The only contraceptive product that remained legal under French legislation of 1920 was the condom, which kept its place in the market because of its efficacy against venereal disease. Legislation of November 1987 governs manufacture, importation, marketing, and free distribution of condoms in France. Condoms sold in France must meet specific conditions for size, form, strength, packaging, and labeling. With 110 million units distributed in 1992, France represents 3.9% of the world market. The 61 approved brands of condoms are all imported. Only natural latex condoms are currently approved. Measures to increase condom use in France for AIDS prevention may focus on increasing accessibility or increasing acceptability. During the 1980s the principal factors limiting condom use were reported to be interference with sensation, interruption of coitus, the association of condoms with prostitution, and the negative attitude of physicians. The increased use of oral contraceptives, which largely replaced condoms in France, allowed men to disengage themselves from contraception. The decline of condom use has probably increased the difficulty of its reacceptance. Condoms are used primarily by young persons and those with multiple partners, but even in these groups usage should be increased. The efficacy of condoms must be evaluated in different ways. Condoms are impermeable to sperm and apparently to the AIDS virus, although apparently some smaller viruses are not barred. Neither the efficacy in vivo of spermicides used with condoms nor the greater efficacy of condoms with reservoirs have been demonstrated. Failure rates for condoms are very difficult to evaluate and depend greatly on motivation. Two recent studies of couples with one HIV seropositive and one seronegative partner indicate that systematic and correct condom use prevents HIV transmission.
In most deuterostome eggs, a transient increase in the intracellular free calcium concentration (Cai) occurs after fertilization and is essential for egg activation. How one spermatozoo triggers this calcium signal remains an enigma. In the light of our own results, we suggest a model, leading to the calcium signal and common to invertebrate and mammalian systems, where phosphorylation on tyrosine and phospholipase C gamma (PLC gamma) are interconnected pathways stimulated by a multimolecular complex involving integrins.
Some cases of infertility considered inexplicable have been found to have an immunologic basis. Spermatozoa are highly antigenic cells. When the state of immune tolerance is disrupted, auto-immunization in the man or isoimmunization in the woman can occur. The appearance of antibodies directed against the sperm antigens results in a condition of hypofertility more than of absolute sterility. Numerous antigens have been identified on sperm using monoclonal antibodies. Immunosuppressive substances have been isolated in the seminal liquid in vitro, and various other protective mechanisms have been identified. Autoimmunity apparently results from failure of the protective processes. Physical, chemical, or infectious trauma may explain the entry of immunocompetent cells. The most commonly used techniques for study of antisperm antibodies are those that detect antibodies directed against surface antigens. Sperm agglutination tests have been criticized for their numerous false positive findings and their failure to identify the classes of immunoglobulins implicated. Tests of immobilization or cytotoxicity are specific, with no false positives, but not sensitive, giving rise to false negatives. The Mixed Antiglobulin Reaction Test (MAR- test) is very specific, easy, inexpensive, and rapid, but it only detects IgG and determination of the place of fixation is difficult. The immunobead test proposed in 1982 overcame some of the limitations of the MAR-test. These two are the methods of choice in exploration of male autoimmunity. Radioimmunologic techniques, an ELISA-type test, and others have given less satisfactory results. The frequency of antisperm antibodies has been estimated at 3 to 15% in nonselected infertile men, 35% among men with some symptoms or a history of the condition, and less than 1% among fertile men. The antisperm antibodies have functional significance only when they are fixed to their antigens. Modifications of sperm mobility are the main problem, with blockage of transport to the oocyte and union with it. It is difficult to establish a prognosis because evaluation must be done individually. As the level of antibodies increases, the chances of spontaneous pregnancy decline. Several treatments have been developed but results have been disappointing. In vitro fertilization after separation of motile sperm without antibodies may improve the prospects of pregnancy.
The relationship between endometriosis and infertility is not clear despite a large literature. 30-40% of women with endometriosis are infertile, compared to fewer than 10% in the general population. A direct relationship has never been proven, but numerous physiopathological hypotheses have been advanced to explain such a relationship. The role of severe forms of endometriosis in infertility is clear and there is consensus concerning treatment. In cases of destruction of the ovarian parenchyma by voluminous endometriomas, drug treatment is not sufficient and laparoscopic removal of the cyst is required. In cases of complete bilateral obstruction of the proximal tubes, drug treatment is usually disappointing and surgery or in vitro fertilization is required. Treatment choice for nonobstructing lesions is less clear. The role of small polyps and isolated localized diverticuli is doubtful. The most difficult treatment problems arise in cases of minimal to moderate endometriosis. Several cycle anomalies have been reported. In order to establish causality, such effects must be studied hormonally and sonographically for at least six consecutive cycles. Several potential mechanisms have been suggested to explain such effects, including hyperproduction of prostaglandins, hyperprolactinemia, anomalies in luteolysis, and biphasal LH peak, among others. Peritoneal endometrial implants may cause an aseptic inflammatory reaction and an antigenic stimulation leading to increased volume of peritoneal liquid, elevation of prostaglandins in the peritoneal liquid that then cause other problems, augmented number and activation of peritoneal and tubal macrophages with various effects, or auto-immune type responses. Associated male infertility factors may play a role. If endometriosis is a cause of infertility, pregnancy rates should be increased by specific treatment. Efficacy of different treatments was evaluated in a meta-analysis of 25 studies. Systematic destruction of lesions during laparoscopy appeared to offer the best results. In vitro fertilization may be proposed in severe forms or associated male infertility. The results have been similar to those for other indications, except possibly in severe and extensive forms characterized by diminished retrieval of oocytes. It is possible that endometriosis does not explain infertility except in forms severe enough to alter pelvic anatomy.
The encouragement to use condoms meant by the late 1980's, this method of contraception had come to reveal the contraceptive pill as the leading method in the United Kingdom. This swing from a medicalized method to a very readily available, non-medicalized method was superimposed on a trend of shift in contraceptive provision by family planning clinics to provision by general family doctors. The rate of women attending community family planning centres declined, and among those attending these clinics, the rate of condom users increased. Simultaneously, in England and Wales (where statistics on abortions are done every year) the number of unwanted pregnancies increased, the acceleration being noticeable in the mid-1980s. Two studies show that these unwanted pregnancies are frequent in young women using condoms; those women are likely to abandon condom use after such experience. The pill-condom, "Double Dutch", should reduce the number of unwanted pregnancies.
