[Predictive factors of spontaneous pregnancies among women with diminished ovarian reserve patients treated with DHEA]

INTRODUCTION

Diminished ovarian reserve remains a challenge in the reproductive medicine field. Treatment options for these patients are limited and there is no consensus to make any recommendations. Regarding adjuvant supplements, DHEA could play a role in follicular recruitment and, therefore, may increase spontaneous pregnancy rate.

MATERIALS AND METHODS

This study was a monocentric historical and observational cohort study carried out in the reproductive medicine department at the University Hospital, Femme-Mère-Enfant in Lyon. All women presenting with a diminished ovarian reserve treated with 75mg/day of DHEA were consecutively included. The main objective was to evaluate the spontaneous pregnancy rate. The secondary objectives were to identify predictive factors for pregnancy and the evaluation of treatment side effects.

RESULTS

Four hundred and thirty-nine women were included. In all, 277 were analyzed, 59 had a spontaneous pregnancy (21.3%). The probability of being pregnant was respectively 13.2% (IC95 9-17.2%), 21.3% (IC95 15.1-27%) and 38.8% (IC95 29.3-48.4%) at 6, 12 and 24 months. Only 20.6% of patients complained of side effects.

CONCLUSION

DHEA may improve spontaneous pregnancies in women with diminished ovarian reserve without any stimulation.

P-013 Testicular spermatozoa for intra-cytoplasmic sperm injection after IVF failure with ejaculated spermatozoa: a propensity score-matched cohort study

Study question

Does the use of testicular spermatozoa from non-azoospermic infertile men after failed IVF with ejaculated spermatozoa increases the pregnancy rate?

Summary answer

Depending on semen characteristics and obtained embryos number at the previous IVF failure with ejaculated spermatozoa, it seems licit to propose ICSI with testicular spermatozoa.

What is known already

Ejaculated spermatozoa are generally considered to possess better fertilisation potential than testicular spermatozoa as their maturation has been completed. However, it has been shown that in selected cases, the use of testicular spermatozoa from non-azoospermic infertile men resulted in a higher implantation and pregnancy rate than the use of ejaculated spermatozoa. One of the reasons for this result is a higher DNA fragmentation index (DFI) in ejaculated spermatozoa compared to testicular spermatozoa. This increase in DFI would negatively affect embryo development and implantation.

Study design, size, duration

A retrospective matched cohort study using propensity score matching (PSM) analysis was performed. After an IFV failure (cycle_1), IVF with ejaculated or testicular spermatozoa was performed (cycle_2). Female age, female BMI, IVF rank, stimulation protocol, gonadotropin total quantity, treatment duration, punctured oocytes number, and mature oocytes punctured were included in PSM. The matching was performed for IVF performed in cycle_1 for cases and controls identified in cycle_2. 26 couples were included between 01/01/2012 and 30/09/2021.

Participants/materials, setting, methods

Among the 126 couples, for 63 couples, the cycle_2 was performed with ejaculated spermatozoa (controls) and for 63 couples with testicular spermatozoa (cases). Mixed logistic regression was used to compare outcomes of cases versus controls groups. The cycle_1 have allowed finding the prognostic factors to propose a cycle_2 ICSI with testicular spermatozoa in case of cycle_1 IVF failure. The study outcomes were the pregnancy rate (PR) and the cumulative pregnancy rate (CPR).

Main results and the role of chance

In cycle_1, no difference was observed for the parameters included in PSM. The DFI was higher in case group (13.7% ± 10.5% versus 9.3% ± 4.4%, p < 0.05), no difference was observed for fertilization rate, blastulation rate and frozen embryo rate. However, the PR was higher in case group (22.2% versus 0.0%, p < 0.001), the same result was found for the CPR (25.4% versus 6.3%, p < 0.001). The main prognostics factors to propose a cycle_2 ICSI with testicular spermatozoa after cycle_1 IVF failure with ejaculated spermatozoa: teratozoospermia or cryptozoospermia in cycle_1 (OR = 6.0 [1.2 ; 31.1], p < 0.05), a number of obtained embryos greater than 7 in cycle1 (OR = 5.3 [1.5 ; 18.0], p < 0.01), independently of male age in cycle_1 (OR = 2.3 [0.8 ; 6.5], p > 0.05

Limitations, reasons for caution

The main limitations of the current study is being retrospective rather than prospective randomized. However, the used of the propensity score to perform a case-control study allow this study to be more reliable and to obtain results corresponding to real life.

Wider implications of the findings

This study is in favour of using testicular spermatozoa after IVF failure with ejaculated spermatozoa when the semen morphology is altered or in case of cryptozoospermia, and when at least 8 embryos was obtained in the previous IVF procedure

Trial registration number

not applicable

[Comparison of oral dydrogesterone with micronized vaginal progesterone in fresh embryo transfert in IVF/ICSI]

INTRODUCTION

Luteal insufficiency corresponds to a progesterone deficiency affecting women who receive treatment for in vitro fertilization (IVF). Different routes of progesterone administration exist and have varying degrees of acceptability to patients. The aim of this study was to compare two luteal phase support (LPS) treatments: oral dydrogesterone versus micronized vaginal progesterone on the clinical pregnancy occurrence after fresh embryo transfer.

MATERIAL AND METHODS

This study was a monocentric historical and observational cohort study carried out in the reproductive medicine department at the University Hospital, Femme Mère Enfant in Lyon. All the data were collected retrospectively. Women between 18 and 43 years old, who completed an IVF cycle with or without ICSI, followed by fresh embryo transfer on the second or third day after oocyte retrieval (D2 or D3) or at the blastocyst stage (D5 or D6) between July 2019 and July 2020 were included. The 290 patients included between July 2019 and January 2020 received 600mg per day of PMV. The 290 patients in the OD group included between January and July 2020 received 30mg OD per day.

RESULTS

In the univariate analysis, the clinical pregnancy occurrence per transfer was comparable between the MVP and OD groups (P>0.05) (OR [95% CI]): 0.904 [0.630 ; 1.296]. In the multivariate analysis, OD also appeared to be associated with a similar pregnancy occurrence compared to MVP, with a non-significant difference (OR [95% CI]): 0.940 [0.640; 1.380]. The use of OD compared to MVP did not significantly influence the clinical pregnancy occurrence in any age group. There was no significant difference between the two groups in the clinical pregnancy occurrence, whether the patients belonged to the reference population of the center or not (P>0.05) (OR [95% CI]): 2.367 [0.568; 3.568].

CONCLUSION

This important French retrospective study confirms the safety and efficacy of OD.

P–453 Fertility preservation in endometriosis: Impact of the ovarian endometriosis and it’s surgical treatment on oocyte yield

Study question

Does a previous history of surgery for ovarian endometriosis (OMA) has an impact on controlled ovarian stimulation (COS) response in case of fertility preservation (FP) for endometriosis?

Summary answer

After COS, a prior history for OMA surgery was associated with poorer ovarian responsiveness compared to non-previously operated women.

What is known already

Endometriosis is a chronic disorder that affects 10% of woman, which can be responsible for infertility. The presence of OMA and/or it’s excision could induce a reduction of the ovarian reserve (ROR), and for some women, an increased risk of premature ovarian failure. Therefore, FP with oocyte/embryo vitrification can be proposed for OMA-affected women, considering the relationship between endometriosis, infertility and ROR. Although a complete surgery excision of endometriosis lesions may be appropriate for some patients to relieve them from pain, the more efficient time to preserve fertility is still unknown in the management of women presenting OMA lesions.

Study design, size, duration

We conducted an observational multicentric study from April 2015 to December 2019, in two tertiary care university hospitals. Women presenting OMA or having a previous history of surgery for OMA that had performed a FP with COS for oocytes/embryo vitrification during the study period were included. Diagnosis of endometriosis was based on published imaging criteria using transvaginal sonography and magnetic resonance imaging or histologically proven in women who had past surgery.

Participants/materials, setting, methods

A total of 165 women were allocated to two groups, according to the presence of a previous history of surgery for endometrioma(s). Main outcome measure was the total number of oocytes retrieved.

Main results and the role of chance

Fifty-one (30,9%) women were included in the group ‘previous history of surgery’ and 115 (69,1%) in the group ‘no history of surgery’. Mean age was 31,6±4,4 years and was not significantly different between groups (p = 0.09). However, women in ‘No previous surgery’ group had higher AMH levels than women in ‘previous surgery’ group (2.27±1.70ng/ml versus 1.56±1.89ng/ml; p < 0,001). In the group ‘previous history of surgery’, 21(41.2%) women had a recurrence of OMA(s) and 31 (60.8%) had at least one deep infiltrating endometriosis (DIE) lesion at FP. In the group ‘no history of surgery’, 92(80.7%) of the women had DIE. In addition, women in ‘No previous surgery group’ had larger OMA than women in ‘previous surgery’ group (mean diameter size: 5.56±4.34cm versus 3.25±2.16cm, respectively; p:0,03).

The mean number of COS with oocyte-retrieval was significantly higher in the group ‘previous history of surgery’ (2.0±1.02 versus 1.65±0.82 in the group ‘no surgery’, p = 0.03), however, the total number of oocytes retrieved per women was significantly higher in women ‘history of surgery’, compared to women ‘no previous surgery’ (13.7±8.4 versus 10.3±7.5, p = 0.02). In addition, the cancellation rate per cycle was significantly lower in ‘No previous surgery’ group compared to the ‘previous surgery’ group (0.09±0.31 versus 0.28±0.53; p < 0.001).

Limitations, reasons for caution

No data concerning the thawing of oocytes/embryo are available for now.

Wider implications of the findings: FP is an essential component to integrate in ovarian endometriosis-management and should be proposed before surgery to optimize oocyte yield.

Trial registration number

Not applicable

Factors related to unstained areas in whole ewe ovaries perfused with a metabolic marker

STUDY QUESTION

What factors are associated with the presence of areas unexposed to the perfusate after whole ovary perfusion?

SUMMARY ANSWER

Over half the ovaries perfused with the metabolic marker methylthiazolyl blue tetrazolium (MTT) were incompletely stained. Incomplete staining was statistically significantly associated with a small ovarian slice surface area, inexperience of the experimenter, and the presence of a corpus luteum.

WHAT IS KNOWN ALREADY

Whole ovary cryopreservation followed by vascular auto-transplantation has provided poor outcomes as an alternative way to safeguard fertility. Perfusion, commonly used to expose the ovaries to cryoprotectants, may miss areas excluded from the vascular network, explaining subsequent poor ovarian functionality.

STUDY DESIGN, SIZE, DURATION

An observational study of 360 ewe ovaries stained by in vitro perfusion with MTT as a qualitative marker of tissue blood supply was performed. A logistic regression model was built to identify factors associated with incomplete ovary staining.

MATERIALS, SETTING, METHODS

Whole ewe ovaries with their vascular pedicles were perfused at 0.35 ml/min with 1 g/l MTT for 2 h at 39°C under 19 experimental conditions. The pedicles were removed and the ovaries cut in half sagittally and photographed. The unstained area of the slice surface was measured. Times from ovary collection to ovary rinsing and to MTT perfusion initiation, ovary weight and slice surface area, presence of a corpus luteum and operator experience (number of ovaries previously perfused) were recorded. Pedicle MTT staining was quantified at 564 nm after solubilization in alcohol.

MAIN RESULTS AND THE ROLE OF CHANCE

Unstained areas were observed in 64.4% of the ovaries. Multivariate analysis found that incomplete ovary staining was independently associated with lower experimenter experience (P < 0.02), smaller ovary slice surface area (P < 0.0001) and presence of a corpus luteum (P < 0.01). The presence of unstained areas was independent from experimental conditions. The rate of incomplete ovary staining decreased from 83 to 60% beyond the 80th perfused ovary (P < 0.0001).

LIMITATIONS, REASONS FOR CAUTION

Descriptive study.

WIDER IMPLICATIONS OF THE FINDINGS

Blood-supply impairments that result in incomplete perfusion might adversely affect outcomes after whole ovary cryopreservation. Improved perfusion techniques should enhance success.

Validation of a new metabolic marker to assess the vascular viability of vitrified whole sheep ovaries

BACKGROUND

Whole ovary cryopreservation has been suggested as a means to preserve fertility. In animal models, autologous cryopreserved ovary transplants frequently undergo thrombosis and a method to assess the vascular viability of cryopreserved ovaries would be valuable. We developed a staining method using methylthiazolyl blue tetrazolium (MTT, a metabolic marker) to assess the pedicle metabolism of whole ovaries vitrified using cryoprotectant called 'VS4'.

METHODS

Whole sheep ovaries were perfused with MTT (1 g/l). In one group, ovarian tissue lesions were induced by immersing the ovarian pedicle in medium at 53°C or 65°C or in liquid nitrogen prior to MTT perfusion. In the second group, several metabolic substrates (d-glucose, l-glucose and pyruvic acid) and inhibitors [2-deoxy-d-glucose for d-glucose metabolism, azide for mitochondrial respiration and diphenyleneiodonium (DPI) for NADPH oxidase (an effector of the pentose phosphate pathway)] were added to the MTT stain. The third group was subjected to VS4 ± vitrification/warming prior to MTT perfusion. Pedicle MTT staining was assessed qualitatively by histological examination of frozen sections or quantified at 564 nm after solubilization in alcohol.

RESULTS

MTT strongly and reproducibly stained the vascular smooth muscle. Heating at 53°C or 65°C or cooling in liquid nitrogen significantly diminished MTT staining by 48% (P = 0.001, n = 10), 94% (P = 0.0002, n = 10) and 94% (P = 0.0002, n = 10), respectively. MTT staining was affected by d-glucose metabolism: absence of d-glucose, substitution of unmetabolized l-glucose for d-glucose or addition of 2-deoxy-d-glucose significantly decreased MTT staining by 44% (P < 0.01, n = 10), 45% (P < 0.01, n = 10) and 29% (P < 0.01, n = 10), respectively. Pyruvic acid failed to correct the MTT staining decrease induced by d-glucose deprivation and azide did not decrease MTT staining, suggesting that MTT staining could be independent of mitochondrial metabolism. Adding DPI significantly inhibited MTT staining by 25% (P < 0.001, n = 10), suggesting involvement of the pentose phosphate pathway's effectors. Compared with controls, VS4-vitrified/warmed pedicles showed significantly less MTT staining (-30%, P < 0.005, n = 10), with unstained foci, whereas unvitrified VS4-exposed pedicles showed no difference.

CONCLUSIONS

MTT can serve as a qualitative and quantitative vascular viability marker.VS4 vitrification caused alterations in ovarian vascular metabolism. MTT staining should allow accurate comparisons of whole-organ cryoprotection protocols.

Towards whole sheep ovary cryopreservation

Cryopreservation of ovarian tissue aims to assist young women who require treatments that may lead to sterility or infertility. Cryopreservation procedures should therefore be as simple and efficient as possible. This study investigates rapid cooling outcomes for whole sheep ovaries. Ovaries were perfused with VS4 via the ovarian artery, and cooled by quenching in liquid nitrogen in less than a minute (estimated cooling rate above 300 degrees C/min till the vitreous transition temperature). The ovaries were rewarmed in two stages: slow warming (12-16 degrees C/min from -196 to -133 degrees C) in liquid nitrogen vapour, followed by rapid thawing in a 45 degrees C water bath at about 200 degrees C/min. DSC measurements showed that under these cryopreservation conditions VS4 would vitrify, but that VS4 perfused ovarian cortex fragments did not vitrify, but formed ice (around 18.4%). Immediately following rewarming, a dye exclusion test indicated that 61.4+/-2.2% of small follicles were viable while histological analysis showed that 48+/-3.8% of the primordial follicles were normal. It remains to be clarified whether follicle survival rates will increase if conditions allowing complete tissue vitrification were used.

[Ovarian tissue vitrification: Cortex and whole ovary in sheep]

OBJECTIVE

The aim of this study was to evaluate a cryopreservation technique by vitrification of cortex or whole ovaries in sheep, using two cryoprotectant solutions: VS1 and VS4 and to study their physical properties to avoid ice crystallisation by vitrification of whole sheep ovaries permeated with a cryoprotectant solution.

ANIMALS AND METHODS

From 6-month-old ewes, whole sheep ovaries with their vascular pedicles were collected at the slaughterhouse or at the veterinary school and prepared for cryoprotectant toxicity tests and freezing procedure. Follicle viability was measured by trypan blue test and histological examination of ovary. The hemi-ovarian cortex was stored in liquid nitrogen. Four to six weeks after the first laparotomy, the controlateral ovary was removed and the vitrified-warmed hemi-ovary was sutured. Thermal properties of a cryoprotectant solution called VS4 (critical cooling rates [Vccr], vitreous transition temperature [Tg], end of melting temperature [Tm]) were measured by differential scanning calorimetry.

RESULTS

No significant difference in follicle viability or normal follicle rates was observed between ovarian cortex exposed or non-exposed to cryoprotectant solutions. Nor was any significant difference observed before and after vitrification. Three pregnancies occurred, from which four lambs were born after autografts of vitrified ovarian cortex. With whole ovary, the decrease in the number of normal follicles was lower when frozen-thawed ovaries were treated with VS4 (P = 0.04). There were less nuclear anomalies (P = 0.02). The Vccr of VS4 has been estimated to be 14.3+/-1.1 degrees C/min and Tg was -125.0+/-0.2 degrees C. Because the penetration of cryoprotectants was very low, Vccr was very high and the cooling speed did not allow cortex to vitrify.

DISCUSSION AND CONCLUSIONS

Cryopreservation of cortex or whole ovary by vitrification seems a promising technique in reproductive medicine. The best histologic results were obtained with the VS4 cryoprotectant when whole ovary was vitrified.

Comparisons between LIBS and ICP/OES

In the framework of the development of new techniques, the ability of laser-induced breakdown spectroscopy (LIBS) to analyse remotely complex aqueous solutions was investigated. The jet configuration with a collimated gas stream was chosen because it appeared to be the most promising method for the LIBS probe, particularly in terms of sensitivity and repeatability. For emission collection, the echelle spectrometer offers a simultaneously recorded wavelength range from the UV to the near IR and is interesting for multielemental analysis for LIBS and also for inductively coupled plasma (ICP) optical emission spectroscopy (OES). The importance of parameters influencing the quantitative results of LIBS such as multispecies analysis, sheath gas, use of an internal standard and temporal parameters for analysis is described. LIBS quantitative data have been directly compared with results from the more standard ICP/OES technique.

Acute efficacy of a sublingual dose of nifedipine on uterine arterial blood flow: preliminary data in prematurely menopausal women

OBJECTIVES

To determine whether the calcium blocker nifedipine alters Doppler velocimetry and impedance parameters in the uterine artery in prematurely menopausal women.

METHODS

Uterine artery Doppler examinations were performed transvaginally in seventeen prematurely menopausal women without the use of calcium blocker (T0). Following a 10-mg sublingual dose of nifedipine patients were subsequently rescanned at successive time intervals (T25 = 25, T40 = 40, T60 = 60 min). PI (normalized (NPI) for heart rate) and maximum, minimum and average velocities of the uterine artery were recorded and waveforms were qualitatively assessed using Goswamy and Steptoe's waveform classification.

RESULTS

Quantitative analysis showed a significant decrease in NPI at T(25) in the right and left uterine arteries (T0: PI = 2.95 and 3.01; T25: PI = 1.52 and 1.52, respectively; P < 0.001) and until the end of the experiment. Minimum and average blood flow velocities increased strongly (P < 0.001) whereas the maximum velocities did not change significantly (P = 0.12). Qualitative analysis revealed more conspicuous results: eight subjects presented 'abnormal' spectra: one was type A (absence of protodiastole), three were type B (absence of telediastole) and four were type O (no diastolic blood flow); all of them recovered type C waveforms (normal spectrum) during the hour following nifedipine administration.

CONCLUSIONS

Nifedipine induces a reversible decrease in NPI and an increase in blood flow velocities in the uterine artery in prematurely menopausal women. These results suggest that nifedipine is a potent uterine arterial vasodilator.

Pregnancy after safe IVF with hepatitis C virus RNA-positive sperm

In France, assisted reproductive technology (ART) for hepatitis C virus (HCV)-infected patients is now subject to strict control after the publication of recent guidelines. Infertile serodiscordant couples (HCV-viraemic men and their seronegative female partners) require special care to carried out in designated 'viral risk' laboratories. Twelve sequential semen samples taken from an HCV chronically infected patient were analysed within 22 months. HCV RNA was detected in all the seminal plasma sampled before antiviral treatment with relatively high viral loads, and in two of the corresponding fractions of motile sperm obtained after a gradient selection, suggesting that a contamination risk by HCV through ART cannot be excluded. When the selection of sperm on a discontinuous gradient was followed by an additional swim-up step, HCV RNA was never detected in the motile sperm suspension that was frozen in highly secure straws. IVF was performed using cryopreserved sperm that tested negative for HCV RNA, resulting in a pregnancy. One month after embryo transfer, testing for HCV RNA and antibodies in the woman gave negative results.

Reproducibility of transvaginal three-dimensional endometrial volume measurements with virtual organ computer-aided analysis (VOCAL) during ovarian stimulation

OBJECTIVE

To calculate inter- and intraobserver reliabilities for three-dimensional endometrial volume measurements during in vitro fertilization using virtual organ computer-aided analysis (VOCAL).

PATIENTS AND METHODS

Three-dimensional ultrasound measurements of the endometrium using VOCAL software were performed on the day of oocyte retrieval in each of 79 consecutive patients undergoing in vitro fertilization or intracytoplasmic sperm injection. Endometrial volume was calculated every 15 degrees and every 30 degrees by two different observers in order to determine the reproducibility of the technique.

RESULTS

Intraobserver reliability for the 15 degrees measurements was 0.97 for both observers; for the 30 degrees measurements, it was 0.93 for one observer and 0.96 for the other. Interobserver reliability was 0.80 for the endometrial volumes calculated every 15 degrees and 0.83 for the volumes calculated every 30 degrees. The intra- and interobserver measurement agreement showed good reproducibility. However, the volumes calculated every 15 degrees were more accurate because the means of differences were close to zero.

CONCLUSION

VOCAL provides a reproducible method for the estimation of the endometrial volume.

Comparison of two blastocyst culture systems: coculture on Vero cells and sequential media

OBJECTIVE

To compare two blastocyst culture systems: culture on Vero cells and sequential media in the same time period.

DESIGN

Retrospective study.

SETTING

Institutional practice assisted reproductive technology center.

PATIENT(S)

Ninety-nine selected patients undergoing IVF with blastocyst culture.

INTERVENTION(S)

In vitro fertilization and transfer of at least one expanded blastocyst after culture using either Vero cells or sequential media (S(2) medium).

MAIN OUTCOME MEASURE(S)

Blastocyst, pregnancy, and implantation rates.

RESULT(S)

The blastocyst formation rate (41.6% vs. 31.6%) is significantly increased with sequential media compared with the coculture system, but there is no statistically significant difference in the pregnancy and implantation rates (39.5% vs. 38.6% and 23.7% vs. 15.1%, respectively).

CONCLUSION(S)

Blastocyst culture on sequential media offers a better dynamic of embryo development (22% vs. 13.6% blastocyst at day 5). There was no statistically significant difference between the two groups in the take-home baby rate (18 vs. 12).

Follicular viability and morphology of sheep ovaries after exposure to cryoprotectant and cryopreservation with different freezing protocols

OBJECTIVE

To test the toxicity of cryoprotectant in sheep ovarian tissue and to determine optimal conditions for freezing hemiovary cortex.

DESIGN

Small follicles (<60 microm in diameter) were isolated enzymatically for viability testing. Dead and live follicles were identified by using trypan blue staining, and follicle morphology was examined histologically.

SETTING

Centre hospitalo-universitaire de Biologie de la Reproduction, Hôpital Edouard Herriot, Lyon, France.

ANIMAL(S)

Lambs 5 to 6 months of age.

INTERVENTION(S)

Two-millimeter slices of hemiovarian cortex were prepared for cryoprotectant toxicity tests and freezing procedures.

MAIN OUTCOME MEASURE(S)

Follicular mortality and histologic structure.

RESULT(S)

For freezing procedures, the concentration of cryoprotectant was increased to 2 M on the basis of results of cryoprotectant toxicity tests in fresh tissues. Follicular mortality rates were 4.6% with of 2 M dimethyl sulfoxide (DMSO) and 3.8% with 2 M of propylene glycol (PROH). After freezing with semiautomatic seeding, follicular mortality rates were 8.4% (2 M of DMSO) and 12.4% (2 M of PROH). Tissue morphology was well preserved with 1.5 M of DMSO or PROH. With 1.5 M DMSO, results of the slow cooling protocol (2 degrees C/min) without seeding and the standard very slow cooling protocol (0.3 degrees C/min) were similar.

CONCLUSION(S)

Optimal survival of primordial follicles in the sheep was obtained by using a slow cooling protocol with semiautomatic seeding at 2 M of DMSO.

New insights into the postnatal growth of infants born 'idiopathic' small for gestational age

Infants born small for gestational age (SGA) are defined as those with a birth weight and/or birth length below two standard deviations for gestational age. Postnatal catch-up growth is absent in 8-12% of children born SGA and these children achieve adult heights far below their target height. The objectives of our retrospective study were to confirm the prevalence of catch-up growth and to refine the kinetics of the catch-up process. The 'Lyon series' of patients consisted of 179 children with 'idiopathic' SGA, of whom 8% did not achieve catch-up growth (i.e. their height remained below -2 SD throughout the study). The number of days that the mother was hospitalized before delivery was found to be significantly correlated with lack of catch-up growth. Maternal hypertension, term delivery and postnatal parenteral nutrition were also associated with lack of catch-up growth, but the relationship was not significant. In addition, an oscillatory growth velocity pattern was observed in boys and girls born SGA, with alternating periods of growth acceleration and deceleration. This suggests that catch-up growth is regulated in a sophisticated way by the hypothetical 'Somatostat', although further confirmation of this process is needed.

Multiple hormone resistance in short children born with intrauterine growth retardation?

Intrauterine growth retardation (IUGR) is encountered in 2.5% (-2 SD) of newborns. Lack of postnatal catch-up growth is found in 8-20%. If GH secretion is increased early postnatally in IUGR, then some persistently short IUGR children may present with GH insufficiency. However, the mechanism of postnatal catch-up growth is heterogenous. The response to GH treatment with regard to plasma IGF-1, GH dose and growth velocity was analyzed in persistently short idiopathic IUGR children and compared to GH-deficient (GHD) and familial short stature (FSS) children of similar age and degree of short stature. IUGR children require both a greater basal and GH-induced plasma IGF-1 in order to achieve a growth velocity of similar magnitude to that of FSS and GHD children. These data suggest a different sensitivity to GH in IUGR compared to FSS or GHD children, sustaining the hypothesis that these idiopathic IUGR children may be partially IGF-1 resistant. The recent report of partial insulin resistance in IUGR subjects raises the possibility of an IGF-1 receptor- or post-receptor-mediated defect.

Dual-energy X-ray absorptiometry in small subjects: influence of dual-energy X-ray equipment on assessment of mineralization and body composition in newborn piglets

There is a growing body of literature that describes the use of dual-energy x-ray absorptiometry (DXA) for bone mineral content (BMC) and fat mass (FM) assessment in neonates, but the reproducibility and accuracy of the method are still controversial. Two different software programs have been developed for use on Hologic densitometers: the Pediatric Whole Body (PWB) and the Infant Whole Body (IWB) programs. They differ in scan time, radiation exposure, and in the algorithm used to assess BMC. We evaluated the reproducibility and accuracy of PWB and IWB in newborn piglets. Reproducibility of body mass (BM), FM, and BMC measurements from PWB and IWB were similar. BM agreed well with scale weight with both software programs; IWB was within +/- 0.5% and PWB was within +/- 0.3% of scale weight. FM was highly correlated with carcass fat (PWB: r = 0.962; IWB: r = 0.980). Errors in the DXA estimation of fat were similar with PWB and IWB. With both software programs, BMC was highly correlated with carcass calcium (PWB: r = 0.925, IWB: r = 0.987), but errors in the DXA estimation of calcium were about twice as high with PWB (+/- 16.9%) than with IWB (+/-9.2%). In four piglets, the addition of a layer of porcine lard was associated with an increase in BMC; this effect was more pronounced with PWB (+ 156%) than with IWB (+ 15%). The IWB software provided BMC measurements that were more precise, accurate, and stable in the presence of added fat than the measurements obtained with PWB, indicating that IWB is superior to PWB for in vivo determination of BMC and body composition.

Restoration of ovarian steroid secretion and histologic assessment after freezing, thawing, and autograft of a hemi-ovary in sheep

OBJECTIVE

To evaluate the effects of freezing, thawing, and autograft of a hemi-ovary on steroid secretion, endometrial maturation, and ovarian histology in ewes.

DESIGN

Experimental animal study.

SETTING

Laboratoire de Zootechnie, Ecole Nationale Vétérinaire, Marcy l'Etoile, France.

ANIMAL(S)

Six lambs aged 6 months to 1 year old.

INTERVENTION(S)

Hemi-ovaries were prepared and frozen from the right ovary of six lambs and autografted 4 weeks later to the contralateral ovarian hilus. The autografts and the uterus were recovered 1 year later. Blood tests were performed each week to measure P concentration.

MAIN OUTCOME MEASURE(S)

Number of primordial follicles; levels of plasma P.

RESULT(S)

Histologic examination of ovarian slices after freezing showed no destruction of primordial, primary, secondary, or cavitary follicles. The frozen ovarian autograft showed good recovery of the macroscopic and microscopic ovarian structure. After autografting, histologic examination revealed primordial to cavitary follicles. Secretion of P started to rise 4 weeks after the autograft. Histologic analysis of the endometrium showed numerous glands, vessels, and mucous secretion.

CONCLUSION(S)

Frozen ovarian autografts achieved P secretion and endometrial maturity.

Transvaginal sonohysterographic evaluation of intrauterine adhesions

PURPOSE

We assessed the role of preoperative sonohysterography in the diagnosis of intrauterine synechiae.

METHODS

Nineteen patients with a suspected diagnosis of intrauterine adhesion underwent hysterosalpingography, transvaginal sonography, and sonohysterography performed in the consultation room. The patients were then treated by hysteroscopy under laparoscopic or ultrasound guidance.

RESULTS

Transvaginal sonography showed an abnormal uterine cavity in only 10 cases. The sensitivities of sonohysterography and hysterosalpingography in the diagnosis of intrauterine adhesions were both 100%. Sonohysterography showed complete correlation with hysterosalpingography.

CONCLUSIONS

We recommend routine sonohysterography after transvaginal sonography in cases of suspected intrauterine synechiae.

Freezing, thawing, and autograft of ovarian fragments in sheep: preliminary experiments and histologic assessment

OBJECTIVE

To evaluate the effects of freezing and thawing on the histologic changes in ovarian fragments from sheep and to determine the feasibility of ovarian autografts.

DESIGN

Histologic evaluation of follicles that survived after freezing at -196 degrees C for 2 weeks. Histologic evaluation of ovarian fragments 6 months after the autografts.

SETTING

Laboratoire de Zootechnie, Ecole National Véterinaire, Marcy l'Etoile, France.

ANIMAL(S)

Six ewes aged 6 months to 1 year.

INTERVENTION(S)

Cortical fragments were prepared from the right ovary of 6 lambs and were grafted immediately to the contralateral ovarian hilus or were cooled slowly to -196 degrees C in medium containing dimethyl sulfoxide for 2 weeks. The autografts were recovered 6 months later.

RESULT(S)

Histologic examination of ovarian slices after freezing showed no destruction of primordial, primary, secondary, or cavitary follicles. The ovarian autograft showed good recovery of the macroscopic and microscopic ovarian structure. After autografting, histologic examination revealed primordial to cavitary follicles.

CONCLUSION(S)

Freezing of ovarian fragments is possible without damaging the follicles. Ovarian autografts showed good recovery of ovarian structure.

Preliminary report of an ultrasonography and colour Doppler uterine score to predict uterine receptivity in an in-vitro fertilization programme

A total of 96 women undergoing in-vitro fertilization (IVF) treatment were examined by transvaginal ultrasonography with colour and pulsed Doppler ultrasound on the 22nd day of the menstrual cycle preceding IVF. We assessed endometrial thickness, endometrial morphology, myometrial echogenicity, subendometrial vascularization, the uterine artery pulsatility index, protodiastolic notch and end diastolic blood flow in order to define a uterine score which could be correlated with the pregnancy rate. The overall pregnancy rate was 30.2%, and there was no difference between the pregnant and non-pregnant groups with regard to any of the ultrasonographic and Doppler parameters when examined separately. However, the uterine score was significantly higher in the pregnant group (15.9 +/- 2.81 versus 12.7 +/- 5.3, P = 0.002; t-test). No pregnancy occurred if the score was between 0 and 10. With a score of 11-15 there was a 34.7% chance of pregnancy, and scores >16 had a 42% chance of pregnancy. In conclusion, individual ultrasonographic and Doppler parameters are not of sufficient accuracy to predict uterine receptivity. The uterine score calculated prior to IVF cycles appears to be a useful predictor of implantation.

Another two cases of ovarian tumours in women who had undergone multiple ovulation induction cycles

Many questions have been raised recently about the possible association between ovulation induction and ovarian cancer. In order to contribute to the limited literature on this important issue, two cases of ovarian cancer in women who had multiple ovulation induction are presented here. In the first case the patient had ovarian induction by clomiphene citrate while she already had an ovarian cyst. The cyst enlarged under induction. During laparoscopy, the cyst was removed. Histological examination showed a borderline and invasive sero-papillary cystadenoma. In the second case, the patient underwent ovulation induction and intrauterine insemination. During the first ultrasound in the beginning of the cycle, an ovarian cyst was discovered. Laparoscopy was performed and the cyst removed. Histological examination showed a borderline and invasive mucinous cystadenoma.

Comparative study of three vaginal markers of the premature rupture of membranes. Insulin like growth factor binding protein 1 diamine-oxidase pH

OBJECTIVE

To assess the diagnostic value of three vaginal markers-insulin-like growth factor binding protein 1 (= IGFBP1), diamine-oxidase (= DAO) and pH-for diagnosis of the premature rupture of membranes.

STUDY

One hundred pregnant women participated in the study. They were divided into three groups: group A (34 cases with intact membranes), group B (35 cases with total rupture of the membranes), group C (31 cases of suspected rupture of the membranes). Each patient underwent three successive tests for each of the three markers. The test order was allocated at random. For pH the reaction is colorimetric, for DAO the reaction is radio-enzymatic and for IGFBP1 the reaction is immuno-chromatographic. All three reactions are qualitative in nature. The parameters studied were conventional statistical parameters (sensitivity = SN, specificity = SP, positive predictive value = PPV and negative predictive value = NPV).

RESULTS

The analysis of the statistics gave the following results in percentages for SN, SP, PPV and NPV respectively; pH: 90.7%, 77.2%, 75%, 91.7%. DAO: 83.7%, 100%, 100%, 89%. IGFBP1: 95.3%, 98.2%, 97.6%, 96.5%.

CONCLUSION

The determination of variations in pH is not satisfactory. IGFBP1 is at least better than DAO with, additionally, advantages of rapidity and simplicity.

Micro-albuminuria analysis and pregnancy. An approach to detect placentary insufficiency?

OBJECTIVE

To assess the value of micro-albuminuria analysis (MA) in predicting clinical complications of placentary insufficiency in women with no known risk factor.

STUDY DESIGN

A blind prospective investigation 20-24 weeks into pregnancy in a nulliparous population with no known risk factor. A reactive strip with a positive threshold value of 10 mg/l is used to detect MA. Judgment criteria concerning the progress of pregnancy are based on blood pressure during the 8th and 9th month of pregnancy and on the 2nd day after delivery, on albuminuria analysis in the 8th and 9th month of pregnancy and by the existence of fetal hypotrophia at birth.

RESULTS

Some 218 patients participated in the investigation. MA was positive in 62 cases (28.4%). Of the 197 births which occurred 54 (27.4%) cases of positive MA, 34 (17.2%) cases presented positive judgment criteria indicating placentary insufficiency. The 21 others pregnancies are in course. MA sensitivity was thus 79.4% and specificity 83.4%. Negative predictive value (NPV) was 95.1% and positive predictive value (PPV) 50%.

CONCLUSION

Our test is a reliable, simple and easily reproducible indicator of micro-albuminuria. In comparison with other tests it gives a good detection rate of a risk group for complication of placentary insufficiency. NPV is excellent, virtually excluding the occurrence of excessive blood pressure or intra-uterine growth retardation. PPV is less good.

Transvaginal ultrasound studies of vascular and morphological changes in uteri exposed to diethylstilbestrol in utero

The aim of this prospective study was to establish complementary data of uteri exposed to diethylstilbestrol (DES) in utero for transvaginal analysis and vascularity changes during the menstrual cycle. A total of 28 women with DES-exposed uteri were compared with 60 non-exposed women. Transvaginal ultrasound and colour Doppler imaging were performed on days 5 and 22 of the menstrual cycle. Uteri were measured on sagittal and transverse scans. Uterine length, width, thickness and uterine cavity length and width were measured. Uterine volume and uterine cavity area were calculated. DES-exposed uterine volume was equal to 31.84 +/- 3.37 cm3. The cavity area of DES-exposed uterus was equal to 35.85 +/- 3.93 cm2. Cervix length of DES-exposed uterus was significantly smaller than that of non-exposed uterus. The uterine artery pulsatility index (PI) of DES-exposed uterus was significantly higher than that of normal uterus. Blood flow remained stable throughout the menstrual cycle. The PI of DES-exposed uterus remained stable during the menstrual cycle, as in non-exposed uterus, and it decreased during the luteal phase. This lack of modification in vascularity of DES-exposed uterus may explain miscarriages and obstetric complications such as intrauterine growth retardation or pre-eclampsia. The data may have implications for the assessment of reproductive status and the design of future studies on disorders of implantation in DES-exposed uterus.

Transvaginal hysterosonographic evaluation of septate uteri: a preliminary report

The objective of this study was to evaluate the diagnostic value of hysterosonography in septate uterine congenital abnormalities and more particularly in septate uteri. A total of 14 patients with a history of repeated spontaneous abortion or infertility who had previously undergone hysterosalpingography were included in this study. Patients were first examined by standard transvaginal ultrasound. Hysterosonography was then carried out by the intrauterine injection of an isotonic saline solution. The septate uteri were diagnosed by hysterosonography in all 14 patients (100%). Hysterosonography permitted the measurement of the thickness and height of the septum. Hysterosonography and transvaginal ultrasound enabled the correct diagnosis of malformation type in eight cases (57%). The accuracy of hysterosonography in postoperative control was greater than that of hysteroscopy. Transvaginal hysterosonography with saline solution is a low-cost, easy and helpful examination method for septate uteri. We propose that hysterosonography should be performed for the primary investigation of infertility and repeated miscarriages.

[Activation of T-lymphocytes in Crohn disease and in ulcerative hemorrhagic rectocolitis. Therapeutic implications]

Inflammatory bowel disease (IBD) encompasses two forms of intestinal inflammation: ulcerative colitis and Crohn's disease. Besides abnormalities of immunoglobulins production and complement activation, T lymphocytes play an important role in pathogeny of these diseases. Although T-cells number is increased in intestinal mucosa of such patients, CD4/CD8 ratio of T lymphocytes subsets is normal in mucosa. Activated T-cells expressing interleukin-2 receptors (CD25) are increased in lamina propria from patients with IBD. Cytokines induce abnormal expression of class II antigens of major histocompatibility complex by epithelial cells which may act as antigen presenting cells to CD4 T-cells. Better understanding of pathogenic mechanisms in IBD might justify new immunosuppressive therapeutics to treat these patients.

Spontaneous and evoked otoacoustic emissions in pre-term and full-term neonates: is there a clinical application?

In neonates and infants, hearing impairment leads to impaired language and cognitive development. For that reason, early detection of this sensory deficit is of outstanding importance, particularly in pre-term neonates, who constitute a high risk population in regard to very early acquired hearing loss. Evoked (EOAE) and spontaneous otoacoustic emission (SOAE) recording in 93 pre-term and full-term neonates revealed that this technique is potentially useful for auditory screening in neonatology units. EOAEs and SOAEs can be recorded successfully from 30 weeks of conceptional age. SOAEs were found to be prevalent in females and presented higher peak numbers in right than in left ears. Furthermore, SOAE incidence in pre-term and full-term neonates was found to be high in EOAE positive ears, associated with strong and robust EOAEs.

Spontaneous otoacoustic emissions in preterm neonates: prevalence and gender effects

A number of lines of evidence indicate that the human cochlea is fully functional as a mature sound transducer by 6 months of age. However, information about the development of the active cochlear mechanisms and notably the development of outer hair cell (OHC) activity is yet incomplete. Recording and analysis of otoacoustic emissions (OAEs), probably generated by the OHCs of the organ of Corti, have led to a better understanding, in humans, of how sounds are analysed in the cochlea by means of active mechanisms. Evoked OAEs (EOAEs) and spontaneous OAEs (SOAEs), when they can be recorded in full-term and preterm neonates, show different characteristics from those in adults, suggesting that maturation of the peripheral auditory system is incomplete at birth. To learn more about this maturation, using the best-established facts concerning SOAEs in adults, such as their greater prevalence in females and also in right ears, SOAEs were studied in more detail in 81 preterm neonates, from 30 to 40 weeks of conceptional age, all presenting bilateral EOAEs according to objective criteria. The first finding of this study was that SOAEs existed and could be recorded as of 30 weeks of conceptional age in humans. Some SOAE characteristics in preterm neonates, such as prevalence, peak number and acoustic frequencies, showed similarity with full-term neonates. Comparison of other criteria between the two populations, such as greater SOAE prevalence in right ears and higher SOAE peak number in females, suggested that these developmental factors emerge around term in humans. Comparison of SOAE characteristics between male and female preterms suggested that male preterms were less advanced in peripheral auditory development than were female preterms.

[Hospital infection in maternity homes]

The results of the prospective survey of hospital infections in mothers and newborns at the obstetrical clinic of the Edouard Herriot Hospital in Lyon are presented. Surveillance lasting six successive years covered 18,026 deliveries with or without the use of cesarean section. The incidence of hospital infections (not taking into account cases of bacteriuria) was 1.6% in parturient women not subjected to cesarean section and 11.7% in those having had this operation. Urinary tract and parietal infections, endometritis were in leading cases. The average incidence of hospital infection in newborns was 2.68%, the leading clinical manifestations being peripheral staphylococcal lesions in the form of pustules.

Sonohysterography of the uterine cavity: preliminary investigations

OBJECTIVE

To compare sonohysterography (SH), in the exploration of the uterine cavity, with classical transvaginal sonography (TVS), hysterography (HSG), and hysteroscopy.

STUDY DESIGN

104 consecutive patients evaluated for uterine disorders underwent both TVS and SH. SH was obtained by distension of the uterine cavity with the instillation of an isotonic saline solution; 36 patients also underwent HSG; 82 women underwent surgery. Histologic findings were considered as gold standard. The criteria used to compare these methods were sensitivity, specificity, and negative and positive predictive values (NPV, PPV) for identifying pathology.

RESULTS

3 instillation failures occurred. SH was found to be more effective (sensitivity 94%, specificity 98%) than HSG (sensitivity 67%, specificity 94%). The difference between TVS and SH was less marked, SH showing some superiority (sensitivity 88%, specificity 98%) to TVS (sensitivity 77%, specificity 93%).

CONCLUSION

SH represents an improvement over conventional TVS and is fully capable of replacing HSG for the study of the uterine cavity.

[Hysterosonographic study of the uterine cavity]

OBJECTIVE

Evaluate the reliability, safety and performance of hysterosonographic assessment of the uterine cavity.

MATERIALS AND METHODS

Hysterosonography was performed in 220 patients with injection of sterile saline into the uterine with a novel catheter. Among these patients, 132 patients then underwent a hysteroscopy or hysterectomy with a histology examination.

RESULTS

There were 8 failures: 2 synechiae, 3 atresias of the cervix, and massive reflux in 3 cases. No other complication occurring. Hysterosonography appeared to give more information on the uterine cavity than standard vaginal sonography. In cases with metrorrhage before menopause, the diagnosis was correct in 75.4% of the cases. Errors were related to confusion between polyp and hyperplasia. In post-menopausal metrorrhagia, there was 92% agreement between sonography and histological results. Agreement was 86.3% in cases of infertility.

CONCLUSION

Hysterosonography using saline solution injected with a novel catheter can be an excellent means of evaluating the uterine cavity and can completely replace classical hysterography, thus avoiding many exploratory hysterocopies.

Regional chemotherapy (with mitomycin C) and intra-operative hyperthermia for digestive cancers with peritoneal carcinomatosis

Intraperitoneal chemo-hyperthermia with mitomycin C was used to treat 28 patients with far advanced digestive adenocarcinoma and histologically confirmed peritoneal carcinomatosis. Surgical resection of the primary tumor was possible in 17 cases. After closure of the abdominal wall, intraperitoneal chemo-hyperthermia was performed for 90 to 120 minutes under general anesthesia and 32 degrees C hypothermia, through 3 intraperitoneal drains forming a closed circuit, using 10 mg/l of mitomycin C in 6 liters of peritoneal dialysate heated to an inflow temperature of 46-49 degrees C. No mortality occurred, and there were 2 post-operative complications, with transitory biological side effects. In 9 out of 10 patients with preoperative malignant ascites, the ascites cleared after treatment. One-year survival rate was 54.2%. These encouraging preliminary results show that intraperitoneal chemohyperthermia with mitomycin C is a safe and reliable treatment for peritoneal carcinomatosis in far advanced digestive cancers.