Delaying testicular sperm extraction in 47,XXY Klinefelter patients does not impair the sperm retrieval rate, and AMH levels are higher when TESE is positive.

STUDY QUESTION: Should testicular sperm extraction (TESE) in non-mosaic 47,XXY Klinefelter syndrome (KS) patients be performed soon after puberty or could it be delayed until adulthood? SUMMARY ANSWER: The difference in sperm retrieval rate (SRR) in TESE was not significant between the 'Young' (15-22 years old) cohort and the 'Adult' (23-43 years old) cohort of non-mosaic KS patients recruited prospectively in parallel. WHAT IS KNOWN ALREADY: Several studies have tried to define predictive factors for TESE outcome in non-mosaic KS patients, with very heterogeneous results. Some authors have found that age was a pejorative factor and recommended performing TESE soon after puberty. To date, no predictive factors have been unanimously recognized to guide clinicians in deciding to perform TESE in azoospermic KS patients. STUDY DESIGN, SIZE, DURATION: Two cohorts (Young: 15-22 years old; Adult: 23-43 years old) were included prospectively in parallel. A total of 157 non-mosaic 47,XXY KS patients were included between 2010 and 2020 in the reproductive medicine department of the University Hospital of Lyon, France. However 31 patients gave up before TESE, four had cryptozoospermia and three did not have a valid hormone assessment; these were excluded from this study. PARTICIPANTS/MATERIALS, SETTING, METHODS: Data for 119 patients (61 Young and 58 Adult) were analyzed. All of these patients had clinical, hormonal and seminal evaluation before conventional TESE (c-TESE). MAIN RESULTS AND THE ROLE OF CHANCE: The global SRR was 45.4%. SRRs were not significantly different between the two age groups: Young SRR=49.2%, Adult SRR = 41.4%; P = 0.393. Anti-Müllerian hormone (AMH) and inhibin B were significantly higher in the Young group (AMH: P = 0.001, Inhibin B: P < 0.001), and also higher in patients with a positive TESE than in those with a negative TESE (AMH: P = 0.001, Inhibin B: P = 0.036). The other factors did not differ between age groups or according to TESE outcome. AMH had a better predictive value than inhibin B. SRRs were significantly higher in the upper quartile of AMH plasma levels than in the lower quartile (or in cases with AMH plasma level below the quantification limit): 67.7% versus 28.9% in the whole population (P = 0.001), 60% versus 20% in the Young group (P = 0.025) and 71.4% versus 33.3% in the Adult group (P = 0.018). LIMITATIONS, REASONS FOR CAUTION: c-TESE was performed in the whole study; we cannot rule out the possibility of different results if microsurgical TESE had been performed. Because of the limited sensitivity of inhibin B and AMH assays, a large number of patients had values lower than the quantification limits, preventing the definition a threshold below which negative TESE can be predicted. WIDER IMPLICATIONS OF THE FINDINGS: In contrast to some studies, age did not appear as a pejorative factor when comparing patients 15-22 and 23-44 years of age. Improved accuracy of inhibin B and AMH assays in the future might still allow discrimination of patients with persistent foci of spermatogenesis and guide clinician decision-making and patient information. STUDY FUNDING/COMPETING INTEREST(S): The study was supported by a grant from the French Ministry of Health D50621 (Programme Hospitalier de Recherche Clinical Régional 2008). The authors have no conflicts of interest to disclose. TRIAL REGISTRATION NUMBER: NCT01918280.

Simultaneous bilateral tubal ectopic pregnancy after intracytoplasmic sperm injection and embryo transfer, in a patient with Stage 3 endometriosis.

INTRODUCTION: The incidence of extrauterine pregnancy increases to 2-12% following in vitro fertilization -embryo transfer. Several pathogenic theories have been suggested, including abnormal hormonal secretion or exogenous hormones administered in assisted reproductive technology (ART). CASE REPORT: A 32-year-oId nulliparous woman with primary infertility and Stage 3 endometriosis was treated by ART with intracytoplasmic sperm injection and embryo transfer. The patient showed simultaneous bilateral extrauterine pregnancy, managed by laparoscopic salpingectomy. DISCUSSION: The various possible pathophysiological mechanisms are described, with a review of the literature on simultaneous bilateral extrauterine pregnancy following ART. In pregnancies following ART, ectopic pregnancy should always be screened for by serum ß-human chorionic gonadotropin monitoring and transvaginal ultrasound until the implantation site can be confirmed as the incidence is higher than in spontaneous pregnancy. Even if serum ß-human chorionic gonadotropin concentration increases normally, possible bilateral ectopic pregnancy should always be investigated if no intrauterine gestational sac can be seen.

Premature preterm rupture of the membrane diagnosis in early pregnancy: PAMG-1 and IGFBP-1 detection in amniotic fluid with biochemical tests.

OBJECTIVES: Previable premature rupture of the membranes (pPROM), occurring before 24WG, is associated with a 25% neonatal survival rate. This terrible prognosis may lead to elective pregnancy termination on parents' request. Therefore, certain diagnosis is essential but remains difficult in about 10% of patients. Bed-side biochemical tests developed to help in diagnosis had never been evaluated in early pregnancies. This study aimed to evaluate and compare the in vitro sensitivity, detection limit, reaction time and consistency of AmniSure detecting placental alpha microglobulin-1 (PAMG-1) and actim PROM detecting Insulin Growth Factor Binding Protein-1 (IGFBP-1) in amniotic fluid between 15 and 20weeks of gestation (WG). DESIGN AND METHODS: Samples of amniotic fluid were collected by amniocentesis performed between 15 and 20 completed WG in 55 patients. Dilution series were prepared and both tests were performed twice at each dilution. In vitro sensitivity, detection limit, and reaction time were evaluated and compared in serial dilution. RESULTS: A total of 460 AmniSure and 476 actim PROM tests were performed. Both tests' in vitro sensitivity was 100% at dilution 1:20 and remained up to 90% until dilution 1:80. In vitro sensitivities were not different at any dilution. Detection limit and consistency were similar for both tests at all dilution. Actim PROM reaction time was shorter than AmniSure at all dilutions, except 1:320 (p<0.05). CONCLUSIONS: PAMG-1 and IGFBP-1 can be detected in amniotic fluid between 15 and 20 completed WG, using respectively AmniSure and actim PROM.

Successful pregnancy outcome after in vitro fertilization in a pancreas-kidney recipient.

OBJECTIVE: To describe the first case of IVF pregnancy in a pancreas-kidney recipient. DESIGN: Case report. SETTING: Reproductive Medicine Department, Hôpital Edouard Herriot, Lyon, France. INTERVENTION(S): In vitro fertilization in a pancreas-kidney recipient. PATIENT(S): A 39 year-old nulliparous woman, with primary infertility and a history of pancreas-kidney transplant at 29 years of age. MAIN OUTCOME MEASURE(S): Multidisciplinary agreement for the couple to be managed by IVF. Follow-up of pregnancy and delivery. RESULT(S): Singleton IVF pregnancy in a pancreas-kidney recipient, maintained up to 34 weeks. Cesarian delivery ahead of labor. No severe maternal or fetal complications. Live birth. Normal postpartum renal function and glycemia. CONCLUSION(S): An IVF pregnancy is feasible in a pancreas-kidney recipient. Such treatment should follow agreement by all the medical teams following the patient. Pregnancy in a pancreas-kidney recipient is at-risk, requiring close monitoring.

Case of progressive intrauterine twin pregnancy after surgical treatment of cornual pregnancy.

OBJECTIVE: To report on a case of heterotopic triplet pregnancy after in utero transfer of three embryos obtained by in vitro fertilization (IVF), with progression of the intrauterine twin pregnancy after resection of the cornual pregnancy. DESIGN: Technique and instrumentation. SETTING: Département de Médecine de la Reproduction, Hôpital Edouard Herriot, Lyon, France. PATIENTS: A 32-year-old woman, nulliparous with primary infertility for the previous 12 years due to mixed causes (tubal and male infertility). INTERVENTIONS: Diagnosis by ultrasound scan and per-laparoscopic confirmation, followed by resection of the cornual pregnancy by laparotomy. MAIN OUTCOME MEASURES: Ultrasound diagnosis and follow-up of the pregnancy. Delivery. RESULTS: Complete ablation of the cornual pregnancy. Progression of the intrauterine twin pregnancy without difficulties until 31 weeks of gestation. Cesarean upon onset of labor. Birth of two living infants. The scar of the uterine horn, examined during the caesarean, was thick and solid. CONCLUSIONS: The early diagnosis and surgical treatment of an ectopic pregnancy permitted the development of the intrauterine pregnancy. The risk of heterotopic pregnancy is increased by medical techniques that facilitate procreation. This risk is directly related to the number of embryos transferred. In the case of heterotopic pregnancy, the rate of progressive intrauterine pregnancy after treatment of the ectopic pregnancy is encouraging.

Normal gestations and live births after orthotopic autograft of vitrified-warmed hemi-ovaries into ewes.

BACKGROUND: The aim of this study was to evaluate the long-term outcome of autotransplantation of vitrified warmed hemi-ovaries into ewes. METHODS: Six hemi-ovaries from six ewes aged 6 to 12 months were vitrified. After dissection of the medulla, the hemi-ovarian cortex was stored at -196 degrees C in liquid nitrogen. Four to six weeks after the first laparotomy, the left ovary was removed and the vitrified-warmed hemi-ovary was sutured. RESULTS: Plasma progesterone concentration increased in a regular manner in all ewes. Three pregnancies occurred, from which four lambs were born. The first delivery of a normal lamb occurred in February 2003. The second delivery of two normal lambs occurred in March 2003 (a 2.5 kg male and a 2.8 kg female). The last lamb had a normal delivery but had a malformation of the left leg and the oesophagus. This lamb died two months after delivery from pneumariae. Histological examination of the grafted vitrified ovaries showed few primordial and antral follicles. CONCLUSIONS: These three pregnancies in a ewe model may indicate that ovarian vitrification gives results as good as those from a slow cooling protocol in autograft. It is impossible to establish a link between the vitrification procedure and the malformation of the last lamb, and further studies are needed to evaluate the feasibility of ovarian vitrification.