First-line surgery vs first-line ART to manage infertility in women with deep endometriosis without bowel involvement: A multi-centric propensity-score matching comparison.

OBJECTIVE: To compare first-line surgery with first-line assisted reproductive techniques (ART) in infertile women with deep infiltrating endometriosis (DIE) without colorectal involvement. STUDY DESIGN: A retrospective comparative cohort study with a propensity-score matching analysis, in four tertiary-care referral centers. The population was infertile women with DIE without colorectal involvement. The patients were managed either by first-line surgery followed by spontaneous conception attempts and/or ART, or by first-line ART. 284 patients were extracted from the databases. After matching, 92 patients were compared in each group. Clinical pregnancy rates (PR) and live-birth rates (LBR) were the primary outcomes, and cumulative pregnancy rate (CPR) and cumulative live birth rate (CLBR) were the secondary outcomes. RESULTS: The mean number of IVF-ICSI cycles per patient was 1.4, with a significant difference between the groups: 1.6 in the first-line ART group and 1.2 in the first-line surgery group (p = 0.006). The PR was significantly higher in the first-line surgery group (72 % vs 35 %; p < 0.001). In the first-line surgery group, non-ART pregnancies occurred in 18 % (17/92) while no non-ART pregnancies was noted in the first-line ART group. The LBR was significantly higher in the first-line surgery group (61 % vs 24 %; p < 0.001). After ART, the CPR were 72 % (47/67) in the first-line surgery group, and 35 % (32/92) in the first-line ART group (p < 0.001). CONCLUSION: After matching, our results support that first-line surgery offer higher pregnancy and live-birth rates than first-line ART in patients with DIE without colorectal involvement.

Fertility preservation in women with malignant and borderline ovarian tumors: Experience of the French ESGO-certified center and pregnancy-associated cancer network (CALG).

OBJECTIVE: To describe strategy and results of fertility preservation (FP) in patients with malignant and borderline ovarian tumors. METHODS: Consecutive cohort study of 43 women with malignant or borderline ovarian tumors who underwent FP between February 2013 and July 2019. The study was conducted in national expert center in Tenon University Hospital, Sorbonne University: French ESGO-certified ovarian cancer center and pregnancy-associated cancer network (CALG). Main outcome measure was FP technique proposed by multidisciplinary committee, FP technique used, time after surgery, number of fragments, histology and follicle density (if ovarian tissue freezing), number of expected, retrieved and frozen oocytes (if ovarian stimulation). RESULTS: Pathological diagnosis was malignant epithelial ovarian tumor in five women (11.6%), rare malignant ovarian tumor in 14 (32.6%), borderline in 24 (55.8%), and mostly unilateral (79.1%) and stage I (76.7%). Mean age at diagnosis was 26.8 ± 6.9 years and mean tumor size 109.7 ± 61 mm. Before FP, mean AFC was 11.0 ± 6.1 and AMH levels were 2.7 ± 4.6 ng/mL. Six ovarian tissue-freezing procedures were performed (offered to 13). Twenty-four procedures of ovarian stimulation and oocyte freezing were performed after surgical treatment for 19 women (offered to 28) with a median interval of 188 days. The mean number of mature oocytes retrieved per stimulation was 12.4 ± 12.8. At least 10 mature oocytes were frozen for 52.6% of the women. No FP was offered to five women. CONCLUSION: Oocyte and ovarian tissue cryopreservation should be offered to patients with malignant and borderline ovarian tumors. More data are needed to confirm ovarian stimulation and ovarian tissue grafting safety.

[Impact of the menstrual cycle on the quality of interpretation of the MRI result in the follow-up of women at genetic risk for breast]. / Impact du cycle menstruel sur la qualité de l'interprétation du résultat de l'IRM dans le suivi des femmes à risque génétique de cancer du sein.

INTRODUCTION: Breast MRI is used as a reference for screening breast cancer among women with a genetic high risk. Its sensitivity and specificity might decrease because of the background parenchymal enhancement. Therefore, it is recommended to plan the MRI between the 7th and the 14th day of the menstrual cycle despite of the burden of this organization. Our aim was to evaluate the interpretation (performance) of the MRI performance when it was done out of this period. METHODS: We analyzed the MRI done in the Tenon Hospital among patients with a genetic high risk, without a history of breast cancer, between 2006 and 2016. We analyzed the rate of enhancement hindering the interpretation (EH) - that is to say grade III and IV -, the rate of additional explorations (MRI and biopsy), and the occurrence of interval events in 2 groups according to the programming of the examination: appropriate programming (D7-D14) and inappropriate programming (outside this period). RESULTS: In total, 126 MRI were analyzed, done in a population of 62 women with a genetic predisposition to Breast Cancer (BRCA 1 or 2: 91%, others: 9%), median age was 34.5 years old. 84 were in appropriate programming and 42 were in an inappropriate one. The rate of EH was comparable between the two groups (respectively 31% and 35.7%, P=1), as well as the rate of additional explorations (respectively 31% and 45%, P=0.11). CONCLUSION: Our results suggest that the programming of screening MRI could be simplified among patients with a genetic predisposition of breast cancer.

A short anogenital distance on MRI is a marker of endometriosis.

STUDY QUESTION: Could the anogenital distance (AGD) as assessed by MRI (MRI-AGD) be a diagnostic tool for endometriosis? SUMMARY ANSWER: A short MRI-AGD is a strong diagnostic marker of endometriosis. WHAT IS KNOWN ALREADY: A short clinically assessed AGD (C-AGD) is associated with the presence of endometriosis. STUDY DESIGN SIZE DURATION: This study is a re-analysis of previously published data from a case-control study. PARTICIPANTS/MATERIALS SETTING METHODS: Women undergoing pelvic surgery from January 2018 to June 2019 and who had a preoperative pelvic MRI were included. C-AGD was measured at the beginning of the surgery by a different operator who was unaware of the endometriosis status. MRI-AGD was measured retrospectively by a senior radiologist who was blinded to the final diagnosis. Two measurements were made: from the posterior wall of the clitoris to the anterior edge of the anal canal (MRI-AGD-AC), and from the posterior wall of the vagina to the anterior edge of the anal canal (MRI-AGD-AF). MAIN RESULTS AND THE ROLE OF CHANCE: The study compared MRI-AGD of 67 women with endometriosis to 31 without endometriosis (controls). Average MRI-AGD-AF measurements were 13.3 mm (±3.9) and 21.2 mm (±5.4) in the endometriosis and non-endometriosis groups, respectively (P < 10-5). Average MRI-AGD-AC measurements were 40.4 mm (±7.3) and 51.1 mm (±8.6) for the endometriosis and non-endometriosis groups, respectively (P < 10-5). There was no difference of MRI-AGD in women with and without endometrioma (P = 0.21), or digestive involvement (P = 0.26). Moreover, MRI-AGD values were independent of the revised score of the American Society of Reproductive Medicine and the Enzian score. The diagnosis of endometriosis was negatively associated with both the MRI-AGD-AF (ß = -7.79, 95% CI (-9.88; -5.71), P < 0.001) and MRI-AGD-AC (ß = -9.51 mm, 95% CI (-12.7; 6.24), P < 0.001) in multivariable analysis. Age (ß = +0.31 mm, 95% CI (0.09; 0.53), P = 0.006) and BMI (ß = +0.44 mm, 95% CI (0.17; 0.72), P = 0.001) were positively associated with the MRI-AGD-AC measurements in multivariable analysis. MRI-AGD-AF had an AUC of 0.869 (95% CI (0.79; 0.95)) and outperformed C-AGD. Using an optimal cut-off of 20 mm for MRI-AGD-AF, a sensitivity of 97.01% and a specificity of 70.97% were noted. LIMITATIONS REASONS FOR CAUTION: This was a retrospective analysis and no adolescents had been included. WIDER IMPLICATIONS OF THE FINDINGS: This study is consistent with previous works associating a short C-AGD with endometriosis and the absence of correlation with the disease phenotype. MRI-AGD is more accurate than C-AGD in this setting and could be evaluated in the MRI examination of patients with suspected endometriosis. STUDY FUNDING/COMPETING INTERESTS: N/A. TRIAL REGISTRATION NUMBER: The protocol was approved by the 'Groupe Nantais d'Ethique dans le Domaine de la Santé' and registered under reference 02651077.

Selective progesterone receptor modulators: current applications and perspectives.

Selective progesterone receptor modulators (SPRMs) are steroid progesterone receptor ligands able to induce agonistic or antagonistic activities. Mifepristone, the class leader, was primarily used for pregnancy termination from the 1980s. Emergency contraception with extended activity was the second major development 30 years later, with mifepristone in some countries and ulipristal acetate world-wide. More recently, ulipristal acetate was released for the treatment of myoma-related uterine bleeding. In addition to a very rapid cessation of bleeding, SPRMs allow a decrease in myoma volume, as do gonadotropin releasing hormone analogs. However, estradiol secretion is not blunted by SPRMs. This offers new alternatives for myoma treatment, especially in women close to menopause. In conclusion, use of SPRMs has allowed significant progress in emergency contraception and treatment of myoma-related symptoms. Numerous future perspectives in women's health care are currently under evaluation.

Pregnancy outcomes after controlled ovarian hyperstimulation in women with endometriosis-associated infertility: GnRH-agonist versus GnRH-antagonist.

BACKGROUND OR OBJECTIVE: Endometriosis is common in women referred for infertility. In vitro fertilization provides good results but the choice of the best-controlled ovarian hyperstimulation protocol remains a subject of debate. The objective of this retrospective study was to compare pregnancy outcomes in women with endometriosis-associated infertility after COH with a long agonist protocol or a six-week oral contraception-antagonist protocol. MATERIAL AND METHODS: Retrospective analysis of a prospective database identified 284 COH cycles - 165 with GnRH-agonist protocol (GnRH-agonist group) and 119 with GnRH-antagonist protocol (GnRH-antagonist group) - in 218 women, with endometriosis from January 2013 to October 2015. RESULTS: No difference in the epidemiological characteristics was found between the groups. Per started cycle, pregnancy and live-birth rates after fresh embryo transfer were higher with the GnRH-agonist protocol (25% vs. 13%, P=0.02 and 18% vs. 8%, P=0.04, respectively). Considering analysis per cycle with embryo transfer, the pregnancy rate was similar in both groups while the live-birth rate was higher in the GnRH-agonist group (29% vs. 17%, P=0.053 and 22% vs. 10%, P=0.02, respectively). No difference was observed between the groups with freeze-thaw embryo transfer. Subgroup analysis (endometrioma alone, deep infiltrating endometriosis with and without endometrioma, endometriosis with and without adenomyosis) revealed no difference between the groups for either pregnancy or live-birth rates. CONCLUSION: A GnRH-agonist protocol appears to result in higher pregnancy and live-birth rates after fresh embryo transfer in women with endometriosis-associated infertility, suggesting that a GnRH-antagonist protocol might negatively impact endometrial receptivity.