Your health

Infertility, a rising concern

We speak of infertility when a couple failed to achieve pregnancy after 1 year of regular contraception-free sexual activity. According to the Epidemiological Observatory of Fertility in France, this is the case of 18-24% of couples after one year of trial. After two years, couples who are still waiting to get pregnant are 8-11% ⁽¹⁾. This number is gradually increasing.

Increasing older reproductive age

In France, couples decide more and more to have a child at an older age. The mean age of the first pregnancy increased from 25.1 years old between 1980 and 1984 ⁽²⁾ to 30 years old in 2011 ⁽³⁾. However, this increase in age is detrimental to fertility. After 38 years old, the egg cells stock begins to run out and egg cells have a less good quality.

Decline in the quality of sperm

A constant decline in the quality of sperm is also observed (number and/or mobility of sperm cells). The quantity of sperm cells decreases from 443.2 to 300.2 millions in 34 years (between 1976 and 2009). Actually, numerous factors have been implicated, notably environmental pollutants such as heavy metals and some organic pollutants (PCB…).

From now on, contrary to conventional wisdom; infertility involves men as often as women.

Origins of infertility – WHO study ⁽⁴⁾

In 5% of cases, this infertility remains unexplained, no causes haven been found ⁽⁴⁾.

^REFERENCES:

^{1 – BEH, INVS, N°7-8-9 du 21 février 2012 FERTILITÉ et Environnement : La perpétuation de l’espèce est-elle menacée?}

^{2 – Maire Ni Bhrolchain M N et Beaujouan E, Bulletin mensuel d’information de l’institut national d’études démographiques : En France comme en Grande-Bretagne, l’allongement des études retarde les maternités, décembre 2012, numéro 495}

^{3 – INSEE data, birth and fertility rates, TEF, 2012 edition}

^{4 – Recent advances in medically assisted conception; WHO technical report series: Geneva 1992}

Causes of infertility

There are many causes, sometimes hard to detect and often requiring thorough additional tests during diagnosis.

In women

Ovulation disorders are the main cause of infertility: Ovulation may be irregular (dysovulation) or totally absent (anovulation). Some of these anovulations are related to a polycystic ovary syndrome.

Distribution of the main causes of female infertility ⁽¹⁾

We also find:

• Fallopian tube damage: Blockage or damage, secondary to an infection (salpingitis), a congenital anomaly…
• Endometriosis: Pathological presence of endometrial glands outside of the uterus (in the ovaries, tubes, peritoneal cavity…)
• Infertility related to abnormalities of the cervix and its secretion
• Hormonal disorders, such as thyroid disorders, or uterine anomaly or pelvic abnormality, fibroma, polyps…

In men

Here again, there are many causes:

• Changes in the number, mobility and/or morphology of sperm cells
• Hormonal disorders such as male hormone deficiency
• History of trauma, surgery or infections
• Retrograde ejaculation, varicocele (dilated veins within the testicles)
• Genetic disorders, birth defects…

Between couples

Some behaviours or lifestyles are also harmful to the occurrence of a pregnancy: Tobacco, excessive alcohol, overweight, few or outside fertile period sexual intercourse, or even simply and unfortunately, being afraid …. of not having a baby!

^REFERENCE:

^{1 – Recent advances in medically assisted conception ; WHO technicals report series: Geneva 1992}

Management: first steps

Infertility evaluation

Medical tests are usually prescribed after a period of 18-24 months of unsuccessful sexual activity for a young couple without any known risk. For older couples, or couples with a history of eventual insufficient fertility, it is recommended to do the tests starting from the 6^th month. It specifies the cause or causes of infertility relying, if needed, on additional tests that involve both partners (spermanalysis for men and hormonal examination for women). The outcome of these tests allows drawing a number of therapeutic solutions for the couple. Most of them are medical or surgical. If a major infertility is detected, the couple is referred straightaway to a center for assisted reproduction.

Initial medical treatments

The most frequent treatment of infertility is ovarian stimulation. It consists in stimulating the ovary with hormonal treatments (anti-estrogens or hormones such as FSH, usually secreted to stimulate the ovaries). We therefore obtain a simultaneous development of many follicles, each containing one egg. When the development is deemed satisfactory, ovulation is triggered by an injection. Other treatments (anti-infectives, etc.) are also prescribed according to an individual assessment, sometimes with vitamin supplementation (vitamin B12 and folic acid), notably in women with polycystic ovaries.

Reproduction surgery

In women, it is first of all a surgery of fallopian tubes. We can also remove endometrial lesions, pelvic adherences, polyps… in men, surgery mainly applies in case of atrophy of vas deferens or some important varicocele.

^REFERENCES

^{1 – www.procreation-medicale.fr/infertilite/les-causesde-infertilite/}

Assisted reproduction

Assisted reproduction or medically assisted procreation (MAP) consists in reproducing part of the natural process of fertilization, in a laboratory. Several techniques exist, each with precise indications. They allow considering serenely having children even in case of infertility.

Artificial insemination

It consists in collecting and preparing the spouse’s sperm to inject it in the woman’s uterus at the time of ovulation, most often after ovarian stimulation. Fertilization then occurs naturally, inside the woman’s body.

In vitro fertilization (IVF)

Eggs are obtained after important ovarian stimulation (FSH). Eggs are harvested then placed in culture, in contact with the spouse’s sperm cells harvested the same day.

1- Ovarian stimulation and ovarian puncture for oocyte retrieval

2- Putting sperm cells with oocyte for fertilization

3- In vitro development of the embryo

4- Embryo(s) transfer into the uterus

Embryos will then develop for 48 hours or even 5 days (what is called extended culture). They are then transferred into the womb for implantation.

Sperm microinjection

It involves the direct injection of sperm into an egg, instead of waiting for spontaneous fertilization to occur, just like in IVF. The other steps are identical to those of an IVF, from ovarian stimulation until embryo transfer.

Lastly, anonymous donations of embryos or gamete (oocyte and/or sperm) may be a last resort.

Nearly 3% of children are born today this way by MAP in France in 2012 ⁽¹⁾.

^REFERENCES

^{1 – Agence de biomédecine, Activité d’assistance médicale à la procréation 2012}

Main locations

Osteoarthritis mainly affects the joints of the knees, fingers, hips and cervical lumbar spine ⁽¹⁾.

It may also affect the spine (cervical, lumbar vertebrae…), ankle, shoulders…

In general, several joints may be affected. We generally use the term generalized osteoarthritis when more than 3 joints are affected.

^REFERENCES

^{1 –  Richette. Généralités sur l’arthrose : épidémiologie et facteurs de risque. In Elsevier Masson, 2008.}

Osteoarthritis is the most common joint disease

Today, osteoarthritis affects nearly 10 million people in France: one French out of 6. It is one of the primary causes of invalidity in developed countries ⁽¹⁾ and its frequency increases with age, despite the existence of juvenile forms. With the increase of elderly population and the expected doubling of the number of new cases by 2030; osteoarthritis is considered a true public health challenge.

Beyond the pain, this benign disease causes the loss of freedom of movement in time limiting progressively the mobility of affected joints. In 2005, osteoarthritis represents the second cause of invalidity in France, after cardiovascular diseases ⁽²⁾.

^REFERENCES

^{1 – Brooks PM. Impact of osteoarthritis on individuals and society : how much disability ? Socials consequences and health economic implication. Curr. Opin. Rheumatol. 2002; 14 : 573-7
2 – Etude COART : Revue du rhumatisme 72 (2005) 1326-1330}

Clinical symptoms of osteoarthritis

Pain is generally a revealing sign of osteoarthritis; being its main symptom. At the start of the disease, the pain is mechanical and marked by effort: It appears and deteriorates with the mobilisation of the affected joint and eases when rested.

In some people, a more or less long phase of stabilization may appear. However, osteoarthritis inevitably progresses.

The progression of osteoarthritis may also be associated with inflammatory outbreaks characterized by even painful swelling for a few days. In this case, pain persists at rest and may cause nocturnal awakening.

How is osteoarthritis diagnosed?

The treating physician will first ask about specifics on the pain characteristics, sensation of stiffness, and disruption of everyday life…. He/She will search for the presence of a reduced joint mobility, deformations, swelling.

He/She will rely on lab analyses and x-rays for more specifics, if necessary (presence of bone excrescence, narrowing of the joint space…)

He/She may ask for a rheumatologist or an orthopaedic surgeon opinion at an advanced stage.

Risk factors

Age is the first enabling factor but it is not the only one. Other factors are now well identified:

• Gender: Osteoarthritis is more frequent in women than in men and its frequency dramatically increases after menopause, especially osteoarthritis of the knees and fingers. Thus, osteoarthritis at the base of the thumb (carpometacarpal osteoarthritis) mainly affects women (80-90% of cases) and increases from 8% of women before menopause to 25% after.

• Genetics: Osteoarthritis runs in many families due to its inheritance nature ⁽¹⁾. 

• Traumas or repetitive strains: In case of high level sport activities or jobs exposed to repetitive violent movements or vibrations (pneumatic drills for miners, drillers…)

• Overweight: Overweight is responsible for overload on the knee joints (gonarthrosis). In women, obesity may multiply the risk of gonarthrosis by 9 especially through hormonal factors.

• Certain anatomic abnormalities: By modifying the normal weight borne by joints; some cartilage areas are overburden.

Osteoarthritis is therefore multifactor disease. Causes are complex and some of them, still little known, are still under investigation: Diabetes, hypercholesterolemia, hypertension…

^REFERENCES

^{1 – Richette, Généralités sur l’arthrose : épidémiologie et facteurs de risques. In Elsevier Masson, 2008.}

Treatments

 Management of osteoarthritis targets on one hand pain relief, the most afflictive symptom, and on the other hand it limits its progression and the subsequent disablement that it creates. For this reason, experts recommend the combination of medical and non medical treatments and to individualize the treatment to each patient ⁽¹⁾.

Thus, in case of pain, we usually prescribe analgesics or anti-inflammatory medicines (paracetamol or oral anti-inflammatory drugs for a short treatment period to limit digestive adverse events that are sometimes serious). These treatments are nowadays combined with more specific medicines for osteoarthritis called “anti-arthritics”.

Lifestyle is also a core part of the treatment and complement medicine-based treatments. Lifestyle maintenance is recommended by doctors in accordance to each patient way of life and needs: Possible reduction of overweight, regular physical activities during off periods of inflammatory outbreaks, physiotherapy, use of orthesis, use of canes…

 The earlier this management occurs; the better controlled the progression of osteoarthritis. Therefore, it is better to consult your doctor upon the first signs as he/she will be the best to develop a global strategy.

^REFERENCES

^{1 – Zhang  W. et al., OARSI recommandations for the management of hip and knee osteoarthritis, Part II : OARSI evidence-based, expert consensus guidelines. Ostéoarthrisis and cartilage, 2008, 16, 137 – 162.}

Fiche Arthrose de l’épaule
Fiche Arthrose digitale
Fiche Arthrose du genou
Fiche Ceintures lombaires
Fiche Eviter les effets indésirables des médicaments

Daily life wounds

Cuts, scratches, abrasions by a rough surface…small wounds of everyday life may seem harmless but they must be adequately treated to heal well, without any risk of infection.

First acts

1. Compress the wound until the bleeding stops.
2. Use physiological serum to clean; or in case of heavy contamination, you may first wash the affected area with soap and water ⁽¹⁾. If too painful, do not insist.
3. Protect the infection using an antiseptic, preferably colourless, to mask the progression of the wound. Avoid using alcohol.
4. if needed, apply a bandage: Sterile gauze, sterile compress or pre-cut bandage.

In addition to classic bandages, there are more specific bandages (watertight, humid, hydrocolloidal…) as well as creams and healing compresses. Ask your pharmacist for advice.

Whatever the type of the wound, one must always check if anti-tetanus immunization is up to date.

When to consult?

• In case of any doubt for children and elderly and systematically for newborns.
• In case of extended wound, more than half the surface of the palm, or if very contaminated by foreign bodies.
• When the wound is located on the back of the hand, on the neck or near a natural orifice such as the eyes which are risky areas.
• In case of a disease that further weakens the victim: diabetes, corticoids treatment or anti-coagulants…
• In case of signs of infection: swelling, oozing, purulent drainage.
• If bitten by an animal or crush injury.

^REFERENCES

^{1 – Prise en charge des plaies aux urgences SFMU 2005}

Les brûlures

In everyday life, there are plenty of opportunities to get burned. Burns may be due to heat (90% of burns) and also to sunlight (sunburns) and rarely to electric current or a chemical product.

Mains causes of burns ⁽¹⁾

While little burns can be easily healed, more extensive or deep burns require immediate consultation.

Different types of burns

To assess their seriousness, burns are classified depending on their extent and depth:

• First degree burns: Only epidermis is affected. The skin is red, painful, even swollen. It’s the standard “sunburn” or a kitchen burn.
• Second degree burns: Dermis is affected. Very painful, the skin is pinkish and humid, blisters appear.
• Third degree burns: The affected area is deeper. The skin is usually white but may be brown or even black. Ironically, there is little or no pain because the nerve ends have been destroyed.

What to do?

When the burn is superficial, the extent is less than half the palm of the victim’s hand and is not located near a natural orifice, topical care is sufficient.

First degree burn

• Cool down the burn by splashing fresh water for at least 5 minutes. This limits the progression of lesions;
• Apply an antibacterial-free hydrating cream or ointment ⁽²⁾. There are burn specific creams and ointments. Ask your pharmacist for advice.

Little extended second degree burn

• Do not cut through the blisters as they protect from infections and reduce the pain;
• Wash with fresh water;
• Disinfect the wound with an alcohol-free antiseptic as there is a risk of infection if blisters are cut;
• Protect the wound using specific bandages “non adhereing wound dressing” type, “membrane dressing” type or with antibacterial ointments or bandages ⁽²⁾.

Consult your doctor in case of any doubt or in case of more extensive burn. In case of serious burn, call SAMU/Center 15.

^REFERENCES

^{1 – Carsin H. Prise en charge des brûlures en milieu non-spécialisé. Médecine d’urgence 2003.
2 – Recommandations S.F.E.T.B- Brûlures, mars 2006, vol VI, n°4, p215-217.}

Leg ulcers

Poor blood circulation, either due to venous insufficiency or atherosclerosis, leads to complications including leg ulcer. It is defined as a wound, a loss of substance affecting the skin up to the dermis, particularly difficult to heal with a risk of infection.

Signs

Ulcers of venous origin, by far the most common (80% of leg ulcers), represent a very progressive stage of chronic venous insufficiency (varicose vein, or more frequently, history of thrombosis). It appears progressively, most often within the ankles, and is generally not painful. Which is the entire issue! In absence of treatment, the ulcer becomes chronic. One should always check any wound in the leg.

Arterial ulcer is less frequent and rather affects men aged over 50 years old with vascular risk factors (tobacco, hypertension, obesity…). Unlike the previous, it appears brutal, mostly after a shock, and is very painful.

In both cases, immediate consultation is advised.

Medical care

To heal a leg ulcer, it is not enough to just treat the wound, one must also treat the cause.

The wound will be cleaned; residues that are hindering the healing process will be removed. Conducive local conditions will then be restored using bandages that adapt to each healing phase. After the detersion phase, interface, hydrocellular, hydrocolloidal, Vaseline or hyaluronic acid containing dressings will be used.

In parallel, what caused the ulcer will be treated. If it is of venous origin, a venous contention will be positioned using specific dressing. In case of arterial ulcer, the patient will be advised to limit the cardiovascular risk factors (tobacco, arterial hypertension, overweight…).

^{REFERENCES
1- Recommandations HAS, 2011}

Wounds and diabetes

People with diabetes know the attention they should pay, particularly, to their feet. Because a poorly controlled diabetes exposes the patient to healing difficulties in case of injury, even in case of a wound that went undetected for a very long time. Eventually, there is a risk of amputation.

Globally, 15% of diabetic patients will present a foot ulcer at one moment of their lives ⁽¹⁾. An old or a poorly controlled diabetes may, in fact, cause a loss of sensitivity within extremities which favour the occurrence of injuries as well as vascular disorders that are detrimental to healing, with an increased risk of infection due to the decrease in immune defences.

More worryingly, some wounds may pass completely undetected. It’s the case of the “diabetic foot ulcer”, ulceration at the sole of the foot which is luckily increasingly rare, is deep and painless and may progress undetected. This is why it is advised to daily inspect the feet of a diabetic person with regular visits to the chiropodist ⁽¹⁾. Consultation is required even with the smallest injury!

Medical care

Within the wound, the best possible conditions are to be established to help the healing process. This is achieved by dehorning (horn removal) and debridement around the wound using a lancet, then application of a bandage specific to each healing phase. After the detersion phase, interface, hydrocellular, hydrocolloidal, vaseline or hyaluronic acid containing dressings will be used to significantly reduce the size of the ulcer.

On a general level, controlling diabetes is imperative to heal. In case of diabetic foot ulcer, the foot will be strictly and permanently offloaded until healing, ideally with suitable shoes.
^REFERENCES

^{1 – HAS 2011, Les pansements indications et utilisations recommandées}

Cracks and infant diaper rashes…

Cracks

Cracks are skin injuries that are due to severe drought and repetitive aggressions by the cold, irritant products (detergents), intensive pressures (foot cracks) or repetitive micro-trauma (cracked nipples when breastfeeding). Usually shallow, they must be treated in time to avoid exacerbation and pain.

The solution: Regularly hydrate the skin.

There are a number of hydrating creams. Some are specifically formulated without aggressive components (perfume, conservatives…) to respect fragile skin. They hydrate, relieve and favour skin repair.

Infant diaper rash

Diaper rash is an irritation that alters the superficial layer of the skin. It is localized in the areas that are covered by diapers (bottom, genitalia, and inner thighs) and is displayed by a dry or exuding redness, with or without small spots. In most cases, it is due to the rubbing of diapers against the skin, diapers that are too tight or not enough changed. Contact with urine and faeces also cause a chemical “burn” that is increased if the baby suffers from diarrhoea. The natural protection that is ensured by the skin is disrupted and must be re-established as soon as possible to limit the risks of infection.

What to do?

Avoid all sources of maceration of the skin by leaving the baby diaper free whenever possible. Apply a soothing and protecting cream after every nappy change: Zinc oxide, copper sulphate, dexpanthenol based creams or healing care products that are conceived to repair as soon as possible the weakened skin of the baby. Ask your pharmacist for advice.