Uterine Factor Infertility, a Systematic Review

Uterine factor infertility (UFI) is defined as a condition resulting from either a complete lack of a uterus or a non-functioning uterus due to many causes. The exact prevalence of UFI is currently unknown, while treatments to achieve pregnancy are very limited. To evaluate the prevalence of this condition within its different causes, we carried out a worldwide systematic review on UFI. We performed research on the prevalence of UFI and its various causes throughout the world, according to the PRISMA criteria. A total of 188 studies were included in qualitative synthesis. UFI accounted for 2.1 to 16.7% of the causes of female infertility. We tried to evaluate the proportion of the different causes of UFI: uterine agenesia, hysterectomies, uterine malformations, uterine irradiation, adenomyosis, synechiae and Asherman syndrome, uterine myomas and uterine polyps. However, the data available in countries and studies were highly heterogenous. This present systematic review underlines the lack of a consensual definition of UFI. A national register of patients with UFI based on a consensual definition of Absolute Uterine Factor Infertility and Non-Absolute Uterine Factor Infertility would be helpful for women, whose desire for pregnancy has reached a dead end.

Description of an initiation program to robotic in vivo gynecological surgery for junior surgeons

INTRODUCTION

Most gynecological residents or junior surgeons do not practice nor experience robotic surgery due to lack of access during residency or poor knowledge about this growing surgical technology. This study evaluated the feasibility and safety of a 3-half-day experiencing and training session for robot-assisted gynecological surgery designed for residents and fellows.

MATERIEL AND METHODS

This is a prospective, single-center observational study about a training course aimed at residents or fellows at the university teaching hospital of Limoges (France). It spreads over three consecutive half-days: one dedicated to simulation exercises involving the Da Vinci Skills Simulator© and the other two, to practice in two robot-assisted procedures with dual-console equipment supervised by a senior surgeon (as it is usually performed in a university teaching hospital). Complications during surgery, patient's medical records as well as the participants' performances during in vivo suturing acts were gathered. Feedback on the session was obtained with a questionnaire at the end of the course.

RESULTS

Twelve sessions involving 24 patients operated on by 34 trainees from 16 different teaching university hospitals across the country took place. No conversion to laparotomy nor any major peri- or post-operative complication was reported. Time for stitching decreased significantly (p=.016) between the first and the second in vivo surgery. Use of the dual console was found helpful and most attendees (96.8%) would recommend this training session.

CONCLUSION

We showed this training course with both simulation and in vivo surgery was feasible, safe and was a well-liked initiation program for robotic surgery.

In vitro survival of follicles in prepubertal ewe ovarian cortex cryopreserved by slow freezing or non-equilibrium vitrification

PURPOSE

Vitrification is a well-accepted fertility preservation procedure for cryopreservation of oocytes and embryos but little is known regarding ovarian tissue, for which slow freezing is the current convention. The aim of the present study was to assess the efficiency of non-equilibrium vitrification compared to conventional slow freezing for ovarian cortex cryopreservation.

METHODS

Using prepubertal sheep ovaries, the capacity of the tissue to sustain folliculogenesis following cryopreservation and in vitro culture was evaluated. Ovarian cortex fragments were cultured in wells for 9 days, immediately or after cryopreservation by conventional slow freezing or non-equilibrium vitrification in straws. During culture, follicular populations within cortex were evaluated by histology and immunohistochemistry for PCNA and TUNEL. Steroidogenic activity of the tissue was monitored by assay for progesterone and estradiol in spent media.

RESULTS

No significant differences in follicle morphology, PCNA, or TUNEL labeling were observed between cryopreservation methods at the initiation of culture. Similar decreases in the proportion of primordial follicle population, and increases in the proportion of growing follicles, were observed following culture of fresh or cryopreserved ovarian tissue regardless of cryopreservation method. At the end of culture, PCNA and TUNEL-positive follicles were not statistically altered by slow freezing or vitrification in comparison to fresh cultured fragments.

CONCLUSIONS

Overall, for both cryopreservation methods, the cryopreserved tissue showed equal capacity to fresh tissue for supporting basal folliculogenesis in vitro. Taken together, these data confirm that both non-equilibrium vitrification and slow-freezing methods are both efficient for the cryopreservation of sheep ovarian cortex fragments.

[Uterus transplantation. Current situation]

Except adoption, absolute uterine factor infertility lacks solution in case of motherhood desire. Gestational surrogacy is still not approved in France. Over the last decade, uterus transplantation experimentation made advances. Data from animal research, progress in immunosuppressive treatment and knowledge about pregnancy after transplantation provide a scenario in which a human allotransplantation project can become reality.

Children born after autotransplantation of cryopreserved ovarian tissue. a review of 13 live births

INTRODUCTION. Premature ovarian failure (POF) can occur naturally at an early age or be due to iatrogenic agents. Indeed, ovaries are very sensitive to cytotoxic treatment, especially to radiation and alkylating agents. METHODS. Several options are currently available to preserve fertility in cancer patients and allow them to conceive when they have overcome their disease: embryo cryopreservation, oocyte cryopreservation, and ovarian tissue cryopreservation. Cryopreservation of ovarian tissue is the only option available for pre-pubertal girls and women who cannot delay the start of chemotherapy. FINDINGS. Since the first live birth after autotransplantation of cryopreserved ovarian tissue in humans was reported in 2004, orthotopic reimplantation has led to the birth of 13 healthy babies. Restoration of ovarian activity and prognostic factors are evaluated by comparison with 7 cases of fresh ovarian tissue transplantation. We report 13 live births after orthotopic transplantation of frozen-thawed ovarian tissue in cancer patients (n = 8) and in patients treated with high doses of chemotherapy for benign diseases (n = 2) (microscopic polyangiitis, sickle cell anemia). INTERPRETATION. Based on our review, we believe that ovarian cortex cryopreservation, associated or not with cryopreservation of immature oocytes, should be offered before gonadotoxic chemotherapy in all cases where there is a high risk of POF and where emergency IVF is not possible.

[Uterine transplantation: animal and human studies]

Many cases of not life saving transplanted organs were described with the aim of improving quality of life. Uterus graft could be an alternative solution to adoption or surrogacy for women who have uterine factor infertility. Different animals' studies with mouse, sheep or monkey showed feasibility of the surgical technique with large vessels patch. One case of human uterine transplant has been reported but failed. Cold storage of the uterus in protective solution has been explored with mouse, sheep and human. Only pregnancy after uterus graft by syngenic mouse has been published. Results about pregnancy after allograft with sheep or monkey are necessary before pregnancy after human uterus graft becomes a reality.

[Uterine factors limiting ART coverage]

Transvaginal sonographic evaluation of endometrial texture and thickness may be an indicator of the likelihood of achieving pregnancy. Very few pregnancies occur when the endometrial thickness was less than 6 mm. When type C endometrium (multilayered endometrium consisting of prominent outer and midline hyperechogenic lines and inner hypoechogenic regions) greater than or equal to 6 mm thick was seen, the pregnancy rate per embryo transfer is goods. MR imaging is highly accurate in helping to diagnose adenomyosis which is a cause of repeated implantation failures in women undergoing IVF. Furthermore the MRI evaluation of junctional zone thickness (AJZ>7 mm and MJZ>10 mm) is the best negative predictive factor of implantation failure (97%). Thus, we advocate the measurement of junctional zone thickness with MRI in women with 2 consecutive implantation failure following IVF.

[Cryopreservation of ovarian tissue]

Ovarian tissue cryopreservation (OTCP) is a new procedure of medically assisted procreation, still at the experimental stage, whose primary aim is to store female gametes as sperm cryopreservation permits to do for male gametes. Ovarian tissue is removed very simply by laparoscopy. It survives well to freezing if the medium contains a cryoprotective agent and the rate of freezing is slow. In contrast, thawing must be rapid. There are three processes for the utilization of ovarian tissue after thawing. In vitro maturation and xenografting remain impossible for technical and ethical reasons. Autologous transplantation (orthotopic or heterotopic) of the tissue is therefore the only foreseeable method over the short term. Indications for OTCP must remain rare as long as no pregnancy has been obtained in human. At the present time, only female patients who would inevitably suffer the loss of their fertility should be able to take advantage of OTCP. Basically, this would mean women subjected to castrating anticancer therapy. It would seem reasonable to set the age limit at 35-years for carrying out OTCP. Lastly, female patients should be clearly informed that the method is still at the research stage, and in France samples must be taken in accordance with the laws governing clinical research.

[Uterine Doppler study for pre-implantation prognosis of the embryo]

To assess if a simple US criteria was present allowing pre- and post-implantation evaluation of the quality of the embryo. Measurement of the pulsatility index (PI) of the uterine arteries in association with evaluation of the type of curves was useful for follow-up. PI correlates with the number of follicules, the number of cells at Day 2, and the likelihood of pregnancy whereas the type of curve directly correlates with the appearance of the oocytes and embryo before the transfer. These results should be confirmed by larger studies but they could lead to early detection and a treatment of these abnormalities of vascularization.

Ovarian tissue cryopreservation and gynecologic oncology: a review

Sperm cryopreservation permits young men, undergoing cancer treatments, to preserve their fertility. Ovarian tissue cryopreservation have the same goal for young women and could also be an option for children. However, only primordial follicles survive after freezing and a follicular maturation is needed after thawing. This maturation has not yet been realized in humans, pregnancies have only been obtained in animal models. As cryopreservation is yet effective in humans, many teams have already cryopreserved the ovarian tissue of patients who have nothing to lose as their follicular reserve would have been destroyed or severely depleted by cancer treatment. The preservation of fertility is rarely an issue in gynecologic oncology because it usually concerns post-menopausal women. However, they are early-onset forms of gynecologic cancers and in these cases fertility is often threatened. Ovarian tissue cryopreservation may be performed when curative or prophylactic ovariectomy must be undergone, when chemotherapy with high-dose alkylating agents is planned or when pelvic radiation is needed (particularly in cases requiring chemotherapy combined with radiotherapy). In some of these situations it would be dangerous to graft back the tissue to the patient as cancer cells could remain within the grafts, the best solution in this case would be the in vitro follicular maturation.

[Indications for cryopreservation of ovarian tissue]

BACKGROUND

The first attempts at ovarian tissue cryopreservation (OTCP) were performed in the 1950s. Recent research efforts have demonstrated the possibility of obtaining pregnancy with this technique in three animal species and have shown good primordial human follicle survival up through the freezing process.

POTENTIAL INDICATIONS

OTCP is a procedure designed to protect ovarian tissue from threats to its follicular reserves. The first threat is the time-related massive physiological destruction of the follicular reserve ending with menopause. OTCP would enable this wastage to be arrested, thereby prolonging ovarian cycling beyond limits. Conditions producing premature menopause, when known in advance, may also potentially benefit from OTCP. The iatrogenic destruction of the follicular reserve by radiation therapy or alkylating agents is another situation where OTCP would enable the patient's fertility to be preserved. Among these clinical settings, iatrogenic destruction of follicular stocks appears to us, with the current state of research, to be an acceptable indication for OTCP.

[Heterotopic pregnancy: a report of 5 cases and review of the literature]

Heterotopic pregnancy, also called combined pregnancy, associates extra-uterine pregnancy and intra-uterine pregnancy. We report five cases of heterotopic pregnancy illustrating this condition and reviewed the recent literature from 1994 to 1999. We compared the results of this review with earlier data in the literature from 1971 to 1993. We observed that therapeutic management of the extra-uterine pregnancy and course of the intra-uterine pregnancy have changed little over this period. Conversely, the frequency of heterotopic pregnancy has steadily increased since the development of medically assisted reproduction, although spontaneous cases continue to occur. The diagnosis of heterotopic pregnancy is often difficult as the symptomatology is often misleading. Transvaginal ultrasound generally gives the diagnosis which may be confirmed by laparoscopy, allowing treatment of the extra-uterine pregnancy. Maternal and intra-uterine fetal prognosis depends on early diagnosis which should be made, if possible, prior to termination of the extra-uterine pregnancy.

Orthotopic and heterotopic autografts of frozen-thawed ovarian cortex in sheep

Freezing ovarian cortex is a new option to preserve the fertility of young patients undergoing cancer treatment or in women facing premature menopause. However, the best way to use this banked tissue remains unclear. The function of heterotopic and orthotopic autografts of frozen-thawed ovarian cortex of sheep was compared in the present study. Fresh and frozen-thawed fragments of ovarian cortex were autografted on the uterine horn of six ewes (orthotopic grafts) and under the skin of the belly in nine ewes (heterotopic grafts). In both orthotopic and heterotopic grafts, the resumption of follicular growth and ovulation was monitored. In orthotopically grafted ewes, fertility was recorded. Oocytes from both types of grafts were collected, matured and fertilized in vitro. In both fresh and frozen-thawed grafts follicular growth resumed normally; preantral and antral follicles were first detectable 4 and 10 weeks respectively following grafting but only 5% of the primordial follicles appeared to have survived. This confirms that grafting procedures are more deleterious for follicle survival than cryopreservation. Although ovulation resumed in most ewes, none of the ewes grafted orthotopically became pregnant at a synchronized mating. Seven months following grafting, oocytes could be collected from heterotopic and orthotopic grafts, matured and some of them fertilized, but none developed to the blastocyst stage. Heterotopic grafting may be an alternative to orthotopic grafting to preserve fertility provided follicle survival in the grafts is markedly improved.

[Folates and the neural tube. Review of the literature]

There are two types of neural tube fusion abnormality (NTFA)--craniorachischisis and rachischisis--with a prevalence of 11.2/10,000 in continental Europe. Their prevalence varies widely and is influenced by many factors, including geographical, racial and seasonal components. The transmission of NTFAs is usually polygenic and affected by many factors, and far more rarely of the mendelian monogenic type. The occurrence of NTFAs has been shown to be due to folic acid (FA) deficiency. First suspected in 1965, FA deficiency was proved to be a cause of NTFAs both occurring and recurring in the 1980s. FA deficiency might act by preventing the remethylation of homocysteine to methionine, the latter is known to play an essential role in fusion of the neural tube in animals. Primary prevention of NTFAs therefore requires that FA supplementation be given to women planning a pregnancy and after conception. Two possible ways of preventing FA deficiency can be envisaged, ie. via folic acid supplementation or systemic enrichment of the basic diet. Neither of the two alternatives is sufficient by itself and probably a combination of the two would provide the best means of preventing neural tube defects.

[Primary cytomegalovirus infection and pregnant women: epidemiological study on 1100 women at Limoges]

During 13 months, 1101 women attending for antenatal care at Limoges University Hospital were prospectively studied to determine the prevalence of Cytomegalovirus (CMV) antibodies: 47.9% of these women were CMV seropositive. Ethnic group was strongly associated with CMV status: 42.6% of metropolitan and 94.5% of immigrant women were seropositive. Seropositivity was associated with increasing parity and older age. The risk of a susceptible woman to acquire CMV infection during pregnancy is 0.7%. Among the 4 seroconversions, 3 children were infected, with developmentally and neurologically normal status in one case, moderate ear damage in an other case and a disseminated infection in the third case requiring a provoked abortion.

[Orthotopic autografts of ovarian slices in pregnant rats]

We carried out orthotopic autografts of ovarian tissue on 15 Wistar rats. One ovary has been removed and cut in 2 or 3 slices. The other ovary has been removed, and the controlateral slices grafted in the empty ovarian bursa by mean of a microscope, without vascular anastomosis. The endocrine function of the graft was assessed by checking the vaginal smears. The animals were mated. Two of them became pregnant with normal offsprings, two others has vaginal bleeding which could be miscarriages. This experimentation suggests that the orthotopic autograft of ovarian slices is possible in rats. The endocrine function of the ovary is restored with a very good rate. Fertility is restored for a small proportion of animals.

Laparoscopically assisted vaginal hysterectomy for non-malignant disease of the uterus. Report on a personal series of 126 cases

OBJECTIVE

A report is given of a series of 126 laparoscopically-assisted vaginal hysterectomies (LAVH) for benign lesions, carried out between September 1990 and December 1995.

MATERIALS AND METHOD

The mean age of the patients was 50.3 years, and the main indications for hysterectomy were metrorrhagia (88). The main reasons why LAVH was chosen from among other hysterectomy techniques were a large uterus (55), associated ovarian surgery (45), and a difficult vaginal approach (35). The surgical technique always began with a laparoscopic stage followed by a vaginal stage. The laparoscopic stage generally finished at the lower part of the broad ligament. The vagina was opened and the uterine arteries were ligatured by a vaginal approach (116). Only 10 total laparoscopic hysterectomies were performed.

RESULTS

The mean duration of the operation was 72 +/- 28 min, mean blood loss was 1.89 g/dl, and mean uterus weight was 224 g (maximum = 1093 g). Operative complications consisted of two bladder wounds and two switches to abdominal hysterectomy. Postoperative complications were urinary infections (17), hemorrhages needing second-look operations [2] and abscess of the vaginal section requiring evacuation [3].

CONCLUSION

LAVH should never be carried out instead of vaginal hysterectomy (VH), since VH is the best procedure when it is easy to perform. The authors use LAVH when VH is difficult or contraindicated (the aim being to avoid laparotomy) and actually carry out less than 5% of hysterectomies for benign lesions by laparotomy.

[Follicle freezing and autografting. A new method of medically assisted procreation?]

Although frozen human follicles were shown to be viable after thawing, more than forty years, the low yield of primordial follicles after cryopreservation has greatly limited research in this area. The aim of freezing follicles is to stock a patient's ovocytes before potentially destructive therapy for cancer then to reimplant the follicular tissue after successful treatment. The patient's ovulatory capacity would then theoretically be restored, allowing natural or possibly in vitro fertilization. As have other teams, we recently renewed work in cryopreservation of follicles in experimental models in search for a better cryopreservation agent and have had encouraging results suggesting that primordial human follicles or ovarian fragments can be grafted successfully after cryopreservation. Questions still under study include the optimal site for implantation, the survival time for grafts and the quantity of follicles needed to achieve pregnancy. Work on large animal models or xenografts of human tissues on immunotolerant animals may provide further insight. The possibilities of grafting primordial follicles, either alone or within ovarian tissue, may raise hope for many women, although new questions such as an age limit for reimplantation and use of allografts requiring preparation with major immunosuppressive therapy require further debate.