Henri Leridon

Europe the continent with the lowest fertility

INTRODUCTIONnAlthough fertility rates are falling in many countries, Europe is the continent with the lowest total fertility rate (TFR). This review assesses trends in fertility rates, explores possible health and social factors and reviews the impact of health and social interventions designed to increase fertility rates.nnnMETHODSnSearches were done in medical and social science databases for the most recent evidence on relevant subject headings such as TFR, contraception, migration, employment policy and family benefits. Priorities, omissions and disagreements were resolved by discussion.nnnRESULTSnThe average TFR in Europe is down to 1.5 children per woman and the perceived ideal family size is also declining. This low fertility rate does not seem directly caused by contraception since in Northern and Western Europe the fertility decline started in the second half of the 1960s. Factors impacting on lower fertility include the instability of modern partnerships and value changes. Government support of assisted human reproduction is beneficial for families, but the effect on TFR is extremely small. Government policies that transfer cash to families for pregnancy and child support also have small effects on the TFR.nnnCONCLUSIONSnSocietal support for families and for couples trying to conceive improves the lives of families but makes no substantial contribution to increased fertility rates.

Seasonal patterns of reproduction in Matlab Bangladesh.

This study explored seasonal variations in reproductive risks and their associated subintervals (fecundability and the conception-wait interval fetal loss risks of resumption of menstruation and the postpartum amenorrhea interval) in Bangladeshs Matlab area. 2368 noncontracepting women from 14 villages were followed in 1975-79. The general fertility rate during the study was 264/1000. Study data indicated that fertility components have a clear seasonal pattern for Matlab women. Risks of conception were high in the spring and risks of resumption of menses were high in November. These risks were elevated for all women regardless of the length of time in the subinterval. Fertility differentials were higher by season than by any socioeconomic variable. Reported pregnancy loss rates were highest in March and October and lowest in November-December. The seasonability of fecundability was only partially explained by variations in the frequency of sexual intercourse. The sexual intercourse data predicted actual fecundability quite well in the cool months but overestimated it in the hot months of the year. Finally comparison of the seasonal patterns of fecundability estimated from observed conceptions and from the sexual intercourse data indicate that there may be environmental temperature effects or nutrition effects on the probability of having ovulatory cycles of fertilization or of early fetal loss.

Realizing a desired family size: when should couples start?

STUDY QUESTION Until what age can couples wait to start a family without compromising their chances of realizing the desired number of children? SUMMARY ANSWER The latest female age at which a couple should start trying to become pregnant strongly depends on the importance attached to achieving a desired family size and on whether or not IVF is an acceptable option in case no natural pregnancy occurs. WHAT IS KNOWN ALREADY It is well established that the treatment-independent and treatment-dependent chances of pregnancy decline with female age. However, research on the effect of age has focused on the chance of a first pregnancy and not on realizing more than one child. STUDY DESIGN, SIZE, DURATION An established computer simulation model of fertility, updated with recent IVF success rates, was used to simulate a cohort of 10 000 couples in order to assess the chances of realizing a one-, two- or three-child family, for different female ages at which the couple starts trying to conceive. PARTICIPANTS/MATERIALS, SETTING, METHODS The model uses treatment-independent pregnancy chances and pregnancy chances after IVF/ICSI. In order to focus the discussion, we single out three levels of importance that couples could attach to realizing a desired family size: (i) Very important (equated with aiming for at least a 90% success chance). (ii) Important but not at all costs (equated with a 75% success chance) (iii) Good to have children, but a life without children is also fine (equated with a 50% success chance). MAIN RESULTS AND THE ROLE OF CHANCE In order to have a chance of at least 90% to realize a one-child family, couples should start trying to conceive when the female partner is 35 years of age or younger, in case IVF is an acceptable option. For two children, the latest starting age is 31 years, and for three children 28 years. Without IVF, couples should start no later than age 32 years for a one-child family, at 27 years for a two-child family, and at 23 years for three children. When couples accept 75% or lower chances of family completion, they can start 4–11 years later. The results appeared to be robust for plausible changes in model assumptions. LIMITATIONS, REASONS FOR CAUTION Our conclusions would have been more persuasive if derived directly from large-scale prospective studies. An evidence-based simulation study (as we did) is the next best option. We recommend that the simulations should be updated every 5–10 years with new evidence because, owing to improvements in IVF technology, the assumptions on IVF success chances in particular run the risk of becoming outdated. WIDER IMPLICATIONS OF THE FINDINGS Information on the chance of family completion at different starting ages is important for prospective parents in planning their family, for preconception counselling, for inclusion in educational courses in human biology, and for increasing public awareness on human reproductive possibilities and limitations. STUDY FUNDING/COMPETING INTEREST(S) No external funding was either sought or obtained for this study. There are no conflicts of interest to be declared.

Ultrasonographically guided fine needle aspiration cytology and core-needle biopsy in the diagnosis of breast tumors

The present study was designed to assess the performance of fine needle aspiration cytology (FNAC) and core-needle biopsy (CNB) of breast lesions when these procedures are performed under sonographic guidance. The results obtained in 1142 FNAC procedures and 180 CNB procedures were analysed. The study took place in a University Hospital and a private practice clinic. The patients eligible for this study were a series of women, in whom at least one hypoechoic, limited mass was found at breast ultrasonography. Cystic masses were excluded from the study. Each individual mass was investigated using either FNAC or CNB under sonographic guidance. Accuracy characteristics to suspect or diagnose malignant and pre-malignant breast lesions, such as sensitivity and specificity, were calculated. The cytological results were classified into four categories according to standard criteria: benign; atypical and/or suspicious for cancer (hyperplasia with atypia); malignant; and unsatisfactory for diagnosis specimen. Tissue specimens were classified according to the W.H.O. The 1142 lesions submitted to FNAC included 66 invasive carcinomas, 4 intraductal carcinomas, and 4 atypical hyperplasias. FNAC led to 6 false-negative examinations, equally distributed between small (volume < or = 1 cm3), and larger lesions, and 1 false-positive examination. There were 12.9% (147/1142) inadequate smears. Only 3 inadequate samples were obtained in the presence of a discrete pathologic lesion (3/363, or 0.1%). All 3 corresponded to invasive carcinomas. The majority of inadequate samples (144/147, or 98.0%) were obtained in the normal/dystrophic group. Overall, the sensitivity is 92.1%, and the specificity is 84.8%. The 180 lesions submitted to CNB included 31 invasive carcinoma, 5 intraductal carcinomas, and 17 atypical hyperplasias. CNB, in this series, had an accuracy rate of 100%. In conclusion, US guidance increases the accuracy of breast tissue sampling procedures. This is of particular importance as the number of suspicious images to be investigated steadily increases, as the result of mass screening.

Cohabitation marriage separation: an analysis of life histories of French cohorts from 1968 to 1985.

As a result of recent changes in marriage behaviour, it is no longer possible to study this subject solely by using information from vital registration and censuses. For instance, in France two-thirds of first unions are not legal marriages, and one-third of first births take place outside marriage. It is, therefore, necessary to collect individual detailed marital histories, such as those that were obtained in the Enquiry on Family Life towards the end of 1985. In the present paper, we consider the conditions under which first unions take place (type of union and age of parties), as well as their eventual outcome (marriage or separation). Successive cohorts of first unions after 1968 have experienced different histories: the transition from the traditional model to the present one has been characterized by discontinuities. In the most recent cohorts (1980-82), marriage is still the most frequent outcome of first unions that began outside marriage (50 per cent marry within the first three years of the uni...

Extra-Marital Cohabitation and Fertility

In France, as in many other Western European countries, attitudes and behaviour regarding marriage have changed drastically over the past 20 years. One of the major changes has been the increasing propensity to begin ones matrimonial career outside marriage: two-thirds of first unions begun in 1983–85 were outside marriage. A special survey was carried out at the end of 1985 to collect detailed information on life-courses for a sample of 4,091 women and men aged between 21 and 44 years. In a previous paper, we focused on the characteristics and on the outcome of first unions, with no account of interactions with fertility, which will be the guideline of the present paper.

The Efficacy of Natural Insemination: A Comparative Standard for Aid

In order to measure the effectiveness of sterility therapy of whatever type, it is necessary to have a reference for comparison. Of course, if it were certain that all che couples undergoing treatment were absolutely sterile, any success obtained, even after years of effort, could be attributed to the effect of the treatment. However, this is not the case in practice. For example, women seeking help for fertility problems who receive hormone medication are most likely not sterile but merely subfertile, the aim of the treatment being to shorten the time required for conception to a more nearly normal duration. Measurement of the efficiency of the method used therefore presupposes the possibility of comparing the results obtained after treatment to values observed in a “normal” population.

Social Inequalities in Access to Contraception in France

Depuis la legalisation de la contraception en 1967, le recours a la contraception medicalisee, et notamment aux pilules de troisieme generation non remboursees, ne cesse d’augmenter. Cette modification du paysage contraceptif a pu generer de nouvelles formes d’inegalites. L’article montre que les inegalites sociales en matiere de contraception en France se sont deplacees de decennie en decennie. Au debut des annees 1980, l’acces a la pilule et au sterilet etait marque par de fortes disparites. Ces disparites se sont par la suite fortement reduites, pour la pilule dans les annees 1990, puis pour le sterilet a la fin des annees 1990. Pour la premiere fois, les donnees de l’enquete Cocon montrent qu’elles concernent desormais l’acces aux pilules de troisieme generation. Ces inegalites d’acces a des produits non rembourses par la Securite sociale semblent resulter, outre du frein financier que represente leur prix eleve, d’attentes differentes des femmes, liees a leur appartenance sociale, ainsi que des comportements des prescripteurs qui varient aussi selon l’appartenance sociale des femmes. Ces nouveaux produits ne semblent toutefois pas etre plus apprecies des femmes.

Patterns of marital unions and fertility in Guadeloupe and Martinique

3 measures of the relationships between union patterns and fertility are compared. The statistics are taken from a fertility survey carried out in 1975-76 in Guadeloupe and Martinique where marriage common law and visiting unions are the 3 types of current union. Fertility achieved at ages 35-49 is 1st broken down by current union status. The highest fertility that of married women is mainly attributable to a longer duration of union life despite a later age at 1st union and a smaller number of partners. Age and union-specific fertility rates are computed; marital rates are higher especially before the age of 30. However this method is somewhat artificial because it ignores indivdual biographies rates having been totalled as if the woman had remained in the same type of union throughout. A typology of union histories shows that only 1/2 the women remain in a single type of union over their reproductive period. This typology is used to study union-specific rates: these rates are recalculated for those women who have been in a single type of union all of their reproductive life. Comparisons with those who experienced unstable union histories show that the fertility of the former group is lower: changes of partner would thus favor a higher fertility. (authors)

Public Opinion on Aid and Sterility

Little data is available on the incidence of sterility at the present time, and what little there is is often difficult to interpret. The statistics quoted here are intended to provide the background for veiwing the opinions on sterility problems and possible solutions which were obtained mainly from responses to a dozen questions posed as part of the census conducted by I.N.E.D. in late 1976, using a representative sample of 2471 individuals. These questions were prepared in a cooperative effort involving the author, the psychosociology department of I.N.E.D.(A. Girard) and the Paris-Bicetre C.E.C.O.S. Center(G. David and P. Huerre). Other aspects of this survey, together with the questionnaire used, were published in 1977.1