OBJETIVO: avaliar a histomorfometria do endométrio na fase lútea de mulheres férteis e inférteis. MÉTODOS: foram triadas 40 pacientes, 30 inférteis e 10 férteis, em seguimento na Clínica Ginecológica do HC-FMUSP, que concordaram em participar deste estudo. Foi realizada avaliação ultrassonográfica seriada a partir da menstruação, para determinação da ovulação. Na fase lútea as pacientes eram submetidas à histeroscopia. Foram excluídas 14 pacientes sendo 12 por falta durante a avaliação ultrassonográfica e 2 pela presença de pólipos. A casuística foi composta por 6 controles férteis, que foram comparadas a 20 casos inférteis (endometriose-8, causa tubo-peritoneal-5, causa masculina-5, sem causa aparente-2). Na histeroscopia foram coletadas duas biópsias dirigidas (sistema de Bettocchi) da parede posterior (terço distal), e da parede anterior (terço médio), e uma biópsia aspirativa com Pipelle. Foram avaliados parâmetros histomorfométricos endometriais. RESULTADOS: as duas formas de biópsia foram apropriadas para análise endometrial; a dirigida coletou menor área tecidual, porém sem sangue. Nenhum paciente fértil apresentou heterogeneidade endometrial (atraso de fase em algum sítio); isto ocorreu em 7 (35%) das inférteis (p=0,11). Foi diagnosticada endometrite em 2 (10%) casos. CONCLUSÃO: não foram observadas diferenças histomorfométricas entre o endométrio de mulheres férteis e inférteis na fase lútea. Parte das pacientes inférteis mostrou heterogeneidade endometrial e endometrite. A biópsia dirigida, assim como a aspirativa, foi adequada ao estudo endometrial na fase lútea / Objective: to evaluate the endometrial histomorphometry of fertile and infertile women during their luteal period. Methods: 40 female patients- 30 infertile and 10 fertile- who were being followed-up at the Gynecological Clinic at the Hospital das Clinicas (HC),-Faculdade de Medicina da Universidade de Sao Paulo (FMUSP), agreed to participate in the study. Serial ultra sonograms, starting from their menstrual period, were performed to identify their ovulation. In the luteal phase the patients underwent hysteroscopy. From the initial sample, 14 patients were excluded from the study, 12 of whom for being absent during scheduled ultra sonograms and 2 for presenting polyps. The final sample thus consisted of 6 fertile females (control subjects) who were compared to 20 patients with infertility, categorized as follows: 8 due to endometriosis, 5 due to peritoneal tube conditions, 5 due to male infertility, and 2 with no apparent cause. During the hysteroscopy 2 directed biopsies (Bettocchis System) of the posterior wall (distal third section) and of the anterior wall (medial third) were performed, as well as Pipelle sampling. Endometrial histomorpholometric parameters were evaluated. Results: the two forms of endometrial sampling performed were appropriate for the endometrial analysis. The directed biopsy collected tissue from a smaller area, but it had no blood. None of the fertile patients presented endometrial heterogeneity, i.e., phase delay in any site. In contrast, this occurred in 7(35%) of the infertile females (p=0.11). Endometritis was diagnosed in 2 (10%) of the cases. Conclusions: no histomorphometric differences were observed in the endometrium of the fertile and infertile female patients during their luteal phase. About a third of infertile cases (35%) displayed endometrial heterogeneity and a small percentage of which (10%) had endometritis. Both the directed biopsy and Pipelle sampling were found satisfactory for studies of endometrium during the luteal phase

A infertilidade é para muitas mulheres geradora de sofrimento psíquico, visto que a reprodução humana condiz com a perpetuação do ser. Tendo como método de estudo a psicanálise, podemos pensar o desejo de filho como sintoma do laço conjugal e, ainda na cultura contemporânea, inscrição de feminilidade para algumas mulheres. Casais inférteis, atualmente, têm a chance de recorrer às Novas Tecnologias de Reprodução Assistida, ao invés de buscar a adoção ou de permanecer sem filhos. Esta pesquisa faz uma discussão acerca das chamadas Novas Tecnologias Reprodutivas e estuda os efeitos que a infertilidade tem no psiquismo e na condição subjetiva dos sujeitos de desejo. Busca dissociar a demanda consciente de ter um filho do desejo inconsciente que opera na produção subjetiva, fazendo sintoma. Também, faz questão quanto à diferenciação do desejo de ter um filho ao desejo de maternidade e suas implicações na articulação das pulsões. / To most women, infertility is a generator of psychic suffering, considering that human reproduction aims the perpetuation of the living being. Having Psychoanalysis as a study method, we may see the will of having a child as a conjugal symptom and, still in contemporaneity, femininity enrollment to some females. Nowadays, infertile couples have the chance to appeal to New Assisted Reproduction Technologies instead of adoption or even remaining without descendents. This research discusses the so-called new reproductive technologies and studies the impacts that infertility has in the psychism and in the subjective condition. It pursuits to dissociate the conscious demand of having a child from unawareness, which may operate in the subjective production causing symptoms. Also, it questions the difference of wishing a child, the motherhood will and their implication on the articulation of the drives.

Introdução: A toxicidade da cisplatina é bem compreendida nos sistemas renal, gastrointestinal, auditivo e nervoso, assim como na medula óssea. No entanto, os mecanismos causadores de infertilidade induzidos pela cisplatina são pouco compreendidos. Objetivo: Nosso objetivo foi verificar a participação do sistema calicreína-cininas e do estresse oxidativo na infertilidade induzida pela cisplatina, auxiliando no desenvolvimento de novas alternativas terapêuticas. Métodos: Os camundongos fêmeas C57BL/6 adultos (n=9) receberam dois ciclos de 2,5 mg/kg de cisplatina por via intraperitoneal durante cinco dias, com um período de recuperação de sete dias entre os ciclos. O grupo controle (n=9) recebeu solução de NaCl 0,9%. Foi feita a avaliação do ciclo estral e a contagem de folículos ovarianos. O marcador Ki67 foi avaliado por imunohistoquímica. Testes bioquímicos para calicreína plasmática, intersticial e glandular, tempo de tromboplastina parcial ativada (TTPa), óxido nítrico (NO), superóxido dismutase (SOD), glutationa reduzida (GSH), mieloperoxidase (MPO) e N-acetil glucosaminidase (NAG); e Western-blot para os receptores de bradicinina B1R e B2R também foram realizados Resultados: Após o protocolo de cisplatina, 100% das fêmeas do grupo controle mantiveram a ciclicidade estral versus 44,4% das fêmeas do grupo cisplatina. O grupo controle apresentou maior número de folículos antrais (p=0,011) e folículos viáveis totais (p=0,006). O grupo cisplatina apresentou maior número de folículos atrésicos (p=0,014). O marcador Ki67 demonstrou semelhantes taxas de proliferação celular entre os grupos. Os marcadores inflamatórios foram aumentados no grupo cisplatina, incluindo a geração de calicreína plasmática (p=0,003), a diminuição do TTPa (p=0,02), o aumento da atividade da calicreína intersticial (p=0,002) e glandular (p=0,008) e na expressão dos receptores B1R (p=0,001) e B2R (p=0,001), MPO (p=0,03) e NAG (p=0,04). Os marcadores de estresse oxidativo também foram aumentados no grupo cisplatina, com maior produção de NO (p=0,01) e diminuição na SOD (p=0,003) e na GSH (p=0,01). Conclusão: Todas as reações inflamatórias parecem ser ativadas pelo tratamento com cisplatina, exemplificadas pelo aumento da atividade da calicreína plasmática, intersticial e glandular, bem como a diminuição no TTPa e o aumento na expressão de B1R e B2R. A toxicidade mediada pela reação inflamatória da cisplatina é bem conhecida em seus efeitos colaterais, como ototoxicidade e nefrotoxicidade. Houve aumento da produção de NO nos ovários dos animais tratados, associado à indicação de menores concentrações de SOD e de GSH. Os desequilíbrios nos antioxidantes parecem contribuir para o estresse oxidativo ovariano. Quanto à MPO (neutrófilos) à NAG (macrófagos), a maior atividade de ambas no grupo cisplatina se explica pelo fato de que as células fagocíticas ativadas produzem grandes quantidades de espécies reativas de oxigênio, aumentando ainda mais o estresse oxidativo e a inflamação. O aumento da atividade do sistema calicreína-cininas e dos marcadores de estresse oxidativo no tecido ovariano propiciaram uma melhor compreensão da infertilidade induzida por cisplatina e indicam possíveis alternativas para proteção ovariana durante a quimioterapia, como inibidores do sistema calicreína-cinina e antioxidantes. / Background: Cisplatin toxicity is well understood in the renal, gastrointestinal, auditory and nervous systems, as well as in the bone marrow. However, the mechanisms causing infertility induced by cisplatin are poorly understood. Purpose: Our objective was to verify the participation of the kallikreinkinin system and oxidative stress in cisplatin-induced infertility, aiding in the development of new therapeutic alternatives. Methods: C57BL/6 adult (n=9) female mice received two 2.5 mg/kg intra-peritoneal cycles of cisplatin for five days, with a seven-day recovery period between cycles. The control group (n=9) received 0.9% NaCl solution. The ovarian follicles were counted with hematoxylin and eosin staining. Ki67 marker was evaluated by immunohistochemistry. Biochemical tests for plasma, interstitial and glandular kallikrein, activated partial thromboplastin time (aPTT), nitric oxide (NO), superoxide dismutase (SOD), reduced glutathione (GSH), myeloperoxidase (MPO) and N-acetyl glucosaminidase (NAG); and Western blotting for the bradykinin B1R and B2R receptors were also performed. Results: After cisplatin protocol, 100% of the females in the control group maintained estral cyclicity versus 44.4% of females in cisplatin group. The control group had a higher number of antral follicles (p=0.011) and total viable follicles (p=0.006). Cisplatin group had a higher number of atretic follicles (p=0.014). Ki67 marker demonstrated similar rates of cell proliferation between groups. Inflammatory markers were increased in cisplatin group, including plasma kallikrein generation (p=0.003), a decrease of aPTT (p=0.02), increased interstitial (p=0.002) and glandular (p=0.008) kallikrein, B1R (p=0.001) and B2R (p=0.001) expression, MPO (p=0.03) and NAG (p=0.04) Oxidative stress markers were also increased in cisplatin group, with higher NO production (p=0.01) and a decrease in SOD (p=0.003) and GSH (p=0.01). Conclusion: All inflammatory reactions appear to be activated by cisplatin treatment, exemplified by increased plasma, interstitial and glandular kallikrein activity, as well as the decrease in aPTT and increased expression of B1R and B2R. The toxicity mediated by cisplatin inflammatory reaction is well known in its side effects, such as ototoxicity and nephrotoxicity. There was an increase in NO production in the ovaries of treated animals, associated with the indication of lower concentrations of SOD and GSH. Imbalances in antioxidants appear to contribute to ovarian oxidative stress. Regarding MPO (neutrophils) and NAG (macrophages), the greater activity of both in cisplatin group is explained by the fact that activated phagocytic cells produce large amounts of reactive oxygen species, further increasing oxidative stress and inflammation. Increased activity of the kallikrein-kinin system and markers of oxidative stress in ovarian tissue provided a better understanding of cisplatin-induced infertility and indicate possible alternatives for ovarian protection during chemotherapy, such as inhibitors of the kallikrein-kinin system and antioxidants.

Made available in DSpace on 2017-07-10T14:17:11Z (GMT). No. of bitstreams: 1 FINALIZADA _ABRIL2015.pdf: 3170133 bytes, checksum: 1d4668fdaca4f714ff23eb80e3ac0b68 (MD5) Previous issue date: 2015-06-30 / The prevalence of obesity has increased in recent decades in many countries, and harmful effects to the body can begin in childhood and persist into adulthood. Obesity is associated with disturbances of reproductive function in women and in female rodents, such as early onset of puberty, change in menstrual / estrous cycle and infertility, with impaired ovulation or anovulation (lack of ovulation). Angiotensin II (Ang II) appears to exert effects on reproduction and obesity, contributing to the development of the deleterious effects of obesity and affecting pre-ovulatory surge of luteinizing hormone (LH), estradiol and progesterone, thus reducing ovulation in adult rats. The objective of this study was to evaluate losartan effect, an antagonist of Ang II AT1 receptor, administrated in adulthood, in follicular development of adult Wistar rats with obesity induced by cafeteria diet. After weaning at 21 days of life, female Wistar rats were divided into 02 groups: control (CTL) that received standard chow diet; Cafeteria (CAF) received the cafeteria diet. From 70 days of life began losartan administration by gavage. The CTL group received water in gavage (CTL) and CAF group was separated into 02 groups, CAF (which received water in gavage) and CAF + LOS (who received losartan in gavage), in total 03 groups were performed. 05 animals were used per group. Euthanasia was performed on the first proestrous after 30 days of administration of losartan or water. The retroperitoneal, perigonadal and subcutaneous fat were removed and weighed. Morphological analysis of ovaries was performed, proceeding to count the number of primary follicles, secondary, antral and mature follicles per ovary. Was also collected blood sample for determination of FSH, LH, prolactin and progesterone. Body weight and the weight of the 03 fats were measured, and the number of antral follicles were higher in group CAF in relation to the group CTL (p <0.001). However, FSH and LH levels were lower in the CAF animals compared to the animals of the group CTL (p <0.001). The administration of losartan normalized the body weight and accumulation of retroperitoneal and subcutaneous fat as well as the number of antral follicles. Thus, we suggest that the use of the antagonist of Ang II AT1 receptor, losartan, in adulthood, can improve follicular development in females with cafeteria diet-induced obesity and, can be, in the future, an coadjuvant drug in the treatment of infertility associated to obesity. / A prevalência da obesidade aumentou nas últimas décadas em vários países, tendo efeitos prejudiciais ao organismo que podem iniciar na infância e persistir até a vida adulta. A obesidade está associada a distúrbios da função reprodutiva, em mulheres e em fêmeas de roedores, como início precoce da puberdade, alteração do ciclo menstrual/estral e infertilidade, com alterações da ovulação (disovulias) ou anovulação (ausência da ovulação). A Angiotensina II (Ang II) parece exercer efeitos sobre a reprodução e a obesidade, contribuindo para o desenvolvimento dos efeitos deletérios da obesidade e afetando o pico pré-ovulatório do hormônio luteinizante (LH), progesterona e estradiol, reduzindo, consequentemente, a ovulação em ratas adultas. O objetivo deste estudo foi avaliar o efeito do losartan, um antagonista do receptor AT1 da Ang II, sobre o desenvolvimento folicular de ratas Wistar adultas, com obesidade induzida pela dieta de cafeteria. Após o desmame, aos 21 dias de vida, ratas Wistar foram separadas em 02 grupos: controle (CTL) que recebeu ração padrão e Cafeteria (CAF) que recebeu a dieta de cafeteria. A partir dos 70 dias de vida iniciou-se a administração de losartan por gavagem. O grupo CTL recebeu água na gavagem (CTL) e o grupo CAF foi separado em 02 grupos, CAF (que recebeu água na gavagem) e CAF+LOS (que recebeu losartan na gavagem), totalizando 03 grupos. Foram utilizados 05 animais por grupo. A eutanásia foi realizada no primeiro proestro após 30 dias da administração de losartan ou de água. As gorduras retroperitoneal, perigonadal e subcutânea foram retiradas e pesadas. Foi realizada a análise morfológica dos ovários, procedendo-se a contagem do número dos folículos primários, secundários, antrais e maduros por ovário. Também foi coletado o sangue total para dosagens de FSH, LH, Prolactina e Progesterona. O peso corporal, bem como, o peso das 03 gorduras foram avaliados, e, o número de folículos antrais foi estatisticamente maior no grupo CAF em relação ao CTL (p<0,001). Todavia, as concentrações de FSH e LH foram menores nos animais CAF em relação ao CTL (p<0,001). A administração do losartan normalizou o peso corporal e o acúmulo das gorduras retroperitoneal e subcutânea, bem como, o número de folículos antrais. Dessa forma, sugerimos que o uso do antagonista do receptor AT1 da Ang II, o losartan, na vida adulta, possa contribuir para melhorar o desenvolvimento folicular em fêmeas com obesidade induzida pela dieta de cafeteria e, futuramente, ser uma droga coadjuvante no tratamento da infertilidade associada à obesidade.

OBJETIVO: avaliar a histomorfometria do endométrio na fase lútea de mulheres férteis e inférteis. MÉTODOS: foram triadas 40 pacientes, 30 inférteis e 10 férteis, em seguimento na Clínica Ginecológica do HC-FMUSP, que concordaram em participar deste estudo. Foi realizada avaliação ultrassonográfica seriada a partir da menstruação, para determinação da ovulação. Na fase lútea as pacientes eram submetidas à histeroscopia. Foram excluídas 14 pacientes sendo 12 por falta durante a avaliação ultrassonográfica e 2 pela presença de pólipos. A casuística foi composta por 6 controles férteis, que foram comparadas a 20 casos inférteis (endometriose-8, causa tubo-peritoneal-5, causa masculina-5, sem causa aparente-2). Na histeroscopia foram coletadas duas biópsias dirigidas (sistema de Bettocchi) da parede posterior (terço distal), e da parede anterior (terço médio), e uma biópsia aspirativa com Pipelle. Foram avaliados parâmetros histomorfométricos endometriais. RESULTADOS: as duas formas de biópsia foram apropriadas para análise endometrial; a dirigida coletou menor área tecidual, porém sem sangue. Nenhum paciente fértil apresentou heterogeneidade endometrial (atraso de fase em algum sítio); isto ocorreu em 7 (35%) das inférteis (p=0,11). Foi diagnosticada endometrite em 2 (10%) casos. CONCLUSÃO: não foram observadas diferenças histomorfométricas entre o endométrio de mulheres férteis e inférteis na fase lútea. Parte das pacientes inférteis mostrou heterogeneidade endometrial e endometrite. A biópsia dirigida, assim como a aspirativa, foi adequada ao estudo endometrial na fase lútea / Objective: to evaluate the endometrial histomorphometry of fertile and infertile women during their luteal period. Methods: 40 female patients- 30 infertile and 10 fertile- who were being followed-up at the Gynecological Clinic at the Hospital das Clinicas (HC),-Faculdade de Medicina da Universidade de Sao Paulo (FMUSP), agreed to participate in the study. Serial ultra sonograms, starting from their menstrual period, were performed to identify their ovulation. In the luteal phase the patients underwent hysteroscopy. From the initial sample, 14 patients were excluded from the study, 12 of whom for being absent during scheduled ultra sonograms and 2 for presenting polyps. The final sample thus consisted of 6 fertile females (control subjects) who were compared to 20 patients with infertility, categorized as follows: 8 due to endometriosis, 5 due to peritoneal tube conditions, 5 due to male infertility, and 2 with no apparent cause. During the hysteroscopy 2 directed biopsies (Bettocchis System) of the posterior wall (distal third section) and of the anterior wall (medial third) were performed, as well as Pipelle sampling. Endometrial histomorpholometric parameters were evaluated. Results: the two forms of endometrial sampling performed were appropriate for the endometrial analysis. The directed biopsy collected tissue from a smaller area, but it had no blood. None of the fertile patients presented endometrial heterogeneity, i.e., phase delay in any site. In contrast, this occurred in 7(35%) of the infertile females (p=0.11). Endometritis was diagnosed in 2 (10%) of the cases. Conclusions: no histomorphometric differences were observed in the endometrium of the fertile and infertile female patients during their luteal phase. About a third of infertile cases (35%) displayed endometrial heterogeneity and a small percentage of which (10%) had endometritis. Both the directed biopsy and Pipelle sampling were found satisfactory for studies of endometrium during the luteal phase

Justificativa: Há evidências de que o uso de progesterona para suporte de fase lútea melhora os resultados reprodutivos em mulheres submetidas a técnicas de reprodução assistida (TRA). Há várias hipóteses para justificar a deficiência de fase lútea após a estimulação ovariana controlada (EOC) para TRA. Atualmente, acredita-se que os níveis supra-fisiológicos de esteroides alcançados durante a EOC persistem após a aspiração folicular, graças à formação de múltiplos corpos lúteos. Dessa forma, ocorre um feedback negativo prematuro na secreção de hormônio luteinizante (LH), causando um defeito da fase lútea e baixos níveis de progesterona. A progesterona natural por via intramuscular ou vaginal apresenta efeitos comparáveis sobre os parâmetros de gravidez clínica e gravidez em curso, embora as pacientes possam apresentar vários efeitos colaterais, como dor e abscesso local com a progesterona intramuscular, e corrimento vaginal, irritação perineal e interferência com o coito com a progesterona vaginal. Desta forma, a didrogesterona, uma progesterona sintética com boa biodisponibilidade oral, vem sendo estudada como uma alternativa para suporte de fase lútea em mulheres submetidas à TRA. Objetivo: Comparar a didrogesterona oral com a progesterona vaginal como suporte de fase lútea em ciclos de reprodução assistida. Métodos de busca: As buscas por ensaios clínicos randomizados (ECRs) foram realizadas nos principais bancos eletrônicos de dados; além disso, examinamos manualmente as listas de referências dos estudos incluídos em revisões semelhantes. A última busca eletrônica foi feita em 18 de outubro de 2015. Critérios de Seleção: Apenas estudos verdadeiramente randomizados que comparassem o uso da didrogesterona com a progesterona como suporte de fase lútea foram considerados elegíveis. Os estudos que permitiam a inclusão de uma mesma paciente duas vezes foram incluídos apenas se os dados do primeiro ciclo estivessem disponíveis. Coleta e Análise de Dados: Dois revisores avaliaram, independentemente, a elegibilidade dos estudos, extração de dados e os riscos de vieses dos estudos incluídos. Quaisquer discordâncias foram resolvidas por consenso. Quando necessário, os autores dos estudos incluídos foram contatados para maiores informações. Resultados: A busca selecionou 343 registros, 8 dos quais eram elegíveis. Nenhum estudo relatou nascidos vivos. Não há diferença relevante entre didrogesterona oral e progesterona vaginal para gravidez em curso, (RR 1.04, IC 95% 0.92 a 1.18, I² = 0%, p = 0.53, 7 ECRs, 3,134 mulheres), gravidez clínica (RR 1.07, IC 95% 0.93 a 1.23, I² = 34%, p = 0.35, 8 ECRs, 3,809 mulheres), e para abortamento (RR 0.77, IC 95% 0.53 a 1.10, I² = 0%, p = 0.15, 7 ECRs, 906 gestações clínicas). Três estudos reportaram o grau de insatisfação com o tratamento. Dois deles mostraram uma redução importante na insatisfação entre as mulheres que utilizaram didrogesterona em comparação com a progesterona vaginal: didrogesterona oral = 2/79 (2.5%) vs. progesterona vaginal em cápsulas = 90/351 (25.6%), e didrogesterona oral = 19/411 (4.6%) vs. progesterona vaginal em gel = 74/411 (18.0%); o outro estudo não mostrou diferença na taxa de insatisfação: didrogesterona oral = 8/96 (8.3%) vs. progesterona vaginal em cápsulas = 8/114 (7.0%). Conclusão: As evidências atuais sugerem que o uso de didrogesterona oral é tão eficaz quanto a progesterona vaginal como suporte de fase lútea em ciclos de reprodução assistida. Em relação ao grau de satisfação com o tratamento, a didrogesterona oral parece causar menos insatisfação entre as pacientes, em comparação ao uso de progesterona vaginal. / Background: There is evidence that using progesterone for LPS improves the reproductive outcomes in women undergoing ART. There are several hypotheses to justify the lutheal phase deficiency (LPD) after controlled ovarian stimulation (COS) for ART. Currently, it is believed that the supra-physiological levels of steroids achieved during COS and sustained after oocyte aspiration by the multiple corpora lutea causes a prematurely negative feedback in pituitary LH secretion, consequently causing a luteal phase defect and low progesterone levels. Both intramuscular and vaginal routes of natural progesterone exhibit comparable effect on the endpoints of clinical pregnancy and ongoing pregnancy, although patients may exhibit multiple side effects, such as pain and local abscess with intramuscular progesterone, and vaginal discharge, perineal irritation and interference with coitus with vaginal progesterone. In this way, dydrogesterone, a synthetic progesterone with good oral availability, has being studied as an alternative for LPS in women undergoing ART. Objectives: To compare dydrogesterone and progesterone for luteal-phase support in women undergoing assisted reproduction technique. Search methods: The searches for randomized controlled trials (RCT) were performed in the main electronic databases; in addition, we handsearched the reference lists of included studies and similar reviews. We performed the last electronic search on October 18, 2015. Selection criteria: Only truly randomized controlled trials comparing oral dydrogesterone to vaginal progesterone as luteal phase support were considered eligible. We included studies that permitted the inclusion of the same participant more than once (cross-over or \'per cycle\' trials) only if data regarding the first treatment of each participant were available. Data collection and analysis: Two reviewers independently performed study eligibility, data extraction, and assessment of the risk of bias and we solved disagreements by consensus. We corresponded with study investigators in order to resolve any queries, as required. Results: The search retrieved 353 records; eight studies were eligible. No study reported live birth. There is evidence of no relevant difference between oral dydrogesterone and vaginal progesterone on ongoing pregnancy (RR 1.04, 95% CI 0.92 to 1.18, I² = 0%, 7 RCTs, 3,134 women), on clinical pregnancy (RR 1.07, 95% CI 0.93 to 1.23, I² = 34%, 8 RCTs, 3,809 women), and on miscarriage (RR 0.77, 95% CI 0.53 to 1.10, I² = 0%, 7 RCTs, 906 clinical pregnancies). Three studies reported dissatisfaction rate with the treatment. Two of them reported a large reduction in dissatisfaction among women using oral dydrogesterone than among women using vaginal progesterone: oral dydrogesterone = 2/79 (2.5%) vs. vaginal progesterone capsules = 90/351 (25.6%), and oral dydrogesterone = 19/411 (4.6%) vs. vaginal progesterone gel = 74/411 (18.0%). The other included study showed no difference in the dissatisfaction rate: oral dydrogesterone = 8/96 (8.3%) vs. vaginal progesterone capsules = 8/114 (7.0%). Authors\' conclusions: Oral dydrogesterone is as effective as vaginal progesterone for luteal-phase supplementation in ART cycles. Regarding dissatisfaction with treatment, oral dydrogesterone seems to cause less dissatisfaction among patients, in comparison to vaginal progesterone.

L’infertilité est considérée actuellement par l’organisation mondiale de la santé (OMS) comme une préoccupation majeure de santé affectant plus de 50 millions de couples dans le monde. Dans les pays occidentaux, la majorité des couples infertiles ont recours aux techniques d’assistance médicale à la procréation (AMP) pour obtenir une grossesse. Malgré le succès de ces techniques, près de la moitié des couples qui ont recours à l’AMP sortent du parcours de soin sans enfant. Une partie de ces échecs est expliquée par l’altération de la gamétogenèse. Chez l’homme, la spermatogenèse fait interagir des centaines de gènes spécifiquement exprimés dans le testicule. L’abondance de ces gènes suggère que les troubles de la spermatogenèse présentent une forte composante génétique. Récemment, les avancées techniques ont favorisé l’identification de gènes responsables de ces anomalies mais la grande majorité des cas d’infertilité masculine reste classée comme idiopathique. L’objectif de la thèse est d’identifier de nouvelles causes génétiques responsables d’infertilité masculine et d’élucider les mécanismes physiopathologiques associés à ces anomalies.Au cours de ma thèse j’ai participé avec l’équipe GETI (génétique, épigénétique et thérapies de l’infertilité) à l’exploration génétique et moléculaire de deux phénotypes distincts d’anomalies spermatiques liés à des défauts post-méiotiques de la spermatogenèse : une forme rare d’azoospermie non obstructive (ANO) et le phénotype d’anomalies morphologiques multiples du flagelle spermatique (AMMF). Enfin j’ai joué un rôle important dans la création et l’analyse de modèles murins pour caractériser la pathogénie de ces anomalies.L’analyse génétique de deux frères infertiles nés de parents consanguins et présentant une ANO idiopathique associée à un arrêt post-méiotique de la spermatogenèse nous a permis d’identifier un variant homozygote délétère dans le gène SPINK2 qui code pour un inhibiteur de sérine-protéases. L’étude des souris KO pour ce gène nous a permis d’observer que les souris mâles adultes sont infertiles et miment parfaitement les phénotypes spermatique et testiculaire observés chez nos patients. Nous avons montré que la protéine codée par ce gène est exprimée dans l’acrosome à partir du stade de spermatide ronde. En l’absence de Spink2, l’activité protéolytique non-neutralisée des protéases cibles qui transitent par le Golgi cause sa fragmentation et bloque la spermiogénèse au stade de spermatide ronde. Nous avons également pu observer que les spermatozoïdes provenant de patients et de souris hétérozygotes présentent un taux élevé d’anomalies morphologiques et une baisse de la mobilité progressive conduisant à une hypofertilité à expressivité variable. Ces résultats montrent pour la première fois que l’oligo-tératozoospermie et l’azoospermie peuvent constituer un continuum pathologique dû à une même pathogénie.Nous avons également réalisé le séquençage exomique complet d’une cohorte de 78 individus AMMF non apparentés et avons identifié chez 49 sujets des mutations bi-alléliques délétères dans 11 gènes candidats dont DNAH1, CFAP43, CFAP44, WDR66 et FSIP2, soit un rendement diagnostique de 63%. Ces résultats confirment l’hétérogénéité génétique du phénotype MMAF et l’efficacité diagnostique du séquençage haut débit dans son exploration. Nous avons également validé l’implication de certains gènes candidats (n=4) dans ce phénotype chez le modèle murin knock-out créé par la nouvelle technologie d’édition du génome, CRISPR/Cas9.Dans son ensemble, ce travail montre l’intérêt et l’efficacité de la combinaison du séquençage exomique et de la technique de CRISPR/Cas9 pour étudier les troubles de la spermatogenèse et l’infertilité masculine. / Infertility is currently considered by the World Health Organization (WHO) as a major health concern affecting more than 50 million couples worldwide. In western countries, the majority of infertile couples seek assisted reproductive technologies (ART) to achieve a pregnancy. Despite the success of these techniques, almost half of these couples fail to obtain a child. Part of these failures are explained by the alteration of gametogenesis. In humans, spermatogenesis involves hundreds of genes specifically expressed in the testis. The abundance of these genes suggests that spermatogenic defects are associated with a strong genetic component. Recently, technical advances have led to the identification of numerous causative genes, but the vast majority of male infertility cases remain idiopathic. The aim of the present thesis is to identify new genetic causes responsible for male infertility and to elucidate the physiopathological mechanisms associated with these anomalies.During my thesis, I participated with the team GETI (genetics, epigenetics and therapies of infertility) in the genetic exploration of two phenotypes of male infertility related to post-meiotic defects of spermatogenesis: a rare form of non-obstructive azoospermia and the phenotype of multiple morphological abnormalities of the sperm flagella (MMAF). I have also played a key role in creation and analysis of transgenic mice to better characterize the pathogeny of the identified genetic causes in Human.Genetic analyses performed on two infertile brothers born form consanguineous parents and presenting an-idiopathic non-obstructive azoospermia associated with a post-meiotic arrest of spermatogenesis allowed us to identify a homozygous variant in the SPINK2 gene that encodes a serine-protease inhibitor. Phenotypic analysis of Spink2-/- adult male mice showed that they are infertile and perfectly mimic the sperm and testicular phenotypes observed in our patients. We showed that Spink2 protein is expressed from the round spermatid stage and localized in the acrosome, a lysosomal-like vesicle rich in proteases that play a key role during fertilization. When Spink2 is absent, the deregulated proteolytic activity of the targeted proteases such as acrosin leads to the fragmentation of the Golgi apparatus and arrest of spermiogenesis at the round spermatid stage. We also showed that sperm from heterozygous human and mice present a high level of morphological abnormalities and a decrease of progressive motility leading to a variable subfertility. These results showed for the first time that oligo-teratozoospermia and azoospermia could present a pathological continuum due to the same pathogeny.We also performed exome sequencing in a cohort of 78 non related MMAF subjects and identified in 49 cases deleterious bi-allelic mutations in a total of 11 candidate genes including DNAH1, CFAP43, CFAP44, WDR66 and FSIP2 giving a genetic diagnosis yield of 63%. These results confirm the genetic heterogeneity of MMAF and the efficiency of high throughput sequencing in genetic exploration of this phenotype. We also demonstrated the pathogenic implication of certain candidate genes (n=4) using knock-out mice created by the new technology of genome editing, CRISPR/Cas9.Overall, this work demonstrates the interest and effectiveness of combining exome sequencing and CRISPR/Cas9 system to study spermatogenesis disorders and male infertility.

The number of women diagnosed as infertile continues to grow every year. The psychological impact of the infertility experience has been said to create distress equivalent to that associated with life-threatening illnesses and has been linked with posttraumatic stress disorder (PTSD). Using shattered assumption and stress-buffering theory, this quantitative causal comparative study explored the potential functional relationship between infertility and PTSD. The majority of the (all-female) participants were 24- to 34-year-old college graduates. A 2 X 3 factorial between-subjects ANOVA examined and compared the cause and effect of the independent variables, fertility treatment and psychological intervention, on the dependent variable, PTSD. A multiple linear regression was conducted to understand PTSD symptomology scores. The results revealed that the type of infertility treatment does not impact PTSD symptomatology in medically diagnosed women. However, the main effect of psychological treatment was significant, as was infertility treatment by psychological treatment interaction. Additionally, the impact of fertility problems on the participant's physical health was the highest ranking predictor, which suggests that stress levels in women receiving infertility treatment are equivalent to those in women with cancer, AIDS, and heart disease, as suggested by other researchers. This study has implications for positive social change, in that it may promote better understanding of the psychological impact of infertility and decreased PTSD symptomatology for medically diagnosed infertile women. It opens the door for future research about the effectiveness of psychological intervention, and provides awareness of possible PTSD susceptibility.

"April 2002" Includes bibliographical references (leaves 200-249)

"April 2002" / Includes bibliographical references (leaves 200-249) / xv, 249 leaves : ill., plates (some col.) ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (Ph.D.)--University of Adelaide, Dept. of Animal Science, 2003