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Place des tests d’interaction sperme-mucus dans le bilan masculin de l’infécondité

Sperm-Mucus interaction tests in male infertility work-up

Resumé

Il est souvent nécessaire de faire une analyse fine du pouvoir fécondant des spermatozoïdes chez des couples infertiles. Le mucus cervical protège les spermatozoïdes et permet leur survie, assurant, à l’ovulation, une ascension continue de spermatozoïdes dans les voies génitales de la femme. Le test post-coïtal a longtemps été la seule épreuve fonctionnelle des spermatozoïdes. Il teste la pénétration et la survie des spermatozoïdes dans la glaire cervicale, les premieres d’une longue série d’étapes que doivent parcourir les gamètes mâles dans leur ascension vers l’ovule. Mais le TPC n’est pas dépourvu d’implications émotives et doit se faire le plus simplement possible pour éviter des inhibitions sexuelles. Dans les conditions optimales, le nombre de spermatozoïdes mobiles dans la glaire de l’endocol corrèle bien avec l’analyse du sperme et avec les chances de grossesses. En présence d’anticorps antispermatiques, on ne trouve au TPC que fort peu de spermatozoïdes en contraste avec la qualité de l’éjaculat ou beaucoup, mais immobiles ou agités. On peut aussi faire des tests in-vitro, (techniques de Kurzrok ou de Kremer) avec une glaire humaine ou avec des substituts bovins ou synthétiques. Ces épreuves évaluent bien la qualité du sperme mais ne corrèlent que partiellement avec le TPC naturel en raison de la nature complexe de la fonction du col utérin. Dans un groupe de FIV que nous avons analysé, le TPC corrèle avec les taux de fécondations et de grossesses en FIV et contribue à dépister le groupe à haut risque dans lequel des examens complémentaires peuvent trier les couples relevant de micro-injection. Cependant, le TPC a été critiqué pour sa méthodologie et surtout pour sa faible validité. Dans notre groupe de FIV, l’analyse de la validité du TPC et de tous les autres éléments d’appréciation de la qualité du sperme vis à vis des fécondations et grossesses confirme cette faible validité et montre qu’elle est commune à tous ces éléments d’appréciation, sans doute à cause de la nature multifactorielle du pouvoir fécondant des spermatozoïdes. L’analyse multifactorielle montre néanmoins que le TPC tient une place de premier plan parmi les examens pratiqués. Ainsi, l’évaluation du pouvoir fécondant des spermatozoïdes ne peut se fonder sur aucune épreuve isolée. Elle requiert une cascade judicieuse d’examens et c’est à leur lumière que l’on peut dresser un bilan valable et décider du geste thérapeutique rationnel.

Abstract

In infertile couples, it may be necessary to finely analyze the fertilization ability of spermatozoa. The postcoital test (PCT) has long been the only sperm functional assay. It tests the sperm penetration and survival ability in the cervical mucus. These are the first steps of a long cascade of events that spermatozoa have to undergo during their ascension in the female genital tract, on their way to the site of fertilization. However, the PCT may evoke emotional stress and should be done in a simple way to avoid sexual inhibitions. In optimal conditions, the number of motile spermatozoa seen in the upper cervical mucus correlates well with semen analysis and the odds of subsequent pregnancies. Antisperm antibodies may impair the PCT and only few, if at all, or many immobile or shaking spermatozoa, may be seen in cervical mucus, in contrast to the sperm quality in the ejaculate. In vitro Sperm-Mucus tests may be done using Kurzrok or Kremer technique with human or bovine mucus as well as with synthetic media. These in vitro tests do allow a good evaluation of sperm quality but only partially correlate with natural PCT. In an IVF group the PCT correlates with IVF fertilization and pregnancy outcome. It helps detecting the high risk group in which additional tests, antisperm antibody detection, acrosome reaction test, hamster test (SPA), hemizona assay (HZA), are recommended. These tests may sort those couples requiring sperm egg micro-injection. However, the PCT has been criticized for its poor methodology and mainly for its weak validity. In this IVF group, we performed a validity analysis of PCT and all sperm tests against fertilization and pregnancy rate. It confirms the weak validity indices of PCT and of all sperm tests as well. Nevertheless, in the stepwise regression analysis of all these tests against IVF fertilization and pregnancy, F-test value of PCT was almost similar to SPA/HZA and higher than sperm morphology. Thus, PCT is important and the weak validity indices of all sperm tests are probably due to the multifactorial nature of sperm quality. So, no single test may reliably check sperm fertilization potential. Male work-up does require a cascade of examinations including PCT to allow reliable evaluation and rational therapeutic act.

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Soffer, Y., Raziel, A., Friedler, S. et al. Place des tests d’interaction sperme-mucus dans le bilan masculin de l’infécondité. Androl. 8, 36–46 (1998). https://doi.org/10.1007/BF03034760

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Mots-clés

  • infertilité-masculine
  • test post-coital
  • spermatozoïdes
  • mucus cervical
  • épreuves fonctionnelles des spermatozoïdes
  • fécondations
  • grossesses
  • FIV

Key-words

  • Infertility-male
  • Postcoital test
  • spermatozoa
  • cervical mucus
  • sperm functional assays
  • fertilization
  • pregnancy
  • VF