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The fertility preservation when it is threatened is a right enshrined in the french law on bioethics. It is most often performed before gonadotoxic treatments for cancers with a long survival. When the patient has a limited life expectancy, is the preservation of fertility lawful? The authors present the arguments for and against the preservation of fertility in this particular situation and give driving they adopt in their team.

El desarrollo de las tecnicas de reproduccion asistida ha permitido la aparicion de las donaciones de gametos y de embriones, asi como la creacion de bancos de semen, de embriones, e incluso de ovocitos desde hace poco. En este articulo se detallan las modalidades de reclutamiento y de seleccion de donantes, asi como las indicaciones de cada tipo de donacion. Tambien se exponen las distintas tecnicas disponibles (inseminacion, fecundacion in vitro simple o con microinyeccion, transferencia sincronica, congelacion de ovocitos, transferencia de embriones congelados), asi como las modalidades de su eleccion y sus resultados. Estos metodos suscitan muchas cuestiones eticas y juridicas: filiacion, secreto, anonimato, remuneracion, proteccion de los donantes, actitud ante las parejas homosexuales y las mujeres solas, riesgo de consanguinidad, etcetera. Existe una gran variabilidad en cuanto a las respuestas en funcion de criterios religiosos, culturales, filosoficos o simplemente personales. En la practica, estas cuestiones han dado origen a legislaciones muy distintas entre los paises. Esta disparidad ha dado lugar en la actualidad a la edad de oro del turismo medico. Por ultimo, se describira la situacion de la legislacion francesa en 2012.

From the literature, the crucial knowledge were drawn among endometriosis related infertility. Endometriosis is an important factor of infertility in minimal or light stages and a major one in mild or moderate stages. Thus, a laparoscopy must be performed to confirm endometriosis when suggestive clinical or biological signs exist. In absence of them, laparoscopy can be delayed after intra-uterine inseminations (IUI). The first line treatment is laparoscopic surgery. Its efficacy is proven. It is useless to prescribe a post-operative medical treatment (GnRH analogues). Surgery leads to 25 to 40% of deliveries. It is dependant on age, infertility duration, tubo-ovarian adhesion and tubes involvement. But, surgery can be avoided and the patient is directly referred to In Vitro Fertilization (IVF) when the lesions extension is so important that surgery exposes to complications or when there is a permanent other indication for IVF (severe male infertility). When infertility persists 6 to 12 months after surgery and without patent recurrence, ovulation stimulations and IUI are performed as the second line treatment. After IUI failure, or in case of recurrence, IVF must be applied. A second surgery is not recommended. The IVF results are not impaired by the presence of endometriosis and even of endometriomas. Thus, it is useless to operate again endometriosis before IVF. In opposition, in severe stages or in cases of recurrence, a pre-IVF medical treatment (GnRH analogues) improves the results. IVF do not increased the risk of endometriosis acute growth. In case of infertility and pain, infertility is considered as the first target. But medical treatment can be prescribed between the IVF attempts.

La conservation ovarienne dans les tumeurs de l’ovaire doit etre envisagee chez toutes les femmes jeunes. Son indication repose principalement sur l’âge, l’extension et le type histologique. Elle permet de preserver la fertilite chez un nombre important de patientes. Les techniques de procreation medicalement assistee peuvent etre un complement dans cette situation.

Resume Objectifs Les auteurs ont etudie le taux d’implantation en fonction de l’administration ou non d’une antibiotherapie preventive lors du transfert embryonnaire en fecondation in vitro (FIV). Materiels et methodes Pendant une periode de 5 mois, toutes les patientes âgees de moins de 38 ans ont ete randomisees selon un critere independant : 2 groupes ont ainsi ete formes, un recevant amoxicilline + acide clavulanique 1 g/125 mg a partir du jour de la ponction et un groupe de controle (sans traitement). Au total 275 patientes ont ete incluses soit 130 dans le groupe antibiotique et 145 dans le groupe controle. Resultats Les deux groupes etaient identiques pour tous les criteres (type de stimulation, rapport FIV/ICSI, indications, âge moyen). Le nombre moyen d’ovocytes recueillis, d’embryons obtenus et d’embryons transferes a ete similaire dans les deux groupes. Le taux d’implantation par transfert a ete similaire (36,9 % versus 36,5 % ; p > 0,95). Le taux cumule de grossesses biologiques, GEU, fausses couches precoces et tardives, a ete plus eleve de facon non significative (p = 0,15) dans le groupe sous antibiotique avec 33,3 % (16/48) contre 20,8 % (11/53) dans le groupe sans antibiotique. Conclusion Cette etude prospective randomisee nous conduit a ne pas recommander la prescription d’antibiotiques du type amoxicilline + acide clavulanique lors du transfert embryonnaire en fecondation in vitro.

To date, little is known about the fertility of women suffering from mucopolysaccharidosis type I (MPS I). We report on a female patient with MPS I treated by allogeneic bone marrow transplantation (BMT) at the age of 4 years (after a conditioning regimen containing busulfan 16 mg/kg and cyclophosphamide 100 mg/kg) who had four successful pregnancies without any reproductive assistance. Clinical and biological examinations of the children were normal. On the basis of this case, we discuss the fertility counselling of female MPS I patients at the time of BMT.

In humans, age-related decline in female fertility can be explained by a reduction in quality either of the older uterus or of the embryos arising from aging oocytes. The aim of this study was to examine the latter hypothesis, using in vitro fertilization (I.V.F.) and co-culture of embryos until the blastocyst stage. We determined the blastocyst formation rate ([blastocysts/embryos on day 2]* 100) and the blastocyst expansion rate ([expanded blastocysts/blastocysts]*100) according to the patient's age the day of I.V.F. With increase in age, the number of retrieved oocytes decreased, without alteration of the cleavage rate. In patients above age 30 years, preimplantation development to blastocysts declined due to an increase in embryo arrest at the morula stage. If blastocyst stage was reached, a negative linear relationship between blastocyst expansion rate and patient age was observed. Drops in gamete production and embryo development with increasing age led to a drastic decrease in patients having at least one expanded blastocyst (

Cytogenetic studies of arrested oocytes and zygotes were used to understand in vitro fertilization (IVF) failures.We investigated the cytogenetics (Giemsa banding and FISH) of 710 uncleaved oocytes and 94 arrested zygotes from 208 patients undergoing IVF procedures.Of uncleaved oocytes without a polar body, 39% were judged cytogenetically abnormal (17% unbalanced predivision and 21.5% diploid). Of 575 oocytes with a polar body, 124 (21.5%) showed numerical or structural chromosome aberrations. In arrested zygotes, approximately equal cases were found with separate condensed haploid complements (no syngamy), nuclear asynchrony and pulverized DNA, and apparently cytogenetically normal zygotes arrested at mitosis. These data on chromosome abnormalities were also analyzed with respect to two ovarian stimulation protocols and to maternal age. Both ovarian stimulation protocols and to maternal age. Both ovarian stimulation protocols showed the same levels of chromosome abnormalities. Overall chromosome abnormalities and premature chromosome condensation were also unchanged with maternal age. These data illustrate the significance of chromosome aberrations in IVF failures.

Co-culture systems have been designed to overcome the embryonic developmental arrest observed in vitro in conventional culture media. Oviduct and uterine epithelial cells can sustain embryonic development, as can trophoblastic tissue and transport epithelia of non-genital origin. Its benefits involve neither hormone dependency nor histo-specificity. Fibroblasts do not overcome the developmental arrest in most mammalian species, but whether they do in humans is still unsure. In all systems, the quality of the feeder cells and the co-culture medium are very important. Using the Vero cell line, 60% of human IVF embryos reach the blastocyst stage. The quality of the sperm seems to affect results. We have observed: For 10% of the patients with unexplained fertility, blastocyst stage is not attained; this probably involves a maternal (ovarian) problem. When at least one blastocyst is transferred, the pregnancy rate per transfer is 31%. The implantation rate in pregnant women is higher than after transfer at day 2. After repeated failures of transfer at early stages (2-6 cells), transfer at the blastocyst stage gives high pregnancy rates (40%). This indicates an in vitro selection. There is a strong paternal effect on blastocyst formation: poor quality sperm give lower rates of blastocyst. Co-culture helps to understand treatment failures related to male factors. Around 60% of the patients having spare embryos have had blastocysts frozen. Transfers of frozen-thawed blastocysts give a 20% pregnancy rate and an implantation rate per embryo of 11%. Co-culture is a new tool which has to be carefully evaluated in human IVF programs. It does not impair "a minima" embryo viability and it allows in vitro selection.(ABSTRACT TRUNCATED AT 250 WORDS)

Malgre de multiples recherches, ni l’etiologie de l’endometriose, ni sa physiopathologie dans l’infertilite n’ont pu etre elucidees hormis les cas d’endometriose severes ou existe un facteur mecanique (1–3).

Seminal fluid inhibits sperm capacitation mainly because of its high cholesterol content. Prostasomes are the main source of cholesterol in seminal fluid. They are known to have numerous protective properties and are able to transfer proteins and lipids to spermatozoa, but their impact on capacitation and acrosome reaction (AR) is not yet well understood. The aim of this study was to determine the effects of prostasomes on human sperm capacitation and AR. After 80% Percoll selection, freshly ejaculated human spermatozoa were incubated for 3 h under capacitating conditions with prostasomes, phosphodiesterase inhibitor 3-iso-butyl-methylxantine (IBMX), or a combination of prostasomes and IBMX. Physiological concentration of prostasomes significantly decreased tyrosine phosphorylation levels of human sperm capacitation markers P110 and P80 (p0.01), and the proportions of capacitated (p0.05) and acrosome-reacted spermatozoa (p0.05). Prostasomes significantly increased the proportion of spermatozoa that did not incorporate propidium iodide and significantly attenuated the effect of IBMX on P110 tyrosine phosphorylation. Prostasomes had no effect on the pH(i) increase associated with capacitation. They significantly increased intracellular cAMP concentration ([cAMP](i)) and, when prostasomes and IBMX were present together, [cAMP](i) was further increased. To our knowledge, this is the first study to show clearly that prostasomes inhibit capacitation and spontaneous AR.

A stage IIIA borderline serous ovarian tumour was treated conservatively by laparoscopy to preserve the fertility of a 21 year old nulligravid woman. Six months later, recurrent lesions were resected. An 'urgent' IVF was performed to obtain frozen embryos. Oncological treatment was then completed by radical surgery with uterine conservation. Fifteen months later, two thawed embryos were successfully transferred and the patient delivered one baby. From this observation, the authors discuss an alternative to oocyte donation in cases of bilateral ovariectomy for stage IIIA borderline serous ovarian tumour.

A combination of an extra-uterine and an intra-uterine pregnancy is defined as heterotopic pregnancy. An infertile patient, pregnant at her fourth in-vitro fertilization/embryo transfer attempt, was diagnosed at 21 weeks' gestation as having simultaneous abdominal and intra-uterine pregnancy. Expectant management under strict hospitalization was proposed and accepted by the couple, fetal assessment was by serial ultrasound evaluation of growth and amniotic fluid volume and by non-stress tests. Planned operative delivery was accomplished at 34 weeks' gestation. Both the mother and infants are alive and well.

In humans, age-related decline in female fertility can be explained by a reduction in quality either of the older uterus or of the embryos arising from aging oocytes. The aim of this study was to examine the latter hypothesis, using in vitro fertilization (I.V.F.) and coculture of embryos until the blastocyst stage. We determined the blastocyst formation rate ([blastocysts/embryos on day 2]* 100) and the blastocyst expansion rate ([expanded blastocysts/blastocysts]* 100) according to the patient's age the day of I.V.F. With increase in age, the number of retrieved oocytes decreased, without alteration of the cleavage rate. In patients above age 30 years, preimplantation development to blastocysts declined due to an increase in embryo arrest at the morula stage. If blastocyst stage was reached, a negative linear relationship between blastocyst expansion rate and patient age was observed. Drops in gamete production and embryo development with increasing age led to a drastic decrease in patients having at least one expanded blastocyst (30 years, 82%;or = 40 years, 36%). A high delivery rate per oocyte retrieval (25.8%) was observed in patients above age 40 years after embryo transfer at the blastocyst stage. These results give a clear indication of decline in the quality of human embryos arising from aging oocytes. The origin of this alteration is discussed in terms of chromosome abnormalities, role of maternally-inherited products from the oocyte, timing of genomic activation, and temporal pattern of gene expression during initial development of the human embryo.

Co-culture systems have been designed to overcome the embryonic developmental arrest observed in vitro in conventional culture media. Oviduct and uterine epithelial cells can sustain embryonic development, as can trophoblastic tissue and transport epithelia of non-genital origin. Its benefits involve neither hormone dependency nor histo-specificity. Fibroblasts do not overcome the developmental arrest in most mammalian species, but whether they do in humans is still unsure. In all systems, the quality of the feeder cells and the co-culture medium are very important. Using the Vero cell line, 60% of human IVF embryos reach the blastocyst stage. The quality of the sperm seems to affect results. We have observed: For 10% of the patients with unexplained fertility, blastocyst stage is not attained; this probably involves a maternal (ovarian) problem. When at least one blastocyst is transferred, the pregnancy rate per transfer is 31%. The implantation rate in pregnant women is higher than after transfer at day 2. After repeated failures of transfer at early stages (2-6 cells), transfer at the blastocyst stage gives high pregnancy rates (40%). This indicates an in vitro selection. There is a strong paternal effect on blastocyst formation: poor quality sperm give lower rates of blastocyst. Co-culture helps to understand treatment failures related to male factors. Around 60% of the patients having spare embryos have had blastocysts frozen. Transfers of frozen-thawed blastocysts give a 20% pregnancy rate and an implantation rate per embryo of 11%. Co-culture is a new tool which has to be carefully evaluated in human IVF programs. It does not impair "a minima" embryo viability and it allows in vitro selection.(ABSTRACT TRUNCATED AT 250 WORDS)

In human in vitro fertilization (I.V.F.), it was first assumed that all the embryos obtained had the same developmental potential whatever the quality of sperm. However, this has not been confirmed. We have used the coculture technique and determined the blastocyst formation rate in three groups of patients: group 1: patients with normal sperm count (> 20 x 10(6)/ml), motility (> 30%), and morphology (> 50%); group 2: patients treated by I.V.F. with frozen donor sperm; group 3: patients with severely impaired sperm quality (< 3 x 10(6) forward motile and morphologically normal spermatozoa per ml). In group 1, we found a strong correlation between cleavage rate and blastocyst formation rate (P < 0.0001) with a blastocyst formation rate comprised between 40% and 50%. This was not true for the two other groups for which the overall number of blastocysts obtained and the number of patients having at least one blastocyst were severely reduced (P < 0.0001). These data are discussed in terms of DNA quality, timing of formation of the pronuclei, and delays in cell cycles at the time of genomic activation. These observations lead to a new approach to the study of fertilizing ability of poor quality sperm. It may help in the decision as to whether couples treated for male infertility should be excluded from I.V.F. protocols.

Whatever the culture medium, embryo culture generally leads to a major loss of viability in mouse, rabbits even if the morphological development of the embryo is preserved. Moreover, Embryo metabolism is commonly depressed in culture media. The protein turnover is accelerated and the quality of the metabolites transport systems is impaired. Various coculture systems have been designed to avoid this loss of viability and in some animal species, to overcome the so called "embryo developmental arrest" usually observed at the approximate time of genomic activation. Moreover, it is clear now that cocultured embryos have usually higher cells numbers than those observed for embryos cultured in classical culture media. In the human, the problems seem less complicated because embryos can be transferred into the uterus on the second day post fertilization, at a time when they would normally be in the Fallopian tube: this is not possible in animal species. Also, blastocysts can be obtained, even at low rates, in conventional culture media and there is no apparent block of development. In this paper, we will present an overview of Cocultures in different species. Then, we will focus on the Human including the blastocyst formation rate and freezing at the Blastocyst stage. At the beginning of the Story, For coculturing, 2 ideas were put forward: The use of embryonic tissue (trophoblast) to help the embryo through an autocrine effect. The use of female genital tract cells, to assist the embryo through a paracrine effect.

Fluorescence in-situ hybridization with DNA probes for X, Y and no. 18 chromosomes was used to analyse human morulae (n = 13) and blastocysts (n = 41), obtained after co-culture on Vero cells. On the basis of the number of hybridization signals, the proportion of embryos with more than five polyploid cells was 30.8% for morulae and 29.3% for blastocysts. These values are similar to those for mixoploidy (mosaicism of diploid and polyploid cells) observed in blastocysts of animal species. The results were confirmed by scanning electron microscopy, which showed a wide variation in the size of blastocyst nuclei, and by classical cytogenetic analysis. Mixoploidy seems to be a normal feature in preimplantation embryos and to occur very early in human embryo development. This lays open to doubt the preimplantation diagnosis of genetic errors at these stages, since results obtained from single cell analysis may not be representative of the whole embryo.

A combination of an extra-uterine and an intra-uterine pregnancy is defined as heterotopic pregnancy. An infertile patient, pregnant at her fourth in-vitro fertilization/embryo transfer attempt, was diagnosed at 21 weeks' gestation as having simultaneous abdominal and intra-uterine pregnancy. Expectant management under strict hospitalization was proposed and accepted by the couple, fetal assessment was by serial ultrasound evaluation of growth and amniotic fluid volume and by non-stress tests. Planned operative delivery was accomplished at 34 weeks' gestation. Both the mother and infants are alive and well.

Sperm examination, quantitative sperm culture, citric acid, acid phosphatase, and fructose were assayed in three groups of men: fertile controls without significant bacteriospermia (group I), infertile men with significant bacteriospermia; idiopathic infertile men (group II), and infertile men with varicocele (group III). Level of significance of bacteriospermia was greater than or equal to 10(4) germs/ml of ejaculate. In group II, motility and typical morphology percentages were lower, independently of the degree and the nature of bacteriospermia. Incidence of pathogenic bacteria was higher than in group III and linked to the degree of bacteriospermia. Fructose was unaltered in the two groups of infected men. No modification of prostatic markers was observed in any groups, except in group II, where they decreased when bacteriospermia was lower than 10(5) germs/ml and when biological pattern of semen evoked chronic prostatitis. Thus, the presence of germs in ejaculate alters the motility and the typical morphology percentages but does not result in any obvious modifications of biochemical markers of prostate and seminal vesicles. For idiopathic infertile men, it is suggested that the quantitative criterion of pathogenic bacteriospermia is a germ count greater than or equal to 10(5)/ml.

Intracranial pressure (ICP) is, now, a familiar concept, its major variations being identifiable and admitting physiopathological interpretation.