Intracytoplasmic sperm injection in infertile patients with structural chromosome abnormalities.

In the present study we investigated the results of cytogenetic analysis in male and female patients included in an intracytoplasmic sperm injection (ICSI) programme for severe male infertility as well as in conceptuses resulting from these ICSI treatments. In the 261 couples treated, 11 male (4.2%) and three female (1.2%) abnormal karyotypes were found, all consisting of structural chromosome anomalies. Chromosomal translocation exhibited the highest frequency (eight males and two females), and there were also three cases of chromosomal inversion (two males and one female) and one male with one additional marker chromosome. There was no difference in fertilization rates among couples with abnormal (n = 14) and normal (n = 147) cytogenetic results, and the rates of clinical pregnancy per ICSI attempt were 25.0% (5/20) and 20.6% (78/ 378) respectively. In pregnancies obtained in couples with normal karyotypes, all of the 108 fetuses were free of chromosomal abnormalities. Among the eight fetuses from couples with chromosome structural anomalies, three out of five and two out of three inherited from the cytogenetic defects found in their father or mother respectively. In this series of 83ICSI pregnancies there were no chromosomal abnormalities other than those inherited from the parents. These findings suggest that normal pregnancy rates can be obtained by ICSI in cases of chromosomal translocation in couples with severe male infertility. However, until further evaluations of available data can be performed, cytogenetic analysis must be conducted prior to ICSI in men with low sperm counts, and genetic counselling must include prenatal diagnosis for all growing conceptuses.

Spermatid injection into human oocytes. II. Clinical application in the treatment of infertility due to non-obstructive azoospermia.

We have reported recently the first birth after intrauterine transfer of embryos obtained by injection of round spermatids into oocytes in cases of unexpected azoospermia. Here we provide a complete documentation of the series of 11 cases in which this novel method of infertility treatment was employed. In four of these cases, elongated spermatids were identified in the ejaculate, and it was decided to perform elongated spermatid injection (ELSI). In the other six cases, only round spermatids were present, and round spermatid injection (ROSI) was done. In one case, ROSI was given preference to ELSI because of a very poor viability status of elongated spermatids present in the ejaculate. Fertilization of at least one oocyte was achieved in 10 of the 11 treatment cycles; the fertilization rate in these 10 cycles ranged between 7 and 100% with a mean value of 45%. All of the two-pronucleated zygotes cleaved and were transferred to the patient's uterus. A singleton pregnancy was achieved in two ROSI cycles. Both pregnancies developed uneventfully and resulted in the birth of normal infants. These data show the intra-ooplasmic injection of spermatids obtained from the ejaculate may become the treatment of first choice in patients with non-obstructive azoospermia.

Retrograde tubal transfer of human embryos.

This preliminary study was designed to evaluate retrograde cannulation of the Fallopian tubes up to the isthmo-interstitial junction using the new technique of tubal embryo stage transfer (TEST). Follicular aspiration was performed under the guidance of a vaginal ultrasound probe in 51 women treated with GnRH + HMG. The oocytes retrieved were inseminated in vitro with 50,000 motile spermatozoa and kept in Menezo B2 medium without serum, at 37 degrees C, in an atmosphere of air + 5% CO2. The eggs were checked 24 and 36 h after insemination. No fertilization occurred in 23 patients. Cleaved embryos were obtained in the 28 other patients. One to seven embryos at the 2-4-cell stage were transferred with the 'Baudelocque Black Catheter' (BBC) into one tube and spare embryos were frozen. Five pregnancies occurred after retrograde TEST, for a pregnancy rate of 9.8% per cycle and 17.9% per transfer. One patient has given birth to a normal full-term baby. One singleton and one twin pregnancy are ongoing (8 months in June 1989). The other two pregnancies were ectopic.

Ovarian programming and GIFT.

The procedures used for programming and ovarian stimulation in GIFT are identical to those used for in-vitro fertilization. At the Baudelocque Hospital, the hypophyseal gonadal axis is suppressed by administering a gonadotrophin-releasing hormone analogue (Decapeptyl, D-Trp-6-LHRH). Programming for the week of GIFT is then possible by controlling three stages: the beginning of treatment, which is independent of the date of the patient's period, the duration of treatment, which has 5 days' maximum variation, and an end-point of suppressing the spontaneous LH surge.

Ovarian stimulation for in-vitro fertilization combining administration of gonadotrophins and blockade of the pituitary with D-Trp6-LHRH microcapsules: pilot studies with two protocols.

In women undergoing in-vitro fertilization and embryo transfer (IVF-ET), a total of 408 IVF cycles were stimulated using human menopausal gonadotrophin (HMG) or pure follicle stimulating hormone (FSH) plus HMG in combination with a single injection of D-Trp6-LHRH microcapsules in order to enhance the ovarian response to gonadotrophins and to avoid spontaneous LH surges. Sixty-seven pregnancies were achieved. Two protocols were employed. In protocol 1 ('blocking protocol', n = 268), the pituitary was first inhibited with a full dose (3.75 mg) of D-Trp6-LHRH in microcapsules and ovarian stimulation was started after the hypogonadotrophic hypogonadal state was ascertained (E2 less than 50 pg/ml). In protocol 2 ('flare-up protocol', n = 140), the treatment with D-Trp6-LHRH microcapsules (half-dose = 1.80 mg) and the ovarian stimulation with gonadotrophins were started at the same time. Higher doses of gonadotrophins were needed (39.5 +/- 11.2 ampoules FSH and/or HMG) in protocol 1, in which the pituitary was blocked prior to and during the stimulation, than in protocol 2 (20 +/- 9 ampoules) where the exogenous gonadotrophin stimulation appeared to be augmented by the initial agonistic effect of the injection of D-Trp6-LHRH microcapsules. In patients with purely tubal infertility, under 38 years old and no male factor, the results obtained with protocols 1 and 2 were similar in terms of pregnancy rate per cycle or per embryo transfer: 22.6 versus 20.5% and 28.3 versus 27.4%, respectively. However, considering the cost benefit, 'flare-up' protocols appeared to be a better choice and could be recommended.

[Preventive treatment of lymphoceles after enlarged lymphadeno-colpohysterectomy: non-reperitonization with epiplooplasty]. / Un traitement préventif des lymphocèles après lymphadéno-colpo-hystérectomie élargie (L.C.H.E.): la non repéritonisation avec épiplooplastie.

Pelvic lymphadenectomy for genital cancer can lead to numerous complications, particularly lymphoceles. Two types of drainage were compared in a series of 86 patients treated by enlarged lymphadeno-colpohysterectomy. In the first group (n = 66), hermetic peritonization with aspiration drainage was performed and in the second group (n = 20), non-peritonization combined with omentoplasty was practiced. Lymphoceles developed in 23% of patients in group I, requiring 7.7% of recovery operations (5 cases). Lymphoceles did not occur in group 2. Qualities of reabsorption of peritoneum and omentum are discussed. Their combined use to avoid lymphocele complications is of benefit, particularly in patients receiving preoperative pelvic radiotherapy.

[Results of the treatment and prevention of urinary stress incontinence by Bologna's operation in prolapse with voluminous cystoceles]. / Résultats de la cure et de la prévention de l'incontinence urinaire d'effort par l'intervention de Bologna dans les prolapsus avec volumineuse cystocèle.

Bologna's operation to relieve stress incontinence in patients with large cystoceles uses two vaginal strips to form a subcervical sling. Of 60 patients treated in this way, urodynamic exploration was performed preoperatively in 83% and postoperatively in 50%, while 42% underwent lateral retention and pressure cystography. All patients presented at least a stage II cystocele and hysteroptosis, 47% a patent and 93% a potential stress incontinence and 40% a sphincter incompetence. Anatomic results were excellent: 77% of total relief and 23% improvement in the cystoceles. Of greatest interest was efficacy against urinary incontinence: all patent stress incontinences were cured; none occurred after correction of cystocele, and only two cases of potential incontinence due to anatomic failure were observed. These good clinical results could be correlated with postoperative urodynamic exploration findings: the lack of persistent dysuria was related to the correction or even hypercorrection of the transmission anomaly without alteration of sphincter function. Paradoxically, images of pressure cystography showed elevation of the bladder neck in relation to symphysis pubis to be limited in extent. In 26% of cases the neck was in fact below this limit. These findings raise the question of the mechanism of re-establishment of pressure transmission. Because of the simplicity of technic of Bologna's operation, its low morbidity and it very great reliability with respect to urinary results, this method is now practised routinely in cases of prolapse with marked cystocele and patent or potential stress incontinence, even in the presence of major sphincter incompetence.