[Overview of cancellations between November 2004 and March 2005 at the Antoine-Béclère hospital]

We analyzed 229 cycles in our IVF program between November 2004 and April 2005. The cancellation rate was 25%, but ranged from 20% in women below 37 years, to 50% in women aged over 41. Between 38 and 40 years old, it was 45%. FSH levels are significantly raised in women cancelled. Most of cancellations occurred at day 8 (46%) or at day 10 (40%), mostly because of low number of growing follicles. The risk of cancellation was increased when women had several pejorative predictive factors. The predictive value of the whole follicular cohort homogeneity is now being studied. It should be an important predictive factor of ovarian response to next stimulation cycle.

[Oocyte donation: parents's secrets and lies]

BACKGROUND

Since 1994, oocyte donation in France must be organized anonymously, in compliance with the bioethics law. The donation is free and any publicity to enrol donors is forbidden. In this system, the recipients are encouraged to incite a donor to visit the recipient's fertility unit. These donors are called "symbolic" donors, since they allow the recipient to be entitred to receive oocytes from another anonymous donor. According to the law, this procedure can be performed both anonymously and non-anonymously.

OBJECTIVES

We wanted to study the implication of the anonymous system, focusing on the secret of the child's conception and on the relationship between the recipient family and the "symbolic" donor.

MATERIAL AND METHODS

We contacted all the patients (n=83) who had children with oocyte donation in our center between 1988 and 1998. These patients participated in an interview conducted with a standardized questionnaire.

RESULTS

Fourteen (17.8%) of the couples were lost to follow-up and three declined to participate. Five recipient couples preferred a non-anonymous donation. In all, 70% of the couples had not yet told their child about the donation. They had mentioned the IVF but not the donation despite of the fact that 50% of symbolic donors came from the family of the recipients, 34% from their friends, or 6% from their professional environment; 10% were not related to the recipients. Long after the child's birth, 25% of the recipients had no contact with the symbolic donor but 41% had selected her as the child's godmother and 15% of symbolic donors were the first to be informed of the birth of the child. After the donation, a gift was offered to the "symbolic" donor by 57% of couples, 33% did not know how to thank them (retribution is forbidden by law) and 10% of couples mentioned that their donor refused any gift. Concerning the donor whose oocytes were used, 63% of recipients did not want to know anything about her. 20% would have liked to have medical information and 13% would like to have all kind of information about her. Only 2% of recipients would have liked to know her identity and 2% would have liked to meet her.

CONCLUSION

In agreement with earlier reports in the literature, the majority (70%) of the parents did not inform their child about the oocyte donation even though the symbolic donor was in contact with the child (being his aunt or his godmother for example). The French system has created a double debt: one related to the real donor and another related to the symbolic donor. In the long run, the parents have found a way to humanize this technique: they have given a symbolic place of godmother to the volunteer donor.

Le diagnostic préimplantatoire couplé au typage HLA : l'expérience parisienne

Preimplantation genetic diagnosis (PGD) consists in the genetic analysis of one or two cells. These cells (blastomeres) are sampled from embryos, obtained by in vitro fertilization, at the third day of development. Since 1998, the bioethical laws (1994) and their decrees restricted PGD practices in France, strictly to the avoidance of the birth of a child affected with a genetic defect. In parallel, works on blood cord transplantation, taken at the birth of a compatible HLA sibling, showed very encouraging results, particularly for the treatment of Fanconi anemia. In 2001, Verlinsky et al., have reported the first PGD for Fanconi anaemia combined with HLA typing, allowing the birth of a healthy child, HLA-identical with his affected sister. The "designer baby" concept was born. The French law, which allowed PGD under specific conditions, i.e. when the genetic defect has been characterized in one parent at least, recently extended PGD to HLA typing when embryos are at risk of a genetic disorder. Article L.2131-4-1 (August 2004) allows the practice of HLA typing for PGD embryos when an elder sibling is affected with a genetic disorder and need stem cell transplantation. The HLA-matched offspring resulting from PGD can give cord blood at birth to supply the necessary therapy. This double selection give rise to serious ethical problems, but technical difficulties and legal restrictions will probably limit the development of such a procedure.

Agonistes de la GnRH versus antagonistes dans la fécondation in vitro

During in vitro fertilization (IVF) GnRH antagonists or agonists are used to optimize the control of organization of oocyte collection. The choice of stimulation protocol also takes into account the ovulatory, clinical, biological and ultrasound characteristics of the FIV candidate, as well as any stimulation measures already taken. Age appears to be the major predictive factor of oocyte response to stimulation and ultrasonography on the 3rd day is a predictive element of the success of oocyte collection. Determination of hormonal parameters on the 3rd day of the cycle (FSH, oestradiol, inhibin B, anti-mullerian hormone) makes it possible to refine the choice of therapy. All these elements are used to define various categories of patients in terms of response to hormonal stimulation. Agonists induce a suppression of pituitary secretion which inhibits the preovulatory LH peak and blocks natural ovulation. Nevertheless, there is an initial transient stimulating effect (flare-up) for a few days and a risk of prolonged ovarian desensitization responsible for side effects. The antagonists, administered just before the supposed ovulatory phase, provoke a rapid diminution in LH while avoiding the flare-up and prolonged ovarian desensitization. Various meta-analyses to compare both types of treatments currently suggest that agonists are superior in terms of number of oocytes produced, though the percentage of mature oocytes obtained as well as the levels of fertility are comparable whatever the type of treatment. In practice, organization of stimulation protocols using agonists is easier especially for teams working in a sequential manner. However, protocols using antagonists may be particularly useful in poor responders and are globally better tolerated.

In vitro fertilization and embryo transfer in seminatural cycles for patients with ovarian aging

OBJECTIVE

To investigate whether seminatural cycle is a reasonable management for ovarian aging patients.

DESIGN

Prospective study.

SETTING

ART Unit, Clamart, France.

PATIENT(S)

Seventy-five women, 158 cycles.

INTERVENTION(S)

Infertile women who presented with ovarian aging (defined as low ovarian reserve and characterized by cycle day 3 high FSH, high E2, and/or low inhibin B and/or previous cycle cancellations due to poor ovarian response to COH) were studied. Patients were offered up to three cycles. Treatment was scheduled as follows. From cycle day 8 onward the selection of the dominant follicle was monitored by ultrasound and hormonal measurements. When the dominant follicle appeared, patients received GnRH antagonist and, thereafter, hMG to support further follicular development.

MAIN OUTCOME MEASURE(S)

Implantation rate and clinical pregnancy.

RESULT(S)

Twenty-eight of 158 cycles were cancelled (17.7%). Oocyte pickups were performed in 119 (75.3%) cycles, 91 (57.6%) mature oocytes were retrieved, and 67 (42.4%) embryos transferred. Nineteen clinical pregnancies were obtained; the cumulative pregnancy rate per patient, after 3 cycles, was 35.2%.

CONCLUSION(S)

Use of a seminatural cycle is a reasonable management for patients with ovarian aging who have ovulatory menstrual cycles. It achieves a high implantation rate (28.3%).

Myotonic dystrophy: does it affect ovarian follicular status and responsiveness to controlled ovarian stimulation?

BACKGROUND

Myotonic dystrophy (MD) is characterized by myotonia, multisystemic lesions and hypogonadism. In women, the relationship between MD and infertility remains controversial. This study investigated the ovarian status and response to controlled ovarian stimulation (COS) in MD women entering our preimplantation genetic diagnosis programme.

METHODS

We elected to compare MD patients with X-linked disorders (XLD) carriers, given that XLD have not been shown to affect ovarian status. On the one hand, we analysed all the cycles performed and, on the other hand, we conducted a subanalysis based on only first cycles.

RESULTS

MD and XLD groups were similar with regard to women's ages, day 3 parameters, number of oocytes retrieved, embryos obtained and prevalence of top quality embryos. The day of HCG was significantly delayed and the prevalence of poor quality embryos was higher in the MD group. The subanalysis on first cycles only also showed significantly fewer mature follicles on the day of HCG in MD population. Implantation and pregnancy rates were similar in both groups; however, no pregnancy occurred at the first cycle in MD (0 out of 4), whereas 77% of pregnancies (10/13) occurred at the first attempt in XLD carriers.

CONCLUSIONS

These results indicate that the responsiveness to COS was moderately hindered in MD women as compared to controls. Reassuring data about implantation and pregnancy rates support the feasibility of PGD in selected mildly affected MD women.

Hormonal manipulations in the luteal phase to coordinate subsequent antral follicle growth during ovarian stimulation

During the early follicular phase in the menstrual cycle, antral follicle sizes are often markedly heterogeneous. These follicular size discrepancies may, at least in part, result from the early exposure of FSH-sensitive follicles to gradient FSH concentrations during the preceding luteal phase. In addition, they potentially affect the results of ovarian stimulation. Indeed, pre-existing follicle size discrepancies may encumber coordinated follicular growth during ovarian stimulation, thereby reducing the number of follicles that reach maturation at once. To investigate this issue, three clinical studies were conducted to test the hypothesis that luteal FSH suppression could coordinate follicular growth. First, luteal FSH concentrations were artificially lowered by administering physiological oestradiol doses and measured follicular characteristics on the subsequent day 3. Second, it was verified whether luteal oestradiol administration could promote the coordination of follicular growth during ovarian stimulation and improve its results. Third, the effects of premenstrual gonadotrophin-releasing hormone (GnRH) antagonist administration on follicular characteristics were assessed during the early follicular phase. The results showed that luteal FSH suppression by either oestradiol or GnRH antagonist administration reduces the size and improves the homogeneity of early antral follicles during the early follicular phase, an effect that persists during ovarian stimulation. Coordination of follicular development may optimize ovarian response to short GnRH agonist and antagonist protocols, and constitutes an attractive approach to improving their outcome.

Analysis of mtDNA variant segregation during early human embryonic development: a tool for successful NARP preimplantation diagnosis

BACKGROUND

Diseases arising from mitochondrial DNA (mtDNA) mutations are usually serious pleiotropic disorders with maternal inheritance. Owing to the high recurrence risk in the progeny of carrier females, "at-risk" couples often ask for prenatal diagnosis. However, reliability of such practices remains under debate. Preimplantation diagnosis (PGD), a theoretical alternative to conventional prenatal diagnosis, requires that the mutant load measured in a single cell from an eight cell embryo accurately reflects the overall heteroplasmy of the whole embryo, but this is not known to be the case.

OBJECTIVE

To investigate the segregation of an mtDNA length polymorphism in blastomeres of 15 control embryos from four unrelated couples, the NARP mutation in blastomeres of three embryos from a carrier of this mutation.

RESULTS

Variability of the mtDNA polymorphism heteroplasmy among blastomeres from each embryo was limited, ranging from zero to 19%, with a mean of 7%. PGD for the neurogenic ataxia retinitis pigmentosa (NARP) mtDNA mutation (8993T-->G) was therefore carried out in the carrier mother of an affected child. One of three embryos was shown to carry 100% of mutant mtDNA species while the remaining two were mutation-free. These two embryos were transferred, resulting in a singleton pregnancy with delivery of a healthy child.

CONCLUSIONS

This PGD, the first reported for a mtDNA mutation, illustrates the skewed meiotic segregation of the NARP mtDNA mutation in early human development. However, discrepancies between the segregation patterns of the NARP mutation and the HV2 polymorphism indicate that a particular mtDNA nucleotide variant might differentially influenced the mtDNA segregation, precluding any assumption on feasibility of PGD for other mtDNA mutations.

Improved single-cell protocol for preimplantation genetic diagnosis of spinal muscular atrophy

OBJECTIVE

To develop and validate a simple and reliable single-cell analysis protocol for the preimplantation genetic diagnosis (PGD) of spinal muscular atrophy (SMA).

DESIGN

Molecular tests based on specific enzymatic digestion have already been described for SMA diagnosis. We modified the amplified DNA fragments so as to introduce a novel restriction site that provides an internal control for the completeness of the digestion.

SETTING

The genetics and reproduction departments of two teaching hospitals.

PATIENT(S)

Six informed couples at risk of transmitting SMA.

INTERVENTION(S)

All patients underwent standard procedures associated with intracytoplasmic sperm injection.

MAIN OUTCOME MEASURE(S)

Improvement of SMA diagnostic efficiency and accuracy on single cell.

RESULT(S)

One hundred fifty lymphocytes were analyzed with our protocol. One hundred percent diagnostic accuracy was achieved from both homozygous normal and SMN1-deleted leukocytes. Successful molecular analysis was achieved for 36 of 42 biopsied embryos (86%). Twenty-five normal embryos were transferred, but no pregnancy was achieved.

CONCLUSION(S)

We developed an improved protocol for PGD of SMA that is simple, robust, and accurate; unfortunately, no pregnancies were achieved for any of the six patients who have undergone PGD in the program thus far.

[The Paris experience in preimplantation genetic diagnosis: evaluation after the first births]

OBJECTIVE

To report the birth of the first thirteen infants conceived after preimplantation genetic diagnosis (PGD) within the medical assistance federation of Paris.

PATIENTS AND METHODS

Fifty-nine couples were enrolled between January 2000 and July 2001. They had a total of 71 oocyte pick-up cycles. The collected oocytes were inseminated by intracytoplasmic sperm injection. The resulting embryos were biopsied on the third day of development and the genetic analysis was performed on the same day. Most of the embryo transfers were carried out on the fourth day.

RESULTS

The 71 oocyte pick-up cycles yielded 872 oocytes of which 731 were suitable for intracytoplasmic sperm injection. 421 embryos were biopsied and genetic diagnosis was obtained from 312 (74%) of these. 127 embryos were transferred during the course of 58 transfer procedures. There were 18 biologic and 12 clinical (7 singles, 4 twins and 1 triple) pregnancies. Thirteen infants have been born and 4 are expected.

CONCLUSIONS

PGD has gained a place among the choices offered to couples at risk of transmission of a serious and incurable genetic disease.

Per-follicle measurements indicate that anti-müllerian hormone secretion is modulated by the extent of follicular development and luteinization and may reflect qualitatively the ovarian follicular status

OBJECTIVE

To investigate the possible influence of follicular maturation and luteinization on anti-müllerian hormone (AMH) secretion and the relationship between per-follicle AMH levels, ovarian follicular status, and responsiveness to controlled ovarian hyperstimulation (COH).

DESIGN

Prospective study.

SETTING

University hospital in France.

PATIENT(S)

Thirty seven in vitro fertilization/embryo transfer candidates undergoing COH.

INTERVENTION(S)

On the day of oocyte retrieval, serum samples and follicular fluids from two small (8-12 mm in diameter) and two large (16-20 mm in diameter) follicles were collected for AMH, E2, and progesterone (P4) measurements.

MAIN OUTCOME MEASURE(S)

Per-follicle AMH levels.

RESULT(S)

Small follicles secreted AMH levels that were approximately three times as high as large follicles. Follicular fluid AMH and P4 levels were negatively correlated to each other both in small and large follicles. Per-follicle AMH levels in both follicular classes were positively correlated with antral follicle count on cycle day 3 before COH and with growing follicle (> or =12 mm) count and oocytes retrieved, but negatively correlated with FSH requirement.

CONCLUSION(S)

Both final follicular maturation and luteinization interfere with granulosa cell AMH production. The relationship between intrafollicular AMH content, the surrounding follicular status, and ovarian response to COH indicates that peripheral AMH levels reflect not only follicle count but also per-follicle AMH production.

Prise en charge des placentas percreta

Placenta percreta is a severe condition associated with maternal morbidity and mortality even when surgery is performed electively. Arteries ligation, embolisation, medical treatment by methotrexate can be appropriate treatment to avoid catastrophic surgery. The purpose of this report is to present a case where the placenta was left in situ to avoid cystectomy at the time of cesarean section, with subsequent failure of the conservative treatment.

Severe Pulmonary Hypertension during Pregnancy

Background

Available literature on pregnant women with severe pulmonary hypertension (PH) relies mainly on anecdotal case reports and two series only.

Methods

The authors reviewed the charts of all pregnant women with severe PH who were followed up at their institution during the past 10 yr, to assess the multidisciplinary treatment and outcome of these patients.

Results

Fifteen pregnancies in 14 women with severe PH were managed during this period: There were 4 cases of idiopathic pulmonary arterial hypertension (PAH), 6 cases of congenital heart disease-associated PAH, 1 case of fenfluramine-associated PAH, 1 case of mixed connective tissue-associated PAH, 1 case of human immunodeficiency virus-associated PAH, and 2 cases of chronic thromboembolic PH. PH presented during pregnancy in 3 patients. Two patients died before delivery at 12 and 23 weeks' gestation. Four patients had vaginal deliveries with regional anesthesia: One died 3 months postpartum, one worsened, and two remained stable. Four had cesarean deliveries during general anesthesia: One died 3 weeks postpartum, one worsened, and two remained stable. Five had cesarean deliveries during low-dose combined spinal-epidural anesthesia: One died 1 week postpartum, and four remained stable. There were two fetal deaths: one related to therapeutic abortion at 21 weeks' gestation and one stillbirth at 36 weeks' gestation followed by the death of the mother 1 week later.

Conclusions

Despite the most modern treatment efforts, the maternal mortality was 36%. Scheduled cesarean delivery during combined spinal-epidural anesthesia seemed to be an attractive approach, but there was no evidence of actual benefit. Therefore, pregnancy must still be discouraged in patients with severe PH.

[Pre-implantation genetic diagnosis and spontaneous pregnancies: an unexpected acting out]

OBJECTIVES

To understand the psychological motives that led these couples to take risks involved in genetic transmission and the possibility of another spontaneous pregnancy. To report our psychoanalytic experience to explain why after a request of pre-implantation genetic diagnosis (PGD), some women prefer to be spontaneously pregnant.

PATIENTS AND METHOD

Between 2000 and 2004, out of 643 requests of PGD, 541 have been admitted, among which 123 spontaneous pregnancies appeared during the process of PGD.

RESULTS

Some encounters with the patients have shown some reasons to these spontaneous pregnancies - denial of IVF, ambivalence of this desire for a child, denial of the risk, control of the procreation, family loyalty and fertility affirmation.

DISCUSSION AND CONCLUSION

The resort to PGD is more ambivalent than the thought of it because it means, beyond the request, conflict with transmission, culture, and history origins.

Cytogenetic, molecular and testicular tissue studies in an infertile 45,X male carrying an unbalanced (Y;22) translocation: case report

(Y;autosome) translocations have been reported in association with male infertility. Different mechanisms have been suggested to explain the male infertility, such as deletion of the azoospermic factor (AZF) on the long arm of the Y chromosome, or meiosis impairment. We describe a new case with a de novo unbalanced translocation t(Y;22) and discuss the genotype-phenotype correlation. A 36 year old male with azoospermia was found to have a mosaic 45,X/46,X, + mar karyotype. Fluorescence in situ hybridization (FISH) showed the presence of a derivative Y chromosome containing the short arm, the centromere and a small proximal part of the long-arm euchromatin of the Y chromosome and the long arm of chromosome 22. The unstable small marker chromosome included the short arm and the centromere of chromosome 22. This unbalanced translocation t(Y;22)(q11.2;q11.1) generated the loss of the long arm of the Y chromosome involving a large part of AZFb, AZFc and Yq heterochromatin regions. Testicular tissue analyses showed sperm in the wet preparation. Our case shows the importance of documenting (Y;autosome) translocations with molecular and testicular tissue analyses.

Repopulation of athymic mouse liver by cryopreserved early human fetal hepatoblasts

Transplantation of hepatocytes is a promising alternative to liver transplantation for the treatment of severe liver diseases. However, this approach is hampered by the shortage of donor organs and intrinsic limitations of adult hepatocytes. To investigate whether most of the hurdles faced with adult hepatocytes could be surmounted by the use of human fetal hepatoblasts, we have developed a method to isolate, transduce, and cryopreserve hepatoblasts from human livers at an early stage of development (11-13 weeks of gestation). Cells were characterized in vitro for expression of specific markers, and in vivo for their proliferation and differentiation potential after transplantation into athymic mice. Most of the cells (80-90%) harbored a bipotent phenotype, expressing cytokeratins 8/18, albumin, and CK19. They proliferated spontaneously in culture and were efficiently transduced by a beta-galactosidase-expressing retrovirus (90%). After transplantation, cryopreserved cells engrafted into the liver of athymic mice and proliferated, resulting in up to 10% repopulation. Engrafted cells expressed markers of differentiated adult hepatocytes including albumin, alpha1-antitrypsin, cytochrome P450 3A4, and alpha-glutathione-S-transferase. When retrovirally transduced before transplantation they expressed the transgene in vivo. In summary, early human fetal hepatoblasts engraft, proliferate, and mature in athymic mouse liver, without conditioning the donor.

Single cell quantification of the 8993T>G NARP mitochondrial DNA mutation by fluorescent PCR

When a mitochondrial DNA (mtDNA) mutation is identified, the reliable and sensitive quantification of the mutation load is a prerequisite for evaluating the feasibility of prenatal/pregestational diagnosis of the disease. We have developed a quantification assay of the 8993T>G NARP mutation using semi-quantitative fluorescent PCR. The test was reproducible and the experimental values were linear even at extremely low concentrations of mutant mtDNA molecules, making quantification of the mutant load in individual cells feasible (including blastomeres). Studying single circulating lymphocytes from a single NARP 8993T>G patient, we found a broad distribution of the disease causing mutation (0-44%) supporting the remarkable variability of heteroplasmy at the cellular level. This observation and the experimental approach reported here should be relevant to either prenatal or preimplantation diagnosis.

Role of the endometrial tripod interleukin-18, -15, and -12 in inadequate uterine receptivity in patients with a history of repeated in vitro fertilization–embryo transfer failure

OBJECTIVE

To document in the endometrium the correlation among the interleukin (IL)-12, -15, and -18 mRNA and the correlation between cytokine levels, vascular status, and endometrial natural killer (NK) cell count in the context of recurrent implantation failure.

DESIGN

A pilot study.

SETTING

Department of Reproductive Immunology.

PATIENT(S)

Women who failed to become pregnant after repeated IVF-embryo transfer and fertile control subjects.

INTERVENTION(S)

Ultrasonic evaluation and endometrial biopsy in luteal phase.

MAIN OUTCOME MEASURE(S)

Uterine artery Doppler, count of uterine CD56 bright cells/field, and quantification by real-time polymerase chain reaction (PCR) to monitor IL-12 family (IL-12p40, IL-12p35, EBI3, IL-23), the IL-18 system (IL-18, IL-18R, IL18BP), and the IL-15 mRNA ratio.

RESULT(S)

The uterine artery Doppler and the CD56 bright cell counts were significantly different in fertile and infertile patients. The mean uterine artery pulsatility index correlated significantly negatively with the IL-18/actin ratio suggesting a defect of the cytokine-dependent vascular remodeling pathway. The number of uterine CD56 bright cells was significantly correlated with the IL-15/actin and IL-18/IL-18BP ratios. Thus, IL-18 and IL-15 seems to be involved in the local recruitment and the activation of uterine natural killer (uNK) cells. IL-18 was itself correlated with IL-15 and IL-12, suggesting a local control of uNK cells activation.

CONCLUSION(S)

The assessment of the tripod IL-12/-15/-18 shows distinct immune-related mechanisms that are involved in the broader context of inadequate uterine receptivity.

Dynamics of serum anti-Müllerian hormone levels during the luteal phase of controlled ovarian hyperstimulation

BACKGROUND

To investigate the dynamics of serum anti-Müllerian hormone (AMH) levels during the luteal phase of controlled ovarian hyperstimulation (COH) and its possible association with follicle development.

METHODS

We prospectively studied 34 women undergoing COH with GnRH agonist and FSH. On the day of hCG (dhCG), serum AMH, estradiol (E2), progesterone and hCG levels were measured, and ovarian follicles were sorted into three size classes: <12, 12-15 and 16-22 mm. Hormonal measurements were repeated 4 days (hCG + 4) and 7 days (hCG + 7) after hCG.

RESULTS

From dhCG to hCG + 4, we observed a decline in serum AMH levels (-64 +/- 3%; P < 0.0001), which paralleled that of E2 levels. From hCG + 4 to hCG + 7, an increase in AMH levels occurred (82 +/- 28%; P < 0.02), whose magnitude was correlated with the number of < 12 mm follicles (r = 0.68; P < 0.0001) but not with other follicle size classes nor with the remaining hormone levels.

CONCLUSIONS

After hCG, AMH levels initially decline, presumably as an effect of follicle luteinization, then increase during the mid-luteal phase. Although the mechanisms implicated in the mid-luteal AMH increase are unclear, its positive association with small follicle count, but not with luteal progesterone and E2 levels, supports the hypothesis that AMH levels might reflect luteal follicle development.

In vitro oocyte maturation for the treatment of infertility associated with polycystic ovarian syndrome: the French experience

BACKGROUND

In vitro oocyte maturation (IVM) permits the use of immature oocytes in IVF. IVM does not require ovarian stimulation and so can be offered to patients at risk of ovarian hyperstimulation syndrome.

METHODS

For this indication, we carried out 45 cycles of IVM in 33 women with polycystic ovarian syndrome (PCOS).

RESULTS

A total of 509 cumulus-oocyte complexes was obtained; 276 (54.2%) oocytes matured in 24 h and 45 (8.8%) in 48 h. The normal fertilization (2PN) rate of oocytes matured in 24 and 48 h was 69.5 and 73.3% respectively. Among the 214 embryos obtained, 103 were transferred and 30 were frozen. Forty transfers were performed (2.5 embryos/transfer). Eleven women had a positive beta-hCG test (26.2% of pregnancies/puncture, 27.5% of pregnancies/transfer) and nine women had a clinical pregnancy (20.0% of pregnancies/puncture, 22.5% of pregnancies/transfer). Five babies have been born and one pregnancy is ongoing. Results of the clinical examination carried out at birth were normal.

CONCLUSIONS

Our results show that IVM may be offered as an alternative to conventional IVF and to ovarian drilling in women with PCOS. The role of IVM in the therapeutic armamentarium for this condition should be further clarified.

High reproducibility of serum anti-Mullerian hormone measurements suggests a multi-staged follicular secretion and strengthens its role in the assessment of ovarian follicular status

BACKGROUND

Our aim was to compare the intercycle reproducibility of serum anti-Mullerian hormone (AMH) measurements with that of other markers of ovarian follicular status.

METHODS

Forty-seven normo-ovulatory, infertile women underwent serum AMH, inhibin B, estradiol and FSH measurements and early antral follicle (2-12 mm in diameter) counts by transvaginal ultrasound on cycle day 3 during three consecutive menstrual cycles. Reproducibility of measurements was estimated using intra-class correlation coefficient (ICC) calculation. We also assessed the number of replicate measurements theoretically needed to reach satisfactory reliability of results.

RESULTS

Serum AMH showed significantly higher reproducibility (ICC, 0.89; 95% confidence interval, 0.83-0.94) than inhibin B (0.76; 0.66-0.86; P < 0.03), estradiol (0.22; 0.03-0.41; P < 0.0001) and FSH levels (0.55; 0.39-0.71; P < 0.01), and early antral follicle counts (0.73; 0.62-0.84; P < 0.001), and reached satisfactory reliability with a single measurement.

CONCLUSIONS

The improved cycle-to-cycle consistency of AMH as compared with other markers of ovarian follicular status is in keeping with its peculiar production by follicles at several developmental stages and further supports its role as a cost-effective, reliable marker of ovarian fertility potential.

Coordination of Antral Follicle Growth: Basis for Innovative Concepts of Controlled Ovarian Hyperstimulation

Among the key objectives of controlled ovarian hyperstimulation (COH) is the achievement of adequate coordination of multiple follicular growth to trigger ovulation when most of follicles have reached concomitant maturation. However, during the early follicular phase, early antral follicles present noticeable size heterogeneities that may be amplified during COH. To challenge the hypothesis that this phenomenon results, at least in part, from the early exposure of antral follicles to gradient follicle-stimulating hormone (FSH) levels during the preceding late luteal phase, we conducted three clinical studies. First, we artificially lowered luteal FSH levels by administering estradiol (E (2)) and measured follicular characteristics on the subsequent day 3. Second, we verified whether luteal E (2) administration could promote the coordination of follicular growth during COH and improve its results. Third, we assessed the effects of premenstrual gonadotropin-releasing hormone (GnRH) antagonist administration on follicular characteristics during the early follicular phase. Our results showed that luteal FSH suppression by either E (2) or GnRH antagonist administration reduces the size and improves the homogeneity of early antral follicles during the early follicular phase, an effect that persists during COH. Coordination of follicular development may optimize ovarian response to short GnRH agonist and antagonist protocols, and constitutes an attractive approach to improving their outcome.

Preimplantation genetic diagnosis (PGD) in France

In vitro fertilization is strongly regulated in France. An agreement is needed for the clinicians and the embryologists; and the activity is under the control of CNMBRDP, a governmental commission. PGD is even more controlled; an agreement is needed for embryo biopsy and for genetic/FISH testing. Only three centers are allowed to perform PGD. All the agreements are given for five years and submitted to renewal. Regulations are under the "Ethical" law which should have been re-examined in 1999, but still not redone. This leads to problems, especially in relation with the research on embryos. Evolution of the techniques and indications necessitates a follow-up by the representatives on a regular basis.

Prediction of Preeclampsia or Intrauterine Growth Restriction by Second Trimester Serum Screening and Uterine Doppler Velocimetry

OBJECTIVE

To assess the performance of screening for preeclampsia and intrauterine growth restriction by combining second trimester maternal serum screening and uterine Doppler ultrasound.

METHODS

A cohort of 2,615 women underwent both maternal serum screening (using human chorionic gonadotropin (hCG) and alpha-fetoprotein (AFP)), and second trimester uterine artery Doppler. The sensitivity, specificity and predictive value of different combinations of both tests were compared.

RESULTS

The mean values for hCG and AFP were significantly higher in women with subsequent preeclampsia (p < 0.0003 and p < 0.03, respectively). Taking into account obstetrical history, hCG and AFP levels, notching on uterine artery Doppler and parity, the adjusted odds ratios were significantly higher for a high level of hCG for preeclampsia, intrauterine growth restriction (IUGR) and pregnancy-induced hypertension. AFP level >1.5 MoM (multiples of the median) was significantly correlated with subsequent IUGR. The presence of a uterine notch was associated with a significantly higher risk of both preeclampsia and IUGR. The combination of an elevated serum level and the presence of a uterine notch had a positive predictive value (PPV) for preeclampsia of 25 and 21% for hCG and AFP, respectively. The combination of a bilateral notch with a low level of hCG or a high level of AFP had a PPV for IUGR of 50 and 43%, respectively. The sensitivity of the different tests ranged from 2 to 40%.

CONCLUSION

The combination of serum markers and abnormal uterine Doppler ultrasound improves the identification of women at risk for subsequent pregnancy complications. These results should encourage care providers to perform a uterine Doppler ultrasound when serum markers are abnormal. However, the sensitivity of these tests is too low to provide an efficient generalized screening.

La place du cycle semi-naturel dans la prise en charge de patientes ayant un mauvais pronostic en fécondation in vitro

OBJECTIVE

To evaluate the efficacy of semi natural cycle as option of treatment for the patients who have a poor prognosis to controlled ovarian hyperstimulation (COH).

PATIENTS AND METHODS

Prospective study. Sixty-six patients with an ovulatory cycle who presented either altered ovarian status (AOS) or implantation failure (IMF) and had carried out a total of 133 semi natural IVF cycles were included. Once follicular dominance was established, the growth of this follicule was controlled by administration of the GnRH antagonist with exogenous gonadotrophins.

RESULTS

Groups AOS (n = 47) and IMF (n = 19) were similar with regard to oocyte pickup rate (81.2% and 81.1%), the oocyte recovery rate (61.4% and 64.8%) and clinical pregnancies per oocyte pickups rate (15.4% and 16.6%), respectively.

CONCLUSIONS

The semi natural cycle appears as option of treatment for patients who have a poor prognosis for successful in vitro fertilization.

[GnRH antagonists in natural cycles]

Since the introduction of IVF treatments, natural cycle has been largely replaced by ovarian stimulation. However, natural cycle IVF has several advantages. It is associated with a close to zero multiple pregnancy rate, and a zero risk of ovarian hyperstimulation syndrome. Per cycle, natural cycle IVF is less time consuming, physically and emotionally less demanding for patients, and cheaper than stimulated IVF, but also less effective. Many cycles are cancelled because of a premature LH surge. GnRH antagonists prevent LH surge and therefore improve the results of natural IVF cycles. The GnRH antagonist should be started at day 8, at the daily dose of 0.5 mg. The natural cycle is a successful option of treatment in poor responders and implantation failure.

Reproductive outcome after methotrexate treatment of tubal pregnancies

OBJECTIVE

To evaluate reproductive outcome after ectopic pregnancy (EP) treated with methotrexate (MTX) and to assess the relative contribution of various risk factors to future fertility.

DESIGN

Telephone follow-up interviews in a cohort of patients treated for EP.

SETTING

University hospital.

PATIENT(S)

A cohort of 158 patients treated with MTX for tubal pregnancies between April 1991 and March 1999.

INTERVENTION(S)

Assessment of fertility outcomes.

MAIN OUTCOME MEASURE(S)

Cumulative pregnancy rates for intrauterine and ectopic pregnancies.

RESULT(S)

Thirty-two patients (20.2%) were lost to follow-up. Of 126 patients, 93 (73.8%) sought to become pregnant, and of these 93 women, 76 (81.7%) did. Sixty-four pregnancies were spontaneous, and 12 resulted from in vitro fertilization (IVF). No pregnancies occurred in the group not trying to become pregnant. Of the 64 spontaneous pregnancies, 52 (81.2%) were intrauterine, with 12 (18.7%) resulting in miscarriages, and 12 (18.7%) were recurrent ectopic pregnancies. The cumulative intrauterine pregnancy rate was 57.5% after 1 year and 66.9% after 2 years. The cumulative ectopic pregnancy rate was 15.4% after 1 year and 23.7% after 2 years. After adjusting for factors associated with fertility with a Cox regression, only one factor was associated with poor reproductive performance: previous history of infertility.

CONCLUSION(S)

Within 1 year of seeking to become pregnant, more than half the women previously treated medically for EP conceived and had ongoing pregnancies. Our analysis indicates that fertility depends more on the patients' previous medical history than on her treatment for EP.

Fertility after Ovarian Drilling by Transvaginal Fertiloscopy for Treatment of Polycystic Ovary Syndrome

STUDY OBJECTIVE

To evaluate fertiloscopy ovarian drilling with bipolar energy in women with clomiphene citrate-resistant polycystic ovary syndrome (PCOS).

DESIGN

Prospective study (Canadian Task Force classification II).

SETTING

University teaching hospital and private clinic.

PATIENTS

Eighty women with clomiphene citrate-resistant PCOS.

INTERVENTION

Operative transvaginal fertiloscopy with a coaxial bipolar electrode.

MEASUREMENTS AND MAIN RESULTS

During a mean follow-up of 18.1 months (+/- 6.4), 73 women (91%) recovered regular and ovulatory cycles. The cumulative pregnancy rate was 60% (44/73) for spontaneous and stimulated cycles, with 39.7% (29/73) imputed to drilling alone. The mean time to conceive was 3.9 months (range 1-11.8). There were eight miscarriages (18%), and no ectopic pregnancies or multiple pregnancy. No complications occurred.

CONCLUSION

Ovarian drilling by transvaginal fertiloscopy with bipolar electrosurgery appears to be an effective minimally invasive procedure in patients with PCOS resistant to clomiphene citrate.

Vaginal misoprostol for cervical ripening before operative hysteroscopy in pre-menopausal women: a double-blind, placebo-controlled trial with three dose regimens

BACKGROUND

To evaluate the effects of vaginal misoprostol on cervical dilatation before operative hysteroscopy in pre-menopausal women.

METHODS

Four groups of 12 women were randomly assigned to receive either placebo or vaginal misoprostol in doses of 200, 400 or 800 micro g 4 h before the surgical procedure. The number of patients was calculated with an alpha = 0.01 and beta =0.20 for a difference of 50%. The primary outcome measure was cervical width, assessed by the largest size of Hegar dilator that could be inserted without resistance. The secondary outcomes were subjective assessments of the ease of dilatation and pre-operative pain, as well as adverse effects and complications.

RESULTS

There was no difference in the baseline diameter of the cervical opening between the placebo group (6.1 +/- 1.4 cm) and the misoprostol groups (6.3 +/- 2.1 cm). The groups did not differ significantly in the time required for dilatation, ease of dilation, or the number of adverse effects. Pre-operative pain, evaluated by a pain scale, was greater in the treatment groups and was rated at 2.5 +/- 2.3 (P = 0.015), 2.4 +/- 1.2 (P = 0.073) and 2.8 +/- 2.9 (P = 0.012) respectively for each increasing dose group.

CONCLUSIONS

Vaginal misoprostol applied 4 h before operative hysteroscopy at three different doses did not reduce the need for cervical dilatation, did not facilitate hysteroscopic surgery, and increased pre-operative pain.

Controlled natural in vitro fertilization may be an alternative for patients with repeated unexplained implantation failure and a high uterine natural killer cell count

Patients with a history of repeated and unexplained implantation failure after IVF-embryo transfer and a high uterine natural killer cell count during estrogen-progestin treatment may benefit from controlled natural IVF-ET.

Detectable levels of interleukin-18 in uterine luminal secretions at oocyte retrieval predict failure of the embryo transfer

BACKGROUND

Most implantation failures after successful in vitro fertilization-embryo transfer (IVF-ET) result from inadequate uterine receptivity. There is currently no way to predict this receptivity.

METHODS

We investigated whether the detection of interleukin-(IL)18 by ELISA in uterine luminal secretions might predict implantation failure. Secretions of 133 patients enrolled in our IVF-ET program were sampled by uterine flushing immediately before oocyte retrieval. We assessed the following outcomes: pregnancy rate, multiple pregnancy rate, and implantation rate per embryo transferred.

RESULTS

Interleukin-18 was detected in the flushing fluid of 38 patients (28.6%). Although the two groups were comparable for all other characteristics (age, etiology, ovarian reserve, number of embryos transferred, quality of embryos), all outcome variables differed significantly. The pregnancy rate was 37.9% in the IL-18 - ve group and 15% in the IL-18 + ve group, the multiple pregnancy rate 27.7% and 0%, and the implantation rate per embryo transferred 19.4% and 6.7% (all comparisons, P=0.02). Only embryos meeting good quality criteria were transferred to 65 patients: 50 IL-18 - ve and 15 IL-18 + ve. The pregnancy rate was 51% for the IL-18 - ve group and 20% for the IL-18 + ve group, the multiple pregnancy rate 36% and 0.0%, respectively, and the implantation rate 29% and 8.3% (P = 0.02).

CONCLUSION

This non-invasive and simple method predicted inadequate uterine receptivity, independent of embryo quality.

Premenstrual administration of gonadotropin-releasing hormone antagonist coordinates early antral follicle sizes and sets up the basis for an innovative concept of controlled ovarian hyperstimulation

OBJECTIVE

To investigate whether premenstrual administration of a GnRH antagonist coordinates early antral follicle sizes during the subsequent follicular phase.

DESIGN

Prospective, longitudinal study.

SETTING

University Hospital in France

PATIENT(S)

Twenty-five women, 50 cycles.

INTERVENTION(S)

On cycle day 2 (control/day 2), women underwent measurements of early antral follicles by ultrasound and serum FSH and ovarian hormones. On day 25, they received a single cetrorelix acetate administration, 3 mg. On the subsequent day 2 (premenstrual GnRH antagonist/day 2), participants were re-evaluated as on control/day 2.

MAIN OUTCOME MEASURE(S)

Magnitude of follicular size discrepancies.

RESULT(S)

Follicular diameters (4.1 +/- 0.9 vs. 5.5 +/- 1.0 mm) and follicle-to-follicle size differences decreased on premenstrual GnRH antagonist/day 2 as compared with control/day 2. Consistently, FSH (4.5 +/- 1.9 vs. 6.7 +/- 2.4 mIU/mL), E(2) (23 +/- 13 vs. 46 +/- 26 pg/mL), and inhibin B (52 +/- 30 vs. 76 +/- 33 pg/mL) were lower on GnRH antagonist/day 2 than on control/day 2.

CONCLUSION(S)

Premenstrual GnRH antagonist administration reduces diameters and size disparities of early antral follicles on day 2, likely through the prevention of luteal FSH elevation and early follicular development. This simple, original approach may be used to coordinate multifollicular development in controlled ovarian hyperstimulation.

Cytokines, implantation and early abortion: re-examining the Th1/Th2 paradigm leads to question the single pathway, single therapy concept

PROBLEM

Human in vitro fertilization (IVF) embryo transfer is accompanied by a low implantation rate even after a very successful IVF, and there are a certain number of 'idiopathic sterilities' which are due to repeated implantation failures. In the very same vein, the question of improving implantation rates is of prime importance in agricultural research to improve the management of livestock. Preimplantation prenatal diagnosis cannot be accomplished in individuals who have a high rate of implantation failure, whether women undergoing IVF, or animals, during genetic cloning. Implantation cytokine networks need to be known in such a perspective.

METHODS

We review the evolution and theories in reproductive immunology, briefly deal with the complexity of implantation as a step by step developmental event, and then present some of our recent data in mice and human.

CONCLUSIONS

We conclude that the T helper cell type 1/2 (Th1/ Th2) paradigm, as useful as it has been to explain pregnancy, is no longer sufficient in view of the emerging complexity of the cytokine network at the materno-fetal interface. This is peculiarly true for implantation, which, as a step by step developmentally regulated process, involving inflammatory molecules, cannot fit into such a scheme.