Biomedical subjects
Publications and source records attributed to M Camus.
The authors report the results of four IVF attempts, performed on the same couple, in 16 months, because of tubal problems. June 1985 (T1): spontaneous miscarriage after 8 weeks of amenorrhea; october 1985 (T2): negative tap; january 1986 (T3): extra-uterine pregnancy; october 1986 (T4): rejected because of "poor response" and spontaneous extra-uterine pregnancy during the same cycle.
Thirty-three cases of obstetrical paralysis of the brachial plexus have been seen in 15 years in the gynaecological and obstetrical department of the University Hospital Pitié Salpêtrière. The authors, from studying these cases, work out the factors that tend to bring about this pathological condition. They are: multiparity, excessive weight gain in pregnancy, fetal excessive growth, prolonged second stage of labour, instrumental delivery and shoulder dystocia in cephalic presentations. In breech presentations it is mainly faulty performance of the manoeuvres that are needed to deliver the shoulders. These lesions involve, in most cases, the roots of C5 and C6. Spontaneous regression occurs very often. The authors have found 25% of sequellae. It is difficult to prevent shoulder dystocia. It consists in realising well the size of the fetus and using instruments really sensibly when the presenting part is high in a primiparous woman. In a multiparous woman one has to be on the look-out for increasing macrosomia of the fetus and it is important to teach the manoeuvres that are necessary to deal with shoulder dystocia. As far as breech delivery is concerned the major risk is the delivery itself without there being any need for fetal or maternal criteria to alter matters. Therefore prevention in this presentation has to be the presence of a competent obstetrician at each delivery always.
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This retrospective study compares results of artificial insemination by donor (AID) and in-vitro fertilization (IVF) trials, and especially of IVF treatment with fresh donor spermatozoa in patients who were unsuccessfully treated on 18 occasions by AID using frozen semen. AID gives cumulative pregnancy rate of 54.6% after six trials. But after 18 trials, 22.4% of the patients were still not pregnant. Treating them with IVF gave a probability of pregnancy as good as in the other IVF patients, 53.9% after six trials. However, pregnancy loss rates differed resulting in cumulative normal pregnancy rates of 16.2% in AID cycles ranking from 19 to 24 compared with 41.8% when going to IVF. In 'ex-AID' women, significantly more follicles were punctured, but the number of oocytes obtained and fertilized, embryos replaced, and the incidence of pregnancy did not differ from the other patients. Considering separately the various infertility factors encountered in the patients, the pregnancy rates still did not differ between ex-AID women and the others. Changing from long-term failed AID to IVF is certainly acceptable and even more so with the newly introduced technique of trans-vaginal puncture. The female infertility factors involved in AID failure are corrected in IVF.
The results of 100 gamete intra-Fallopian transfer (GIFT) procedures to treat persistent infertility are reported. Twenty-four pregnancies were achieved, of these six aborted, two were extra-uterine, two stillbirths occurred and nine patients delivered 11 healthy children (two sets of twins) and five pregnancies are progressing well, including two sets of twins. Pregnancy rate in the different groups of patients was: 28% for idiopathic infertility (n = 39), 13% for male infertility (n = 16), 22% for endometriosis (n = 27), and 29% in the presence of antisperm antibodies (n = 7). In our GIFT procedure, we place three oocytes and 50,000 to 100,000 motile spermatozoa per patient into one healthy tube, the remaining oocytes being inseminated and cultured in vitro. Of 502 oocytes recovered, 252 fertilized normally and 178 early embryos were frozen. The replacement of 41 frozen-thawed embryos resulted in five additional, ongoing pregnancies. The combined treatment by gamete intra-Fallopian transfer, in-vitro fertilization and cryopreservation increases the chance of conception.
The addition of the gonadotropin releasing hormone (GnRH) agonist Buserelin to human menopausal gonadotrophin/human chorionic gonadotropin (HMG/HCG) during ovarian stimulation was evaluated in 23 cycles of 21 women who previously had unsuccessful IVF treatments when stimulated with clomiphene--HMG/HCG. No adverse effects of GnRH-agonist on folliculogenesis were seen. A mean number of 7.2 oocytes per retrieval was collected in 20 treatment cycles. Oocytes quality, fertilization and cleavage parameters were normal. Replacements by gamete intra-Fallopian transfer (GIFT) or IVF took place for 16 patients. Four patients became pregnant in their treatment cycle, one aborted. For 8 patients 18 embryos were cryopreserved, one transfer of a frozen--thawed embryo in a subsequent natural cycle led to a pregnancy. Inadequate luteal phases were constantly observed when supplementation was omitted. Further study is required to confirm that systematic luteal support improves the pregnancy rate.
During a one-year period 636 excess embryos obtained after in-vitro fertilization and gamete intra-Fallopian transfer combined with in-vitro fertilization were cryopreserved using two different protocols. For early stage embryos including the pronucleate stage, 1,2-propanediol was used as cryoprotectant (procedure A, adapted from Renard) and for later stage embryos dimethylsulphoxide was used in protocol B, adapted from Trounson and Mohr. After thawing 288 embryos, half of them were of sufficient quality to be replaced. After cryopreservation, procedure A gave the best survival in embryos having less than or equal to 2 blastomeres; for later stage embryos best survival was obtained using the dimethylsulphoxide protocol. Survival after cryopreservation was also clearly related to the quality of the embryos prior to freezing. Embryos were replaced during endocrinologically monitored natural cycles and were transferred in synchrony between endometrial and embryonic age. After replacement of 126 embryos in 110 patients, 20 pregnancies occurred. So far six healthy children have been born, two patients aborted and 12 pregnancies are ongoing. In this series no statistical difference was observed between the implantation rate of embryos cryopreserved by procedure A or B. Six pregnancies occurred in patients from the oocyte and embryo donation programme. An adequate cryopreservation programme circumvents the difficult problem of synchronizing the ovarian cycles of donor and acceptor patients.
The successive stages leading to fertilization in mammals are reviewed in this article. Methods of human sperm preparation for IVF are described and the "ideal" delay between oocyte pick-up and insemination time is discussed, as well as methods to reduce the incidence of polyspermy. Different culture media and their supplementation are mentioned, as well as a semi-quantitative embryonic scoring system, defined by the IVF team of the Saint-Pierre Hospital in Brussels. Finally the optimal transfer time, and the handling of embryos at replacement are discussed.
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The accuracy and the low radiation dosage administered when tomodensitometry is carried out for pelvimetry has led us to specify the use of this technique in every day practice. We propose to make is still more reliable and to simplify it. We have correlated the measurements obtained on the ultrasound screen with those that have been obtained by measuring the dried pelvis and have sought ways of measuring directly the three fundamental diameters of the pelvis. We have achieved exact measurements within one millimeter. This very precise correlation has been reproduced when we examined skeletons using the tomodensitometer. Then, when we checked again the accuracy of these measurements, we used the method on pregnant women. We have taken two views and two slices: an AP view to study the contents of the uterus and the morphology of the upper strait; a profile view to measure the diameter between the promontory of the sacrum and posterior surface of the symphysis, and we have programmed the two following slices: a perpendicular slice at the level of the upper strait measuring directly the transverse median diameter; another slice at the level of the sciatic spines to measure directly the diameter between these spines. We present this method because it is very simple and absolutely precise and gives all the information that is necessary. The patient does not have to stay still for long and only has a small dose of irradiation. This procedure does not need the use of conversion tables, nor parallel rulers nor standardisation.
One hundred forty-six embryo transfers were carried out in the In Vitro Fertilization (IVF) Clinic at St. Pierre Hospital, Brussels, between November 1983 and February 1985. In each of these cases a series of characteristics of the replacement procedure was systematically recorded. Analysis of these data in relation to pregnancy rates indicated that no significant differences appeared among three different operators, the absence or occurrence of cervical bleeding and subjective evaluation of the procedure were related to the chances of establishing a pregnancy, and the duration of replacement had no influence on the outcome of trials. A prospective randomized study of 100 replacements showed that no better pregnancy rate was obtained by placing patients in the knee-to-chest rather than the dorsal position and the addition of a rigid external sleeve to the catheter did not provide any advantage. A simplified method of replacement is thus advocated.
Luteal phases after in vitro fertilization (IVF) and embryo replacement have been studied in 241 cycles. A positive correlation was observed between the follicular estradiol (E2) peak and the progesterone (P) level on day 3 of the luteal phase, but no correlation was found between the E2-peak value and the luteal-phase duration or midluteal P concentration. When the trials were classified in relation to their outcome (i.e., clinical pregnancies, chemical pregnancies, or failures), the mean P level on day 3 of the luteal phase was significantly higher in clinical pregnancies than in chemical pregnancies and in failures. Mean E2 levels on day 3 were not significantly different among the three groups. Values of the E2/P ratio were significantly higher in chemical pregnancies than in the other groups. No significant differences were observed among the three groups on day 8. When comparing trials ending in failure to those leading to clinical pregnancy for the same patients, pregnancies were obtained in cycles in which early luteal P was higher and the early luteal E2/P ratio was lower than in failures cycles. These data suggest that high P levels and a low E2/P ratio in the early luteal phase might have a favorable influence on the implantation process in human IVF.
After ovarian stimulation with clomiphene citrate combined with human menopausal gonadotropin for in vitro fertilization, the appearance of a spontaneous luteinizing hormone (LH) surge before fulfillment of the minimal criteria of follicular maturity (at least one follicle greater than 19 mm and serum estradiol [E2] greater than 400 pg/ml/follicle greater than 17 mm) is associated with reduced pregnancy rates. In these cases, follicles are smaller and serum E2 values are lower at the time of the LH surge. Oocyte recovery rate is reduced, embryonic anucleate fragments are more frequently observed, and the level of luteal progesterone on day 4 after oocyte retrieval is lower. Hyperandrogenic patients are more prone to display such premature spontaneous LH surge. We concluded that in case of an untimely LH rise, laparoscopy for oocyte retrieval should be cancelled.
Four-hundred-and-ninety-one oocytes were collected from 142 successive patients attending for in-vitro fertilization. The systematic observation of pronuclei between 14 and 18 h after insemination revealed 27 cases of tripronucleate eggs among 391 fertilized eggs (6.9%), which corresponds to rates generally reported in the literature. The following parameters were analysed in relation to the incidence of these eggs: aetiology of infertility, follicular response to hormonal stimulation, type of ovulatory stimulus, sperm count and motility and the incidence of fertilization. Only fertilization rates and concentration of motile spermatozoa in the insemination medium were found to be correlated with tripronucleate eggs, confirming that the condition is predominantly due to polyspermy. Comparisons with data from animals, and measures aimed at preventing polyspermy are suggested.
Thirty-eight single and 10 multiple pregnancies obtained after in-vitro fertilization were compared. In the group of multiple gestations, maternal age was lower and the amounts of ovulatory drugs given were significantly smaller than in relation to single pregnancies. All multiple pregnancies arose from triple embryo transfers and the embryos from this group exhibited significantly higher vitality scores. In both groups, plasma levels of oestradiol and progesterone followed the same pattern until day 8 after oocyte retrieval. Following implantation, the secretion of these hormones increased more rapidly in multiple pregnancies pointing at greater luteal activity in this group. HCG levels became significantly higher in multiple gestation on day 25 after oocyte collection. Echographic examination showed that, compared to normal pregnancy, growth in both groups of IVF conceptuses was initially retarded but caught up with normal evolution at approximately 30 days after egg retrieval. The need for adjusting the number of embryos transferred not only to expected success rates but also to the risk of high rank multiples is emphasized.
Triploidy in a common chromosomal abnormality that gives rise to early abortion in most cases. Rarely triploidies carry on past the end of the first trimester. When they do they are always accompanied by severe intra-uterine growth retardation with occasionally molar changes in the placenta. These changes are different from hydatidiform moles but they can become malignant. The formal diagnosis of triploidy depends on the fetal caryotype.
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