[Impact of advanced maternal age on fecundity and women's and children's health]. / Impact de l'âge maternel élevé sur la fertilité, la santé de la mère et la santé de l'enfant.

OBJECTIVE: There has been a consistent trend towards delayed childbearing in most Western countries. We present a review of the current epidemiological understanding of the effects of advanced maternal age on fecundity, maternal and child health. MATERIALS AND METHODS: A narrative review of the literature based mostly on the key population-based studies on the subject. RESULTS: Delayed childbearing results in a substantial decrease in fecundity and a considerable increase in fetal loss; risk of the latter is doubled between 20-24 and 40-44 years of age. Other risks include those related to maternal health (maternal mortality and morbidity) and adverse pregnancy outcomes (multiple births, preterm delivery, fetal growth retardation and congenital anomalies). CONCLUSION: Risks associated with delayed childbearing become significant for maternal age greater than 35 years, and are particularly high for women aged 40 years and greater. Knowledge about the risks associated with advancing age can be helpful for couples in their decisions regarding childbearing.

The impact of a decline in fecundity and of pregnancy postponement on final number of children and demand for assisted reproduction technology.

BACKGROUND: Over the past decades, the proportion of couples who resort to infertility treatment has tremendously increased, and fertility (the final number of children) sharply declined. We explored the roles of two potential causes of these trends: a temporal decline in the couples' fecundability and a postponement of age at initiation of pregnancy attempts. METHODS: We conducted a Monte-Carlo simulation for the reproductive history of 100,000 women based on the fertility and socio-demographic characteristics of the 1968 birth cohort in France. Declines in fecundability of various amplitudes have been implemented, as well as increases in the distribution of age at initiation of pregnancy attempts. RESULTS: A decline in fecundability by 15% implied a decrease in fertility by 4%, and an increase in the proportion of couples eligible for infertility treatments by 73%. An increase in the mean age at initiation of first pregnancy attempt by 2.5 years from 25 years entailed a decrease by 5% in fertility and an increase by 32% in the proportion of couples eligible for infertility treatments. CONCLUSION: A relatively important decrease in fecundability and an increase by 2.5 years in age at first pregnancy attempt are likely to have only a limited impact on fertility. However, they may have a large impact on the proportion of involuntarily infertile couples, likely to resort to assisted reproduction techniques.

Fertility and ageing.

The late 20th century trend to delay birth of the first child until the age at which female fecundity or reproductive capacity is lower has increased the incidence of age-related infertility. The trend and its consequences have also stimulated interest in the possible factors in the female and the male that may contribute to the decline in fecundity with age; in the means that exist to predict fecundity; and in the consequences for pregnancy and childbirth. In the female, the number of oocytes decreases with age until the menopause. Oocyte quality also diminishes, due in part to increased aneuploidy because of factors such as changes in spindle integrity. Although older male age affects the likelihood of conception, abnormalities in sperm chromosomes and in some components of the semen analysis are less important than the frequency of intercourse. Age is as accurate as any other predictor of conception with assisted reproductive technology. The decline in fecundity becomes clinically relevant when women reach their mid-30s, when even assisted reproduction treatment cannot compensate for the decline in fecundity associated with delaying attempts at conceiving. Pregnancies among women aged >40 years are associated with more non-severe complications, more premature births, more congenital malformations and more interventions at birth.

[Induced abortion in France: results of the COCON study]. / Prise en charge de l'IVG en France: résultats de l'enquête COCON.

OBJECTIVE: The aim of this article is to describe conditions of abortions practices in France. MATERIALS AND METHODS: The study was based on the COCON survey. This survey was carried out among a representative sample of 2863 women aged 18 to 44 living in metropolitan France. Women were interviewed by telephone. The analysis was performed among a sub-sample of 320 women who had had an abortion between 1996 and 2000. Results were compared with those of the national notification of induced abortions. RESULTS: Altogether, the way in which abortions were carried out was appropriate, but differences were observed according to the type of hospital: access to care was easier in the private sector; however a pre-abortion interview was less often carried out and a post-abortion interview less often proposed in the private sector. Besides, in both sectors, women were rarely allowed to choose the abortion technique, or the type of anesthesia in the case of a surgical abortion. CONCLUSION: The COCON study is the first population based survey describing the characteristics of care regarding voluntary abortion. It shows the persistence of differences in practices between the public and the private sectors.

How effective is assisted reproduction technology? A model assessment.

BACKGROUND: All conceptions occurring after a treatment for infertility are usually attributed to the treatment. This is only true when only totally sterile couples are treated: subfecund couples may still conceive without treatment. METHODS: We used a computer simulation (Monte Carlo) model of reproduction, combining the monthly probability of conceiving, the risk of miscarriage and the probability of age dependent permanent sterility. After a delay (D) without conceiving, the couples are assumed to turn to assisted reproduction technology. The treatment increases the fecundability (monthly rate of conception) of subfecund couples and restores the fertility of some totally sterile couples. The overall effectiveness of the therapy is based on data (by age of women) for two attempts of IVF. The number of conceptions ending in a live birth with ART is compared to the number of conceptions after one or two additional years without ART. RESULTS: At 30 years of age, the crude effectiveness of ART, based on all conceptions after treatment, is double that observed without treatment (30% vs. 15%), and beyond 41 years of age, the number of conceptions with treatment is no higher than without treatment over two years of exposure to conception (15% for both at 41 years of age, 7% at 45 years of age). Shortening the delay (D) does not improve the total number of women conceiving and having a live birth unless we assume the couple try again to spontaneously conceive. CONCLUSIONS: The chances of conceiving spontaneously must not be ignored when defining an infertility treatment, especially in cases of unexplained infertility. Shortening the delay before using ART is not in itself a more efficient strategy.

Towards less confusing terminology in reproductive medicine: a proposal.

The use of the term "infertility" and related terms in reproductive medicine is reviewed. Current terminology is found to be ambiguous, confusing and misleading. We recommend that the fertility investigation report of a couple should consist of statements concerning description, diagnosis and prognosis. The description concerns the duration of non-pregnancy before consulting the clinician. A system for prognostic grading is proposed. The fertility investigation report forms the basis for further action, including the possibility of waiting with treatment in case of almost normal or only slightly reduced fertility. The use of the terms infertility, subfertility and fecundity is not necessary, and it is recommended to avoid them.

Analysis of the underestimation of induced abortions in a survey of the general population in France.

INTRODUCTION: A pilot study has been conducted in France to estimate the extent of underreporting of induced abortion and the factors linked to underreporting. METHODS: A representative random sample of 300 women aged between 18 and 44 years of age who had been pregnant during the previous 2 years and 100 women who had not was selected from the telephone directory. Interviews were conducted by telephone. RESULTS: The annual incidence of induced abortion for the 18-44-year-old age group was 6.9 per 1000 (95% confidence interval 2.2-11.6), while the rate derived from national statistics was 15 per 1000. Five women who reported a therapeutic abortion in their lifetime had confused induced abortion and therapeutic abortion. There was no significant difference in the proportion of women reporting induced abortion in their lifetime between those answering with another adult present and those who were alone when answering (13.1% versus 11.1%, p = 0.8). There was also no significant difference according to the sex of the interviewer (10.0% for men versus 12.2% for women, p = 0.6). CONCLUSION: The results suggest that the context in which the questions were asked does not affect the validity of the answers and that there is a problem in the comprehension of the terminology used. Extensive rewriting and reformulation of the questions is required to minimize the underreporting of induced abortion.

[Evolution of the member population of the French Academy of Medicine]. / Evolution de la population des membres de l'Académie nationale de médecine.

This survey includes all the 843 members of the French Academy of Medicine elected over the last 150 years (1850-1999). Various variables are analysed, namely the age at election, the length of life and the duration of membership. The main trends observed during the 20th century are the following. 1. A regular increase in the length of life (about 20 years), greater than in the overall French population. 2. A rising in the mean age at election until 1970 and a stabilisation afterwards. 3. A steady increase of the mean age of the population of members. Some projections are also developed for the next 25 years, based on various hypotheses: 1. A continuation of the current trends, taking only into account the foreseeable lengthening of life; this makes the difficulties observed during the last two decades becoming more acute; 2. The introduction of new rules such as a decrease in the mean age at election, or the settling of an upper age limit for regular membership (giving access to an Emeritus status). These measures induce a decrease of the mean age of the population, less or more intense. Some of the assumptions may also have a negative effect, by reducing the turnover rate.

[30 years of contraception in France]. / 30 ans de contraception en France.

Modern contraceptive methods have diffused almost continuously over the last 30 years in France. The progress of the pill has been masqued during the recent years by the spread of new treatments of perimenopause, while the use of IUD seems to have reached a ceiling. French couples rely now basically on these two methods for their contraception, and sterilisations remain uncommon. The use of pill is highest among younger women, while IUD is at a maximum between 35 and 45 years. Differences by social status are limited, and the number of unplanned births has decreased dramatically. The relatively high number of abortions, however, shows that the situation is not yet fully satisfactory.

Contraceptive practices and trends in France.

CONTEXT: Contraceptive use has been legal in France for the past 30 years, and patterns of use changed substantially from the 1960s to the 1980s. Given the rapidity with which use patterns change and the possible impact of rising concern about infection with HIV and other sexually transmitted diseases, it is important to determine trends of contraceptive practice into the 1990s. METHODS: A total of 5,900 French households were selected in 1994 for inclusion in the Fertility and Family Survey. Respondents were questioned about their contraceptive use patterns and family formation status. The results were compared with those of comparable surveys conducted in 1978 and 1988. RESULTS: Two-thirds of French women used some form of reversible contraceptive method in 1994. Oral contraceptive use has grown steadily in France: About 40% of women aged 20-44 reported using the pill alone or combined with another method in 1994, compared with 34% in 1988 and 28% in 1978. Condom use has also been on the rise: Nearly 8% of women were using condoms alone or combined with another method in 1994, up from 5% in 1988 and 6% in 1978. IUD use has declined from 19% in 1988 to 16% in 1994, and both male and female sterilizations remain rare. CONCLUSIONS: Contraceptive behavior in France appears unique among developed countries, with fairly high levels of oral contraceptive use--even among older women--relatively high levels of IUD use and little reliance on either male or female sterilization. As with other countries, however, condom use has climbed in recent years, and is especially common at first intercourse.

PIP: This study describes current contraceptive practices in France over the past 30 years, by method, among single men and women, for dual method use, for pregnancy or sexually transmitted disease (STD) prevention, and at 1st intercourse. Data were obtained from the 1994 Fertility and Family Survey and previous fertility surveys. In 1994, 69% of women aged 20-49 years used contraceptives. Most women relied on the pill (about 36%), followed by the IUD (16%). 7% of women were sterilized. About 5% used condoms, and 6% used abstinence or withdrawal. 31% reported not using contraceptives, of whom 3% were sterile. 4% were infertile. 4% were pregnant. 4% desired pregnancy, and 11% had no ongoing sexual relationship. 5% were determined to be at risk for unintended pregnancy. About 83% of women reported ever use of the pill, and 58% had ever used condoms. Typical patterns of use during the 1980s include 10 years of pill use followed by IUD use. Contraceptive behavior only differed among single men and women not in a union. Some men and women reported multiple method use, especially pills and condoms. During 1988-94, pill use increased, IUD use decreased, and condom use increased. Condom use was higher among singles, among the well educated, and in large cities. During 1978-94, natural method use and sterilization declined. Women tended to identify condom use with pregnancy prevention. Men tended to include STD/AIDS prevention. Contraceptive use at 1st intercourse increased over time. Even though contraceptive use increased, the number of induced abortions remained constant, suggesting lower use-effectiveness.

[Contraceptive practices in France]. / Les pratiques contraceptives en France.

Between 20 and 44 years of age, in France, two women out of three use contraception; 41% use oral contraception, and 16% the IUD; 5% use condoms, and sterilization remains uncommon. Since 1988, when some information was made about the AIDS epidemics, condoms have become widely used, as a temporary method, especially by young people and people not living as a couple; 59% of women and 83% of men aged 20-24 ever used condom, and half of the women who had their first sexual intercourse during the two last years used condoms.

PIP: In France, about 66% of women aged 20-44 use a contraceptive method. The remaining women have no need to protect themselves against the risk of unwanted pregnancy. The most common contraceptive method used in France is oral contraceptives (41%), followed by the IUD (16%). Nonmedical methods comprise only 15% (5% for condoms). Since 1988, condom use has increased greatly (8% vs. 45% in 1993), especially among youth and persons not in a union and as a temporary method. Its increased use is largely due to its ability to protect against sexually transmitted diseases, including AIDS. In the 20-24 year old age group, 59% of women and 83% of men have already used condoms. In the last 2 years, condoms were used in almost 61% and 46% of first sexual relationships for men and women, respectively. Condom use declines thereafter.

Ultrasonographically guided fine needle aspiration cytology and core-needle biopsy in the diagnosis of breast tumors.

The present study was designed to assess the performance of fine needle aspiration cytology (FNAC) and core-needle biopsy (CNB) of breast lesions when these procedures are performed under sonographic guidance. The results obtained in 1142 FNAC procedures and 180 CNB procedures were analysed. The study took place in a University Hospital and a private practice clinic. The patients eligible for this study were a series of women, in whom at least one hypoechoic, limited mass was found at breast ultrasonography. Cystic masses were excluded from the study. Each individual mass was investigated using either FNAC or CNB under sonographic guidance. Accuracy characteristics to suspect or diagnose malignant and pre-malignant breast lesions, such as sensitivity and specificity, were calculated. The cytological results were classified into four categories according to standard criteria: benign; atypical and/or suspicious for cancer (hyperplasia with atypia); malignant; and unsatisfactory for diagnosis specimen. Tissue specimens were classified according to the W.H.O. The 1142 lesions submitted to FNAC included 66 invasive carcinomas, 4 intraductal carcinomas, and 4 atypical hyperplasias. FNAC led to 6 false-negative examinations, equally distributed between small (volume < or = 1 cm3), and larger lesions, and 1 false-positive examination. There were 12.9% (147/1142) inadequate smears. Only 3 inadequate samples were obtained in the presence of a discrete pathologic lesion (3/363, or 0.1%). All 3 corresponded to invasive carcinomas. The majority of inadequate samples (144/147, or 98.0%) were obtained in the normal/dystrophic group. Overall, the sensitivity is 92.1%, and the specificity is 84.8%. The 180 lesions submitted to CNB included 31 invasive carcinoma, 5 intraductal carcinomas, and 17 atypical hyperplasias. CNB, in this series, had an accuracy rate of 100%. In conclusion, US guidance increases the accuracy of breast tissue sampling procedures. This is of particular importance as the number of suspicious images to be investigated steadily increases, as the result of mass screening.

[Difficulties in conceiving. Discussion about methodology concerning the INED-INSERM survey carried out in France in 1988 on 3,181 women aged between 18 and 49]. / Difficultés à concevoir. Discussion méthodologique à propos de l'enquête INED-INSERM réalisée en France en 1988 sur 3 181 femmes âgées de 18 à 49 ans.

Different types of enquiries can be carried out in the field of infertility: descriptive ones (to find out the "frequency" of difficulties in conceiving and their causes) or analytical ones (to show and quantify the risk factors). A descriptive one was conducted on a representative national sample of women ages 18 and 49 years by INED and INSERM in 1988. The results shown here deal with the proportions of women who had had difficulties in conceiving as well as those who had consulted doctors for this reason. One notes that 27% of the women who were questioned had had difficulties and of those who had been waiting for more than one year, 62% had consulted a doctor. On the other hand, from the knowledge that has been gained from this enquiry, some methodological points are discussed, as far as the precise definition of infertility, the sample on which the study is carried out as well as the measured variable (prevalence, annual incidence and cumulative incidence). A particular reference is made to another enquiry carried out on patients who consulted because of infertility in three departments of France in 1988-89.

[Current status of reproduction control in France]. / Conditions actuelles de la maîtrise de la reproduction en France.

Fertility declined rapidly in France between 1965 and 1976, mainly because of a decrease in the number of births of parity 3 or more. This change was due to both a decline in the desire for children and to a large reduction in the number of unwanted births. The INED national survey of 1988 showed a rapid spread of medical contraceptive techniques (pill and IUD) since 1965. In the same survey, a significant proportion of women reported difficulties in conceiving: these difficulties resulted in a much longer time-interval before conception; in addition women tended to become more and more impatient in this regard.

[From natural fertility to aided fertility: the demographer's contribution]. / De la procreation naturelle a la procreation assistee: le point de vue du demographe.

PIP: Demographers and physcians have, largely independently, been involved in analysis of fecundity and intrauterine pregnancy loss for several decades. Demographers were primarily responsible for precise measurement of the reproductive capacity of human beings, for definition of the notion of fecundability, and for significant progress in measurement of the risk of fetal mortality using the multiple entry life table. The apparent rate of fertility mortality was under 10%, but precise calculation using the life table yielded an estimate of 23.2 stillbirths and miscarriages per 100 pregnancies at 4 weeks of amenorrhea. Demographers recognized the contribution of breastfeeding to fertility control in traditional societies, and demographers determined the rate of sterility of cohorts of women at different ages. Increasing knowledge of genetics and the role of genetic anomalies in early spontaneous abortions and the advent of new techniques of "assisted procreation" in the late 1960s brought with them new questions of measurement and definition. Studies of the delay to conception in populations using no contraception indicate that effective fecundability, the rate of conceptions leading to live births, generally averages from 20-30% for the 1st cycle of exposure to risk and decreases regularly month by month thereafter. A form of equation for a probability distribution using just 2 parameters has been found useful for demonstrating the heterogeneity of couples; it shows that even after 12 or 24 months of unsuccessful attempts, the odds are in favor of eventual conception. Programs to assist conception imply hormonal stimulation of ovulation, attempts at fertilization in the optimal cycle phase, and other such steps. The success rate to which assisted fertility programs is compared should refer in this case to the probability of conception under optimal conditions, which may be closer to 50% than to 25%. The risk of intrauterine pregnancy loss increases rapidly with age and with previous pregnancy loss. The analogy with the unequal distribution of fecundability suggests use again of the same type of probability distribution. 1 of the few studies done of very early pregnancy loss suggested a rate of around 50%. Even assuming a lower rate, it is clear that only a minority of fertilizations actually lead to a live birth, and that fecundability and intrauterine mortality are in fact 2 aspects of a single phenomenon comprising effective fecundability. Evaluation of treatments for infertility depend on the odds of conception in the absence of treatment. If all couples treated are truly sterile, then each conception leading to a live birth represents a success of the treatment. But inclusion of hypofertile couples, a large proportion of whom would eventually conceive even without treatment, changes the evaluation criteria. In cases the effectiveness of various types of treatment should be evaluated in double-blind studies.^ieng

The new couples: number, characteristics and attitudes.

PIP: The authors examine family characteristics in France based on a 1985-1986 INED family history survey. They question whether the decrease in nuptiality is an actual representation of the number of cohabiting couples or if it reflects a change in the definition of a couple. They explore attitudes toward marriage, numbers of married and unmarried couples, and illegitimacy rates. Findings indicate the necessity of a broader definition of the word couple.^ieng

[Recent trends in late child-bearing]. / Evolution de la frequence des grossesses tardives.

PIP: The number of births to mothers aged 35 and over has been increasing in France since 1988, following an earlier period of decline. The number of births to mothers aged 35-39 in 1978 was 37% of the number observed in 1964. By 1984 the proportion had risen to 60%. On the other hand, births to mothers aged 40-44 declined in 1979 to 28% of the number in 1964 and increased only slightly to 29% in 1984. The recent increase has not compensated the earlier decline. Legitimate births of order 2 or higher accounted for about 2/3 of the 54,300 births to mothers aged 35-39 in 1984. Legitimate 1st births accounted for less than 20% of the total. Extramarital births have been increasing; their number tripled in 10 years and now almost equals that of legitimate 1st births for women aged 35-39. Among the 8280 births to women aged 40-44 in 1984, only the proportion illegitimate has increased since 1975. The increased number of births to women over 35 since 1977 is explained largely by the increasing number of women in the relevant age cohorts. If the observed number of births is related to the number of women in the 2 age groups, it becomes clear that recent changes in their rate of fertility are much more limited than the changes in absolute number of births. Only extramarital fertility in the 35-39 cohort is increasing significantly, but it has merely regained a level already attained in 1966 or 1973. Extramarital fertility is increasing among younger women as well as among those over 35. Births after age 35 are still rare; 8% in 1984 were to mothers over 35 and only 1% were to mothers over 40. At least 1/2 of pregnancies in women over 40 and 1/3 in women over 45 are terminated by abortion. In 1973-77, about half of pregnancies in women over 40 were unplanned, but it appears reasonable that a greater number of late pregnancies occurring at present are desired. Development of contraception and liberalization of abortion laws have undoubtedly caused a decline in unplanned births to older women.^ieng