Definition: what is infertility?
We speak of infertility when it is difficult for a heterosexual couple to conceive a child. The probability of a pregnancy occurring at each menstrual cycle, in a couple not using contraception, is around 20 to 25% when the woman is 25 years old. Infertility means NSAIDs i an absence of pregnancy, despite regular sexual intercourse (2 to 3 per week) unprotected for at least 12 months. Thus, after a year of attempts, it is necessary to consult and turn to a doctor specializing in reproductive disorders.
“Furthermore, when there is a risk of infertility – in case of menstrual cycle disorders (especially in the case of irregular cycles), endometriosis or after 35 years – it is necessary to consult earlier: from 6 months of unsuccessful attempt”, indicates Dr Marine Leflon, gynecologist and reproductive doctor, at the Clinique des Femmes in Paris.
Numbers: how common is it?
According to data from the National Perinatal Survey (ENP) and the Epidemiological Observatory of Fertility in France (Obseff), 15 to 25% of couples are affected by infertility after a year of regular sexual intercourse. After two years of attempts, these figures are reduced: about 8 to 11% of couples are still affected by conception difficulties.
What are the symptoms of infertility?
Several signs can alert us:
- irregular cycles (less than 26 days or more than 35 days); or lack of rules
- endometriosis (chronic disease of women of childbearing age characterized by the development of a uterine lining (endometrium) outside the uterus, colonizing nearby organs)
- history of pelvic infection (appendicitis, sexually transmitted infection chlamydia)
- In humans, the erectile dysfunction or ejaculation can be responsible for infertility
Infertility: what are the causes in women?
Infertility can have several causes:
- in 30% of cases, infertility is of female origin
- in 30% of cases, the origin is male
- in 30% of cases, it is mixed (male and female origin)
- and in 10% of the cases, no origin is found after a complete assessment of the two members of the couple, we then speak of idiopathic infertility.
the polycystic ovary syndrome (PCOS) is the leading cause of infertility in young women. About 10% of women are affected. It is an ovulation disorder: release of a reproductive cell (oocyte) from the ovary. Its definition is based on several criteria: excess production of androgens (male hormones) by the ovaries which can cause acne and hyperpilosity, excess follicles and cycle disorders.
Endometriosis is also a common cause of conception difficulties. “This disease can lead to a decrease in the stock of follicles (small sac-like structures located in the ovaries, in which oocytes develop), tubal patency and disorders of the implantation of the embryo in the uterus”, specifies Dr. Leflon.
At birth, a baby girl has several million follicles. The decrease in the number of follicles and the alteration of their quality is a physiological phenomenon that occurs over time. This can be more or less rapid until menopause.
This decrease is responsible for a significant drop fertility after 35 years. Beyond the age of 40, 50% of women can no longer conceive; after age 45, reproductive function becomes exceptional. The age of the woman is therefore an important element to take into account when talking about infertility. If the follicular growth is accelerated, we speak of a reduction in the ovarian reserve, i.e. an insufficient supply of ovarian follicles in relation to age.
“From anatomical causes may explain conception difficulties : uterine malformation, obstruction of the fallopian tubes secondary to genital infections or inflammatory diseases such as endometriosis. The fallopian tubes receive the oocyte from the ovary, guide the spermatozoa to the oocyte, thus allowing fertilization (encounter between the oocyte and the spermatozoon), then promote the migration of the embryo to the uterus where it will take hold,” notes Dr. Leflon.
At last, endometrial polyps Uterine fibroids (benign growths on the inner lining of the uterus) and fibroids (benign tumors made up of muscle and fibrous tissue) can explain infertility.
What is the origin of infertility in men?
Abnormalities of spermatogenesis (impaired sperm production) can lead to poor sperm quantity or quality. “It may be azoospermia (total absence of spermatozoa), oligozoospermia (decrease in the number of spermatozoa), teratozoospermia (morphological abnormalities of spermatozoa), asthenozoospermia (abnormality of sperm motility), abnormality of sperm survival after ejaculation or semen infection,” says Dr. Leflon.
Those abnormalities may be constitutional, secondary to underlying pathologies (diabetes, varicocele) or due to exposure to factors that disrupt spermatogenesis: tobacco, cannabis, alcohol, endocrine disruptors, drugs, chemotherapy. Erection and ejaculation disorders can be added to spermatogenesis disorders.
Age is also a factor in the alteration of spermatogenesis.
What causes are common to both sexes?
Certain diseases affecting areas of the brain (such as the hypothalamus and the pituitary gland) can cause an alteration in the production of hormones inducing an absence of ovulation or a deficit in the production of spermatozoa. Certain cancer treatments (chemotherapy/radiotherapy) can also be responsible for infertility. Environmental factors (smoking, cannabis, alcohol, exposure to endocrine disruptors) are also incriminated.
Infertility: what tests to perform in women?
A hormonal assessment (blood sample) is first carried out to assess ovarian function and reserve. Pelvic ultrasound (examination of the female genital sphere: uterus, ovaries and fallopian tubes) also makes it possible to measure the ovarian reserve (number of follicles present in the ovaries), but also to look for possible uterine malformations.
“Two types of examinations may be prescribed for assess the condition of the uterine tubes : hysterosalpingography, an X-ray examination which consists of an instillation of iodinated contrast product, injected into the uterus via a probe and hysterosalpingo-foam Sonography (HyFoSy), a more recent technique for checking the permeability of the tubes to using an ultrasound that can be done in the consulting room,” says Dr. Leflon.
In addition to this initial assessment, other examinations may be offered to patients. For example, a specific ultrasound, in the event of suspicion of endometriosis, which can be supplemented by a pelvic MRI or even a hysteroscopy (examination making it possible to visualize the interior of the uterine cavity with a camera introduced through the cervix). A vaginal swab may also be offered to detect any abnormalities in the vaginal flora or sexually transmitted diseases. Finally, in some cases, the doctor can prescribe a specific assessment (blood sample) to detect genetic abnormalities.
What does the male infertility assessment consist of?
A semen and sperm analysis (via an examination called a spermogram) makes it possible to evaluate the volume of semen then to study the number, appearance and mobility of the spermatozoa. Concretely, the man collects his sperm by masturbation in the laboratory. Then, thanks to this collection, the doctor-biologist carries out the spermogram as well as a spermoculture to detect possible infections. “In the event of anomalies, explorations may be prescribed: an ultrasound of the genital organs, hormonal assays, genetic examinations such as a karyotype (study of the chromosomes), a consultation with a urologist”, specifies Dr. Leflon.
What are the treatments for infertility?
In case of ovulation disorders, the doctor suggests a simple stimulation of ovulation. He prescribes hormones in the form of injections (gonadotropins) to stimulate follicular growth and maturation. “From regular checks by ultrasound and blood sampling are necessary : they make it possible to follow the development of the follicles (containing an oocyte) to limit the risk of multiple pregnancy and to induce ovulation at the appropriate time. Intercourse is then scheduled after ovulation is triggered,” explains Dr. Leflon.
If simple ovulation stimulation fails, unexplained infertility or when other causes of infertility are involved, the doctor offers techniques of Medically Assisted Procreation (MAP). Artificial (or intra-uterine) insemination can, in particular, be carried out. This ART technique consists of depositing the sperm of the partner or of a donor, in the uterus of the woman, after a collection of sperm. “We try to make a follicle grow and, at the time of ovulation, the spouse collects sperm. We select the best spermatozoa, we deposit them in the uterine cavity thanks to a small catheter in order to obtain fertilization. “, notes Dr. Leflon.
In Vitro Fertilization (IVF)
When this technique proves unsuccessful or immediately, in case of more severe fertility disorders,in vitro fertilization (IVF) may be offered.
When reproduction cannot take place naturally, it is thus possible to reproduce the fertilization of an ovum by a spermatozoon to obtain an embryo, in the laboratory. IVF is performed outside the woman’s body (in vitro), in culture media whose composition is close to the natural environment of the fallopian tubes.
In case of severe sperm abnormality, IVF with ICSI (Intracytoplasmic Sperm Injection) can be performed. This technique consists of selecting a spermatozoon, then injecting it directly into the oocyte to obtain an embryo.
Finally, there is several medical indications calling for the donation of oocytes, spermatozoa or embryos. The success rate (delivery), all ART techniques combined, is estimated at approximately 20% per attempt.
Until recently, ART was only authorized in France for heterosexual couples. Since the bioethics law of August 2, 2021 the ART is open to single women and couples of womenall these techniques can therefore be offered to them (including oocyte or embryo donation).
What advice should be given to limit the risk of infertility?
From recommendations in terms of lifestyle must be given to anyone wishing to conceive. A balanced diet, normal weight, regular physical activity, cessation of psycho-toxic substances (tobacco, cannabis), moderate alcohol consumption (maximum one glass of wine per day) and low exposure to endocrine disruptors ( pollutants, pesticides) optimize the chances of conception.