Whole-exome sequencing in patients with maturation arrest: a potential additional diagnostic tool for prevention of recurrent negative testicular sperm extraction outcomes.

STUDY QUESTION: Could whole-exome sequencing (WES) be useful in clinical practice for men with maturation arrest (MA) after a first testicular sperm extraction (TESE)? SUMMARY ANSWER: WES in combination with TESE yields substantial additional information and may potentially be added as a test to predict a negative outcome of a recurrent TESE in patients with MA. WHAT IS KNOWN ALREADY: At present, the only definitive contraindications for TESE in men with non-obstructive azoospermia (NOA) are a 46,XX karyotype and microdeletions in the azoospermia factor a (AZFa) and/or AZFb regions. After a first negative TESE with MA, no test currently exists to predict a negative outcome of a recurrent TESE. STUDY DESIGN, SIZE, DURATION: In a cohort study, we retrospectively included 26 patients with idiopathic NOA caused by complete MA diagnosed after a first TESE. PARTICIPANTS/MATERIALS, SETTING, METHODS: Twenty-six men with MA at the spermatocyte stage in all seminiferous tubules, according to a histopathological analysis performed independently by two expert histologists, and a normal karyotype (i.e. no AZF gene microdeletions on the Y chromosome) were included. Single-nucleotide polymorphism comparative genomic hybridization array and WES were carried out. The results were validated with Sanger sequencing. For all the variants thought to influence spermatogenesis, we used immunohistochemical techniques to analyse the level of the altered protein. MAIN RESULTS AND THE ROLE OF CHANCE: Deleterious homozygous variants were identified in all seven consanguineous patients and in three of the 19 non-consanguineous patients. Compound heterozygous variants were identified in another 5 of the 19 non-consanguineous patients. No recurrent variants were identified. We found new variants in genes known to be involved in azoospermia or MA [including testis expressed 11 (TEX11), meiotic double-stranded break formation protein 1 (MEI1), proteasome 26s subunit, ATPase 3 interacting protein (PSMC3IP), synaptonemal complex central element protein 1 (SYCE1) and Fanconi anaemia complementation group M (FANCM) and variants in genes not previously linked to human MA (including CCCTC-binding factor like (CTCFL), Mov10 like RISC complex RNA helicase 1 (MOV10L1), chromosome 11 open reading frame 80 (C11ORF80) and exonuclease 1 (EXO1)]. LARGE SCALE DATA: Data available on request. LIMITATIONS, REASONS FOR CAUTION: More data are required before WES screening can be used to avoid recurrent TESE, although screening should be recommended for men with a consanguineous family background. WES is still a complex technology and can generate incidental findings. WIDER IMPLICATIONS OF THE FINDINGS: Our results confirmed the genetic aetiology of MA in most patients: the proportion of individuals with at least one pathologic variant was 50% in the overall study population and 100% in the consanguineous patients. With the exception of MEI1 (compound heterozygous variants of which were identified in two cases), each variant corresponded to a specific gene-confirming the high degree of genetic heterogeneity in men with MA. Our results suggest that WES screening could help to avoid recurrent, futile TESE in men with MA in general and in consanguineous individuals in particular, but these results need to be confirmed in future studies before clinical implementation. STUDY FUNDING/COMPETING INTEREST(S): The study was funded by the Fondation Maladies Rares (Paris, France), Merck (Kenilworth, NJ, USA), IRSF (Montigny le Bretonneux, France) and Agence de la Biomédecine (Saint Denis, France). There are no competing interests. TRIAL REGISTRATION NUMBER: N/A.

Qualitative and quantitative contrast-enhanced ultrasonography for the characterisation of non-palpable testicular tumours.

AIM: To assess the diagnostic performance of conventional ultrasound (US) and contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of non-palpable intratesticular tumours. MATERIALS AND METHODS: The local ethics review board approved the protocol, and all of the patients provided written informed consent. Between December 2011 and February 2014, men with non-palpable testicular tumours and normal tumour markers who were referred for surgery were included. The tumours were analysed by conventional US, including B-mode and colour Doppler US (CDUS) as well as by CEUS. Morphological aspects and qualitative and quantitative CEUS criteria, based on visual enhancement and time-intensity curves, were assessed for each lesion. RESULTS: Forty patients were ultimately included. Based on histopathological results, the tumours were classified into three groups: benign tumours (n=16), malignant tumours (n=15), and burned-out tumours (n=9). In B-mode, the morphological aspects were significantly different between benign and malignant tumours (p-values from 0.0002 to 0.008). Qualitative and quantitative analyses of the CEUS images revealed that burned-out tumours exhibited significantly less enhancement than malignant and benign tumours: in burned-out tumours, time-intensity curves were flat, whereas in both benign and malignant tumours the curves had a bell-shaped pattern. All intensity parameters were lower for burned-out tumours compared to benign and malignant tumours (p-value from 0.0001 to 0.026). Both benign and malignant tumours enhanced strongly, however, and no significant difference between the two was noted (p-value from 0.0721 to 0.0953). CONCLUSION: Unlike conventional US, which enable benign lesions to be differentiated from malignant or burned-out tumours, CEUS failed to enabled differentiation between benign lesions and malignant vascularised testicular tumours. CEUS appears to have the potential, however, to differentiate burned-out tumours from vascularised testicular tumours.

Preliminary study of elastic-tension digital neoprene orthoses for proximal interphalangeal joint flexion contracture.

Flexion contracture of the proximal interphalangeal joint (PIPJ) is one of the most frequent complications in finger trauma. Orthoses are the most widely used method to optimize total end-range time (TERT). No previous studies showed that an elastic tension orthosis could be applied for longer than 12 h. We aimed to demonstrate that the elastic-tension digital neoprene orthosis (ETDNO) can achieve higher TERT and therefore better range of motion than other elastic-tension orthoses (ETO) described in the literature. A prospective study of treatment of PIPJ flexion contracture included 10 PIP joints in 8 patients who met the selection criteria. They were instructed to use the ETDNO for around 23 h per day as far as possible, during a period of 3 weeks. Patients reported a mean TERT of 20.6 h a day. PIPJ contracture improved by a mean Torque Range of Motion (TROM) of 23.5° at 500 g and 22.9° at 800 g of passive extension force during the 3-week treatment. Based on the results of this study, the ETDNO appears to offer a highly effective approach for improving PIPJ flexion contracture, increasing range of motion in extension. ETDNO's efficacy probably lies in the significantly improved comfort and low-profile design, enabling excellent compliance and thus optimizing TERT. LEVEL OF EVIDENCE: Level III.

[Optimal evaluation of the infertile male. 2007 French urological association guidelines]. / Evaluation de l'homme infertile: recommandations AFU 2007.

An infertility evaluation should be performed if a couple has not achieved conception after one year of unprotected intercourse. An evaluation should be performed earlier if male or female infertility risk factors exist and if the couple questions its fertility potential. The initial screening of the male should include a reproductive history and a physical examination performed by a urologist or a specialist in male fertility and two semen analyses. Additional procedures and testing may be used to elucidate problems discovered during the full evaluation. The minimal initial endocrine evaluation should include serum total testosterone and serum follicle-stimulating hormone levels. An endocrine evaluation should be performed if sperm concentration is abnormally low, sexual function is impaired, and when other clinical findings suggest a specific endocrinopathy. A postejaculatory urinalysis should be performed if ejaculate volume is less than 1 mL, except in patients with bilateral vasal agenesis or possible hypogonadism. With a diagnosis of retrograde ejaculation, specific management should be considered before advising assisted reproductive technology. Scrotal ultrasonography is indicated when physical examination of the scrotum is difficult or inadequate, or when a testicular mass is suspected. Transrectal ultrasonography (TRUS) is indicated in patients who are azoospermic or have a low ejaculate volume. Specialized testing of semen is not required for routine diagnosis of male infertility. However, some tests may be useful for a few patients to identify a male factor contributing to unexplained infertility, or to select therapy (e.g., assisted reproductive technology). Before performing intracytoplasmic sperm injection, karyotyping and Y-chromosome analysis should be offered to men who have nonobstructive azoospermia and severe oligospermia. Genetic testing for gene mutations of the ABCC7 (ex-CFTR) gene should be offered to male and female partners before proceeding with treatments that use the sperm of men with congenital bilateral absence of the vasa deferentia or congenital unilateral abnormality of the seminal tract. Genetic counseling may be offered when a genetic abnormality is suspected in the male or female partner, and it should be provided when a genetic abnormality is detected. Genetic testing in the female partner, when non symptomatic, should only be advised by a physician from a multidisciplinary team registered by the ministry of health. Evaluation by testis biopsy and deferentography should be performed by a urologist or an andrologist registered for sperm retrieval.

[Extracorporeal lithotripsy in the treatment of common bile duct calculi]. / La lithotritie extracorporelle dans le traitement de la lithiase de la voie biliare principale.

Thirty-three patients with common bile duct stones which could not be extracted by routine endoscopic measures were treated with extracorporeal lithotripsy. Two electrohydraulic lithotripters were used: Dornier HM3 and Technomed Sonolith 3000 using fluoroscopy and ultrasonography, respectively, for stone localisation. Twenty-nine patients were treated with only one session and four patients in two sessions. Fragmentation of stones was obtained in 29 patients (88 p. 100) and complete bile duct clearence in 26 patients (79 p. 100). The fragments passes spontaneously through the papilla in 7 cases; in 19 cases complete removal of fragments was achieved with a Dormia basket (16 cases) or after mechanical lithotripsy (3 cases). There were no significant differences in successful fragmentation rates between the two lithotriters. No serious adverse effects or mortality were observed within the 30 days following treatment. In conclusion, extracorporeal lithotripsy is an effective and safe method for the treatment of bile duct stones when, after sphincterotomy, routine endoscopic measures have failed.

[Pelvic pain in women. Evaluation of a celioscopic intraperitoneal appendectomy technique]. / Douleurs pelviennes de la femme. Evaluation d'une technique d'appendicectomie intra-péritonéale per-coelioscopique.

The diagnostic and therapeutic value of laparoscopic surgery has been established for ovarian cysts and ectopic pregnancies. The diagnosis of appendicitis is difficult and laparoscopy is useful. The aim of this study is to assess feasibility, efficacy and advantages of a new technique of laparoscopic appendectomy. From 1st August to 15th December 1989, the women seen for pelvic pain were divided into three groups: appendicitis, pelvic inflammatory disease (PID) and doubtful. Intra-peritoneal appendectomy was performed when the laparoscopic diagnosis was not PID. Via three supra symphyseal trochars, the appendix was exposed and its mesentery was coagulated. The appendix stump was closed with a clip applicator. Twelve women were included in this study. In two thirds of cases, laparoscopy confirmed the clinical diagnosis. Mean operation time was 39 minutes. Laparotomy was never necessary. There were no post-operative complications and intestinal transit was always complete on the second post-operative day. The patient's and nurse's appreciation was excellent. This operation was possible on every occasion. This technique is sure, quick and easily reproducible. A comfortable post-operative period and esthetic advantages were reported by the women.

[Sedative measures during surgery on old patients. Result on ocular tension (author's transl)]. / Sédation pour interventions ophtalmologiques chez le sujet âgé. Impact sur la tension oculaire.

An attempt of sedative procedures associated with a locoregional anesthesia was performed on fifty old patients before cataract operation. The blood gases, the blood pressure and the heartrate were measured and the behaviour of the patient just before he awoke was examined to determinate the sedative value. A parallel study revealed a decrease of the intra ocular pressure of 2,5 mm d'Hg due to a slight decrease of the blood pressure and to the effect of the neurolep mixture: the Innovar. This method seems to be very satisfactory in Ophthalmology.

[Value of celioscopic surgical treatment of ovarian tumors at the beginning of pregnancy]. / Intérêt du traitement coeliochirurgical des tumeurs ovariennes en début de grossesse.

Ovarian tumours complicate one in every thousand pregnancies. New techniques have changed the way of diagnosing and treating this condition. This study aims to demonstrate the value of laparoscopic surgery for ovarian cysts in the early months of pregnancy. From the 7th November 1985 to the 1st September 1989, eight pregnant women with less than 17 weeks amorrhoea consulted for ovarian tumours that were more than 6 centimeters in diameter. They were all operated on for ovarian tumours of more than 6 centimeters diameter and they were all operated on laparoscopically. Four operations were emergency and four non-emergency. In seven cases cystectomy was carried out transparietally and in one oophorectomy was. Laparoscopic surgery was possible in every case. These was no complication to the pregnancy due to the operation. Laparoscopic surgery permits early treatment of ovarian tumours in pregnancy without the risks of laparotomy. In emergency a quick diagnosis and treatment diminishes the risk of abortion. In non urgent cases a simple technique made it possible to avoid complications of the cyst and to obtain a histological assessment that they were benign.

[Padding of the uterine wall in severe obstetrical hemorrhage]. / Le capitonnage des parois utérines dans les hémorrhagies obstétricales graves.

Severe obstetrical hemorrhage demand an emergency treatment, and hysterectomy is not always adequate. We report our technique of uterine wall padding (UWP), as performed on five women who underwent surgery with UWP for an obstetrical hemorrhage that was severe either at the onset (n = 3) or after transfer to our department (n = 2). The technique consists of padding the uterine walls with X stitches of slowly resorbable thread. The reasons for the operation were: uterine muscle atonia in 2 cases and vaginal laceration, placenta preavia and placenta accreta in 1 case each. The UWP technique was carried out during or after subtotal hysterectomy for hemorrhage in 4 patients, and with preservation of the uterus in one patient. No secondary operation was required after UWP. Less blood products were transfused in women who had immediate UWP than in those for whom UWP was a second-line operation. UWP was more efficient when performed at an early stage. In the woman with placenta accreta the uterus could be salvaged by UWP. This simple technique contributes to the reduction of blood transfusions in severe obstetrical hemorrhage.

[Primary cancer of the fallopian tube. A case revealed by pelvic peritonitis]. / Cancer primitif de la trompe. Un cas révélé par une pelvi-péritonite.

We report the case of a primary carcinoma of the fallopian tube in which the diagnosis was done through laparoscopy for pelvic peritonitis. The pathologic diagnosis was possible with tubal sampling at the same time. The treatment associated radical surgery and radiotherapy. This rare kind of tumor is exceptionally diagnosed this way.

[Breech extraction of the second twin with or without version by internal maneuvers]. / La grande extraction du deuxième jumeau avec ou sans version par manoeuvres internes.

A retrospective study was done to appraise the recent practice of breech extraction of the second twin (with or without internal version) in our unity. From January 1st, 1988 to April 30, 1991 23 patients with a twin gestation were delivered in our unity (0.5% of all deliveries). Nineteen patients (83%) were delivered vaginally. Each procedure was done by a resident under control of a senior obstetrician and in the presence of two midwives, a pediatrician, and an anesthesiologist. Ten patients having had a breech extraction (GE group) were studied, 13 patients were excluded for not having had a breech extraction. In the GE group the presentations were: 7 vertex/breech and 3 breech/breech. Mean Apgar scores of the second twin at 3 minutes were 8 in the GE group. These results suggest that breech extraction of the second twin is not a pernicious technique if done by trained operators with precise limits. These results need to be confirmed through a prospective randomized and comparative study.

[Abdominal ectopic pregnancy. Limits of laparoscopic treatment]. / Grossesse ectopique abdominale. Limites du traitement coelioscopique.

We report a case of early abdominal pregnancy (6 weeks amenorrhea). The diagnosis of ectopic pregnancy was suspected according to the usual clinical, serologic, and sonographic procedure. It was confirmed by laparoscopy. Laparoscopic surgery was unable to assess the trophoblastic site and the hemostasis of the lesion that was histologically proven.

[Hernias of the groin. A new complication of celioscopy]. / Les hernies de l'aine. Nouvelle complication de la coelioscopie.

Crural hernia is acquired and mainly affects women. We report a case of hernia discovered after two laparoscopic operations. There was no hernia or risk factor for abdominal wall hernia before the operations. We consider that this hernia is the consequence of repeated abdominal distensions over a short period of time. We have not found this complication in the literature.

[Retroperitoneal liposarcoma. Disclosure by anemia and prolonged fever]. / Liposarcome rétropéritonéal. Révélation par une anémie et une fièvre prolongée.

We report the case of a 79-year old woman with a retroperitoneal liposarcoma. The condition was discovered because of the association, in a woman of that age, of anaemia and persistent fever. The diagnosis was suggested by computed tomography. Treatment was exclusively surgical. Liposarcomas usually affect men in their sixth decade. Postoperative radiotherapy improves the quality of life but does not prolong survival. Metastases are frequent, and death usually occurs in the year that follows discovery.

[Is today's man really less fertile?]. / L'homme d'aujourd'hui est-il vraiment moins fertile?

In 1992, a statistical analysis of data from 61 studies of semen quality among normal men led to the conclusion that human sperm count fell of 40% from 1940 to 1990. This meta-analysis has since been invalidated for methodological reasons as well as for statistical reasons, but it caused enormous concern to both the scientific community and to the international media. A decline of human fertility was speculated. To date, the most popular hypothesis offered to explain this alleged decline has been increasing exposure to environmental estrogen mimicking chemicals. However, there is no evidence that male or mammal fertility is declining. Moreover, the sperm count of breeding mammals did not declined in the meanwhile. Since 1992, numerous papers reported on men investigated during the last 20 years have shown conflicting results, from sperm count improvement to sperm count decline. However, several publications included methodological and analytical biases. In fact, the techniques used for semen analysis have to be questioned. It is a subjective exam, lacking laboratory standards and quality control procedures. This induces very important variations between laboratories and between biologists. For the sperm count itself, numerous errors can occur, provoked by the technique, the equipment and the reader: for the same sperm, the coefficient of variation can exceed 40% between two technicians. Therefore, the current techniques of semen analysis cannot warrant epidemiological studies. It is indispensable to admit the limits of the semen analysis in order to improve as much as possible its quality and its reliability.

[Comparative study of the University of Wisconsin solution versus Eurocollins in kidney transplant]. / Etude comparative de la solution de l'Université de Wisconsin versus Eurocollins en transplantation rénale.

UW (University of Wisconsin) solution, formulated by Belzer's team in Madison, has already been proved to increase cold ischemia time in liver and pancreas preservation. A multicentre clinical trial is being conducted to compare renal preservation in human transplantation using two different solutions: UW and Eurocollins (EC). This paper, whose results will be included in the multicentre trial, reports local comparative results between UW and EC perfused Kidneys. The two donor populations UW (28 cases) and EC (47 cases) were not randomized. They were however comparable in renal function prior to harvesting but not in age (35 +/- 13.4 years EC versus 27.7 +/- 12.4 years UW). The two recipient populations (48 EC versus 48 UW) were more homogeneous. Comparative results were significant with better graft function in the UW group: creatinine at one week: 499.2 +/- 296.3 EC versus 277.6 +/- 226.2 mumol/l, p less than 0.0001; creatinine at one month: 228.7 +/- 135 EC versus 159.7 +/- 135.6 mumol/l, p less than 0.02 and a decrease in acute tubular necrosis (39.5% EC versus 14.5% UW) and hospital stay. These results justify the use of UW solution by intraaortic flush especially during multi-organ procurement.

[Tension force in dynamic splints made of neoprene]. / Le collage en tension dans les orthèses dynamiques en matériau néoprène.

Dynamic splints are the most difficult ortheses to make. Unrestricted finger joint mobility is usually prevented by the size of their components. Ortheses made out of neoprene material have the advantage of being pliable and at the same time can be constructed as dynamic splints. Neoprene material elasticity allows conforming it into a tube that can be fitted over a finger, spreading uniform pressure. A traction slip can be cemented to the neoprene finger tube. With neoprene splints, lever arms are more efficient. Their tubular design applies and spreads traction and countertraction forces in all directions. Neoprene material's elasticity contributes in reducing edema formation as well as distributes forces applied to the finger over a large area. The risk of excessive pressure is the only drawback of an elastic tubular design, it may cause pain and tissue ischemia. A meticulous tailoring prevents this potential risk.

[Intra-peritoneal appendectomy by celioscopy. Preliminary results of a new technique]. / Appendicectomie intra-péritonéale per-coelioscopique. Résultats préliminaires d'une nouvelle technique.

The diagnostic and therapeutic value of laparoscopic surgery is known for ovarian cysts and ectopic pregnancies. The diagnostic of appendicitis is difficult and laparoscopy is useful. The aim of this study is to assess the feasibility, the efficacy and the advantages of a new technique of laparoscopic appendectomy. From August 1, 1989 to July 31, 1990 the women seen for pelvic pain have been divided in three groups: appendicitis, pelvic inflammatory disease (PID) and doubt. Intra peritoneal appendectomy has been performed if the laparoscopic diagnosis was not PID. Via three supra symphyseal trocars the appendix has been exposed and his meso coagulated. The appendix stump has been closed with a clip applicator (Ethnor T1300). Thirty-one women have been involved in this study. Twenty women had a laparoscopic appendectomy. Mean operation time was 36 minutes. In no occasion laparotomy was necessary. There was no post-operative complication and stool was obtained on the second post operative day. Patients and nurses appreciation was excellent. This operative procedure was possible in each attempt. This technique is sure, quick and easily reproducible. Comfortable post operative period and esthetic advantage have been noticed by the women. This operation has been possible in each attempt. This technique is sure, quick and easily reproducible.

[Intracytoplasmic sperm injection (ICSI) in the management of azoospermia]. / L'injection intra cytoplasmique de spermatozoïdes (ICSI) dans la prise en charge des azoospermies.

OBJECTIVES: The objective of this study was to analyse all attempts of ICSI performed in our centre between 1995 and 1997 with surgically harvested sperm for the treatment of secretory and excretory azoospermia. MATERIAL AND METHODS: 71 infertile couples, in which the man suffered from secretory (n = 8) or excretory azoospermia (n = 63), were managed with 94 attempts of ICSI. RESULTS: ICSI was able to be performed 85 times with 82 embryo transfers resulting in 29 clinical pregnancies. The clinical pregnancy rate per ICSI attempt was comparable with sperm obtained on the day of ICSI or previously harvested and frozen (30.5% and 31.4% respectively). The clinical pregnancy rate per ICSI attempt was 33.3% for testicular sperm (n = 18), and 30.3% for epididymal sperm (n = 76). Twenty-seven clinical pregnancies (32.1%) were obtained for men with excretory azoospermia (47.2% for vas deferens agenesis and 20.8% for acquired urinary tract obstruction, p = 0.01), and 2 (20%) for men with secretory azoospermia. CONCLUSION: ICSI can achieve pregnancy in infertile couples in whom no other solution can be considered. Cryopreservation allows surgical harvesting to be dissociated from ICSI without decreasing the pregnancy rate, justifying freezing of sperm during any surgical procedure on the seminal tract. The better results obtained in congenital excretory azoospermia compared to acquired obstructions, usually post-infectious, suggest a harmful effect of infection on the quality of sperm.