Clinical considerations of the role of palbociclib in the management of advanced breast cancer patients with and without visceral metastases.

Background: This report assesses the efficacy and safety of palbociclib plus endocrine therapy (ET) in women with hormone receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer (ABC) with or without visceral metastases. Patients and methods: Pre- and postmenopausal women with disease progression following prior ET (PALOMA-3; N = 521) and postmenopausal women untreated for ABC (PALOMA-2; N = 666) were randomized 2 : 1 to ET (fulvestrant or letrozole, respectively) plus palbociclib or placebo. Progression-free survival (PFS), safety, and patient-reported quality of life (QoL) were evaluated by prior treatment and visceral involvement. Results: Visceral metastases incidence was higher in patients with prior resistance to ET (58.3%, PALOMA-3) than in patients naive to ET in the ABC setting (48.6%, PALOMA-2). In patients with prior resistance to ET and visceral metastases, median PFS (mPFS) was 9.2 months with palbociclib plus fulvestrant versus 3.4 months with placebo plus fulvestrant [hazard ratio (HR), 0.47; 95% confidence interval (CI), 0.35-0.61], and objective response rate (ORR) was 28.0% versus 6.7%, respectively. In patients with nonvisceral metastases, mPFS was 16.6 versus 7.3 months, HR 0.53; 95% CI 0.36-0.77. In patients with visceral disease and naive to ET in the advanced disease setting, mPFS was 19.3 months with palbociclib plus letrozole versus 12.9 months with placebo plus letrozole (HR 0.63; 95% CI 0.47-0.85); ORR was 55.1% versus 40.0%; in patients with nonvisceral disease, mPFS was not reached with palbociclib plus letrozole versus 16.8 months with placebo plus letrozole (HR 0.50; 95% CI 0.36-0.70). In patients with prior resistance to ET with visceral metastases, palbociclib plus fulvestrant significantly delayed deterioration of QoL versus placebo plus fulvestrant, whereas patient-reported QoL was maintained with palbociclib plus letrozole in patients naive to endocrine-based therapy for ABC. Conclusions: Palbociclib plus ET prolonged mPFS in patients with visceral metastases, increased ORRs, and in patients previously treated for ABC, delayed QoL deterioration, presenting a standard treatment option among patients with visceral metastases amenable to endocrine-based therapy. Clinical trial registration: NCT01942135, NCT01740427.

Multivariate analysis identifies the estradiol level at ovulation triggering as an independent predictor of the first trimester pregnancy-associated plasma protein-A level in IVF/ICSI pregnancies.

STUDY QUESTION: Can independent predictors of pregnancy-associated plasma protein-A (PAPP-A) levels be identified in a group of women who conceived following IVF/ICSI? SUMMARY ANSWER: The significantly decreased PAPP-A level in IVF and ICSI pregnancies compared with non-IVF/ICSI pregnancies was correlated strongly with the serum estradiol (E2) level at ovulation triggering. WHAT IS KNOWN ALREADY: The first trimester prenatal combined screening test for fetal aneuploidies in pregnancies conceived following assisted reproduction techniques (ART) is complicated by an alteration of the maternal biomarkers free ß-hCG and PAPP-A, causing a higher false-positive rate compared with pregnancies which are conceived naturally. The use of controlled ovarian stimulation prior to IVF/ICSI is suggested to be the principle reason for these alterations of biomarkers in ART pregnancies. STUDY DESIGN, SIZE, DURATION: Between January 2010 and December 2011, 1474 women who conceived naturally and 374 women who conceived following IVF (n = 89), ICSI (n = 204) or intrauterine insemination (IUI, n = 81) were included in this retrospective study. Only singleton pregnancies were eligible for this study. For all women, serum analysis was performed in the same clinical laboratory. Measurement of nuchal translucency (NT) thickness was performed by four physicians belonging to the same infertility centre. PARTICIPANTS/MATERIALS, SETTING, METHODS: First-trimester combined screening test of aneuploidy parameters (maternal age, PAPP-A and free ß-hCG, NT thickness) were compared between non-ART and ART (IVF, ICSI and IUI) singleton pregnancies. Next, a minimal threshold E2 level at ovulation triggering was suggested for IVF/ICSI pregnancies above which the PAPP-A levels were significantly decreased compared with non-ART pregnancies. Finally, a multivariate analysis was performed to reveal independent predictors of PAPP-A level in IVF/ICSI pregnancies. MAIN RESULTS AND THE ROLE OF CHANCE: We showed a decrease of the multiple of the median (MoM) PAPP-A level in IVF and ICSI singleton pregnancies compared with non-ART singleton pregnancies (P < 0.001), with MoM values of 0.74 (0.16-3.16) and 0.81 (0.12-4.61) versus 0.98 (0.14-5.76), respectively. Analysis of variance of the overall model was highly significant (Fisher test 3.76, P = 0.01), indicating that the model explains a significant portion of the variation in the data. No difference in PAPP-A level was found between non-ART and IUI pregnancies. The free ß-hCG level and NT thickness did not differ between ART and non-ART pregnancies. PAPP-A levels in IVF and ICSI pregnancies were strongly correlated with the E2 level at ovulation triggering. We showed by multivariate analysis that an E2 cut-off level of 1300 pg/ml at the time of ovulation could predict a significantly lower PAPP-A level at first trimester combined screening (ß -0.239 ± 0.088, P < 0.005). LIMITATION, REASONS FOR CAUTION: The measures of biochemical markers can differ between laboratories and with the used equipment; therefore, extrapolation of the E2 cut-off level to other infertility centres should be undertaken with caution. WIDER IMPLICATIONS OF THE FINDINGS: One should be careful when using correction factors for ART patients undergoing the first trimester combined screening test. The proposed E2 cut-off level may help to identify a subgroup of women within the population of ART patients for whom use of a correction factor is justified. STUDY FUNDING/COMPETING INTEREST(S): None.

[How to improve ART results? Is France behind other countries? Strategy for single embryo transfer: The value of embryo selection and embryo freezing]. / Comment améliorer nos résultats en AMP? La France est-elle en retard? Stratégie de transfert de l'embryon unique: la place du choix de l'embryon et de la congélation embryonnaire.

Multiple embryo transfer is associated with a high frequency of twin pregnancies with costly complications involving both mother and child. As a result high priority is currently being given to the development of single embryo transfer (SET) programs. France seems to be lagging behind Northern European countries in the development of SET and widespread use of SET will depend on convincing physicians that this policy will not have a negative impact on success rate, as has been the case for many protocols described in the literature as well as in our own experience. Our SET program includes patients less than 36 years of age undergoing their first FIV-ICSI. If two embryos showing satisfactory morphology are obtained, one is selected transferred and the other is systematically frozen. Selection for transfer is based on two criteria, i.e. observation of even early cleavage 26 hours after FIV-ICSI and evaluation of embryo morphology score on day 2. Embryo morphology score is based on the presence of four blastomeres and absence of blastomere irregularities and anucleated fragmentation. Last, a prerequisite for SET is an effective freezing program. A pregnancy rate of 13% per thawing was sufficient enough to obtain a cumulative pregnancy rate after SET (N = 205) and subsequent frozen embryo transfer (FET) similar to the cumulative pregnancy rate obtained after double embryo transfer (N = 394) and subsequent FET (46.3 vs 46.7%, NS). Twin delivery rate were respectively 2,6% after SET and 26,6% after double embryo transfer (P < 0.01).

[Elective single embryo transfer: a justified policy for selected patients]. / Transfert électif d'un seul embryon: une option justifiée pour une population de patientes sélectionnées.

OBJECTIVE: Prevention of twin pregnancies using elective Single Embryo Transfer (e-SET) is now considered by many Assisted Reproductive Techniques teams as a necessity. The aim of this study was to assess the efficacy of e-SET in a prospective manner in a selective population of patients using Take Home Baby Rate per couple as principal parameter. PATIENTS AND METHODS: This prospective study was conducted from January 2003 to December 2004. Elective Single Embryo was proposed to women above 37 years in their first IVF or ICSI attempt. It was then performed only in cases when at least one embryo with high implantation potential (score-4 embryo in our embryo scoring) was obtained for transfer and one more (score-3 or score-4 embryo) was available for freezing. RESULTS: e-SET was proposed and accepted in 225 couples (25% of eligible couples and 7.8% of total population) and was possible in 96 of these). Two embryos were transferred in all other eligible patients (Double Embryo Transfer group=DET). Cumulative delivery rate after fresh embryo transfers and, if necessary, after frozen-thawed embryo transfers were 39.5% per couple e-SET group and 41.7% in DET group (NS). On the other hand, the percentage of twin pregnancies was significantly different between the two groups (2.6% vs 26.6% respectively; P<0.01). DISCUSSION AND CONCLUSION: In women younger than 37 years in their first IVF/ICSI attempt, the elective transfer of only one embryo with high implantation potential strongly allowed to avoid twin pregnancies without any significant delivery rate decrease. This transfer policy is particularly efficient in laboratories displaying good results in their embryo freezing program.

A new germline VH36-60 gene is used in the neonatal primary and adult memory response to (T,G)-A--L.

Our previous studies of the neonatal primary response to (T,G)-A--L showed that the majority of anti-(T,G)-A--L antibodies bind the copolymer L-Glu:L-Tyr (GT), share idiotypy (Id), and use the H10 germline VH gene from the VHJ558 family and a V kappa 1 gene. We also identified two hybridomas from different neonatal donors that produced GT+, Id+ antibodies using a V kappa 1 gene with a VH gene from the VH36-60 family. In the study reported here, we show that both neonatal hybridomas use the same germline VH gene from the VH36-60 gene family. However, the VH gene sequence is different from previously identified germline genes of the VH36-60 gene family. To determine whether the expressed heavy chain gene had undergone somatic mutation, we isolated the corresponding germline gene from kidney DNA. Sequence analysis of this gene shows that it is a new member of the VH36-60 family which is not mutated in the neonatal antibodies. Furthermore, the deduced amino acid sequences of the two neonatal antibodies are identical not only in the VH region but also in the VH-D-JH joins, suggesting that there is a strong selection for CDRIII among neonatal anti-(T,G)-A--L antibodies using this germline gene (designated here as VH3A1) with a V kappa 1 gene. Also, the VH gene from the VH36-60 family that we showed previously was used by an adult memory B cell clone specific for (T,G)-A--L, can now be identified as a rearrangement of the VH3A1 germline gene. Elucidation of the germline variable region genes that are used in the antigen-specific neonatal response will help us understand the mechanisms that shape the preimmune B cell repertoire during B cell development.

Papaverine as a replacement for pentoxifylline to select thawed testicular or epididymal spermatozoa before ICSI.

OBJECTIVES: Pentoxifylline has been used to improve sperm motility in Assisted Reproductive Technology mainly by initiating sperm motility in immotile spermatozoa samples obtained surgically. Indeed, as Intracytoplasmic Sperm Injection leads to very poor results when using immotile gametes, pentoxifylline gives better results by easing the selection of viable sperm mobilized after incubation. In 2011, the French Haute Autorité de santé decided that pentoxifylline used for in vivo purpose proposed Insufficient Medical Service and pentoxifylline was thus withdrawn from the French materia medica. We here assessed the efficacy on spermatozoa motility and the safety of papaverine, another phosphodiesterase inhibitor, for the replacement of pentoxifylline. METHODS: Sixteen frozen-thawed epididymal or testicular samples displaying no or very poor spontaneous motility (≤5% total motility) were subjected to both pentoxifylline (3.6mM) and papaverine (93µM). A duplicate Mouse Embryo Assay and an In Vitro Fertilization Mouse Assay in duplo were used to discard any toxic effect of papaverine. RESULTS: Papaverine gave better results than pentoxifylline (mean total motility: 27% vs 23%, P<0.05). No Effect Level were observed in the two different Mouse Embryo Assays performed. CONCLUSION: Papaverine is a useful tool to replace pentoxifylline in ICSI programs to select viable spermatozoa in frozen-thawed sperm samples displaying no or very poor motility.

Thrombomodulin is a cofactor for thrombin degradation of recombinant single-chain urokinase plasminogen activator "in vitro" and in a perfused rabbit heart model.

Thrombin cleaves single-chain urokinase-type plasminogen activator (scu-PA) to a two-chain derivative (tcu-PA) fibrinolytically inactive. This reaction was accelerated in vitro by purified rabbit lung thrombomodulin in equimolar complex with thrombin. Polyclonal antibodies to rabbit thrombomodulin prevented this effect. We also observed that heparin and other sulfated polysaccharides had an accelerating effect on thrombin cleavage of recombinant scu-PA. Their effect was concentration-dependent and then reversed at high levels. The effect of heparin and heparan sulfate was independent and synergic with respect to thrombomodulin. All observations except the effect of heparin, could be confirmed in a Langendorff isolated rabbit heart model. From competition experiments carried out with scu-PA derivatives and mutants, we postulate that the amino-terminal sequence of rscu-PA, containing the epidermal growth factor (EGF)-like and the kringle domains is involved in the cofactor effect of thrombomodulin on scu-PA inactivation by thrombin. We conclude that a regulatory mechanism of scu-PA inactivation is present at the cell surface.

Embryo score is a better predictor of pregnancy than the number of transferred embryos or female age.

OBJECTIVE: To compare the value of 17 IVF variables, including a new mean score of transferred embryos (MSTE), in predicting pregnancy rate. DESIGN: Retrospective study. SETTING: Private IVF unit. PATIENT(S): Women who underwent 10,000 embryo transfers. MAIN OUTCOME MEASURE(S): Duration of infertility, type of infertility, female age, rank of IVF attempt, type of ovarian treatment, progesterone level, sperm count, sperm motility, sperm morphology, number of retrieved oocytes, number of mature oocytes, maturation rate, number of embryos obtained, fertilization rate, number of transferred embryos, cumulative embryo score (CES), mean score of transferred embryos (MSTE), and pregnancy rate. RESULT(S): Outcome of IVF-ET was significantly correlated with female age, type of infertility, number of retrieved oocytes, number of mature oocytes, maturation rate, embryos obtained, fertilization rate, transferred embryos, CES, and MSTE. Multivariate analysis demonstrated that MSTE was a better predictor of pregnancy than the number of transferred embryos and female age. CONCLUSION(S): Embryo quality is the best predictor of pregnancy. The embryo score described herein should be used in IVF-ET programs to choose the best embryos for transfer.

Subzonal sperm insemination and total or extreme asthenozoospermia: an effective technique for an uncommon cause of male infertility.

OBJECTIVE: To assess the value of subzonal insemination (SUZI) in cases of total or extreme asthenozoospermia. DESIGN: The results of IVF after SUZI were assessed in six cycles (four couples) with documented asthenozoospermia. SETTING: Institut de Médecine de la Reproduction, Marseille, France. PATIENTS: Four couples underwent six retrieval cycles. In all cases asthenozoospermia was total (100% of immotile spermatozoa) or extreme (5% nonprogressive motility). Oligozoospermia and teratozoospermia were ruled out in all cases. In two cases electron microscopy revealed the absence of the central singlet in the flagellum axonemal complex and in one case a major dysplasia of the fibrous sheath in the flagellum principal piece. RESULTS: The overall fertilization rate was 45%. The diploid embryo rate was 33%. Embryo quality was satisfactory. In five of six cycles, three embryos were transferred. Two triplet pregnancies were obtained corresponding to an implantation rate per transferred embryo of 40%. CONCLUSION: Total or extreme asthenozoospermia seems to be a good indication for SUZI.

[GnRH antagonists and embryo implantation potential]. / Antagonistes de la GnRH et potentiel implantatoire embryonnaire.

In several trials, the GnRH antagonists regimens have been associated with a slightly lower pregnancy and implantation rate than the established GnRH agonist protocols. Several embryo classification systems have been developed to grade embryo quality, and a cumulative embryo score has been proposed to predict pregnancy. The cumulative embryo score is based on a 4-point embryo score in which all cleaved embryos were assigned 1 point and 1 additional point was added for each of the following features: absence of fragmentation (or fragmentation involving <20% of the embryonic surface), absence of irregularities in blastomere size or shape, and four-cell stage (regardless of cell morphology). This cumulative embryo score is highly correlated with embryo implantation rates. In a non prospective study concerning 641 IVF cycles with oocyte retrieval, pregnancy and implantation rates were statistically lower in the group of patients treated with GnRH antagonist. The explanation of this difference is the indication in IVF cycles: the women with tubal infertility and/or endometriosis had lower pregnancy and implantation rates in IVF cycles if an antagonist was administrated. There was no difference between the 2 groups in ICSI cycles. Subsequently, in IVF cycles, antagonist should not be administrated to women with tubal infertility and/or endometriosis.

[Indications and results of artificial insemination with donor semen (AID) (author's transl)]. / Indications et résultats de l'insémination artificielle avec sperme de donneur.

Among 1,000 couples requesting for AID at CECOS Sud-Est in Marseille azoospermia is found in 572, oligoasthenozoospermia in 395. Cryptorchidism is recorded in 20% of these men. Several hypofertility factors are frequently associated. Ejaculation is absent in 23 men. 10 couples are requesting for AID because a risk of severe autosomic disease. Mean success rate is 10% per cycle, increased by sperm quality, decreased in women older than 35 years.