A tendency to get pregnant very frequently, even under contraception… According to the women it affects, hyperfertility is a largely underestimated phenomenon thanks to the problems of infertility. But what is the medical profession’s position on hyperfertility? Is it really a proven medical condition? Decryption.

The infertility assessment brings together all the examinations allowing the practitioner to establish a diagnosis of the couple’s infertility and thus recommend treatment adapted to their situation. Far from being a one-off appointment or a first contact with a specialist in Medically Assisted Procreation (AMP), the infertility assessment can last several weeks. And for good reason: according to the recommendations for clinical practice of the French National College of Obstetrician Gynecologists (CNGOF) issued in 2010, “the two members of the couple, man and woman, must be associated equally in the search for the diagnosis ” , which sometimes implies the multiplication of medical examinations for the two members of the couple. A double line of investigation which should allow the practitioner to answer 3 main questions which will guide the diagnosis towards male, female or couple infertility:

• Is the quality of the sperm sufficient for procreation?
• Does the quality of the oocytes allow a possible pregnancy to be considered?
• Can sperm and oocyte meet?

The explorations carried out in women in case of suspicion of infertility vary depending on the patient. However, 5 major gynecological examinations are recommended according to the needs of the patient, in the clinical practice recommendations, namely:

The ovarian reserve assessment

If it is not systematic, the ovarian reserve assessment is largely carried out in women:

• over 35 years old,
• having
• a family history of ovarian failure,
• in cases of foreseeable use of ART.

  As part of this investigation, a hormonal assessment (FSH, estradiol, anti-mülleriienne hormone, or AMH) is performed as well as an antral follicle count (CFA) by ultrasound.

Pelvic ultrasound

First-line examination as part of the infertility assessment, pelvic ultrasound also allows CFA to be performed.

Hysterosalpingography

Hysterosalpingography is recommended to explore the uterine cavity and tubes if infertility is suspected. The principle: the female genitalia is observed by x-ray after having been opacified with an iodine-based contrast product.

The laparoscopy

Laparoscopy is recommended if there is suspicion of tubal or pelvic pathology. In the event of a history of complicated appendicitis, suspicion of endometriosis, chlamydial infection, a laparoscopy may therefore be performed to confirm a diagnosis and sometimes to correct abnormalities in the area.

L’hysteroscopie

Hysteroscopy is usually performed if an abnormality in the endometrium or uterine cavity is suspected.

To detect possible infertility of male origin, a first in-depth interview is carried out. Its objective: to take stock of genital history, lifestyle, possible environmental exposures that could explain infertility. In parallel, several medical examinations may be recommended.

The spermogram 

 A key examination of semen analysis, the spermogram makes it possible in particular to observe and evaluate:

• the number of sperm per ml,
• the volume of the ejaculate,
• sperm vitality,
• the presence of antibodies produced by the patient against his own sperm (sperm agglutinates),
• possible infection of the sperm (clumps of sperm).

The spermocytogram

The spermocytogram is used to assess potential abnormalities in the shape of spermatozoa, whether of the head or of the flagellum. This exploration can in particular lead the practitioner to make a diagnosis of teratozoospermia, which can have an impact on the chances of pregnancy.

Note: if variations can be observed depending on the patient and the examination, the normality of the sperm has been set, within the framework of the recommendations of the World Health Organization at 15 million spermatozoa per milliliter, a mobility progressive spermatozoa greater than 32% and typical forms of male gametes greater than 4%.

To verify this data, 2 spermograms and spermocytograms are usually performed within at least 3 months.

Scrotal ultrasound:

Rarer, testicular ultrasound is recommended if testicular abnormalities are suspected. However, it is only carried out in the event of severe sperm abnormalities or if the practitioner suspects such abnormalities.

If the man and the woman are subjected to many separate explorations within the framework of the infertility assessment, certain examinations make it possible to evaluate if the infertility does not result from an interaction of the couple. The first of these: the Hühner test or TPC (Post-coital test), the objective of which is to observe the presence, mobility and survival of spermatozoa in the cervical mucus after intercourse and the quality of this last. Very often prescribed, this test must however be interpreted with caution and always be observed in addition to other examinations starting with the spermogram.

For couples waiting to conceive, the infertility assessment sometimes comes down to a long inventory of gynecological examinations. However, this assessment is (or must also be) the opportunity for an exchange between the practitioner and his patients, an exchange whose main purpose is information.

 In fact, according to the recommendations for clinical practice of the CNGOF, the doctor is required, within the framework of the management of a couple consulting for infertility:

• to inform about the frequency of sexual intercourse and the hygienic-dietetic measures to promote the occurrence of a natural pregnancy,
• to give him the preconception information necessary to understand his care,
• to inform them about certain risks on fertility related to age (maternal and paternal), obesity, tobacco, etc.