[Polycystic ovary syndrome does not affect blastulation nor cumulative live birth rates]. / Le syndrome des ovaires polykystiques n'altère pas les taux de blastulation ni les taux cumulés de naissances vivantes.

OBJECTIVES: Polycystic ovarian syndrome (PCOS) brings complications in the management of the assisted reproductive technology (ART) because of an oocyte quality probably impaired due to modifications of intra- and extra-ovarian factors. Our study aimed to investigate the extended culture in PCOS patients and its influence on the cumulative live birth rates. METHODS: Fifty-nine PCOS patients (as defined by the Rotterdam criteria) and 114 normo-ovulatory patients (i.e. with tubal, male or idiopathic infertility, regular cycles and AMH>2ng/mL) aged<37years old who underwent a 1st or 2nd ART attempt with extended culture to day 6 were included from October 2015 to December 2017. The blastulation and cumulative live birth rates were compared between the two groups. RESULTS: The PCOS and control patients were 32.22 and 32.91years old respectively (P=0.05). The median number of oocytes retrieved was significantly higher in the PCOS group and the median oocyte maturity rate significantly lower compared with controls. The blastulation rates were similar between the PCOS and the control groups, respectively 57.8% vs. 58.6%, P=0.88. Because of the risks of hyperstimulation syndrome, a freeze all strategy was achieved for 38.9% of PCOS patients vs. 14.0% of the control patients (P<0.01). The cumulative live birth rates were not statistically different: 31.7% in the PCOS group vs. 37.2% in the control group, P=0.50. CONCLUSIONS: PCOS was not observed to affect the extended culture nor the cumulative live birth rates in comparison to normo-ovulatory patients, supporting the blastocyst transfer strategy as a suitable option to PCOS patients.

[Teratozoospermia, myth or reality? A 10-years retrospective study on 101404 consecutive sperm samples]. / Tératozoospermie: mythe ou réalité? Étude d'une cohorte de 101 404 examens de sperme.

OBJECTIVES: Several studies have reported a time-related decline in semen quality. In this context, 101,404 spermograms-spermocytograms performed in a single andrology laboratory from January 2000 to December 2009 were investigated retrospectively. Variations of sperm parameters were analyzed over the years. PATIENTS AND METHODS: For each semen sample, age at semen collection, duration of sexual abstinence, volume of seminal fluid, pH, concentration of spermatozoa, percentages of overall motile and progressive motile sperm, percentage of morphologically abnormal spermatozoa (according to David's classification) and amplitude of lateral head displacement (ALH) were analyzed. For each parameter, the mean value per year was determined. To examine trends over time the statistical tests used were analyses of variance and correlation studies. RESULTS: Data showed an increasing age of patients from 36.5 years in 2000 to 37.2 years in 2009. The semen concentration was 63.5 millions/mL in 2000 and 63.6 millions/mL in 2009 with a slight fall from 2001 to 2008. The vitality continuously increased from 67.8% in 2000 to 73.5% in 2009 as well as the overall motility (from 37.7% to 39.2%) and the progressive motility (from 34.6% to 36.2%). The percentage of morphologically abnormal spermatozoa continuously increased from 64.5% to 84.2% (r=0.43, P<0.001). DISCUSSION AND CONCLUSION: Contrary to a variety of works, our very large study of semen analysis did not show a real decline in semen WHO parameters during a 10-year period, except for the percentage of morphologically abnormal spermatozoa, which dramatically increased over the years.

[FSH and IVF management: the best and worst case scenarios]. / FSH et prise en charge en fécondation in vitro: la meilleure et la pire des choses.

OBJECTIVE: A recent meta-analysis covering 21 studies shows that, when taken in isolation, the basal FSH level (commonly used to assess the ovarian reserve) is a poor indicator of successful in vitro fertilization (IVF) outcome. PATIENTS AND METHODS: We present a personal series of 3592 IVF procedures. Analysis of the results compares the age and basal FSH values, based on a statistical analysis that is essentially descriptive. RESULTS: When FSH levels are high, the pregnancy rate remains acceptable in young women (<38 years); it drops sharply, however, in older women. In each age group, the rate of spontaneous miscarriage does not increase according to FSH level. The pregnancy rate is better in young women with high FSH levels than in older women with normal FSH levels. DISCUSSION AND CONCLUSION: The results presented agree with the studies published in the literature, which suggest that FSH is a prognostic factor for the quantity of oocytes obtained (ovarian reserve) while age defines the quality of the oocyte: it is this difference in quantity, and not in quality, which makes the difference between cases of poor and normal response to IVF. In young women at least, a high FSH level is not a contra-indication in principle for IVF.

[Diethylstilbestrol exposure in utero. Polemics about metroplasty. The pros]. / Utérus DES. Polémiques sur l'hystéroplastie d'agrandissement. Arguments pour.

The diethylstilbestrol (DES) is a synthetic estrogen which was prescribed from 1941 onwards for the prevention of miscarriage. As well as a possible risk of cancer, another side effect of this treatment was the possible abnormality of the genitalia in the female issue of the prescribed user. Apart from possibly having a hypoplasic uterus, the patient is also prone, in the case where she has an undersized uterus, to having a much narrower than normal cavity. Consequently, there is a tendency for an excess of muscle tissue on the uterus walls. This can be observed on a RMN. The most significant characteristics of this abnormality are: constriction rings around the proximal uterine segment, a T shaped uterus, uterus with an arched base. The idea of the plastic enlargement operation (metroplasty) is to widen the cavity by making careful incisions of the excess muscle tissue located on the uterus wall. The objective of this is to obtain a triangular shaped cavity taking care though to weaken the walls themselves. 61 patients were treated. We observed 37 pregnancies after 16 months with 30 ongoing pregnancies. Generally, the anatomic results are excellent but it is difficult to measure the functional results of the success rate in future pregnancies. The reason for this is the enlarging of the cavity alone does not guarantee successful fertility. There are other problems to take into account e.g. implantation, miscarriage and premature labor. There are risks with this operation, such as placenta percreta, a possible rupture of the uterus, though this can happen at any time with DES patients. This operation can only be recommended once a thorough examination of the patient has been made.

[Is the concentration of plasma FSH a criterion for refusal?]. / Le dosage de la FSH plasmatique est-il un critère de refus?

FSH level is correlated with ovarian reserve. Oocyte quality is correlated with women age. Pregnancy rate decreases and miscarriage rate increases with woman age. In young women, high FSH level are not associated with a lower pregnancy rates. Thus, in young women, high basal FSH is not a contraindication to IVF treatment. Miscarriage rate is not correlated with FSH level. The outcome of IVF is higher in young patients with elevated FSH levels, than in patients older than 40 years of age with normal FSH levels.

[Difficult embryo transfer: what can be done in practice?]. / Transfert embryonnaire difficile: que faire en pratique ?

Embryo transfer is an important step in the success of IVF treatment. One must avoid, at all cost, difficult transfers provoking bleeding, uterine contractions, and the retention of the embryo in the cervix, or even, its expulsion. Evaluation before IVF treatment, including a trial transfer, should allow one to evaluate the transfer step, anticipate problems, and thus improve treatment. The difficult insertion into the womb is most often associated with the presence of curves, which can be easily overcome by using pre-curved catheters.

[Hysteroplasty for enlargement: apropos of the results]. / L'hystéroplastie d'agrandissement: à propos des résultats.

The DiethylstilBbestrol (DES) is a synthetic estrogen which was prescribed from 1941 onwards for the prevention of miscarriage. As well as a possible risk of cancer, another side effect of this treatment was the possible of abnormality of the genitalia in the female issue of the prescribed user. Apart from possibly having a hypoplasic uterus, the patient is also prone, in the case where she has an undersized uterus, to having a much narrower than normal cavity. Consequently there is a tendency for an excess of muscle tissue on the uterus walls. This can be observed on an RMN. The most significant characteristics of this abnormality are: constriction rings around the proximal uterine segment, a T shaped uterus, uterus with an arched based. The idea of the plastic enlargement operation is to widen the cavity by making careful incisions on the excess muscle tissue located on the uterus wall. The objective of this is to obtain a triangular shaped cavity taking care though not to weaken the walls themselves. 51 patients were treated. We observed 31 pregnancies (49%) after 16 months with 25 ungoing pregnancies. Generally the anatomic results are excellent but it's difficult to measure the functional results or the success rate in future pregnancies. The reason for this is the enlarging of the cavity alone does not guarantee successful fertility. There are other problems to take in to account e.g. implantation, miscarriage and premature labor. There are risks with this operation: placenta percreta, a possible rupture of the uterus, though this can happen at any time with DES patients. This operation can only be recommended once a thorough examination of the patient has been made. It is not advisable with a patient who has a hypoplasic cavity in a hypoplasic uterus (hysterometry < 4 cm). This operation should never be done as a first course of action but it can be recommended above all if the patient has a constriction ring: as a sole reason for infertility; where infertility has been diagnosed and unsuccessfully treated; and an unexplained failure of ART, and where the patient has unexplained repeated miscarriages.

Embryos with high implantation potential after intracytoplasmic sperm injection can be recognized by a simple, non-invasive examination of pronuclear morphology.

Embryos are conventionally selected for transfer based on the evaluation of the cleavage speed and extent of blastomere fragmentation. Here we examined whether the predictive value of these criteria, as indicators of the chance of embryo implantation, can be further potentiated by adding previously described criteria reflecting the regularity of pronuclear development. In a group of embryos selected for transfer in 380 fresh embryo transfer cycles according to the conventional criteria, the transfer of only those embryos that developed from zygotes judged normal at the pronuclear stage (pattern 0) gave significantly higher pregnancy (44.8%) and implantation (30.2%) rates compared with the pregnancy (22.1%; P < 0. 05) and implantation rates (11.2%; P < 0.001) for the transfers of only those embryos that developed from zygotes judged abnormal (non-pattern 0). The transfer of only one pattern 0 embryo was sufficient for the optimal chance of pregnancy (no differences in pregnancy rates after transfer of one, two or three pattern 0 embryos), whereas the transfer of two pattern 0 embryos mostly resulted in a twin pregnancy. The inclusion of the criteria based on pronuclear morphology can thus lead to the application of a single embryo transfer policy and optimize the selection of embryos for transfer and cryopreservation.

[Uterus and diethylstilbestrol: which examinations, which antecedents for an active management? Which treatments?]. / Utérus et diethylstilbestrol: quelles explorations, quels antécédents pour une prise en charge active? Quels traitements?

Diethylstilbestrol (DES) was widely prescribed to pregnant women from 1946 to 1977. This resulted in multiple abnormalities of the genital tract. Many studies show an increased incidence of infertility, ectopic pregnancy, spontaneous abortions and premature delivery. For women with certain abnormalities such as a construction of the upper uterine cavity, with or without a T configuration of the uterus, hysteroscopic metroplasty is feasible with good anatomic and functional results.

[Non-obstructive azoospermia and ICSI]. / Azoospermies sécrétoires et ICSI.

50 cases of non obstructive azoospermia required testicular sperm extraction and ICSI. Results are promising but ability to find spermatozoa remains questionable. Further studies are necessary to improve success of the method. Genetic research also need to be developed for better understanding the process.

Sterilization reversal: fertility results.

Fertility outcome following sterilization reversal by laparotomy was evaluated. We studied all sterilization reversals performed between January 1978 and December 1991; a total of 226 women were treated. Tubal anastomosis was performed according to the rules for microsurgery. The microsurgical technique comprised two main phases: preparation of the healthy tube segments and the anastomosis carried out on two layers. It was possible to study the subsequent fertility of 206 patients in all, as 20 patients were lost to follow-up (8.8%). Cumulative pregnancy rates were evaluated by life-table analysis. The overall intrauterine pregnancy rate, including births and miscarriages, was 69.9% (144 patients) after 2 years. The cumulative intrauterine pregnancy rate was 62% at 18 months. Analysis of the fertility results demonstrated that age was the most significant predictive factor. The cumulative intrauterine pregnancy rate at 2 years was 83.5% (61 cases) for patients < or = 33 years, 70% (35 cases) for patients aged 34-36 years, 62.5% (30 cases) for patients aged 37-39 years, and 51.4% (18 cases) for patients aged > or = 40 years. Even for patients aged approximately 40 years, microsurgical repermeabilization can be retained as the first choice rather than in-vitro fertilization.

PIP: At Cochin-Port Royal Hospital in Paris, France, gynecologic surgeons used laparotomy to perform microsurgical sterilization reversal on 226 patients aged 6-41 during January 1978-December 1991. 20 women were lost to follow-up. The researchers used life-table analysis to examine cumulative pregnancy rates. The mean interval between sterilization and sterilization reversal was 6.15 years. The surgeons first prepared the healthy tube segments and then performed anastomosis on two layers. At 18 months and 2 years post-reversal, the overall intrauterine pregnancy rates (births and miscarriages) stood at 62% and 69.9%, respectively. The average time between sterilization reversal and intrauterine pregnancy was 9.6 months. At 2 years, there were 4 ectopic pregnancies (2%). Even though women who had undergone bilateral sterilization reversal were more likely to become pregnant and to become pregnant more quickly than those who had undergone unilateral sterilization (73% vs. 56.4% and 8.8 vs. 12.2 months), the differences were insignificant. The type of anastomosis (e.g., isthmic-isthmic or isthmic-ampullary) had no bearing on fertility, as long as the tubes were at least 3 cm in length. The intrauterine pregnancy rates decreased with age (p = 0.01) (at 2 years post-reversal: 83.5% for age 33 or younger; 70% for age 34-36; 62.5% for age 37-39; and 51.4% for age 40 or older). Age was the most significant predictive factor of return to fertility. The findings show that microsurgical repermeabilization can remain the first choice rather than in-vitro fertilization for sterilized women wishing to bear a child, even women around age 40.

[Laparoscopic salpingostomies: analysis of results]. / Salpingostomies percoelioscopiques: analyse des résultats.

One hundred and twenty three infertile women were treated by laparoscopic salpingostomy. The intra-uterine pregnancy rate is 30.4%. The mucosal status seems to be the principal prognostic factor.

[Total laparoscopic hysterectomy. Operative technique, results and indications]. / Hystérectomie totale per-coelioscopique. Technique opératoire, résultats et indications.

Total hysterectomy was performed via laparoscopy alone in 50 patients. In all cases, the operation was carried out using conventional, re-usable instruments (grasping forceps, laparoscopic scissors, bipolar coagulation). The mean duration of the operation was 163 min (range: 110-270 min). The mean drop in haemoglobin was 1.97 g/100 ml (range: 0-4 g/100 ml) and the average length of hospital stay was 3.9 days (range: 2-13 days). In one case (2%), we converted to laparotomy because a lateral myoma made it impossible to achieve haemostasis of the uterine pedicule under suitably safe conditions. No serious peri or post-operative complications were encountered. No second surgery was necessary and no transfusion was required. These results confirm that total laparoscopic hysterectomy via laparoscopy is a safe, feasable and reproductible technique. Future work will establish the exact place and methods for laparoscopic surgery for hysterectomy. Laparoscopic surgery is only indicated when vaginal hysterectomy is contraindicated or impossible. Laparoscopic hysterectomy constitutes an alternative to laparotomy rather than the vaginal hysterectomy. The combination of an immobile uterus and poor vaginal accessibility is the prime indication for total hysterectomy via laparotomy.

[Laparoscopic surgery of large uterine fibromas. Operative technique and results]. / Traitement coeliochirurgical des volumineux fibromes utérins. Technique opératoire et résultats.

OBJECTIVE. To describe the technique of laparoscopic myomectomy for large myomas (5 cm and more) and to evaluate the results. RESULTS. Only myomas which are complicated (and/or resistant to properly conducted medical treatment) require surgical treatment. Between October 1, 1990 and October 31, 1994, we carried out 72 laparoscopic myomectomies for intramural myomas measuring 5 cm or more, in 71 patients. The operations lasted 130 +/- 60 min (range: 40-330 min). We converted to laparotomy for two cases (2.7%). We observed no serious per or postoperative complications. We never needed a repeat operation, whether by laparotomy or by laparoscopy. CONCLUSION. Despite these encouraging results, it must be remembered that the operation is lengthy and difficult and is reversed for laparoscopic surgeons perfectly familiar with endoscopic knot tying. Although it is a difficult technique, laparoscopic myomectomy is possible even for large myomas and those that are completely intramural. These results need to be assessed over the long term especially with respect to the risk of adhesions and the quality of the laparoscopic suture.

Total laparoscopic hysterectomy: preliminary results.

Total hysterectomy carried out entirely via laparoscopy benefited 31 patients. In all cases the operation was carried out using conventional, re-usable instruments (grasping forceps, laparoscopic scissors, bipolar coagulation). The mean duration of the operation was 171 min. No serious peri- or post-operative complications were encountered and no transfusion was required. The mean drop in haemoglobin was 1.3 g/100 ml and the average length of hospital stay was 4 days. In one case (3.26%) we converted to laparotomy because a lateral myoma made it impossible to achieve haemostasis of the uterine pedicle under suitably safe conditions. These results confirm that total hysterectomy via laparoscopy is a safe, feasible and reproducible technique. Future work will establish the exact place and methods for laparoscopic surgery for hysterectomy; it can be suggested, however, that laparoscopic surgery is only indicated when vaginal hysterectomy is contra-indicated or impossible. So, laparoscopic hysterectomy constitutes an alternative to laparotomy rather than to vaginal hysterectomy. The combination of an immobile uterus and poor vaginal accessibility is the prime indication for total hysterectomy via laparoscopy.

Treatment of ovarian dermoid cysts. Place and modalities of operative laparoscopy.

The purpose of this study was to discuss the place and the specific modalities of laparoscopic surgery in the management of ovarian dermoid cysts. This retrospective and noncomparative study was carried out in 65 patients who presented dermoid ovarian cyst between January 1986 and December 1990 in our institution. The surgical treatment was performed purely by laparoscopy in 86.2% of the cases (56 patients). The modalities of laparoscopic surgery were as follows: ovariectomy (8 cases; 14.3%), transparietal cystectomy (4 cases; 7.1%) and intraperitoneal cystectomy (44 cases; 78.6%). In 15 cases (15/44 = 34%) the intraperitoneal cystectomy was carried out without opening the cyst and the intact cyst was extracted using an endoscopic impermeable sack. We observed no cases of chemical peritonitis. The risk of recurrence after conservative treatment is 4% (two patients) and out of the ten patients for whom a second-look laparoscopy was performed only two (20%) presented adhesions. Laparoscopic treatment of dermoid ovarian cysts is feasible, safe, and effective. The treatment can be conservative in over 80% of the cases. The specific risk of chemical peritonitis can be countered by a change in the cystectomy technique. The use of an impermeable laparoscopic sack permits extraction of the cyst without any peritoneal contamination.