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Research question Can cannabis consumption alter sperm nuclear integrity in infertile men? Design A retrospective cross-sectional study conducted between July 2003 and December 2013, which included 54 men who consulted for male-factor infertility. Twenty-seven infertile men who were regular cannabis users were matched to 27 infertile men who were cannabis non-users. To complement the conventional semen parameter and plasma hormone level assessments, sperm nuclear alterations were explored using fluorescence in-situ hybridization to assess numerical chromosomal abnormalities, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling to investigate DNA fragmentation, aniline blue staining to examine chromatin condensation and a motile sperm organelle morphology examination to detect vacuoles in sperm heads. Results The rates of sperm aneuploidy (P = 0.0044), diploidy (P = 0.037), total chromosome abnormalities (P = 0.0027) and DNA fragmentation (P = 0.027) were significantly higher in cannabis users than in non-cannabis users. Conclusions Cannabis consumption might have deleterious effects on sperm nuclear quality in infertile men by increasing numerical chromosome abnormalities and DNA fragmentation. Cannabis consumption induces these detrimental effects on the progression of spermatogenesis from meiotic stages to spermiogenesis and potentially on post-testicular sperm maturation in infertile men. Any potential findings, however, need to be validated with larger sample size, and our data are only exploratory findings.

Previous preclinical and preliminary clinical data suggest an appetite-stimulating effect of propofol compared with halogenated drugs. This study compared the effects of propofol with those of sevoflurane on recovery of hunger during the postoperative period.Patients undergoing outpatient transvaginal oocyte retrieval were randomized to propofol-remifentanil (propofol group) or sevoflurane-remifentanil (sevoflurane group) anesthesia. The primary endpoint was the time before feeling hungry (≥ 50/100 mm on a visual analogue scale). Secondary endpoints included plasma levels of ghrelin, leptin, and insulin (ten minutes, one hour, and two hours after anesthesia), caloric intake at first feed, and discharge readiness time.In the 58 patients allocated to either the propofol or sevoflurane group, there was no difference in the median [interquartile range] recovery time of hunger (97 [75-138] vs 97 [80-140] min, respectively; median difference, 1; 95% confidence interval [CI], - 15 to 14; P = 0.91); caloric intake (245 [200-343] vs 260 [171-314] kcal; P = 0.39); or discharge readiness time (125 [85-153] vs 125 [95-174] min, P = 0.29). The groups showed no difference in crude plasma levels of ghrelin, leptin, and insulin at any time-point. When peptide plasma levels were expressed as a % change from baseline, there was a higher insulin plasma level one hour after anesthesia in the sevoflurane group (median difference, 4.9%; 95% CI, - 16.2 to 43.4) compared with the propofol group (median difference, - 21.2%; 95% CI, - 35.7 to 9.1; adjusted P = 0.01).Propofol did not accelerate the recovery of hunger compared with sevoflurane after outpatient minor surgery. Moreover, propofol did not have distinguishable effects on other clinical or biological parameters associated with food intake.www.ClinicalTrials.gov (NCT02272166); registered 22 October, 2014.RéSUMé: OBJECTIF: Des données précliniques et cliniques préliminaires suggèrent un effet de stimulation de l’appétit du propofol par rapport aux gaz halogénés. Cette étude a comparé les effets du propofol à ceux du sévoflurane sur le rétablissement de la faim en période postopératoire. MéTHODE: Des patientes subissant un prélèvement des ovocytes par voie transvaginale ont été randomisées à recevoir une anesthésie à base de propofol et rémifentanil (groupe propofol) ou de sévoflurane et rémifentanil (groupe sévoflurane). Le critère d’évaluation principal était la période de temps avant de ressentir de la faim (≥ 50/100 mm sur une échelle visuelle analogique). Les critères d’évaluation secondaires comprenaient les taux plasmatiques de ghréline, de leptine et d’insuline (à dix minutes, une heure et deux heures après l’anesthésie), l’apport calorique lors du premier repas, et le moment où les patientes étaient prêtes à recevoir leur congé. RéSULTATS: Chez les 58 patientes allouées aux groupes propofol ou sévoflurane, aucune différence n’a été observée dans le temps médian [écart interquartile (ÉIQ)] jusqu’à retour de la faim (97 [75–138] vs 97 [80–140] min, respectivement; différence médiane, 1; intervalle de confiance [IC] 95 %, − 15 à 14; P = 0,91), ni dans l’apport calorique (245 [200–343] vs 260 [171–314] kcal; P = 0,39) ou le moment où elles étaient prêtes à recevoir leur congé (125 [85-153] vs 125 [95-174] min, P = 0,29). Les groupes n’ont démontré aucune différence en matière de taux plasmatiques de ghréline, de leptine et d’insuline à quelque point dans le temps que ce soit. Lorsque les taux plasmatiques de peptides étaient exprimés en % de changement par rapport aux taux de base, on a observé un taux plasmatique plus élevé d’insuline une heure après l’anesthésie dans le groupe sévoflurane (différence médiane, 4,9 %; IC 95 %, − 16,2 à 43,4) par rapport au groupe propofol (différence médiane, − 21,2 %, IC 95 %, − 35,7 à 9,1; P ajusté = 0,01). CONCLUSION: Le propofol n’a pas accéléré le retour de la faim par rapport au sévoflurane après une chirurgie ambulatoire mineure. De plus, le propofol n’a pas démontré d’effets distinctifs sur d’autres paramètres cliniques ou biologiques associés à l’ingestion de nourriture. ENREGISTREMENT DE L’éTUDE: www.ClinicalTrials.gov (NCT02272166); enregistrée le 22 octobre 2014.

Hormonal contraceptives remain among the most popular methods used by women. The purpose of this work is to review the effectiveness and use of these different methods. In addition, some side-effects are feared and/or frequently reported by users of hormonal contraceptives: unscheduled bleeding, acne, catamenial migraines, weight gain, libido and/or mood disorders. In this review of the literature, the accountability of hormonal contraceptives for the occurrence of some of these side-effects was discussed and a management strategy was proposed.

International audience; Colorectal surgeons often participate in the multidisciplinary management of young females with endometriosis. Complications of endometriosis as well as its management often result in infertility since they can involve all pelvic organs including the procreative organs: uterus, ovaries and fallopian tubes. Complete excision of all endometriotic lesions should not be performed at the expense of irreversible destruction of the procreative organs; definitive infertility should not be the price to pay in order to obtain an improvement of the painful symptoms caused by endometriosis. Surgery for ovarian endometriomas should be specifically adapted to the patient's desire for future conception and to her preoperative ovarian reserve. Two main techniques are used to treat ovarian endometriomas: ovarian cystectomy excises the wall of the cyst while ablation consists of destruction of the internal surface of the cyst. The use of mono polar or biolar coagulation for cyst ablation is strongly contra-indicated. Ablation using laser or plasma energy has resulted in comparable rates of post-operative pregnancy to those obtained by ovarian cystectomy. Patients who wish to delay their attempt to conceive for some period of time, should be placed on long-term oral contraception with prevention of menstruation to reduce the risk of recurrent endometriosis. When surgery for colorectal endometriosis is necessary, the laparoscopic approach increases the chances of spontaneous conception compared to laparotomy. Surgery for deep-seated endometriosis has been accompanied by a high rate of spontaneous conception and successful pregnancy and does not seem to decrease the chances for conception by in vitro fertilization.

Deeply infiltrating endometriosis is a severe form of the disease, defined by endometriotic tissue peritoneal infiltration. The disease may involve the rectovaginal septum, uterosacral ligaments, digestive tract or bladder. Deeply infiltrating endometriosis is responsible for disabling pain and infertility. The purpose of these recommendations is to answer the following question: in case of deeply infiltrating endometriosis associated infertility, what is the best therapeutic strategy? First-line surgery and then in vitro fertilization (IVF) in case of persistent infertility or first-line IVF, without surgery? After exhaustive literature analysis, we suggest the following recommendations: studies focusing on spontaneous fertility of infertile patients with deeply infiltrating endometriosis found spontaneous pregnancy rates about 10%. Treatment should be considered in infertile women with deeply infiltrating endometriosis when they wish to conceive. First-line IVF is a good option in case of no operated deeply infiltrating endometriosis associated infertility. Pregnancy rates (spontaneous and following assisted reproductive techniques) after surgery (deep lesions without colorectal involvement) varie from 40 to 85%. After colorectal endometriosis resection, pregnancy rates vary from 47 to 59%. The studies comparing the pregnancy rates after IVF, whether or not preceded by surgery, are contradictory and do not allow, to date, to conclude on the interest of any surgical management of deep lesions before IVF. In case of alteration of ovarian reserve parameters (age, AMH, antral follicle count), there is no argument to recommend first-line surgery or IVF. The study of the literature does not identify any prognostic factors, allowing to chose between surgical management or IVF. The use of IVF in the indication "deep infiltrating endometriosis" allows satisfactory pregnancy rates without significant risk, regarding disease progression or oocyte retrieval procedure morbidity.

STUDY QUESTION What are the fertility outcomes in women wishing to conceive after experiencing a severe complication from surgical removal of colorectal endometriosis? SUMMARY ANSWER The pregnancy rate (PR) among women who wished to conceive after a severe complication of surgery for colorectal endometriosis was 41.2% (spontaneously for 80%, after ART procedure for 20%). WHAT IS KNOWN ALREADY While the long-term benefit of surgery on pain and quality of life is well documented for women with colorectal endometriosis, it exposes women to the risk of severe complications. However, little is known about fertility outcomes in women experiencing such severe postoperative complications. STUDY DESIGN, SIZE, DURATION This retrospective cohort study included women who experienced a severe complication after surgery for colorectal endometriosis between January 2004 and June 2014, and who wished to conceive. A total of 53 patients met the inclusion criteria. The fertility outcome was available for 48 women, who were therefore included in the analysis. The median follow-up was 5 years. PARTICIPANTS/MATERIALS, SETTING, METHODS All the women underwent complete removal of colorectal endometriosis. Postoperative severe complications were defined as grades III-IV of the Clavien-Dindo classification. Fertility outcomes, PR and cumulative pregnancy rate (CPR), were estimated. MAIN RESULTS AND THE ROLE OF CHANCE Most women experienced a grade IIIb complication (83.3%). Of 48 women, 20 became pregnant (overall PR: 41.2%); spontaneously for 16 (80%) and after ART procedure for 4 (20%). The median interval between surgery and first pregnancy was 3 years. The live birth rate was 14/48 (29.2%). The 5-year CPR was 46%. A lower CPR was found for women who experienced anastomotic leakage (with or without rectovaginal fistula) (P = 0.02) or deep pelvic abscess (with or without anastomotic leakage) (P = 0.04). LIMITATIONS REASONS FOR CAUTION Due to a lack of information, no sub-analysis was done to investigate other parameters potentially impacting fertility outcomes. WIDER IMPLICATIONS OF THE FINDINGS The PR for our population was slightly lower to that observed in the literature for women who experience such surgery without consideration for the occurrence of complications. However, 'severe complications' covers a range of conditions which are likely to have a very different impacts on fertility. Even if the PR and CPR appear satisfactory, septic complications can negatively impact fertility outcomes. Rapid ART may be a good option for these patients. STUDY FUNDING/COMPETING INTEREST(S) No funding was required for the current study. Pr H. Roman reported personal fees from Plasma Surgical Inc. (Roswell, GA, USA) for participating in a symposium and a masterclass, in which he presented his experience in the use of PlasmaJet®. None of the other authors declared any conflict of interest. TRIAL REGISTRATION NUMBER N/A.

Study Objective To report postoperative outcomes after dual digestive resection for deep endometriosis infiltrating the rectum and the colon. Design A retrospective study using data prospectively recorded in the CIRENDO database (Canadian Task Force classification II-2). Setting A university tertiary referral center. Patients Twenty-one patients managed for multiple colorectal deep endometriosis infiltrating nodules. Interventions Concomitant disc excision and segmental resection of both the rectum and sigmoid colon. Measurements and Main Results The assessment of postoperative outcomes was performed. Rectal nodules were managed by disc excision and segmental resection in 20 patients and 1 patient, respectively. Sigmoid colon nodules were removed by short segmental resection and disc excision in 15 and 6 patients, respectively. The rectal nodule diameter was between 1 and 3 cm and over 3 cm in 33% and 67% of patients, respectively. Associated vaginal infiltration requiring vaginal excision was recorded in 76.2% of patients. The mean diameter of the rectal disc removed averaged 4.6 cm, and the mean height of the rectal suture was 5.8 cm. The length of the sigmoid colon specimen and the height of the anastomosis were 7.3 cm and 18.5 cm, respectively. The mean operative time was 290 minutes, and the mean postoperative follow-up averaged 30 months. Clavien-Dindo 3 complications occurred in 28% of patients, including 4 with rectal fistulae (19%). The pregnancy rate was 67% among patients with pregnancy intention. Conclusion Our data suggest that combining disc excision and segmental resection to remove multiple deep endometriosis nodules infiltrating the rectum and the sigmoid colon can preserve the healthy bowel located between 2 consecutive nodules. However, the rate of postoperative complications is high, particularly in patients with large low rectal nodules.

To evaluate postoperative complications, digestive function and fertility outcomes in patients managed by rectal shaving using plasma energy in deep infiltrating endometriosis of the rectum.A single-center retrospective cohort study using data recorded prospectively.Canadian Task Force classification II-2.Department of Gynecology and Obstetrics of Rouen University Hospital (France).One hundred and ten patients treated between December 2012 and December 2016.Laparoscopic rectal shaving using plasma energy.Clinical history, baseline symptoms, preoperative assessment, intraoperative findings, and postoperative outcomes were recorded prospectively. Follow-up evaluations were performed at 1 year and 3 years. Mean age of patients was 37 ± 6.4 years. Most patients had rectal nodules infiltrating either the mid or upper rectum and measuring3 cm long. No intraoperative complications were recorded. One patient with multiple previous surgical procedures presented with a postoperative rectovaginal fistula (0.9%), and 1 patient presented with a postoperative rectouterine fistula treated exclusively with antibiotics (0.9%). Two patients (1.8%) had bladder atony necessitating ≥3 weeks of daily self-catheterization. Four patients (3.6%) had Clavien-Dindo grade I complications, 12 (10.9%) had grade II complications, 1 (0.9%) had a grade IIIa complication, 5 (4.5%) had grade IIIb complications, and 1 (0.9%) had a grade 4a complication. The vast majority of patients (n = 103 patients; 93.6%) were free of serious complications. Significant improvements in constipation and gastrointestinal quality of life were recorded at 1 year and 3 years postoperatively. Thirty-two patients attempted pregnancy after surgery (29.1%), and 17 of them conceived (53.1%).Rectal shaving using plasma energy allows for a low rate of postoperative complications with good digestive function and fertility outcomes and appears to be suitable in selected women with symptomatic rectal endometriosis.

Objective To report the outcomes of surgical management of urinary tract endometriosis. Design Retrospective study based on prospectively recorded data (NCT02294825) (Canadian Task Force classification II-3). Setting University tertiary referral center. Patients Eighty-one women treated for urinary tract endometriosis between July 2009 and December 2015 were included, including 39 with bladder endometriosis, 31 with ureteral endometriosis, and 11 with both ureteral and bladder endometriosis. Owing to bilateral ureteral localization in 8 women, 50 different ureteral procedures were recorded. Intervention Procedures performed included resection of bladder endometriosis nodules, advanced ureterolysis, ureteral resection followed by end-to-end anastomosis, and ureteroneocystostomy. Measurements and Main Results The main outcome measure was the outcome of the surgical management of urinary tract endometriosis. Fifty women presented with deep infiltrating endometriosis (DIE) of the bladder and underwent either full-thickness excision of the nodule (70%) or excision of the bladder wall without opening of the bladder (30%). Ureteral lesions were treated by ureterolysis in 78% of the patients and by primary segmental resection in 22%. No patient required nephrectomy. Histological analysis revealed intrinsic ureteral endometriosis in 54.5% of cases. Clavien–Dindo grade III complications were present in 16% of the patients who underwent surgery for ureteral nodules and in 8% of those who underwent surgery for bladder endometriosis. Overall delayed postoperative outcomes were favorable regarding urinary symptoms and fertility. Patients were followed up for a minimum of 12 months and a maximum of 7 years postoperatively, with no recorded recurrences. Conclusion Surgical outcomes of urinary tract endometriosis are generally satisfactory; however, the risk of postoperative complications should be taken into consideration. Therefore, all such procedures should be managed by an experienced multidisciplinary team.

International audience; Over the last decade, the number of cancer survivors has increased thanks to progress in diagnosis and treatment. Cancer treatments are often accompanied by adverse side effects depending on the age of the patient, the type of cancer, the treatment regimen, and the doses. The testicular tissue is very sensitive to chemotherapy and radiotherapy. This review will summarize the epidemiological and experimental data concerning the consequences of exposure to chemotherapy during the prepubertal period or adulthood on spermatogenic progression, sperm production, sperm nuclear quality, and the health of the offspring. Studies concerning the gonadotoxicity of anticancer drugs in adult survivors of childhood cancer are still limited compared with those concerning the effects of chemotherapy exposure during adulthood. In humans, it is difficult to evaluate exactly the toxicity of chemotherapeutic agents because cancer treatments often combine chemotherapy and radiotherapy. Thus, it is important to undertake experimental studies in animal models in order to define the mechanism involved in the drug gonadotoxicity and to assess the effects of their administration alone or in combination on immature and mature testis. These data will help to better inform cancer patients after recovery about the risks of chemotherapy for their future fertility and to propose fertility preservation options.

Objective To assess the relationship between age, location of the disease, and surgical procedures performed in patients undergoing surgical management of endometriosis. Design Retrospective study using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis database. Setting University tertiary referral center. Patients Women who underwent surgical management of symptomatic endometriosis between April 2009 and April 2014. Interventions Patients were allocated to 6 groups according to their age at the time of surgery: ≤20, 21 to 25, 26 to 30, 31 to 35, 36 to 40 and >40 years. Patient characteristics, prior history, location of endometriotic lesions, stage of disease, intraoperative findings, and surgical procedures were retrieved from a prospectively recorded database. Measurements and Main Results Patient characteristics, symptoms, location of endometriosis, and type of surgery performed were compared between groups. In total, 1560 procedures were performed. Of these, more than one-half were carried out in women between the age of 26 to 35 years and the majority were performed in women aged between 26 and 30 years. Only 2% of procedures were performed in women under the age of 20 years. The mean stage of the disease at the time of surgical diagnosis was stage II for women younger than 20 years, stage III for those in the age group of 21 to 25 years, and stage IV for those older than 26 years. The rate of diagnosis of deep colorectal nodules increased progressively from 20 to 26 years and remained stable thereafter. Conclusion Our data confirm that endometriosis is a disease that probably progresses from adolescence until the adult period when symptoms (pain or infertility) become debilitating and require surgery. Our data suggest that policies relating to the prevention and early diagnosis of endometriosis should focus on women younger than 25 years.

STUDY QUESTION Is there a difference in functional outcomes and recurrence rate between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 5 years postoperatively? SUMMARY ANSWER No evidence was found that long-term outcomes differed when nodule excision was compared to rectal resection for deeply invasive endometriosis involving the bowel. WHAT IS KNOWN ALREADY Functional outcomes of nodule excision and rectal resection for deeply invasive endometriosis involving the bowel are comparable 2 years after surgery. Despite numerous previously reported case series enrolling patients managed for colorectal endometriosis, long-term data remain scarce in the literature. STUDY DESIGN, SIZE, DURATION From March 2011 to August 2013, we performed a two-arm randomized trial, enrolling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring >20 mm in length, involving at least the muscular layer in depth, and up to 50% of rectal circumference. Among them, 55 women were enrolled at one tertial referral centre in endometriosis, using a randomization list drawn up separately for this centre. Institute review board approval was obtained to continue follow-up to 10 years postoperatively. One patient requested to stop the follow-up 2 years after surgery. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients underwent either nodule excision by shaving or disc excision, or segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of randomization results. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation (1 stool/>5 consecutive days), frequent bowel movements (≥3 stools/day), anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were values taken from the Knowles–Eccersley–Scott-symptom questionnaire (KESS), the gastrointestinal quality of life index (GIQLI), the Wexner scale, the urinary symptom profile (USP) and the Short Form 36 Health Survey (SF36). MAIN RESULTS AND THE ROLE OF CHANCE Fifty-five patients were enrolled. Among the 27 patients in the excision arm, two were converted to segmental resection (7.4%). One patient managed by segmental resection withdrew from the study 2 years postoperatively, presuming that associated pain of other aetiologies may have jeopardized the outcomes. The 5 year-recurrence rate for excision and resection was 3.7% versus 0% (P = 1), respectively. For excision and resection, the primary endpoint was present in 44.4% versus 60.7% of patients (P = 0.29), respectively, while 55.6% versus 53.6% of patients subjectively reported normal bowel movements (P = 1). An intention-to-treat comparison of overall KESS, GIQLI, Wexner, USP and SF36 scores did not reveal significant differences between the two arms 5 years postoperatively. Statistically significant improvement was observed shortly after surgery with no further improvement or impairment recorded 1–5 years postoperatively. During the 5-year follow-up, additional surgical procedures were performed in 25.9% versus 28.6% of patients who had undergone excision or resection (P = 0.80), respectively. LIMITATIONS, REASONS FOR CAUTION The presumption of a 40% difference concerning postoperative functional outcomes in favour of nodule excision resulted in a lack of power for demonstration of the primary endpoint difference. WIDER IMPLICATIONS OF THE FINDINGS Five-year follow-up data do not show statistically significant differences between conservative and radical rectal surgery for long-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum. STUDY FUNDING/COMPETING INTEREST(S) No specific funding was received. Patient enrolment and follow-up until 2 years postoperatively was supported by a grant from the clinical research programme for hospitals in France. The authors declare no competing interests related to this study. TRIAL REGISTRATION NUMBER This randomized study is registered with ClinicalTrials.gov, number NCT 01291576. TRIAL REGISTRATION DATE 31 January 2011. DATE OF FIRST PATIENT’S ENROLMENT 7 March 2011.

Objective Endometriosis affects 10% of women in reproductive age and alters fertility. Its management is still debated notably the timing of surgery and ART in infertility. Several tools have been created to guide the practitioner and the couple yet many limitations persist. The objective is to create a nomogram to predict the likelihood of a live birth after surgery followed by assisted reproductive technology (ART) for patients with endometriosis-related infertility. Study design All women in a public university hospital who attempted to conceive by ART after surgery for endometriosis-related infertility from 2004 to 2016 were included. We created a model using multivariable linear regression based on a retrospective database. Result Of the 297 women included, 171 (57.6%) obtained a live birth. Age, duration of infertility, number of ICSI-IVF cycles, ovarian reserve and the revised American Fertility Society (rAFS) score were included in the nomogram. The predictive model had an area under the curve (AUC) of 0.77 (95% CI, 0.75–0.79) and was well calibrated. The external validation of the model was achieved with an AUC of 0.71 (95% CI, 0.69–0.73) and calibration was good. The staging accuracy according to AUC criteria for the nomogram compared to the currently used Endometriosis Infertility Index to predict live births were 0.77 (95% CI, 0.75–0.79) and 0.60 (95% CI: 0.57–0.63), respectively. Conclusion This simple tool appears to accurately predict the likelihood of a live birth for a patient undergoing ART after surgery for endometriosis-related infertility. It could be used to counsel patients in their choice between spontaneous versus ART conception, or oocyte donation.

Polycystic ovary syndrome (PCOS) and hyperprolactinemia (HPRL) are the two most common etiologies of anovulation in women.Since the 1950s, some authors think that there is a pathophysiological link between PCOS and HPRL. Since then, many authors have speculated about the link between these two endocrine entities, but no hypothesis proposed so far could ever be confirmed. Furthermore, PCOS and HPRL are frequent endocrine diseases and a fortuitous association cannot be excluded.The evolution of knowledge about PCOS and HPRL shows that studies conducted before the 2000s are obsolete given current knowledge. Indeed, most of the studies were conducted before consensual diagnosis criteria of PCOS and included small numbers of patients. In addition, the investigation of HPRL in these studies relied on obsolete methods and did not look for the presence of macroprolactinemia. It is therefore possible that HPRL that has been attributed to PCOS corresponded in fact to macroprolactinemia or to pituitary microadenomas of small sizes that could not be detected with the imaging methods of the time.Recent studies that have conducted a rigorous etiological investigation show that HPRL found in PCOS correspond either to non-permanent increase of prolactin levels, to macroprolactinemia or to other etiologies. None of this recent study found HPRL related to PCOS in these patients.Thus, the link between PCOS and HPRL seems to be more of a myth than a well-established medical reality and we believe that the discovery of an HPRL in a PCOS patient needs a standard etiological investigation of HPRL.

International audience; Emerging evidence suggests that bariatric surgery improves pregnancy outcomes of women with obesity by reducing the rates of gestational diabetes, pregnancy-induced hypertension, and macrosomia. However, it is associated with an increased risk of a small-for-gestational-age fetus and prematurity. Based on the work of a multidisciplinary task force, we propose clinical practice recommendations for pregnancy management following bariatric surgery. They are derived from a comprehensive review of the literature, existing guidelines, and expert opinion covering the preferred type of surgery for women of childbearing age, timing between surgery and pregnancy, contraception, systematic nutritional support and management of nutritional deficiencies, screening and management of gestational diabetes, weight gain during pregnancy, gastric banding management, surgical emergencies, obstetrical management, and specific care in the postpartum period and for newborns.

To determine whether adding intramuscular to vaginal administration of progesterone reduces miscarriage rates compared with those of vaginal administration alone for luteal phase support in women receiving oocyte donation and to determine the best time to introduce intramuscular progesterone.Retrospective analysis of miscarriage rates in women receiving oocyte donation. Recipients underwent endometrial preparation by hormone replacement treatment. Vaginal progesterone alone or associated with intramuscular progesterone was used for luteal support.This study analysed 186 oocyte donation cycles from January 2016 to May 2018 with embryo transfer on Day 2 or 3 and vaginal progesterone administration: 106 embryo transfer cycles with vaginal progesterone alone, 29 with weekly intramuscular progesterone added once the human chorionic gonadotrophin (HCG) assay was positive, and 51 with weekly intramuscular progesterone added the evening of embryo transfer. The rates of positive HCG assays, biochemical pregnancies and clinical pregnancies did not differ between the treatment groups. The miscarriage rate was significantly lower when intramuscular progesterone began the evening of embryo transfer than with vaginal administration alone (16.7% versus 47.0%, respectively; P = 0.049 after Bonferroni correction). The live birth rate was higher when intramuscular progesterone began the evening of embryo transfer than with vaginal administration alone (37.3% versus 16.0%, respectively; P = 0.009 after Bonferroni correction).Adding intramuscular to vaginal progesterone administration appears to decrease the miscarriage rate and increase the live birth rate in oocyte donations. The initiation of intramuscular progesterone is most beneficial when it is introduced the evening of embryo transfer.

The prevalence of ovulation disorder (OD) is 3-fold higher in obese than normal-weight women. Most ODs are associated with concomitant polycystic ovary syndrome (PCOS), but obesity by itself can cause OD, through mechanisms that remain poorly documented. The literature on obese non-PCOS women with OD is sparse. The aim of the present study was to analyze a population of obese non-PCOS women with OD to shed further light on the mechanism of ovulation disorder.This retrospective observational study of infertile obese women without PCOS compared a control group without OD (n=45) to a study group with OD (n=30) (OD group). Clinical, hormonal, and ultrasound characteristics were collected between cycle days 2 and 5. Women older than 37 years and women with PCOM (polycystic ovarian morphology) or hormonal disorder were excluded.Body mass index (BMI) was significantly higher in the OD group, as were waist circumference and insulin and leptin serum levels. Conversely, serum follicle stimulating hormone (FSH) levels were significantly lower. After adjustment for BMI, only serum FSH level remained significantly different between the 2 groups. Discriminant analysis suggested that FSH may have a much stronger effect on OD than BMI.Low serum FSH level may contribute to OD in some obese women, independently of BMI. The pathophysiological mechanism of this finding and its impact on therapeutic strategies must be clarified.

International audience

International audience; The French College of Obstetrics and Gynecology (CNGOF) has released its first comprehensive recommendations for clinical practices in contraception, to provide physicians with an updated synthesis of the available data as a basis for their practice. The organizing committee and the working group adopted the objective methodological principles defined by the French Authority for Health (HAS) and selected 12 themes relevant to medical professionals' clinical practices concerning contraception. The available literature was screened through December 2017 and served as the basis of 12 texts, reviewed by experts and physicians from public and private practices, with experience in this field. These texts enabled us to develop evidence based, graded recommendations. Male and female sterilization, as well as the use of hormonal treatments not authorized for contraception ("off-label") were excluded from the scope of our review. Specific practical recommendations are provided for the management of contraception prescription, patient information concerning effectiveness, risks, and benefits of the different methods, patient follow-up, intrauterine contraception, emergency contraception, local and natural methods, contraception in teenagers, in women after 40, for women at high thromboembolism or cardiovascular risk, and for those at of primary cancer or relapse. The short- and mid-term future of contraception depends mainly on improving the use of currently available methods. This includes reinforced information for users and increased access to contraception for women, regardless of their social and clinical contexts. The objective of these guidelines is to aid in enabling this improvement.

PURPOSE: The impact of sperm DNA damage on intracytoplasmic sperm injection (ICSI) outcomes remains controversial. The purpose of the study was to evaluate the prognostic value of several types of sperm nuclear damage on ICSI clinical pregnancy. METHODS: Our retrospective study included a total of 132 couples who consulted for male or mixed-factor infertility that benefited from ICSI cycles from January 2006 to December 2015. All infertile males presented at least one conventional semen parameter alteration. Sperm nuclear damage was assessed using the Motile Sperm Organelle Morphological Examination for sperm head relative vacuolar area (RVA), aniline blue staining for chromatin condensation, terminal deoxynucleotidyl transferase dUTP nick-end labeling for DNA fragmentation, and fluorescence in situ hybridization for aneuploidy. RESULTS: Infertile males who achieved pregnancy after ICSI had fewer chromatin condensation defects than did males who did not achieve any pregnancy (15.8 ± 12.0% vs. 11.4 ± 7.9%, respectively, P = 0.0242), which remained significant in multivariate regression analysis (RR = 0.40 [0.18 to 0.86], P = 0.02). RVA, DNA fragmentation, and aneuploidy were not predictive factors of ICSI outcomes. The pregnancy rate was significantly decreased by number of progressive motile spermatozoa with normal morphology after migration (P = 0.04). In female partners, 17β estradiol of less than 2000 pg/mL on the day of ovulation induction significantly reduced the occurrence of clinical pregnancy (P = 0.04). CONCLUSION: Sperm chromatin condensation defects were more frequently observed in couples with ICSI failure and should be considered a negative predictive factor for the occurrence of clinical pregnancy.

International audience; We present the case of a young woman at 16 weeks' gestation who presented to a peripheral hospital with severe recurrent hemoperitoneum related to severe deep endometriosis infiltrating the left parametrium. She underwent 2 surgical open procedures in emergency, followed by pregnancy loss. Deep endometriosis infiltrated the rectum, the vagina, and the left parametrium, leading to stenosis of the left ureter and advanced destruction of the left kidney. Ovarian reserve was low with an antimullerian hormone level at .6 ng/mL. To improve endometriosis-related symptoms and preserve fertility, a laparoscopic conservative rectal and ureteral management was proposed with an aim to relieve symptoms, avoid further destruction of the left kidney, preserve the right splanchnic nerves and inferior hypogastric plexus, and enhance spontaneous conception. We performed a combined vaginal-laparoscopic approach that consisted of vaginal infiltration resection, adhesiolysis, rectal shaving, ureterolysis, and restoration of the permeability of the fallopian tubes. Seven months after surgery the patient spontaneously conceived and is doing well.

To compare the suppressive effect of anti-androgen therapy by cyproterone acetate (CPA) and by oral contraceptive pill (OCP) on anti-müllerian hormone (AMH) levels in women with polycystic ovary syndrome (PCOS) in order to detect a putative direct anti-androgen effect on AMH excess.This is a prospective longitudinal study including 58 women with PCOS between January 2010 and April 2014 at the Lille University Hospital. A total of 47 women with clinical hyperandrogenism were treated by CPA (50 mg/d was administered 20 days out of 28) and 11 women with PCOS but without clinical hyperandrogenism received OCP.Serum AHM levels at baseline were similar in CPA and OCP groups (median [5-95th percentiles]: 60.4 pmol/l [25.1-200.2] versus 58 pmol/l [27.6-100], respectively, p = 0.39). After 3 months of treatment, serum AMH levels decreased significantly by 28% ± 20% and by 22% ± 27% in CPA and OCP groups, respectively. The decrease under both treatments was similar (p = 0.48).That any anti-androgen effect could be observed on AMH in our CPA group in addition to the gonadotropin-suppressing effect suggests that either androgens are not involved in AMH regulation or that they act by interfering with gonadotropin effects on granulosa cells.

International audience

Objective Fertiloscopy is as safe as laparoscopy in literature, but we don’t know its relevance in women with unexplained infertility (UI). Our objective was to assess the effects of fertiloscopy procedures on the outcomes of subsequent pregnancy occurrences in patients with UI. Methods Retrospective, single-center study of all patients followed up after fertiloscopy procedures between 2002 and 2007. The occurrence and outcome of pregnancies were studied in the five years following the procedure. Results 124 fertiloscopies were performed. Pelvic exploration was considered as sufficient in 83.8% of cases, of which no abnormalities were found in 78.2%. Laparoconversions occurred for 19 patients (16.5%). The pregnancy rate at five years was 76.9%. The mean delay for pregnancy occurrence was 10.7 months (±17). Conclusion The pregnancy rate in our study is similar to that after laparoscopy. Fertiloscopy, a less intrusive procedure, should be considered as a reliable option for the management of patients with UI.

Resume Objectif Evaluer les resultats en termes d’efficacite au cours du temps des ballons latero-uretraux ACT® chez la femme dans le traitement de l’incontinence urinaire d’effort (IUE) par insuffisance sphincterienne (IS). Methode Toutes les patientes ayant une IUE par IS traitees par l’implantation de ballons latero-uretraux ACT bilateraux entre septembre 2008 et novembre 2015 et suivies regulierement pendant une duree d’au-moins 24 mois etaient eligibles. Les resultats etaient evalues a 6, 12 et 24 mois. Les criteres d’efficacite etaient definis ainsi : Le succes – port au maximum d’une protection par jour et une evaluation par echelle verbale simple (EVS) ≥ a 9/10. L’amelioration – diminution du nombre de protections par jour et EVS ≥ 5/10. L’echec–augmentation ou stabilite du nombre de protections par jour et/ou EVS Resultats 18 patientes ont ete suivies pendant 24 mois. Le taux de succes etait respectivement de 17 %, 33 % et 33 %, a 6, 12 et 24 mois de suivi. Le taux d’amelioration etait respectivement de 61 %, 39 % et 17 % a 6,12 et 24 mois de suivi. Le taux d’echec primaire etait de 22 %. Le taux d’echec secondaire etait de 6 % a 12 mois et de 33 % a 24 mois de suivi. Conclusion Les resultats en termes d’efficacite des ballons ACT s’alterent avec le temps necessitant un suivi prolonge des patientes implantees. Niveau de preuve 4.

The French College of Obstetrics and Gynecology (CNGOF) releases its first global recommendations for clinical practice in contraception, to provide physicians with an updated synthesis of available data as a basis for their practice. The French Health Authority (HAS) methodology was used. Twelve practical issues were selected by the organizing committee and the task force members. The available literature was screened until December 2017, and allowed the release of evidence-based, graded recommendations. This synthesis is issued from 12 developed texts, previously reviewed by experts and physicians from public and private practices, with an experience in the contraceptive field. Male and female sterilization, as well as the use of hormonal treatments without contraceptive label were excluded from the field of this analysis. Specific practical recommendations on the management of contraception prescription, patient information including efficacy, risks, and benefits of the different contraception methods, follow up, intrauterine contraception, emergency contraception, local and natural methods, contraception in teenagers and after 40, contraception in vascular high-risk situations, and in case of cancer risk are provided. The short/mid-term future of contraception mostly relies on improving the use of currently available methods. This includes reinforced information for users and increased access to contraception for women, whatever the social and clinical context. That is the goal of these recommendations.

Study Objective To evaluate whether combining computed tomography–based virtual colonoscopy (CTC) with magnetic resonance imaging (MRI) improves preoperative assessment of colorectal endometriosis. Design Retrospective study using prospectively recorded data (Canadian Task Force classification II-2). Setting University tertiary referral center. Patients Seventy-one women treated for colorectal endometriosis managed between June 2015 and May 2016. Interventions Patients included in our study underwent colorectal surgery for deep endometriosis infiltrating the rectum or the sigmoid colon and had preoperative assessment using MRI and CTC. To establish the correlation between preoperative and intraoperative findings, the concordance kappa index was used. Measurements and Main Results Preoperative data provided by MRI, CTC, and a combination of both were compared with intraoperative findings. All 71 patients had a total of 105 endometriotic intestinal lesions intraoperatively confirmed. Some 71.2% of rectal nodules and 60.0% of sigmoid nodules infiltrated the muscularis propria of the intestinal wall, with most infiltrating between 25% and 50% of the rectal circumference; 73% of rectal nodules and 96% of sigmoid nodules led to varying degrees of stenosis. The concordance between intraoperative and preoperative findings concerning the presence of rectal nodules was high, at .88 when associating CTC with MRI, whereas each imaging technique taken individually provided lower concordance coefficients. In our study 80.3% of patients underwent the procedure that had been preoperatively planned. Conclusion Our study suggests that associating MRI with CTC leads to improved accuracy in preoperative assessment of colorectal endometriosis and in subsequent preoperative choice of surgical procedures on the digestive tract.

STUDY QUESTION What are fertility outcomes in patients surgically managed for large deep endometriosis infiltrating the rectum who intend to get pregnant postoperatively? SUMMARY ANSWER Surgical management for rectal endometriosis is followed by high pregnancy rates, with a majority of natural conceptions. WHAT IS KNOWN ALREADY Optimal management such as surgery versus first-line ART for patients with severe deep endometriosis who desire pregnancy is not defined. STUDY DESIGN, SIZE, DURATION The study included the patients enrolled in ENDORE randomized trial who attempted pregnancy after the surgery. From March 2011 to August 2013, we performed a two-arm randomized trial, enrolling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring more than 20 mm in length, involving at least the muscular layer in depth, and up to 50% of rectal circumference. Postoperative follow-up was prolonged in 55 patients recruited at Rouen University Hospital, and varied from 50 to 79 months. No women were lost to follow-up. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients had either conservative surgery by shaving or disc excision, or radical rectal surgery by segmental resection. One gynecologist experienced in deep endometriosis surgery performed all the procedures, assisted when required by three general surgeons experienced in colorectal surgery. Institutional review board approval was obtained to extend postoperative follow-up to 10 years after the surgery. Among patients enrolled at Rouen University Hospital, women who intended to get pregnant after surgery were selected and followed up postoperatively every 6 months for 2 years, then every year. Pregnancy intention, fertility outcomes, conception mode, endometriosis recurrences and digestive and urinary outcomes were rigorously recorded. The primary outcome was postoperative pregnancy rate. Secondary outcomes were conception mode, the delay to conception from the day of surgery and the day when hormonal treatment was stopped, and delivery rate. Kaplan Meier curves were used to estimate the probability of conception after surgery. MAIN RESULTS AND THE ROLE OF CHANCE Among the 55 patients enrolled at Rouen University Hospital, 25 had conservative and 30 had radical surgery, and their postoperative follow-up varied from 50 to 79 months. No patient was lost to follow-up. Among the 55 patients, 36 intended to get pregnant after surgery, 23 of whom had unsuccessfully attempted to conceive for more than 12 months before surgery (63%). At the end of follow-up, 29 patients achieved pregnancy (81%), and natural conception was recorded in 17 of them (59% of conceptions). As several women had more than 1 pregnancy (range: 0–3), we recorded 37 pregnancies, 24 natural conceptions (65%) and 29 deliveries (78%). The probabilities of achieving pregnancy at 12, 24, 36 and 48 months postoperatively were 33.4% (95% CI: 20.6–51.3%), 60.6% (44.8–76.8%), 77% (61.5–89.6%) and 86.8% (72.8–95.8%), respectively. Women who had been advised to attempt natural conception achieved pregnancy significantly earlier than patients referred for ART (P = 0.008). In infertile patients, the postoperative pregnancy rate was 74%, and 53% of conceptions were natural. LIMITATIONS, REASONS FOR CAUTION The main outcomes of the original trial were related to digestive function and not to fertility. Several factors impacting fertility could not be revealed due to small sample size. The study included a high percentage of young women with an overall satisfactory prognosis for fertility, as patients’ median age was 28 years. The inclusion of only large infiltrations of the rectum does not allow the extrapolation of conclusions to small nodules of

International audience; Polycystic ovary syndrome (PCOS) is the main cause of female infertility worldwide and corresponds with a high degree of comorbidities and economic burden. How PCOS is passed on from one generation to the next is not clear, but it may be a developmental condition. Most women with PCOS exhibit higher levels of circulating luteinizing hormone, suggestive of heightened gonadotropin-releasing hormone (GnRH) release, and anti-Müllerian hormone (AMH) as compared to healthy women. Excess AMH in utero may affect the development of the female fetus. However, as AMH levels drop during pregnancy in women with normal fertility, it was unclear whether their levels were also elevated in pregnant women with PCOS. Here we measured AMH in a cohort of pregnant women with PCOS and control pregnant women and found that AMH is significantly more elevated in the former group versus the latter. To determine whether the elevation of AMH during pregnancy in women with PCOS is a bystander effect or a driver of the condition in the offspring, we modeled our clinical findings by treating pregnant mice with AMH and followed the neuroendocrine phenotype of their female progeny postnatally. This treatment resulted in maternal neuroendocrine-driven testosterone excess and diminished placental metabolism of testosterone to estradiol, resulting in a masculinization of the exposed female fetus and a PCOS-like reproductive and neuroendocrine phenotype in adulthood. We found that the affected females had persistently hyperactivated GnRH neurons and that GnRH antagonist treatment in the adult female offspring restored their neuroendocrine phenotype to a normal state. These findings highlight a critical role for excess prenatal AMH exposure and subsequent aberrant GnRH receptor signaling in the neuroendocrine dysfunctions of PCOS, while offering a new potential therapeutic avenue to treat the condition during adulthood.

Objective To report postoperative outcomes after surgery for deep endometriosis without involvement of the digestive or urinary tracts. Design Retrospective study using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) database. Setting University tertiary referral center. Patient(s) One hundred thirty consecutive patients whose follow-up ranged from 1 to 6 years. Intervention(s) Laparoscopic excision of deep endometriosis nodules. Main Outcome Measure(s) Postoperative complications were recorded in the CIRENDO database and medical charts. Postoperative digestive function was assessed using standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index and the Knowles-Eccersley-Scott Symptom Questionnaire. Result(s) Deep endometriosis nodules involved uterosacral ligaments, rectovaginal space, and vagina and spared the bowel, the bladder, and the ureters. Nodule size was 3 cm in diameter in 20.8%, 64.6%, and 14.6% of cases, respectively. Clavien-Dindo 1, 2, and 3b complications occurred in 0.8%, 4.6%, and 5.4% of cases, respectively. Among Clavien-Dindo 3b complications, most involved pelvic hematoma. Gastrointestinal scores revealed significant improvement in digestive function or defecation pain at 1 and 3 years after surgery. The pregnancy rate was, respectively, 43.3% and 56.7% at 1 and 3 years postoperatively, among which 66.7% and 64.7% were spontaneous conceptions. Conclusion(s) Our data suggest that surgery for deep endometriosis without involvement of the digestive or urinary tracts provides a low rate of postoperative complications and satisfactory fertility outcomes.

Objective To evaluate delivery and neonatal outcomes in women with resected or in situ bowel endometriosis. Design Retrospective cohort study. Setting France. Population and sample Analysis of 72 pregnancies from 67 women followed for colorectal endometriosis from 2001 to 2014 in six centres including two university expert centres for endometriosis. Methods Univariate analysis of maternal and neonatal outcomes. Main outcome measures Routes for delivery and rate of complications. Results The colorectal surgery group comprised 41 women and the in situ colorectal group, 26 women. Overall, half of the women underwent caesarean section. A high incidence of postoperative complications (39%) was observed after caesarean section with no difference between the groups. Surgical difficulties at newborn extraction (22%) and postoperative complications (39%) occurred more often in women with anterior deep infiltrating endometriosis (respectively 63 versus 11%, P = 0.007 and 67% versus 26%, P = 0.046) independently of prior surgery for endometriosis. In the remaining half, vaginal delivery required an operative procedure in 28% of the women with a significant increase in postpartum complications compared with those who did not require a procedure (P = 0.001). Overall, the incidence of postpartum complications was lower after vaginal delivery (14%) than after caesarean section (39%) (P = 0.03). Conclusion Pregnant women with colorectal endometriosis, irrespective of prior surgery, should be informed of the high risk of delivery by caesarean section. Vaginal delivery is preferrable in this setting because of the lower incidence of postpartum complications. Tweetable abstract Due to the incidence of postpartum complications whatever the route of delivery, women should receive level III maternal care.

National and international guidelines recommend referring patients with severe forms of endometriosis to expert centers. However, there is a lack of clear criteria to define an expert center. We examined the roles of surgeon and hospital procedure volumes as determinants of morbidity in deep infiltrating endometriosis of the rectum and sigmoid colon (DIERS). We conducted a French retrospective multicenter study of hospital facilities performing colorectal surgery for DIERS in 2015. The primary end point was to analyze the relation between case volume and the incidence of complications. We estimated the optimal cut-off (OCO) determined by a minimal p-value approach. The study included 56 hospital facilities and collected data of 1135 cases of surgical management of colorectal endometriosis. The mean and median number of procedures per year and per surgeon were 9.17 and 5.58, respectively. The overall rate of grade III–V complication was 7.6% (82/1135). One grade V complication occurred. The rates of rectovaginal fistula, anastomotic leakage, pelvic abscess, and ureteral fistula were: 2.7% (31/1135), 0.79% (9/1135), 3.4% (39/1135), and 0.70% (8/1135), respectively. An OCO of 20 procedures per center and per year (p

Study question Is the negative correlation between the numbers of 2-5 and 6-9 mm follicles influenced by ovarian and/or metabolic parameter(s) in young control women and in patients with polycystic ovarian syndrome (PCOS)? Summary answer Our study confirmed that the negative correlation between numbers of follicles sized 2-5 and 6-9 mm was stronger in PCOS than in young control women and was not linked to any ovarian or metabolic parameter. What is known already Previous reports described a direct negative correlation between the number of small antral follicles (2-5 mm) and large antral follicle (6-9 mm) during the early follicular phase (cycle Days 2-5) in normal and PCOS women. Numerous factors, that could be either intrinsic to the ovary or secondary to metabolic influence and/or gonadotropin regulation, might account for this. Study design, size, duration Six hundred and thirty-nine patients with PCOS according to Rotterdam Criteria and 157 control women were recruited in this retrospective cross-sectional study from January 2009 to January 2016. Participants/materials, setting, methods Data were obtained from a database of clinical, hormonal and ultrasound (U/S) features recorded consecutively in a single reproductive medicine centre. Univariate correlations between the various parameters were analysed by the Spearman's correlation test. All variables significantly related to the 2-5 and/or 6-9 mm follicle numbers were included in a principal component analysis (PCA) in order to structure the data and to obtain collections of uncorrelated variables, called principal components (PC), which are linear combinations of the original variables. Main results and the role of chance By univariate analysis, the 2-5 and 6-9 mm follicle numbers were strongly but negatively correlated in both populations. Many other variables were correlated to the 2-5 and/or 6-9 mm follicle numbers and to each other. By PCA, these relationships were gathered into four independent PCs in each population. In both groups, the 2-5 and 6-9 mm follicle numbers correlated strongly and inversely to a specific PC. Among the other variables tested, only serum oestradiol level correlated weakly to this PC in the control group. Two other uncorrelated PCs gathered relationships between variables linked to the metabolic status and the gonadotropin regulation both in control and PCOS women. Lastly, a fourth PC included relationships which linked to ovarian ageing in controls and to follicle dysregulation in patients with PCOS. Limitations, reasons for caution Our controls did not represent the general population since they were recruited in an ART centre; we used a modified Rotterdam classification for PCOS using follicle count and/or serum AMH level with in-house thresholds to define the follicle excess; the AMH assay used is no longer commercially available. Wider implications of the findings Factor(s) regulating specifically the equilibrium between the 2-5 and 6-9 mm follicle numbers still need(s) to be identified. More attention should be paid to the oocyte. Study funding/competing interest(s) None.

First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma.

Resume Introduction Dans un cadre institutionnel aux regles strictes, l’objectif de ce travail etait de rediger des recommandations de bonnes pratiques cliniques, a l’aide d’une revue de la litterature, sur les indications et resultats des traitements hors fecondation in vitro (FIV ± ICSI) des patientes endometriosiques infertiles, afin d’obtenir une grossesse. Materiel et methode Recherche et analyse des publications scientifiques en anglais et francais de janvier 1990 a mars 2017 issues des bases de donnees bibliographiques. Les populations d’interet etaient les femmes endometriosiques infertiles. Chaque recommandation devait etre assortie d’un grade valide par un groupe de redacteurs et de relecteurs (methodes CNGOF et HAS). Resultat La prise en charge de l’infertilite dans un contexte d’endometriose doit etre pluridisciplinaire, prenant en compte les douleurs possiblement associees a l’infertilite, mais egalement du bilan d’un couple infertile et du phenotype des lesions endometriosiques (accord d’experts). La prescription d’un traitement hormonal antigonadotrope chez une patiente endometriosique infertile dans le but d’optimiser les chances de grossesse hors FIV n’est pas recommandee (grade A). A l’issue d’une chirurgie chez une patiente infertile, l’utilisation de l’Endometriosis Fertility Index (EFI) est recommandee pour guider la strategie en vue de l’obtention d’une grossesse (grade C). En cas d’endometriose minime a legere (stades I et II d’apres la classification ASRM) documentee par cœlioscopie, l’utilisation d’une stimulation ovarienne, avec ou sans insemination intra-uterine, peut etre envisagee en postoperatoire (grade C). En cas de stimulation, le recours aux gonadotrophines en 1er intention est preferable (grade B). Un nombre maximum de 3 a 6 cycles de stimulation ovarienne, avec ou sans insemination spermatique, semblerait souhaitable avant un passage en FIV (accord d’experts). Les donnees de la litterature sont insuffisantes pour recommander une prise charge ou un traitement, en vue de l’obtention d’une grossesse, en cas d’endometriose pelvienne profonde ou d’endometriome. Conclusion Chez des patientes endometriosiques infertiles, l’obtention d’une grossesse hors-FIV est envisageable et documentee. L’EFI connait son interet, tout comme la stimulation ovarienne, avec des bons niveaux de preuves.

International audience

International audience; Deep endometriosis with colorectal involvement is considered one of the most severe forms of the disease due to its impact on patients' quality of life and fertility but also by the difficulties encountered by the clinicians when proposing a therapeutic strategy. Although the literature is very rich, evidence based medicine remains poor explaining the great heterogeneity concerning the management of such patients. Surgery therefore remains a therapeutic option. It improves the intensity of gynecological, digestive and general symptoms and the quality of life. Concerning the surgical approach, it appears that laparoscopy should be the first option; the laparoscopic robot-assisted route can also be proposed. The techniques of rectal shaving, discoid resection and segmental resection are the three techniques used for surgical excision of colorectal endometriosis. The parameters taken into account for the use of either technique are: the surgeon's experience, the depth of infiltration of the lesion within the rectosigmoid wall, the lesion size and circumference, multifocality and the distance of the lesion from the anal margin. In the case of deep endometriosis with colorectal involvement, performing an incomplete surgery increases the rate of pain recurrence and decreases postoperative fertility. In case of surgery for colorectal endometriosis, pregnancy rates are similar to those obtained after ART in non-operated patients. Existing data are insufficient to formally recommend first line surgery or ART in infertile patients with colorectal endometriosis. The surgery for colorectal endometriosis exposes to a risk of postoperative complications and recurrence of which the patients should be informed preoperatively.

Fertility preservation (FP) techniques are progressing rapidly these past few years thanks to the oocyte vitrification. Indication of FP techniques is now extended to non-oncological situation that may induce risk of premature ovarian failure. Ovarian endometriosis can lead to premature ovarian failure and further infertility due to the high risk of ovarian cysts recurrence and surgery. To date, there is no cohort study regarding FP and endometriosis as well as no recommendation. Our purpose is to review the arguments in favor of FP in this specific area and to elaborate strategies according to each clinical form.

The management of endometriosis related infertility requires a global approach. In this context, the prescription of an anti-gonadotropic hormonal treatment does not increase the rate of non-ART (assisted reproductive technologies) pregnancies and it is not recommended. In case of endometriosis related infertility, the results of IVF management in terms of pregnancy and birth rates are not negatively affected by the existence of endometriosis. Controlled ovarian stimulation during IVF does not increase the risk of endometriosis associated symptoms worsening, nor accelerate the intrinsic progression of endometriosis and does not increase the rate of recurrence. However, in the context of IVF management for women with endometriosis, pre-treatment with GnRH agonist or with oestrogen/progestin contraception improve IVF outcomes. There is currently no evidence of a positive or negative effect of endometriosis surgery on IVF outcomes. Information on the possibilities of preserving fertility should be considered, especially before surgery.

Minimal and mild endometriosis (stage 1 and 2 AFSR) can lead to chronic pelvic pain and infertility but can also exist in asymptomatic patients. The prevalence of asymptomatic patients with minimal and mild endometriosis is not clear but typical endometriosis lesions are found in about 5 to 10% of asymptomatic women and more than 50% of painful and/or infertile women. Laparoscopic treatment of minimal and mild endometriotic lesions is justified in case of pelvic pain because their destruction decrease significatively the pain compared with diagnostic laparoscopy alone. In this context, ablation and excision give identical results in terms of pain reduction. Moreover, literature shows no interest in uterine nerve ablation in case of dysmenorrhea due to minimal and mild endometriosis. Then, it is recommended to treat these lesions during a laparoscopy realised as part of pelvic pain. On the other hand, it is not recommended to treat asymptomatic patients. With regard to treatment of minimal and mild endometriosis in infertile patients, only two studies can be selected and both show that laparoscopy with excision or ablation and ablation of adhesions is superior to diagnostic laparoscopy alone in terms of pregnancy rate. However, it is not recommended to treat these lesions when they are asymptomatic because there is no evidence that they can progress with symptomatic disease. There is no study assessing the interest to treat these lesions when they are found fortuitously. Adhesion barrier utilisation permits to reduce post-operative adhesions, however literature failed to demonstrate the clinical profit in terms of reduction of the risk of pain or infertility.

Background Artificial urinary sphincter (AUS) implantation is recommended for women suffering urinary stress incontinence. Robot-assisted laparoscopy allows improved dexterity and visibility compared to traditional laparoscopy, potentially providing significant advantages for deep pelvic surgery. Objective To report our surgical technique and initial experience in transperitoneal robot-assisted laparoscopic AUS implantation in women with urinary stress incontinence. Design, setting, and participants Eleven eligible patients with AUS implantation or revision using robot-assisted laparoscopy for urinary stress incontinence were included between January 2012 and February 2014 at Department of Urology, Lille University Hospital. Surgical technique Procedures were performed with the assistance of a four-arm da Vinci robot. The urethrovaginal space was dissected after transperitoneal access to the Retzius space. An 11-mm port placed in the right iliac fossa allowed introduction of the AUS device. The cuff and balloon tubes were externalised via a 5-mm suprapubic incision. The peritoneum was finally sutured. Measurements Clinical data were prospectively collected before, during, and after the procedure. Results were classified as complete continence (no leakage and no pad usage), social continence (leakage and/or pad usage with no impact on social life), or failure (leakage and/or pad usage impacting social life). Results and limitations After mean follow-up of 17.6 mo (interquartile range 10.8–26 mo), eight patients (72.7%) had a successful AUS implantation, of whom seven (87.5%) reported complete continence and one had social continence. Two vaginal injuries and two bladder injuries occurred intraoperatively . Two patients experienced early minor postoperative complications and two had a major postoperative complication. Conclusions Robot-assisted laparoscopic AUS implantation is a feasible procedure. Further studies will better assess the place of robot-assisted laparoscopy in AUS implantation. Patient summary We investigated the treatment of 11 patients with stress urinary incontinence using robot-assisted implantation of an artificial urinary sphincter (AUS). The results show that the procedure is feasible procedure, and future studies will to help assess the place of robot-assisted laparoscopy in AUS implantation.

International audience; Objective of the study. - Recent data demonstrate the usefulness of (1,3) beta-D-glucan (BG) Bronchoalveolar lavage detection in serum samples to distinguish patients developing Pneumocystis pneumonia and samples; patients who are colonized by the fungus. In contrast, data of BG detection in bronchoalveolar Pneumocystis lavage (BAL) samples from these patient populations are still rare. pneumonia; Patients. - In this context, we determined BG levels in BAL samples from 11 Pneumocystis Pneumocystis pneumonia (PCP) patients, 10 colonized patients, and 24 Pneumocystis-uninfected patients. Materials and methods. - BG levels were determined on each BAL sample using the Fungitell (R) kit (Associates of Cape Cod, Inc., Cape Cod, MA, USA) according to the manufacturer's instructions applied to serum sample examination. Results. - The BG levels in BAL samples from the PCP patient group (mean value 20 588 pg/mL) were significantly higher than those in the colonized patient group (mean value 105 pg/mL) (P = 0.0001, Mann-Whitney test) and than those in the Pneumocystis-uninfected patient group (mean value 74 pg/mL) (P < 0.0001, Mann Whitney test). The BG levels in BAL samples from the colonized patient group did not differ significantly from those in the Pneumocystis-uninfected patients group (P = 0.21). Conclusion. - The results suggest that measurements of BAL BG levels may facilitate the differential diagnosis of PCP and pulmonary colonization with Pneumocystis. (C) 2014 Elsevier Masson SAS. All rights reserved.

International audience

The purpose of the present multicenter study was to investigate whether an artificial insemination with donor sperm (AID) procedure after intra-couple intracytoplasmic sperm injection (ICSI) failure offers a significant chance of pregnancy and to identify prognostic factors for pregnancy after an AID procedure. An eleven-year retrospective multicenter study was conducted among 13 Centre d'Etude et de Conservation des Oeufs et du Sperme (CECOS) centers. A total of 319 couples having undergone an AID procedure after intra-conjugal ICSI failure were included in this study; a total of 1,159 AID and 1,011 intra-conjugal ICSI cycles were performed. Among the prognostics parameters, the parity and the embryo quality could not be adequately addressed, therefore the parity was not included in the statistical analysis and the embryo quality has been presented as preliminary observations. The pregnancy rate per cycle was 12.0% (139/1,159) and the overall AID pregnancy rate per couple was 43.6% (139/319). Normal or oligoasthenoteratozoospermia (OAT) semen and women aged 34 years or above at the time of AID procedure obtained the lowest AID clinical pregnancy rate. Azoospermia or cryptozoospermia semen and women aged below 34 years obtained the highest AID clinical pregnancy rate. In conclusion, the transition to the AID procedure after intra-conjugal ICSI failure allows such couples to obtain a pregnancy, however after each ART failure AID transition should be proposed according to the woman's age and sperm characteristics.AID: artificial insemination with donor sperm; ICSI: intracytoplasmic sperm injection; CECOS: Centre d'Etude et de Conservation des Oeufs et du Sperme; OAT: oligoasthenoteratozoospermia; IVF: in vitro fertilization; ART: artificial reproductive technology; β hCG: beta human chorionic gonadotrophin; SD: standard deviation; OR: Odds ratio.

International audience; The management of patients presenting deep infiltrating endometriosis involving the rectum (DIER) and pregnancy intention is controversial. Assisted Reproduction Techniques (ART) are often proposed first, but this may lead to complications and further difficulties managing DIER. A 29-years-old woman was diagnosed with pre-occlusive DIER. However, she was offered in vitro fertilization (IVF) and underwent six unsuccessful cycles with serious complications: an ectopic pregnancy and a hemoperitoneum following arterial injury during oocyte retrieval, requiring two laparotomies in emergency. The patient's symptoms worsened over time and colorectal resection with diverting colostomy was performed. The patient's quality of life was then improved. In our opinion, prior ART in patients presenting DIER delays surgery and may have harmful complications. Therefore, primary surgery followed by ART may be a valuable option in some cases and should be discussed with the patients.

Study objective To assess the value of performing a protective stoma in patients operated for rectal endometriosis. Material and methods From June 2009 to December 2011, 47 patients were operated for rectal endometriosis by segmental or discoid resection in 4 different centers. Two groups were formed: one with protective stoma (group S), n = 33 and one without protective stoma (group NS), n = 14. Data were collected from the CIRENDO database. Measurements and main results Postoperative complication rate of group NS was 57% against 48% in group S (P = 0.75). There was an increasing trend of the rate of anastomotic leakage in group S as compared to group NS: 21% against 3% (P = 0.073). All 3 patients of group NS with an anastomotic leakage were reoperated and the group S patient had medical treatment. In a center, digestive operative time was not necessarily performed in association with a gastrointestinal surgeon. All patients in group S had a restoration of continuity in about 3 months. Two of them had dilation of anastomotic stricture and 3 others showed a transient postoperative ileus during this recovery. Quality of life was assessed by the MOS SF-36 and significantly improved in both groups thanks to the intervention. Conclusion Temporary digestive stoma in patients operated for rectal endometriosis has to be considered because in our study, it seems reducing complications such as anastomotic leakage. This must be confirmed with studies with larger numbers.

International audience

Polycystic ovarian syndrome (PCOS) is the most common cause of chronic anovulation and hyperandrogenism in young women and represents a true public health concern and an economic burden.The pathophysiology of PCOS is still not fully understood, but progresses have been made and the relationships between anti mullerian hormone (AMH), follicle stimulating hormone, luteinizing hormone, E2 and androgens have been explored. The follicle excess plays a central role in the syndrome and AMH is definitively a major component of this phenomena.The aim of this chapter is to present the recent work studying the role of AMH in the pathophysiology of PCOS and to discuss the improvement that serum AMH assay brings in the diagnosis of PCOS.

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Is there a difference in functional outcome between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 2 years postoperatively?, 31 January 2011.