Sylvie Epelboin

Ovarian reserve after treatment with alkylating agents during childhood

STUDY QUESTION What is the effect of different alkylating agents used without pelvic radiation to treat childhood cancer in girls on the ovarian reserve in survivors? SUMMARY ANSWER Ovarian reserve seems to be particularly reduced in survivors who received procarbazine (in most cases for Hodgkin lymphoma) or high-dose chemotherapy; procarbazine but not cyclophosphamide dose is associated with diminished ovarian reserve. WHAT IS KNOWN ALREADY A few studies have demonstrated diminished ovarian reserve in survivors after various combination therapies, but the individual role of each treatment is difficult to assess. STUDY DESIGN Prospective cross-sectional study, involving 105 survivors and 20 controls. PARTICIPANTS/MATERIALS, SETTING, METHODS One hundred and five survivors aged 17-40 years and 20 controls investigated on Days 2-5 of a menstrual cycle or Day 7 of an oral contraceptive pill-free interval. MAIN OUTCOME MEASURES ovarian surface area (OS), total number of antral follicles (AFC), serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol and anti-Müllerian hormone (AMH). MAIN RESULTS AND THE ROLE OF CHANCE Survivors had a lower OS than controls: 3.5 versus 4.4 cm(2) per ovary (P = 0.0004), and lower AMH levels: 10.7 versus 22 pmol/l (P = 0.003). Ovarian markers (OS, AMH, AFC) were worse in patients who received high-dose compared with conventional-dose alkylating agents (P = 0.01 for OS, P = 0.002 for AMH, P < 0.0001 for AFC). Hodgkin lymphoma survivors seemed to have a greater reduction in ovarian reserve than survivors of leukaemia (P = 0.04 for AMH, P = 0.01 for AFC), sarcoma (P = 0.04 for AMH, P = 0.04 for AFC) and other lymphomas (P = 0.04 for AFC). A multiple linear regression analysis showed that procarbazine but not cyclophosphamide nor ifosfamide dose was associated with reduced OS (P = 0.0003), AFC (P = 0.0007), AMH (P < 0.0001) and higher FSH levels (P < 0.0001). LIMITATIONS, REASONS FOR CAUTION The small percentage of participating survivors (28%) from the total cohort does not allow conclusion on fertility issues because of possible response bias. The association between procarbazine and HL makes it impossible to dissociate their individual impacts on ovarian reserve. The number of controls is small, but ovarian volume and AMH levels in survivors were compared with published normal values and results were unchanged. WIDER IMPLICATIONS OF THE FINDINGS Early detection and follow-up of compromised ovarian function after cancer therapy should help physicians to counsel young survivors about their fertility window. However, longitudinal follow-up is required to determine the rate of progression from low ovarian reserve to premature ovarian failure. STUDY FUNDING/COMPETING INTERESTS La Ligue contre le Cancer (grant no., PRAYN7497). The authors have no competing interests to disclose.

Timing of intermittent seminal HIV-1 RNA shedding in patients with undetectable plasma viral load under combination antiretroviral therapy.

It was demonstrated that combination antiretroviral therapy (cART) reduces the HIV-1 viral load (VL) in the blood and the seminal compartment. Some studies have reported that the seminal HIV-1 VL is undetectable in individuals with an undetectable blood plasma viral load (bpVL) under cART. However, some recent studies have demonstrated that seminal HIV-1 RNA may still be detected, and potentially infectious, even in the case of an undetectable bpVL. The aim of this retrospective study was to determine the detection rate of a seminal VL and whether shedding could be intermittent over a very short time. From January 2006 to December 2011, 88 HIV-1 infected men, enrolled in an Assisted Reproduction program, provided 306 semen samples, corresponding to 177 frozen sperm samples (two samples delivered at a one-hour interval (n = 129) or one sample (n = 48)). All enrolled men were under cART, with an undetectable bpVL for more than 6 months. HIV-1 RNA was quantified in seminal plasma using a Roche COBAS Ampliprep COBAS TaqMan HIV-1 test. Seminal HIV-1 RNA was detected in 23 samples (7.5%) from 17 patients (19.3%). This detection rate was stable over years. With regards to the freezing of two samples delivered at a one-hour interval, the proportion of discordance between the first and second samples was 9.3% (12/129). Our results confirm the intermittent shedding of HIV-1 in semen. While this finding has been shown by studies examining longer time intervals, to our knowledge, this has never been demonstrated over such a short time interval.

The use of the antiprogestin RU486 (Mifepristone): As an abortifacient in early pregnancy — clinical and pathological findings; predictive factors for efficacy☆

RU486, a potent antiprogesterone steroid was administered to 124 women requesting therapeutic abortion. All were less than 49 days from their last menstrual period. Ten of these subjects (Group I) received high doses of RU486 in a decremental dose regimen (400, 300, 200 and 100 mg/day) over 4 successive days and 14 received 50 mg/day for 7 days (Group II). A further 50 subjects (Group III) received 100 mg/day for seven days and the remaining 50 subjects (Group IV) received 450 mg in a single dose. In the first three groups, half the daily dose was given in the morning and the remainder in the evening. Blood was collected before, and on Days 4 and 7 and then once a week after commencing therapy until disappearance of circulating beta HCG. In addition to beta HCG, estradiol-17 beta (E2), progesterone (P), cortisol, and various metabolic and hematological parameters were measured. Plasma RU486 concentrations were also assayed in Group II, III and IV subjects on Day 7 of therapy and in some cases on Days 14 and 21. Ultrasonography was performed in all cases on Day 1 and on Day 14. All the patients bled within five days following RU486 administration, for 1 to 21 days. A complete abortion occurred in 60% in Group I, 50% in Group II, 86% in Group III, and 80% in Group IV. The difference between the last two groups and the first two was significant at p less than 0.01. The non-responders were submitted to a uterine vacuum aspiration. A stepwise discriminant analysis was performed and indicated that the best predictors of the outcome of therapy were beta HCG values and the gestational sac diameter. With these criteria, the prediction was accurate in 86.4% of the cases. The best results were obtained in the cases where the ultrasonic measurement of gestational sac was under 10 mm in diameter and the initial beta HCG values under 15,000 mIU/ml. Among the observed side effects were moderate pelvic cramps (20.9%), nausea (27%), fainting (4.8%); 61.3% of the women complained of fatigue. Heavy bleeding occurred in 15.3% of the women but only one of them required blood transfusion. In the patients with complete abortion, beta HCG values decreased to below 500 mIU/ml by Day 14 (but in 11 cases values fell below 2,000 mIU/ml only by Day 21). Plasma estradiol and progesterone also fell. Cortisol levels increased during therapy especially in subjects of Group I, but returned to basal values after termination of treatment.(ABSTRACT TRUNCATED AT 400 WORDS)

Optimal timing for oocyte denudation and intracytoplasmic sperm injection.

Objectives. To analyze the impact of oocyte denudation and microinjection timings on intracytoplasmic sperm injection (ICSI) outcomes. Study Design. We included ICSI cycles with the following parameters: rank 1 or 2, female age <36 years, male factor infertility, long protocol using GnRH agonist and rFSH for ovarian stimulation, and use of freshly ejaculated sperm (n = 110). Several ICSI parameters were analyzed according to the time between oocyte retrieval and denudation (T 1) and the time between denudation and ICSI (T 2) using a statistical logistic regression analysis. Results. Neither T 1 nor T 2 had a significant influence on the Metaphase II (MII) rate but the fertilisation rate (FR) showed a significant improvement when T 1 was longer (optimal results at T 1 = 3 hours) while FR significantly decreased with the increase of T 2. Optimal implantation (IR) and pregnancy (PR) rates were obtained when T 1 was around 2 hours. Conclusion. Incubation of oocytes around 2 hours between retrieval and denudation may not increase MII rate but appears to lead to the optimal combination of FR and IR.

Diethylstilbestrol exposure: evaluation of the doses received in France

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The daughters of diethylstilbestrol: Lessons from an error

Diethylstilbestrol (DES) has been used extensively to prevent pregnancy disorders in Europe but at different levels depending upon the countries. Lessons from the DES story can be learned for research, information for physicians, communication, administration and industry. However, this paper will focus on the incidence of this story in our practice. We will propose guidelines for different conditions: clear cell adenocarcinoma, adenosis, cervical dysplasia, infertility and pregnancy.

Premature progesterone rise on day of hCG negatively correlated with live birth rate in IVF cycles: An analysis of 1022 cycles

OBJECTIVE To investigate the relationship between serum P levels on the day of hCG administration and pregnancy outcomes in patients undergoing IVF. DESIGN Retrospective study. SETTING Teaching hospital. PATIENTS A total of 1022 IVF-ICSI cycles, frozen embryo transfer excluded. INTERVENTION(S) Patients-all types of responder - underwent IVF with agonist or antagonist protocols. Clinical outcomes of IVF were analyzed according to plasma P levels. MAIN OUTCOME MEASURE(S) Ongoing pregnancy rates. RESULTS We proposed a serum P level of 1.57ng/ml on day of hCG as a threshold for all types of responders and all protocols combined. Ongoing implantation rates were not affected by elevated progesterone. Live birth rate was inversely associated with serum P levels on day of hCG and more miscarriages were associated with P>1.57ng/ml. We have not found the progesterone>1.57ng/ml on the day of hCG as a prognostic factor for pregnancy. CONCLUSION(S) Elevated P level on the day of hCG administration negatively influence live birth rate and is correlated to an increase of miscarriage. The detrimental effect of P elevation on pregnancy seems not to be related substantially to endometrium receptivity. Thus, despite a comparable clinical pregnancy rate and an initial implantation rate, we demonstrate more spontaneous abortion and it would seem that the effect of progesterone is later.

Sperm concentration measurement with a disposable counting chamber

of the experiment. The counting chamber was left for 10–15 min and counting was then performed using positive phase-contrast optics with a magnification of ×400, according to the instructions provided by the WHO.1 In light of the absence of a state of the art definition in spermiology, our results were compared with data from the literature (when available) and with the criteria defined by the biological variations calculated on within-subject and between-subject biologic variation (Ricos).3 All of the determinations of concentrations were done blinded by four different operators on 60 sperm samples (concentrations ranging from 0.4 × 106 ml−1 to 382.5 × 106 ml−1). Differences in Bland–Altman plots4 showed concordance of sperm concentration values measured with the Kova and the Neubauer devices (Figure 1a). Three points of discrepancy were above the 95% limit of agreement, without any clinical impact given the high values. The correlation between the two methods was studied with Tessier’s least rectangle regression, by fitting a linear equation to the observed data. Statistical correlation revealed a coefficient of determination R2 = 0.982 (Figure 1b), indicating correct linearity of the regression and thus a strong association between the values determined with the Kova and the Neubauer devices.5 Differences in accuracy,5 evaluated for four levels of selected clinical interest (5 × 106 ml−1, 30 × 106 ml−1, 100 × 106 ml−1, and 300 × 106 ml−1), were 13.8%, 1.9%, 4.1%, and 4.7%, respectively. The mean relative difference between both of the methods was 3.6%, with a 95% confidence interval that ranged from 1.7% to 8.9%. All of these values were lower than the limit of inaccuracy B (15.6%).3 The statistical power of comparison between both methods, calculated with a threshold of 10% and a risk of 5%, was 99.5%, assuming that there is no statistical difference between both methods for sperm concentration measurement. Repeatability was expressed as the coefficient of variation (CV). Each sample was counted ten times for each calibrated bead and five times for each semen sample by the same operator. The CVs were 9.2% and 5.7% for level 1 and level 2 bead solutions, respectively. They were 8.6% and 7.9% for the low (20 × 106 ml−1) and high (200 × 106 ml−1) sperm level samples, respectively. All of the CVs were lower than the reported intratechnician CV, which averaged 12.5% for hemocytometer counts,6 and they were similar to that reported for technicians with daily practice (9.8%).7 Reproducibility was expressed as the CV. To our knowledge, there is no consensus in regard to the method to obtain reproducibility. Dear Editor, In its latest edition, the World Health Organization (WHO) provides guidelines regarding the standardization of techniques for the measurement of sperm concentration1 and recommends use of a 100 μm-deep hemocytometer. However, these instructions are not always followed correctly.2 Furthermore, although hemocytometers provide more accurate and consistent results, they present several drawbacks: the chamber must be properly assembled prior to its use so as to ensure that the counts are correct and it needs to be cleaned thoroughly to remove all traces of sperm, which risks breaking the glass coverslip. A disposable counting chamber (Kova) exhibits several advantages: low cost, ease of use (e.g., no cleaning, no need for mounting the coverslip, and a fixed device); disposability, which is particularly advantageous with sperm infected with virus; and the possibility of processing 10 samples. Here, we sought to validate the Kova chamber as a reliable device for the measurement of sperm concentration, according to the ISO 15189 standards. Samples consisted of latex beads (Qwik Check®, Theradiag, Marne-la-Vallée, France) and semen samples from infertile patients collected by masturbation in the laboratory, after having provided informed consent (Bichat Hospital, APHP, Paris, France). Two levels of latex beads were used: level 1 ((22 ± 5.5) × 106 beads ml−1) and level 2 ((46 ± 11.5) × 106 beads ml−1). After the samples were mixed, they were diluted using positive-displacement pipettes in a 0.35% (v/v) formalin solution (dilutions ranged from 1:2 to 1:100). A 10 μl diluted aliquot of either latex beads or patient sperm sample was then loaded in a counting chamber (Kova® Glasstic® Slide 10 [CML, Nemours, France] and/or an improved Neubauer chamber [Dutscher, Brumath, France]) depending on the nature LETTER TO THE EDITOR