Infertility, the challenge of prevention



“Infertility, all concerned. “ It is under this motto that opened, Monday 1er November, the awareness week organized for the eighth year by the BAMP! collective, the main French association of patients following or having followed a course of medically assisted procreation. “Reproductive health is a major public health issue”, considers its founder, Virginie Rio. According to the National Institute of Demographic Studies (INED), one in four couples fail to conceive naturally after twelve months. “When we created the association in 2013, it was a couple in seven”, alert Virginie Rio, who calls for a “Collective awareness”.

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Increasingly advanced, the average age of childbearing (30.8 years in 2020) is the primary risk factor for infertility. A societal change that has led the World Health Organization to review its criteria. “For a long time, we spoke of infertility when there was no pregnancy after two years of regular and unprotected sex. Since 2009, we have gone to one year and even six months for women over 35 ”, recalls Professor Joëlle Belaisch-Allart, head of the obstetric gynecology service at the Quatre Villes hospital center in Saint-Cloud (Hauts-de-Seine).

The role of the environment

For Luc Multigner, epidemiologist at Inserm, this reduction in the timeframe wrongly suggests a greater prevalence of infertility in the population. “In some of these couples, a pregnancy could occur spontaneously at the 13e or at 14e months or more if they continued to try ”, raises the researcher.

We must also take into account the emergence of medically assisted procreation techniques, which have changed society’s expectations. “This introduced a therapeutic option where the problem could, in certain cases, have been solved by letting time and nature take its course”, he points out, while understanding the impatience of couples to become parents. This redefinition of infertility was nevertheless necessary, argues Joëlle Belaisch-Allart. “Waiting two years before consulting when you are already 35 and fertility in full decline is an aberration”, believes the president of the National College of French Gynecologists and Obstetricians.

Besides age, the environment ” at large ” weighs on the reproductive functions of both sexes, recognizes Luc Multigner. “Overeating or dietary imbalance, which results in overweight and obesity, have a major role because they lead to a change in hormonal balance. We can also mention smoking, cannabis consumption, the quality and duration of sleep, stress… All of these attacks affect reproductive functions. However, their impact on the individual varies according to their genetic background ”, qualifies the epidemiologist, who has been working for 25 years on the impact of the environment on fertility. In particular endocrine disruptors – pesticides, solvents, plasticizers, etc. -, potentially responsible for the decline of sperm in men and the increase in hormonal diseases in women, such as polycystic ovary syndrome. “At this point, we have more questions than answers, underlines Luc Multigner, but the suspicions are important. “

Increasingly late recourse to medical aid

This is one of the subjects on which Professor Samir Hamamah intends to examine, charged by the government with a report on infertility with a view to a national fight plan. At the head of the reproductive biology service of the Montpellier University Hospital, the doctor pleads for an acceleration of research on the causes of infertility, but also for the establishment of a real prevention policy on reproductive health. and more broadly sexual. Objective: to spare couples the long and painful course of assisted reproduction, which is all the more likely to fail as the use of these techniques is also increasingly late. According to INED, the rate of women aged 34 and over treated for infertility has thus increased by 24% over the past decade.

“We remain in the fantasy that science and technology can solve everything, deplores Virginie Rio. But assisted reproduction isn’t about pushing a button and being delivered from a baby. In 75% of cases, it does not work. ” “PMA is an alternative, but it only represents progress if it is accompanied by good information that allows informed choices to be made and not to suffer”, confirms Professor Hamamah, who daily rubs shoulders with ” pain ” infertile couples. “When we tell them that they will not be able to conceive with their own reproductive cells, the sky falls on their heads”, he testifies.

It remains to be seen how far to go in prevention. Is it necessary, on the model of the “fertility check-up” proposed at the hospital of Créteil, to generalize the screening? Without speaking out clearly,Samir Hamamah argues that early or even very early exploration makes it possible to anticipate tragedies. “Take the example of a young girl with a genetic defect such as Turner syndrome. At 13, there will still be eggs to freeze, but at 20, it will be over! ” For Virginie Rio, “The idea is not to force all women and men to do check-ups from the age of 18 nor to encourage them to self-conserve their oocytes and their gametes, but to empower people by informing them. “

Wait for the desire for a child

Joëlle Belaisch-Allart, she warns against the negative impact of the assessments performed on women who have not yet tried to conceive and have, a priori, no particular reason to worry. “It’s a false good idea”, estimates the doctor, who regularly sees young patients “Distraught”. “They are desperate because they have been found to have low levels of anti-Müllerian hormone (AMH). However, the majority of studies show that this has no predicative value on fertility. , she points out.

Psychotherapist specializing in supporting infertile couples, Benoît Cayol, too, wonders about the psychological impact of these diagnoses. “Of course, we have to get out of the belief that a pregnancy happens easily, but it is also important that the couple waited until they wanted to have a child before wondering about their fertility. And above all, that he tried to get there for a few months before going crazy ”, considers the psychologist.

For women who wonder about their chances of getting pregnant, Joëlle Belaisch-Allart first advises to “Take stock of your lifestyle” with a doctor. “But once again, the most decisive criterion is age, she insists. And for that, there is no examination to do. “

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Infertility, sometimes unrecognized causes

In France, 15 to 25% of couples not using contraception remain infertile after one year of attempting, compared to 11% after two years.

In three quarters of the cases, infertility is of female or male origin or is associated with both sexes. In 10 to 25% of cases, it is not attributable to any of the partners and remains unexplained despite clinical examinations and hormonal tests.

The main cause of infertility in young women is polycystic ovary syndrome (PCOS), a hormonal imbalance that affects about 10% of women. In those over 35, the first cause is ovarian failure, which cannot be resolved by medically assisted procreation (ART), “Unless you call for an egg donation”. Endometriosis is also one of the factors of female infertility.

In humans, testicular failure, which affects the quantity or quality of sperm, is the most common cause of infertility.

(Source: Inserm, 2019)

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