Should we perform oocyte accumulation to preserve fertility in women with Turner syndrome? A multicenter study and systematic review of the literature.

STUDY QUESTION: Should we perform oocyte accumulation to preserve fertility in women with Turner syndrome (TS)? SUMMARY ANSWER: The oocyte cryopreservation strategy is not well adapted for all TS women as their combination of high basal FSH with low basal AMH and low percentage of 46,XX cells in the karyotype significantly reduces the chances of freezing sufficient mature oocytes for fertility preservation. WHAT IS KNOWN ALREADY: An oocyte cryopreservation strategy requiring numerous stimulation cycles is needed to preserve fertility in TS women, to compensate for the low ovarian response, the possible oocyte genetic alterations, the reduced endometrial receptivity, and the increased rate of miscarriage, observed in this specific population. The validation of reliable predictive biomarkers of ovarian response to hormonal stimulation in TS patients is necessary to help practitioners and patients choose the best-personalized fertility preservation strategy. STUDY DESIGN, SIZE, DURATION: A retrospective bicentric study was performed from 1 January 2011 to 1 January 2023. Clinical and biological data from all TS women who have received from ovarian stimulation for fertility preservation were collected. A systematic review of the current literature on oocyte retrieval outcomes after ovarian stimulation in TS women was also performed (PROSPERO registration number: CRD42022362352). PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 14 TS women who had undergone ovarian stimulation for fertility preservation were included, representing the largest cohort of TS patients published to date (n = 14 patients, 24 cycles). The systematic review of the literature identified 34 additional TS patients with 47 oocyte retrieval outcomes after ovarian stimulation in 14 publications (n = 48 patients, n = 71 cycles in total). MAIN RESULTS AND THE ROLE OF CHANCE: The number of cryopreserved mature oocytes on the first cycle for TS patients was low (4.0 ± 3.7). Oocyte accumulation was systematically proposed to increase fertility potential and was accepted by 50% (7/14) of patients (2.4 ± 0.5 cycles), leading to an improved total number of 10.9 ± 7.2 cryopreserved mature oocytes per patient. In the group who refused the oocyte accumulation strategy, only one patient exceeded the threshold of 10 mature cryopreserved oocytes. In contrast, 57.1% (4/7) and 42.9% (3/7) of patients who have underwent the oocyte accumulation strategy reached the threshold of 10 and 15 mature cryopreserved oocytes, respectively (OR = 8 (0.6; 107.0), P = 0.12; OR= 11 (0.5; 282.1), P = 0.13). By analyzing all the data published to date and combining it with our data (n = 48 patients, n = 71 cycles), low basal FSH and high AMH concentrations as well as a higher percentage of 46,XX cells in the karyotype were significantly associated with a higher number of cryopreserved oocytes after the first cycle. Moreover, the combination of low basal FSH concentration (<5.9 IU/l), high AMH concentration (>1.13 ng/ml), and the presence of 46,XX cells (>1%) was significantly predictive of obtaining at least six cryopreserved oocytes in the first cycle, representing objective criteria for identifying patients with real chances of preserving an adequate fertility potential by oocyte cryopreservation. LIMITATIONS, REASONS FOR CAUTION: Our results should be analyzed with caution, as the optimal oocyte number needed for successful live birth in TS patients is still unknown due to the low number of reports their oocyte use in the literature to date. WIDER IMPLICATIONS OF THE FINDINGS: TS patients should benefit from relevant clinical evaluation, genetic counseling and psychological support to make an informed choice regarding their fertility preservation technique, as numerous stimulation cycles would be necessary to preserve a high number of oocytes. STUDY FUNDING/COMPETING INTEREST(S): This research received no external funding. The authors declare no conflict of interest. TRIAL REGISTRATION NUMBER: N/A.

[What issues, changes and adaptations for French ART centers in the context of the new bioethics law?] / Quels enjeux et adaptations pour les centres d'AMP dans le cadre de la mise en place de la nouvelle loi de bioéthique ?

OBJECTIVE: This review intends to introduce the changes of the new Bioethics law in the reproductive field and its application in French ART centers. MATERIAL AND METHODS: The review details the main provisions of the Bioethics Law of August 2nd 2021 as well as the three decrees published since: the first one on September 29th 2021, which specifies in particular the age conditions to benefit from ART and self-preservation of one's gametes; another decree on December 31st, 2021, to set the terms and conditions for gamete self-preservation activities for non-medical reasons and the last decree on April 14th 2022, relating to the allocation of donated gametes and embryo donation. RESULTS: Since the law of August 2nd, 2021, access conditions to assisted reproductive technology (ART) have evolved in France. Previously based on pathological infertility or the risk of transmission of a serious disease, ART is now intended to respond to the parental project of a couple formed by a man and a woman, two women or an unmarried woman. With the widening of access conditions, the use of gamete donation will likely increase. The upcoming raise of children born from gamete donation has led the legislator to question their right to access their origin. From September 1st 2022, adults born from gamete donation will be able to request a special administrative authority in order to access the donor's non identifying data (age, physical characteristics, family and professional situation, motivation for the donation…) and/or the donor's identity. Moreover, the new bioethics law opens up the possibility of autologous gamete cryopreservation without medical reasons, under specific age conditions, in order to carry out an assisted reproduction technique later. If gametes are not used, autologous gamete preservation could also allow an increase in gamete donation. However, the modification of gamete donation conditions could suggest a short term decrease in donors' number. Finally, the new bioethics law further opens up research on human embryos and embryonic stem cells. CONCLUSION: The arrangements introduced by the Bioethics Law promulgated on August 2nd, 2021 represent a major revolution in the field of Reproductive Medicine and are expected to transform the practices of reproductive biology centers and CECOS in France.

[HLA-C KIR interactions and placental defects: Implications in ART pregnancy issues]. / Interactions HLA-C KIR et anomalies de la placentation : implications dans les issues de grossesses obtenues en AMP.

OBJECTIVE: The aim of this review is to update data concerning the impact of HLA-C KIR system on placental disorders and assess the involvement on ART clinical outcomes. METHOD: Ensuring the maintenance of human pregnancy requires the set up of immunological tolerance to prevent foetus rejection. This phenomenon involves different actors of the immune system: among them, uterine NK cells (uNK) hold specific KIR (killer-cell immunoglobulin-like) receptors linking to HLA molecules on the surface of trophoblastic cells at implantation. Many studies provided evidence that the specific interaction between maternal KIR and foetal HLA-C could influence the process of placentation; according to the KIR haplotype and the type of HLA-C, the interaction could be detrimental for placental function. We reviewed the latest data available regarding HLA-C KIR interactions and ART outcomes. RESULTS: The available results highlight a significant increase of preeclampsia risk and recurrent miscarriages when the maternal inhibitory haplotype KIR AA is present, this risk is all the more enhanced when the interaction occurs with foetal HLA-C2. Recent data suggest the consequences of this detrimental interaction in case of DET (double embryo transfer) or use of donor's oocytes in ART practice. On the other hand, maternal KIR AB or BB haplotypes haven't been related to an additional obstetrical risk, as well as the foetal HLA-C1 homozygous allotype. CONCLUSION: Despite the existence of many confoundings in current literature on the subject, interaction between maternal KIR and foetal HLA-C represent a promising target lead to broaden the spectrum of placental defects etiologies, especially in the reproductive health area.

[Environmental endocrine disruptors and fertility]. / Perturbateurs endocriniens environnementaux et fertilité.

Endocrine disruptor chemicals (EDCs) are ubiquitous contaminants in the environment, wildlife, and humans. During the last 20 years, several epidemiological, clinical and experimental studies have demonstrated the role of EDCs on the reduction of male and female fertility. The concept of foetal origins of adult disease is particularly topical in the field of reproduction. Moreover, exposure to EDCs during pregnancy has been shown to influence epigenetic programming of endocrine signalling and other important physiological pathways, and provided the basis for multi- and transgenerational transmission of adult diseases. However, the large panel of EDCs simultaneously present in the air, sol and water makes the quantification of human exposition still a challenge. Gas chromatography coupled with mass spectrometry, the measurement of total plasmatic hormonal bioactivity on stably transfected cell lines as well as the EDC analysis in hair samples are useful methods of evaluation. More recently, microRNAs analysis offers a new perspective in the comprehension of the mechanisms behind the modulation of cellular response to foetal or post-natal exposure to EDCs. They will help researchers and clinicians in identifying EDCs exposition markers and new therapeutic approaches in the future.

[Cesarean scare niche: Definition, diagnosis, risk factors, prevention, symptoms, adverse effects, and treatments]. / Isthmocèle : définition, diagnostic, facteurs de risque, prévention, symptômes, complications, et traitements.

OBJECTIVES: To review the definitions, diagnostic methods, risk factors, symptoms, and treatments for caesarean scar niche. METHODS: Review of the literature, critical reflection, and pragmatic advice. RESULTS: There is no consensus on the definition of caesarean scar niche. Some suggest an indentation≥2mm of the myometrium of the caesarean scar, but this is present in more than half of women with caesarean history and takes no account of woman's symptoms. The most popular diagnostic method is ultrasound±hysterosonography. Risks factors for niche are multiple Caesareans, Cesarean during labor with too low incision, and retroverted uterus. Symptoms include abnormal gynaecologic bleeding and pelvic pain, and their presence establish the "Caesarean scar syndrome". The risks of pregnancy with niche is poorly studied, but pregnancy is not contraindicated, even if the niche is untreated. The treatment of caesarean scar niche is mainly surgery and conservative. The former should be reserved for symptomatic patients, and those with secondary infertility and fertility treatment failure. Patients with residual myometrium thickness≥2.5mm may benefit from first-line hysteroscopic treatment, whereas a laparoscopic or vaginal approach could be offered in other cases. CONCLUSIONS: A pragmatic definition of caesarean scar niche as a disease including symptoms is the necessary prerequisite for the management of women. The treatment is mainly surgical, or conservative depending on the desire for subsequent pregnancy.

[Assessment of genital microbiota: An emerging approach in assisted reproductive techniques]. / Évaluation du microbiote génital : une approche émergente en assistance médicale à la procréation.

The genital microbiota actively participates in women's reproductive health. Indeed, a genital dysbiosis (microbial imbalance associated with adverse effects on host health) can lead to vaginal infections (such as mycoses or bacterial vaginosis). Recent data reported that genital dysbiosis (e.g. vaginal or endometrial) was associated with fewer chances of live births in assisted reproductive technologies (ART), via decreased pregnancy rates and an increased risk of miscarriages. The presence or diversity of certain bacterial strains (in particular Gardenellavaginalis, Proteobacteria, Lactobacillusjensenii, Lactobacilluscrispatus or Atopobiumvaginae) within the genital microbiota seem to be associated with the outcomes of ART cycles, suggesting new approaches to improve ART results. In this review, we aim at presenting the state of art on the association between the female genital microbiota and ART success. The diagnostic and therapeutic approaches (i.e. probiotics, antibiotic therapy and transplantation of vaginal microbiota) in the management of patients with altered microbiota will also be discussed. The confirmation of these data in the coming years could significantly improve the management of infertile patients in ART with a more personalized approach partially based on the female genital microbiotic profile.

[Endometrial receptivity in assisted reproductive techniques: An aspect to investigate in embryo implantation failure]. / La réceptivité endométriale en aide médicale à la procréation : Une piste à ne pas oublier devant un échec d'implantation.

Infertility affects between 8 and 12% of reproductive-age couples worldwide. Despite improvements in assisted reproductive techniques (ART), live birth rates are still limited. In clinical practice, imaging and microscopy are currently widely used, but their diagnostic effectiveness remains limited. In research, the emergence of innovative techniques named OMICS would improve the identification of the implantation window, while progressing in the understanding of the pathophysiological mechanisms involved in embryo implantation failures. To date, transcriptomic analysis seems to be the most promising approach in clinical research. The objective of this review is to present the results obtained with the different approaches available in clinical practice and in research to assess endometrial receptivity in patients undergoing ART.

[Comparison of birth weights of children born after slow frozen embryo replacement versus fresh embryo transfer]. / Embryons vitrifiés, embryons frais : comparaison des poids de naissance.

OBJECTIVE: It is already known that children born after slow frozen embryo replacement have a significantly higher birth weight compared to children born after fresh embryo transfer. Similar data have been reported related to frozen embryo transfer using an open vitrification system. However, few data relative to birth weight using a complete embryo closed vitrification system has been reported. The purpose of this study was to know if frozen embryo in closed vitrification system is associated with a higher birth weight compared to fresh embryo replacement. DESIGN: This was a monocentric retrospective cohort study, 371 children were issued from fresh embryo replacement and 127 from vitrified embryo transfer. MATERIALS AND METHODS: All singletons born after fresh or vitrified embryo transfer between January 2011 and April 2015 were included. Births from the vitrified or fresh transfers of egg or sperm donation, and preimplantation genetic diagnosis were excluded. In addition, pregnancies with more than one gestational sac at the first ultrasound were excluded. An analysis of covariance (ANCOVA) was used for multivariate analysis. RESULTS: Mean birth weight was 205g higher in the frozen embryo compared with fresh embryos transfer groups (3368g vs. 3163g respectively, P<0.001). This difference remained after multivariate analysis adjusted on confounding factors such as gestational age, maternal age, maternal body mass index (BMI), tobacco exposure, number of embryo transferred and birth order (P<0.001).. CONCLUSIONS: Embryo frozen in closed vitrification system is associated with a higher birth weight compared to fresh embryo replacement. Our findings are consistent with the previous studies related to slow freezing and open vitrification systems data. The effects of controlled ovarian stimulation (COS), ex vivo culture conditions and cryopreservation systems on birth weight of children born should be further explored.

Global, Survival, and Apoptotic Transcriptome during Mouse and Human Early Embryonic Development.

Survival and cell death signals are crucial for mammalian embryo preimplantation development. However, the knowledge on the molecular mechanisms underlying their regulation is still limited. Mouse studies are widely used to understand preimplantation embryo development, but extrapolation of these results to humans is questionable. Therefore, we wanted to analyse the global expression profiles during early mouse and human development with a special focus on genes involved in the regulation of the apoptotic and survival pathways. We used DNA microarray technology to analyse the global gene expression profiles of preimplantation human and mouse embryos (metaphase II oocytes, embryos at the embryonic genome activation stage, and blastocysts). Components of the major apoptotic and survival signalling pathways were expressed during early human and mouse embryonic development; however, most expression profiles were species-specific. Particularly, the expression of genes encoding components and regulators of the apoptotic machinery were extremely stable in mouse embryos at all analysed stages, while it was more stage-specific in human embryos. CASP3, CASP9, and AIF were the only apoptosis-related genes expressed in both species and at all studied stages. Moreover, numerous transcripts related to the apoptotic and survival pathway were reported for the first time such as CASP6 and IL1RAPL1 that were specific to MII oocytes; CASP2, ENDOG, and GFER to blastocysts in human. These findings open new perspectives for the characterization and understanding of the survival and apoptotic signalling pathways that control early human and mouse embryonic development.

[Birth weight and frozen embryo transfer: State of the art]. / Poids de naissance et transfert d'embryon congelé : état de l'art.

The aim of this study was to update our acknowledgment if there is a link between assisted embryo cryopreservation and epigenetics in human? Animal studies have demonstrated epigenetics consequence and especially imprinting disorders due to in vitro culture. In human, it is important to note that after frozen embryo transfer birth weight is significantly increased by 81 to 250g. But these studies cannot identify the reasons of such difference. This review strongly suggests that embryo cryopreservation is responsible for birth weight variations but mechanisms not yet elucidated. Epigenetics is probably one of these but to date, none study is able to prove it. We have to be attentive on a possible link between assisted reproductive technology (ART) and epigenetics reprogrammation.

[Natural cycle for frozen-thawed embryo transfer: Spontaneous ovulation or triggering by HCG]. / Transferts d'embryons congelés en cycle naturel : ovulation spontanée ou déclenchement par hCG ?

OBJECTIVE: To compare frozen-thawed embryo transfer (FET) outcomes in natural cycles according to ovulation induction: spontaneous versus recombinant human chorionic gonadotrophin (r-hCG) triggering. METHODS: This retrospective study included all patients monitored for natural cycle FET during one year. When serial monitoring were performed until spontaneous LH rise, patients were included in group A (n=38) whereas those receiving r-hCG for ovulation triggering formed group B (n=43). All embryos had been cryopreserved by a vitrification method following a previous IVF cycle. No luteal phase support had been given. We compared outcomes between the 2 groups. RESULTS: After checking groups comparability, we didn't find significant difference for the implantation rate, clinical pregnancy rate and live birth (31% vs 45%, 32% vs 51% et 21% vs 32%, respectively for group A and B). The number of monitoring was significantly lower in group B (1,9±0,8 versus 2,5±1, P=0,006). DISCUSSION: Although no consensus has been yet established, natural cycle seems indicated for normo-ovulating patients but the question of ovulation induction is still debated. In our study, triggering ovulation by r-hCG, respecting strict criteria, seems provide good results while reducing both protocol's constraints and cost.

[Quality of oocytes and embryos from women with polycystic ovaries syndrome: State of the art]. / Qualité ovocytaire et embryonnaire chez les femmes avec syndrome des ovaires polykystiques : état de l'art.

The frequency of polycystic ovary syndrome (PCOS) and the consequent fertility disorders cause many difficulties in the management of the assisted reproductive technics. Some studies are focused on different additional treatments, stimulation protocols or techniques that could optimize the in vitro fertilization cycles. The quality of the oocytes and embryos of these patients is also an outstanding issue. They remain difficult to actually evaluate during management, and none of the few published studies on this subject demonstrated any inferiority, compared to control patients. However, many differences have been highlighted, studying intra- and extra-ovarian factors. The advent of new genetic techniques could allow a better understanding of the pathophysiological mechanisms of the syndrome, as well as refining the evaluation of oocytes and embryos, in order to better predict the results of in vitro fertilization attempts. Pregnancy and birth rates, however, appear to be comparable to those of the general population.

[Biomarkers of the cumulus cells in medically assisted procreation: State-of-the-art]. / Biomarqueurs des cellules du cumulus en assistance médicale à la procréation : état des lieux.

The oocyte grows within a follicle composed of layers of somatic cells. It undergoes with the cumulus cells that form the innermost layer a dialogue that is critical for its maturation. Based on the assumption that the transcriptome of the cumulus cells reflects the physiology of the oocyte, it may prove a useful non-invasive tool in embryo selection to improve assisted reproduction outcomes. During the past decade, various studies have been conducted with the objective of identifying cumulus biomarker genes as prognosis tools for oocyte quality and competence. Remarkably no common biomarkers stand out among all these studies. In this review we perform a critical analysis of the literature in order to reveal some of the parameters that may account for these discrepancies, such as patients' inclusion criteria (maternal age, stimulation protocols), day of embryo transfer (day 3 or 5), outcome criteria (oocyte potential, embryo competence, pregnancy). Moreover there is a lack of standardization in the experimental designs used for RNA extraction and gene expression assessment (microarrays, RT-qPCR) and for the statistical analyses. In conclusion, critical analyses such as the present one are indispensable to pave the way for future searches of predictive biomarkers of pregnancy.

Male infertility: an obstacle to sexuality?

Interactions between infertility and sexuality are numerous and complex. Infertile men may suffer from sexual dysfunction (SD) when undergoing an assisted reproductive technology programme. We undertook a review both in French and English of the available data on male SD when being diagnosed with a fertility problem with a specific focus on azoospermic men. The review was performed over a 30-year time period using PubMed/Medline. The sexual concerns and needs of infertile/sterile men for whom potential parenting can be compromised were evaluated. When diagnosed with infertility, men usually go through a crisis that can have a deleterious effect on their sexuality with sometimes a feeling of sexual inadequacy. Infertile men will feel stigmatized because they are perceived as being deficient in a specific component of their masculinity. Hence, subsequent SD may occur that can impact the couple sexuality and the infertility management. However, little is known on how the announcement of azoospermia may affect male on a sexual and psychological point of view. The present review suggests that a global management through a healthcare network (biologist, andrologist, sexologist and psychologist) is required which will allow to consider infertility and its subsequent sexual disorders as a whole and not as dichotomized issues.

Circulating microRNAs in follicular fluid, powerful tools to explore in vitro fertilization process.

Circulating or "extracellular" microRNAs (miRNAs) detected in biological fluids, could be used as potential diagnostic and prognostic biomarkers of several disease, such as cancer, gynecological and pregnancy disorders. However, their contributions in female infertility and in vitro fertilization (IVF) remain unknown. This study investigated the expression profiles of five circulating miRNAs (let-7b, miR-29a, miR-30a, miR-140 and miR-320a) in human follicular fluid from 91 women with normal ovarian reserve and 30 with polycystic ovary syndrome (PCOS) and their ability to predict IVF outcomes. The combination of FF miR-30a, miR-140 and let-7b expression levels discriminated between PCOS and normal ovarian reserve with a specificity of 83.8% and a sensitivity of 70% (area under the ROC curve, AUC = 0.83 [0.73-0.92]; p < 0.0001). FF samples related to low number of mature oocytes (≤2) contained significant less miR-320a levels than those related to a number of mature oocytes >2 (p = 0.04). Moreover, FF let-7b predicted the development of expanded blastocysts with 70% sensitivity and 64.3% specificity (AUC = 0.67 [0.54-0.79]; p = 0.02) and FF miR-29a potential to predict clinical pregnancy outcome reached 0.68 [0.55-0.79] with a sensitivity of 83.3% and a specificity of 53.5% (p = 0.01). Therefore, these miRNAs could provide new helpful biomarkers to facilitate personalized medical care during IVF.

[Circulating nucleic acids and infertility]. / Les acides nucléiques circulants et infertilité.

Circulating nucleic acids (cell-free DNA and microRNAs) have for particularity to be easily detectable in the biological fluids of the body. Therefore, they constitute biomarkers of interest in female and male infertility care. Indeed, in female, they can be used to detect ovarian reserve disorders (polycystic ovary syndrome and low functional ovarian reserve) as well as to assess follicular microenvironment quality. Moreover, in men, their expression levels can vary in case of spermatogenesis abnormalities. Finally, circulating nucleic acids have also the ability to predict successfully the quality of in vitro embryo development. Their multiple contributions during assisted reproductive technology (ART) make of them biomarkers of interest, for the development of new diagnostic and/or prognostic tests, applied to our specialty. Circulating nucleic acids would so offer the possibility of personalized medical care for infertile couples in ART.

[Comparison of frozen embryo transfer outcomes at blastocyst stage according to freezing method and type of endometrial preparation]. / Comparaison des issues de transferts d'embryons congelés au stade blastocyste selon la technique de congélation et le type de préparation endométriale.

OBJECTIVE: This study intended to compare frozen embryo transfer (FET) outcomes at blastocyst stage according to freezing methods, slow freezing versus vitrification and according to the type of endometrial preparation. PATIENTS AND METHODS: A total of 172 FET at blastocyst stage (day 5 or 6) were included retrospectively from April, 2007 to December, 2012. The FET outcomes from slow freezing (group 1, n=86) were compared with those from vitrification (group 2, n=86). More particularly, the survival rate after thawing, as well as implantation and pregnancy rates (clinical and ongoing pregnancy rates) were compared respectively between these two groups, after matching on women's age at freezing day, embryo number and embryo development stage for transfer. Furthermore, for each freezing method, FET outcomes were compared according to the type of endometrial preparation, i.e. natural cycle (group N) versus stimulated cycle (group S). RESULTS: The survival rate as well as implantation and clinical pregnancy rates were significantly higher for FET after vitrification compared to FET after slow freezing (97% vs 85%, P<0.0001; 32% vs 20%, P=0.02; 43% vs 28%, P=0.04, respectively). By taking into account the number of transferred embryos for each group, the multiple pregnancy rate was three-fold higher in the group of FET after vitrification compared to the group of FET after slow freezing but not significantly (27.3% vs 8.3%, NS). However, FET outcomes were not affected significantly by the type of endometrial preparation whatever freezing methods. Nevertheless, the early spontaneous abortion (ESA) rate was lower in the case of embryos that were frozen by vitrification and transferred in natural cycle (group N2 vs group S2: 20% vs 47%, NS). DISCUSSION AND CONCLUSION: Our study confirms that the survival rate after thawing at blastocyst stage (day 5 or 6) is significantly improved after freezing by vitrification compared to slow freezing method. Likewise, implantation and clinical pregnancy rates are significantly increased in the case of FET at blastocyst stage when these embryos were frozen by vitrification. The results obtained by vitrification are very satisfactory but are also associated with an increased multiple pregnancy rate. Moreover, FET associated with natural or stimulated cycle does not modify significantly the outcomes of attempts, whatever the freezing method. However, the risk of ESA is reduced in the case of FET with natural cycle and after embryo vitrification.