[Hormone determination in the management and monitoring of cycles of medically-assisted reproductive technology: value and difficulties of use]. / Les dosages hormonaux dans la prise en charge et le monitorage des cycles d'assistance médicale à la procréation: intérêt et difficultés de réalisation.

In assisted reproductive technology (ART), serum levels of several key hormones are used to evaluate ovarian follicular reserve and to monitor gonadotropin-stimulated follicle growth. Currently, serum estradiol, FSH, LH and inhibin B levels are examined and combined at the beginning of the menstrual cycle to evaluate the functional status of the ovaries, providing information for appropriate ovarian stimulation treatment and prognosis for in vitro fertilization (IVF) outcome. In women undergoing in vitro fertilization and embryo transfer (IVF-ET), ovulation stimulation is monitored by serial measurements of estradiol, progesterone and LH to monitor follicular growth, evaluate the progression of stimulation, adjust daily gonadotropin therapy for each patient, and predict the optimal day for the induction of ovulation. We analyze the importance of each hormone and discuss the discrepancies frequently reported resulting from differences in methods.

Down's syndrome screening with nuchal translucency at 12(+0)-14(+0) weeks and maternal serum markers at 14(+1)-17(+0) weeks: a prospective study.

BACKGROUND: Sonographic and biochemical methods for Down's syndrome screening have developed simultaneously, but independently. As a consequence, the rate of invasive procedures for fetal karyotyping has dramatically increased and become an important public health issue which needs to be controlled. One approach is to combine sonographic and biochemical results into a single risk assessment. METHODS: In a multicentre interventional study, nuchal translucency (NT) was measured between 12(+0) and 14(+0) weeks of gestation. Maternal serum markers (MSM) were measured between 14(+1) and 17(+0) weeks of gestation. Karyotyping was advised when: (i) NT was > or =3 mm; or (ii) the MSM-related risk was > or =1 in 250 at term. Karyotyping was delayed until after a maternal blood sample had been taken. NT and MSM were expressed as multiples of the medians (MoMs), and risks were calculated and tailored to the study population. A combined risk for NT and MSM was estimated retrospectively. Costs per case diagnosed, and the cost per case averted were calculated for the three screening strategies. RESULTS: A total of 9444 women was screened. Twenty-one fetuses (0.22%) had Down's syndrome, whilst 326 women (3.4%) were lost to follow-up. Among 9118 women followed up, 5506 had both NT and MSM, 821 had only NT, and 2791 had only MSM. Median maternal age was 30.5 years. False-positive rates for NT, MSM and NT combined with MSM were 3.0, 5.8 and 0.23% respectively. The false-positive rate generated by a sequential two-stage screening was 8.6%. Detection rates of Down's syndrome were 62 and 55% for NT and MSM respectively. Seven cases with Down's syndrome (35%) had raised NT and MSM, and 17 (81%) had either raised NT, MSM, or both. For a 5% false-positive rate, detection rates were 55 and 80% for NT alone and for combined NT and MSM respectively. Ultrasound alone appears to be more cost-effective ( pound50 per case diagnosed) than both tests ( pound61 per case diagnosed). CONCLUSIONS: The study results suggest a 25% increase in the detection rate of Down's syndrome using a combination of NT measurement at 12(+0)-14(+0) weeks and MSM at 14(+1)-17(+0) weeks for a 5% false-positive rate, with modest increase in cost.

Is routine amniocentesis for advanced maternal age still indicated?

OBJECTIVE: To evaluate a policy of selective rather than routine use of amniocentesis for advanced maternal age. METHOD: A consecutive series of 359 pregnant women aged 38-47 underwent nuchal translucency measurement (NTM) at 10-14 weeks, maternal serum screening (MSS) by alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) at 15-17 weeks, and second trimester ultrasound at 21-23 weeks. Women with NTM <3 mm, MSS-derived risk <1/250, and a normal second trimester sonography were considered at low risk and were suggested not to have an amniocentesis. RESULTS: Either the NTM or MSS test was positive in 130 women; 105 (81%) of them elected to have an amniocentesis, versus 122 (53%) of 229 in whom both tests were negative (p < 0.001). Nineteen (5%) of 359 patients had NTM > or =3 mm; all 7 cases of Down's syndrome were in this group; 122 (34%) of 359 patients had a MSS-derived risk > or =1/250; 6 of the 7 cases of Down's syndrome were in this group: Ten patients had an abnormal second trimester ultrasound, 1 of which had trisomy 18. Of the 219 patients with MSS-derived risk <1/250, a NTM <3 mm, and a normal second trimester ultrasound, none had a baby with a chromosomal abnormality (95% confidence interval: 0-1.4%). CONCLUSION: Amniocentesis may be offered on a selective rather than routine basis in women over 38, based upon the results of noninvasive screening tests.

[Diagnosis of trisomy 21: nuchal translucency and/or serum markers?]. / Dépistage de la trisomie 21: clarté nucale et/ou marqueurs sériques?

OBJECTIVES: To compare alternative methods of antenatal screening for Down's syndrome (nuchal translucency measurement and second trimester maternal serum screening) in a low-risk population and to evaluate the consequences of a sequential estimation of risk. METHODS: In a consecutive series of 4308 women aged less than 38 with a singleton pregnancy, we examined the detection rate of nuchal translucency (NT) measurement at 10-14 weeks and maternal serum screening (MSS) by human chorionic gonadotropin and alpha-feto-protein at 14-18 weeks. Women with a NT measurement = 3 mm and women with a MSS derived risk = 1/250 were recommended to have an amniocentesis. A second trimester detailed ultrasound scan was also performed in all women. The outcome of all pregnancies was entered in a computerized database and the detection rate and false-positive rate of different screening strategies were analysed. RESULTS: Of the 4308 pregnancies that were followed (mean maternal age 30.1 years), there were 12 cases of Down's syndrome (0.28%), all detected prenatally. Seven of twelve cases had a NT measurement above 3 mm (58%), and 6 out of ten cases with available MSS had a calculated risk = 1/250 (60%). Four of the five cases with NT measurement below 3 mm were detected by subsequent MSS. At a threshold giving 5% of positive tests, the sensitivity of NT screening and MSS were 75% and 60%, respectively. DISCUSSION AND CONCLUSION: Sequential screening for Down's syndrome by nuchal translucency and second trimester biochemistry is effective and appears to increase the detection rate compared to the use of any single test. However, this strategy is likely to raise the false-positive rate and the interpretation of MSS derived risk should be combined to the first trimester NT measurement.

Screening for Down syndrome using first-trimester ultrasound and second-trimester maternal serum markers in a low-risk population: a prospective longitudinal study.

OBJECTIVES: To compare nuchal translucency and second-trimester maternal serum measurements as alternative methods of antenatal screening for Down syndrome in a low-risk population and to evaluate the consequence of combining the results in the estimation of risk. DESIGN: In a consecutive series of 4130 women aged less than 38 years with a singleton pregnancy, we examined both the detection rate of Down syndrome by nuchal translucency measurement at 10-14 weeks and maternal serum screening by human chorionic gonadotrophin and alpha-fetoprotein at 14-18 weeks. Women with a nuchal translucency measurement of > or = 3 mm and women with a maternal serum screening-derived risk > or = 1/250 were recommended to have amniocentesis. A second-trimester detailed ultrasound scan was also performed in all women. The outcome of all pregnancies was recorded prospectively and the detection rate and false-positive rate of different screening strategies were retrospectively analyzed. RESULTS: Out of the 4130 pregnancies that were followed (mean maternal age, 30.1 years), 12 cases of Down syndrome were observed (0.28%), all detected prenatally. Seven of 12 cases had a nuchal translucency measurement of > or = 3 mm (58%), and six out of 10 cases with available maternal serum screening had a calculated risk of > or = 1/250 (60%). Four of the five Down syndrome cases with a nuchal translucency measurement of < 3 mm were detected by subsequent maternal serum screening. At a threshold giving 5% of positive tests, the sensitivity of nuchal translucency, maternal serum screening and combined risk screening were 75%, 60% and 90%, respectively. CONCLUSIONS: In screening for Down syndrome, an approach which combines the results from first-trimester nuchal translucency and second-trimester biochemistry is effective and increases the detection rate compared to the use of any single test. However, this strategy is likely to raise the false-positive rate and the interpretation of maternal serum screening-derived risk should be combined with the first-trimester nuchal translucency measurement.

[A new technique for measuring 17beta-estradiol using Kryptor (Cis Bio International): utilization to monitor ovulation stimulation]. / Une nouvelle technique de dosage du 17beta-estradiol sur le Kryptor (Cis Bio international): utilisation au cours des cycles stimulés.

We studied the performances of the 17b-estradiol determination with the Kryptor System (Cis Bio international), in assisted medical procreation cycles. The detection is based on Trace technology. We compared this method with Estradiol-6 method on ACS-180 (Bayer Diagnostics). The Kryptor method is sensitive, has a good precision and accuracy. Comparison with ACS-180 showed a good correlation but results were much higher. Patients under stimulation for assisted procreation were followed by the two methods. The results were close to those obtained with ACS-180 but significantly higher. Thus it was necessary to define the levels which have to be reached before ovulation induction.

Efficiency of ultrasound and biochemical markers for Down's syndrome risk screening. A prospective study.

OBJECTIVE: To evaluate the sequential combination of ultrasound screening for fetal aneuploidy at 11-14 weeks with maternal biochemistry at 12-14 and 15-18 weeks of gestation. METHODS: A prospective study including 1,656 women, with a singleton pregnancy booked before 13 weeks of gestation. Nuchal translucency (NT) thickness was measured by transabdominal ultrasound examination. alpha-Fetoprotein, free betahCG and hCG were measured by immunoradiometric (12-14 weeks) or immunometric (15-18 weeks) assays. Derived risks were then calculated. Cutoff risks were chosen first arbitrarily at 1/250 and then adjusted for a 5% false-positive rate. RESULTS: Seven fetal aneuploidies were diagnosed, including 5 Down's syndromes, 1 trisomy 18 and 1 triploidy. Three Down's syndromes had concordant high risk with the 3 screenings. One was at low risk with NT, and another was at low risk by maternal serum screening, but sequential combination of screenings led to a 100% detection rate with cutoffs of 1/240, 1/160 and 1/250 for NT, first- and second-trimester biochemistry, respectively (i.e. for a cutoff adjusted for a 5% false-positive rate). CONCLUSION: This preliminary study suggests a benefit in combining maternal age-related risk together with NT and biochemical markers in the first or the second trimester. The algorithm combining these risks needs to be established in a wide population.

Rapid fetal fibronectin swab-test in preterm labor patients treated by betamimetics.

OBJECTIVE: A preliminary study to examine the value of a rapid fetal fibronectin swab-test used as a bedside test in the prognosis of preterm labor. STUDY DESIGN: Women presenting with preterm labor and intact membranes and less than 3 cm dilated were enrolled in a single referral center. Cervicovaginal swabs were assessed for the presence or absence of fetal fibronectin by means of a rapid monoclonal antibody assay the positivity of which was revealed by a colorimetric reaction. Results were compared with uterine contractions frequency, Bishop cervical score, duration of tocolysis and interval to delivery. The predictive value of fetal fibronectin test for delivery within 7, 14 or 21 days from sampling and before 32 and 37 weeks' of gestation was assessed in the two groups. RESULTS: Among 124 eligible patients, 19 presented with a positive fibronectin test and 105 with a negative one. Gestational age at sampling, Bishop cervical score and duration of tocolysis were identical in the two groups. The number of contractions was significantly lower and gestational age at delivery was significantly higher in the fibronectin negative group. Fetal fibronectin in cervicovaginal secretions has a high sensitivity (89%) for delivery within 7 days. Absence of fetal fibronectin in cervicovaginal secretions of patients presenting with uterine contractions could rule out preterm labor within 7 and 14 days with a predictive value of 99 and 95.2%, respectively. In negative fetal fibronectin patients, preterm delivery before 32 and 37 weeks' is unlikely to occur with a predictive value of 97 and 85%, respectively. CONCLUSION: Cervicovaginal fetal fibronectin detected by a rapid bedside swab-test in women with symptoms of preterm labor compares favourably with quantitative assays and could prove useful in the management of preterm labor. This should be confirmed in a longer prospective study.

In vivo role of IL-6 on the viral load and on immunological abnormalities of HIV-infected patients.

In vitro experiments have suggested that interleukin (IL)-6 may contribute to human immunodeficiency virus (HIV) burden and to immunological abnormalities in HIV-infected patients. We had the opportunity to directly address this question in vivo through the virological and immunological monitoring of HIV-infected patients treated with an anti-IL-6 monoclonal antibody (mAb) for a lymphoma (ANRS 018 trial). Sixteen courses of anti-IL-6 mAb administration, performed in 11 patients, were studied. All patients were at a late stage of HIV infection. The HIV load and the immunological status were determined at the initiation of each course and at its end, 21 days later. The mAb induced no significant change of HIV load, as evaluated by p24 antigenemia, plasma viremia, and quantification of circulating HIV RNA by reverse transcriptase-polymerase chain reaction and branched DNA techniques. The anti-IL-6 mAb also did not affect CD4+, CD8+, and CD19+ circulating cell counts, nor the serum concentrations of sIL-2R and of sCD8. In contrast, the mAb completely abrogated acute-phase reaction, as demonstrated by the normalization of C-reactive protein and fibrinogen circulating levels (p = 0.013 and p = 0.008, respectively). It increased serum albumin concentration. The latter effect was restricted to patients with a spontaneously low albuminemia (p = 0.01). It decreased B-lymphocyte hyperactivity, as reflected by decreased IgG and IgA serum levels (p = 0.008 and p < 0.001, respectively), and by a decreased production of IgG in vitro (p = 0.017). In contrast, the IgM hyperproduction was not affected by the mAb. Therefore, increased IL-6 production in HIV-infected patients at a late stage of the infection may not stimulate HIV replication in vivo, but it may represent a key mechanism contributing to the metabolic and immunological dysbalance of the disease.

Alpha-2-macroglobulin and hepatic fibrosis. Diagnostic interest.

Alpha-2-macroglobulin (A2M) is a proteinase inhibitor. Cells synthesizing A2M are in first-order hepatocytes and in second-order activated Ito cells (in culture starting at day 4-5 after seeding). This study was undertaken in 525 alcoholic patients with different histological stages of alcoholic liver disease to assess if the A2M could improve the diagnostic value of PGA index for detection of cirrhosis or fibrosis among drinkers, particularly in patients without clinical symptoms of liver failure and portal hypertension, and to assess the specific correlation of serum A2M with the score of liver fibrosis adjusted for steatosis and alcoholic hepatitis and thereafter adjusted for GGT, PT, and ApoA1, the three components of the PGA index. In 525 alcoholic patients, we have demonstrated the independent diagnostic value of A2M. The predictive values of the weighted score, using linear discriminant function combining PT, GGT, ApoA1 and A2M of the PGAA score and of the PGA score were assessed in a training step and validated in a second step. Then, 316 alcoholic clinically asymptomatic patients were studied. In these patients, the discriminant function permitted correct classification of 72% of patients. The PGAA index had comparable diagnostic value with 70% of patients correctly classified. On the other hand, the PGA index including only PT, GGT, and ApoA1 had classified correctly less patients (65%) than the discriminant function and the PGAA index (P < 0.01). For a value of 7, PGAA had 79% specificity and 89% sensitivity for the diagnosis of cirrhosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum concentrations of albumin, C-reactive protein, alpha 2-macroglobulin, prealbumin, fibronectin, fibrinogen, transferrin, and retinol binding protein in 55 patients with hepatic glycogen storage diseases.

Hepatic glycogen storage diseases are hereditary metabolic disorders involving the metabolism of glycogen. This study was designed to investigate the serum protein status in such diseases. Fifty-five patients with glycogen storage disease types I, III, VI, and IX, whose ages ranged from 1 month to 27 years, were included in this work. C-reactive protein, fibrinogen, alpha 2-macroglobulin, albumin, transferrin, fibronectin, retinol binding protein, and prealbumin serum concentrations were measured in each patient. In patients affected with type I glycogen storage disease, serum concentrations of alpha 2-macroglobulin, fibrinogen, C-reactive protein, and transferrin were significantly increased. In patients with types III, VI, and IX glycogen storage diseases, the concentration of alpha 2-macroglobulin was the only one that was significantly increased. Thus, even though this study raises more questions than it answers, it seems likely that the hepatic synthesis of some proteins may be increased in patients affected by hepatic glycogen storage diseases. This may indicate some degree of mild hepatic dysfunction in such metabolic disorders. However, further investigations are required to elucidate the discrepancies observed among the different types of diseases.

[Evaluation of the technique of CKMB assay using Ektachem (500 and 700)]. / Evaluation de la technique de mesure de la CKMB de l'Ektachem (500 et 700).

The aim of this study was to compare the dry-chemistry CKMB Ektachem method to a liquid immunoinhibition method (Merck/Cobas Bio) and to the electrophoretic method (Helena France), both on patients (n = 95) and control (4 specimens from different commercial origin) sera. The Ektachem method was found linear in the range tested (7 to 97 U/l). Within run imprecision tested with low, medium and high control sera were satisfying (CV 3-4%) as well as between run imprecision (CV < 10%), for CKMB activities of at least 30 U/l. As compared to the liquid immunoinhibition method (Merck), the results of patient sera were very close but slightly lower (y = 0.97x-1; r = 0.74; y = Ektachem, x = Merck). As compared to the electrophoretic method, the Kodak Ektachem method showed a specificity of 74% and a sensitivity of 85% (n = 95). A close agreement (r = 0.73) between these two methods was obtained for samples with a total CK activity at least 3 times over the upper limit of normal range. We therefore conclude that the Kodak Ektachem CKMB method allows a rapid and easy determination of CKMB activity for samples undergoing total CK activity 3 times over the upper limit of normal range. Like all liquid immunoinhibition methods, the Kodak Ektachem method shows some lack of specificity and does not show a better concordance with the electrophoretic method than does the Merck/Cobas Bio method.

Investigation of total and conjugated bilirubin determination during the neonatal period.

During the neonatal period, total and conjugated bilirubin determinations are necessary to identify the origin of jaundice, to predict its evolution and to treat it. We discuss the results obtained in 108 neonates (less than 15 days old), undergoing phototherapy or not, using a colorimetric diazo reaction and dual wavelength reflectance with a Kodak Ektachem analyzer. Concerning total bilirubin determination, the methods correlate well (r > 0.96). Discrepancies are observed for conjugated or "direct" bilirubin, and high performance liquid chromatography was carried out in order to explain them. The chromatograms show 4 neonate samples with only classic mono- but no di-glucurono-conjugate fractions, whereas all the neonates present two unusual fractions (I and II) not seen in adults. A correlation was found between the amount of fraction II and the conjugated bilirubin determined by diazo reaction and between fraction I and the conjugated bilirubin obtained in the Kodak Ektachem assay. A better correlation between fraction I and conjugated bilirubin on Kodak was observed (r = 0.79, vs r = 0.66) when the newborns were submitted to phototherapy. Moreover, fraction II and conjugated bilirubin measured by the diazo reaction on Hitachi 717 rose significantly. In conclusion, total bilirubin is accurately determined during the neonatal period; for conjugated or "direct" bilirubin determination, our study points out significant differences. Further investigation will determine the nature of the fractions observed by liquid chromatography in neonatal sera, and the components actually determined by the automatized methods usually employed.

[Gestational age and fetal lung maturity]. / Age gestationnel et maturité pulmonaire foetale.

In order to assess the lung maturity of the fetus, a biochemical analysis using two reliable, simple and rapid methods (FLM-TDX Abbott and determination of phosphatidylglycerol (PG) have been carried out on 166 amniotic fluids taken by amniocentesis. The patients were particularly pregnant women presenting disorders such as diabetes (n = 41), premature rupture of the membranes (n = 30), hypertension (n = 20), intra uterine growth retardation (n = 13) and gemellar pregnancies (n = 27). The lung maturity of the fetus has been considered as mature (no risk of any hyaline membrane disease: HMD) when the phospholipid rate is higher than 50 mg/g albumin (FLM-TDX Abbott), associated or not with the presence of PG (PG positive). The latter phospholipid was present only in women whose pregnancy was about 35 weeks. Besides, our results show a very large disparity of the phospholipid rates (FLM-TDX) in the amniotic samples for an identical gestational age. Values from 9 to 124 for pregnancies with term of 31 weeks, and from 21 to higher than 160 for those of 38 weeks. In infants born not later than 48 hours after the amniotic punction (n = 30), four of them presented an HMD. The FLM-TDX values were less than 30 for three cases and equal to 52 for the fourth. The term of these newborns was 37 weeks or more for three of them, and 31 weeks for the last one. Our study confirm that the TDX-FLM Abbott is useful to assess the fetal lung maturity and does not correlate with the gestational age.