[EUGIC (Extension of the Use of Gametes in Intra-Conjugal): New uses of gametes within the couple]. / EUGIC (Extension de l'Utilisation de Gamètes en IntraConjugal) : les nouveaux usages des gamètes au sein du couple.

OBJECTIVE: New possibilities for using gametes within a couple were created by the French law of August 2, 2021 related to bioethics by opening Assisted Reproductive Technics (ART) to all women. It concerns previously self-preserved gametes, thus avoiding the need for gamete donation. The objective of our study is to evaluate the perception of these new uses by ART practitioners. METHOD: A questionnaire of twelve short questions was sent to professionals concerned with gamete donation. RESULTS: One hundred and ten professionals answered the questionnaire. The majority of them approve of the Reception of Oocytes from the Partner (ROPA), notably if there is a medical indication. Requests are rarer for the care of trans* people, and raise more questions. Although less favorable to the use of eggs from trans* men, more of them support the practice when it is an alternative to oocyte donation. CONCLUSION: The acronym EUGIC (Extension of the Use of Gametes in Intra-Conjugal) makes it possible to group together these new situations generated by the change in the French law.

[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.

Management of endometriosis: CNGOF/HAS clinical practice guidelines - Short version.

First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas.

[Management of endometriosis: CNGOF-HAS practice guidelines (short version)]. / Prise en charge de l'endométriose : recommandations pour la pratique clinique CNGOF-HAS (texte court).

First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma.

[Strategies and surgical management of endometriosis: CNGOF-HAS Endometriosis Guidelines]. / Synthèse des stratégies et prise en charge chirurgicale de l'endométriose, RPC Endométriose CNGOF-HAS.

The article presents French guidelines for surgical management of endometriosis. Surgical treatment is recommended for mild to moderate endometriosis, as it decreases pelvic painful complaints and increases the likelihood of postoperative conception in infertile patients (A). Surgery may be proposed in symptomatic patients with ovarian endometriomas which diameter exceeds 20mm. Cystectomy allows for better postoperative pregnancy rates when compared to ablation using bipolar current, as well as for lower recurrences rates when compared to ablation using bipolar current or CO2 laser. Ablation of ovarian endometriomas using bipolar current is not recommended (B). Surgery may be employed in patients with deep endometriosis infiltrating the colon and the rectum, with good impact on painful complaints and postoperative conception. In these patients, laparoscopic route increases the likelihood of postoperative spontaneous conception when compared to open route. When compared to conservative rectal procedures (shaving or disc excision), segmental colorectal resection increases the risk of postoperative stenosis, requiring additional endoscopic or surgical procedures. In large deep endometriosis infiltrating the rectum (>20mm length of bowel infiltration), conservative rectal procedures do not improve postoperative digestive function when compared to segmental resection. In patients with bowel anastomosis, placing anti-adhesion agents on contact with bowel suture is not recommended, due to higher risk of bowel fistula (C). Various other recommendations are proposed in the text, however, they are based on studies with low level of evidence.

[Surgical management of endometrioma: Different alternatives in term of pain, fertility and recurrence. CNGOF-HAS Endometriosis Guidelines]. / Traitement chirurgical des endométriomes. Modalités et résultats en termes de douleur, fertilité et récidive des techniques chirurgicales et de ses alternatives. RPC Endométriose CNGOF-HAS.

Surgical management of ovarian endometrioma is most often part of a global approach of endometriosis pathology. Isolated endometrioma are rare. Laparoscopic cystectomy is the gold standard for surgical management of endometrioma. Nevertheless, this technique impacts the ovarian function. The hemostasis of the ovarian cyst bed should be performed to conserve the ovarian stroma. Ultrasonography-guided cyst aspiration, laparoscopic drainage and simple bipolar coagulation are not recommended as first line of treatment. Based on the actual literature, we cannot state the place of laser-vaporization and plasma-energy ablation in surgical management. Ethanol sclerotherapy could be an alternative to treat recurrent endometrioma. Uncompleted surgical removal of endometriosis lesions increases the recurrence rate. Endometriosis management should take into account the research and treatment of all the pelvic lesion, especially before surgical management of endometrioma. In this context, the evaluation of ovarian reserve could be useful before surgery.

[An update on adenomyosis and implantation]. / Adénomyose et implantation : mise au point.

Adenomyosis is an enigmatic disease whose impact on implantation and fertility outcome is still controversial. A negative effect on IVF outcome was already observed, but it is mainly explained by an increase in early spontaneous miscarriages. We reviewed scientific data in order to bring relevant information about adenomyosis and endometrial receptivity for patient counselling and to precise if screening of adenomyosis is indicated before IVF treatment.

Can rectal endoscopic sonography be used to predict infiltration depth in patients with deep infiltrating endometriosis of the rectum?

OBJECTIVES: To evaluate the diagnostic accuracy of rectal endoscopic sonography (RES) in the prediction of the infiltration depth of rectal endometriosis and to ascertain whether RES could be used to choose between segmental bowel resection and a more conservative approach, such as shaving or discoid resection. METHODS: In this retrospective study, 38 consecutive patients with symptomatic deep infiltrating endometriosis of the rectum who underwent laparoscopic colorectal resection were included. RES results for infiltration depth of rectal endometriosis were compared with results of pathological examination. The sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), positive and negative likelihood ratios (LRs) and test accuracy were calculated for the presence of infiltration of the muscularis layers and submucosal/mucosal layers, as demonstrated by RES and confirmed by histopathological analysis. RESULTS: For the detection of muscularis layer infiltration by endometriosis, the PPV of RES was 100%, whereas for the detection of submucosal/mucosal layer involvement, the sensitivity was 89%, specificity was 26%, PPV was 55%, NPV was 71%, test accuracy was 58% and positive and negative LRs were 1.21 and 0.40, respectively. CONCLUSIONS: RES is a valuable tool for detecting rectal endometriosis as endometriotic infiltration of the muscularis layer can be predicted accurately. However, RES is less accurate in detecting submucosal/mucosal layer involvement and cannot, therefore, be used to choose between bowel resection and a more conservative approach.

[Preoperative imaging of deeply infiltrating endometriosis in: Transvaginal sonography, rectal endoscopic sonography and magnetic resonance imaging]. / Imagerie préopératoire dans l'endométriose profonde : échographie pelvienne, écho-endoscopie rectale et IRM.

OBJECTIVES: Compare the accuracy of transvaginal ultrasonography (TVUS), rectal endoscopic sonography (RES), and magnetic resonance imaging (MRI) before deeply infiltrating endometriosis surgery. PATIENTS AND METHODS: A retrospective study with 25 deeply endometriosis patients underwent the three imaging examinations before surgery. Calculation of sensitivity, specificity, positive predictive value, negative predictive value and accuracy for the different locations: ovaries, uterosacral ligaments and torus, rectovaginal septum, rectosigmoid junction, bladder. RESULTS: Ovarian and deep pelvic endometriosis was found in surgery and confirmed by histology in all patients. Sensitivity and specificity are respectively: for ovaries: 88.2% and 71% of TVUS; 80% and 81.2% of RES; 87.5% and 71% of MRI. For uterosacral ligaments: 63% and 82,6% of TVUS; 37% and 100% of RES; 69% and 82.6% of MRI. For torus: 57.1% and 100% of TVUS; 76.2% and 100% of RES; 76.2% and 100% of MRI. For rectovaginal septum: 63.2% and 100% for TVUS; 89.5% and 66.7% of EER; 47.4% and 100% of MRI. For rectosigmoid junction: 73.7% and 66.7% of TVUS; 94.7% and 66.7% of RES; 89.5% and 50% of MRI. For bladder: 16.7% and 100% of TVUS; 16.7% and 100% of RES; 33.3% and 89.5% of MRI. DISCUSSION AND CONCLUSION: We found that TVUS is the more performant for endometriomas, it is MRI for torus, uterosacral ligaments and little bladder lesions, RES for rectovaginal septum and rectosigmoid junction. So in the clinical practice, the three imaging examinations are complementary for the preoperative assessment of deeply endometriosis.

[Postoperative abdominal adhesions and their prevention in gynaecological surgery: II. How can they be prevented?]. / Adhérences postopératoires et leur prévention en chirurgie gynécologique : II. Comment les prévenir ?

This paper is the second of a two-part publication. The initial paper provided a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. There is rising evidence that surgeons can take important steps to reduce the burden of adhesions. In this second paper, we review the various strategies to reduce the impact of adhesions, improve surgical outcomes and provide some practical proposals for action on adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be considered for use particularly in high-risk surgery and in patients with adhesiogenic conditions. Further research into new strategies to prevent adhesions more effectively through an improved surgical environment, new and combination devices and pharmacological agents should be encouraged. Formal recommendations would ensure better prioritisation of adhesion-reduction within the French health system. Patients should also be better informed of the risks of adhesions.

[Postoperative abdominal adhesions and their prevention in gynaecological surgery: I. What should you know?]. / Adhérences postopératoires et leur prévention en chirurgie gynécologique : I. Ce qu'il faut savoir.

Adhesions are the most frequent complications of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with increased morbidity and mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, including laparoscopy, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in many patients. The extent of the problem of adhesions has been underestimated by surgeons and the health authorities. There is rising evidence however that surgeons can take important steps to reduce the impact of adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. This paper is the first of a two-part publication providing a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. In the second paper we review the various strategies to reduce the impact of adhesions and improve surgical outcomes to assist fellow surgeons in France to consider the adoption of adhesion reduction strategies in their own practice.

[Assisted Reproductive Technologies in HIV patients: a comprehensive review of indications, techniques and results]. / Assistance médicale à la procréation et VIH: revue des indications, techniques et résultats.

Assisted Reproductive Technologies (ART) are authorized in France in couples infected by the human immunodeficiency virus (HIV) since the French legislation of May 10th, 2001. The goals are to reduce the risk of viral transmission between partners and to treat an underlying infertility. The classical techniques are used: IUI, IVF or ICSI, but all of them must be done in specifically authorized laboratories. ART outcome is favourable when only the man is infected, but seems to be less favourable when the woman is infected. Management of pregnancy planning should first propose to women infected by HIV, self inseminations when possible, and if needed, a quick ART treatment as some studies showed ovarian function alterations in HIV women. When the man is infected, IUI would be first proposed. Thousands of HIV positive male partners have used ART in Europe and no contamination has been reported so far. Approximately half of couples with one or both partners infected can hope to have a child through the ART process.

[Reproductive surgery]. / La chirurgie de la reproduction.

The place of surgery in the management of an infertile couple is still under debate. Good pregnancy outcomes in assisted reproductive technologies have led to a decrease in surgical indications. In this evidence based review, we updated our data of high powered articles in order to establish national guidelines for clinical practice about the role and benefits of surgery in principal etiologies of female infertility.

Impact of serum tumor marker determination on the management of women with borderline ovarian tumors: multivariate analysis of a French multicentre study.

OBJECTIVE: To evaluate the contribution of preoperative serum tumor markers to manage borderline ovarian tumors (BOT). STUDY DESIGN: Retrospective multicentre study including 317 BOT. Serum tumor marker levels of CA125, CA19-9, CEA, and CA15-3 were determined by radio-immunoassay. RESULTS: Among 181 women with serous BOT and 136 women with mucinous BOT, respectively 55 of 114 (48.2%) and 38 of 91 (41.8%) had at least one abnormal value. Women with preoperative tumor marker assays were more likely to have radical treatment (p=0.0001), full staging (p=0.004), and intra-operative histology (p<0.0001). Women with at least one abnormal tumor marker were more likely to undergo laparotomy (p=0.007), to have intra-operative histology (p=0.04) and complete staging (p=0.0008). In multivariate analysis, first-line laparoscopy was associated with abnormal tumor marker levels (OR=9.63; 95%CI=1.40-66.39; p=0.02), while laparotomy was associated with large tumors, bilateral tumors, and ascitis visible on sonography. CONCLUSION: Serum tumor marker assays modified both preoperative assessment and surgical management of BOT.