Intra-individual variability of serum progesterone levels on the day of frozen blastocyst transfer in hormonal replacement therapy cycles

STUDY QUESTION

Is there a significant intra-individual variability of serum progesterone levels on the day of single blastocyst Hormone Replacement Therapy-Frozen Embryo Transfer (HRT-FET) between two consecutive cycles?

SUMMARY ANSWER

No significant intra-individual variability of serum progesterone (P) levels was noted between two consecutive HRT-FET cycles.

WHAT IS KNOWN ALREADY

In HRT-FET cycles, a minimum P level on the day of embryo transfer is necessary to optimise reproductive outcomes. In a previous study by our team, a threshold of 9.8 ng/ml serum P was identified as significantly associated with the live birth rates in single autologous blastocyst transfers under HRT using micronized vaginal progesterone (MVP). Such patients may benefit from an intensive luteal phase support (LPS) using other routes of P administration in addition to MVP. A crucial question in the way towards individualising LPS is whether serum P measurements are reproducible for a given patient in consecutive HRT-FET cycles, using the same LPS.

STUDY DESIGN, SIZE, DURATION

We conducted an observational cohort study at the university-based reproductive medicine centre of our institution focusing on women who underwent at least two consecutive single autologous blastocyst HRT-FET cycles between January 2019 and March 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients undergoing two consecutive single autologous blastocyst HRT-FET cycles using exogenous oestradiol and vaginal micronized progesterone for endometrial preparation were included. Serum progesterone levels were measured on the morning of the Frozen Embryo Transfer (FET), by a single laboratory. The two measurements of progesterone levels performed on the day of the first (FET1) and the second FET (FET2) were compared to evaluate the intra-individual variability of serum P levels. Paired statistical analyses were performed, as appropriate.

MAIN RESULTS AND THE ROLE OF CHANCE

Two hundred and sixty-four patients undergoing two consecutive single autologous blastocyst HRT-FET were included. The mean age of the included women was 35.0 ± 4.2 years. No significant intra-individual variability was observed between FET1 and FET2 (mean progesterone level after FET1: 13.4 ± 5.1 ng/ml vs after FET2: 13.9 ± 5.0; P = 0.08). The characteristics of the embryo transfers were similar between the first and the second FET. Forty-nine patients (18.6%) had discordant progesterone levels (defined as one progesterone measurement > and one ≤ to the threshold of 9.8 ng/ml) between FET1 and FET2. There were 37/264 women (14.0%) who had high intra-individual variability (defined as a difference in serum progesterone values >75th percentile (6.0 ng/ml)) between FET1 and FET2. No specific clinical parameter was associated with a high intra-individual variability nor a discordant P measurement.

LIMITATIONS, REASONS FOR CAUTION

This study is limited by its retrospective design. Moreover, only women undergoing autologous blastocyst HRT-FET with MVP were included, thereby limiting the extrapolation of the study findings to other routes of P administration and other kinds of endometrial preparation for FET.

WIDER IMPLICATIONS OF THE FINDINGS

No significant intra-individual variability was noted. The serum progesterone level appeared to be reproducible in >80% of cases. These findings suggest that the serum progesterone level measured on the day of the first transfer can be used to individualize luteal phase support in subsequent cycles.

STUDY FUNDING/COMPETING INTEREST(S)

No funding or competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Endometriosis-related infertility: severe pain symptoms do not impact assisted reproductive technology outcomes

STUDY QUESTION

Do severe endometriosis-related painful symptoms impact ART live birth rates?

SUMMARY ANSWER

Severe pain symptoms are not associated with reduced ART live birth rates in endometriosis patients.

WHAT IS KNOWN ALREADY

ART is currently recognized as one of the main therapeutic options to manage endometriosis-related infertility. Presently, no data exist in the literature regarding the association between the core symptom of the disease, e.g. pain and ART reproductive outcomes.

STUDY DESIGN, SIZE, DURATION

Observational cohort study of 354 endometriosis patients, who underwent ART at a tertiary care university hospital, between October 2014 and October 2021. Diagnosis of endometriosis was based on published imaging criteria using transvaginal sonography and magnetic resonance imaging, and histologically confirmed in women who had a previous history of endometriosis surgery (n = 127, 35.9%).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The intensity of painful symptoms related to dysmenorrhea (DM), dyspareunia (DP), noncyclic chronic pelvic pain, gastrointestinal (GI) pain, or lower urinary tract pain was evaluated using a 10-point visual analog scale (VAS), before ART. Severe pain was defined as having a VAS of 7 or higher for at least one symptom. The main outcome measure was the cumulative live birth rate (CLBR) per patient. We analyzed the impact of endometriosis-related painful symptoms on ART live births using univariable and multivariate analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Three hundred and fifty-four endometriosis patients underwent 711 ART cycles. The mean age of the population was 33.8 ± 3.7 years, and the mean duration of infertility was 3.6 ± 2.1 years. The distribution of the endometriosis phenotypes was 3.1% superficial endometriosis, 8.2% ovarian endometrioma, and 88.7% deep infiltrating endometriosis. The mean VAS scores for DM, DP, and GI pain symptoms were 6.6 ± 2.7, 3.4 ± 3.1, and 3.1 ± 3.6, respectively. Two hundred and forty-two patients (68.4%) had severe pain symptoms. The CLBR per patient was 63.8% (226/354). Neither the mean VAS scores for the various painful symptoms nor the proportion of patients displaying severe pain differed significantly between patients who had a live birth and those who had not, based on univariate and multivariate analyses (P = 0.229). The only significant factors associated with negative ART live births were age >35 years (P < 0.001) and anti-Müllerian hormone levels <1.2 ng/ml (P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

The diagnosis of endometriosis was based on imaging rather than surgery. This limitation is, however, inherent to the design of most studies on endometriosis patients reverting to ART first.

WIDER IMPLICATIONS OF THE FINDINGS

Rather than considering a single argument such as pain, the decision-making process for choosing between ART and surgery in infertile endometriosis patients should be based on a multitude of aspects, including the patient's choice, the associated infertility factors, the endometriosis phenotypes, and the efficiency of medical therapies in regard to pain symptoms, through an individualized approach guided by a multidisciplinary team of experts.

STUDY FUNDING/COMPETING INTEREST(S)

No funding; no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Clinical factors associated with low serum progesterone levels on the day of frozen blastocyst transfer in hormonal replacement therapy cycles

STUDY QUESTION

Which factors are associated with low serum progesterone (P) levels on the day of frozen embryo transfer (FET), in HRT cycles?

SUMMARY ANSWER

BMI, parity and non-European geographic origin are factors associated with low serum P levels on the day of FET in HRT cycles.

WHAT IS KNOWN ALREADY

The detrimental impact of low serum P concentrations on HRT-FET outcomes is commonly recognized. However, the factors accounting for P level disparities among patients receiving the same luteal phase support treatment remain to be elucidated, to help clinicians predicting which subgroups of patients would benefit from a tailored P supplementation.

STUDY DESIGN, SIZE, DURATION

Observational cohort study with 915 patients undergoing HRT-FET at a tertiary care university hospital, between January 2019 and March 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients undergoing single autologous blastocyst FET under HRT using exogenous estradiol and vaginal micronized progesterone for endometrial preparation. Women were only included once during the study period. The serum progesterone level was measured in the morning of the FET, in a single laboratory. Independent factors associated with low serum P levels (defined as ≤9.8 ng/ml, according to a previous published study) were analyzed using univariate and multivariate logistic regression models.

MAIN RESULTS AND THE ROLE OF CHANCE

Two hundred and twenty-six patients (24.7%) had a low serum P level, on the day of the FET. Patients with a serum P level ≤9.8 ng/ml had a lower live birth rate (26.1% vs 33.2%, P = 0.045) and a higher rate of early miscarriage (35.2% vs 21.5%, P = 0.008). Univariate analysis showed that BMI (P < 0.001), parity (P = 0.001), non-European geographic origin (P = 0.001), the duration of infertility (P = 0.018) and the use of oral estradiol for endometrial preparation (P = 0.009) were significantly associated with low serum P levels. Moreover, the proportion of active smokers was significantly lower in the 'low P concentrations' group (P = 0.002). After multivariate analysis, BMI (odds ratio (OR) 1.06 95% CI (1.02-1.11), P = 0.002), parity (OR 1.32 95% CI (1.04-1.66), P = 0.022), non-European geographic origin (OR 1.70 95% CI (1.21-2.39), P = 0.002) and active smoking (OR 0.43 95% CI (0.22-0.87), P = 0.018) remained independent factors associated with serum P levels ≤9.8 ng/ml.

LIMITATIONS, REASONS FOR CAUTION

The main limitation of this study is its observational design, leading to a risk of selection and confusion bias that cannot be ruled out, although a multivariable analysis was performed to minimize this.

WIDER IMPLICATIONS OF THE FINDINGS

Extrapolation of our results to other laboratories, or other routes and/or doses of administering progesterone also needs to be validated. There is urgent need for future research on clinical factors affecting P concentrations and the underlying pathophysiological mechanisms, to help clinicians in predicting which subgroups of patients would benefit from individualized luteal phase support.

STUDY FUNDING/COMPETING INTEREST(S)

No funding/no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

O-245 Clinical factors associated with low serum progesterone on the day of frozen blastocyst transfer in hormonal replacement therapy cycles

Study question

Which factors are associated with low serum progesterone (P) levels on the day of frozen embryo transfer (FET), in hormonal replacement therapy (HRT) cycles?

Summary answer

Body Mass Index (BMI), parity, and non-European geographic origin are factors associated with low serum P levels on the day of FET in HRT cycles.

What is known already

While the detrimental impact of low serum P concentrations on HRT-FET outcomes is unanimously recognized, the factors accounting for P levels disparities among patients receiving the same luteal phase support treatment remain to be elucidated, in order to help clinicians predicting which subgroups of patients would benefit from a tailored P supplementation.

Study design, size, duration

Observational cohort study with 915 patients undergoing HRT-FET at a tertiary care university hospital, between January 2019 and March 2020.

Participants/materials, setting, methods

Patients undergoing single autologous blastocyst FET under HRT using exogenous estradiol and vaginal micronized progesterone for endometrial preparation. Women were only included once during the study period. The serum progesterone level was measured in the morning of the FET, in a single laboratory. Independent factors associated with low serum P levels (defined as ≤ 9.8 ng/mL, according to a previous published study) were analyzed using univariate and multivariate logistic regression models.

Main results and the role of chance

The live birth rate was 31.5% (288/915) in the overall population. Two hundred and twenty-six patients (24.7%) had a low serum P level, on the day of the FET. Univariate analysis showed that BMI (p &lt; 0.001), parity (p = 0.001), non-European geographic origin (p = 0.001), and the duration of infertility (p = 0.018) were significantly associated with low serum P levels. Moreover, the proportion of active smokers was significantly lower in the “low P concentrations” group (p = 0.002). After multivariate analysis, BMI (OR 1.06 95%CI [1.02-1.11], p = 0.002), parity (OR 1.31 95%CI [1.04-1.65], p = 0.024), non-European geographic origin (OR 1.67 95%CI [1.19-2.35], p = 0.003), and active smoking (OR 0.43 95%CI [0.21-0.85], p = 0.016) remained independent factors associated with serum P levels ≤ 9.8 ng/mL. 

Limitations, reasons for caution

The main limitation of our study is linked to its observational design. Extrapolation of our results to other laboratories, or other routes and/or doses of administering progesterone also needs to be validated.

Wider implications of the findings

There is urgent need for future research on clinical factors affecting P concentrations to help clinicians predicting which subgroups of patients would benefit from individualized luteal phase support. More data are also needed on the underlying mechanisms explaining the relationship between patients’ characteristics and serum P levels in HRT-cycles.

Trial registration number

NA

[French clinical practice guidelines developed by a modified Delphi consensus process for oocyte vitrification in women with benign gynecologic disease]

OBJECTIVES

To provide clinical practice guidelines about fertility preservation (FP) for women with benign gynecologic disease (BGD) developed by a modified Delphi consensus process for oocyte vitrification in women with benign gynecologic disease.

METHODS

A steering committee composed of 14 healthcare professionals and a patient representative with lived experience of endometriosis identified 42 potential practices related to FP for BGD. Then 114 key stakeholders including various healthcare professionals (n=108) and patient representatives (n=6) were asked to participate in a modified Delphi process via two online survey rounds from February to September 2020 and a final meeting. Due to the COVID-19 pandemic, this final meeting to reach consensus was held as a videoconference in November 2020.

RESULTS

Survey response of stakeholders was 75 % (86/114) for round 1 and 87 % (75/86) for round 2. Consensus was reached for the recommendations for 28 items, that have been distributed into five general categories: (i) Information to provide to women of reproductive age with a BGD, (ii) Technical aspects of FP for BGD, (iii) Indications for FP in endometriosis, (iv) Indications for FP for non-endometriosis BGD, (v) Indications for FP after a fortuitous diagnosis of an idiopathic diminished ovarian reserve.

CONCLUSION

These guidelines provide some practice advice to help health professionals better inform women about the possibilities of cryopreserving their oocytes prior to the management of a BGD that may affect their ovarian reserve and fertility.

STUDY FUNDING/COMPETING INTEREST(S)

The CNGOF (Collège National des Gynécologues Obstétriciens Français) funded the implementation of the Delphi process.

P–454 Oocyte vitrification for fertility preservation in women with benign gynecological disease: French national clinical guidelines with a modified Delphi consensus process

Study question

Is there consensual clinical practices about fertility preservation (FP) for benign gynecological diseases BGD)?

Summary answer

A consensus study using the modified Delphi method identified 28 consensual practices concerning oocyte vitrification for fertility preservation in women with benign gynecological disease.

What is known already

Clinical Practical international guidelines are still published in oncology for offering standardized information and care for adults and children with cancer. Recently, the ESHRE Female Fertility Preservation Guideline Development Group published recommendations for healthcare professionals involved in fertility preservation for post-pubertal women and transgender adolescents and young adults. However, benign gynecological indications weren’t distinctly individualized of malignant conditions. There’s a lack of large cohort studies assessing the risks and outcome of FP for benign gynecological diseases. Healthcare professionals need consensus for defining the “good” indications of FP for benign gynecological diseases that could impair fertility.

Study design, size, duration

A steering group composed by 14 healthcare professionals and a patient representative with lived experience of endometriosis identified 42 potential practices concerning fertility preservation for benign gynecological disease. Then, 114 key stakeholders including various healthcare professionals (n = 108) and patient representatives(n = 6) were asked to answer at two rounds of a modified Delphi via an online survey from February to September 2020.

Participants/materials, setting, methods

Participants had to score 42 items for the first round and 31 for the second round using a nine-point Likert scale. These statements were distributed into five categories: Information to deliver to age-reproductive women with a BGD (n = 9), technical aspect of fertility preservation for BGD (n = 6), indications of FP for endometriosis (n = 13), indications of FP for none-endometriosis BGD (n = 10), idiopathic diminished ovarian reserve in the absence of gynecologic and endocrinologic diseases (n = 4).

Main results and the role of chance

Survey response of stakeholders was 75% (86 out of 114) for the round 1 and 87% (75 out of 86) for the round 2. Consensus recommendations were achieved for 28 items, and no consensus between stakeholders was achieved in the remaining items. Stakeholders rated the importance of an age-specific information concerning the risk of diminished ovarian reserve after surgery and the necessity to inform about the benefice/ risk balance of oocyte vitrification, in particular about the chance of live-birth according to the age at the time of oocyte vitrification. They endorsed oocyte vitrification as the reference FP technique for those benign indications. Experts rejected to determine lower and upper age limits in women for fertility preservation. FP shouldn’t be offered in rAFS stages I and II endometriosis without endometriomas.

Limitations, reasons for caution

Experts were only French native speakers from France, and Belgium. It would have been interesting to conduct this survey with experts from other continents.

Wider implications of the findings: At our knowledge, we present here the first guideline s focusing on FP in women with BGD, following a designed scientific Delphi procedure. These guidelines could be useful for gynecologists to better inform women with benign gynecological diseases about the indication or not to offer a FP procedure.

Trial registration number

Not applicable

P–453 Fertility preservation in endometriosis: Impact of the ovarian endometriosis and it’s surgical treatment on oocyte yield

Study question

Does a previous history of surgery for ovarian endometriosis (OMA) has an impact on controlled ovarian stimulation (COS) response in case of fertility preservation (FP) for endometriosis?

Summary answer

After COS, a prior history for OMA surgery was associated with poorer ovarian responsiveness compared to non-previously operated women.

What is known already

Endometriosis is a chronic disorder that affects 10% of woman, which can be responsible for infertility. The presence of OMA and/or it’s excision could induce a reduction of the ovarian reserve (ROR), and for some women, an increased risk of premature ovarian failure. Therefore, FP with oocyte/embryo vitrification can be proposed for OMA-affected women, considering the relationship between endometriosis, infertility and ROR. Although a complete surgery excision of endometriosis lesions may be appropriate for some patients to relieve them from pain, the more efficient time to preserve fertility is still unknown in the management of women presenting OMA lesions.

Study design, size, duration

We conducted an observational multicentric study from April 2015 to December 2019, in two tertiary care university hospitals. Women presenting OMA or having a previous history of surgery for OMA that had performed a FP with COS for oocytes/embryo vitrification during the study period were included. Diagnosis of endometriosis was based on published imaging criteria using transvaginal sonography and magnetic resonance imaging or histologically proven in women who had past surgery.

Participants/materials, setting, methods

A total of 165 women were allocated to two groups, according to the presence of a previous history of surgery for endometrioma(s). Main outcome measure was the total number of oocytes retrieved.

Main results and the role of chance

Fifty-one (30,9%) women were included in the group ‘previous history of surgery’ and 115 (69,1%) in the group ‘no history of surgery’. Mean age was 31,6±4,4 years and was not significantly different between groups (p = 0.09). However, women in ‘No previous surgery’ group had higher AMH levels than women in ‘previous surgery’ group (2.27±1.70ng/ml versus 1.56±1.89ng/ml; p &lt; 0,001). In the group ‘previous history of surgery’, 21(41.2%) women had a recurrence of OMA(s) and 31 (60.8%) had at least one deep infiltrating endometriosis (DIE) lesion at FP. In the group ‘no history of surgery’, 92(80.7%) of the women had DIE. In addition, women in ‘No previous surgery group’ had larger OMA than women in ‘previous surgery’ group (mean diameter size: 5.56±4.34cm versus 3.25±2.16cm, respectively; p:0,03).

The mean number of COS with oocyte-retrieval was significantly higher in the group ‘previous history of surgery’ (2.0±1.02 versus 1.65±0.82 in the group ‘no surgery’, p = 0.03), however, the total number of oocytes retrieved per women was significantly higher in women ‘history of surgery’, compared to women ‘no previous surgery’ (13.7±8.4 versus 10.3±7.5, p = 0.02). In addition, the cancellation rate per cycle was significantly lower in ‘No previous surgery’ group compared to the ‘previous surgery’ group (0.09±0.31 versus 0.28±0.53; p &lt; 0.001).

Limitations, reasons for caution

No data concerning the thawing of oocytes/embryo are available for now.

Wider implications of the findings: FP is an essential component to integrate in ovarian endometriosis-management and should be proposed before surgery to optimize oocyte yield.

Trial registration number

Not applicable

O-092 Sperm phenotype, ICSI outcome and genetic diagnosis in case of severe asthenozoospermia with multiple morphological abnormalities of the flagellum

Study question

What are the feasibility and outcome of ICSI in case of presumably genetic severe asthenozoospermia with Multiple Morphological Abnormalities of the Flagellum (MMAF phenotype)?

Summary answer

ICSI outcome for couples with MMAF phenotype does not differ from that of other couples requiring ICSI, regardless to the genetic etiology

What is known already

Severe asthenozoospermia, especially when associated with multiple morphological abnormalities of the sperm flagellum (MMAF phenotype), results in male infertility. Recent findings confirm that a genetic etiology is frequently responsible for this phenotype. In such situations, pregnancies can be obtained using ICSI. However, few studies have provided detailed analyses of the flagellar ultrastructural defects underlying this phenotype, of its genetic etiologies and of the results of ICSI in such cases of male infertility.

Study design, size, duration

We performed a retrospective study including 25 infertile men showing severe asthenozoospermia associated with a MMAF phenotype identified through standard semen analysis. These men were recruited from an academic center for Assisted Reproduction in Paris between 2009 and 2017. Transmission electron microscopy (TEM) and Whole Exome Sequencing (WES) were performed in order to precise the sperm ultra-structural phenotype and identify causal mutations, respectively. Twenty of the 25 patients benefited from assisted reproductive therapy by ICSI.

Participants/materials, setting, methods

MMAF patients were recruited based on reduced sperm progressive motility and increased frequencies of absent, short, coiled or irregular flagella, in comparison with fertile control men. A quantified analysis of the ultrastructural defects was performed for the MMAF patients and for fertile control men. ICSI results for the MMAF patients were compared to those of 528 ICSI attempts performed for non-MMAF individuals considering the sperm parameters and the distribution of ultrastructural axonemal anomalies.

Main results and the role of chance

Thorough categorization by TEM analysis of the flagellar anomalies found in these patients brought important precisions about the structural defects underlying asthenozoospermia and sperm tail abnormalities detectable through standard microscopy. In particular, absence of the central pair of axonemal microtubules was the predominant anomaly, observed significantly more frequently than in control men (p &lt; 0.01). Exome sequencing performed for 24 of the 25 patients (96%), identified in ten of them homozygous or compound heterozygous mutations that were described to be pathogenic (CFAP43, CFAP44, CFAP69, DNAH1, DNAH8, AK7, TTC29, MAATS1). A majority of those patients (55.5%,5/9) displayed the most severe ultra-structural defects of the axoneme. Forty ICSI attempts were performed for 20 MMAF patients. A hypo-osmotic swelling (HOS) test was required in 13 cycles (5 couples). Fertilization rate in MMAF group (65.7%) was not statistically different from the rate obtained for non-MMAF patients (66.0%) and did not differ according to the flagellar phenotype, nor to the use of HOS test, nor to the genotype. Clinical pregnancy rate per embryo transfer did not significantly differ between the MMAF group (23.3%) and the ICSI control group (37.1%). To date, 11 healthy babies were born among 20 MMAF patients.

Limitations, reasons for caution

The outcome of ICSI procedure was retrospectively assessed on a small sample and may be susceptible to recall bias. Moreover, TEM analysis was not available for some of the patients due to too low sperm concentration, and WES results are not yet available for all men included.

Wider implications of the findings

Couples requiring ICSI for presumably genetic severe asthenozoospermia should benefit precociously from appropriate phenotypic and genetic investigations. So far ICSI results appear similar to those observed in other ICSI indications. Identifying a genetic etiology and its mode of inheritance allows providing to these couples a most often reassuring genetic counseling.

Trial registration number

Not applicable

P–323 Ovarian response to stimulation according to endometrioma size, in women with deep infiltrating endometriosis – A comparative study

Study question

Does endometrioma (OMA) size affect the number of oocytes retrieved after ovarian stimulation (OS) in women with deep infiltrating endometriosis (DIE)? Summary answer: No significant difference in the number of oocytes retrieved was observed according to the endometrioma size.

What is known already

Ovarian endometriosis lesions (OMA) per se and above all, the surgical excision, appears to result in a risk of alteration of the ovarian reserve. In vitro fertilization (IVF) is a validated therapeutic option to treat infertility related to endometriosis. Nevertheless, it has been described that the presence of OMA could have a detrimental impact on ovarian responsiveness to hyperstimulation involving mechanisms still unclear. Some recent studies suggest that the size of the OMA may be relevant and that there may be a threshold in cyst diameter above which ovarian responsiveness might be affected. Study design, size, duration: This was an observational study using data prospectively collected in a cohort of infertile women aged between 18 and 43 years presenting OMA associated with DIE lesions, between December 2012 and July 2019. Every patient underwent their first in vitro fecundation or intracytoplasmic sperm injection (IVF/ICSI) cycle. Included women were women with an adequate imaging work up with Transvaginal ultrasound and/or magnetic resonance imaging (TVUS/MRI) performed by senior radiologists before the beginning of the OS.

Participants/materials, setting, methods

One hundred and eighty-two women were included in the study. Women were allocated in 5 groups according to the largest diameter of their ovarian endometriosis lesions: OMA &lt; 2 cm, 2 cm ≤ OMA &lt; 4 cm, 4 cm ≤ OMA &lt; 6 cm, 6 cm ≤ OMA &lt; 8 cm, OMA ≥ 8 cm. The main outcome was the number of oocytes retrieved.

Main results and the role of chance

Mean age of the included women was 32.8 years. 96(52.7%) women had unilateral endometrioma and 86 (47.3%) had bilateral endometriomas. The mean OMA size was 3.63 cm for right ovary and 3.60 cm for left ovary. Considering the largest diameter of OMA retained, the mean size was 4.12 cm. Repartition among groups, according to the size of the largest OMA diameter was: OMA &lt; 2cm group (n = 32); 2 £OMA&lt; 4 cm (n = 70); 4 £OMA&lt; 6 cm, (n = 37); 6 £OMA&lt; 8 cm (n = 27); OMA8 cm (n = 16).

Mean number of oocytes retrieved was not significantly different between groups (p = 0.635): 8.4±5.7 for OMA&lt; 2 cm, 7.3 ± 5.4 for 2 cm≤OMA&lt;4 cm, 6.6 ± 3.9 for 4 cm≤OMA&lt; 6 cm, 8.6 ± 5.8 for 6 cm ≤OMA&lt;8 cm and 7.1 ± 3.6 for OMA≥8 cm. Mean number of matures oocytes was also comparable between groups (p = 0.674). Clinical pregnancy rate and live birth rate was similar between groups (p = 0.798 and p = 0.913). No significant difference was found concerning the number of cancelled cycles between groups (p = 0.703).

Limitations, reasons for caution

For almost half of the included women, endometriosis diagnosis was based on imaging technics, without histological proof of endometriosis. However, it was performed by specialized seniors radiologists.

Wider implications of the findings: Our study suggests that whatever endometrioma size, OS can be benefit for women with endometrioma, even for largest ones, without the requirement of prior treatment to reduce their size

Trial registration number

NA

[An update on adenomyosis and implantation]

Adenomyosis is an enigmatic disease whose impact on implantation and fertility outcome is still controversial. A negative effect on IVF outcome was already observed, but it is mainly explained by an increase in early spontaneous miscarriages. We reviewed scientific data in order to bring relevant information about adenomyosis and endometrial receptivity for patient counselling and to precise if screening of adenomyosis is indicated before IVF treatment.

[Pre-washing catheter dramatically improves the post intrauterine insemination pregnancy rate]

OBJECTIVE

To analyze the effectiveness of pre-washing the intrauterine insemination catheters on IUI outcome.

PATIENTS AND METHODS

Infertile couples (n=322) involved in a IUI program were included in the study. IUI indications were cervical factors, ovulation dysfunction, cryopreserved semen and unexplained infertility. Every other week for two years, IUI catheters were washed with culture medium prior to intrauterine sperm insemination.

RESULT(S)

Only the first IUI for each couple were analyzed. Washing the catheter, prior to use, resulted in a 49.7% increase in clinical pregnancy rate (22.0% vs 14.7% P<0.05). This result is observed with fresh sperm (15.7% vs 11.1%) and frozen-thawed sperm as well (31.1% vs 19.8%). The early pregnancy termination rate was similar in all groups.

DISCUSSION AND CONCLUSION

Pre-washing the catheter before IUI should be recommended in Good Laboratory Practice Guidelines as it is already the case for embryo transfer catheters. This raises the problem of washing all single-use devices, in contact with gametes or embryos during IVF.

ICSI outcomes in obstructive azoospermia: influence of the origin of surgically retrieved spermatozoa and the cause of obstruction

BACKGROUND

Spermatozoa can be retrieved from the testis and epididymis of men with obstructive azoospermia (OA) and used for ICSI. However, it is unknown whether the outcome of ICSI depends on the cause of obstruction or the origin of surgically retrieved spermatozoa.

METHODS

A cohort of 171 men with OA and normal spermatogenesis were included in this retrospective study. They were divided into three groups according to the site and origin of obstruction: 83 men had congenital bilateral absence of vas deferens; 55 and 33 had acquired epididymal and deferent duct obstructions, respectively. The outcome of 368 ICSI cycles was determined and compared according to the origin of spermatozoa: epididymal (n = 253) or testicular (n = 115).

RESULTS

Fertilization and clinical pregnancy rates did not differ between spermatozoa of different origin (58.9% versus 51.9% and 22.1% versus 24.3% with epididymal and testicular spermatozoa, respectively). However, the miscarriage rate was significantly higher for testicular spermatozoa (35.7% versus. 12.5% P < 0.05, chi2 test). Findings were similar whatever the aetiology of the OA.

CONCLUSION

This study suggests that the use of testicular spermatozoa, even those generated during normal spermatogenesis, alters embryonic development and that epididymal spermatozoa should be preferentially used, irrespective of the aetiology of OA.

Is the CAG repeat of mitochondrial DNA polymerase gamma (POLG) associated with male infertility? A multi-centre French study

BACKGROUND

Recent data emphasized the implication of polymerase gamma (POLG) CAG repeats in infertility, making it a very attractive gene for study. A comparison of POLG CAG repeats in infertile and fertile men showed a clear association between the absence of the usual 10-CAG allele and male infertility, excluding azoospermia. It has also been suggested that the POLG gene polymorphism should be considered as a possible contributing factor in unexplained couple infertility where semen parameters are normal. In this study, we investigated the POLG CAG repeats, in a well-defined population of patients with severe male factor infertility.

METHODS

We conducted a large study of POLG CAG repeats in 433 infertile and 91 fertile, normozoospermic and healthy males. In all subjects, phenotypic data, including semen parameters, hormonal status and clinical profiles, were available.

RESULTS

Thirteen 'homozygous mutants' (3%) were found among the 433 idiopathic infertile patients. The follow-up of the 13 'homozygous mutant' resulted in pregnancy for more than half of the couples, through assisted reproductive techniques or even spontaneously. In addition, one 'homozygous mutant' was identified in 91 fertile men (1.1%)

CONCLUSION

Under our conditions, our study does not confirm any relationship between the polymorphic CAG repeat in the POLG gene and male infertility.

[Molecular detection of Y chromosome microdeletions: a new approach based on the denaturing gradient gel electrophoresis]

Ten percent of couples trying for a child fail to conceive. In approximately 50% of cases, infertility is due to the inability of the male partner to produce spermatozoa in sufficient numbers to effect conception. Over the past 5 years, molecular studies have suggested that interstitial microdeletions in Yq11 represent an etiological factor for male infertility. Y-microdeletions have been detected in 12% of non-obstructive azoospermia and 6% of severe oligozoospermia. In general, microdeletions were detected by separate multiplex-polymerase chain reaction (PCR) reactions using primer pairs for single tagged sites (STSs) of all three azoospermia factor (AZF) regions (AZFa, AZFb and AZFc). This review describes the molecular methods and laboratory guidelines for molecular diagnosis of Y-chromosomal microdeletions. The diagnostics of Y-chromosomal microdeletions should be performed in two steps: in any case, the routine diagnostic should include six STS loci, two STS loci localised in each AZF region, and once a deletion is detected, the analysis can be extended to STS loci known to cross the proximal and the distal borderlines of each AZF region. Other molecular techniques such as DGGE, Southern blot should be performed to detect partial deletions of gene copies or mosaicism. These different molecular approaches should allow explaining 10% of male infertility, to evaluate the risk to pass the defect onto their male offspring (by intracytoplasmic sperm injection) and improve the genetic counselling of couples undergoing micromanipulative assisted reproduction.

Mucoviscidose féminine et projet d’enfant : spécificités des indications et résultats de l’aide médicale à la procréation

OBJECTIVE

To treat cystic fibrosis women who failed to conceive.

PATIENTS AND METHODS

Multidisciplinary coordinated approach in 20 infertile women affected with cystic fibrosis. Advisability of pregnancy was based on the assessment of pulmonary and nutritional status, risks of maternal health deterioration, infertility factors, risk of cystic fibrosis in the offspring. Assisted reproductive techniques in moderately affected women are described.

RESULTS

Three patients requested only information, three were discouraged, two are still evaluated, 12 were treated and three delivered healthy children. The pulmonary status of each patient remained unchanged 36 months after delivery, and all three children remain healthy.

DISCUSSION AND CONCLUSION

Assisted reproductive techniques are an option in moderately affected infertile cystic fibrosis women. Advisability and management of pregnancy should be provided by a coordinated team of healthcare professionals with knowledge and experience in cystic fibrosis.

Progesterone induces hyperpolarization after a transient depolarization phase in human spermatozoa

Progesterone (P4) induces a membrane depolarization and various ion fluxes (chloride efflux, sodium and calcium influxes), which are required for the human sperm acrosome reaction (AR). By use of the potentiometric fluorescent dye DiSC3(5) and two different technical approaches, the present study aimed to quantify and further analyze P4-induced modifications in membrane potential in capacitated human spermatozoa. Spectrofluorimetric analysis revealed that the mean resting membrane potential of sperm was -58 +/- 2 mV (n = 12). When 10 microM P4 was added, the sperm membrane depolarized by approximately +15 mV, partly driven by a Cl- efflux. It subsequently repolarized to reach a significant lower potential than the initial resting potential in two thirds of the tested samples. The flow cytometry analysis showed a heterogeneous resting membrane potential and revealed that the depolarization-hyperpolarization events concerned only subpopulations, between 3% and 40% of the sperm cells according to the samples (n = 7). We hypothesize that P4 has a beneficial effect on the ability of zona pellucida to promote the AR in a sperm subpopulation by increasing the number of hyperpolarized cells presenting a membrane potential that is compatible with the opening of T-type calcium channels by subsequent zona pellucida-induced depolarization.

[Male infertility and microdeletions of the Y chromosome]

It is estimated that about 10% of men suffer from male infertility. Male infertility is associated with a reduction in the quantity, reduced mobility or abnormal morphology of sperm. In about 50-60% of cases the etiology can be identified. When the cause is unknown, it is referred to as idiopathic infertility. A genetic cause is suspected in some of the latter cases since chromosome anomalies and familial forms of male infertility have been reported. Three different regions of the Y chromosome, termed AZFa, AZFb and AZFc are recurrently deleted in about 15% of cases of idiopathic azoospermia or severe oilgozoospermia. AZFc deletions form the majority of these deletions. The presence of a Y microdeletion does not seem to alter the fertilisation of the oocyte or the development of the embryo. However, if the child is a boy, he will inherit the deletion from his father and will most likely be infertile when he is an adult. In the absence of any other information concerning an association between Y chromosome microdeletions and other development anomalies of the child, in genetic counselling the principal risk for male offspring appears to be infertility.

Reduction in the DAZ gene copy number in two infertile men with impaired spermatogenesis

Microdeletions of Yq are associated with azoospermia and severe oligozoospermia. Recently, we described a new molecular genetic strategy based on the denaturing gradient gel electrophoresis (DGGE) to rapidly identify deletions of the Y chromosome that include the DAZ locus. Using this approach, we have shown not a complete deletion but only a reduction in the number of copies of the DAZ gene by PCR-DGGE in two oligozoospermic patients. These results have been confirmed by Southern blot analysis. This finding suggests that partial deletion of the DAZ cluster could be cause of impaired spermatogenesis.

The acrosome reaction in human spermatozoa

During gamete interaction, sperm acrosome reaction (AR) induced by oocyte investment is a prerequisite event for the spermatozoa to pass through the zona pellucida (ZP), fuse with and penetrate the oocyte. Progesterone (P4), secreted by cumulus cells, is an important cofactor for the occurrence of this exocytosis event. The AR results from the fusion between outer acrosomal and plasma membranes, leading to inner acrosomal membrane exposure. Binding of agonists, P4 or ZP3 glycoprotein, to plasma membrane sperm receptors activates intraspermatic signals and enzymatic pathways involved in the AR. Among the proteins or glycoproteins described as potential sperm receptors for ZP, Gi/Go protein-coupled and tyrosine kinase receptors have been described. Sperm receptors for P4 are poorly characterized, except a putative GABA(A)-like receptor. ZP- and P4-promoted AR is mediated by an obligatory intracellular calcium increase, appearing first at the acrosome equatorial segment and spreading throughout the head. The plasma membrane channels involved in calcium entry are operated by a plasma membrane depolarization and protein phosphorylations mediated by protein kinase C and tyrosine kinase protein. Part of the calcium increase could also be due to intracellular store release through IP3- and nucleotide (cAMP)-gated channels. Besides adenylate cyclase and phospholipase C activations, intracellular calcium increase also stimulates PLA2 activity and actin depolymerization, leading to membrane fusion. Evaluation of AR by staining or fluorescent probes can be useful to predict fertilization success and to direct the therapeutic strategy in male infertility.

Induction of a sodium ion influx by progesterone in human spermatozoa

In human spermatozoa, progesterone (P(4)) induces a depolarization of the plasma membrane, a rapid calcium (Ca(2+)) influx, and a chloride efflux. The sodium ion (Na(+)) was partly responsible for the P(4)-induced depolarizing effect but was not required for calcium influx. We used fluorescent probes for spectrofluorometry to investigate whether P(4) induced a Na(+) influx and whether voltage-operated channels were involved in Na(+) and/or Ca(2+) entries. We found that 10 microM P(4) significantly increased intracellular Na(+) concentration from 17.8 +/- 2.0 mM to 27.2 +/- 1. 6 mM (P < 0.001). Prior incubation of spermatozoa with 10 microM flunarizine, a Na(+) and Ca(2+) voltage-dependent channel blocker, inhibited the sodium influx induced by 10 microM P(4) by 84.6 +/- 15.4%. The Ca(2+) influx induced by 10 microM P(4) was also significantly inhibited in a Na(+)-containing medium by 10 microM flunarizine or 10 microM pimozide (P < 0.01). In contrast, flunarizine had no inhibitory effect on the Ca(2+) influx induced by 10 microM P(4) in spermatozoa incubated in Na(+)-depleted medium. The P(4)-promoted acrosome reaction (AR) was significantly higher when spermatozoa were incubated in Na(+)-containing medium as compared to Na(+)-depleted medium. These data demonstrate that P(4) stimulates a Na(+) influx that could be involved in the AR completion. They also suggest that voltage-dependent Na(+) and Ca(2+) channels are implicated in P(4)-mediated signaling pathway in human spermatozoa.

A novel, rapid, and accurate method for detecting microdeletion involving the DAZ gene in infertile men

OBJECTIVE

To report on a novel, accurate method for detecting microdeletion involving the DAZ gene in infertile men.

DESIGN

Retrospective clinical study.

SETTING

University Infertility Center of Cochin Hospital, Paris, France.

PATIENT(S)

Infertile patients (n = 25) consulting our infertility department during 1998. The patient cohort included subjects with nonobstructive azoospermia and oligoasthenospermia.

INTERVENTION(S)

Blood samples were collected from each subject.

MAIN OUTCOME MEASURE(S)

DNA analysis using polymerase chain reaction (PCR)-denaturing gradient gel electrophoresis (DGGE).

RESULT(S)

We used a new molecular genetic strategy to rapidly identify deletions of the Y chromosome that include the DAZ locus. The experiment consists of amplifying simultaneously exon 4 of the DAZ and DAZLA genes with the use of specific primers that are complementary to intronic sequences of these genes. DGGE was used to separate the two PCR products, with good resolution. In infertile men with a microdeletion of the DAZ gene, this method allows amplification of an internal control when a deletion of that portion of the Yq chromosome is observed on a single amplification.

CONCLUSION(S)

This PCR-DGGE method for detection of DAZ gene deletion is simple and fast and does not require the use of radioactive elements. Compared with the classic PCR approach, this new method allows the amplification of the DAZLA copy to be used as an effective internal control in infertile men with microdeletion of the DAZ locus. This procedure could be particularly useful in screening for the DAZ locus in the diagnostic workup of nonobstructive azoospermia and severe oligoasthenoteratozoospermia.

Pregnancies, growth and development of children conceived by subzonal injection of spermatozoa

Subzonal injection of spermatozoa (SUZI) was one of the first micromanipulation techniques efficient in treating male factor infertility and unexplained in-vitro fertilization failures. The aim of this retrospective study was to evaluate the in-vitro development of embryos conceived by SUZI, the obstetric outcome, the rate of congenital malformations and subsequent follow-up in children. Fifty-five pregnancies were obtained between 1991 and 1994 (54 after fresh embryos were transferred and one after cryopreserved embryos were transferred). Among the 50 clinical pregnancies, there were seven miscarriages (14%) and two ectopic pregnancies (4%). Among the 41 resulting evolutive pregnancies, the discovery of one anencephaly led to a medical abortion. Forty deliveries including six twin pregnancies occurred, leading to the births of 45 live neonates and one stillbirth. The gender distribution of the offspring included 17 males and 29 females (ratio 0.59:1). Birth weight, length and head circumference were within the expected ranges. Two children presented a malformation: the first one had one thumb with congenital shelf and the second a polymalformative neurological syndrome. Growth curves were normal for all these children except one (weight above the 2 SD curve). Medical follow-up detected no pathological features in these children apart from a physical disability in one girl. In this small series a 4.2% rate of malformation was observed, particularly affecting the neural tube, in SUZI offspring. However, no firm conclusions can be drawn since the study was carried out on a small cohort. SUZI is no longer performed but these observations suggest that it is necessary to collect extensive data about children conceived by microfertilization.