnancies obtained using medically assisted procreation between May 1982 and May 1990. Among 922 successful pregnancies, 372 were singleton, 102 were twin and 13 were triplet. Data from this analysis and from a French multicentre study of 262 embryo reduction procedures demonstrated the value of an embryo quality score for minimizing the risk of multiple pregnancy and the existence of extremely infrequent, ethically acceptable indications for embryo reduction. These indications included ultrasound-proven malformations of one fetus, multiple pregnancies in patients with extensive uterine scarring, and multiple pregnancy despite the appropriate use of preventative measures which can be expected to make this technique unnecessary in the future.

Hormonal secretions in singleton pregnancies arising from the implantation of fresh or frozen embryos after oocyte donation in women with ovarian failure

OBJECTIVE

To determine whether levels of human chorionic gonadotropin (hCG), 17 beta-estradiol (E2), and progesterone (P) are different in the peri-implantation phase of fresh versus frozen embryos.

DESIGN

Hormonal secretions were measured on days 9 and 11 after implantation and at 4, 5, and 6 weeks gestation.

PATIENTS

Thirty-one pregnancies were achieved in 65 patients with ovarian failure. Seventeen singleton pregnancies developed after implantation of 4 frozen and 13 fresh embryos.

RESULTS

Human chorionic gonadotropin and E2, contrary to P, were higher in cases of fresh embryos from the 9th day after transfer to the 5th week at which time they become statistically significant (respectively, for hCG and E2, 5,800.3 +/- 332.3 versus 2,027.3 +/- 916.3 [mean +/- SD] mIU/mL for hCG and 562.3 +/- 215 versus 291 +/- 152 pg/mL for E2).

CONCLUSIONS

This difference might be explained by either the higher number of fresh embryo replaced or by the fact that the number of blastomeres and also their metabolic activity could be reduced after freezing and thawing.

Obstetric evolution of pregnancies obtained from donated oocytes

Of 44 pregnancies obtained at the Tenon Maternity Hospital by in vitro fertilization (IVF) using donated oocytes, 25 have already been completed by spontaneous delivery or cesarean section: 22 (88%) single; 2 (8%) twins, and 1 (4%) triple. The most frequently seen complications of pregnancy were hypertension (16%) and preterm labor in the last 3 months (12%). However, as compared to a control group of 275 pregnancies resulting from classical IVF, the only difference was a very high percentage of cesarean sections (72%). No fetal deaths or neonatal malformations were reported.