[A patient with pulmonary endometriosis]. / Une observation d'endométriose pulmonaire.

A 30-year-old woman consulted for recent repeated episodes of hemoptysis occurring at the onset of the menses a few months after interruption of estrogen-progesterone treatment. This patient's only surgical history involved uterine curetage. She was a smoker and had cumulated 10 pack-years. Physical examination and chest x-rays were normal. Bronchial endoscopy and cytological examination of the bronchial aspiration were normal. Thoracic CT demonstrated an alveolar image in the right lower lobe. A second CT performed later after resolution of the episode of hemoptysis was normal. Laparoscopy was performed and visualized an endometrial nodule in the pelvis which was removed. The patient's clinical signs disappeared after treatment with triptoreline. Bronchopulmonary endometriosis is an uncommon condition. The main manifestations are catamenial hemoptysis during the first days of the menses. Chest pain is exceptional. Diagnosis may result from an incidental discovery. A traumatic intervention on the uterus is often found in the patient's history. The most commonly proposed pathogenic mechanism involves hematogenic migration following a uterine procedure. Imaging does not disclose specific signs and bronchial endoscopy is often normal but may demonstrate a tracheal or bronchial plaque of endometriosis, or exceptionally endometrial tissue in the endoscopy biopsies. LH-RH agonists remain the current treatment.

The molecular basis of embryo implantation in humans.

The implantation of the human embryo is a double paradox, immunological and biological. The immunological paradox is that it consists of a heterologous graft in which the uterine immune system (via the cytokines) and the embryo's antigenicity (HLAG) collaborate to make possible both implantation and the maintenance of the pregnancy. The biological paradox arises because several different mechanisms must be successively implemented for these two epithelia to fuse and then for one to allow invasion by the other (that is, the for the endometrium to be decidualized by the trophoblast): preparation of the endometrium throughout the menstrual cycle under the influence of estrogens and then progesterone, with the involvement of growth factors (EGF, TGF and IGF), neoangiogenesis (estradiol, FGF and VEGF), recognition by the trophoblastic cells of the various components of the decidua and of the extracellular matrix (integrins and cadherin) and the progressive invasion of the decidua, to the depth of the spiral arteries (by the trophoblastic secretion of metalloproteases). A defective or excessive trophoblastic invasion can result in complications of pregnancy: early spontaneous miscarriage, preeclampsia and growth retardation of vascular origin in the case of defects, placenta accreta or percreta in the case of excess.

[Oocyte donation after the bioethics law. Medical, ethical and legal implications drawn form a series of 300 cases at the Tenon hospital]. / Le don d'ovocytes depuis la loi de bioéthique. Implications médicales, éthiques et juridiques déduites d'une série de 300 cas à l'hôpital Tenon.

This is the perfect example of the problems which are the consequences of the actual medicine. We carried out an ovocyte donation study at the Tenon Hospital, in Paris, between 1994 and 1999 involving 177 cryopreserved thawed embryo transfers among 300 recipients. This study enables us to stress the ethical difficulties posed by the so called bioethical laws of 1994. Simultaneously two consequences became clearly evident: a paucity of donors, and the necessity to only transfer frozen embryos due to decree of 1996 upon sanitary security that imposes the quarantine of embryos for six months. On the other hand, the use of this method has yielded important new information regarding embryo implantation and the importance of ovocyte quality that is closely correlated to donor age.

[Role of hysteroscopy in the diagnosis and treatment of infertility]. / Place de l'hystéroscopie dans le diagnostic et le traitement de l'infertilité.

UTERINE DISORDERS: Because they can prevent implantation, anomalies within the uterine cavity play an important role in fertility. The uterine disorders most often observed during hysteroscopy and implicated in infertility are adhesions, septa, polyps, submucous myomas, adenomyosis, endometritis, anomalies of the cervical canal, and lesions of the uterotubal junction. EXPLORATIONS: Hysterosalpingography can be used to evaluate tubal permeability but provides inadequate information about the uterine cavity (numerous false-positives and false-negatives). Pelvic ultrasound is especially helpful for diagnosing interstitial anomalies in the uterus. HYSTEROSCOPY: Diagnostic hysteroscopy also has a place in infertility investigations, for it allows direct visualization of the uterine cavity, the endometrial mucus (endometritis, adenomyosis), and the cervical canal. The examination is practiced on a out-patient basis, without anesthesia, using appropriate small-caliber instruments and irrigation with physiological saline. Surgical hysteroscopy is used to treat these anomalies. Patients receive general anesthesia. A high-frequency, low-voltage electric current is used, and glycine for irrigation. This procedure allows resection of submucous myomas and polyps and of septa and adhesions. Some groups use laser beams and irrigation by physiological saline for these treatments. Coagulation of a superficial focal spot of adenomyosis is not useful in infertility therapy. RESULTS: As assessed by the percentage of patients with each indication who subsequently became pregnant, the results of surgical hysteroscopy have been satisfactory: 62 per cent (%) of cases after myomectomy, 66% after section of uterine septa, and 61% after treatment of complicated adhesions. A new exploration of the uterine cavity will be necessary sometime after the surgery to verify the absence of any iatrogenic disorders (adhesions, myomatous fragments).

[Therapeutic management of ovarian dystrophy and insufficiency in abortion disorders: recent data]. / Prise en charge thérapeutique de la dystrophie et de l'insuffisance ovarienne débutante dans la maladie abortive: données récentes.

Many reports suggested that the high rate of miscarriage in women with polycystic ovaries may be due to increased urine and/or plasma LH concentration. In fact, with the exception of pulsatile GnRH, any treatment likely to increase the plasma LH level results in unchanged or rather low miscarriage rates. Conversely, a reduction in this rate by GnRH agonists is not conclusive. Excess weight may also increase the risk of miscarriage. In women with incipient ovarian failure, the miscarriage rate is mainly linked to age. No stimulation has been found to be effective in these patients. There is a need for more extensive evaluation in GnRH analog microdoses, recombinant FSH and GnRH antagonists. Oocyte donations from younger women are difficult to obtain because of the lack of donors in France.

[Atypical mammary hyperplasia: interpretation, therapeutic strategy, and post therapeutic survey]. / Hyperplasie atypique mammaire: interprétation, stratégie thérapeutique et surveillance post-thérapeutique.

Defining elements leading to atypical hyperplasia's diagnosis, interpreting histological diagnosis of atypical hyperplasia and determining therapeutic strategy.

[Outcome of patients treated with intra-peritoneal immunochemotherapy for ovarian cancer]. / Devenir des patientes traitées pour un cancer de l'ovaire par immunochimiothérapie intra-péritonéale.

OBJECTIVE: The aim of this study is to show that i.p. chemotherapy improves the evolution of the patients with an ovarian cancer, as the risk of a small number of complications due to this route of administration. METHODS: 85 patients (11 stage Ic, 4 IIc and 70 stage III) were treated from 1980 to 1993 (median of follow up > 77 months) by a cisplatin based immunochemotherapy administered intraperitoneally, by a needle. RESULTS: Median overall survival exceeds, 72 months (60 months for stage III). Out of 41 relapses, 11 took place after 48 months of follow up. Delayed general complications consisted of 2 chronic nephotoxicities due to CDDP and one leukemia. Local complications are dominated by serous adherences (5 cases of plastic peritonitis). Secondary cytoreductions turned out to be beneficial in this series in spite of relapse diagnosis of them being carried out to late. CONCLUSION: Classic imagery remains disappointing for the exploration of the pelvic abdominal region. Paclitaxel by i.p. way seems very promising, which should launch once again interest in secondary debulking surgery.

The use of a GnRH antagonist (Cetrorelix) in a single dose protocol in IVF-embryo transfer: a dose finding study of 3 versus 2 mg.

New gonadotrophin-releasing hormone (GnRH) antagonists, which allow suppression of luteinizing hormone (LH) surges, have recently become available. We compared in this study the results of a single administration of 3 versus 2 mg Cetrorelix in 65 patients undergoing ovarian stimulation and in-vitro fertilization (IVF). The GnRH antagonist (Cetrorelix) was non-randomly administered at a dose of 3 mg (34 patients) or 2 mg (32 patients) on day 8 of the stimulation cycle. In the case of slow follicular development, the injection was delayed until oestradiol reached 400 pg/ml. No difference was observed in the decrease in LH and in oestradiol secretion between the 3 and the 2 mg groups, but the LH secretion was suppressed for a shorter time in the 2 mg group. No LH surge was observed in the 3 mg group, while one surge (3%) and one significant rise in LH were observed in the 2 mg group. No significant difference was observed in IVF results in the two groups of patients. This study demonstrates that a single injection of 3 or 2 mg successfully prevents LH surges for at least 3 days in all the patients treated. The LH rises in the 2 mg group led us to choose the 3 mg dose as a safer dose in our single administration protocol.

Cryopreservation in human assisted reproduction is now routine for embryos but remains a research procedure for oocytes.

Human embryo cryopreservation represents an indispensable extension of in-vitro fertilization (IVF) programmes as long as they are based upon the recovery of a large number of oocytes. The most widely used procedures include the cryopreservation of human zygotes or embryos in early cleavage, using 1,2-propanediol and sucrose as cryoprotectants. Our results over a 10 year period (1986-1995) on 5032 thawed cycles involving 14 222 stored embryos make it possible to appraise the results and the contribution of embryo freezing to assisted reproduction. Embryos survived the freeze-thaw process in 73% of cases leading to 4590 transfers of 2.2 embryos (91% of thawed cycles). The clinical pregnancy rate per transfer was 16%, the live birth rate 12%, and the rate of babies born alive per transferred embryo was 6%. Embryo freezing monitored 10 years later produced an average of 8% of additional births. By then, 86% of stored embryos had been thawed for transfer to patients. Destruction or donation were required for only 8% of all frozen embryos and there was no news from the parental couple in relation to almost 6% of embryos. The fate of the vast majority of embryos was decided during the first 5 years of storage. Blastocyst cryopreservation is making new strides, thanks to co-culture systems and embryo selection. Micromanipulation procedures seem to have little impact on the outcome of embryo freezing. Human oocyte freezing is again clinically applied. Indeed, much of the concern about injuries to the oocyte structures through the freeze-thaw process do not seem to be justified, and the problems with frozen-thawed oocyte fertilization has been overcome using intracytoplasmic sperm injection (ICSI). As long as oocyte in-vitro maturation is not well controlled, better results will probably be obtained with mature oocyte cryopreservation. Emerging methods include the freezing of immature oocytes, follicles and ovarian tissue.

Lone hyperuricemia during pregnancy: maternal and fetal outcomes.

OBJECTIVE: Study of maternal and fetal consequences of lone hyperuricemia during pregnancy and demonstration that lone hyperuricemia is not a risk factor regarding the onset of preeclampsia. STUDY DESIGN: Retrospective study of two groups of women, one found to have lone hyperuricemia during pregnancy (n=102) and the others with normal serum uric acid levels (n=100). RESULTS: The only consequence identified of the lone hyperuricemia was a lower birth weight of children born to mothers found to have lone hyperuricemia for more than 2 weeks (P<0.05). CONCLUSIONS: Lone hyperuricemia is not a risk factor regarding the onset of preeclampsia. It is therefore unnecessary to measure serum uric acid level during a normal pregnancy.

[Are there indications for intra-cytoplasmic sperm injection in female infertility?]. / Y-a-t-il des indications féminines d'ICSI?

ICSI for oocyte pathology may represent the solution in case of zona pellucida anomalies, deficiency of the oolemma fusion ability or absence of cortical reaction. These indications remain scarce and difficult to be displayed. A link could be shown by some authors between some oocyte morphologic anomalies and IVF fertilization failures which are overcome by ICSI. Other dysmorphic oocytes are associated with an impairment in cytoplasm function which results in a poor embryonic viability on which ICSI has no effect. When few oocytes are recovered (< or = 5) and the semen characteristics are not optimal, ICSI may rectified the decrease in fertilization rates obtained after classical insemination. Lastly, ICSI will become increasingly used in case of oocyte in-vitro maturation or freezing instead of classical IVF which is less efficient.

[Clinical use of recombinant gonadotropins (FSH, LH, hCG)]. / L'utilisation en clinique des hormones gonadotropes recombinantes (FSH, LH, hCG).

The production of recombinant gonadotropins is independent of urine collection. They have a high specific activity and a better batch to batch consistency than urinary gonadotropins. In our IVF programme 62 normo-ovulatory patients less than 38 years old, with tubal or idiopathic infertility and normal sperm, were treated by r-FSH and randomized into four groups : with or without LHRH agonist, step-up or step-down stimulation. The overall results were higher in the agonist groups, but did not reveal any significant difference between step-up and step-down stimulation.

[Severe preeclampsia: management. Is conservative treatment justified?]. / La Prééclampsie sévère: prise en charge. Un traitement conservateur est-il justifié?

Severe preeclampsia is a major contributor to maternal and perinatal morbidity and mortality. This review was performed to assess the fetal and maternal benefits of allowing women presenting with severe preeclampsia between 24 and 32-34 weeks of amenorrhea to continue their pregnancy following antihypertensive treatment. After ultrasound scanning to assess growth and biophysical state of the fetus, patients without deteriorating maternal conditions, were managed with volume expansion, antihypertensive drugs (as hydralazine, labetalol, nifedipine), anticonvulsants and prophylactic steroids to promote fetal pulmonary maturity. Previous studies have indicated that this conservative management is also possible with the HELLP syndrome, without an increase in maternal morbidity.

[Autosomal dominant polycystic kidney. Apropos of 2 cases. Review of the literature]. / Polykystose rénale autosomique dominante et grossesse. A propos de deux cas. Revue de la littérature.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary disease. Genetic molecular methods can make the diagnosis of at least three different types of ADPKD. ADPKD concerns young people and complications such as hypertension and decreased renal function occur more frequently if onset is early, if it is a type 1, and if the patient is a woman. The pregnant woman with autosomal dominant cystic disease is at particular high risk of obstetrical complications. Prenatal diagnosis is possible.

Large-Loop Excision Using a New Probe: Variloop for the Treatment of CIN.

BACKGROUND: Our objective was to evaluate the efficiency of using a diathermic loop with an adjustable diameter (Variloop for the treatment of cervical intraepithelial neoplasia (CIN) in outpatient surgery. MATERIALS AND METHODS: Loop electrosurgical excision was performed on 185 patients, including 21 (11.3%) with low-grade lesions and an endocervical squamocolumnar junction, 44 (23.7%) with CIN2, 118 (63.7%) with CIN3, and 2 (1%) with discrepancies between cytological and histological findings. The procedure was performed in an average of 10 minutes. For 177 patients, local anesthetic was used. In all cases, the specimen was removed in one piece. RESULTS: We observed minimal epithelial distortion with mild coagulation necrosis at the edge of the specimens in 2 of 185 (1%) cases, but this did not interfere with the histological evaluation. Correlation between the biopsy and the conization diagnosis was the best for CIN3, found in 70% of the cases. However, two cases of microinvasion and three cases of adenocarcinoma in situ that were diagnosed were not suspected preoperatively in any of these patients. In 171 of 185 cases (92.4%), there was no endocervical margin involvement. At the 1-year follow-up, two patients had a moderate stenosis with a squamocolumnar junction not visualized, and two others had a severe stenosis with a marked cervical narrowing. CONCLUSIONS: The use of the diathermic loop with adjustable diameter (Variloop) allows efficient treatment of CIN, wherein endocervical development does not exceed 15 mm from the external os without causing significant thermic alterations.

[Hysteroscopic resection of the endometrium: an alternative to hysterectomy?]. / La résection hystéroscopique de l'endomètre: une alternative à l'hystérectomie?

A study carried out on 342 cases of endometrial resection, with a follow up of 3 to 36 months, has allowed us to precise: 1. The indications of this technique: patients more than 40 years, suffering of abnormal uterine bleeding. 2. The endometrial ablation was performed by electrosurgery through an operating channel of the hysteroscopic sheet (9 mm) and with a glycocol distended media (1.5%). The mean time to complete the operation was 35 +/- 10 minutes, the mean length of the hospital stay was 1 day. We had no serious complications. 3. And the rate of success (amenorrhea or hypomenorrhea) was 95% at 3 months but decreased at 90% at 36 months. The rate of secondary hysterectomy was 10%, due to the associated lesions: myoma with adenomyosis in 50% of the cases. There was some evidence of superior health related quality of life among hysterectomy patients. It's the reason why it is necessary to make a serious selection of the patients who are to be treated by this method in order to avoid complications and secondary hysterectomy.