[Infertility over forty: Pros and cons of IVF]. / Prendre en charge les femmes de 40ans et plus en FIV : pour ou contre ou pour et contre ?

The population attempting pregnancy and having babies is ageing. The declining fertility potential and the late age of motherhood are increasing significantly the number of patients over forty consulting infertility specialists. Assisted reproductive technologies (ART) cannot compensate the natural decline in fertility with age. In France, in public hospital, ART is free of charge for women until 43 years, over 43, social insurance does not reimburse ART. Hence, 43 years is the usual limit, but between 40 and 42 is ART useful? The answer varies according to physicians, couples or society. On medical level, the etiology of the infertility must be taken into account. If there is an explanation to infertility (male or tubal infertility) ART is better than abstention. If the infertility is only due to age the question is raised. In France, the reimbursement by the society of a technique with very low results is discussed. However efficacy is not absolutely compulsory in Medicine. On the opposite to give false hopes may be discussed too. To obtain a reasonable consensus is rather difficult.

[Social egg freezing: which problems?]. / Conservation ovocytaire, quelle problématique ?

In today's society, many women push pregnancy further away from the "right" childbearing age. Assisted reproduction, except egg donation, is unable to fully overcome the effect of age on fertility loss. The effectiveness of oocyte vitrification is demonstrated, and oocyte vitrification is allowed in the French Bioethics law of 2011. In the French law, oocyte' s cryopreservation is proposed to oocyte donors without child. Social egg freezing for non-medical reason is already legal in some countries, but leads to new debates and discussions.

[Is it possible to avoid working on weekends in an Assisted Reproductive Technology program?]. / Peut-on éviter le travail du week-end en Assistance Médicale à la Procréation ?

Is it possible to safely avoid weekend oocyte retrievals and embryo transfers? It is possible to safely avoid Sunday oocyte retrieval and embryo transfers during GnRH agonist or antagonist cycles, to avoid oocyte retrievals 2 days seem also possible by delaying or advancing hCG administration in both analogs cycles but it is more difficult to avoid embryo transfers during two days. In intra uterine insemination programs, it is possible to avoid ovulation monitoring and inseminations by the use of GnRH antagonists. In IVF programs, ovulation monitoring could be avoid on weekends but the risk of ovarian hyperstimulation would exists in case of polycystic ovary or polycystic like ovary.

[Endometrial preparation in oocyte recipients]. / Préparation endométriale chez les receveuses dans un programme de don d'ovocytes.

Oocyte donation is offered to patients with premature ovarian failure to achieve pregnancy when no other assisted reproductive technology is possible. Some clinical and biological factors have been identified for influencing the outcome of oocyte donation cycles. Embryo implantation depends on embryo quality, method for the embryo transfer, and endometrial differentiation. In our center, the oocyte recipients receive for the endometrial preparatory cycle the same treatment that for the patients undergoing frozen embryos transfers, with good clinical pregnancy rates, about 35% per transfer. Estrogen and progesterone supplementation with GnRH agonist down regulation are used in synchronized protocols or for frozen embryos transfers. The synchronization between recipient's endometrium and donor's ovarian stimulation is very restrictive. Nowadays, the oocytes vitrification lithens the oocyte donation process: the endometrial preparation has a limited duration and is well controlled, and embryos that are transferred are all fresh embryos.

[In Vitro Fertilization: beware of oocyte retrieval without oocyte!]. / Fécondation in vitro : ponction blanche : méfions-nous !

A 30-year-old woman undergoing an In Vitro Fertilization (IVF) treatment for tubal infertility and for whom no oocyte was retrieved at the puncture ("white puncture") presented an ectopic pregnancy. The patient was asymptomatic except some bleeding events reported for several days prior to the puncture. The ovulation monitoring was normal throughout the stimulation by gonadotrophin and hCG was administered for the final oocyte maturation on the twelfth day of stimulation at a rate of 2771 pg/ml of estradiol with a perfect ultrasound follicular growth. This case demonstrates that we have to beware of a "white puncture" and that the hCG measurement the day of the oocyte retrieval is necessary because of the possibility of an ectopic pregnancy.

[Single embryo transfer: is Scandinavian model valuable in France?]. / Faut-il systématiser le transfert de l'embryon unique ? Le modèle scandinave est-il applicable en France ?

The aim of infertility treatment is clearly to obtain one healthy baby. If the transfer of a top quality single embryo could provide a baby to all the patients, there would be no more discussion. The problem is that, nowadays, French pregnancy rates after fresh embryo or frozen embryo transfer are not the same as in Nordic countries. All studies show that in unselected patients, single embryo transfer decreases twin pregnancy rate but decreases pregnancy rate too. Pregnancy rate is dependent on embryo quality, women's age, rank of IVF attempt (clear data) but also on body mass index, ovarian reserve, smoking habits. All these data cannot be taken into account in a law. That is the reason why a flexible policy of transfer adapted to each couple is preferable. Each couple and each IVF team are unique and must keep the freedom to choose how many embryos must be transferred to obtain healthy babies, and to avoid twin pregnancies but without demonizing them.

[A study comparing previous induced abortion rates in populations of newly delivered women and infertile women]. / Etude comparative sur les antécédents d'interruption volontaire de grossesse dans une population de femmes infertiles et dans une population de femmes accouchées.

OBJECTIVE: For years, induced abortions (IA) have been deemed responsible for altered fertility. The implication of various mechanisms including tubal infertility, intra-uterine adhesions, spontaneous abortion, ectopic pregnancy, cervical incompetence, shortened gestations, and any psychological trouble leading to anovulation has been raised. Though many authors find no evidence of an increased risk on fertility for women, whose IA is not complicated by infection, it might sometimes be insinuated that infertility is the consequence of previous abortion. Thus, we compared the rate of patients with any prior IA in a population of newly delivered women and in women ongoing IVF. PATIENTS AND METHODS: A retrospective study was conducted at Sèvres hospital, comparing two populations of women, newly delivered women (n=1738) between January 1st and December 31st 2005, and women ongoing IVF at the same period (n=430). We reported the number of previous medical or surgical induced abortions and compared it in both groups. Another analysis compared these rates, among two subgroups of women with one or more prior pregnancy (secondary infertility (n=148), and secondary gestation (n=1088). RESULTS: The rate of prior IA was not different in the two populations. In the IVF group, 13% (n=56) had undergone one or more IA, versus 16.7% (n=291) in the newly delivered group (P=0.06). Among women with previous pregnancy, 37.8% (56) women of the IVF group had undergone one or more previous IA, versus 26.7% (291) of the newly delivered women (P=0.007). DISCUSSION AND CONCLUSION: As expected by literature data on IA and fertility, rates of prior induced abortions were not different in the population of fertile women versus infertile. However, women with one or more previous pregnancy are more likely to have undergone previous IA in the IVF group than in the newly delivered group, possibly due to a bias of age. More data are requested to eliminate linkage between IA and infertility.

[Intra-uterine insemination: ovarian stimulation or not?]. / Insémination intra-utérine: pourquoi continuer à stimuler l'ovulation?

Conflicting results have been published about intra-uterine insemination efficacy. In many studies, success rates is due to ovarian stimulation and number of follicles. In the present fight against multiple pregnancies, ovarian stimulation is discussed and present pregnancy rates are weak. Our aim is to demonstrate that there is a place for the association controlled ovarian hyperstimulation and intra-uterine insemination in the field of infertility treatments. It is possible to try and recognise women at high risk of multiple pregnancies, keeping the benefit of ovarian stimulation.

Detection of Toxoplasma gondii in 94 placentae from infected women by polymerase chain reaction, in vivo, and in vitro cultures.

The biological diagnosis of congenital toxoplasmosis at birth is important to determine the infant's treatment. The aim of this study was to evaluate the placenta results in the congenital toxoplasmosis diagnosis and to compare them with those obtained with other samples collected at birth (cord blood and newborn blood). A total of 94 placentas, of which 33 came from fetuses suspected of or with proven congenital toxoplasmosis (CT+) and 61 from definitely or probably non-infected fetuses (CT-), was analysed by in vitro culture, mouse inoculation and polymerase chain reaction (PCR). The PCR sensitivity was higher (60.9 per cent) than that of cell culture (29.6 per cent) and mouse inoculation (51.5 per cent) but the number of PCR positive results in CT - patients was also higher (9.5 per cent). The presence of Toxoplasma gondii in the placenta tissues was the only argument at birth (IgM and neosynthesized Ig were negative) in three out of the 33 CT+ cases. The detection of IgM by ELISA and ISAGA and the detection of neosynthesized Ig by immunoblotting were more satisfactory to diagnose congenital toxoplasmosis but the placenta analysis was important to improve the sensitivity of the diagnosis at birth, especially when the prenatal diagnosis was negative or not performed.

Infertility evaluation in fertile women: a model for assessing the efficacy of infertility testing.

A standard infertility evaluation consists of a semen analysis, hysterosalpingogram, post-coital test, endometrial biopsy and laparoscopy. Although these tests are well grounded in clinical experience, information on their ability to discriminate between fertile and infertile couples is limited. In this study, we performed standard infertility tests plus two others--sperm antibodies and cervical culture for Mycoplasma hominis and Ureaplasma urealyticum--on fertile and infertile couples. Women in the fertile group were selected from those who had delivered a child within the previous 2 years and who were scheduled for a laparoscopic tubal ligation. Women in the infertile group were selected from those presenting for an infertility evaluation (mean duration of infertility 4.2 years), and they were matched by age (+/- 3 years) and race with fertile subjects. Subjects were recruited from both private and clinic patients. A total of 64 couples (32 matched pairs) completed the evaluation. At least one 'abnormal' infertility test was found in 69% of fertile and 84% of infertile couples. With the exception of tubal damage and endometriosis, which as expected were more common in infertile couples, no significant differences between groups for remaining infertility factors could be demonstrated. Despite the small size of the current study, these results confirm the feasibility and importance of comparisons of the prevalence of infertility factors in fertile and infertile couples.

[Outcome of 470 pregnancies after artificial insemination with frozen sperm]. / Devenir de 470 grossesses obtenues après insémination artificielle avec sperme congelé de donneur.

UNLABELLED: This article describes the outcome of the pregnancies conceived after AID with frozen semen in the Tours CECOS Centre between January 1st 1988 and December 31st 1986. There were 487 (including multiple pregnancies). These have been compared with a control group and with the national study conducted by INSERM in 1981. The study of the literature allows comparisons. The rate of pregnancies not resulting in a living child is not significantly different from the control series (abortions 11.4%, ectopic pregnancies 1% and in utero fetal deaths 0.4%). Pregnancies that continued: the rate of multiple pregnancies was higher (2.7%). There were more cases of bleeding (6.8% compared with 2.4%), more hypertensions (13.3% compared with 11.6%) and the same rate of premature labour (9.4%) as in the control group. The Caesarean section rate (22% as against 6%) was higher. The rate of forcepts delivery was lower (9.2% as against 12.8%). Concerning the children we found more premature babies (15.8% versus 5.6%) but no difference in the sex ratio, their height-weight as against their term, their Apgar score, morbidity or number or type of malformations (3.4%). IN CONCLUSION: the quality of the children is about the same with the proviso that the group is too small to conclude about the incidence of chromosomal abnormalities.