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Objectives: This study presents nationally representative estimates and trends for infertility service use among women aged 25-43 and men aged 25-49 in France in 2013-2016., Methods: Two retrospective repeated cross-sectional analyses for years 2013 to 2016 were performed on the statutory French health care insurance reimbursement database for independent workers. Use rate was calculated on the number of individuals who underwent at least one infertility service within the studied year per women and men who utilized health services the same year., Results: 1.69% [IC 95%: 1.65; 1.72] of women aged 25-43 who utilized health services had used infertility services during the year 2016: 1.5% used ovulation induction, 0.7% ultrasound monitoring of follicles, 0.3% embryo transfer, 0.3% in vitro fertilization.The use increased significantly from 2013 to 2016 for the following services: ultrasound monitoring of follicles (+ 10%), intracytoplasmic sperm injection (+ 12%), freezing of embryos (+ 32%), thawing of embryos (+ 29%), embryo cryopreservation (+ 88%).In a multivariate analysis, the use was higher among women aged 30-39 years, with a liberal profession, living in the North-east or the south-east, in Corsica or over-seas, receiving health care outside the French territory.0.19% [IC 95%: 0.18; 0.20] of men aged 25-49 years had used infertility services during the year.There was a significant increase from 2013 to 2016 of the proportion of users for sperm freezing (+ 19.18%) and sperm cryopreservation for fertility preservation when cytotoxic therapy is required (+ 84.92%)., Conclusion: Some increases resulted from expanded indications. Follow-up will be required in case of legislative enlargement for access to certain techniques.

The aim of this study was to update our acknowledgment if there is a link between assisted embryo cryopreservation and epigenetics in human? Animal studies have demonstrated epigenetics consequence and especially imprinting disorders due to in vitro culture. In human, it is important to note that after frozen embryo transfer birth weight is significantly increased by 81 to 250g. But these studies cannot identify the reasons of such difference. This review strongly suggests that embryo cryopreservation is responsible for birth weight variations but mechanisms not yet elucidated. Epigenetics is probably one of these but to date, none study is able to prove it. We have to be attentive on a possible link between assisted reproductive technology (ART) and epigenetics reprogrammation., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objectives: In Assisted Reproductive Technologies (ART), impaired ovarian reserve represents a therapeutic challenge. The Anti-Mullerian Hormone (AMH) serum level would be a good marker of ovarian reserve and a predictor of response to stimulation. The objective of this study is to assess into a population of infertile couples where the woman has at least one patent tube and where the man has sperm parameters compatible with insemination, whether AMH level less than 12pmol/L can be used to establish a strategy supporting the couple's infertility by comparing their chances of pregnancy after Intra-uterine insemination (IUI) or in vitro fertilization (IVF)., Materials and Methods: This single-center retrospective study of 1012 patients over 28months compared the pregnancy rates of 2011 ART attempts (1385 IUI and 626 IVF, ICSI excluded) according to the value of serum AMH, either reduced if≤12pmol/L or non-reduced if greater., Results: In IVF, a low AMH reduced pregnancy rate (18.4% vs. 32.9% in the normal AMH group, P<0.0001). Conversely, the AMH value did not influence the success in IUI cycles (14.2% vs. 14.5%, respectively, NS). In cases with low AMH, the pregnancy rate per initiated cycle in IVF (18.4%) was not significantly greater than in IUI cycles (14.2%). Converting an IVF attempt in IUI did not impair the pregnancy rate (13.5% vs. 14.5% after immediate IUI, NS)., Conclusion: When the serum AMH level is less than 12pmol/L, IUI may be an interesting option in case of IVF failure. However, its place remains to be defined: converting IVF in IUI, IUI in relay of failed IVF, or even as first line therapy when the chances with IVF appear to be minimal., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

This work aims to show, from data available in the literature and our own experience, how embryos' vitrification change and/or improve the management of infertile couples. In all, 652 cycles of frozen-thawed embryo transfers (FET) following vitrification were prospectively included and compared with 1126 FETs from slow freezing (SF) method. Primary end points were the (i) survival rate (SR) (% of embryos with>50% post-thaw intact blastomeres) and (ii) intact survival rate (ISR) (% of embryos with 100% post-thaw intact blastomeres). Secondary end point was the clinical pregnancy rate (CPR) defined as the presence of an intra uterine gestational sac with positive foetal heart beat. In all, 1097 and 2408 embryos have been thawed following vitrification and SF, respectively. We observed a highly significant increase of SR and ISR respectively when thawing concerned vitrified embryos rather than those from SF method (97.0% vs. 72.7%, P<10(-4); 91.5% vs. 49.8%, P<10(-4)). Furthermore, CPR were of 26.5% (73/652) and of 18.1% (204/1126) following FETs performed after vitrification or SF and thawing (P=0.0002), respectively. At the blastocyst stage, ISR was significantly improved following vitrification compared to SF (94.5% vs. 21.4%, P<10(-4)). In the study period, vitrification (i) reduced the mean number of fresh transferred embryos (1.5 vs. 1.6; P=0.08) and (ii) increased the rate of FETs at the blastocyst stage when compared with the control period (18.1% vs 2.5%., P<10(-4)). Embryo vitrification preserves all embryos from an ART cycle because of its excellent results regarding ISR at all stages of embryo development. This procedure allows a significant increase of pregnancy rates after thawing. In addition, there is a trend for increasing ART cycles performed using extended culture embryo and vitrification. The expected improvement of the cumulative birth rate at the blastocyst stage following vitrification remains to be demonstrated in a prospective randomized study., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Background, Material and Methods: In order to determine the characteristic features of requests for assisted reproduction formulated by same-sex couples consulting physicians in France, we conducted a study in collaboration with professional organizations, general practitioners, gynecologists and obstetricians who distributed an email questionnaire among their recruitment., Results: In our sample, 191 physicians (71% of responders) reported that 1040 homosexual couples expressed desire to become parents in 2011-2012. Nearly all of the physicians (94%) reported that the couples sought assistance before participating in an assisted reproduction technology (ART) program in a foreign country, but 35% reported that advice was solicited concerning natural reproduction and 48.5% reported requests for advice concerning inseminations performed by the woman herself. Most of the physicians responded to all or part of the requests and 61% of those who had been consulted reported they had directly participated in preparing an ART program in a foreign country. Among the 270 physicians who participated in this study, 162 (60%) believed that ART should be assessable to homosexual couples in France, but less than half of them were in favor of reimbursement by the national health insurance fund., Discussion: Although biased and non-representative, this study shows that assisted reproduction, with or without medical intervention, is a real-life phenomenon for many homosexual couples, and for many physicians, even before same-sex marriage became legal., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Around 3% of children are conceived by assisted reproductive technology (ART) in France. Several questions concerning the early or late follow-up of these children are raised, as there are differences in the population in charge and because of clinical or biological procedures used. Nevertheless, one has to be cautious in interpreting the data as it is difficult to study one factor at a time, and as many other events can bias the results. However, ART is associated with a higher risk, even moderate, of prematurity, foetal hypotrophy, and neo natal complications, as compared to natural conceived children. There is also increasing evidence that ART-conceived children present more epigenetic diseases and congenital mainly concerning cardio-vascular, uro-genital and musculo-skeletal systems, as natural conceived children. Absolute risks remain anyway moderate and reassuring. Long term follow up is encouraging, with correct growth or psychomotor development of these children, and no significant excess of risk for cancer, but it is necessary to carry on this follow up in order to have data on their development to adulthood and on their fertility.

Currently in France, all the children born as a result of an assisted reproduction procedure, represent 2.5% of all births. Although this proportion is not high, it is not to be neglected, particularly with regard to the sociological issues raised by assisted reproduction technologies (ART) - i.e. removing anonymity of gamete donation, post mortem insemination, ART access to single women and gay couples, surrogacy - to name four of the most prominent debates. What is new with ART is that a new therapeutic target of medicine is being developed, in other words procreation. Now it is no longer necessary for a man and a woman to resort to sex to have a child. This is a profound questioning of the representation of what appeared to be intangible, with some sort of divine aura. How, in this context, developing an ethics for ART? From a fethnographic field survey, we show here how this ethos of ART develops and how, therefore, we consider the multiple ways of being a family today., (Copyright © 2013. Published by Elsevier SAS.)

Since the birth of the first baby conceived by in vitro fertilization (IVF) 30 years ago (Louise Brown in 1978), there has been a rapid and constant increase in the number of couples using assisted reproductive technologies (ART). Around four million of children have been born from couples experiencing fertility problems, through the use of ART, comprising roughly 2-3 % of all births in Europe and U.S. That highlights that these modes of fertilization are now well assumed by our societies. However, several questions on health of these children remain to be elucidated. As evoked in this review, even if methodological limitations exist, numerous studies have reported increased risks of birth defects, like prematurity, foetal hypotrophy, neonatal complications, congenital malformations and epigenetic diseases among ART-conceived children as compared to naturally conceived children. Nowadays, it is difficult to determine if these increased risks found in ART infants are a consequence of the ART procedures or are inherent to the infertility problems per se. However, absolute risks remain moderate and reassuring as well as the data on follow-up into infancy and early childhood. Nevertheless, because the effects may occur at the adulthood, there is a need for long-term follow-up of children born after ART., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Introduction: Syphilis has recently re-emerged in young adults. However, serological testing of patients undergoing assisted reproductive technology (ART) cycles and/or semen cryopreservation is not mandatory in every country., Patients and Method: We conducted a retrospective analysis on our local database to evaluate the prevalence of syphilis among infertile couples, and discuss the interest of systematic syphilis serology testing in these patients., Results: Between 2000 and 2010, only one patient out of 4314 was diagnosed with chronic syphilis., Conclusion: This study illustrates that systematic serological screening for syphilis in couples referred for semen cryopreservation or ART only allows exceptionally rare diagnosis. The cost-effectiveness of this strategy should be reconsidered., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

A predictive model is a mathematical expression estimating the probability of pregnancy, by combining predictive variables, or indicators. Its development requires three successive phases: formulation of the model, its validation--internal then external--and the impact study. Its performance is assessed by its discrimination and its calibration. Numerous models were proposed, for spontaneous pregnancies, IUI and IVF, but with rather poor results, and their external validation was seldom carried out and was mainly inconclusive. The impact study-consisting in ascertaining whether their use improves medical practice--was exceptionally done. The ideal ART predictive model is a "Center specific" model, helping physicians to choose between abstention, IUI and IVF, by providing a reliable cumulative rate of pregnancy for each option. This tool would allow to rationalize the practices, by avoiding premature, late, or hopeless treatments. The model would also allow to compare the performances between ART Centers based on objective criteria. Today the best solution is to adjust the existing models to one's own practice, by considering models validated with variables describing the treated population, whilst adjusting the calculation to the Center's performances., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

In addition to NF EN ISO 15189, the second version of "GBEA AMP", published in the official journal of the French Republic, had set for "AMP" exams, the actions to be implemented in order to achieve an efficient quality management system. As part of continuous improvement of quality, and besides our external and internal quality systems, we have been developping indicators that will allow an early detection of potential drifts within operators performing sperm morphology testing. We have extracted nearly 1900 sperm morphology tests from our database. These tests were performed by three operators. The analysis of the data collected has shown a cross correlation between the percentages of typical forms, malformative acrosomes and "MAI". We have been using these correlations as quality indicators in our laboratory in order to highlight any potential drift in reading sperm morphology tests.

Objectives: ART transparency of results and ways to submit are in centre of present biologists and clinical cares. This work aims at identifying ART results' presentation pertinent tests., Patients and Methods: At first time, we propose a questions' list to French ART professionals. Next, we apply results on Amiens' ART center 2006, 2007 and 2008 IVF parameters., Results: One hundred and twenty questions' lists were analysed. Ninety percent of interrogated people were in favour of the results' center public communication. Most quoting criterions hold to define a reference population are (percentage of favourable opinions): IVF/ICSI treatment (96%), first of second rank's attempts (71%), women age less than 35 years old (68%), one or two top embryos quality transfer (60%). In 2007, 2008 and 2009, we made 1123 tentative IVF±ICSI in Amiens' ART center. Pregnancy rates were analysed for these years with criterions next quoting as most pertinent (women's age and rank's attempt), and in function of puncture retrieval oocytes number and indications., Discussion and Conclusion: Most of professionals are in favour of ART transparency of results. All would like that results presentation holds to special criterions to allow a fair comparison. Pregnancy predictive factors, which are women age, rank attempt, puncture retrieval oocytes number, seem to be main criterions for evaluation. These criterions pertinence has been shown thanks to Amiens ART center results., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

At present, it is estimated that fibroids may be associated with infertility in 5 to 10% and are possibly the sole cause of infertility in 1 to 3%. Their effects on fertility remain debated. The aim of this review of published studies between January 1990 and November 2010 was to clarify the relation between myoma and fertility, and to assess the role of myomectomy in infertile patients. In assisted reproduction technology and spontaneous conception, hysteroscopic sub-mucous myoma resection increased pregnancy rates. Intramural fibroids appear to decrease fertility, but the myomectomy does not improve assisted reproduction technology and spontaneous fertility. More high-quality studies are needed to conclude toward the value of myomectomy for intramural fibroids. Subserosal fibroids do not affect fertility outcomes, and removal does not confer benefit., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objectives: Comparison of pregnancy pathologies (diabetes, high blood pressure, preeclampsia), the stages of delivery, the weight at birth, the method of delivery, and the neonatal outcome for spontaneous pregnancies, and pregnancies from assisted reproductive technology (ART) obtained by in vitro fertilization (IVF), by intra cytoplasmic sperm injection (ICSI) or intrauterine insemination (IUI) or ovulation induction., Patients and Methods: A retrospective study over 6 years from January 1st, 2003 and December 31st, 2008 including all births at Jean-Verdier hospital in Bondy, France (n=14,049) taking into account therapeutic abortions, late miscarriages and intrauterine fetal deaths. The population was divided into four groups: spontaneous pregnancies (SP), pregnancies resulting from IVF, those obtained by ICSI and those obtained by other modes of "simple" ART., Results: The distribution of the four populations is: SP: 96.5%, IVF: 1.20%, ICSI: 0.95% and other modes of "simple" ART: 1.35%. There is no significant difference in rates of high blood pressure, preeclampsia, HELLP syndrome, therapeutic abortions and intrauterine fetal deaths between the four populations studied. In contrast, ICSI has a rate of gestational diabetes significantly lower compared to the other three groups (6.7%). The terms of delivery are later and birth weight heavier for spontaneous pregnancies (P<0.05). For the singletons, the terms of delivery are later for "heavy" ART (IVF/ICSI) than for SP (P<0.05). For twins' birth weights, we notice that they are heavier for ICSI (P<0.05) and the terms of delivery are identical between the SP and heavy ART., Conclusion: Our study showed no obstetrical complications for the heavy ART (IVF/ICSI). Pregnancies resulting from ICSI are more favourable than those from IVF and the most unfavourable are the one obtained by simple ART., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Information on adoption must be given to couples who seek treatment for medically-assisted procreation. But is adoption a real alternative? What are the chances for a couple who consults to see its desire for adoption be achieved according to its own situation, the characteristics of the child he wants, and the general situation of adoption? Can adoption, just like assisted procreation, often described by the couples as a "obstacle course", go parallel? Or should one try adoption once assisted reproduction failed? Is the couple willing to suffer the social and legal control of adoption after having supported the medical control of the ART? In all cases, the reality is that two out of three couples engaged in assisted reproduction will have a child whereas scarcely more than one candidate to adoption will be offered to adopt a child after three or four-years procedure., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

The first chapter analyses the ART methods of the Centre Hospitalier of Luxembourg, in the department of reproductive medicine between 2001 and 2009. The second chapter examines the techniques individually, their influence on pregnancy outcomes, the complications on offsprings and their health. The results coincide with literature in that risks are acceptable as long as good medical and biological conditions are maintained. Multiple pregnancies remain the most frequent complication, particularly once out of IVF. These are analysed separately as well as the pregnancies after egg and semen donation.

Retrospective study on a nine year ART practice focusing on pregnancy outcomes and multiple pregnancies, their complications, the gestational duration, delivery options, the new born weights and health statements til the age of two. Post ART pregnancies seem to have an increased complication rate; multiple births are more frequent than with spontaneous conception. The first chapter deals with the entire group. The second chapter analyses several sub-groups according to the ART method employed. The results are compared to publications in PubMed and Medline.

Preimplantation embryo development is one of the key features with implantation itself to achieve a pregnancy. Assisted Reproductive Technologies both in human and animal have improved our knowledge on these events, although it remains elusive to predict embryo potential to give a baby. Among various ways to define embryo viability, noninvasive approaches get a serious advantage linked to the final transfer of the embryo. Techniques devoted to characterize the embryo secretome using proteomic or metabolomic approaches may be non invasive. Based on a direct identification of products of the embryo metabolism or an assessment of profile(s) related with embryo viability, they have greatly improved their sensitivity to allow their use in clinical embryology, once validated. Oocyte-cumulus dialogue, as a key factor for oocyte competence to meiosis and embryo development, was particularly concerned with both genomic and proteomic assessment of cumulus cells. While it is not possible to designate at the time being which among these approaches will be robust and cost-efficient enough to help routinely the clinical embryologist in assisted reproductive techniques (ART), one can predict that our ability to select the "right" embryo will combine morphological criteria already available with validated biomarkers.

Method: This research enabled us to study the links between the diagnosis of infertility, medical care and the sexuality of the couples treated with Assisted Reproductive Techniques (ART)., Questionnaire/patients: The impact of infertility has been observed in various fields related to sexual intercourse: sexual desire and satisfaction, frequency of intercourse, sexual disorders as well as marital relationship and more generally the patient's experience of this medical follow-up. These effects were studied in the light of various factors, such as sex and age, number of children and years of ART as well as the type of protocol and the origin of infertility., Results: Our study reveals that the marital relationship is preserved as well as the pleasure felt during intercourse. However, the couples express a reduction of their sexual desire, linked to a loss of spontaneity that can be related to the strategies they set up to maximize their chances of pregnancy and to medical care.

Objective: Despite technical progress in In Vitro Fertilisation (IVF) procedure, embryo implantation rate remains low. Assisted hatching has been proposed to facilitate natural embryo hatching and implantation., Patients and Methods: Our study has evaluated whether laser assisted hatching improves implantation, pregnancy and live birth rates in different cases. We studied retrospectively 143 IVF cycles concerning more than 38 years old women, 166 IVF cycles after two previous implantation failures and 180 frozen-thawed embryo transfers., Results: Population characteristics were comparable in hatched and control groups. Implantation, pregnancy and live birth rates in women more than 38 years old were comparable with or without assisted hatching. Concerning repeated implantation failures, even if implantation, pregnancy and live birth rates were higher in assisted hatching group (FIV or ICSI), the differences were not significant. After frozen-thawed embryo transfers, implantation rate was significantly better with assisted hatching (19.14% vs 8.84% [p=0.02])., Discussion and Conclusion: Assisted hatching improves embryo implantation rate after frozen-thawed embryo transfer.

Objective: We studied the impact of infertility and all the more Assisted Reproductive Techniques on marital relations and sexuality., Material and Method: Our study is based on a questionnaire distributed in our centre and on a review of literature., Results: Our inquest shows that both partners keep a good relationship in their couple and support each other. But, whereas pleasure during intercourse is little affected, many couples feel a reduction of their desires., Discussion and Conclusion: This diminution of sexual desires, also noted in literature, can be explained by medical requirements intrusive for intimacy and also by strategies settled by the couples themselves during intercourse in order to optimise the chance of pregnancy. Medical staffs should take into consideration eventual sexual difficulties of the couples. Making them aware that their intimate life must remain or become again an end in itself, and not only a way of procreation, often permits a beneficial change of behaviour.

Infertility treatment has improved greatly with the advent of biological and medical technologies allowing gamete maturation, fertilization and embryo culture before implantation. The ethical, social and medical issues raised by assisted reproductive technologies (ART) led French legislators in 1994 to define the conditions of ART access and realization. These regulatory measures were recently bolstered by the creation of an Agence de la Biomédecine. In 2005, 123,000 ART treatment cycles were performed in France, all techniques included. They resulted in the birth of 19,026 children. The clinical pregnancy rate ranged from 11 to 24.4% per attempt and the multiple pregnancy rate from 11 to 21%, depending on the technique used. Nowadays, the first priority is to improve the quality of the results, which means controlling the risks and constraints as far as possible, while preserving the best chances for pregnancy and birth. A better evaluation of embryo characteristics and of the woman's fertility can reduce the required number of transferred embryos and the multiple pregnancy rate, without reducing the chances of procreation. The main improvements that are likely to occur in the near future are the use of milder hormone treatments to stimulate ovarian function, better selection of functional gametes, and refinement of fertilization and embryo culture conditions. Furthermore, micromethods to measure the embryo's metabolic and developmental capacities should significantly improve the results of ART and infertility treatment.

Objective: Comparative analysis of French results in Assisted Reproductive Techniques (ART) versus those from other European countries and the United States., Population and Methods: The study was achieved by using the officially available data. The analysis was faced with a lot of difficulties in relation with the various methods of collecting data in the different countries., Results: Nevertheless, it appears clearly that French results are among the lowest in Europe with a 22% rate for pregnancy per ovum pick-up with IVF and 23.4% with ICSI, when most of the other countries report rates that are close to or over 30%. Neither the patients' pick-up recruitment nor specific practices of ART can explain this difference that certainly comes from a deficient quality of the French IVF centres., Discussion and Conclusion: We think that four main end-points can explain this situation: the lack of financial support, the lack of human force, the lack of transparency and finally the opposition between clinician and biologist that has blocked the set-up of integrated ART centres, and probably a poor quality culture.

The proportion of twin delivery has increased by approximately 80% since the beginning of the seventies, due to the combined effects of treatments for sterility, accounting for two thirds of the increase, and delayed childbearing, accounting for one third. The twinning rate had previously experienced upward and downward fluctuations, due to the combined effects of various factors, especially the variations in age at childbearing or voluntary birth control. When the mean age at childbearing increases like over the last 30 years, the twinning rate tends to increase, since older women are more likely to have twins than younger women. On the contrary, when this age decreases like over the first 3 quarters of the 20th century, the twinning rate also tends to decrease. In France, the twinning rate reached a peak during World War I, associated in part with a temporary increase in the mean age at childbearing, as well as with a selection effect of the most fecund couples, which are also more likely to have twins. As for voluntary birth control, it tends to decrease the twinning rate as a result of that selection effect associated with fecundity, but in the opposite direction.

Multiple embryo transfer is associated with a high frequency of twin pregnancies with costly complications involving both mother and child. As a result high priority is currently being given to the development of single embryo transfer (SET) programs. France seems to be lagging behind Northern European countries in the development of SET and widespread use of SET will depend on convincing physicians that this policy will not have a negative impact on success rate, as has been the case for many protocols described in the literature as well as in our own experience. Our SET program includes patients less than 36 years of age undergoing their first FIV-ICSI. If two embryos showing satisfactory morphology are obtained, one is selected transferred and the other is systematically frozen. Selection for transfer is based on two criteria, i.e. observation of even early cleavage 26 hours after FIV-ICSI and evaluation of embryo morphology score on day 2. Embryo morphology score is based on the presence of four blastomeres and absence of blastomere irregularities and anucleated fragmentation. Last, a prerequisite for SET is an effective freezing program. A pregnancy rate of 13% per thawing was sufficient enough to obtain a cumulative pregnancy rate after SET (N = 205) and subsequent frozen embryo transfer (FET) similar to the cumulative pregnancy rate obtained after double embryo transfer (N = 394) and subsequent FET (46.3 vs 46.7%, NS). Twin delivery rate were respectively 2,6% after SET and 26,6% after double embryo transfer (P < 0.01).

Clear results in ART need to take into account the technical performances of the centre but also patients selection, cycles cancelling and embryo transfer policies. The risk of a partial transparency is an inappropriate selection of patients. From classical criterias like pregnancies per oocytes retrievals or embryo transfers we are heading towards more global indicators like live births of singletons by initiated cycles rate.

Selection is probably necessary for women undergoing ART (Assisted Reproductive Therapy), since cost of technique is very important. Furthermore, the right to try to achieve a pregnancy is a debatable issue, since the delivery rates are very low for ageing women. Success rates decrease strongly for women over 40, and women must be informed of it. Women 40 years or older are significantly less likely to achieve pregnancy with IUI as compared to women under age 35. The older women are also significantly less likely to achieve pregnancy with in vitro fertilization (IVF and IVF-ICSI). Costs per cycle were similar, however, for both groups. Moreover, older women utilizing assisted reproductive techniques are four to five times less likely to achieve normal delivery than the younger group, since pregnancy loss rate is greater. This poor prognosis for success in older women adds significantly to the mean cost per pregnancy as compared to younger women. Now, public institutions advocate and impose an age limit upon women who which to undergo ART. Ovulation induction should not be administrated for women over 45 years old (AFSSAPS, 2003). One should recommend not to propose to women over 42 years old and to men over 59 years old (Guidelines, 2004). Moreover, ART techniques cannot be reimbursed for women over 43 years old (CCAM, 2005).

The economic implications of the use of assisted reproductive techniques require consideration. Since March 2005, in France, only 6 intrauterine inseminations and 4 IVF attempts are free of charge for the patient. However, definition of "acceptable" pregnancy rate for a new attempt remains discussed (10%, 15%, 20%?). Furthermore, several criteria should be considered when discussing a new IVF attempt, including woman age, FSH levels, antral follicle count and infertility aetiology. For example, in patients with secondary infertility, reasonable pregnancy rates (15-20%) can be archived even after 6 or 7 failures.

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. In the female, the number of oocytes decreases with age until the menopause. Oocyte quality also diminishes, due in part to increased aneuploidy. A significantly lower pregnancy rate per stimulation and delivery rate per retrieval is found in women aged 40 to 45 years when compared with women aged 25 to 39 years. However, acceptable pregnancy can be achieved in woman aged 40 to 43 years (4 to 8%). Furthermore, very few women aged over 40 ask for IVF procedure.

From 1986 to 2002, 16,618 twin babies have been reported to FIVNAT. Mean length of gestation was 36.74 weeks. The mean weight was 2413 g and mean height 46 cm. The proportion of prematurity under 28 weeks of amenorrhea was 1.17% and under 33 weeks: 7.78%. These data are similar to those reported in the French AUDIPOG Report.

Since 1989, the data concerning medically assisted procreation (MAP) in Belgium have been registered through the BELRAP association (Belgian Register for Assisted Procreation). In 1999, the national College of Physicians in Reproductive Medicine has been installed and given the mission to carry out the quality controls and the registration of MAP activities in our country. In 2001, a new on line system of registration of all treatment cycles was started, the basic structure of the corresponding data base having undergone a series of changes along the years. Although the number of MAP trials has considerably increased in our country, mainly because of the introduction of new techniques such as intracytoplasmic injection of sperm (ICSI), the success rate per trial has remained almost unchanged, becoming stabilized around 18.8% of ongoing pregnancies per initiated cycle. The main modification that occurred during the analyzed period has been the reduction of the number of embryos transferred at each trial, being first reduced from 3 to 2 to evolve more recently towards the replacement of only one embryo per trial. Multiple pregnancies are indeed the chief complication of MAP and in order to avoid it Belgian centers have been among the first to reduce drastically the number of transferred embryos. In 2003, legal rules were enacted, fixing the number of replacable embryos in accordance to the patient's age and to the rank of trial, while also solving the problem of the long-awaited reimbursement of MAP by our national social security system.