[First-line management of infertile couple. Guidelines for clinical practice of the French College of Obstetricians and Gynecologists 2022]. / Prise en charge de première intention du couple infertile : mise à jour des RPC 2010 du CNGOF.

OBJECTIVE: To update the 2010 CNGOF clinical practice guidelines for the first-line management of infertile couples. MATERIALS AND METHODS: Five major themes (first-line assessment of the infertile woman, first-line assessment of the infertile man, prevention of exposure to environmental factors, initial management using ovulation induction regimens, first-line reproductive surgery) were identified, enabling 28 questions to be formulated using the Patients, Intervention, Comparison, Outcome (PICO) format. Each question was addressed by a working group that had carried out a systematic review of the literature since 2010, and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) methodology to assess the quality of the scientific data on which the recommendations were based. These recommendations were then validated during a national review by 40 national experts. RESULTS: The fertility work-up is recommended to be prescribed according to the woman's age: after one year of infertility before the age of 35 and after 6months after the age of 35. A couple's initial infertility work-up includes a single 3D ultrasound scan with antral follicle count, assessment of tubal permeability by hysterography or HyFOSy, anti-Mullerian hormone assay prior to assisted reproduction, and vaginal swabbing for vaginosis. If the 3D ultrasound is normal, hysterosonography and diagnostic hysteroscopy are not recommended as first-line procedures. Chlamydia trachomatis serology does not have the necessary performance to predict tubal patency. Post-coital testing is no longer recommended. In men, spermogram, spermocytogram and spermoculture are recommended as first-line tests. If the spermogram is normal, it is not recommended to check the spermogram. If the spermogram is abnormal, an examination by an andrologist, an ultrasound scan of the testicles and hormonal test are recommended. Based on the data in the literature, we are unable to recommend a BMI threshold for women that would contraindicate medical management of infertility. A well-balanced Mediterranean-style diet, physical activity and the cessation of smoking and cannabis are recommended for infertile couples. For fertility concern, it is recommended to limit alcohol consumption to less than 5 glasses a week. If the infertility work-up reveals no abnormalities, ovulation induction is not recommended for normo-ovulatory women. If intrauterine insemination is indicated based on an abnormal infertility work-up, gonadotropin stimulation and ovulation monitoring are recommended to avoid multiple pregnancies. If the infertility work-up reveals no abnormality, laparoscopy is probably recommended before the age of 30 to increase natural pregnancy rates. In the case of hydrosalpinx, surgical management is recommended prior to ART, with either salpingotomy or salpingectomy depending on the tubal score. It is recommended to operate on polyps>10mm, myomas 0, 1, 2 and synechiae prior to ART. The data in the literature do not allow us to systematically recommend asymptomatic uterine septa and isthmoceles as first-line surgery. CONCLUSION: Based on strong agreement between experts, we have been able to formulate updated recommendations in 28 areas concerning the initial management of infertile couples.

Predicting the ovarian response: towards a determinant model and implications for practice.

OBJECTIVE: To improve the reliability of prediction models for ovarian response to stimulation in ART. DESIGN: A multicenter retrospective cohort study. SETTING: Twelve reproductive centers. PATIENTS: A total of 25,854 controlled ovarian stimulations between 2005 and 2016, including cycles cancelled for inadequate response, were included. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Precision of the prediction of the number of oocytes at ovarian pickup and of cancellation rate for poor ovarian response. RESULTS: Both AMH and antral follicle count exhibit a non-linear effect on the oocyte yield, with a linear relationship after log-transformation. After adjustment for age, BMI, and center, ovarian response observed in a previous stimulation was found to be the best predictor, followed by AMH and AFC. The zero-inflated binomial negative model showed that predictors of cycle cancellation and number of oocytes at retrieval were different, and assimilating cancellation to zero oocyte greatly reduces the determination of the model. Our model was characterized by the best ever reached determination (R2=0.505 for non-naïve women, 0.313 for all the women) and provided evidence of a very strong difference among centers. The results can be easily converted in the prediction of response levels (poor-medium-good-high). Finally, in case of partial report of the above predictors, we show that the univariate prediction based on the best predictor provides a good approximation. CONCLUSION(S): A substantial improvement of the ovarian response prediction is possible in modelling the possible cancellation decision, followed by the oocyte retrieval itself, according to an appropriate model based on previous stimulation and non-linear effects of AMH and AFC.

A 16-year bicentric retrospective analysis of ovarian tissue cryopreservation in pediatric units: indications, results, and outcome.

Background: Cancer treatments of the last decades improve the survival rate of children and adolescents. However, chemo- and radiotherapy result in gonadal damage, leading to acute ovarian failure and sterility. The preservation of fertility is now an integral part of care of children requiring gonadotoxic treatments. Ovarian tissue cryopreservation (OTC) is an effective fertility preservation option that allows long-term storage of primordial follicles, subsequent transplantation, and restoration of endocrine function and fertility. The efficacy of this technique is well-demonstrated in adults but the data are scarce for pediatric patients. Currently, OTC represents the only possibility of preserving the potential fertility in prepubertal girls. Procedure: This is a retrospective study of OTC practice of two French centers from January 2004 to May 2020. A total of 72 patients from pediatric units underwent cryopreservation of ovarian tissue before gonadotoxic therapy for malignant or non-malignant diseases. The ovarian cortex was cut into fragments and the number of follicles per square millimeter was evaluated histologically. The long-term follow-up includes survival rate and hormonal and fertility status. Results: The mean age of patients at OTC was 9.3 years [0.2-17] and 29.2% were postpubertal; 51 had malignant diseases and 21 had non-malignant diseases. The most frequent diagnoses included acute leukemia, hemoglobinopathies, and neuroblastoma. Indication for OTC was stem cell transplantation for 81.9% (n = 59) of the patients. A third of each ovary was collected for 62.5% (n = 45) of the patients, a whole ovary for 33.3% (n = 24) of the patients, and a third of one ovary for 4.2% (n = 3) of the patients. An average of 17 fragments [5-35] per patient was cryoconserved. A correlation was found between the age of the patients and the number of fragments (p < 0.001). More fragments were obtained from partial bilateral harvesting than from whole ovary harvesting (p < 0.05). Histological analysis of ovarian tissue showed a median of 6.0 primordial follicles/mm2 [0.0-106.5] and no malignant cells were identified. A negative correlation was found between age and follicular density (p < 0.001). Median post-harvest follow-up was 92 months [1-188]. A total of 15 girls had died, 11 were still under treatment for their pathology, and 46 were in complete remission. Of all patients, 29 (40.2%) were subjected to a hormonal status evaluation and 26 were diagnosed with premature ovarian insufficiency (POI) (p < 0.001). One patient had undergone thawed ovarian tissue transplantation. Conclusion: OTC should be proposed to all girls with high risk of developing POI following gonadotoxic therapies in order to give them the possibility of fertility and endocrine restoration.

The uterine volume is dramatically decreased after hematopoietic stem cell transplantation during childhood regardless of the conditioning regimen.

OBJECTIVE: To study the impact of hematopoietic stem cell transplantation (HSCT) on the uterine volume of childhood acute leukemia (AL) survivor depending on age at HSCT and the type of myeloablative conditioning regimen. SETTING: Thirteen French University Teaching Hospitals. DESIGN: Prospective cohort study. PATIENT(S): Eighty-eight women who underwent HSCT during childhood or adolescence for AL compared to a control group. INTERVENTION(S): A multicentric prospective national study compared the uterine volume in a cohort of childhood AL survivor adult women treated with HSCT, matched 1:1 to control women. Pelvic magnetic resonance imaging scans included diffusion-weighted imaging sequences. Scans were centralized for a double-blinded reading by 2 radiologists. MAIN OUTCOME MEASURE(S): Uterine volume, uterine body-to-cervix ratio, and apparent diffusion coefficient. RESULT(S): The mean age at HSCT was 9.1 ± 0.3 years with a mean follow-up duration of 16.4 ± 0.5 years. The cohort of 88 HSCT survivor women was composed of 2 subgroups depending on the myeloablative conditioning regimen received: an alkylating agent-based regimen group (n = 34) and a total body irradiation (TBI)-based regimen group (n = 54). Among the 88 women, 77 were considered as having a "correct hormonal balance" with estrogens supplied by hormone replacement therapy (HRT) for premature ovarian insufficiency (POI) or because of a residual ovarian function. In the control group (n = 88), the mean uterine volume was 79.7 ± 3.3 mL. The uterine volume significantly decreased in all HSCT survivor women. After the alkylating agent-based regimen, the uterine volume was 45.3 ± 5.6 mL, corresponding to a significant volume reduction of 43.1% (28.8-57.4%) compared with that of the control group. After TBI, the uterine volume was 19.6 ± 1.9 mL, corresponding to a significant volume reduction of 75.3% (70.5%-80.2%) compared with that of the control group. After the alkylating agent-based regimen, the uterine volume dramatically decreased in women with POI without HRT compared with that in those with a correct hormonal balance (15.2 ± 2.6 vs. 49.3 ± 6 mL). In contrast, after TBI, the uterine volume was similar in all women, with no positive effect of hormonal impregnation on the uterine volume (16.3 ± 2.6 vs. 20.1 ± 2.2 mL, respectively). CONCLUSION(S): The uterine volume was diminished after HSCT, regardless of the conditioning regimen. The physiopathology needs to be further investigated: specific impact of a high dose of an alkylating agent; impact of hormone deprivation around puberty; poor compliance to HRT; or different myometrial impact of HRT compared with endogenous ovarian estrogens? CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov/NCT03583294 (enrollment of the first subject, November 11, 2017; enrollment of the last subject, June 25, 2021).

Reliability of AMH and AFC measurements and their correlation: a large multicenter study.

PURPOSE: Anti-Müllerian hormone (AMH) and antral follicle count (AFC) are correlated with the ovarian response, but their reliability and reproducibility are questionable. This large multicenter study describes their distribution, inter-cycle and inter-center variability, and their correlation. METHODS: A total of 25,854 IVF cycles among 15,219 patients were selected in 12 ART centers. Statistical distribution of AMH and AFC was studied by using the Kolmogorov-Smirnov test and Shapiro goodness of fit test. The reproducibility of AFC and AMH was measured using a mixed model regressing the logarithmic transformation of AFC with age. RESULTS: The distribution of AMH and AFC was characterized by a wide dispersion of values, twice more important for AFC, and a logarithmic distribution. The faster decline in AMH than in AFC with age suggests that their correlation changes with age. AMH and AFC showed a very low proportion of concordance in the range of expected poor responders according to Bologna cutoffs. The heterogeneity for AMH and AFC across centers was small, but much larger across patients within each center. Concerning the patients with several successive cycles, the reproducibility for AMH seemed much better than for AFC. Comparing respective performances of AMH and AFC for the prediction of ovarian response depended on the local conditions for measuring these indicators and on the reproducibility of results improved over time. CONCLUSION: Distribution of AMH and AFC was characterized by the wide dispersion of values, and a logarithmic distribution. Establishing cutoffs or a direct relationship AMH/AFC without considering age seems hazardous. Correlation between AMH and AFC was very poor in the range of poor responders.

Ovarian Cortex Transplantation.

STUDY OBJECTIVE: To describe a laparoscopic technique for the transplantation of a cryopreserved ovarian cortex. DESIGN: Educational video. SETTING: University Hospital of Strasbourg, France. INTERVENTIONS: A 28-year-old nulliparous woman presented with anaplastic T lymphoma and was then treated with chemotherapy. Before the treatment, the ovarian cortex was collected by laparoscopy to preserve fertility. Remission was achieved, but the patient suffered from premature ovarian failure. At the age of 32 years, she wished to become pregnant. The patient was thus included in the research protocol Development of Ovarian Tissue Autograft in Order to Restore Ovarian Function, and the transplantation site was chosen accordingly. The cortex was stored in liquid nitrogen at -196°C after slow congelation. To restore ovarian function and because of pregnancy desire, we transplanted the cryopreserved ovarian cortex in the right ovary and inside a pocket of the peritoneum of the left ovarian fossa. The first step included adhesiolysis to treat small adhesions developed after the first surgery. On the right, the ovarian cortex was opened by an antimesial incision with cold scissors. The cryopreserved ovarian cortex was placed through the cortex of the right ovary and fixed with stitches. On the left side, the peritoneum of the ovarian fossa was opened, and a subperitoneal pocket was dissected. The cortex was inserted. It was then closed with absorbable sutures or with a hemostatic pad. Six months after her surgery, the patient had natural cycles. We monitored an ovulation of both the sides. She underwent 3 in vitro fertilizations but with failures of embryo transfer. She conceived spontaneously a year after the surgery. She gave birth to a healthy child weighing 3300 g. CONCLUSION: For patients who have suffered from premature ovarian failure owing to chemotherapy, ovarian cortex transplantation can restore the ovulatory function, allow in vitro fertilization, and permit, as in our case, a spontaneous pregnancy.

Luteal phase stimulation, the future of fertility preservation? Retrospective cohort study of luteal phase versus follicular phase stimulation.

RESEARCH QUESTION: Is luteal phase stimulation capable of improving fertility preservation? MATERIALS AND METHODS: We performed a retrospective cohort study of consecutive ovarian stimulations, during July 2012 and September 2018 at Strasbourg University Teaching Hospital in France. Enrollment criteria were patients aged below 40 who had been referred to our center following a diagnosis of cancer or requiring gonadotoxic treatment. All patients enrolled had regular menstrual cycles and normal ovulation. Non-enrollment criteria were an expected low ovarian response (defined by an anti-Müllerian hormone (AMH) level <0.75µg/L and/or an antral follicle count inferior (AFC) inferior than 5), polycystic ovarian syndrome, amenorrhea, prior history of infertility or gonadotoxic treatment. The primary endpoint is the number of mature oocytes (metaphase II) obtained. Secondary outcomes were oocyte yields obtained, stimulation duration, initial gonadotropin dose and total gonadotropin dose. RESULTS: A total of 100 patients were included: 20 in luteal phase and 80 in follicular phase. A larger number of mature oocytes was obtained in luteal phase versus follicular phase (13.1+/8.0 versus 9.2+/-5.8 with p=0.01). A greater amount of total (mature and immature) oocytes was obtained in luteal phase versus follicular phase with a significant difference (16.8+/-9.3 versus 11.8+/-7.3 with p=0.01). No difference was found for the initial and total doses of gonadotropin. CONCLUSIONS: Luteal phase stimulation has the advantage of a better flexibility with positives results as to the number of oocytes obtained in fertility preservation.

Luteal phase progesterone supplementation following induced natural cycle frozen embryo transfer: A retrospective cohort study.

INTRODUCTION: The objective of this study was to assess the impact on the clinical pregnancy rate of luteal phase progesterone treatment in patients being prepared for natural cycle frozen embryo transfer (FET) with induced ovulation. MATERIAL AND METHODS: This retrospective cohort study collect all the FET protocols over a 6-month period at Strasbourg University Hospital fertility unit between December 2016 and May 2017. In total 293 consecutive patients with regular menstrual cycles were prepared for natural cycle FET during this period. All patients had an embryo cryopreservation secondary to in vitro fertilisation (IVF) or by intracytoplasmic sperm injection (ICSI). There were 2 protocols during this period and patients either received or did not received progesterone. Ovulation was routinely triggered in all patients by injection of choriogonadotrophin alfa. Patients in the treated group received vaginal natural micronized progesterone treatment of 400mg daily, starting on the day of ovulation. The principal assessment criterion was the occurrence of pregnancy. RESULTS: In total, 231 patients were analysed: 108 in the group not receiving progesterone and 123 in the group receiving progesterone. Patient characteristics were comparable between groups. A higher clinical pregnancy rate (39% vs. 24.1%, p=0.02; 95CI [1.10; 3.74]) was recorded in the treated group. CONCLUSIONS: Our results suggest that luteal phase support with vaginal progesterone statistically increases the clinical pregnancy rate following hCG-triggered natural cycle FET and that it should be used more widely.

Breast cancer and ovarian tissue cryopreservation: Review of the literature.

INTRODUCTION: Ovarian tissue cryopreservation is a modern technique of fertility preservation, useful before using ovariotoxic therapies in the treatment of breast cancer. The aim of our literature review was to study ovarian cryopreservation experiences for women with breast cancer, to identify guidelines, constraints and results in the oncological and obstetrical fields. METHODS: We searched articles through the PubMed/Medline database, including all French and English references from January 2000 to October 2017. The combination of key words "breast cancer" and "ovarian tissue cryopreservation" allowed us to select 50 articles. We kept 18 publications which matched our subject. RESULTS: Sixteen cases of ovarian transplants among patients treated for breast cancer were published with 14 pregnancies, 11 births and 3 failures. Two cases of breast recurrences were published after ovarian grafting. However, the hindsight in this technique is limited, with a first transplant published in 2004 and only a low number of cases. PERSPECTIVES: A national census and comprehensive gathering of data among the patients treated for breast cancer using ovarian tissue cryopreservation would make it possible to better evaluate the occurrence of pregnancies and the carcinological risk of this technique.

Influence of medically assisted reproduction techniques on crown-rump length and biochemical markers of trisomy 21 in the first trimester of pregnancy.

OBJECTIVE: To determine whether there is a difference between the known gestational age in pregnancies conceived after IVF and the estimated gestational age based on the crown-rump length (CRL) measurement during the first trimester. DESIGN: We retrospectively (between 2007 and 2012) studied a cohort of 6,739 patients who underwent ultrasonography between 11 and 13+6 weeks of amenorrhea. SETTING: Hospital. PATIENT(S): Group A consisted of 6,621 patients with regular menses whose term was calculated based on the date of their last menstrual period (LMP). Group B consisted of 529 patients whose pregnancies had been achieved by IVF and in whom term was calculated based on the date of fresh or frozen ET. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The gestational age difference was obtained by comparing the age obtained by measuring the CRL (Robinson's curve) with the gestational age calculated in accordance with LMP in group A or with ET day in group B. RESULT(S): The gestational age difference was significantly more in group B (2.3 days vs. 0.84 days in group A). We found a significant difference regarding biochemical markers for trisomy 21 to the detriment of group B with a significantly reduced pregnancy-associated protein P-A multiple of median (0.78 vs. 0.92). CONCLUSION(S): There appears to be a small difference in CRL development between spontaneous pregnancies and pregnancies conceived by assisted reproductive technology (ART). Specific ultrasonographic curves for pregnancies conceived by ART would be more relevant and precise. The underlying pathophysiological mechanisms are not very clear and offer possibilities for future research.

Improving preimplantation genetic diagnosis for Fragile X syndrome: two new powerful single-round multiplex indirect and direct tests.

Fragile X syndrome (FraX) is caused by the expansion of an unstable CGG repeat located in the Fragile X mental retardation 1 gene (FMR1) gene. Preimplantation genetic diagnosis (PGD) can be proposed to couples at risk of transmitting the disease, that is, when the female carries a premutation or a full mutation. We describe two new single-cell, single-round multiplex PCR for indirect and direct diagnosis of FraX on biopsied embryos. These tests include five unpublished, highly heterozygous simple sequence repeats, and the co-amplification of non-expanded CGG repeats for the direct test. Heterozygosity of the new markers ranged from 69 to 81%. The mean rate of non-informative marker included in the tests was low (26% and 23% for the new indirect and direct tests, respectively). This strategy allows offering a PGD for FraX to 96% of couples requesting it in our centre. A conclusive genotype was obtained in all cells with a rate of cells presenting an allele dropout ranging from 17% for the indirect test to 26% for the direct test. The new indirect test was applied for eight PGD cycles: 32 embryos were analysed, 9 were transferred and 3 healthy babies were born. By multiplexing these highly informative markers, robustness of the diagnosis is improved and the loss of potentially healthy embryos (because they are non-diagnosed or misdiagnosed) is limited. This may increase the chances of success of couples requesting a PGD for FraX, in particular, when premature ovarian insufficiency in premutated women leads to a reduced number of embryos available for analysis.

Search for mutations involved in human globozoospermia.

BACKGROUND: Globozoospermia is a severe form of teratozoospermia characterized by round-headed sperm with an absence of acrosomes. Family cases of globozoopermia suggest that this pathology has genetic origins, but the mode of inheritance remains unknown. So far, no responsible genes have been identified. Recently, a mouse lacking the casein kinase IIalpha' (encoded by the Csnk2a2 gene) was described. This mutant mouse presents a single phenotype reminiscent of that seen in human globozoospermia. Interestingly, the fission yeast orthologue (orb5) exhibits, when mutated, a spherical phenotype. Casein kinase II is a heterotetramer, composed of two catalytic subunits alpha or alpha' and two regulatory beta subunits (encoded by the Csnk2b gene). METHODS AND RESULTS: Based on the evolution conservation, phenotypes observed in mouse and yeast mutant and the structure of casein kinase II, we analysed Csnk2a2 and Csnk2b genes in six patients with globozoospermia and 10 fertile controls. Genomic DNA was extracted from peripheral blood and PCR was performed to amplify Csnk2a2 and Csnk2b genes before sequencing. CONCLUSION: No mutation was identified among these six patients. Further work is needed, with a larger patient data set, to identify putative genes involved in this form of male infertility.