Lack of CCDC146, a ubiquitous centriole and microtubule-associated protein, leads to non-syndromic male infertility in human and mouse

From a cohort of 167 infertile patients suffering from multiple morphological abnormalities of the flagellum (MMAF), pathogenic bi-allelic mutations were identified in the CCDC146 gene. In somatic cells, CCDC146 is located at the centrosome and at multiple microtubule-related organelles during mitotic division, suggesting that it is a microtubule-associated protein (MAP). To decipher the molecular pathogenesis of infertility associated with CCDC146 mutations, a Ccdc146 knock-out (KO) mouse line was created. KO male mice were infertile, and sperm exhibited a phenotype identical to CCDC146 mutated patients. CCDC146 expression starts during late spermiogenesis. In the spermatozoon, the protein is conserved but is not localized to centrioles, unlike in somatic cells, rather it is present in the axoneme at the level of microtubule doublets. Expansion microscopy associated with the use of the detergent sarkosyl to solubilize microtubule doublets suggests that the protein may be a microtubule inner protein (MIP). At the subcellular level, the absence of CCDC146 impacted all microtubule-based organelles such as the manchette, the head-tail coupling apparatus (HTCA), and the axoneme. Through this study, a new genetic cause of infertility and a new factor in the formation and/or structure of the sperm axoneme were characterized.

Genetic analyses of a large cohort of infertile patients with globozoospermia, DPY19L2 still the main actor, GGN confirmed as a guest player

Globozoospermia is a rare phenotype of primary male infertility inducing the production of round-headed spermatozoa without acrosome. Anomalies of DPY19L2 account for 50-70% of all cases and the entire deletion of the gene is by far the most frequent defect identified. Here, we present a large cohort of 69 patients with 20-100% of globozoospermia. Genetic analyses including multiplex ligation-dependent probe amplification, Sanger sequencing and whole-exome sequencing identified 25 subjects with a homozygous DPY19L2 deletion (36%) and 14 carrying other DPY19L2 defects (20%). Overall, 11 deleterious single-nucleotide variants were identified including eight novel and three already published mutations. Patients with a higher rate of round-headed spermatozoa were more often diagnosed and had a higher proportion of loss of function anomalies, highlighting a good genotype phenotype correlation. No gene defects were identified in patients carrying < 50% of globozoospermia while diagnosis efficiency rose to 77% for patients with > 50% of globozoospermia. In addition, results from whole-exome sequencing were scrutinized for 23 patients with a DPY19L2 negative diagnosis, searching for deleterious variants in the nine other genes described to be associated with globozoospermia in human (C2CD6, C7orf61, CCDC62, CCIN, DNAH17, GGN, PICK1, SPATA16, and ZPBP1). Only one homozygous novel truncating variant was identified in the GGN gene in one patient, confirming the association of GGN with globozoospermia. In view of these results, we propose a novel diagnostic strategy focusing on patients with at least 50% of globozoospermia and based on a classical qualitative PCR to detect DPY19L2 homozygous deletions. In the absence of the latter, we recommend to perform whole-exome sequencing to search for defects in DPY19L2 as well as in the other previously described candidate genes.

Whole exome sequencing of men with multiple morphological abnormalities of the sperm flagella reveals novel homozygous QRICH2 mutations

Multiple morphological anomalies of the sperm flagella (MMAF syndrome) is a severe male infertility phenotype which has so far been formally linked to the presence of biallelic mutations in nine genes mainly coding for axonemal proteins overexpressed in the sperm flagellum. Homozygous mutations in QRICH2, a gene coding for a protein known to be required for stabilizing proteins involved in sperm flagellum biogenesis, have recently been identified in MMAF patients from two Chinese consanguineous families. Here, in order to better assess the contribution of QRICH2 in the etiology of the MMAF phenotype, we analyzed all QRICH2 variants from whole exome sequencing data of a cohort of 167 MMAF-affected subjects originating from North Africa, Iran, and Europe. We identified a total of 14 potentially deleterious variants in 18 unrelated individuals. Two unrelated subjects, representing 1% of the cohort, carried a homozygous loss-of-function variant: c.3501C>G [p.Tyr1167Ter] and c.4614C>G [p.Tyr1538Ter], thus confirming the implication of QRICH2 in the MMAF phenotype and human male infertility. Sixteen MMAF patients (9.6%) carried a heterozygous QRICH2 potentially deleterious variant. This rate was comparable to what was observed in a control group (15.5%) suggesting that the presence of QRICH2 heterozygous variants is not associated with MMAF syndrome.

Step-by-step loupes-mTESE in non-obstructive azoospermic men, a retrospective study

Background

Men with non-obstructive azoospermia (NOA) may have sperm in their testes and a procedure of sperm retrieval and assisted reproduction is required in them to allow fertility. Standard procedures such as fine needle aspiration (FNA) and conventional testicular sperm extraction (cTESE) harvest random samples with a sperm retrieval rate (SRR) of 45%. Microdissection testicular sperm extraction (mTESE) is nowadays considered to be the most accurate technique to retrieve sperm in men with NOA. This procedure can identify dilated tubules that are more likely to contain viable sperm with a SRR of 60%.

Results

In our center, testicular biopsy was conducted in a standard fashion in 321 patients with NOA until March 2003. From then to December 2017, due to the lack of an operating microscope, we used 6 fold magnifying loupes to perform a step-by-step macro- mTESE in 1050 patients. Sperm was found in the first testis in 61% of the cases, leading to stop the procedure with less testicular damage. We increased our SRR from 43 to 51.8% in an acceptable operating time of 75mn for both sides.

Conclusions

In institutions where surgeons cannot afford an operating microscope, this modified mTESE technique using × 6 magnifying loupes is reliable, especially in patients with low testicular volumes and high FSH, in whom dilated tubules can be easily identified from the surrounding tissue.

Whole-exome sequencing identifies mutations in FSIP2 as a recurrent cause of multiple morphological abnormalities of the sperm flagella

STUDY QUESTION

Can whole-exome sequencing (WES) of infertile patients identify new genes responsible for multiple morphological abnormalities of the sperm flagella (MMAF)?

SUMMARY ANSWER

WES analysis of 78 infertile men with a MMAF phenotype permitted the identification of four homozygous mutations in the fibrous sheath (FS) interacting protein 2 (FSIP2) gene in four unrelated individuals.

WHAT IS KNOWN ALREADY

The use of high-throughput sequencing techniques revealed that mutations in the dynein axonemal heavy chain 1 (DNAH1) gene, and in the cilia and flagella associated protein 43 (CFAP43) and 44 (CFAP44) genes account for approximately one-third of MMAF cases thus indicating that other relevant genes await identification.

STUDY DESIGN, SIZE, DURATION

This was a retrospective genetics study of 78 patients presenting a MMAF phenotype who were recruited in three fertility clinics between 2008 and 2015. Control sperm samples were obtained from normospermic donors. Allelic frequency for control subjects was derived from large public databases.

PARTICIPANTS/MATERIALS, SETTING, METHODS

WES was performed for all 78 subjects. All identified variants were confirmed by Sanger sequencing. Relative mRNA expression levels for the selected candidate gene (FSIP2) was assessed by quantitative RT-PCR in a panel of normal human and mouse tissues. To characterize the structural and ultrastructural anomalies present in patients' sperm, immunofluorescence (IF) was performed on sperm samples from two subjects with a mutation and one control and transmission electron microscopy (TEM) analyses was performed on sperm samples from one subject with a mutation and one control.

MAIN RESULTS AND THE ROLE OF CHANCE

We identified four unrelated patients (4/78, 5.1%) with homozygous loss of function mutations in the FSIP2 gene, which encodes a protein of the sperm FS and is specifically expressed in human and mouse testis. None of these mutations were reported in control sequence databases. TEM analyses showed a complete disorganization of the FS associated with axonemal defects. IF analyses confirmed that the central-pair microtubules and the inner and outer dynein arms of the axoneme were abnormal in all four patients carrying FSIP2 mutations. Importantly, and in contrast to what was observed in patients with MMAF and mutations in other MMAF-related genes (DNAH1, CFAP43 and CFAP44), mutations in FSIP2 led to the absence of A-kinase anchoring protein 4 (AKAP4).

LIMITATIONS, REASONS FOR CAUTION

The low number of biological samples and the absence of a reliable anti-FSIP2 antibody prevented the formal demonstration that the FSIP2 protein was absent in sperm from subjects with a FSIP2 mutation.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings indicate that FSIP2 is one of the main genes involved in MMAF syndrome. In humans, genes previously associated with a MMAF phenotype encoded axonemal-associated proteins (DNAH1, CFAP43 and CFAP44). We show here that FSIP2, a protein of the sperm FS, is also logically associated with MMAF syndrome as we showed that it is necessary for FS assembly and for the overall axonemal and flagellar biogenesis. As was suggested before in mouse and man, our results also suggest that defects in AKAP4, one of the main proteins interacting with FSIP2, would induce a MMAF phenotype. Finally, this work reinforces the demonstration that WES sequencing is a good strategy to reach a genetic diagnosis for patients with severe male infertility phenotypes.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the following grants: the 'MAS-Flagella' project financed by the French ANR and the DGOS for the program PRTS 2014 (14-CE15) and the 'Whole genome sequencing of patients with Flagellar Growth Defects (FGD)' project financed by the Fondation Maladies Rares for the program Séquençage à haut débit 2012. The authors have no conflict of interest.

PATL2 is a key actor of oocyte maturation whose invalidation causes infertility in women and mice

The genetic causes of oocyte meiotic deficiency (OMD), a form of primary infertility characterised by the production of immature oocytes, remain largely unexplored. Using whole exome sequencing, we found that 26% of a cohort of 23 subjects with OMD harboured the same homozygous nonsense pathogenic mutation in PATL2, a gene encoding a putative RNA‐binding protein. Using Patl2 knockout mice, we confirmed that PATL2 deficiency disturbs oocyte maturation, since oocytes and zygotes exhibit morphological and developmental defects, respectively. PATL2's amphibian orthologue is involved in the regulation of oocyte mRNA as a partner of CPEB. However, Patl2's expression profile throughout oocyte development in mice, alongside colocalisation experiments with Cpeb1, Msy2 and Ddx6 (three oocyte RNA regulators) suggest an original role for Patl2 in mammals. Accordingly, transcriptomic analysis of oocytes from WT and Patl2^−/− animals demonstrated that in the absence of Patl2, expression levels of a select number of highly relevant genes involved in oocyte maturation and early embryonic development are deregulated. In conclusion, PATL2 is a novel actor of mammalian oocyte maturation whose invalidation causes OMD in humans.

Bi-allelic Mutations in ARMC2 Lead to Severe Astheno-Teratozoospermia Due to Sperm Flagellum Malformations in Humans and Mice

Male infertility is a major health concern. Among its different causes, multiple morphological abnormalities of the flagella (MMAF) induces asthenozoospermia and is one of the most severe forms of qualitative sperm defects. Sperm of affected men display short, coiled, absent, and/or irregular flagella. To date, six genes (DNAH1, CFAP43, CFAP44, CFAP69, FSIP2, and WDR66) have been found to be recurrently associated with MMAF, but more than half of the cases analyzed remain unresolved, suggesting that many yet-uncharacterized gene defects account for this phenotype. Here, whole-exome sequencing (WES) was performed on 168 infertile men who had a typical MMAF phenotype. Five unrelated affected individuals carried a homozygous deleterious mutation in ARMC2, a gene not previously linked to the MMAF phenotype. Using the CRISPR-Cas9 technique, we generated homozygous Armc2 mutant mice, which also presented an MMAF phenotype, thus confirming the involvement of ARMC2 in human MMAF. Immunostaining experiments in AMRC2-mutated individuals and mutant mice evidenced the absence of the axonemal central pair complex (CPC) proteins SPAG6 and SPEF2, whereas the other tested axonemal and peri-axonemal components were present, suggesting that ARMC2 is involved in CPC assembly and/or stability. Overall, we showed that bi-allelic mutations in ARMC2 cause male infertility in humans and mice by inducing a typical MMAF phenotype, indicating that this gene is necessary for sperm flagellum structure and assembly.

Patients with multiple morphological abnormalities of the sperm flagella due to DNAH1 mutations have a good prognosis following intracytoplasmic sperm injection

STUDY QUESTION

Does DNAH1 status influence intracytoplasmic sperm injection (ICSI) outcomes for patients with multiple morphological abnormalities of the sperm flagella (MMAF)?

SUMMARY ANSWER

Despite a highly abnormal morphology, sperm from MMAF patients with DNAH1 mutations have a low aneuploidy rate and good nuclear quality, leading to good embryonic development following ICSI and a high pregnancy rate.

WHAT IS KNOWN ALREADY

Teratozoospermia represents a heterogeneous group including a wide range of phenotypes. Among all these qualitative defects, a flagellar phenotype called MMAF is characterized by a mosaic of morphological abnormalities of the flagellum, including coiled, bent, irregular, short or/and absent flagella, mainly due to the absence of the axonemal central pair microtubules. We previously demonstrated that homozygous mutations in the DNAH1 gene, encoding an inner arm heavy chain dynein, are frequently found in patients with MMAF (28% of the patients from the initial cohort). Numerous studies have reported an increased rate of aneuploidy and a poor sperm nuclear quality related to sperm flagellar abnormalities, which could impede ICSI outcome. Moreover, success rates after ICSI may be influenced by the type of ultrastructural flagellar defects and/or by the gene defects carried by the patients.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study included 6 infertile males with MMAF due to deleterious homozygous DNAH1 mutations and their respective spouses, who underwent 9 ISCI cycles, with 16 embryos being transferred. ICSI results were compared with two control populations of 13 MMAF men without DNAH1 mutations and an aged-matched control group of 1431 non-MMAF couples. All ICSI attempts took place between 2000 and 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Clinical and biological data were collected from patients treated for infertility at the CPSR les Jasmins in Tunis (Tunisia). We compared the ICSI outcomes obtained with couples including DNAH1 mutated and nonmutated patients and non-MMAF couples. For the analysis of the chromosomal status, fluorescence in situ hybridization (FISH) analyses were performed on sperm cells from 3 DNAH1-mutated patients and from 29 fertile control subjects. Sperm chromatin condensation and DNA fragmentation were evaluated using aniline blue staining and TUNEL assays, respectively, on sperm cells from 3 DNAH1-mutated men and 6 fertile controls.

MAIN RESULTS AND THE ROLE OF CHANCE

There was a significantly increased proportion of disomy XY and 18 in sperm from DNAH1 mutated patients compared with fertile controls (1.52 versus 0.28%, P = 0.0001 and 0.64 versus 0.09%, P = 0.0001). However, there were no statistically significant differences among sperm from the two groups in their frequencies of either 13, 21, XX or YY disomy or diploidy. Measures of DNA compaction and fragmentation demonstrated a good nuclear sperm quality among DNAH1 mutated men. The overall fertilization, pregnancy and delivery rates of couples including DNAH1 mutated men were of 70.8, 50.0 and 37.5%, respectively. There were no statistically significant differences in any of these parameters compared with the two control groups (P > 0.05).

LIMITATIONS, REASONS FOR CAUTION

A limitation of this study is the small number of DNAH1-mutated patients available and the low number of genes identified in MMAF. Further genetic studies are warranted to identify other MMAF-inducing genes to better characterize the genetic etiology of the MMAF phenotype and to improve the management of patients diagnosed with flagellar defects.

WIDER IMPLICATIONS OF THE FINDINGS

MMAF patients with DNAH1 mutations have low aneuploidy rates and good nuclear sperm quality, explaining the high pregnancy rate obtained with these patients. Good ICSI results were obtained for both MMAF groups (DNAH1 mutated and nonmutated), suggesting that patients presenting with asthenozoospermia due to flagellar defects have a good ICSI prognosis irrespective of their genotype. The majority of MMAF cases currently remain idiopathic with no genetic cause yet identified. In depth genetic analysis of these patients using next generation sequencing should reveal new causal genes. Subsequent genotype phenotype analyses could improve advice and care provided to MMAF patients.

STUDY FUNDING/COMPETING INTERESTS

None of the authors have any competing interest. This work is part of the project 'Identification and Characterization of Genes Involved in Infertility (ICG2I)', funded by the program GENOPAT 2009 from the French Research Agency (ANR) and the MAS-Flagella project, financed by the French ANR and the Direction Générale de l'Offre de Soins (DGOS).

A recurrent deletion of DPY19L2 causes infertility in man by blocking sperm head elongation and acrosome formation

An increasing number of couples require medical assistance to achieve a pregnancy, and more than 2% of the births in Western countries now result from assisted reproductive technologies. To identify genetic variants responsible for male infertility, we performed a whole-genome SNP scan on patients presenting with total globozoospermia, a primary infertility phenotype characterized by the presence of 100% round acrosomeless spermatozoa in the ejaculate. This strategy allowed us to identify in most patients (15/20) a 200 kb homozygous deletion encompassing only DPY19L2, which is highly expressed in the testis. Although there was no known function for DPY19L2 in humans, previous work indicated that its ortholog in C. elegans is involved in cell polarity. In man, the DPY19L2 region has been described as a copy-number variant (CNV) found to be duplicated and heterozygously deleted in healthy individuals. We show here that the breakpoints of the deletions are located on a highly homologous 28 kb low copy repeat (LCR) sequence present on each side of DPY19L2, indicating that the identified deletions were probably produced by nonallelic homologous recombination (NAHR) between these two regions. We demonstrate that patients with globozoospermia have a homozygous deletion of DPY19L2, thus indicating that DPY19L2 is necessary in men for sperm head elongation and acrosome formation. A molecular diagnosis can now be proposed to affected men; the presence of the deletion confirms the diagnosis of globozoospermia and assigns a poor prognosis for the success of in vitro fertilization.

The Aurora Kinase C c.144delC mutation causes meiosis I arrest in men and is frequent in the North African population

Infertility concerns a minimum of 70 million couples worldwide. An important proportion of cases is believed to have a genetic component, yet few causal genes have been identified so far. In a previous study, we demonstrated that a homozygous mutation (c.144delC) in the Aurora Kinase C (AURKC) gene led to the production of large-headed polyploid multi-flagellar spermatozoa, a primary infertility phenotype mainly observed in North Africans. We now want to estimate the prevalence of the defect, to improve our understanding of AURKC physiopathology in spermatogenesis and assess its implication in oogenesis. A carrier frequency of 1/50 was established from individuals from the Maghrebian general population, comparable to that of Y-microdeletions, thus far the only known recurrent genetic event altering spermatogenesis. A total of 62 patients were genotyped, all who had a typical phenotype with close to 100% large-headed spermatozoa were homozygously mutated (n = 32), whereas no AURKC mutations were detected in the others. Two homozygous females were identified; both were fertile indicating that AURKC is not indispensible in oogenesis. Previous FISH results had showed a great chromosomal heterogeneity in these patient's spermatozoa. We demonstrate here by flow cytometry that all spermatozoa have in fact a homogeneous 4C DNA content and are thus all blocked before the first meiotic division. Our data thus indicate that a functional AURKC protein is necessary for male meiotic cytokinesis while its absence does not impair oogenesis.

Community-based study of unintentional injuries among preschool children in Damascus

To assess injuries among 1125 preschool children in Damascus, and to investigate the risk factors, a retrospective home survey of childhood injuries for a period of 12 months was carried out in 4 areas of residence: agricultural rural, non-agricultural rural, periurban and urban. More than 75% of mothers believed that injuries were preventable. During the year preceding the study, 261 injuries were reported, an incidence of 23%. The most frequent injuries were from falls, 52.0%, and most injuries (73.9%) occurred inside the home. Area of residence was the only independent predictor for the occurrence of childhood injuries.

[Azoospermia: ICSI with synchronous versus non asynchronous testicular sperm retrieval]

We review the improvement made in the management of infertile couples with obstructive and non obstructive azoospermia thanks to ICSI. We present the difficulties encountered in predicting the presence or the absence of spermatozoa in non obstructive azoospermia according to clinical and complementary investigations. Testicular biopsy is the only effective test. We recommend the practice of non synchronic testicular biopsy and sperm freezing to avoid unnecessary ovarian hyperstimulation.

[Voluntary surgical sterilization by laparoscopy in cases of cardiovascular diseases. Prospective study of 19 cases]

Nineteen women with cardiovascular disease underwent voluntary per-celioscopic sterilisation under local anesthesia at the La Rabta Maternity and Neonatology Centre, Tunis, Tunisia, between 1 July 1988 and 31 March 1989. There were 8 cases of hypertension, 1 of mitral insufficiency and 10 cases of surgically treated valve disease (6 cases of commissurotomy for mitral stenosis and 4 valve replacements). Mean parity of the women was 5 and mean age 35.4. Their educational level was low. Thirteen of them had never used contraception and 4 had had at least 2 therapeutic abortions. Local anesthesia with analgesia was well appreciated since 15 women remained calm and experienced no pain. The procedure involved minimal pneumoperitoneum and Trendelenburg. Recourse to minilaparotomy under general anesthesia was necessary in only one case. The authors stress the importance of counselling patients at the onset and of cooperation with cardiologists and anesthesiologists, and discuss peri-operative treatment protocols (anticoagulants, antibiotics) in particular.

[Induction of labor in fetal death in utero using a Foley catheter and extra-amniotic perfusion of physiologic serum]

Nineteen cases of induction of labour by Foley catheter and extra-amniotic perfusion of normal saline for fetal death in utero occurring more than 24 weeks after the LMP were collected in the La Rabta Maternity and Neonatology Centre, Tunis, during the final 6 months of 1987. The mean age of the women was 27.8 and their mean parity 2.9. Two patients had uterine scars. The mean duration of the pregnancy was 33.3 weeks and initial Bishop score was 4 or less. When the catheter fell out, after 26.4 hours on average, the Bishop score had improved by 4.5 points. Labour occurred spontaneously in 5 cases and required oxytocin stimulation in 5 cases. The interval between induction and fetal expulsion was 44.4 hours. Delivery was followed by routine manual evacuation of the uterus. Two complications were seen: one case of accidental rupture of the membranes and one of rupture of the uterus affecting a scarred uterus. The authors point out certain risk factors concerning rupture of the uterus which should be considered to be contraindications to the method. With the exception of these situations, this method of induction is recommended because of its advantages of efficacy, safety and low cost, in particular in developing countries.

[Voluntary surgical sterilization by laparoscopy in the immediate post partum period. Prospective study in 55 cases]

Fifty five voluntary sterilisations were carried out during the immediate post-partum period via celioscopy and under local anesthesia at the La Rabta maternity and neonatology centre, Tunis, between 1 July 1988 and 31 March 1989. The women had a mean age of 34.6, mean parity of 6 and living children of both sexes. Their socio-economic level was low. They had never used any form of contraception in 50 p. cent of cases and 5 among them had undergone at least one termination of pregnancy. Acceptability of local anesthesia with analgesia was good since 71 p. cent of women remained calm during the procedure and experienced no pain. Among the 16 women who reported pain, this occurred above all when the tubes were grasped (10 cases). There were no notable complications. However, sterilisation was not possible in two cases.

[Abdominal pregnancy, a rare anatomoclinical entity. 4 case reports (1981-1990)]

The opportunity is taken, on the basis of 4 cases of abdominal pregnancy and a review of the literature, to attempt to analyse the various aspects of this increasingly rare pathology. Its incidence is low, being evaluated by our own study at 4/85 757 deliveries, i.e.: 1/21 439 deliveries collected at the Maternity and Neonatology centre of Rabta Tunis during a 10-year period (1981-1990). The essential epidemiological factor is the low socio-economic and cultural status seen in the patients studied. Clinical signs were predominated by metrorrhagia, abdominal pain, disturbed intestinal function and fetal death in utero. The delay in diagnosis explains the onset of frequent fetal complications in the form of fetal death in utero (3 cases out of 4) and of various fetal malformations. Ultrasonography is the essential investigation enabling diagnosis in the presence of clinical suspicion. Surgery is obligatory, excluding any attempt in the majority of cases at extraction of the placenta, which is left in place.

[Results at the Rabta Tunis Maternity and Neonatology Center of the surgical treatment of genital prolapse. 193 cases in 7 years (1982-1988)]

The authors report their experience in the treatment of 193 cases of genital prolapse treated surgically in the Rabta Tunis Maternity and Neonatology Unit during a 7 year period between January 1st 1982 and December 31st 1988. The epidemiological characteristics of the study population were dominated by the following factors: advanced age (mean age 54); multiparity (80 per cent of cases); 65.8 per cent of women were post-menopausal. The commonest association of lesions was triple prolapse, present in 78 per cent of cases. Stress incontinence of urine (SIU) was a common feature (59 per cent of cases). Treatment preference was for vaginal hysterectomy combined with anterior colporrhaphy and posterior perineorrhaphy (73.5 per cent). The Kelly Marion operation was often used for SIU (89 per cent of cases) and gave satisfactory results in 73 per cent of cases.

[Large placental chorioangiomas: 2 case reports]

Two cases of large placental chorioangiomas are reported. These tumors gave rise to obstetric and neonatal complications with perinatal death in both cases. These rare tumors were discovered by pathological examination of the products of delivery, with their precise nature being identified histologically. Review of the literature shows that fetal, neonatal and obstetric consequences are multiple and can often be explained by placental and cardiac insufficiency in utero secondary to the presence of these vascular tumors.