The main difficulty of ovarian tissue autograft (OTA) is to preserve as many follicles as possible because the ovarian tissue undergoes warm ischemia during grafting until revascularisation, resulting in significant follicular loss. We describe a two-stage grafting technique to stimulate new vascularisation in order to enhance the revascularization process to reduce the ischemic injuries. Furthermore we performed ovarian patchwork in the laboratory and then grafting with robotic laparoscopy to facilitate surgery and increase precision. This technique is used in the DATOR study with promising results, such as a 40% delivery rate.

Purpose Vitrification is a well-accepted fertility preservation procedure for cryopreservation of oocytes and embryos but little is known regarding ovarian tissue, for which slow freezing is the current convention. The aim of the present study was to assess the efficiency of non-equilibrium vitrification compared to conventional slow freezing for ovarian cortex cryopreservation. Methods Using prepubertal sheep ovaries, the capacity of the tissue to sustain folliculogenesis following cryopreservation and in vitro culture was evaluated. Ovarian cortex fragments were cultured in wells for 9 days, immediately or after cryopreservation by conventional slow freezing or non-equilibrium vitrification in straws. During culture, follicular populations within cortex were evaluated by histology and immunohistochemistry for PCNA and TUNEL. Steroidogenic activity of the tissue was monitored by assay for progesterone and estradiol in spent media. Results No significant differences in follicle morphology, PCNA, or TUNEL labeling were observed between cryopreservation methods at the initiation of culture. Similar decreases in the proportion of primordial follicle population, and increases in the proportion of growing follicles, were observed following culture of fresh or cryopreserved ovarian tissue regardless of cryopreservation method. At the end of culture, PCNA and TUNEL-positive follicles were not statistically altered by slow freezing or vitrification in comparison to fresh cultured fragments. Conclusions Overall, for both cryopreservation methods, the cryopreserved tissue showed equal capacity to fresh tissue for supporting basal folliculogenesis in vitro. Taken together, these data confirm that both non-equilibrium vitrification and slow-freezing methods are both efficient for the cryopreservation of sheep ovarian cortex fragments.

Severe trauma, tumor removal or congenital defects may result in composite tissue deficits, in which despite the best reconstructive efforts, functional and esthetic outcomes are poor, with increased morbidity, cost, and recovery time. Vascularized composite allotransplantation (VCA) is a new reconstructive option that involves transplantation of the composite tissues in one surgical procedure and allows to restore the appearance, anatomy, and function in the defects that cannot be repaired with conventional techniques. Unlike solid organ transplantation, the VCA is composed of heterogeneous tissues, including skin, fat, muscle, nerves, lymph nodes, bone, cartilage, ligaments, and bone marrow, all presenting different antigenicity. Thus, VCA may elicit different immune responses compared to solid organ transplants.Since the first successful clinical hand transplantation in 1998, and first face transplantation in 2005, over 100 hand and 40 face transplantations have been performed. Despite successful results, routine clinical application of VCA is limited due to known and unknown lifelong side effects of immunosuppressive protocols. Thus, VCA research is aiming to develop new, less toxic, tolerance-inducing strategies that will allow for routine clinical application of VCA. This chapter overviews the historical background, provides basic information on transplantation immunology, and summarizes the VCA experimental models and clinical applications, as well as the outcomes.

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To evaluate 2 cases of uterine transplant surgery that used utero-ovarian veins as outflow channels, internal iliac arteries for perfusion, and the organ harvest surgery performed laparoscopically.Case study (Canadian Task Force Classification III).An urban, private, tertiary care hospital.Two patients, ages 30 and 24years, diagnosed with absolute uterine factor infertility secondary to Mayer-Rokitansky-Küster-Hauser syndrome underwent related living donor uterine transplants; donors were their mothers with normal menses.Retrieval of organs through minilaparotomy and laparoscopic harvest of donor internal iliac arteries and ovarian veins.Anastomosis was completed with bilateral donor internal iliac arteries to recipient internal iliac arteries in an end-to-end manner and with bilateral donor ovarian veins to recipient external iliac veins in an end-to-side manner. The lengths of utero-ovarian veins of both donors were 11 and 11cm on both sides; the lengths of the internal iliac arteries of both donors were 10 and 7.5cm on the left side and 10 and 6cm on the right side. The operative times for harvest surgery, bench surgery and transplant surgery were 2:40 and 3:20 hours, 34:32 and 33:30 min and 4:00 and 4:30 hours respectively for recipients 1 and 2. Daily postoperative uterine Doppler was completed through day 8 and then every other day and showed good intrauterine blood flow (i.e., low resistance arcuate vessel flow; resistance index < .5). Cervical biopsies on postoperative days 7 and 14 showed no evidence of rejection in either recipient. Both recipients started menstruating within 2 months of surgery.By using ovarian veins as outflow channels, the challenges involved in dissection along the internal iliac vein are avoided, and harvesting the donor internal iliac artery reduces the tension on vascular anastomosis. The selection of vessels to be harvested could make the technique reproducible, although larger studies are warranted to confirm results.

Esophageal atresia (EA) is prenatally diagnosed in less than one third of the cases and is usually only suspected. Recently, magnetic resonance imaging (MRI) with dynamic sequence and biochemistry of the amniotic fluid have been proposed to enhance prenatal diagnosis of EA.We report the case of a triple negative screening (ultrasound, MRI with dynamic sequence and biochemistry of the amniotic fluid) with a postnatal diagnosis of EA type III with a small defect. Even using second line tests, prenatal diagnosis of EA remains a challenge.

Although it has been clearly stated that vaginal dilation must be considered the first-line treatment for clinical conditions characterized by an absent or hypoplastic vagina, mainly Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, a great number of scientific papers on surgical vaginal reconstructions are reported every year. This wide variety of surgical techniques (more than 10) are recognized and performed worldwide, making it difficult to compare results and define an evidence-based approach. Standardized treatment should be considered even more important in the pediatric and adolescent population for the implications offered by the uterus transplantation scenario.

OBJECTIVE:Uterine infertility (UI), which can be caused by a variety of congenital or acquired factors, affects several thousand women in Europe. Uterus transplantation (UTx), at the current stage of research, offers hope for these women to be both the biological mother and the carrier of their child. However, the indications of UTx still need to be defined. The main aim of the study was to describe the different etiologies of UI and other data as marital and parental status from women requesting UTx who contacted us in the framework of a UTx clinical trial. Secondarily, we discussed the potential indications of UTx and their feasibility.STUDY DESIGN:This is an observational study.RESULTS:Of a total of 139 patients with UI, 105 patients (75.5%) had uterine agenesis, making it the leading cause of UI in this sample. Among the patients with uterine agenesis, 25% had a solitary kidney and 44.7% had undergone vaginal reconstruction. Peripartum hysterectomy, hysterectomy for cancer, and hysterectomy for benign pathologies accounted for 9.4%, 7.2% and 5% of cases, respectively. Less common causes of UI included complete androgen insensitivity syndrome (2.2% of patients) and prenatal diethylstilbestrol exposure (0.7%). Approximately 14% of the women already had at least one child and 66% were in a couple living together for at least 2 years.CONCLUSION:UTx is still under evaluation and further research is under way. Nulliparous patients with no major medical or surgical history and with normal ovarian function, who meet the legal criteria for medically assisted reproduction, represent the best indications for UTx at this stage of its development.

Objectives. - To study the demand there is for uterus transplantation (UTx).Patients and methods. - Recent media coverage of developments in UTx prompted associations of patients with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome and of women suffering from UI to contact us. We sent them anonymous questionnaires devised to sound out their attitude towards UTx and towards adoption and gestational surrogacy (GS). A clinical psychologist also carried out a qualitative discourse analysis.Results. - Sixty patients answered the questionnaire. Thirty-eight patients were married or living with a male partner. Seven patients had had a hysterectomy. Fifty-one patients had uterine agenesis. Of the 60 patients, 19 and 21, respectively, had ruled out the option of adoption or GS, and 11 would not envisage either possibility. Thirty-five patients were willing to take part in a clinical study into UTx despite the uncertainty of the outcome and the potential risks involved. Of these 35 volunteers, 23 were in a heterosexual relationship and aged <= 35 years.Discussion and conclusion. - For women with Ul the condition is all the more distressing because there is no medical solution for it. UTx could hold out hope for some of these patients despite the complexity of the procedure and the attendant risks. Because of the feelings of vulnerability engendered by Ul, any UTx programme should provide full information to patients and ensure they are carefully screened and selected. (C) 2014 Elsevier Masson SAS. All rights reserved.

La transplantation utérine (TU) est un traitement potentiel de l'infertilité utérine (IU). La demande concernant ce traitement est toutefois méconnue. En raison de l'absence de traitement actuel de l'IU et de la médiatisation des travaux concernant la TU, nous avons été en contact avec l'association des patientes atteintes du syndrome MRKH et d'autres patientes atteintes d'une IU. Un questionnaire leur a été envoyé. Le but du questionnaire était de connaître la position des patientes vis-à-vis de la TU mais également vis-à-vis de l'adoption et de la GPA. Les données concernant leur âge, leur vie de couple, leur pathologie et leurs traitements éventuels ont été recueillies. Une analyse de discours qualitative a été également réalisée par une psychologue clinicienne. Soixante patientes ont répondu au questionnaire. L'âge médian était 26 ans [18–53]. Cinquante-cinq résidaient en France, 3 en Belgique et 2 dans le continent africain. Trente-huit (63,3 %) patientes étaient mariées ou en couple et hétérosexuelles. Vingt (33,3 %) étaient célibataires. Sept patientes (11,7 %) avaient eu une hystérectomie dont 4 pour hémorragie de la délivrance, 1 pour pathologie bénigne et 2 pour cancer. Cinquante et une (85 %) patientes étaient atteintes d'une agénésie utéro-vaginale partielle ou totale. Leur âge médian de diagnostic était 16 ans [1–27]. Trente-deux (53,3 %) ont eu une chirurgie vaginale dont 6 sigmoïdo-colpoplasties. Parmi les 60 patientes, l'adoption et la gestation par autrui ne seraient pas envisagées respectivement par 19 (31,7 %) et 21 patientes (35 %). Onze patientes n'envisageraient pas ces 2 solutions (18,3 %). Trente-cinq (58,3 %) patientes seraient volontaires pour une étude clinique sur la TU malgré l'incertitude des résultats et le risque potentiel de la procédure. Parmi elles, 23 (38,33 %) étaient en couple, hétérosexuelles et ≤ 35 ans. La TU semble être un espoir pour une partie de ces patientes malgré la complexité et le risque de la procédure. Il paraît important de poursuivre les travaux de recherche, les patientes nous en seront reconnaissantes. En cas de projet de TU, l'information et la sélection des patientes seront des problématiques majeures étant donné la vulnérabilité engendrée par l'IU. To study the demand there is for uterus transplantation (UTx). Recent media coverage of developments in UTx prompted associations of patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and of women suffering from UI to contact us. We sent them anonymous questionnaires devised to sound out their attitude towards UTx and towards adoption and gestational surrogacy (GS). A clinical psychologist also carried out a qualitative discourse analysis. Sixty patients answered the questionnaire. Thirty-eight patients were married or living with a male partner. Seven patients had had a hysterectomy. Fifty-one patients had uterine agenesis. Of the 60 patients, 19 and 21, respectively, had ruled out the option of adoption or GS, and 11 would not envisage either possibility. Thirty-five patients were willing to take part in a clinical study into UTx despite the uncertainty of the outcome and the potential risks involved. Of these 35 volunteers, 23 were in a heterosexual relationship and aged ≤ 35 years. For women with UI the condition is all the more distressing because there is no medical solution for it. UTx could hold out hope for some of these patients despite the complexity of the procedure and the attendant risks. Because of the feelings of vulnerability engendered by UI, any UTx programme should provide full information to patients and ensure they are carefully screened and selected.

En cas d’infertilite uterine, les patientes desireuses d’un enfant ont comme seule solution l’adoption, la gestation pour autrui etant interdite a ce jour en France. Depuis le debut des annees 2000, la recherche sur la transplantation uterine, alternative potentielle a l’adoption, a progresse. Les donnees de l’experimentation animale, les progres de l’immunosuppression et l’experience des grossesses de patientes greffees font qu’une procedure d’allo-transplantation uterine chez la femme devient une eventualite de plus en plus envisageable.

Immature Oocyte Syndrome (IOS) is usually defined by < 70 % of retrieved metaphase II (MII) oocytes in IVF cycle. It can be explained by intrinsic abnormalities or inadequate stimulation. Ovulation triggering is critical for resumption of meiosis. As both LH and FSH are needed for oocyte final maturation in natural cycle, it has been suggested to trigger ovulation with a combination of hCG and GnRH agonist in case of oocyte immaturity. In this study we evaluated the interest of 2 strategies of ovulation triggering (dual trigger with combined hCG/GnRH agonist versus increased doses of hCG alone) in women with previous IOS. Retrospective cohort pilot study. We included 66 patients with a history of IOS in a prior IVF cycle. 51 were excluded due to inadequate stimulation or oocyte pick-up difficulties (total oocytes/follicle 14 mm <80%) or premature triggering (MII/follicle 14 mm >80%). The other 15 patients were stimulated with an antagonist protocol, and randomized to receive either dual triggering (250μg r-hCG/Triptorelin 0,2 mg, group 1, n = 7) or high dose of hCG (500μg r-hCG, group 2, n = 8). The main outcome was the number of mature oocytes (MII) retrieved. Paired comparison was performed for statistical analysis. Ovarian stimulation parameters did not differ significantly between both groups. In group 1, the mean number of MII oocytes and embryos significantly increased with the new trigerring strategy (3.4±0.7 vs 8.9±2.1 and 2±0.3 to 6.3±2.2 respectively). In group 2, the mean number of MII oocytes significantly increased (3.1±0.2 to 5±1.1) but the mean number of embryos/patient was not statistically different. This pilot study assessing the comparative efficacy of dual trigger and increased doses of hCG for meiosis resumption shows that both strategies are effective. However, in terms of safety, dual trigger should be preferred to reduce the risk of hyperstimulation Syndrome. Further studies are required to compare the safety issue.

Depuis une dizaine d’annees, de nombreux travaux concernant la transplantation uterine ont ete realises chez l’animal. Plusieurs modeles chirurgicaux ont ete elabores. La tolerance a l’ischemie de l’uterus et les effets de l’immunosuppression sur le rejet ont pu etre etudies. Enfin, plusieurs naissances ont ete obtenues apres auto-transplantation ou transplantation chez des animaux syngeniques alors qu’une seule naissance seulement a ete decrite apres allo-transplantation.

Ectopic endometriosis is a common condition which is often underdiagnosed, where MRI can help make a diagnosis simply, non-invasively and without irradiation. However, imagery signs of it are enormously polymorphic with a wide range of possible locations. In this paper, we have tried to illustrate comprehensively all its MRI appearances depending on the different locations where it occurs.