J. Boujenah

Non-ART pregnancy predictive factors in infertile patients with peritoneal superficial endometriosis

OBJECTIVE To study the predictive factors for non-ART pregnancy in infertile women after laparoscopic diagnosis and surgery for isolated superficial peritoneal endometriosis (SUP). STUDY DESIGN Retrospective observational study from January-2004 to December-2015 in a tertiary care university hospital and Assisted Reproductive Technology (ART) centre. Infertile women with laparoscopic surgery for SUP (with histologic diagnosis) were included. The surgical treatment was followed by spontaneous fertility or post-operative ovarian stimulation (pOS) using superovulation (gonadotrophins)±Intra Uterine Insemination (IUI). The main outcomes were the non-ART clinical pregnancy rates and its predictive factors. RESULT(S) Over the period study, 315 women were included. Of these, 133 (42.3%) women had non-ART pregnancy. The mean time to conceive was 6 months (±6days). Univariate analysis for non-ART pregnancy after surgery showed that: (i) no difference was observed according to age, length of infertility, Body Mass Index (BMI), the rate of previous pregnancy, and the pre-operative ovarian stimulation rate; (ii) diminished ovarian reserve and previous miscarriage were higher in the non-pregnant women group (8.3 versus 19.1%, p<0.05; 3.5% versus 9%, p=0.06, respectively); (iii) the mean EFI score and pOS were higher in pregnant women (7.7 versus 7.2, p=0.02; 49.2% versus 26.7%, p<0.01); and (iv) IUI did not show any benefit for pregnancy (22% after superovulation versus 27.2% after superovulation and IUI). In the multivariate analysis, only pOS (adjusted OR 2.504, 95% CI [1.537-4.077]) and DOR (aOR 0.420, 95% CI [0.198-0.891]) remained significantly associated with the incidence of pregnancy. CONCLUSION(S) After laparoscopic surgery for peritoneal superficial endometriosis related infertility, ovarian stimulation improved pregnancy rate, while diminished ovarian reserve had a worse prognosis for pregnancy.

Endometriosis Fertility Index ou classification de l’American Society of Reproductive Medicine pour les patientes infertiles endométriosiques opérées. Lequel est le plus pertinent ?

The revised American Fertility Society classification system has been most used after surgery by all consensus on endometriosis fertility. However, it does not predict pregnancy. The EFI score has been recently developed to aim at predicting clinical pregnancy after surgery. Several study performed its external validation. It may be a useful new tool to counsel couples for personalized postoperative management.

Second live birth after undergoing assisted reproductive technology in women operated on for endometriosis.

OBJECTIVE To determine prognostic factors for a second live birth, after a first child obtained through assisted reproductive techniques (ART). DESIGN Observational study from January 2004 to December 2014. SETTING Tertiary care university hospital and ART center. PATIENT(S) A total of 164 infertile patients with endometriosis, who underwent laparoscopy surgery and had a first baby obtained by ART, were included and 65 wished a second baby. INTERVENTION(S) No iterative surgery. MAIN OUTCOME MEASURE(S) Spontaneous pregnancy rate (PR) according to endometriosis fertility index. RESULT(S) Among the cohort, 27 patients (41.5%) gave birth to a second child through spontaneous pregnancy, whereas 23 patients (35.3%) required ART to obtain a second live birth. No difference was observed between patients regarding age, endometriosis staging, complete removal of endometriosis lesions and pelvic adhesion, except for the least function score, and the endometriosis fertility index. Taking into account irrespective of both mode of conception a total of 78% of patients obtained a second child, with a median conception time of 17 months. CONCLUSION(S) The second live birth rate in infertile patients with endometriosis and with surgical treatment was high (78%). Spontaneous PR was 54%. Endometriosis fertility index could be considered as a predictive factor for a spontaneous second pregnancy in fertility management. Our results need to be confirmed in larger prospective studies.

Delivery rates after elective single cryopreserved embryo transfer related to embryo survival

OBJECTIVE The objective of this study was to assess if eSCET (elective Single Cryopreserved Embryo Transfer) outcome is related to blastomere survival rate. The final objective was to avoid multiple pregnancies and offer the best chances to women to achieve pregnancy even during their frozen-thawed embryo transfer (FET) cycles. STUDY DESIGN Patients were included in this prospective observational study if they met the following criteria: (i) women age <37 years old; (ii) IVF of ICSI cycle rank ≤2, (iii) eSET proposed during fresh embryo transfer cycle and (iv) ≥1 good quality cryopreserved embryos available (<20% fragmentation and 4-5 blastomeres at day-2 or 7-9 blastomeres at day-3). Live birth rates (LBR) were compared into eSCET groups according to embryo survival (partially damaged or intact transferred embryo). RESULTS We observed among selected patients, that partial loss of blastomeres (1 blastomere for day-2 embryos, 1 or 2 blastomeres for day-3 embryos) following FET cycles did not affect LBR compared with intact embryo. CONCLUSION These results underline the relevance of eSCET as a strategy to reduce multiple pregnancies frequency without reducing LBR.

Use of the endometriosis fertility index in daily practice: A prospective evaluation

OBJECTIVE To perform a prospective evaluation of postoperative fertility management using the endometriosis fertility index (EFI). STUDY This prospective non-interventional observational study was performed from January 2013 to February 2016 in a tertiary care university hospital and an assisted reproductive technology (ART) centre. In total, 196 patients underwent laparoscopic surgery for endometriosis-related infertility. Indications for surgery included pelvic pain (dysmenorrhoea, and/or deep dyspareunia), abnormal hysterosalpingogram, and failure to conceive after three or more superovulation cycles with or without intra-uterine insemination. Multidisciplinary fertility management followed the surgical diagnosis and treatment of endometriosis. Three postoperative options were proposed to couples based on the EFI score: EFI score ≤4, ART (Option 1); EFI score 5-6, non-ART management for 4-6 months followed by ART (Option 2); or EFI score ≥7, non-ART management for 6-9 months followed by ART (Option 3). The main outcomes were non-ART pregnancy rates and cumulative pregnancy rates according to EFI score. Univariate and multivariate analyses with backward stepwise logistic regression were used to explain the occurrence of non-ART pregnancy after surgery for women with EFI scores ≥5. Adjustment was made for potential confounding variables that were significant (p<0.05) or tending towards significance (p<0.1) on univariate analysis. RESULTS The cumulative pregnancy rate was 76%. The total number of women and pregnancy rates for Options 1, 2 and 3 were: 26 and 42.3%; 56 and 67.9%; and 114 and 87.7%, respectively. The non-ART pregnancy rates for Options 1, 2 and 3 were 0%, 30.5% and 48.2%, respectively. The ART pregnancy rates for Options 1, 2 and 3 were 50%, 60.6% and 80.3%, respectively. The mean time to conceive for non-ART pregnancies was 4.2 months. The benefit of ART was inversely correlated with the mean EFI score. On multivariate analysis, the EFI score was significantly associated with non-ART pregnancy (odds ratio 1.629, 95% confidence interval 1.235-2.150). CONCLUSION In daily prospective practice, the EFI was useful for subsequent postoperative fertility management in infertile patients with endometriosis.

Bartholin gland abscess during pregnancy: Report on 40 patients

OBJECTIVE(S) To study the clinical and bacterial characteristic of Bartholin gland abscesses during pregnancy and the obstetric and neonatal outcomes. STUDY DESIGN Retrospective cohort study of all patients with surgical treatment of Bartholin gland abscesses between 2004 and 2015 in our university center. Clinical and bacterial characteristics between pregnant and non-pregnant women were compared. RESULTS During the period study, 156 patients were included (40 pregnant and 116 non pregnant). The incidence of Bartholin gland abscesses during pregnancy was 0.13%. Eight (20%) abscesses occurred in the first, 18 (45%) in the second, 11 (47.5%) in the third trimester and 3 (7.5%) in the post-partum course. No severe perineal and neonatal infections occurred during pregnancy. One late miscarriage and one preterm delivery were observed. We found more multiparity in the pregnant woman group than in non-pregnant women (62.5% versus 45%, p<0.05). A history of Bartholin gland abscesses were also more frequent in pregnant women (55% versus 30.1%, p<0.05). First line antibiotic therapy was more frequent in non-pregnant women (20% versus 45%, p<0.05). The rate of positive culture did not differ between the two groups (70% versus 55.2%). Among negative pus cultures, no patient in the pregnant woman group had received a first line antibiotic therapy, in contrast with non-pregnant women (0% versus 25%, p<0.05). E. coli was the most common pathogen in the two groups (48.9% of positive cultures and 28.2% of the overall population). The distribution of bacterial taxa was not different between the two groups. CONCLUSION Bacterial characteristics did not differ from non-pregnant women. Pregnancy could increase the occurrence of Bartholin gland abscesses in patients with previous surgical treatment of abscesses. When appropriate management is applied, maternal and neonatal outcomes are favorable, and severe infections are not to be expected.

Fetal-maternal chimerism in peritoneal tissue implants after tubal ectopic pregnancy

A 30-year-old woman, with a history of laparoscopic salpingectomy for right ectopic tubal pregnancy (at 8 weeks of pregnancy) the year before, underwent a subsequent laparoscopy for secondary infertility. She did not report any gynecologic complaint. She did not get pregnant before and after this ectopic pregnancy. No genetic family disorder was noted. Fig. 1. Incidental laparoscopic finding of sclerotic peritoneal lesion (!) in right fossae. Available online at