[Introduction in Switzerland of preimplantation genetic testing: progress or downward spiral?]. / Gynecologie. Introduction en Suisse des analyses sur le patrimoine génétique de l'embryon: progrès ou dérive?

The Swiss law on Assisted Reproductive Techniques (LPMA) has been modified in order to authorize preimplantation genetic diagnosis (PGD). PGD has been performed for 20 years. Switzerland is one of the last european countries where it is still prohibited. As a result, couples carrying a severe inherited disease and infertile couples with recurrent implantation failure or miscarriage have to cross the borders in order to have access to the appropriate treatments. Despite the recent popular approval to change the Constitution, the new LPMA cannot be implemented as the opponants have launched a referendum in order to obtain a more restrictive law. If they succeed, the affected couples will be left with a scientifically obsolete law that will not allow them to have access to an effective and compassionate treatment.

Clinical use of aromatase inhibitors (AI) in premenopausal women.

Aromatase inhibitors (AI) block the last enzymatic step of estrogen production, the aromatization of the A-cycle of aromatizable androgens and particularly, androstenedione (delta4) and testosterone (T). Molecules designed for interfering with aromatase activity have existed for many years. Yet the activity of products of the aminogluthetimide era was unspecific and these substances carried too many side effects for being used clinically. Newer third generation AIs, however, are highly specific and essentially devoid of side effects. These molecules have recently been approved for treating breast cancer in postmenopausal women either, in advanced forms or, as part of adjuvant therapy. In women whose ovaries are active, a temporary inhibition of E2 production will raise gonadotropins and in turn, stimulate follicular growth. In cancer patients, this property precludes the use of AIs in women whose ovaries are still active, unless gonadotropins are blocked. But in infertility patients, this property of AIs has been put to play for inducing ovulation. AIs have been used both in women who do not ovulate but whose hypothalamo-pituitary-gonadal (HPG) axis is active (oligo-anovulators of PCOD type) and those who ovulate regularly but in whom multiple ovulation is sought for treating unexplained infertility or as part of IVF. Like clomiphene citrate (CC), AIs are not usable in women whose gonadotropins are suppressed, as in the case of hypothalamic amenorrhea. The sum of data available on the use of AI for inducing ovulation remains however meager to this date and is mainly constituted of pilot and non-randomized trials. Yet mounting evidence tends to support AIs' advantages over CC for induction of ovulation. Hence, we think that the likelihood that these drugs will play a key role in induction of ovulation in the future is high. AIs appear particularly interesting for treating unexplained infertility because AI-FSH/hMG regimens are lighter than FSH-only regimens while retaining the high pregnancy rates of these latter treatments.