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International audience; Study questionWhat is the proportion of men treated for testicular cancer or lymphoma who banked sperm before gonadotoxic treatment in France?Summary answerIn 2018, 41% of men with testicular cancer and 28% of men with lymphoma banked sperm before gonadotoxic treatment in France.What is known alreadyCancer treatments significantly improved survival rates in men. In Europe, the 5-year survival rate is above 90% for testicular cancer (TC) and Hodgkin lymphoma (HL), which, with Non Hodgkin Lymphoma (NHL), are the most frequent cancers in men of reproductive age. However, surgery, chemotherapy and/or radiotherapy may damage male fertility: between 15% and 30% of men remain permanently infertile after treatment. Since 2011, the French bioethics law recommends and guarantees free access to fertility preservation for all patients needing gonadotoxic treatments. Few international data are available about the rate of male cancer patients who receive sperm cryopreservation before cancer treatment.Study design, size, durationWe analyzed the data of male cancer incidence in 2018 published by the French National Institute of Cancer (INCa), only available and latest French national data, estimated from cancer registers of selected metropolitan departments (Defossez et al. 2019). We organized a survey among the 27 metropolitan centers of the CECOS network (public centers for study and conservation of human eggs and sperm) to collect the annual number of sperm cryopreservations for TC, HL or NHL.Participants/materials, setting, methodsWe compared the number of 0-59 years-old men with TC, HL or NHL in metropolitan France (extracted from 2018 INCa data) and the number of sperm banking for TC, HL or NHL in metropolitan centers of the CECOS network.Main results and the role of chanceINCa estimated that 38,048 new cancers were diagnosed in metropolitan France in 2018 in men aged 0-59 years. TC accounted for 2,630 new cases and lymphomas for 3,913 new cases (943 HL and 2,970 NHL).Twenty-six out of 27 metropolitan CECOS centers answered the survey (96% participation rate): in 2018, 1,079 men banked sperm for TC, 375 for HL and 211 for NHL.In 2018, the fertility preservation rate in metropolitan France was 41% for TC and 28% for lymphomas (51% for HL, and 15% for NHL). The results of our national study are in accordance with Uçar et al. 2020, a monocentric study on 110 TC patients showing a 43% fertility preservation rate, but differ from those of Abdel-Razek et al. 2020, a monocentric study on 59 NHL and 26 HL patients, showing respectively 32% and 14% fertility preservation rates.A limit of our study is to be based on estimated cancer incidence from INCa reports without stratification on age and parenthood; sperm banking activity was measured in the CECOS network, which performs 90% of French male fertility preservation (French Biomedicine Agency 2018 data). This design may induce an underestimation of cancer incidence and of sperm banking activity.Limitations, reasons for cautionOur study did not consider patients who were informed of fertility preservation but did not want to/could not bank ejaculated sperm (azoospermia, sperm collection failure, no-show). In CECOS network, the estimated rate of such patients is 10%.French overseas regions were not studied (lack of INCa data).Wider implications of the findingsOur results suggest that despite the recommendations and facilities offered by the French bioethics law, the male patients’ pathway for fertility preservation before cancer treatments could be improved. Further study should evaluate if this suboptimal rate of fertility preservation is homogeneous on French territory or related to postal code.

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.

Purpose To dynamically assess the evolution of live birth predictive factors’ impact throughout the in vitro fertilization (IVF) process, for each fresh and subsequent frozen embryo transfers. Methods In this multicentric study, data from 13,574 fresh IVF cycles and 6,770 subsequent frozen embryo transfers were retrospectively analyzed. Fifty-seven descriptive parameters were included and split into four categories: (1) demographic (couple’s baseline characteristics), (2) ovarian stimulation, (3) laboratory data, and (4) embryo transfer (fresh and frozen). All these parameters were used to develop four successive predictive models with the outcome being a live birth event. Results Eight parameters were predictive of live birth in the first step after the first consultation, 9 in the second step after the stimulation, 11 in the third step with laboratory data, and 13 in the 4th step at the transfer stage. The predictive performance of the models increased at each step. Certain parameters remained predictive in all 4 models while others were predictive only in the first models and no longer in the subsequent ones when including new parameters. Moreover, some parameters were predictive in fresh transfers but not in frozen transfers. Conclusion This work evaluates the chances of live birth for each embryo transfer individually and not the cumulative outcome after multiple IVF attempts. The different predictive models allow to determine which parameters should be taken into account or not at each step of an IVF cycle, and especially at the time of each embryo transfer, fresh or frozen.

EZH2, the enzymatic component of PRC2, has been identified as a key factor in hematopoiesis. EZH2 loss-of-function mutations have been found in myeloproliferative neoplasms, particularly in myelofibrosis, but the precise function of EZH2 in megakaryopoiesis is not fully delineated. Here, we show that EZH2 inhibition by small molecules and short hairpin RNA induces megakaryocyte (MK) commitment by accelerating lineage marker acquisition without change in proliferation. Later in differentiation, EZH2 inhibition blocks proliferation and polyploidization and decreases proplatelet formation. EZH2 inhibitors similarly reduce MK polyploidization and proplatelet formation in vitro and platelet levels in vivo in a JAK2V617F background. In transcriptome profiling, the defect in proplatelet formation was associated with an aberrant actin cytoskeleton regulation pathway, whereas polyploidization was associated with an inhibition of expression of genes involved in DNA replication and repair and an upregulation of cyclin-dependent kinase inhibitors, particularly CDKN1A and CDKN2D. The knockdown of CDKN1A and to a lesser extent CDKN2D could partially rescue the percentage of polyploid MKs. Moreover, H3K27me3 and EZH2 chromatin immunoprecipitation assays revealed that CDKN1A is a direct EZH2 target and CDKN2D expression is not directly regulated by EZH2, suggesting that EZH2 controls MK polyploidization directly through CDKN1A and indirectly through CDKN2D.

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.

Research question Do cryopreservation and in-vitro culture procedures affect the expression of DNA methyltransferases (DNMT) and histone-modifying enzymes, as well as the establishment of DNA methylation and histone post-translational modifications (PTM) in germ cells in prepubertal mouse testicular tissue? Design This study investigated the expression of epigenetic modification enzymes, DNA methylation and histone PTM, and the spermatogenic progression after in-vitro maturation of fresh or cryopreserved mouse prepubertal testicular tissue. Fresh or cryopreserved testicular fragments from 6–7 days post-partum mice were cultured for 30 days in the presence of retinol with or without FSH. Results The in-vitro maturation of fresh or cryopreserved tissue allowed the differentiation of spermatogonia into spermatozoa. Differences in the levels of transcripts encoding epigenetic modification enzymes (Dnmt1, Dnmt3a, Jarid1b, Src1, Sirt1, Hdac1) were found between 30-day tissue cultures and age-matched in-vivo controls. DNMT1/DNMT3a expression and the presence of 5-methylcytosine (5mC) were detected in spermatogonia and leptotene/zygotene spermatocytes in cultures. The relative 5mC fluorescence intensity was similar in spermatozoa produced in cultures of cryopreserved tissues or in vivo. H3K4me3, H3K9ac and H4K8ac were present in all germ cell types but differences in the proportion of germ cells containing these epigenetic marks were found after cultures. Conclusions Despite differences with the in-vivo situation, DNA methylation and histone methylation and acetylation occur in the mouse germline in in-vitro matured fresh or cryopreserved mouse prepubertal testicular tissue, and the expression of the enzymes catalysing these epigenetic modifications are maintained in vitro.

Acephalic spermatozoa syndrome (ASS) is a rare but extremely severe type of teratozoospermia, defined by the presence of a majority of headless flagella and a minority of tail-less sperm heads in the ejaculate. Like the other severe monomorphic teratozoospermias, ASS has a strong genetic basis and is most often caused by bi-allelic variants in SUN5 (Sad1 and UNC84 domain-containing 5). Using whole exome sequencing (WES), we investigated a cohort of nine infertile subjects displaying ASS. These subjects were recruited in three centers located in France and Tunisia, but all originated from North Africa. Sperm from subjects carrying candidate genetic variants were subjected to immunofluorescence analysis and transmission electron microscopy. Moreover, fluorescent in situ hybridization (FISH) was performed on sperm nuclei to assess their chromosomal content. Variant filtering permitted us to identify the same SUN5 homozygous frameshift variant (c.211+1_211+2dup) in 7/9 individuals (78%). SUN5 encodes a protein localized on the posterior part of the nuclear envelope that is necessary for the attachment of the tail to the sperm head. Immunofluorescence assays performed on sperm cells from three mutated subjects revealed a total absence of SUN5, thus demonstrating the deleterious impact of the identified variant on protein expression. Transmission electron microscopy showed a conserved flagellar structure and a slightly decondensed chromatin. FISH did not highlight a higher rate of chromosome aneuploidy in spermatozoa from SUN5 patients compared to controls, indicating that intra-cytoplasmic sperm injection (ICSI) can be proposed for patients carrying the c.211+1_211+2dup variant. These results suggest that the identified SUN5 variant is the main cause of ASS in the North African population. Consequently, a simple and inexpensive genotyping of the 211+1_211+2dup variant could be beneficial for affected men of North African origin before resorting to more exhaustive genetic analyses.

Background In prepubertal boys with cancer, fertility preservation relies on testicular tissue freezing before treatment. In vitro maturation of frozen/thawed tissues could be one of the procedures envisaged to restore the fertility of cured patients. It is necessary to ascertain in the mouse model that in vitro-generated spermatozoa are able to ensure embryo development, without altering the epigenetic processes occurring during the pre-implantation period. Objectives The aims of the present study were to investigate the fertilizing ability of in vitro-produced spermatozoa and explore several epigenetic marks at different stages of embryo development. Materials and methods Fresh or controlled slow-frozen (CSF)/thawed testicular tissues from 6 to 7 days post-partum (dpp) mice were cultured for 30 days. Intracytoplasmic sperm injection (ICSI) experiments were performed using in vitro-produced spermatozoa. Testicular spermatozoa from 36 to 37 dpp mice were used as in vivo controls. DNA methylation/hydroxymethylation and histone post-translational modifications (H3K4me3, H3K27me3 and H3K9ac) were analysed by immunofluorescence from the zygote to the blastocyst stages. Results The spermatozoa generated in cultures of fresh or CSF testicular tissues were able to initiate embryonic development. The freezing of prepubertal testicular tissues limits the production of spermatozoa in vitro and the fertilization rate after ICSI. Similar levels of H3K4me3, H3K27me3 and H3K9ac were found in ICSI embryos derived from in vitro- and in vivo-produced spermatozoa. DNA methylation levels were increased in 4-cell embryos and morula obtained by ICSI with in vitro-produced spermatozoa. Discussion and conclusion Our study shows for the first time that the use of in vitro-produced spermatozoa alters DNA methylation/demethylation dynamics but has little impact on H3K4me3, H3K27me3 and H3K9ac levels in mouse early embryos. Further work will have to be performed to determine whether the use of these gametes is not deleterious for embryo development before considering a human application.

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.

International audience; Cilia and flagella are evolutionarily conserved organelles whose motility relies on the outer and inner dynein arm complexes (ODAs and IDAs). Defects in ODAs and IDAs result in primary ciliary dyskinesia (PCD), a disease characterized by recurrent airway infections and male infertility. PCD mutations in assembly factors have been shown to cause a combined ODA-IDA defect, affecting both cilia and flagella. We identified four loss-of-function mutations in TTC12, which encodes a cytoplasmic protein, in four independent families in which affected individuals displayed a peculiar PCD phenotype characterized by the absence of ODAs and IDAs in sperm flagella, contrasting with the absence of only IDAs in respiratory cilia. Analyses of both primary cells from individuals carrying TTC12 mutations and human differentiated airway cells invalidated for TTC12 by a CRISPR-Cas9 approach revealed an IDA defect restricted to a subset of single-headed IDAs that are different in flagella and cilia, whereas TTC12 depletion in the ciliate $Paramecium\ tetraurelia$ recapitulated the sperm phenotype. Overall, our study, which identifies TTC12 as a gene involved in PCD, unveils distinct dynein assembly mechanisms in human motile cilia versus flagella.

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.

Résumé Comme pour beaucoup de maladies humaines, les analyses génétiques en cas d’azoospermie étaient initialement limitées à la réalisation d’un caryotype, conduisant au diagnostic de réarrangements chromosomiques comme pour le syndrome de Klinefelter ou autres syndromes. L’avènement de la biologie moléculaire, dans les années 1980, a permis l’élargissement du dépistage génétique à la recherche des microdélétions du chromosome Y et aux anomalies du gène CFTR (cystic fibrosis transmembrane conductance regulator). Il a fallu attendre plusieurs décennies et l’apparition des techniques d’analyses du génome entier pour que soit réalisée l’identification d’autres anomalies génétiques associés à l’azoospermie humaine. Si les anomalies des gènes TEX11 et ADGRG2 sont fréquemment décrites dans la littérature pour les hommes présentant une azoospermie, la plupart des altérations génétiques découvertes à ce jour sont privées, identifiées dans un petit nombre de familles souvent consanguines. L’objectif dans cette revue est de fournir un aperçu actualisé de toutes les anomalies génétiques décrites dans la littérature et associées à l’azoospermie humaine tout en essayant de fournir des guides de conduite diagnostique en fonction du phénotype de l’azoospermie. En plus des mutations homozygotes et délétères, les polymorphismes et les défauts épigénétiques sont également brièvement abordés. Néanmoins, comme ces variations ne sont que de potentiels facteurs de prédisposition à l’azoospermie, une étude spécifique sera nécessaire pour compiler l’ensemble des données de la littérature pour chaque variant génétique.

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.

International audience; Freezing-thawing procedures and in vitro culture conditions are considered as a source of stress associated with increased reactive oxygen species (ROS) generation, leading to a damaged cell aerobic metabolism and consequently to oxidative stress. In the present study, we sought to investigate whether vitamin E (Vit E) or reduced glutathione (GSH) enhances sperm production by decreasing ROS accumulation during in vitro maturation of prepubertal mice testes. Testes of prepubertal mice were cryopreserved using a freezing medium supplemented or not supplemented with Vit E and were cultured after thawing. In presence of Rol alone in culture medium, frozen-thawed (F-T) testicular tissues exhibited a higher ROS accumulation than fresh tissue during in vitro culture. However, Vit E supplementation in freezing, thawing, and culture media significantly decreased cytoplasmic ROS accumulation in F-T testicular tissue during in vitro maturation when compared with F-T testicular tissue cultured in the presence of Rol alone, whereas GSH supplementation in culture medium significantly increased ROS accumulation associated with cytolysis and tissue disintegration. Vit E but not GSH promoted a better in vitro sperm production and was a suitable ROS scavenger and effective molecule to improve the yield of in vitro spermatogenesis from F-T prepubertal mice testes. The prevention of oxidative stress in the cytoplasmic compartment should be regarded as a potential strategy for improving testicular tissue viability and functionality during the freeze-thaw procedure and in vitro maturation.

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; 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.

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.

International audience; Since its initial discovery in the 1940s, research into the physiological actions of anti-Müllerian hormone (AMH), from its eponymous role in male developmental biology to its routine clinical use in female reproductive health, has undergone a paradigm shifting change. With several exciting studies recently reporting hitherto unforeseen AMH actions at all levels in the hypogonadal-pituitary-gonadal axis, the importance of this hormone for both hypothalamic and pituitary reproductive control is finding increasing support and significance. In this review, we will briefly summarize what is known about the traditional roles and biology of AMH and how this could be integrated with new findings of AMH actions at the level of the hypothalamic-pituitary axis. We also synthesize the important findings from these new studies and discuss their potential impact and significance to our understanding of one of the most common reproductive disorders currently affecting women, polycystic ovary syndrome.

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; Motile cilia and sperm flagella share an evolutionarily conserved axonemal structure. Their structural and/or functional defects are associated with primary ciliary dyskinesia (PCD), a genetic disease characterized by chronic respiratory-tract infections and in which most males are infertile due to asthenozoospermia. Among the well-characterized axonemal protein complexes, the outer dynein arms (ODAs), through ATPase activity of their heavy chains (HCs), play a major role for cilia and flagella beating. However, the contribution of the different HCs (γ-type: DNAH5 and DNAH8 and β-type: DNAH9, DNAH11, and DNAH17) in ODAs from both organelles is unknown. By analyzing five male individuals who consulted for isolated infertility and displayed a loss of ODAs in their sperm cells but not in their respiratory cells, we identified bi-allelic mutations in DNAH17. The isolated infertility phenotype prompted us to compare the protein composition of ODAs in the sperm and ciliary axonemes from control individuals. We show that DNAH17 and DNAH8, but not DNAH5, DNAH9, or DNAH11, colocalize with α-tubulin along the sperm axoneme, whereas the reverse picture is observed in respiratory cilia, thus explaining the phenotype restricted to sperm cells. We also demonstrate the loss of function associated with DNAH17 mutations in two unrelated individuals by performing immunoblot and immunofluorescence analyses on sperm cells; these analyses indicated the absence of DNAH17 and DNAH8, whereas DNAH2 and DNALI, two inner dynein arm components, were present. Overall, this study demonstrates that mutations in DNAH17 are responsible for isolated male infertility and provides information regarding ODA composition in human spermatozoa.

In recent years, testicular biopsy followed by the freezing of testicular tissue has been proposed to children with cancer before the introduction of a gonadotoxic treatment. This fertility preservation procedure is offered with the hope that a fertility restoration method will be developed. The thawed testicular tissue could thus be used to perform in vitro maturation, avoiding the reintroduction of tumor cells, to produce spermatozoa. This thesis work first consisted in assessing the establishment of DNA methylation in mouse prepubertal testicular tissue during in vitro spermatogenesis. The culture of fresh or thawed mouse testicular testicular tissue allows the expression levels of DNA methyltransferases 1 and 3a to be maintained in spermatogonia and spermatocytes. In addition, DNA methylation is found even in in vitro produced spermatozoa. The nuclear quality of these spermatozoa was then analyzed. The culture of testicular tissue has no impact on sperm aneuploidy rate, chromatin condensation and DNA fragmentation. However, freezing followed by organotypic culture increases the proportion of spermatozoa with oxidized DNA. Finally, the functionality of in vitro produced spermatozoa was analyzed by oocyte microinjection and the dynamics of different epigenetic marks was studied during preimplantation development. Embryo developmental rates are decreased when using in vitro produced spermatozoa. The levels of H3K4me3, H3K27me3 and H3K9ac are slightly modified in embryos derived from spermatozoa generated in vitro whereas DNA methylation and demethylation are more affected. The production of spermatozoa after culture of fresh or thawed prepubertal tissue in the mouse model has shown that this procedure is not without impact on the early embryo, although the quality of the spermatozoa produced is relatively unaltered.; Depuis quelques années, une biopsie testiculaire suivie d’une congélation du tissu testiculaire est proposée aux enfants atteints de cancer avant introduction d’un traitement gonadotoxique. Cette procédure de préservation de la fertilité est proposée avec l’espoir qu’une méthode de restauration de la fertilité soit développée. Le tissu testiculaire décongelé pourrait ainsi être utilisé afin d’effectuer une maturation in vitro, évitant la réintroduction de cellules tumorales, pour produire des spermatozoïdes. Ce travail de thèse a consisté, dans un premier temps, à évaluer la mise en place de la méthylation de l’ADN au sein du tissu testiculaire prépubère de souris au cours de la spermatogenèse in vitro. La culture de tissu testiculaire frais ou décongelé de souris prépubère permet le maintien des niveaux d’expression des ADN méthyltransférases 1 et 3a dans les spermatogonies et les spermatocytes. De plus, la méthylation de l’ADN est retrouvée jusque dans les spermatozoïdes produits in vitro. Par la suite, la qualité nucléaire des spermatozoïdes ainsi obtenus a été analysée. La culture de tissu testiculaire n’a pas d’impact sur le taux d’aneuploïdie, la condensation de la chromatine et la fragmentation de l’ADN spermatique. Cependant, la congélation suivie par la culture organotypique augmente la proportion de spermatozoïdes avec un ADN oxydé. Enfin, la fonctionnalité des spermatozoïdes produits in vitro a été analysée par micro-injection ovocytaire et la dynamique de différentes marques épigénétiques a été étudiée au cours du développement préimplantatoire. Les taux de développement embryonnaire sont diminués par l’utilisation de spermatozoïdes produits in vitro. Les niveaux des histones H3K4me3, H3K27me3 et H3K9ac sont peu modifiés dans les embryons issus de spermatozoïdes générés in vitro alors que la méthylation et déméthylation de l’ADN sont plus impactées. La production de spermatozoïdes après culture de tissu prépubère frais ou décongelé dans le modèle murin a permis de mettre en évidence que cette procédure n’est pas sans impact sur l’embryon précoce bien que la qualité des spermatozoïdes produits soit peu altérée.

International audience; In 80% of infertile men with obstructive azoospermia caused by a congenital bilateral absence of the vas deferens (CBAVD), mutations are identified in the cystic fibrosis transmembrane conductance regulator gene (CFTR). For the remaining 20%, the origin of the CBAVD is unknown. A large cohort of azoospermic men with CBAVD was retrospectively reassessed with more stringent selection criteria based on consistent clinical data, complete description of semen and reproductive excurrent ducts, extensive CFTR testing, and kidney ultrasound examination. To maximize the phenotypic prioritization, men with CBAVD and with unilateral renal agenesis were considered ineligible for the present study. We performed whole-exome sequencing on 12 CFTR-negative men with CBAVD and targeted sequencing on 14 additional individuals. We identified three protein-truncating hemizygous mutations, c.1545dupT (p.Glu516Ter), c.2845delT (p.Cys949AlafsTer81), and c.2002_2006delinsAGA (p.Leu668ArgfsTer21), in ADGRG2, encoding the epididymal- and efferent-ducts-specific adhesion G protein-coupled receptor G2, in four subjects, including two related individuals with X-linked transmission of their infertility. Previous studies have demonstrated that Adgrg2-knockout male mice develop obstructive infertility. Our study confirms the crucial role of ADGRG2 in human male fertility and brings new insight into congenital obstructive azoospermia pathogenesis. In men with CBAVD who are CFTR-negative, ADGRG2 testing could allow for appropriate genetic counseling with regard to the X-linked transmission of the molecular defect.

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

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

International audience; A-kinase anchor protein 4 (AKAP4) is playing a central role in flagellar structure, chemotaxis, capacitation and sperm motility. In mammals, AKAP4 is expressed during spermatogenesis. AKAP4 is synthesized as a precursor, proAKAP4, which is cleaved into mature AKAP4 during fibrous sheath assembly. The proAKAP4 is a good indicator of sperm quality in humans and boars. The aims of this work were to study the expression, the localization and the concentration of proAKAP4 and AKAP4 in equine semen, and to evaluate the possible correlation between the total and progressive motility and the concentration of proAKAP4 measured by ELISA in post-thawed semen. Frozen sperm from 13 different stallions were used. Semen samples (n = 17) were prepared using the INRA Freeze medium to reach a concentration of 150 million spermatozoa/mL, packaged and frozen in 0.5 mL straws. The precursor proAKAP4 and the mature protein AKAP4 both localize to the fibrous sheath of the principle piece of equine sperm flagellum. The concentrations of proAKAP4 were determined in the post-thawed semen using ELISA method (Horse 4MID® kits, 4BioDx, France). The mean concentration of proAKAP4 was then of 7.372 ± 0.79 ng/μL and was significantly correlated with the post-thawed total motility (Pearson coefficient r = 0.66, p = 0.002) and progressive motility (Pearson coefficient r = 0.76, p = 0.0002) and the amount of proAKAP4 represent the amount of spermatozoa that expressed proAKAP4. Taken together, these preliminary results confirm the interest to use proAKAP4 concentrations as a promising marker of stallion sperm quality as close correlation was observed between the proAKAP4 concentration and sperm motility parameters.

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.

International audience; The reported sperm retrieval rate (SRR) in patients with nonobstructive azoospermia (NOA) due to spermatogenic arrest (SA) is highly variable in the literature. This discrepancy could be explained by the heterogeneity of testicular tissues. Surprisingly, even though inhibin B levels reflect directly Sertoli cell function; no studies have evaluated this parameter in SA. We aimed to clarify the morphological and biological profile in 158 men with SA. From the total population, patients whose seminiferous tubules diameter was below 165 µm have higher SRR (46.9% vs. 27.4%, p

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.

Background A-kinase anchor protein 4 (AKAP4) and its precursor pro-AKAP4 are two major proteins in spermatozoa of rodents and mammals. Although researchers have characterized the AKAP4 expression in various species, the protein's expression in humans has not been described in detail. Objectives The objective of this study was to characterize human pro-AKAP4 more precisely (notably the definition of its localization and expression levels in human spermatozoa and testes). Materials and methods pro-AKAP4 protein expression levels were assessed by Western blotting. The pro-AKAP4's localization in spermatozoa and testes was determined using immunofluorescence staining and immunogold electron microscopy. Furthermore, pro-AKAP4 protein expression levels were assessed in a series of 77 human semen samples, and associations with semen parameters were evaluated. Results Western blotting revealed a 100-kDa band in human sperm protein extracts. The pro-AKAP4 was immunolocalized in the fibrous sheath of the flagellum of ejaculated spermatozoa and in elongated spermatids in human testes. A Western blot analysis of 77 normozoospermic semen samples evidenced striking differences in pro-AKAP4 levels from one to another sample (median [interquartile range] integrated optical density = 305 [49-1038]). No correlations were found for pro-AKAP4 levels on one hand and semen volume, sperm concentration, sperm count, sperm motility, or sperm morphology on the other (p > 0.05 for all). However, pro-AKAP4 levels were positively correlated with motility after density gradient centrifugation of the semen (r = 0.224, p = 0.049). Discussion AKAP4 protein might be activated as an alternative pathway to rescue sperm motility. In human spermatozoa, pro-AKAP4 might therefore be a 'reservoir' of mature AKAP4. Conclusion This study generated new knowledge about pro-AKAP4 in human semen, which may be of interest in the management of male infertility.

To evaluate the pathological features and recurrence of incidental testis tumours treated by partial orchiectomy in a population of infertile men.We retrospectively pooled, from four andrology referral centres, 32 patients diagnosed with testis mass during regular infertility workup. Patients included had an impaired sperm analysis and testis sparing surgery was performed to prevent secondary azoospermia or androgen therapy.Mean age was 36 (IQR, 32 to 37). The mean largest tumoral diameter was 8.5 mm (IQR, 5 to 10). A total of 25% (8 of 32) of patients had a malignant tumour (seminoma, 7 of 32, 22%; teratoma, 1 of 32, 3%) and 75% (24 of 32) had a benign lesion (Leydig cell tumour, 23 of 32, 72%; scar tissue, 1 of 32, 3%). Malignant tumours were then managed by total orchiectomy (six of eight) or by radiotherapy (two of eight). With a mean follow up of 26 months (IQR, 8 to 32), one patient (3%) had an homolateral recurrence, which was a Leydig cell tumour. Not a single patient developed metastasis.Seventy-five per cent of the tumours discovered during infertility management were of a benign pathology. A conservative approach could be proposed initially to avoid unnecessary orchiectomies. Orchiectomy and radiotherapy could be discussed as salvage therapies for malignant lesions.

Background The limitations of conventional sperm analyses have highlighted the need for additional means of evaluating sperm quality. Methods In a study of a cohort of 245 men with known conventional sperm parameters, one-dimensional PAGE was used to monitor protein content and quality in samples from individual ejaculates. Results The sperm protein content varied markedly from sample to another, especially in the high-molecular-weight range. The intensity of the 80–110 kDa bands was correlated with progressive motility (r = 0.15, p = 0.015) and was significantly higher (p = 0.0367) in the group of men with conventional parameters above the World Health Organization’s 2010 reference values than in the group with at least one subnormal parameter (i.e. semen volume, sperm concentration, sperm count per ejaculate, progressive motility, proportion of normal forms or multiple anomaly index below the lower reference value). Using mass spectrometry, the 80–110 kDa bands were found to correspond primarily to three proteins from the flagellum’s fibrous sheath: A-kinase anchor protein 4, A-kinase anchor protein 3, and spermatogenic cell-specific type 1 hexokinase. Conclusion One-dimensional PAGE constitutes a simple, rapid, reliable, inexpensive method for analyzing proteins associated with sperm motility in individual human ejaculates.

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

Resume Objectif Decrire retrospectivement l’activite du Centre expert de diagnostic et de prise en charge multidisciplinaire de l’endometriose de Rouen, au cours des periodes precedant et suivant la labellisation en tant que centre expert. Methodes Nous avons realise une etude retrospective qui recense les principales missions d’un centre expert, de janvier 2013 a mars 2018. Resultats Le centre expert de Rouen est un reseau regional, compose d’un centre de reference articule avec des centres de competence publiques et prives de Normandie. Dix a 11 reunions de concertation multidisciplinaire ont ete organisees/an, avec la discussion de 15 a 20 dossiers, et la participation de medecins provenant de 17 etablissements. Parmi, 2066 patientes avec le diagnostic « endometriose » ont ete hospitalisees au centre de reference, dont 615 patientes ont ete operees pour une endometriose colorectale, et 607 parmi elles (98,7 %) par cœlioscopie. Dans 444 interventions (72,2 %) l’equipe chirurgicale a ete multidisciplinaire. 50 cycles de preservation de la fertilite ont ete effectues. L’activite de recherche s’est concretisee par 76 articles scientifiques, dont 41 (53,9 %) ont ete publies dans une revue de rang SIGAPS A ou B. L’enseignement a ete organise pour les professionnels de sante en exercice, en formation et pour les infirmieres scolaires. Conclusion L’experience pilote rouennaise a contribue a l’amelioration de la prise en charge de la maladie en Normandie. Cette experience pourrait etre exportee dans toutes les regions de France, afin de federer les professionnels de sante autour d’un programme national de lutte contre l’endometriose.

International audience; Spermatozoa have occasionally been identified in ejaculate of adult Klinefelter syndrome (KS) patients but very exceptionally in KS adolescents. Spermatozoa can also be retrieved in testicular tissue of KS adolescents. The testis may also harbor spermatogonia and noncompletely differentiated germ cells. Neither clinical features nor hormonal parameters could predict germ cell recovery in KS adults or adolescents. No predictive factors can actually demonstrate that early diagnosis of KS would allow increasing the chance of sperm retrieval even if it has been suggested that semen quality may decline with age in KS patients. Leydig cell dysfunction may also be another factor that might affect the spermatogenesis process in XXY adolescents. Fertility preservation might be preferentially proposed in KS adolescents when semen sampling is possible, when the patient is able to consider alternative options to become a father, and to accept germ cell retrieval failure. However, precocious diagnosis of KS has also to be considered because it might not solely improve the possibility of fertility preservation after the onset of puberty, but also the medical care and the quality of life of these patients.