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Stratégies biologiques à l’heure de l’Assistance Médicale à la Procréation chez le blessé médullaire

Biological strategies in assisted reproductive technologiesin spinal cord injury patients

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Resume

L’incidence du nombre de blessés médullaires est en constante augmentation et parmi eux 41% ont moins de 30 ans. Les possibilités de procréation sont des préoccupations essentielles chez ces jeunes patients.

L’impact délétère du traumatisme médullaire sur la fonction éjaculatoire et sur les principaux paramètres spermatiques sont bien documentés: le volume, la numération et la mobilité sont perturbés.

Des congélations de sperme dites « préventives » sont à envisager rapidement après le traumatisme.

La conduite à tenir chez ces patients lésés médullaires qui désirent un enfant va dépendre de leurs capacités éjaculatoires et du nombre de spermatozoïdes mobiles obtenus.

Si une ejaculation est possible naturellement ou à l’aide de techniques simples (vibromassage) et que le sperme présente des caractéristiques normales une conception pourra être tentée à domicile.

Si les caractéristiques spermatiques sont mauvaises, des techniques d’AMP sont envisageables. En fonction du nombre de spermatozoïdes mobiles recueillis le couple bénéficiera d’une insémination intra-utérine, d’une fécondation in vitro ou d’une injection intracytoplasmique.

Abstract

Most men with spinal cord injury (SCI) men have fertility problems caused by anejaculation and decreased fertility of the ejaculate. There are two main causes for the impaired reproductive potential in SCI men: ejaculatory dysfunction and poor quality semen. However, current treatment techniques allow a large number of SCI males to achieve ejaculation (rectal electro-stimulation, penile vibrator stimulation).

Firstly, masturbation and/or penile vibrator are used at home allowing the couple to perform insemination themselves.

The semen of men with spinal cord injuries has commonly been characterised by small volume, abnormal count (low or high), decreased sperm mobility, increased formation of reactive oxygen species, sperm autoimmunity, necrospermia. This impairment is thought to be due to insufficient drainage, genitourinary infections and raised scrotal temperature. Testicular biopsy reveals varying degrees of tubule degeneration and decreased spermatogenetic activity.

Semen could be used for various assisted reproductive technologies such as intrauterine insemination,in vitro fertilisation (IVF) and microinsemination (ICSI).

The literature reports pregnancy rates by intrauterine insemination of about 15 to 20% per couple. Clinical pregnancy rates after IVF and ICSI techniques are 30% per cycle and these results are comparable to the clinical pregnancy rates when these techniques are performed for female infertility.

However, semen must be frozen as soon as possible after the injury and the patient must be informed about the various available assisted reproductive technologies.

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Correspondence to Manuel Demailly or Henri Copin or Philippe Merviel or Jacques Petit or Isabelle Henry.

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Mots-clés

  • blessé médullaire
  • procréation médicalement assistée
  • éjaculation
  • autoconservation

Key Words

  • spinal cord injury
  • ejaculation
  • fertility
  • semen quality
  • ART