Uterine anomalies and in vitro fertilization: what are the results?

OBJECTIVE: To evaluate the influence of uterine anomalies on the implantation rates after embryo transfer. STUDY DESIGN: A retrospective, multicentric study. This study compare patients presenting a uterine anomaly (septate uterus, umicornuate, pseudonicornuate, bicornuate uterus) having attempted FIVETE between 1987 and 1992 with the normal population treated by IVF, as well as with FIVNAT results. RESULTS: Thirty-eight patients were part of the studied population and total 119 oocyt retrievals which lead to 103 embryo transfers (corresponding to 1.35% of the realised transfers during the same period in the three centers of the study). The pregnancy rate obtained by these patients is significantly lower than those obtained by the control group (11.7% pregnancies by retrievals vs. 19.1%, and 13.6% pregnancies by transfer vs. 24.9%). The implantation rate by embryo transfer is 5.8% in the population studied vs. 11.7% in the control group (P < 0.01). These results significantly improve when the uterine anomaly can be treated (septate uterus). CONCLUSION: The uterine anomalies are associated with a lowered rate of embryo implantation. This implantation rate improves when the anomaly can be treated (septate uterus).

Rapid chromosomal analysis of germ-line cells by FISH: an investigation of an infertile male with large-headed spermatozoa.

A rapid fluorescence in-situ hybridization (FISH) technique was used for direct chromosomal analysis on germ cells from an infertile male with large-headed spermatozoa. The interphase chromosomes were fluorescently-labelled using an extremely bright cyanine dye during a 5-15 min FISH procedure. Germ cells were analysed using a battery of chromosome-specific DNA probes in several consecutive rapid FISH experiments. It was found that the majority of large-headed spermatozoa contained a diploid chromosome number probably due to errors in meiosis I or II divisions, whereas the majority of spermatozoa with normal sized heads are haploid and may be utilized for selective in-vitro fertilization procedures. Rapid FISH may be useful for the detection of major chromosomal aneuploidies in germ cells as an alternative technique to standard or multicolour FISH, and may find an additional application for the chromosomal analysis of human preimplantation embryos.

[Results and indications of laparoscopic distal tuboplasty]. / Resultats et indications de la coeliochirurgie tubaire distale.

We present a retrospective study of a series of 46 patients who have benefited from a laparoscopic treatment for a distal tubal disease. The results have been expressed in terms of tubulars and adherentiels scores, of the type of plastic effected and of the sterility (pure tubular sterility or associated). The global pregnancy rate is 39, 1% of which 34,8% is IUP and 4,3% EP. We have observed: an average delay of 10,8 months to obtain a pregnancy; the superiority of the fimbrioplasties (rate of pregnancy 75%); the predicted value of tubular score (the cases scored I and II obtain pregnancy rates of 57,7%). The association of endometriosis or of light oligoasthenoteratospermia do not constitute a counter indication of the tuboplasty (in those cases, cumulative rate of pregnancy is 50% and 40% respectively). If no pregnancy is observed during the 18 months following the intervention we recommend that the couple be treated by IVF.

[Spontaneous pregnancies in couples after failed or successful in vitro fertilization]. / Grossesses spontanées chez les couples après échec ou réussite de fécondation in vitro.

OBJECTIVE: To determinate the true incidence of treatment-independent pregnancy in an in vitro fertilization programme. To establish and to compare the characteristics of couples with and without spontaneous pregnancy. To analyze the outcome of pregnancies. TYPE OF STUDY: Retrospective. SETTING: In Vitro Fertilization Unit, Conception's Hospital, Marseille, France. SUBJECTS: 594 couples having attempted one or more IVF procedures. The study concerned low-fertility couples (484) ruling our true sterile couples (110). RESULTS: Spontaneous pregnancies occurred in 54 couples (11.2%). The characteristics of the two populations were not statistically different, except a shorter duration of infertility (p < 0.05) in spontaneous pregnancies. The rate of ectopic pregnancies in the spontaneous pregnancies was statistically higher than that observed in IVP pregnancies (12% versus 6.5%). The fertility rare of these couples was very low (0.38%). CONCLUSION: Spontaneous pregnancies in vitro fertilization programmes are not rare. The evaluation of the results of the in vitro fertilization requires taking the possible spontaneous pregnancies into account.

[Ovarian hyperstimulation syndrome in medically assisted reproduction]. / Syndrome d'hyperstimulation ovarienne en procréation médicalement assistée.

Ovarian hyperstimulation syndrome (OHS) is the most serious complication of ovulation induction, particularly in in vitro fertilization. It is a potentially life-threatening situation. Its pathophysiology is poorly understood. This syndrome is explained by a sudden increase in capillary permeability which results in a rapid fluid shift from the intravascular space into a third space leading to haemodynamic changes. In its most severe forms. OHS is characterized by multicystic ovarian enlargement, hemoconcentration, hypovolemia, oliguria, third space accumulation of fluid in the form of ascites and pleural effusion, renal failure, thrombotic disorders. Mild and the most of moderate forms of OHS usually do not require any active form of therapy. Severe OHS requires hospitalization, correction of fluid and electrolyte imbalance, prevention of thromboembolism, aspiration of the ascites and pleural effusion causing respiratory discomfort and dyspnea. Surgical interventions are exceptionally indicated and reserved for ovarian or rupture of ovarian cyst. Although severe OHS may not be completely avoided, early recognition of high-risk factors, judicious monitoring of ovulation induction (plasma estradiol levels and ultrasonography), and, perhaps in future, substitution of hCG for triggering ovulation should reduce the incidence of this iatrogenic syndrome.

Induction of amenorrhea during hormone replacement therapy: optimal micronized progesterone dose. A multicenter study.

The effects of oral micronized progesterone on the endometrium and bleeding pattern have been assessed in a multicenter study of 101 postmenopausal patients. During a minimum of 6 cycles, the participants received either percutaneous 17 beta-estradiol (1.5 mg/day) associated with micronized progesterone (100 mg/day), given at bedtime for 21/28 days or 25 days/calendar month (n = 98) [1], or E2 (3 mg/day) for 25 days associated with progesterone (300 mg/day), from day 16 to day 25 (n = 3) [2], according to their willingness to induce, or not, cyclic withdrawal bleeding. Each endometrial biopsy performed at 6-month minimum was assessed by two independent pathologists: results showed 61% quiescent without mitosis, 23% mildly active with very rare mitoses and 8% partial secretory endometrium. The remaining biopsies showed inadequate tissue (4%) or a sub-atrophy (4%). No hyperplasia was found by any pathologist. In the case of inadequate material, the mean thickness of endometrial mucosa measured by ultrasonography was 3.9 mm. Amenorrhea incidence was 93.3 and 91.6% at the 3rd and 6th month of therapy, respectively. No bleeding occurred in more than 80% of women. The results show that a low dose of oral progesterone (100 mg/day), given during 25 days, efficiently protects the endometrium by fully inhibiting mitoses and induces amenorrhea in the majority of postmenopausal women, allowing better compliance to long-term therapy.

[Metrorrhagia caused by estrogen-progestin combinations]. / Metrorragies sous estroprogestatifs.

PIP: Changes in combined oral contraceptives (OCs) include reduction in the estrogen and progestogen dose and recourse to the third generation, less androgenic progestogens. They retain the efficacy and convenience of OCs while reducing the metabolic and cardiovascular effects and the need to identify contraindications and subjects at risk. OCs sometimes cause menstrual cycle problems: spotting and intercurrent bleeding or bleeding at any time other than menstruation (metrorrhagia). OCs cause loose and edematous stroma in the endometrium where glands maintain a proliferative-like phase throughout the cycle. Many dilated capillaries with hyperplasia of the endothelial cells rise to the surface. Forgetting or failure to take OC pills are often responsible for intercurrent bleeding. It is hard to determine what OCs cause less bleeding than other OCs. The third generation progestogen, gestodene, appears to have better cycle control than the two other third generation progestogens (desogestrel and norgestimate). It is not clear whether triphasic OCs with second generation progestogens are better than monophasic third generation OCs. The OC with low dose ethinyl estradiol (20 mcg) (Mercilon) has as low a bleeding rate as does the OC, Varnoline (30 mcg). Menstrual cycle disturbances rarely happen. Providers must emphasize to new OC users the possibility of spotting or intercurrent bleeding, especially during the first cycle. Providers must also inform them that these disturbances do not affect the effectiveness of the OCs and that they should not stop taking OCs if they are concerned about bleeding. Providers must instruct them what to do if they forget to take a pill(s). Providers should schedule an appointment after a new OC user has completed the third OC packet. They should do a gynecologic exam to search for a genital infection, endo-uterine polyp or fibroma, and hyperplasia of the endometrium. If bleeding persists during the third cycle, the client should change contraception.^ieng

[Cleaning protocol for endoscopic instruments in gynecology]. / Protocole d'hygiène du matériel endoscopique en gynécologie.

The procedure for cleaning endoscopic material include successive step which must be applied correctly: preliminary treatment, predisinfection or cleaning, rinsing, sterilization or disinfection. If sterilization is performed, the material is stocked until its next use. If cold disinfection is performed, the material is rinsed then stocked but cold disinfection must be performed again before using the material again. Personnel who manipulate must of course wear gloves. Cold disinfection is insufficient. Material used for endoscopic gynaecological surgery should be sterilized with an autoclave since it is the only method which can prevent infection.

[Quality of embryos in unexplained sterility]. / Qualité des embryons dans les stérilités inexpliquées.

In our study, the rate of pregnancy by transfer and puncture was not significantly different in unexplained and in tubal infertility, but the mean number of transferred embryos was significantly higher in the first group. To explain these data, we compared the quality of embryos in 32 punctures realized among 29 women with unexplained infertility and in 171 punctures planned among 156 women with tubal infertility. The percentage of embryos with 4 or more blastomeres was significantly lower in the unexplained infertility group than in the pure tubal infertility group.

[Distal tubal surgery using laparoscopy]. / Chirurgie tubaire distale par coelioscopie.

Between January 1987 and May 1990, forty-four women were treated in our department by laparoscopic surgery for distal tubal pathology. Among them, 10 had an intrauterine pregnancy (22.7%) and 2 had an ectopic pregnancy (4.5%) within 28 months after surgery. Subsequently, our results were expressed in terms of the type of operation performed (fimbrioplasty or neosalpingostomy) and according to the tubal and adhesion scores (Mage and Bruhat). We found that most pregnancies were obtained within the first 16 months, that fimbrioplasty gave better results than neosalpingostomy (35.7% versus 16.6%) and that the tubal score was fairly predictive and more so than the adhesion score. These results enabled us to keep as indication of distal tubal laparoscopic surgery those patients who had pure distal tubal lesions with a tubal core of 1 to 2 and normal other parameters of infertility. In case of failure, i.e. if the woman does not become pregnant within 12 months post-laparoscopic surgery, in vitro fertilization is advised.

[Current role of laparoscopy in the diagnosis and treatment of ovarian cysts]. / Place actuelle de la coelioscopie dans le diagnostic et le traitement des kystes ovariens.

Between October 1986 and March 1990, 220 patients underwent surgical treatment for ovarian cysts. 156 of these patients underwent an initial celioscopy and could potentially benefit from celiosciopic treatment. The group mean age was 33.3 years. The circumstances under which the cysts were discovered usually consisted of pelvic pain or diagnosis during a routine examination. Twenty-four patients underwent laparotomy immediately after coelioscopy either due to a suspect macroscopic diagnosis either due to technical difficulties. 84.6 percent of the patients in the group were able to undergo celioscopic treatment only, essentially consisting of intraperitoneal cystectomy. The main advantages were the reduction in adherent sequelae in these women of a sexually active age, but also some financial savings related to the reduced duration of hospitalization and of sick leave. The theoretical reservations consist of the risk of malignancy and macroscopic diagnosis following coelioscopic exploration must be very restricted, with laparotomy whenever there is any doubt. No malignant tumor was escaped detection in this group.

[Complications of gynecologic laparoscopy. Multicentric study of 7,604 laparoscopies]. / Complications de la coeliochirurgie gynécologique. Etude multicentrique à partir de 7,604 coelioscopies.

In a series of 7,604 laparoscopic procedures, the authors report one death and a rate of 2.76 per thousand (21 cases) for complications requiring laparotomy. When exclusively diagnostic laparoscopic procedures are considered (1,191 cases) this rate drops to 1.67 per thousand. The likelihood of laparotomy being required is directly related to the degree of importance of the laparoscopic surgical procedure. For major laparoscopic surgery the rate of laparotomy is 4.46 per thousand (18 cases), whereas it is only 0.42 per thousand (1 case) for minor laparoscopic surgery (p less than 0.01). Intestinal injuries represent 52.4% (11 out of 21) of cases requiring laparotomy. The main problem with this type of accident is to recognize them, because in almost half the cases (42.8%; 3 out of 7) the intestinal injury went unseen during the laparoscopic procedure and gave rise to peritonitis. Vascular complications are less frequent and required laparotomy in only 8 cases (38%; 8 out of 21). This low level of complications is yet further proof that laparoscopic surgery is a reliable technique and does not involve a high risk of laparotomy, provided that the surgeon has received specific training.

Epididymal sperm aspiration in conjunction with in-vitro fertilization and embryo transfer in cases of obstructive azoospermia.

Epididymal sperm aspiration is a new treatment for vasal agenesis. In previous reports, epididymal spermatozoa resulted in pregnancy by utilizing in-vitro fertilization (IVF) or gamete intra-Fallopian transfer (GIFT). We sought to investigate the efficacy of epididymal sperm aspiration in conjunction with IVF in patients with congenital absence of the vas deferens or with secondary extended obstruction of spermatic ducts. Fifty-eight attempts were performed in 23 patients (25-50 years). Eight patients (34.7%) had vasal agenesis and 14 (60.8%) presented with vasal secondary extended obstruction. The sperm count was adequate (greater than or equal 20 x 10(6)/ml) in 13.8% of sperm retrievals and sperm motility of 20% was obtained in 15.5% of sperm retrievals. Fourteen attempts at IVF were performed with epididymal sperm counts of 2-44 x 10(6)/ml and motilities of 0-45%. A mean of six mature oocytes (0-13) were inseminated in each case. Five embryo transfers were performed in five patients' wives (35.7%) and two couples had an early pregnancy loss (14.2%). Epididymal sperm aspiration is an advance in treating such patients, as an adequate number of mature spermatozoa can be obtained and used for IVF. However, spermatozoa directly aspirated from the proximal epididymis and with fertilizing capacity in vitro, gave a high rate of embryo degeneration (greater than 50%) after embryo transfer.

[Efficacy of spermicides]. / Efficacite des spermicides.

PIP: Spermicidal contraceptives, after falling out of favor in the 1960s, are once again being sought be women desiring a natural and safe method. 2-6% of couples in France and other European countries are estimated to use spermicidal contraceptive methods. There is a wide an puzzling gap between the theoretical efficacy of spermicides tested in vitro and efficacy in actual practice. The theoretical failure rate of spermicides used regularly and correctly is 0-7.6%. The principal spermicides used in France at present are the ionic surfactant agent benzalkonium chloride and the nonionic surfactant nonoxynol 9, which destroy the cellular membranes of the sperm. Several tests are used to determine the spermicidal activity of a contraceptive. They include the International Planned Parenthood Federation test which is considered positive if 1 ml of a 1/11 solution immobilizes the sperm in .2 ml solution of selected sperm within 10 seconds in a reproducible fashion; the study of the minimal concentration that completely inhibits .2 ml of fresh sperm in less than 20 seconds; the absence of penetration of sperm in hamster eggs after contact with the products tested, and the Huhner test consisting of a search for sperm in the cervical mucus in the hours following intercourse. The 4 tests have demonstrated that the spermicidal efficacy of benzalkonium chloride is 4 times greater than that of nonoxynol 9. The spermicidal action is reinforced by thickening and coagulation of the mucus on contact with benzalkonium chloride, and the action of the spermicide covering the vaginal mucus. The practical efficacy of spermicides, which takes into account failures attributable to the method itself as well as failures due to incorrect use, is reflected in Pearl indexes ranging from 0.3-30. The efficacy of spermicides is closely related to their correct use. The method should be used regularly and systematically and the product inserted before initiation of sexual contact. Most products require renewed application if intercourse is repeated. Package instructions about duration of action and waiting times for the product to become fully effective should be carefully followed. The product should be left in place at least 2 hours. Baths and vaginal douches should be avoided for 4 hours after intercourse. Products such as soaps which neutralize the ionic surfactants should be avoided. Spermicidal contraceptives are recommended only for women capable of understanding and following the use instructions. Women who find the idea of spermicides distasteful and those requiring absolute efficacy should select another method. Vaginal spermicides may be suggested for women over 40 and those with contraindications to oral contraceptives and IUDs. They provide some protection against sexually transmitted diseases, and have no effects on the vaginal mucus or menstrual cycle and no carcinogenic effect.^ieng

[Venous insufficiency of the lower limbs in pregnancy]. / Insuffisance veineuse gravidique des membres inférieurs.

Pregnancy is a circumstance which may trigger, reveal or aggravate venous insufficiency of the legs. This association (venous insufficiency and pregnancy) is characterized by the rapidity of the onset and aggravation of the signs and by the spectacular nature of the regression which can occur after childbirth. The treatments administered during pregnancy are intended to control the symptoms and prevent complications. After childbirth, a phlebological assessment is carried out to evaluate the sequelae and the therapeutic possibilities.