In vitro oocyte maturation for the treatment of infertility associated with polycystic ovarian syndrome: the French experience.

BACKGROUND: In vitro oocyte maturation (IVM) permits the use of immature oocytes in IVF. IVM does not require ovarian stimulation and so can be offered to patients at risk of ovarian hyperstimulation syndrome. METHODS: For this indication, we carried out 45 cycles of IVM in 33 women with polycystic ovarian syndrome (PCOS). RESULTS: A total of 509 cumulus-oocyte complexes was obtained; 276 (54.2%) oocytes matured in 24 h and 45 (8.8%) in 48 h. The normal fertilization (2PN) rate of oocytes matured in 24 and 48 h was 69.5 and 73.3% respectively. Among the 214 embryos obtained, 103 were transferred and 30 were frozen. Forty transfers were performed (2.5 embryos/transfer). Eleven women had a positive beta-hCG test (26.2% of pregnancies/puncture, 27.5% of pregnancies/transfer) and nine women had a clinical pregnancy (20.0% of pregnancies/puncture, 22.5% of pregnancies/transfer). Five babies have been born and one pregnancy is ongoing. Results of the clinical examination carried out at birth were normal. CONCLUSIONS: Our results show that IVM may be offered as an alternative to conventional IVF and to ovarian drilling in women with PCOS. The role of IVM in the therapeutic armamentarium for this condition should be further clarified.

[Sonographic diagnosis of ectopic pregnancy: optimal strategy?]. / Diagnostic échographique des grossesses extra-utérines. La sémiologie de base: comment optimiser les performances de l'échographie?

AIM AND METHODS: The diagnostic algorithms of ectopic pregnancy (EP) include sonographic procedures. Diagnostic sensitivity is low because the procedure is operator-dependent and each clinical aspect of EP is variable. We analyzed results of standardized ultrasound procedures performed within the framework of a detailed analysis of clinical findings. RESULTS: The sonographic procedure must be performed within the framework of an overall analysis including laboratory results (hCG level), examination of the decidua, localization of the corpus luteum, and careful detailed examination of adnexa. Hematosalpinx is pathognomonic of EP and is observed in 80% of cases. When diagnosis is doubtful, a second ultrasound procedure should be performed 48 hours later before undertaking laparoscopic diagnosis. CONCLUSION: The diagnostic sensitivity of ultrasonography has been consistently high in published series, undoubtedly because the studies were performed in referral centers highly experienced in diagnostic ultrasound.

Successful management of a heterotopic Caesarean scar pregnancy: potassium chloride injection with preservation of the intrauterine gestation: case report.

Caesarean scar pregnancy (CSP), in which the pregnancy is located in the scar of a previous Caesarean section, is a rare situation that carries a high risk of uterine rupture. Improved ultrasound imaging allows early diagnosis of this condition, but there is no standard management. We report the first case of CSP associated with a normal intrauterine pregnancy. Potassium chloride administered under transvaginal ultrasonographic guidance terminated cardiac activity in the CSP. The CSP resolved, and a healthy infant was delivered at 36 weeks. When the diagnosis is early and the patient asymptomatic, surgery can be avoided, the CSP can be terminated selectively and the intrauterine pregnancy thereby preserved.

Simultaneous bilateral tubal pregnancy after intracytoplasmic sperm injection treated by conservative medical treatment. Interest of sonographic follow-up.

We describe a case of early bilateral tubal pregnancy diagnosed by transvaginal ultrasonography after intracytoplasmic sperm injection (ICSI) and embryo transfer (ET). A follow-up by transvaginal sonography was done with a systematic second scan (5 days) after the first diagnosis of left tubal ectopic pregnancy in case of assisted conception procedure. This follow-up sonographic strategy permitted us to perform a conservative treatment for this case of spontaneous bilateral tubal pregnancy by two consecutive (left then right) in-situ methotrexate injections under vaginal ultrasonographic guidance without any complications.

[Contribution of diagnostic ultrasonography in cases of repeated embryonic implantation failure in fertilization in vitro]. / Apport du diagnostic échographique en cas d'échecs répétés d'implantation embryonnaire en fécondation in vitro.

INTRODUCTION: To assess ultrasonic data in the context of repeated failure of implantation in assisted reproduction medicine. MATERIALS AND METHODS: We reviewed ultrasonic data (uterine score at follicular and luteal phase). The same ultrasound exploration was repeated for two consecutive cycles to assess the changes in abnormalities observed and compare findings in 16 patients with repeated failure of implantation and in 14 controls. The controls were women who became pregnant within the three months following the exploration. We then introduced acetylsalicylic acid and prednisolone as first line treatment and nitroglycerin as second line treatment to measure the effects induced in 14 pathological uterine scores. RESULTS: The score obtained under hormonal treatment was representative of other cycles (r = 0.812, p < 0.0014). The score was significantly lower and the luteal uterine artery pulsatility index was significantly higher in the repeated failure group than in the control group (p < 0.0001 and p = 0.008 respectively). For the 14 patients, treatment improved the uterine score in 8 with acetylsalicylic acid and prednisolone and in 4 with nitroglycerin. Two patients did not respond to treatment. Concerning the effect of therapy, of 14 patients, 8 had an improved uterine score with A + P, and with T; 2 patients did not respond to any treatment. CONCLUSION: The uterine score and luteal artery pulsatility index may be valuable tools for patients with implantation failure who all do not respond to the same therapy.

[Severe mixed thrombopenia during interferon treatment for chronic viral hepatitis C]. / Thrombopénie mixte sévère au cours d'un traitement par interféron chez une femme atteinte d'une hépatite chronique virale C.

BACKGROUND: Thrombocytopenia occurred in a woman given alpha interferon for chronic hepatitis C without cirrhosis. Both central thrombocytopenia, clearly demonstrated, and peripheral thrombocytopenia, probably of autoimunne origin, were involved. CASE REPORT: A 55-year-old woman with active chronic hepatitis C (Metavir score A2, F2) was given alpha interferon. One month after treatment onset, she developed thrombocytopenia (32 G/L). A second bone marrow aspirate and osteomedullary biopsy evidenced megalokaryocytes and the platelet count responded to polyvalent immunoglobulins. Five months after discontinuing interferon, the platelet count progressively returned to normal. DISCUSSION: Central thrombocytopenia is classically described in patients given interferon and usually appears during the first weeks of treatment. In our case, the central mechanism was clearly demonstrated by the bone marrow aspirate and osteomedullary biopsy findings at a time when the platelet count was 32 G/L. A peripheral immunological participation was more difficult to prove but was strongly suggested by the persistence of thrombocytopenia despite the interruption of the interferon and the efficacy of immunoglobulins.

Transabdominal fetoscopy in fetal anomalies diagnosed by ultrasound in the first trimester of pregnancy.

The ability of ultrasound to diagnose fetal anomalies is limited in the early stages of gestation. We describe a microendoscope that can be used with an 18-gauge needle at the time of amniocentesis to provide more precise diagnostic information when the first-trimester ultrasound examination suggests a problem.

[Role of conservative therapy and medical treatment in ectopic pregnancy: literature review and clinical trial comparing medical treatment and conservative laparoscopic treatment]. / Place respective de l'abstention thérapeutique et du traitement médical dans les grossesses extra-utérines: revue de la littérature et essai thérapeutique comparant traitement médical et traitement conservateur par coelioscopie.

OBJECTIVE: to compare methotrexate (MTX) to laparoscopic salpingotomy for conservative management of ectopic pregnancy (EP). DESIGN: prospective randomized study. PATIENTS: eighty-nine patients were randomized into 2 groups using a random number table. Inclusion criteria were an EP visualized by ultrasound with a pretherapeutic score < or = 13 as assessed by 6 criteria graded from 1 to 3: gestational age, hCG level, P level, abdominal pain, volume of the hemoperitoneum, and diameter of the hematosalpinx. INTERVENTIONS: 1 mg/kg of MTX injected transvaginally into the ectopic pregnancy without anaesthesia or IM administration (1.5 mg/kg) when EP cannot be safely or easily punctured (group 1) versus laparoscopic salpingotomy (group 2). RESULTS: the success rates defined by hCG levels returned to normal (< 10 mlU/mL) were 43 out of 46 in group 1 and 40 out of 43 in group 2. Medical treatment was significantly associated with shorter post-operative stay (24 vs 46 hours). hCG return to normal was quicker after laparoscopic treatment (13 vs 29 days). Reproductive performances were similar in both groups. CONCLUSIONS: in selected cases of EP with a pretherapeutic score < or = 13, MTX treatment appeared to be as safe and efficient as was conservative treatment by laparoscopy, an expectant management should be offered as a treatment option only in women fulfilling the criteria for a good prognostic.

[Anomalies of umbilical vein in the fetus. A case report and review of the literature]. / Les anomalies de la veine ombilicale intra-abdominale chez le foetus. A propos d'un cas et rèvue de la littérature.

Abnormal connexion of the umbilical vein in the inferior vena cava was diagnosed in a fetus at 18 weeks' gestation. Associated anomalies included nuchal and axillary lymphangiectasia, hypertrophic cardiomyopathy and hepatomegaly. Neonatal death occurred after spontaneous vaginal delivery at 25 weeks. A review of the literature summarizes the diagnostic criteria and associated anomalies.

Ultrasound evaluation of the length of the fetal nasal bones throughout gestation.

Subtle facial abnormalities, including smallness of the nose, are common findings in trisomy 21 and numerous other genetic conditions. The aim of this study was to construct a normal range for the length of the fetal nasal bones with gestation in a Caucasian population. Ultrasound measurements were performed on a strictly mid-sagittal profile in 376 normal singleton fetuses at 14-34 (mean 24) weeks' gestation. It was found that the length of the nasal bones increased from 4 mm at 14 weeks to 12 mm at 35 weeks' gestation, and that there was a linear relationship between the length of these bones and biparietal diameter and femur length. We conclude that the length of nasal bones can easily be measured in fetuses at 14-34 weeks' gestation and that such measurements might prove useful in the evaluation of pregnancies at high risk for associated fetal abnormalities.

Ultrasound-guided injection of methotrexate versus laparoscopic salpingotomy in ectopic pregnancy.

OBJECTIVE: To compare local injection of methotrexate (MTX) under sonographic control to laparoscopic salpingotomy for conservative management of ectopic pregnancy (EP). DESIGN: Prospective randomized study. PATIENTS: Forty patients were randomized into two groups using a random number table. Inclusion criteria were an EP visualized by ultrasound with a pretherapeutic score < or = 13 as assessed by six criteria graded from 1 to 3: gestational age, hCG level, P level, abdominal pain, volume of the hemoperitoneum, and diameter of the hematosalpinx. INTERVENTIONS: Group 1 patients injected transvaginally with 1 mg/kg MTX into the EP without anesthesia versus group 2 patients undergoing laparoscopic salpingotomy. MAIN OUTCOME MEASURES: Postoperative hospital stay, decrease of hCG levels, success rate. RESULTS: The success rates, defined by hCG levels returned to normal (< 10 mIU/mL [conversion factor to SI units, 1.00]), were 19 of 20 in both groups. Medical treatment was associated significantly with shorter postoperative stay (24 versus 46 hours) and a higher initial hCG level. Human chorionic gonadotropin returned to normal more quickly after laparoscopic treatment (14 versus 28 days). CONCLUSIONS: In selected cases of EP with a pretherapeutic score < or = 13, MTX treatment appeared to be as safe and efficient as was conservative treatment by laparoscopy.

Methotrexate treatment of unilateral twin ectopic pregnancy: case report and pharmacokinetic considerations.

We describe a case of spontaneous twin ectopic pregnancy, managed with the combination of local injection under ultrasound control and intramuscular administration of methotrexate. We describe a difference between the area under the curve of declining plasma concentration of methotrexate after intramuscular and local injection.

Nonsurgical treatment of heterotopic pregnancy: a report of six cases.

OBJECTIVE: To evaluate nonsurgical management of heterotopic pregnancy. DESIGN: Retrospective case series. SETTING: Department of Obstetrics and Gynecology (Antoine Béclère Hospital, Clamart, France, Paris-Sud University). PATIENTS: Six women with heterotopic pregnancy who conceived in four cases after ovulation induction. INTERVENTION: Transvaginal ultrasound (US)-guided aspiration/injection of potassium chloride (KCl) was performed in three cornual pregnancies with alive embryo. Expectant management was realized in three other cases. The regression was followed by serial US examination. MAIN OUTCOME MEASURES: Early and late complications related to the procedure, outcome of intrauterine pregnancy (IUP). RESULTS: Five of six patients were treated successfully (3 with KCl and 2 after expectant management). Three of these five patients had a spontaneous vaginal delivery, and two abortions occurred in the remaining two patients. Salpingectomy had to be performed in one case 10 days after medical treatment. This twin pregnancy ended with an abortion at 23 weeks of amenorrhea. Four cornual heterotopic pregnancies were treated successfully. No complication occurred after the initial management. CONCLUSION: Ultrasound permits a reliable and early diagnosis of heterotopic pregnancy. In such cases nonsurgical management is an efficient alternative with a good IUP prognosis.

First-trimester diagnosis of nuchal anomalies: significance and fetal outcome.

High-resolution real-time ultrasonography now permits the differentiation between nuchal translucencies and cystic hygromata of the neck in the first trimester. A series of 85 nuchal anomalies are presented that were diagnosed by ultrasonography at 9-14 weeks' gestation; their association with chromosomal defects and fetal outcome are also presented. Chromosomal anomalies were found in 8/29 nuchal translucencies and in 16/56 cystic hygromata of the neck. However, in fetuses with normal karyotype, additional defects were diagnosed in l0/40 fetuses with cystic hygromata and in none with nuchal translucency. These data may be important for the management of these conditions and for counselling the patients toward further pregnancy.

Chorionic villus sampling after first trimester diagnosis of fetal cystic hygroma colli.

Diagnostic findings of four cases of cystic hygroma discovered at 11 weeks of gestation are reported. The discovery of cystic hygroma by echotomography was followed by sample taking of chorionic villi which revealed one case of monosomy X and three cases of trisomy 18. Caryotype determination in the presence of cystic hydroma is essential for diagnostic confirmation and subsequent genetic counselling.

Chorionic villus sampling (CVS). Randomized study of efficacy of two transcervical biopsy methods: aspiration canulas and small forceps.

A randomized study of two transcervical biopsy methods was performed. One method involved the use of an aspiration catheter and the other a tissue biopsy forceps. 120 chorionic villus samplings were performed in 30 patients. The percentage of success in taking biopsies and the resulting number of karyotypes were identical in both groups. The amount of removed trophoblastic tissue was greater when the forceps was employed. When the aspiration catheter was used, a sufficient amount of trophoblastic tissue was obtained for karyotyping purposes. It was easier to insert the aspiration catheter than the forceps. The echogenicity of the catheter and forceps were identical. The aspiration catheter has two advantages. Firstly, it is malleable and fits to the anatomy of the cervical canal and the site from which the biopsy is to be taken. Secondly, it is disposable.

[Prenatal diagnosis and genetic diseases of the lung]. / Diagnostic anténatal et maladies génétiques pneumologiques.

Currently two genetic pulmonary disorders can be diagnosed before birth: alpha-1-antitrypsin deficiency and mucoviscidosis. For the latter there are two possible diagnostic techniques: first a study of the intestinal enzymes of the amniotic fluid, a reliable method only at the 18th week, and also a study of DNA markers (ADN) of the trophoblastic cells using molecular biological techniques: this can be performed from the 10th to 11th week of pregnancy but presupposes a family study in which there is already a subject suffering from the disorder. Foetal echocardiography enables various pulmonary abnormalities to be detected: pleural effusion, cyst, pulmonary hypoplasia and other disorders. This technique however has some limits, at least at present. Most often these severe malformations are revealed at birth such as respiratory distress or stillbirth. Adenomatous cystic malformations or congenital lobar emphysema, a posterior diaphragmatic hernia, and oesophageal atresia with oesophagotracheal fistula are the most frequent and are curable surgically.