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Prise en charge de l’infécondité dans les troubles de l’éjaculation: avis conjoints de l’andrologue, du biologiste et du gynécologue

Management of infertility in ejaculatory disorders: joint opinion of the andrologist, the biologist and the gynecologist

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Résumé

Quatre-vingts pour cent des hommes qui présentent des troubles de l’éjaculation sont en âge de procréer, mais seul 5 à 10 % en sont spontanément capables. Du sperme antérograde et/ou rétrograde peut être recueilli par éjaculation assistée en association à des traitements pharmacologiques (chlorhydrate de minodrine-vibroéjaculation). En cas d’échecs de recueil de sperme et d’azoospermie, l’extraction chirurgicale des spermatozoïdes épididymaires ou testiculaires permet d’obtenir des spermatozoïdes, en quantité généralement moins importante que les techniques d’éjaculation assistée, mais non infectés et dépourvus de plasma séminal (souvent délétère dans les troubles de l’éjaculation). Même en cas d’éjaculation antérograde, il est impératif de recueillir les urines systématiquement à la recherche d’une éjaculation rétrograde, fréquente dans les troubles de l’éjaculation. Au laboratoire, l’analyse du sperme et de l’urine s’effectue par les méthodes de routine standardisées. La plupart des hommes présentant des troubles de l’éjaculation ont un sperme de mauvaise qualité (asthénospermie, nécrospermie, leucospermie). Les étiologies de la dégradation des paramètres du sperme sont multifactorielles, d’origine centrale et périphérique (testiculaire et extratesticulaire). Optimiser la qualité du sperme et des spermatozoïdes reste un challenge d’actualité dans les troubles de l’éjaculation. Si la cryopréservation doit être systématique, l’utilisation du sperme frais optimisé a généralement la préférence. Réussir à obtenir du sperme offre au couple une chance de grossesse naturelle (rarement) grâce à une éjaculation coïtale, par auto-insémination, par insémination intra-utérine, par fécondation in vitro conventionnelle (FIVc) ou injection intracytoplasmique de spermatozoïdes (ICSI) dans l’ovocyte. Dans les troubles de l’éjaculation, la prise en charge de la fécondité de l’homme doit être la plus rapide possible. Elle s’effectue conjointement à celle de la femme par une équipe coordonnant l’andrologue, le biologiste et le gynécologue.

Abstract

It is estimated that eighty percent of men who present ejaculatory disorders would like to procreate but only 5–10% from them can do it. Ejaculation can be achieved by assisted-techniques used in association with pharmacological treatment. In cases of failure of ejaculation and azoospermia, epididymal and testicular chirurgical sperm extraction allows obtaining spermatozoa. Less numerous than those obtained in ejaculated sperm, these chirurgical spermatozoa offer the advantage to be not infected by bacteria and by seminal plasma. The quality of sperm is evaluated by conventional spermiologic methods and it is important to analyze presence of spermatozoa in the urine together with that in ejaculated sperm. In ejaculatory disorders, the quality of sperm is often impaired and the mobility and vitality of spermatozoa are abnormal. Numerous bacteria and leucocytes are also present. These changes seem to be related to many factors located in the seminal plasma rather than central and testicular damages. As in fertile and infertile man, cryopreservation causes a decrease in conventional variables. However, taking into account the difficulty to obtain sperm, all patients with ejaculatory disorders would benefit from semen cryopreservation. In order to achieved successful pregnancy, several fertility treatment are available: home insemination with semen obtained by vibroejaculation, intrauterine insemination, in vitro fecondation, or intracytoplasmic sperm injection. Counselling couples undergoing such treatment program needs coordinated efforts of different specialities, which may involve andrology, biology and gynaecology.

Abbreviations

AMH:

hormone antimüllérienne

AMP:

assistance médicale à la procréation

FIV:

fécondation in vitro

FSH:

hormone folliculostimulante

ICSI:

injection intracytoplasmique de spermatozoïdes

IIU:

insémination intra-utérine

LH:

hormone lutéinisante

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Correspondence to V. Mitchell.

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Marcelli, F., Leroy, M., Robin, G. et al. Prise en charge de l’infécondité dans les troubles de l’éjaculation: avis conjoints de l’andrologue, du biologiste et du gynécologue. Basic Clin. Androl. 19, 209–217 (2009) doi:10.1007/s12610-009-0049-4

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Mots clés

  • Éjaculation
  • Sperme
  • Fécondance
  • Procréation
  • Bilan féminin

Keywords

  • Ejaculation
  • Sperm
  • Fertility
  • Procreation