[Rupture of membranes in case of internal podalic version: a risk for cesarean section on the second twin]. / Non-intégrité des membranes en cas de manœuvres : facteur de risque de césarienne sur deuxième jumeau.

OBJECTIVES: To evaluate if internal version with ruptured membranes is a risk factor of cesarean section for the second twin. PATIENTS AND METHODS: Two hundred and fifty-nine twins vaginal deliveries after 33 weeks of gestation from 1997 to 2009 in a level 3 maternity. A retrospective case-control study comparing two groups: cases of cesarean section on second twin and five twins vaginal deliveries following the case. Active management of the second twin delivery was performed with a short intertwin delivery. RESULTS: Eleven cesarean sections on the second twin were performed (4.2%). The main indication was failure of internal version. The risk of cesarean section was significantly greater when the internal version was performed with ruptured membranes (OR: 25.4 IC 95% [2.3-275.7] P<0.003) and when intertwin time delivery interval was increased (8.1±5.1 vs 16.7±6.3, P<0.001). DISCUSSION AND CONCLUSION: The rupture of amniotic membranes before or during the internal podalic version is associated with a risk of failure and cesarean for the second twin. We recommend to perform the internal podalic version with unruptured membranes according to the French recommendations.

[Anal sphincter injury during operative vaginal delivery using spatulas. What are the risk factors?]. / Lésions périnéales sévères liées à une extraction fœtale par spatules. Quels facteurs de risques ?

OBJECTIVE: To assess risk factors for anal sphincter injury during operative vaginal delivery using spatulas. PATIENTS AND METHODS: A monocentric retrospective study of all assisted vaginal deliveries using Thierry and Teissier's spatulas between January 1st, 2008 and December 31st, 2009 in a teaching level III maternity. We studied risk factors such as primiparity, gestational age, maternal age, previous perineal laceration, level and type of presentation, type of expulsion, unsuccessful extraction and successive use of tools, episiotomy, type of anaesthesia and birth weight. RESULTS: There were 346 perineal tears (60.5%); among them, 175 (31%) were type 1, 131 (23%) type 2, 35 (6.1%) type 3 and five (0.9%) type 4. There were 235 episiotomy (41.1%). There was no statistically significant difference between all the supposed risk factors and the severe perineal tears. CONCLUSION: There are no relationship between third and fourth degree perineal lesions during spatula's delivery and supposed risk factors of anal sphincter injury. Only statistical tendances between first vaginal delivery and anal sphincter injury and between occipitosacral delivery and anal sphincter injury were found. We need further randomized studies comparing assisted births using spatulas, forceps and vacuum extractors to better assess perineal tears risk factors.

Do female translocations influence the ovarian response pattern to controlled ovarian stimulation in preimplantation genetic diagnosis?

BACKGROUND: Ovarian response in female translocation carriers is not well understood. We aimed to evaluate the impact of chromosomal autosomal balanced translocations on the ovarian response to controlled ovarian stimulation (COS) in female carriers undergoing IVF and PGD. METHODS: In a retrospective study, we included all female translocation carriers who underwent PGD at our centre. We compared these patients to female patients from couples with male translocation carriers who underwent PGD. RESULTS: Results from 79 cycles of PGD from 33 female translocation carriers were compared with 116 cycles from 55 male translocation carriers. No difference was observed for patient characteristics: female age, anti-Müllerian hormone or antral follicle count. No difference in COS parameters was observed for the total dose of recombinant FSH, the number of retrieved oocytes and embryos on Day 3, for unaffected and transferred embryos. For the two groups, pregnancy rate was similar per cycle (12.7 versus 20.7%, P = 0.208). Multivariate analysis demonstrated that female translocation carriers had a significantly higher estradiol level on the day of hCG administration (+540 pg/ml, P = 0.05). CONCLUSIONS: This paper is the largest to report ovarian response of female translocation carriers. This study showed that the ovarian response to COS was not impaired by balanced translocation status, suggesting that female chromosomal structural abnormalities did not influence the results of COS in PGD. Thus, female carriers of balanced translocations could be considered normal responders and standard doses of gonadotrophins used for ovarian stimulation.

[Endometriosis and fertility: Results after surgery and Assisted Reproductive Technology (ART)]. / Fertilité des patientes présentant une endométriose traitées par cœlioscopie et AMP.

OBJECTIVE: To evaluate fertility outcomes after laparoscopic and ART management of endometriosis in an infertile population. PATIENTS AND METHODS: Retrospective analysis including 79 infertile patients treated by laparoscopic surgery. Fertility was studied in relation to pregnancy's mode (spontaneous or ART) and to endometriosis stages (rAFS). RESULTS: After laparoscopy, 8.9% of patients had a spontaneous pregnancy. IIU led to a cumulative rate of pregnant women of 21.5%. Then after laparoscopy, IIU and IVF, 68.4% of patients were pregnant. The average delay was 460 days between laparoscopy and spontaneous pregnancy, 271 days between surgery and IIU pregnancy and 600 days between surgery and IVF pregnancy. Among women with stages I-II endometriosis (62 cases), 11.3% patients obtained a spontaneous pregnancy, the cumulative rate of pregnant women after laparoscopy and IIU was 25,8%. After laparoscopy, IIU and IVF, 66.1% of patients were pregnant. The average post-surgical time to spontaneous pregnancy was 460 days. The average delay between surgery and IIU pregnancy was 279 days and 589 days between surgery and IVF pregnancy. In case of stages III-IV (17 patients), 76.4% of pregnancies were obtained. No spontaneous pregnancy was observed. 94.1% of patients were treated with IVF, leading to a global rate of pregnancy of 70.5%. The average delay between surgery and IVF pregnancy was 563 days. CONCLUSIONS: With a combination of surgery and ART, two-third of patients were pregnant with an average time between surgery and pregnancy of less than two years. This combination (surgery and ART) increases the chances of becoming pregnant. At the moment, the delay between surgery and ART needs to be established.

Effects of cigarette smoking on reproduction.

BACKGROUND Cigarette smoking is associated with lower fecundity rates, adverse reproductive outcomes and a higher risk of IVF failures. Over the last few decades, prevalence of smoking among women of reproductive age has increased. This review focuses on current knowledge of the potential effects of smoke toxicants on all reproductive stages and the consequences of smoke exposure on reproductive functions. METHODS We conducted a systematic review of the scientific literature on the impact of cigarette smoking and smoke constituents on the different stages of reproductive function, including epidemiological, clinical and experimental studies. We attempted to create hypotheses and find explanations for the deleterious effects of cigarette smoke observed in experimental studies. RESULTS Cigarette smoke contains several thousand components (e.g. nicotine, polycyclic aromatic hydrocarbons and cadmium) with diverse effects. Each stage of reproductive function, folliculogenesis, steroidogenesis, embryo transport, endometrial receptivity, endometrial angiogenesis, uterine blood flow and uterine myometrium is a target for cigarette smoke components. The effects of cigarette smoke are dose-dependent and are influenced by the presence of other toxic substances and hormonal status. Individual sensitivity, dose, time and type of exposure also play a role in the impact of smoke constituents on human fertility. CONCLUSIONS All stages of reproductive functions are targets of cigarette smoke toxicants. Further studies are necessary to better understand the deleterious effects of cigarette smoke compounds on the reproductive system in order to improve health care, help to reduce cigarette smoking and provide a better knowledge of the molecular mechanisms involved in reproductive toxicology.

Myotonic dystrophy type 1 and PGD: ovarian stimulation response and correlation analysis between ovarian reserve and genotype.

This study aimed at evaluating parameters and results of ovarian stimulation for myotonic dystrophy type 1 (DM1) female patients undergoing preimplantation genetic diagnosis (PGD) and to assess an eventual association between genotype and ovarian reserve. A retrospective study involved all 17 DM1 patients treated in the study centre's PGD programme. The control group consisted of 22 patients treated for X-linked disorders in the same period. Comparative analysis of ovarian stimulation parameters and results was performed with bivariate and multivariate analysis. Then, among DM1 patients, a correlation between genotype (number of CTG repeats) and ovarian reserve, assessed by antral follicle count, was investigated. Comparative study showed no difference concerning the number of oocytes, embryos and pregnancy rate between the two groups. Multivariate analysis demonstrated that DM1 patients needed a significantly higher dose of gonadotrophins (+544IU, P<0.001) than X-linked disorders patients and suggests a decreased ovarian sensitivity. However, with higher dose of gonadotrophins, PGD for DM1 offers good reproductive outcomes with a clinical pregnancy rate of 35.7%. Genotype was not correlated to ovarian reserve and appeared not to be helpful for the choice of the dose of gonadotrophins.

[Partial uterine wall necrosis following Cho hemostatic sutures for the treatment of postpartum hemorrhage]. / Nécrose pariétale utérine partielle après capitonnage hémostatique selon la technique de Cho au cours d'une hémorragie du post-partum.

A 38-year-old woman, gravida 2, para 2, underwent caesarean section at 41 weeks' gestation and suffered postpartum hemorrhage due to uterine atony. Four Cho sutures were used to control hemorrhage. A systematic postpartum hysteroscopy showed a heterogenous whitish area of the fundus and MRI advocated placental retention. However, hysteroscopically guided biopsies confirmed the diagnosis of partial uterine necrosis. We emphasize the need to undergo postoperative follow-up to confirm uterine wall integrity after placement of compression sutures in order to document the complications of this procedure, which remain under evaluated.

[Laparoscopic cervico-isthmic cerclage evaluation]. / Evaluation du cerclage isthmique par voie coelioscopique.

OBJECTIVE: The transabdominal cervico-isthmic cerclage could to be proposed in case of failure of vaginal cerclage, 2nd trimester fetal losses and cervical defects. The efficiency of the laparoscopic approach, more recently described, has to be demonstrated for the prevention of obstetrical accident. PATIENTS AND METHODS: This study is a retrospective monocentric evaluation of 14 laparoscopic cervico-isthmic cerclages performed with Benson modified technique before pregnancy between 2005 and 2007. Previous obstetrical accidents, etiology of cervical incompetence and patient outcome after cerclage were compared. RESULTS: Median age of the patients was 33.5 years; 93% had previous fetal losses or preterm delivery and 42.9% had failure of Mac Donald cerclages. The indication of laparoscopic cervico-isthmic cerclage was Mac Donald cerclage failure (six cases), and eight cases of anatomic incompatibility of Mac Donald cerclage. Mean duration of laparoscopic cervico-isthmic cerclage was 45 minutes. All patients were hospitalized on an outpatient basis. No operative complication was reported. Six women were pregnant after cerclage: five deliveries by caesarean section at term, and one first trimester foetal loss. DISCUSSION AND CONCLUSION: The cervico-isthmic cerclage can be easily performed by laparoscopy. The indications are strictly the same as cervico-isthmic cerclages by laparotomy. Increasing the number of term deliveries and the obstetrical outcome of these patients, the efficiency of the cervico-isthmic cerclage by laparoscopy is demonstrated.

[Oocyte and embryo quality: do the apoptotic markers have a place in the preimplantation genetic diagnostic?]. / Qualité ovocytaire et embryonnaire : les marqueurs apoptotiques ont-ils leur place dans le potentiel préimplantatoire ?

In Assisted Reproductive Technology (ART), the pregnancy and birth rates following in vitro fertilization (IVF) attempts are still low. Recently, research in the field of ART has explored new oocyte and embryo quality selection criteria such as apoptotic markers. Many studies provided evidence that bad oocyte and embryo quality can be associated with apoptosis. The aim of this review is to summarize our current knowledge on the apoptosis process in oocytes and embryos, and focus on the possibility of using apoptotic markers as a reliable and predictive marker to select competent oocytes and embryos during IFV.

[Pregnancy results in in vitro fertilization in one case of luteinized-unruptured-follicle syndrome]. / Obtention d'une grossesse en fécondation in vitro sur un cas de syndrome de lutéinisation folliculaire sans rupture.

Luteinized unruptured follicle syndrome can explain female infertility. The precise mechanism by which the ovulatory follicle fails to rupture is unclear. The following case reports a pregnancy result in in vitro fertilization (IVF). The first stimulation, a long IVF protocol with low FSH dose, was successful. Different methods used for detection and treatment are discussed.

[Natural cycle in vitro fertilization cycle in poor responders]. / Le cycle naturel en fécondation in vitro chez les mauvaises répondeuses.

Since the beginning of IVF, natural cycle In Vitro Fertilization (NC-IVF) has been largely replaced by IVF with ovarian stimulation. However, natural cycle IVF has several advantages: low cost, no risk of ovarian hyper stimulation syndrome, very low risk of multiple pregnancy. Nevertheless, natural cycle IVF is less effective with a high risk of cancellation due to premature rise of LH, and an increased risk of failed oocyte retrieval. Using GnRH antagonists in a modified natural cycle decreases the occurrence of a premature LH rise. In the context of a poor responder patient, natural IVF could theoretically yield a better quality oocyte coming from a naturally selected follicle and allow a transfer on an endometrium whose receptivity has not been distorted by controlled ovarian stimulation. However, the real place for it has yet to be defined as we lack published data. Only one randomised controlled study in poor responders showed a similar pregnancy rate to a standard protocol representing a cost-effective alternative. Available retrospective data seem to show the same trend especially in the sub group of younger patients (below 38). Natural cycle IVF is a low-risk, low-cost procedure whose interesting results should be further confirmed by large scale prospective studies.

[Ultrasonographical predictive factors of ovarian response to stimulation prior to in vitro fertilization]. / Facteurs échographiques prédictifs de la réponse ovarienne en fécondation in vitro.

OBJECTIVE: Evaluate whether ovarian antral follicles number, ovarian volume and ovarian area are predictive of ovarian response. PATIENTS AND METHODS: Prospective cohort analysis of 41 women with normal basal serum FSH concentration, who were undergoing their IVF cycle. The ovarian antral follicle number, the ovarian volume and area were determined by transvaginal ultrasonography on the third menstrual day for 20 women, and after pituitary suppression for 21 women. The main outcome measures are the number of follicles the day of HCG with a diameter >or=14 mm, the number of oocytes retrieved and the number of embryos. RESULTS: The antral follicle count was significantly correlated to the number of follicles (R=0.7; P<0.001), to the number of oocytes retrieved (R=0.46; P=0.008) and to the number of embryos (R=0.44; P=0.01). The ovarian volume and area was significantly correlated to the number of follicles. DISCUSSION AND CONCLUSION: The total antral follicle number on day 3 has a predictive value for favourable IVF outcome. Because this sonographic count is easy, safe and inexpensive it should be performed prior every IVF cycle.