[Laparoscopic double sacrocolpopexy: a failure for the posterior compartment?]

Aim: To evaluate the anatomical and functional outcomes of laparoscopic sacrocolpopexy using an anterior and a posterior prolen mesh, for the cure of genital prolapse. STUDY Methods: This is a consecutive five year prospective observational study in which 80 patients presented with at least a Stage 2 apical prolapsed [Baden and Walker], with an anterior or a posterior vaginal wall prolapse, who underwent a double sacrocolpopexy. Two prolen prosthesis [Pro-swing[registered sign] - Textile Hi-Tec[Trade Mark Sign], Fr] were used for this technique. Pre- and post-operative data referring to prolapse quantitation [Baden and Walker classification], scores of quality of life and sexuality [French equivalent of the Pelvic Floor Distress Inventory [PFDI], Pelvic Floor Impact Questionnaire [PFIQ] and Pelvic organ prolapse-urinary Incontinence-Sexual Questionnaire [PISQ-12] were compared. Peri and postoperative complications constituted the secondary outcome measures

Results: At 2 years after surgery, all patients were accessible for evaluation. For these patients, the anatomical success rates [Stage 0 or 1] on the apical, anterior or posterior compartments were respectively 100%, 97.5% and 89.3%. On the functional level, all the scores of quality of life and sexuality were significantly improved except anorectal scores CRADI and CRAIQ

Conclusions: This study confirms that PFC is an effective technique for the treatment of the urogenital prolapsed. On the anatomical levelresults are less good for the posterior compartment. On the functional level, our results do not plead in favour of an improvement of anorectal disorders

[Failure of in vitro fertilization: prognosis criteriae]

Background: age, obesity and increased FSH serum level in women are prognosis criteriae associated with decreased fertility and adverse Assisted Reproductive Technologies [ART] outcomes

Objective: To assess the effect of age, FSH and BMI on pregnancy rate in ICSI

Methods: A retrospective and comparative study of 500 women who underwent ICSI cycle during the study period from January 2004 to December 2005. Age, FSH and BMI were compared in two groups of patients: Those achieving a pregnancy: The "pregnancy+" group and those failing to have a pregnancy: The "pregnancy-"group. For each of previous parameters ROC curve and logistic regression study were performed

Results: age was significantly lower in "pregnancy+" group [32,4 +/- 3,9 years vs 33,7 +/- 4,8 ans ; p=0,005]. Analysis of ROC curve and logistic regression study show that for age, the most discriminative cut-off for predicting pregnancy is 38 years [Se=7,5%, Sp=75,6%] [AUC=0,572; p=0,02] [OR=2,1 ; LR+=6,7 ;IC[1 ;1,4] ; p0,009]. FSH was significantly lower in "pregnancy+" group [5,5 +/- 1,8UI /L vs 6,2 +/- 3UI/L, p=0,003]. Analysis of ROC curve and logistic regression study show that for FSH, the most discriminative cut-off for predicting pregnancy is 9UI/L [Se=3,7%, Sp=85.2%] [AUC=0,539 ; p=0,03] [OR=3,6; IC[1,4 ;9,3]; LR+ =10,1; p=0,003]. BMI was also significantly lower in "pregnancy+" group [24,7 +/- 3,6 kgm-2 vs 27,1 +/- 4,5 kgm-2 ; p<10[-3]]. The most discriminative cut-off for predicting pregnancy is 25,4 kgm- 2 [Se=31,7%, Sp=33,3%] [AUC=0,663 ; p<10[-3]] [OR=4; IC[2,1 ;7,7]; LR+ =19,38; p<10[-3]]

Conclusion: age, FSH and BMI affect markedly the prognosis of ICSI. We found significantly lower Pregnancy rates in older women [> 38 years], in women with elevated FSH [> 9UI/L] or elevated BMI [> 25,4 kgm-2]. Our results can be used when counseling and before including patients in an IVF program, to give them probability of success and weight loss required to optimize chances of pregnancy

[Short vs long agonist protocols in poor responders undergoing IVF]

Compare among poor responders: stimulation results, laboratory parameters and the final IVF results by assessing 2 different stimulation protocols: the long agonist protocol and the short agonist protocol. An analytical retrospective study carried out over of period of 2 years: January 2006 and December 2007. During this period, a total of 1192 IVF cycles of ICSI type were performed in 892 patients. Inclusion criteria: short agonist or antagonist stimulated patients protocols and presenting two of the three following criteria: 1- Patients aged more than 38 years with an FSH plasmatic rate on the 3rd day of the cycle 9.5 UI/ml. 2- Antral follicle count [AFC] 5 for both ovaries. 3- Failure of anterior ovary stimulation: abandonment of cycle or ‹ 3 oocytes at data collection in a previous cycle. Exclusion criteria: PCOS or single ovary. 65 patients, undergoing 92 attempts of ICSI cycles have been included in this study. Long agonist protocol was performed in 48 cases and Short agonist protocol was performed in 44 cycles. Both groups were comparable as to age [40,09 +/- 6, 59 vs 41, 04 +/- 1,71 years; NS], BMI [25,2 +/- 3,92 vs 25,35 +/- 4,09 Kgm-2 ; NS], infertility type [primary 41% vs 59%;NS ; ou secondary 58% vs 40,9% ; NS], FSH [9,98 +/- 2,42 vs 10,01 +/- 2,75 ; NS] and antral follicle count on day 3 [4,13 +/- 1,12 vs 3,8 +/- 1,16 FA ; NS]. The estradiol rate, dosed on the onset day was significantly higher in the short protocol group [1534,27 +/- 1034,34 vs 1133,31 +/- 1053,58 pg/ml; p=0.034]. However, the consumed quantity of gonadotrophins was lower in the short protocol group [1550 +/- 235,45 vs 1725,55 +/- 450,35 UI, p=0.01]. A total of 13 cycles was stopped: 9 times for the long protocol [18.75 %] and 4 times for the short protocol [9.09 %] with statistically significant difference. The number of collected oocytes was significantly higher in the short protocol [7,64 +/- 3,70 vs 4,55 +/- 2,01, P<0.001]. We significantly obtained more embryos in the short protocol [4,31 +/- 2,9 vs 2,16 +/- 2,2 embryos ; p<0,001]. With higher number of grade 1 embryos [2,61 vs 1,14 embryons; p<0.001].The results in terms of pregnancy and living births show no significant difference between the 2 groups. The short protocol is more suited to the profile of ovarian poor responders. The long protocol standard has no place in poor responders. However, the long micro dose protocol and the long degressed micro dose protocol yield results at least equivalent to the short protocol

laparoscopic vecchietti technique for vaginal agenesis

To evaluate feasibility and surgical long term, anatomic and functional results of the laparoscopic Vecchietti procedure to treat women with vaginal agenesis. We reported six cases of patients with a Mayer-Rokitansky-Kster-Hauser syndrome. The surgical procedure was the same for all patients. The results have been evaluated on the operative time, the intra and postoperative complications, the antalgic drugs consumption, the transit recovery, the hospital stay, the neovagina length, and the post operative sexual satisfaction. The mean operative time was 77.5 minutes. The mean paracetamol consumption was: 9.8 g. The mean transit recovery, and hospital stay were: 2 days, 9.8 days, respectively. No intra or postoperative complication occurred. The mean neovagina length evaluated at one year follow-up visit was 7.5 cm. Five patients have regular sexual activity. Three of them reported sexual satisfaction and showed having orgasm [clitoral: 3 cases, clitoral and vaginal: 2 cases]. The 2 remaining patients reported dyspareunia. The global satisfaction index was of 71.6%. This surgical technique appeared to be safe, effective and reproducible. It allowed to obtain a neovagina with enough length and have encouraging results on sexual functioning Laparoscopy reduces the psychological and aesthetic consequences of surgery, especially for these young patients already distressed by their malformation

Clinicals and biologicals aspects of ICSI cycles on polycystic ovary syndrome patients

To analyse clinical and biological pecularities of Polycystics Ovarian Syndrome[PCOS] patients enrolled on ICSI cycles and compare them to normo-ovulatory women. 100 controlled ovarian stimulation cycles for ICSI in women with PCOS and 200 cycles in normo-ovulatory women. There was no significant difference in term of cancellation rate [5,5% in PCOS group vs 5%;NS]. The mean number of follicles was higher in patients with PCOS [18,1 +/- 8,5 vs 9,4 +/- 5,5;p<0,05], Oocyte mature rate and fertilization rate were higher in PCOS group [67% vs 52%; p<0,05] [75% vs 63,7%; p<0,05] respectively. Grade 1 Embryo rate was significantly higher in PCOS group [69% vs 53%; p<0,05]. Implantation rate [16,6% vs 12,1%; NS] and clinical pregnancy rate per transfer [3 1,5% vs 22,2%; NS] did not differ statistically in the two groups. Miscarriage rate was higher in PCOS group but this did not reach the statistical significance [20% vs 7,1%; NS]. 11 cases of Ovarian hyperstimulation syndrome occurred in PCOS group versus 4 on normo-ovulatory group. Use of ICSI as fertilization technique was correlated with good biologic parameters on PCOS patients with better fertilization rate and embryo quality and similar pregnancy rate comparing to normo-ovulatory women. However, it still be great concern about high risk of miscarriages and Hyperstimulation ovarian syndrome

[ retrospective study of 339 ICSI cycles: assessment of the two first years of activity of the assisted reproductive technology's center of Aziza Othmana's hospital]

Intracytoplasmic sperm injection [ICSI] is a micro-manipulation-assisted fertilization, whereby one spermatozoon is injected into the oocyte cytoplasm. Initially, ICSI was the treatment of choice for male factor infertility. However, because of the high fertilization and pregnancy rates achieved with this technique, the scope of the procedure has been widened to include couples with other causes of infertility. The aim of this study was to study the progression of the activity of the assisted reproductive technology's center of Aziza Othmana's Hospital and the ICSI results during the first two years. Our study included 269 infertile couples who underwent 339 ICSI cycles between 1st May 2001 and 30 April 2003. Cycles with no oocytes obtained at the follicular aspiration and women aged over 40 years were excluded from this study. The number of ICSI cycles progressed in our center: 150 ICSI cycles in the 1st year, 189 ICSI cycles in the 2nd year. The mean number of picked-up oocytes was 8,8 +/- 5,6. The fertilization rate was 62. The mean number of transferred embryos was 3,1 +/- 1,5. The pregnancy rate per transfer was 32,4%. The miscarriage rate was 28,4%. The take home baby rate was 67,9%. The number of couples undergoing ICSI cycles in our center is increasing. The fertilization rates and pregnancy rates in our center are similar to those published in the literature

[Increased risk of early pregnancy loss and lower live birth rate with GNRH antagonist vs long GNRH agonist protocol in PCOS women undergoing controlled ovarian hyperstimulation]

To compare standard long GnRH agonist protocol [Tripnorelin] anti GnRH antagonist regimens [Cetrorelix] in polycystic ovary syndrome [PCOS] patients undergoing controlled ovarian stimulation [COS] for ICSI cycles. Retrospective case-control study. 106 POS patients undergoing COS for ICSI with long GnRH agonist protocol [Tripnorelin] were matched with age and BMI to 106 PCOS patients undergoing COS for ICSI with GnRH antagonist [Cetrorelix] during the same period. Ovarian stimulation with recombinant follicle stimulating hormone [rFSH] was used in the two groups. Oral contraceptive pill pretreatment was used in all patients undergoing ovarian stimulation using GnRH antagonists. ICSI was performed for male infertility in all casts. The main outcome measures evaluated were: cancellation of the cycles, number of aspirated follicles, oocyte maturity, fertilization rate, Embryo quality, pregnancy and implantation rates, clinical abortion rate, multiple pregnancy rate and the live birth rate rate. Kchi2 teat and t Student test were used for differences between normo-ovulatory and PCOS patients and the limit of significantly was net at p<0.0S. There. was no significant difference in term of cancellation rant [2.8%vs 1.8%; NS], Duration of gonadotrophin stimulation [9,7 +/- 0,7 vs 11,2 +/- 1,9 days; p<0,001] and gonadotrophin consumption [2209.0 +/- S4S Vs 1411,1 +/- 217,9 1.11: p<0,001] were significantly decreased with GnRH antagonist. The mean oestradiol level on the triggering day was significantly higher in the agonist group [3347,85 +/- 99 vs 2354,45 +/- 839; p<0,001]. A fall in LH level of a 50%from sitmulation days [S8] to S1was observed in GnRH antagonist group. Risk of ovarian] hyperstimulation syndrome [OHSS] was significantly decreased with GnRH antagonist [1.8%vs 10.7%; p=0.01]. The mean number of retrival oncytes [15.9 +/- 5,9 vs 17.3 +/- 8.3; ns] and the mean number of mature oncytes [11.43 +/- 4.2 vs 11.9 +/- 6.4; ns3 were similar in the two groups. fertilization rate [73.3%va 75.8%; NS], mean number of grade I and 2 embryos [6.3 +/- 2.7 vs 6.9 +/- 3.9; NS], mean number of transferred embryos [1.9 +/- 0.7 vs 1.8 +/- 0,7; NS],implantation rate[13.3%vs 18.45%; ns] and clinical pregnancy rate per transfer [28.6%vs 31.1%;ns] did not differ statistically is she two groups. Twin and triplet pregnancies rates were also similar in the two groups [7.1%vs 9.3%; NS] and [3S%vs 3.1%; NS] respectively. Live birth rate [12,2%vs 20.7%; p<0.001] was significantly lower in GnRH antagonist group and miscarrage rate was significantly higher in this same group [42.8%vs 18.7%;p<0.001]. GnRH antagonist protocol is a short and simple protocol with a significant reduction in incidence of OHSS and amount of gonadotrophins. However. GnRH antagonist protocol provides a lower live birth rate and an increased risk of early pregnancy loss compared no the GnRH agonist long protocol. Further studies are necessary for more solid conclusions

[Are there any predictive factors for successful intracytoplasmic sperm injection. Statical analysis of 339 cycles]

Intracytoplasmic sperm injection [ICSI] outcome is tightly depinding of male and female factors. The assessment of several clinical and laboratory parameters may predict results of ICSI. This study aimed at investigation which parameter[s] may predict successful intracytoplamic sperm injection for infertility. We restrospectively analysed patients who had intracytoplasmic sperm injection for male or female factor infertility. The clinical and laboratory factors that influenced the fertilization, pregnancy and implantation rates were also analysed. Three hundred and thirty nine cycles in 269 couples were analysed. Women's age, etiology of infertility, duration of infertility, number of retrived oocyts, sperm parametres and number of transferred embryos were evaluated. Optimal pregnancy rates were observed in women aged 25-35 years, with gradual decline with advanced age [p=0.049]. The pregnancy/transfert rate was statistically depending of, the number of retrieved oocytes [p<0.001] and the number of transferred embryos [p<0.001]. However, transferring more than three embryos was no significatively superior to two or three. Etiology of infertility had no influence in fertilization and pregnancy, but may predict the implantation rate [p=0.042]. The duration of infertility was of no value in predicting the fertilization, implantation or pregnancy rates, and neither seems to be the sperm parameters. The only statitically significant variables of ICSI outcome were women partner's age, number of retrived oocytes and number of transferred embryos

[Use of GNRH antagonist [cetrorelix] in controlled ovarian hyperstimulation in women with polycystic ovary disease]

To evaluate the results of the use of GnRH antagonist [GnRH ant] cetrorelix and GnRH analog [GnRH a] in two matched groups of OPK ICSI patients in a restrospective matched pair analysis. Patients [n = 201] were stimulated with recombinant FSH [rFSH]. In group A [n=98], a dose of 3 mg of Cetrorelix was administred when follicles reached a diameter of> 14 mm. Patients in group B [n=103] were first desensitized with GnRHa triptorelin long protocol. The mean length of stimulation, and the dose of FSH required per patient were significantly higher in group B: [11,2 +/- l,9j vs9,7 +/- 0,7jp<0,00l] and [2209,0 +/- 548,3vs 1411,1 +/- 2179: p<0,001] respectively. The mean E2 level on day of hCG administration was significantly higher in the patients of group B [3347,85 +/- 99 vs 2354,45 +/- 839: p<0,001], however, a progressive increase in serum E2 concentration during the cycle were noted in both groups. A median of 15,9 +/- 5,9 and 17,3 +/- 8,3 [p =0,159 retrived oocytes per patients was obtained respectively in group A and B. The median of mature oocytes per patient were similar in both groups [11,43 +/- 4,2 in group A vs 11,9 +/- 6,4 in group B: p=0,526]. Pregnancy rate were better in group B [31,1 vs 28,6% p = 0,69]. No severe ovarian hyperstimulation [OHSS] occured in group A vs 3 cases in group B. GnRHant and GnRHa provide comparable results in OPK patient, while GnRHant allows a higher flexibility in treatment, a lower dose of FSH required and a shorter period of stimulation

[Thermal balloon endometrial ablation for dysfunctional uterine bleeding: technical aspects and results. A prospective cohort study of 152 cases]

Thermal balloon endometrial ablation is a new operative technique recently proposed in the treatment of dysfunctional uterine bleeding. To evaluate the efficacy of thermal balloon endometrial ablation in the treatment of dysfunctional uterine bleeding, and to identify the possible predictifs factors for a successful outcome. A prospective study was conducted including 152 patients with chronic abnormal uterine bleeding refractory to medical treatment. All patients were treated by thermal balloon endometrial ablation [Thermachoice, Gynecare] between January 1, 1996 and December 31, 2003. patients were included if their uterine cavities sounded to less than 12 cm and had undergone hysteroscopy, pelvic ultrasound and endometrial biopsy showing no structural or [pre] malignant endometrial abnormalities. A balloon catheter was placed through the cervix and after inflation in the endometrial cavity with 5% dextrose in water, was heated to 87 +/- 5°C. No one required cervical dilatation. Balloon pressures were 160 to 170mm Hg. All patients underwent 8 minutes of therapy. The average patient was 47 years [range: 30 - 62 years] and was followed for a mean of 3 years and 7 months [range: 6 month - 8 year]. 31,6% of women reported amennorhea, 16,5% hypomenorrhea and 21% eumenonrhea. Menorrhagea persisted in 11,2% of patients. No intraoperative complications and minor postoperative morbidity occurred in 10,5% of patients. Three pregnancy complicated by spontaneous abortions were reported after the treatment. A total of 78% of women reported overall satisfaction with the endometrial ablation procedure and 18% were dissatisfied. 17,8% of patients underwent hysterectomy within I to 5 years of balloon endometrial ablation. Increasing age and menopause were significantly associated with increased odds of success [p <0,05]. Thermal balloon endometrial ablation is a simple, easy, effective, and minimally invasive procedure in menhorragic women with no desire for further childbearning. The chance of successful treatment is thightly depending of several factors such as increased age and menopause, that shows the importance of patients selection. Although rare, pregnancy after endometrial ablation is possible. Women of reproductive age should have a post operative contraception method

[Intrauterine insemination with conjoint semen. How to increase the success rate?]

Intrauterine insemination is usually proposed as the first line therapy for infertility related to cervical hostility, male factor, unexplained infertility or mild endometriosis. The overall success rate of IUI is about 10-20%clinial pregnncy per cycle. The Aim of this study is to evaluate factors that increase the succes rate of IUl. We restrospectively analysed 206 cycles of JUl with partner's semen in 138 infertile couples. The clinical and laboratory factors that may influence the pregnancy rates were analysed women's age, etiology of infertility, duration of infertility, ovarian stimulation, day of hGC and sperm parametres. The per-cycle clinical pregnancy rate was of 14.56%. Optimal pregnancy rates were observed in less than 38 years old women [18.29%vs 9.52%. p<0.05]. The succes rate was statistically depending of the number of IUI cycles until three [p<0.05], the day of hGC [p<0.05] and the sperm count after conventionally prepared semen [p<0.05]. Sperm parameters was of no value in predecting the pregnancy rates, and neither seam's to be the total dose of administrated Gonadotrophin or the etiology of infertility, but it seams that, when a cervical factor or PCO were involved, the succes rate is higher. Besides, getting three or more than three follicles may increase the succes rate but expose to a warrying risk of multiple pregnancy. According to this study, the only statitically significant factors that are associated with successful IUI were, women partner's age [<38 ans], number of IUl cycles [during the first three JUl cycles], day of hGC [>J13] and sperm count after conventional semen preparation [>1.10[6]/mL]

What would be the therapeutic options in dysovulation patients requiring and assistance in reproduction

Dysovulation is a common cause of decreased fertility and unexplained infertility. Dysovulation, whatever related to age, a deficiency in ovarian function or to the poly cystic ovary syndrome, could be the cause of repeated failures of repeated cycles of controlled ovarian stimulation. Medically supervised procreation requires the preliminary evaluation of the patient ovulatory profile prior to the choice of the ovarian stimulation protocole. An early and precise diagnosis will allow for an efficient, appropriate and timely management. We review in this work the therapeutic options available to women presenting with dysovulation and requiring medical supervision for procreation

[Hysterosalpingo-Contrast Sonographie in the assessment of tubal patency]

A major cause of infertility in women is occlusion of fallopian tubes. Hysterosalpingography [HSG] and laparoscopic chemoperturbation are the two traditionnal diagnostic options for tubal assessment. Recently hysterosalpingo-contrast sonography [HyCoSy], an ultrasound-based technique that uses as a contrast agent fluid injected into the fallopian tubes via the uterine cavity, is gaining importance as an alternative procedure. The aim of this study is the analysis of several technic and semiologic aspects of HyCoSy. Results. advantges and limits are discussed throughout a review of literature. HyCoSy is a well tolerated outpatient technique. When performed by experienced operators, it servs as a valable first line screening test of tubal patency in low fertility women. It can confirme that tubes are patent and permits to select patients who need more invasive procedures

[Non surgical management of ectopic pregnancy]

During the past 25 years, the incidence of ectopic pregnancy has progressively increased while the morbidity and mortality have substantialy decreased, and the treatment has progressed from salpingectomy by laparotomy to conservative surgery by laparoscopy and more recently to medical therapy with Methotrexate or expectant management. This therapeutic transition from surgical emergency to non surgical management has been attributed to early diagnosis through the use of sensitive assays for hcg and the high definition of vaginal ultrasound. By using these sensitive diagnostic tools, we are now able to select those patients who are most likely to respond to exectant or medical management versus those who are at high risk of rupture and require surgery. We have reviewed the scientific literature on ectopic pregnancy published over the past 20 years, with the aim to assess the value of non surgical management of etopic pregnancy. Predictor factors of expectant management are discussed. Medical therapy with methotrexate: results, indications, Unplesant side effects and complications are detailed. Several protocols are defined and therapeutic supervision is established. The authors offred several recommendations for OB/GY which will optimize the effectivness of non invasive methods for treatment of ectopic pregnancy