[Impact of infertility and assisted reproductive techniques on sexuality]. / Impact de l'infertilité et de l'Assistance médicale à la procréation sur la sexualité.

OBJECTIVE: We studied the impact of infertility and all the more Assisted Reproductive Techniques on marital relations and sexuality. MATERIAL AND METHOD: Our study is based on a questionnaire distributed in our centre and on a review of literature. RESULTS: Our inquest shows that both partners keep a good relationship in their couple and support each other. But, whereas pleasure during intercourse is little affected, many couples feel a reduction of their desires. DISCUSSION AND CONCLUSION: This diminution of sexual desires, also noted in literature, can be explained by medical requirements intrusive for intimacy and also by strategies settled by the couples themselves during intercourse in order to optimise the chance of pregnancy. Medical staffs should take into consideration eventual sexual difficulties of the couples. Making them aware that their intimate life must remain or become again an end in itself, and not only a way of procreation, often permits a beneficial change of behaviour.

[Embryo donation in France: practice and difficulties. Strasbourg's experience]. / L'accueil d'embryon en France: pratiques et difficultés. L'expérience de Strasbourg.

OBJECTIVE: The aim of this study was to present the situation of embryo donation in France and around the world, to expound the difficulties of its practice and the results obtained in our centre 3 years after the introduction of this procedure. PATIENTS AND METHODS: Embryo donation in France is controlled by implemented decrees published between 1999 and 2004. The couples, who have stored frozen embryos since at least two years, were contacted for a pluridisciplinary medical consultation. The indication of embryo donation was evaluated for the recipients through a pluridisciplinary approach. RESULTS: Among the interviewed couples, 16.7% have chosen embryo donation but only half of them have completed the procedure (6% of the couples with frozen embryos). The main indications for embryo donation were a double sterility, unexplained genetic disease, ART failures (poor fertilization or bad embryo quality) and oocyte donation when the delay was too long for the couples. The pregnancy rate was 28.6% after the 21 first embryo transfers. DISCUSSION AND CONCLUSION: The results of embryo donation confirm the international experience both considering the poor number of donated embryos, medical indications and results. Embryo donation has its place among ART techniques, but one should not ignore the general debate on ethical questions raised by this procedure.

[Abnormal bacterial colonisation of the vagina and implantation during assisted reproduction]. / Colonisation bactérienne vaginale anormale et implantation en assistance médicale à la procréation.

OBJECTIVE: To evaluate the efficiency of our treatment of vaginal infection for couples included in an IVF program. PATIENTS AND METHODS: Microbiologic screening of vaginal flora and semen has been performed one month prior to in vitro fertilization for 951 couples in 2000. Antibiotic treatment was prescribed in case of positive culture. RESULTS: Positive microbial growths were observed from endocervical and vaginal cultures in 218 women (22.9%). The clinical pregnancy rate was 30.29% in the group of patients without growth and 30.27% in the group with positive microbial growth. The implantation rate was significantly diminished in case of bacterial growth: 14.6 compared to 19.3% (P <0.02) for sterile endocervical culture. Five main bacterial species were found at the cervical level: Candida albicans (69 cases), Ureaplasma urealyticum (49 cases), Gardnerella vaginalis (43 cases), Streptococcus B or D (24 cases) and Escherichia coli (22 cases). Positive cultures from both vagina and semen were observed for 77 couples whose clinical pregnancy rate was 19.5 vs 36.2% in case of vaginal infection alone (P <0.01) with a spontaneous miscarriage rate of 46.7 compared to 17.6% (P <0.01). DISCUSSION AND CONCLUSION: Endocervical microorganisms, even treated with adapted antibiotics, may affect embryonic implantation. Positive culture from both female and male partner may enhance this negative effect. In this case, the best strategy would be to cancel the IVF treatment.

[Towards a single embryo transfer: predictive value of uterine and embryological parameters in assisted reproduction outcome]. / Vers un transfert mono-embryonnaire : prise en compte conjointe des paramètres embryonnaires et utérins en assistance médicale à la procréation.

OBJECTIVE: The transfer of a single embryo would avoid obstetrical and neonatal complications due to multiple pregnancies. We studied the clinical value of both uterine and embryological parameters to define precise conditions allowing a single embryo transfer without decreasing pregnancy rates. PATIENTS AND METHODS: Endometrial parameters expressed by a uterine score together with biological criteria of 131 in vitro fertilization or intracytoplasmic sperm injection attempts were retrospectively analysed. RESULTS: Two hundred and sixty-two day-3 embryos were replaced through 131 transfers. Fifty-seven pregnancies were induced and 16 twins were obtained. The clinical pregnancy rate was 35.9% and the embryonic implantation rate 24.0%. After the transfer of two embryos, successful implantation was determined by the occurrence of top-quality embryos and simultaneously by a receptive endometrium. The uterine pulsatility index was significantly decreased for twin compared to singleton pregnancies. DISCUSSION AND CONCLUSION: This study confirms that a uterine score constitutes a powerful tool for evaluating the uterine receptivity. This parameter has to be taken into account as well as the embryonic quality, in order to optimise the success rate. Young patients with at least two top-quality embryos available, a high uterine score and a low pulsatility index, have a high risk of multiple births and are suitable for a single-embryo transfer.

[Fort Lauderdale congress report: advances in infertility treatment - Florida, 24-26 January 2002]. / Compte rendu du congrès de Fort Lauderdale : progrès dans le domaine du traitement de l'infertilité - Floride, 24-26 janvier 2002.

The goal of the treatment of infertility is to apply therapeutic techniques to patients in a safe manner and at the same time increase the chances for conceiving and delivering healthy babies: basic and clinical research is more and more finalized directed to these goals. The conference "Advances in Infertility Treatment" held in Fort Lauderdale, Florida on January 24-26, 2002 covered many clinical and research aspects of this important therapeutic area. Important discussed issues included the impact of age, lifestyle, and the genetic set-up of patients in the pathogenesis and development of infertility-causing disorders such as male reproductive dysfunction, polycystic ovary syndrome, and ovarian failure. New ovulation induction regimens that may optimize, reduce complications, and lower costs of ovarian stimulation procedures and of assisted reproduction in general were presented. This was the 5th Ferring Pharmaceuticals Conference in the area of reproductive medicine held in Florida.

[Evolution of homocysteine during ovarian stimulation for IVF or ICSI]. / Evolution de l'homocystéine lors d'un cycle d'induction ovarienne pour FIV ou ICSI.

OBJECTIVE: To determine the homocysteine evolution during ovarian stimulation in IVF or ICSI protocols and in, a second time, to evaluate the role of hyperhomocysteine as thrombotic risk factor for the treated patients. MATERIAL AND METHODS: Plasma homocysteine was determined three times for each of 31 women included in an IVF/ICSI program. Dosages were realised before stimulation, after gonadotrophin-releasing hormone agonist treatment (GnRH) and on the day of hCG injection. Vitamin B12 and folates were determined before stimulation. In case of hyperhomocysteinemia, a research of APCR (Activated Protein C Resistance) was realised. RESULTS: Five hyperhomocysteinemia cases were discovered (16.12% of studied population). APCR was found in a patient with hyperhomocysteinemia (14 mumol/L, before stimulation). Molecular biology has confirmed an heterozygous mutation of factor V Leiden. During the ovarian stimulation the evolution of homocysteine was independent of the 17 beta oestradiol evolution. CONCLUSION: The prevalence of hyperhomocysteinemia was not significative according to the limited size of the studied population. The increase of oestradiol during induction protocols is unrelated to the homocysteine level. This work must be continued with largest population to have better knowledge of the prevalence of hyperhomocysteinemia among women included in ovarian stimulation protocols.

Allele-specific amplification for preimplantation genetic diagnosis (PGD) of spinal muscular atrophy.

We have developed a new allele-specific amplification method for the preimplantation genetic diagnosis (PGD) of spinal muscular atrophy (SMA; Werdnig-Hoffmann disease) from a single cell. This method is based on the detection of the deletion of exon 7 of the telomeric copy of the survival motor neurone (SMN(t)) gene. An oligonucleotide was designed to be specific to the SMN(t) nucleotidic sequence with exonic mismatch G (for SMN(t))-->A (for SMN(c)) at its 3' end. This test produces reliable PCR products in 95% of single lymphoblasts (85/88) tested as well as in 16/16 blastomeres from normal controls. Specificity analysis showed that we were able to detect homozygous deletion of the SMN(t) gene in 99% of single lymphoblasts (103/104) from a SMA patient. No contamination was detected in 68 blanks tested. Multiple cell and DNA dilution analysis revealed that the test is accurate and specific up to 100 pg DNA and should thus also be suitable for PGD at the blastocyst stage. This rapid procedure requires a single round of fluorescent PCR and no restriction digestion, while previously described single cell methods include nested PCR followed by restriction enzyme digestion. Two PGD cycles for SMA using this procedure were performed in our centre.

Zygote evaluation: an efficient tool for embryo selection.

One of the main problems concerning IVF units is the need to decrease the occurrence of multiple pregnancies in their practice without affecting the overall success rate. Different embryological parameters concerning every step of the early embryo development are known to have some predictive value for implantation potential. In this prospective study, a pronuclear scoring system was used to classify zygotes into six patterns from 0 to 5. Cleaved, day 3 embryos developed from pattern 0 zygotes, which was described as the normal pattern, were transferred when available. For each zygote pattern, the subsequent embryological development was analysed. Pattern 0 zygotes led to significantly more 'good quality' embryos with higher implantation potential than embryos developing from the other zygote patterns (P < 0.01). Embryo transfers including at least one pattern 0 resulted in significantly more pregnancies than transfers without any pattern 0 zygotes (39.3 versus 19.7%, P < 0. 01). No relationship between clinical parameters (age of female partner, infertility cause) and zygote pattern distribution was demonstrated.

[Isolated and recurrent hydrothorax during ovarian stimulation]. / Hydrothorax isolé et récidivant au décours de stimulations ovariennes.

Acute, insulated hydrothorax can be observed after ovulation induction without other signs of hyperstimulation. Usually, it is unilateral, localized on the right side and associated with ongoing pregnancy. We regularly noted a good outcome although the pathogenesis of this affection is still enigmatic. It may recur in the case of a new ovarian stimulation.

A quantitative and morphological analysis of oocytes collected during 438 IVF cycles.

PURPOSE: Our purpose was to determine if the number of retrieved oocytes, oocyte maturity, morphology, and other embryological parameters are related to the outcome of treatment. METHODS: This retrospective study on 438 IVF cycles analyzes the numbers of retrieved oocytes, fractured zona oocytes, germinal vesical-stage oocytes, normally and abnormally fertilized oocytes, pregnancy rate, age of female partner, ovarian stimulation protocol, day of hCG injection, and serum estradiol concentration. RESULTS: (1) Pregnancy rate increases with an increase in the number of retrieved oocytes, (2) a high incidence of fractured zona pellucida oocytes has a negative effect on fertilization rate but none on pregnancy rate, (3) a high incidence of immature oocytes is associated with improved fertilization and pregnancy rates, and (4) an inverse relationship between the presence of immature oocytes and oocytes with fractured zona pellucida is suggested. CONCLUSIONS: Precise oocyte assessment in IVF cycles provides informations useful for the analysis and improvement of ovarian stimulation protocols.

[Future perspectives: oocyte cryopreservation and in vitro maturation]. / Perspectives d'avenir: la congélation et la maturation in vitro des ovocytes.

After treatment for neoplasia, a young patient can nowadays hope to be pregnant. The aim of this paper is to establish a review of the literature about cryopreservation of oocytes and ovarian tissue, and in vitro maturation of oocytes. These studies also concern patients for which ovarian stimulation is difficult, such as PCOS. These techniques could also facilitate the creation of an oocyte bank as the one already existing for sperm. So far the main studies published, in spite of very timid first results, allow us to look to a great future for cryopreservation and in vitro maturation of oocytes.

Does body mass index of infertile women have an impact on IVF procedure and outcome?

PURPOSE: The objective was to explore whether body mass index (BMI) of women related to the different parameters of the in vitro fertilization (IVF) procedure and outcome. METHODS: This retrospective study on 398 couples analyzed epidemiological features, characteristics of ovarian stimulation, number and quality of retrieved oocytes, as well as pregnancy outcome according to three groups of BMI values: BMI < 20, 20 < or = BMI < 25 and BMI > or = 25 kg/m2. RESULTS: The prevalence of underweight and overweight women was 21.8% and 22.3%, respectively. The mean ratio follicle-stimulating hormone-luteinizing hormone increased significantly according to BMI. An increase in the mean number of consummated gonadotropin ampoules together with a decrease in the number of collected oocytes was observed in long stimulating protocol cycles when BMI > or = 25 kg/m2. The same observations were made in short stimulation protocol cycles of BMI < 20 and > or = 25 kg/m2. No significant difference could be found in clinical pregnancy and miscarriage rates between underweight, normal weight, and overweight patients. CONCLUSIONS: Both underweight and overweight have negative effects on IVF parameters and outcome leading to decreased chances of pregnancy.

[Therapeutic strategies in azoospermia: management]. / Stratégie thérapeutique dans les azoospermies: mise au point.

ICSI allows use of epididymal or testicular sperm in case of azoospermia. The aim of this study is to propose an algorithm for the management of the different situations of azoospermia according to our personal experience and according to data of literature. The following points are discussed: epididymal or testicular origin of sperm, retrieval technique, contribution of freezing, interest of in vitro culture, side effects and need of a preliminary biopsy. So a therapeutic strategy adapted to both types of azoospermia obstructive and non obstructive can be proposed.

Hysteroscopic metroplasty in diethylstilboestrol-exposed and hypoplastic uterus: a report on 24 cases.

The aim of this study was to determine the feasibility and safety of hysteroscopic metroplasty in cases of diethylstilboestrol-exposed and hypoplastic malformed uterus. Twenty-four patients were referred for primary infertility (n = 9), secondary infertility (n = 1) or infecundity (n = 14). Fifteen had been exposed to diethylstilboestrol in utero. All patients had a hypoplastic uterus and/or uterine deformity as seen by hysterosalpingography and each served as their own control. All patients underwent hysteroscopic metroplasty. Outcome measures included postoperative hysterosalpingography and the ability to conceive and to carry pregnancy to live birth. Postoperative hysterosalpingograms revealed improvement in 23 cases; the final result was considered excellent in 15 cases and 11 pregnancies occurred. The abortion rate decreased from 88% in previous pregnancies to 12.5%, and the rate of term deliveries increased from 3% to 87.5%. Ten patients were delivered after 30 weeks' gestation of healthy infants and one delivered more prematurely. Six deliveries were normal and four required a Caesarean section. We conclude that hysteroscopic metroplasty gives good results. This technique can be used in women with diethylstilboestrol-exposed or hypoplastic malformed uterus, suffering from severe infertility, recurrent pregnancy loss or implantation failures in an in-vitro fertilization programme.

[When the needle replaces the knife: first pregnancies obtained after percutaneous testicular aspiration and intracytoplasmic sperm injection]. / Quand l'aiguille remplace le bistouri: premières grossesses obtenues après ponction testiculaire transcutanée et injection intracytoplasmique d'un spermatozoïde.

Percutaneous testicular sperm aspiration and ICSI were performed in 5 cases of excretory azoospermia. Usable sperm have always been obtained, two pregnancies were initiated.

[Transcervical hysteroplasty: indications, techniques and results. 125 cases]. / Hystéroplasties transcervicales: indications, techniques et résultats. A propos de 125 cas.

Indications of transcervical metroplasty are uterine septa, synechia, DES-exposed and hypoplastic malformed uterus. These operative procedures give good anatomic and functional results. The pregnancies obtained must be considered as high risk.

Could in vitro fertilization with a modified sperm preparation technique be an option to micromanipulations?

PURPOSE: This study evaluated the efficiency of in vitro fertilization with a modified sperm preparation technique for male infertility, to avoid systematic recourse to ICSI. METHODS: The sperm function stimulants pentoxifylline, 2-deoxyadenosine, and follicular fluid were used during the sperm preparation of IVF trials for two groups of patients: couples with long-standing infertility and previous IVF failures and couples with male-factor infertility scheduled for their first treatment. RESULTS: Forty-nine attempts were performed in the first group. The overall fertilization rate (percentage of zygotes with two pronuclei 18 hr after sperm insemination) was 30% and the clinical pregnancy rate per transfer was 33%. For the second group, 30 attempts were performed. The fertilization rate was 29.6% and the clinical pregnancy rate was 62.5% per transfer. The total number of recovered motile sperm appears to be a significant parameter: a cutoff value of 0.25 million motile sperm recovered after capacitation treatment has a good prognostic value for choosing between IVF with sperm enhancers and ICSI. CONCLUSIONS: The described modified IVF could constitute an alternative to the systematic use of ICSI.

Ultrasound-guided transcervical resection of uterine septa: 7 years' experience.

This study evaluates the performance in our center of Querleu's transcervical resection of uterine septa. The procedure uses cold scissors under ultrasonographic guidance. Ninety-three patients were treated during a 7-year period. Follow-up examination in patients having an obstetric history prior to resection, excluding those suffering from infertility, showed a decrease in premature deliveries (9.4% vs. 13%) and miscarriages (24.5% vs. 78%), and a dramatic increase in term deliveries (62.3% vs. 5.7%). The anatomical and functional results, as well as the complication rate, were similar to those observed following hysteroscopic metroplasty. The advantages of an ultrasound-guided approach are the easy estimation of fundus thickness, the potential of resection regardless of the stage of the menstrual cycle and avoidance of costly equipment. For these reasons we have adopted it as our standard procedure.