The crisis of middle age

Today''s emphasis on youth makes it increasingly difficult to accept growing old. The denial of ageing is reflected in society''s attitudes and in the paucity of medical and psychiatric literature on the subject. In the middle years there is the greatest demand for adequate emotional adaptation during a rapidly changing period in life, which frequently involves two people, both separately and together. This paper discusses some of the problems which may be encountered from the psychosomatic, sexual and psychological aspects in the middle-aged man, woman and the couple. It emphasizes the need for the family physician to be aware of these difficulties and to be able to help the patient deal with them. The more successful the resolution of the middle-age crisis, the more contented and peaceful will be the acceptance of old age by the individual.     

Les troubles sexuels à l’origine d’une infertilité sont-ils une indication ou une contre-indication de l’A.M.P.?

The observation of 11 couples requesting MAP and presenting sexual disorders (male or mixed) responsible for infertility, led us to a number of conclusions: sexual disorders are a rare but not exceptional cause of infertility. Sexuality and the couple dynamics must be systematically assessed at an infertility visit. The absence of fertilizing sexual intercourse is not a disease, but a symptom, a body message, which always reflects psychological conflicts. Schematically, two groups can be distinguished: loving couples blocked by a repressed infantile drama or unresolved transgenerational conflicts; couples in which the desire for a child is designed to resolve serious marital dysfunction. These couples require preliminary psychotherapy and/or sex therapy to elucidate the meaning of the symptom with liberation of the couple’s sexuality, or, on the contrary, abandonment of the desire for a child until the marital conflict has been resolved. Medical management must not mask the couple’s absence of sexuality and must not promote dissociation between the sexual act and reproduction, which inevitably has certain symbolic psychological consequences. Management must be based on a multidisciplinary approach avoiding any position of omnipotence, and allowing evaluation of the indication for MAP.     

Do clinical guidelines improve general practice management and referral of infertile couples?

OBJECTIVE--To evaluate guidelines for general practice management and referral of infertile couples. Guidelines were implemented with a disease specific reminder at the time of consultation (the guidelines were embedded within a structured infertility management sheet for each couple). DESIGN--Pragmatic randomised controlled trial. Participating practices were randomised to a group that received the guidelines and a control group. SETTING--82 general practices in Grampian region. SUBJECTS--100 couples referred by general practitioners receiving the guideline and 100 couples referred by control general practitioners. MAIN OUTCOME MEASURES--Whether the general practitioner had taken a full sexual history and examined and investigated both partners appropriately. RESULTS--Characteristics of patients referred by study and control general practitioners did not differ significantly at baseline. Compliance with the guidelines increased for all targeted activities. General practitioners in the study group were more likely to take a sexual history (for example, couples'' use of fertile period, 85% v 69%, p < 0.01); examine both partners (female partner, 68% v 52%, p < 0.05; male partner 39% v 13%, p < 0.01); and investigate both partners (day 21 progesterone, 72% v 41%, p < 0.001; semen analysis, 51% v 41%, p > 0.05). Improvements were greater when general practitioners used the disease specific reminder. CONCLUSION--Receiving guidelines led to improvements in the process of care of infertile couples within general practice. This effect was enhanced when the guidelines were embedded in a structured infertility management sheet for each couple.     

Retentissement sexuel, conjugal et social d’une population d’hommes stériles consultants en Andrologie: le point de vue du psychiatre de liaison

Material and methods

The study population consisted of 39 subjects divided into two groups: 21 azoospermic males and 18 oligoazoospermic males. These men were selected in andrology departments over a period of six months. The andrology and liaison psychiatry departments of Lille university hospital established a general infertility questionnaire. This semi-structured questionnaire comprising 40 questions was based on clinical experience and describes the clinical and symptomatic context of infertility. An individual 50-item questionnaire was then used to analyse the psychosocial, marital and sexual effects of male infertility and the representation of the psychiatrist in the andrology department.

Results

One third of patients discovered the diagnosis of infertility when the biologist gave them the results of the semen analysis. Our patients initially envisaged marital, psychological and social problems, but very few sexual problems. They imagined that infertility was more disturbing for women than for men, from a psychological and sexual point of view. 82% of our subjects imagined that their partner had no sexual problems. 48.7% of them thought that their partner had no psychological difficulties related to their infertility. The oligoasthenospermia group considered that the partner had significantly more “psychological difficulties” compared to the azoospermia group. 41% of our patients felt guilty towards their partner because of their infertility diagnosis. 10.3% of patients presented sexual disorders before the diagnosis of male infertility and 25.6% presented sexual disorders after this diagnosis. Contrary to data in the literature, a major change of sexuality was not observed in the majority of the couples after the diagnosis. When sexuality changed, it generally consisted of a reduction of the frequency of sexual relations. Among the patients who reported sexual difficulties, only 40% related them to infertility. 50% did not report any relationship between the psychological difficulties related to infertility and the sexual difficulties. Contrary to the data in the literature, neither the loss of spontaneity during sexual relations, nor the complementary investigations necessary for artificial insemination had any influence on sexuality. 89.8% of our patients are ready to change their sexual practices in order to be more fertile without causing any sexual or psychological problems. However, only 34.3% of patients reported a concern about reproductive efficacy during sexual relations. A more marked sexuality/reproduction dissociation was observed in oligoazoospermic males than in azoospermic males. 28.2% of patients reported that talking about their sexual and/or psychological problems with a psychiatrist was helpful.

Conclusion

Many contradictions and underestimations were observed in the answers to the questions. We confirmed the existence of a psychological and sexual distress, but which was quantitatively less severe than that described in “gynaecological” populations. However, a real psychological and sexual distress does exist in our population, which is why we propose from the outset a psychosomatic and sexological treatment of infertility in order to prevent the onset of these sexual difficulties. Our questionnaire was based on clinical experience and helped our patients to identify their psychological and sexual difficulties related to infertility and its treatment. It would therefore be useful for the practitioner, andrologist or psychiatrist, to help the patient express the effects related to this “new medicalized sexuality”.     

A massive ovarian mucinous cystadenoma: a case report

Background  

Infertility is defined as inability of a couple to conceive naturally after one year of regular unprotected sexual intercourse. It remains a major clinical and social problem, affecting perhaps one couple in six. Evaluation usually starts after 12 months; however it may be indicated earlier. The most common causes of infertility are: male factor such as sperm abnormalities, female factor such as ovulation dysfunction and tubal pathology, combined male and female factors and unexplained infertility.     

The appeal to nature implicit in certain restrictions on public funding for assisted reproductive technology

Certain restrictions on public funding for assisted reproductive technology (ART) are articulated and defended by recourse to a distinction between medical infertility and social infertility. We propose that underlying the prioritization of medical infertility is a vision of medicine whose proper role is to restore but not to improve upon nature. We go on to mark moral responses that speak of investments many continue to make in nature as properly an object of reverence and gratitude and therein (sometimes) a source of moral guidance. We draw on the work of Ludwig Wittgenstein in arguing for the plausibility of an appeal to nature in opposition to the charge that it must contain a logical fallacy. We also invite consideration of the moral plausibility of some appeal to nature. Finally, we examine what follows in the case of ART. Should medicine respect as natural limits that should not be overcome: the need for a man and a woman in reproduction; menopause; and even declining fertility with age? We must first ask ourselves to what degree we should defer to nature in the conduct of medicine, at least in the particular if not the general case. This will involve also asking ourselves what we think is natural and in what instances and spirit might we defy nature. Divergent opinions and policies concerning who should receive ART treatment and public funding are more easily understood in view of the centrality, complexity and fundamental nature of these questions.     

Profil spermiologique des hommes infertiles au Mali

Infertility remains a major sociocultural problem in view of the fact that in Africa, in general, and in Mali, in particular, the main purpose of marriage remains procreation. The birth of a child is a source of joy and contributes to maintenance of a certain harmony in the home. In Africa, infertility is a dramatic problem that is difficult to bear for the couple. It is the leading cause of marital discord or divorce. It is considered to be due to fate, or a curse inflicted on the couple. For the woman, it represents a divine punishment, as it is usually the woman who is blamed for the problem male responsibility is only discovered during assessment of the couple’s infertility. Sperm count and sperm cytology are the basic examinations performed on semen. These examinations constitute key elements to evaluate the quality of semen. In Mali, the Cytogenetics and Reproduction Biology laboratory performs the greatest number of semen examinations in the country. The purpose of this study was to present the sperm profile of infertile men in Mali based on a 5-year retrospective study. Male infertility is a public health problem in Mali. The age-group most frequently affected is between 30 and 39 years. Primary sterility was the predominant form, observed in 70% of the subjects studied. Schistosomiasis plays a predominant role in the infectious history. The sperm count results show that cases of oligoasthenozoospermia and azoospermia represent 49.5% and 23.7% of the study population, respectively.     

In vitro fertilization and the right to reproduce

The assumption that people have a right to have children is considered in relation to the question of whether society has an obligation to allocate resources to make clinical in vitro fertilization available, at least to married couples where the woman is infertile and the couple provides the ovum and sperm. The author analyzes various issues that need to be addressed: the distress that accompanies infertility versus the fact that infertility is not a life- or health-threatening condition; the distinction between basic needs or desires on the one hand and claim rights on the other; the extent of the obligations that affluent societies have to fund other services related to the bearing and rearing of children; the costs and benefits of relieving infertility through IVF versus other means; and the concept of compensation to one who has been injured or harmed unjustly, here by the involuntary loss of reproductive capacity.     

Haploinsufficiency of cytochrome P450 17alpha-hydroxylase/17,20 lyase (CYP17) causes infertility in male mice

Cytochrome P450 17alpha-hydroxylase/17,20-lyase (CYP17) is critical in determining cortisol and sex steroid biosynthesis. To investigate how CYP17 functions in vivo, we generated mice with a targeted deletion of CYP17. Although in chimeric mice Leydig cell CYP17 mRNA and intratesticular and circulating testosterone levels were dramatically reduced (80%), the remaining testosterone was sufficient to support spermatogenesis as evidenced by the generation of phenotypical black C57BL/6 mice. However, male chimeras consistently failed to generate heterozygous CYP17 mice and after five matings chimeric mice stopped mating indicating a change in sexual behavior. These results suggested that CYP17 deletion caused a primary phenotype (infertility), probably not due to the anticipated androgen imbalance and a secondary phenotype (change in sexual behavior) due to the androgen imbalance. Surprisingly, CYP17 mRNA was found in mature sperm, and serial analysis of gene expression identified CYP17 mRNA in other testicular germ cells. CYP17 mRNA levels were directly related to percent chimerism. Moreover, more than 50% of the sperm from high-percentage chimeric mice were morphologically abnormal, and half of them failed the swim test. Furthermore, 60% of swimming abnormal sperm was devoid of CYP17. These results suggest that CYP17, in addition to its role in steroidogenesis and androgen formation, is present in germ cells where it is essential for sperm function, and deletion of one allele prevents genetic transmission of mutant and wild-type alleles causing infertility followed by change in sexual behavior due to androgen imbalance.     

Effect of queen number on the production of sexuals in natural populations of the fire ant, Solenopsis invicta

ABSTRACT. To determine whether the production of sexuals in the fire ant, Solenopsis invicta Buren, is related to queen number in the field, the numbers of sexuals in monogyne (M) and polygyne (P) colonies of this species were compared. Large colonies ( n =25 M and 25 P) were collected at random during spring, summer and fall when sexuals are actively produced, and the numbers of sexuals present were counted. The numbers of alates plus sexual pupae and larvae in M colonies far exceeded those in P colonies in each season. Significant differences between M and P colonies were also found when the numbers of alates and sexual immatures (pupae + larvae) were compared separately in each season. In addition, M colonies contained significantly more female sexuals (alates + pupae) than did P colonies in the summer and fall, and significantly more males in all three seasons. The negative relationship between queen number and number of sexuals provides evidence that queen control over the production of sexuals, previously established in laboratory experiments, also occurs under natural conditions.     

Women's mating strategies

What does a woman want? The traditional evolutionist's answer to Freud's famous query is that a woman's extensive investment in each of her children implies that she can maximize her fitness by restricting her sexual activity to one, or at most, a few high-quality males. Because acquiring resources for her offspring is of paramount importance, a woman will try to attract wealthy, high-status men who are willing and able to help her. She must be coy and choosy, limiting her attentions to men who are worthy of her and emphasizing her chastity so as not to threaten the paternity confidence of her mate. The lady has been getting more complicated of late, however. As Sarah Hrdy¹ predicted, we now have evidence that women, like other female primates, are also competitive, randy creatures. Women have been seen competing with their rivals using both physical aggression^2,3 and more subtle derogation of competitors.⁴ While they are still sometimes coy and chaste, women have also been described recently as sexy and sometimes promiscuous creatures, manipulating fatherhood by the timing of orgasm^5,6 and using their sexuality to garner resources from men. The real answer to Freud's query, of course, is that a woman wants it all; a man with the resources and inclination to invest, and with genes that make him attractive to other women so that her sons will inherit his success. Her strategies for attaining these somewhat conflicting aims, and her success in doing so, are shaped by her own resources and options and by conflicts of interest with men and other women.     

La stérilité d'origine immunologique.

Antispermatozoal antibodies in the woman, the man, or both, may be the cause of nonorganic infertility in a small number of couples. The antibodies are most often found in the serum or in the genital fluids. Diagnosis is based on the postcoital test and on various laboratory tests to assess sperm-cervical mucous compatibility and to detect antispermatozoal antibodies. In women the strongest relation between results of laboratory tests and infertility is between the presence of serum antispermatozoal antibodies and infertility of more than 3 years'' duration. In men there is a relation between high levels of these antibodies in the semen and infertility. Various treatments have been proposed, but further prospective studies are needed. However, promising results have been reported with homologous intrauterine insemination and with immunosuppression in men.     

The gift of motherhood: Egg donation in a Barcelona infertility clinic

In this paper we analyse the ways in which egg donors from a private infertility clinic in Barcelona try to render their new experience meaningful. Donors are striving to see their action as a contribution to the creation of a particular kinship bond – motherhood in another woman – by means of the abrogation of a bond that also looks very much like kinship, which links them to the individuals that will be born thanks to their eggs. The specific meaning that egg donation has for each donor varies according to her particular circumstances, but the language constructed in order to convey this meaning emerges from the creative expression of several cultural paradoxes and dichotomies that constitute, in themselves, an original and highly significant cultural grammar.     

Risk factors for male to female transmission of HIV. European Study Group.

OBJECTIVE--To identify risk factors for sexual transmission of HIV from infected men to their female sexual partners. DESIGN--Cross sectional analysis as part of a continuing study. Data were obtained by interviewing heterosexual couples in which the man was infected with HIV. Risks were assessed by comparing couples in which transmission had occurred (woman infected with HIV) with those in which it had not (woman not infected) and estimated by independent odds ratios and their 95% confidence intervals. SETTING--Infectious disease and public health departments from nine centres in six European countries. PARTICIPANTS--153 Male index patients (mean age 30.4 years) and their 155 female partners (mean age 27.8 years). INTERVENTIONS--Women were tested to determine their HIV antibody state. Women with a risk of infection with HIV other than sexual contact with their infected partner were excluded. END POINT--Three risk factors for male to female transmission of HIV. MEASUREMENTS AND MAIN RESULTS--Three risk factors were identified: a history of sexually transmitted disease in the previous five years for the female partner (odds ratio 3.1, 95% confidence interval 1.1 to 8.6); index patient with full blown AIDS (5.4, 1.2 to 25.2); and practice of anal intercourse (5.8, 2.3 to 14.8). The proportion of women positive for HIV antibody was 27% (42/155), ranging from 7% (1 to 13%) (4/60) for couples with none of the three risk factors to 67% (45 to 89%) (12/18) for those with two or three of the risk factors. Duration of the relationship (median three years), frequency of sexual contacts, sexual practices other than anal intercourse, and contraceptive behaviour were not associated with infection of the partner. CONCLUSIONS--The risk of sexual transmission of HIV from an infected man to his female partner varies considerably according to the characteristics of the couple. The differences in rates of transmission in high risk groups may be considerably reduced if the risk factors are taken into account during individual and public health counselling.     

Are men more promiscuous than women?

In spite of the unassailable logic that every new coital partner a man has is also a new partner for the woman concerned, men typically claim more sexual partners than women. If these claims are correct, can prostitutes and other hypersexual women account for this slippage? The present study examines whether the incidence of such women is sufficient to explain the discrepancy in number of lifetime partners claimed by men and women.     

LOSS OF SEX IN CLONAL POPULATIONS OF A FLOWERING PLANT,DECODON VERTICILLATUS (LYTHRACEAE)

The loss of traits that no longer increase fitness is a pervasive feature of evolution, although detailed studies of the genetic, developmental, and evolutionary factors involved are few. Most perennial plants practice both sexual and clonal reproduction, and it has been hypothesized that populations with little sexual recruitment may lose the capacity for sexual reproduction by fixing mutations that disable one or more of the many processes involved in sex. The clonal, tristylous aquatic plant, Decodon verticillatus, exhibits marked geographical variation in sexual recruitment. Populations at the northern limit of the range are usually monomorphic for style length consist of single genotypes, and produce almost no seed, due, in part, to environmental conditions that inhibit pollination, fertilization, and seed maturation. Controlled crosses in a greenhouse provided evidence for greatly reduced sexual capacity in an exclusively clonal, monomorphic population. Plants from this infertile population produced only 3–18% as many seeds per pollination as fertile populations. Observations of pollen tube growth indicated that infertility is due to severe reductions in pollen tube numbers both early after pollination and later when pollen tubes were traversing the ovary, due primarily to the inability of pistils to support normal tube growth. A three-year greenhouse experiment comparing fertility, survival, and growth of F1 progenies produced from reciprocal crosses between plants from the infertile population and those from nearby fertile populations suggested that the genetic basis for infertility is simple and may involve a single recessive mutation. In addition, the results did not reveal any association between infertility and other aspects of survival and vegetative vigor. The infertile genotype was likely fixed in the population through founder effect rather than indirect selection resulting from antagonistic pleiotropy or direct selection of advantages associated with reduced investment in sexual reproduction. A broader comparison of sexual fertility in 15 clonal, monomorphic populations and five genotypically diverse, trimorphic populations under greenhouse conditions revealed substantial infertility in all but one monomorphic population. Populations varied somewhat in the stage at which infertility was expressed, however, pollen tube growth was impaired in all populations. These results provide strong support for the hypothesis that complex traits like sex are degraded by mutation when they no longer increase fitness.     

Birds Do It. Bees Do It. So Why Not Single Women and Lesbians?

Infertile couples have come to take assisted reproductive technologies (ART) for granted. An increasing number of single women and lesbian couples also desire to have children and turn to ART, especially donor insemination, to fulfill this desire. While most married couples find that access to ART is limited primarily by the ability to pay, for single women and lesbian couples, the story may be much different. In the United States, they may find that doctors and infertility clinics view their desires as immoral and refuse to accept them as patients, although other doctors and clinics readily accept them. In most other countries, however, it is against the law for single women and lesbian couples to make use of ART, including donor insemination.
In this paper I will argue that marital status and sexual orientation should not serve as a barrier to accessing the world of reproductive medicine. I will base this conclusion on two arguments. First, that justice requires that we treat like cases alike. Just as we would not accept or reject patients for cardiac rehabilitation programs based on factors such as a history of poor eating habits, so too we should not look at nonmedical factors such as marital status when deciding whether to treat infertility. For the second justification for the conclusion of equal access to ART, I will examine the concept of the family. I will argue that it is morally acceptable for single women and lesbian couples to have children and to head families.     

Birds do it. Bees do it. So why not single women and lesbians?

Infertile couples have come to take assisted reproductive technologies (ART) for granted. An increasing number of single women and lesbian couples also desire to have children and turn to ART, especially donor insemination, to fulfill this desire. While most married couples find that access to ART is limited primarily by the ability to pay, for single women and lesbian couples, the story may be much different. In the United States, they may find that doctors and infertility clinics view their desires as immoral and refuse to accept them as patients, although other doctors and clinics readily accept them. In most other countries, however, it is against the law for single women and lesbian couples to make use of ART, including donor insemination.
In this paper I will argue that marital status and sexual orientation should not serve as a barrier to accessing the world of reproductive medicine. I will base this conclusion on two arguments. First, that justice requires that we treat like cases alike. Just as we would not accept or reject patients for cardiac rehabilitation programs based on factors such as a history of poor eating habits, so too we should not look at nonmedical factors such as marital status when deciding whether to treat infertility. For the second justification for the conclusion of equal access to ART, I will examine the concept of the family. I will argue that it is morally acceptable for single women and lesbian couples to have children and to head families.     

Stable linkage disequilibrium owing to sexual antagonism

Linkage disequilibrium (LD) is an association between genetic loci that is typically transient. Here, we identify a previously overlooked cause of stable LD that may be pervasive: sexual antagonism. This form of selection produces unequal allele frequencies in males and females each generation, which upon admixture at fertilization give rise to an excess of haplotypes that couple male-beneficial with male-beneficial and female-beneficial with female-beneficial alleles. Under sexual antagonism, LD is obtained for all recombination frequencies in the absence of epistasis. The extent of LD is highest at low recombination and for stronger selection. We provide a partition of the total LD into distinct components and compare our result for sexual antagonism with Li and Nei''s model of LD owing to population subdivision. Given the frequent observation of sexually antagonistic selection in natural populations and the number of traits that are often involved, these results suggest a major contribution of sexual antagonism to genomic structure.     

Medicinal plants as potential male anti-infertility agents: a review

For millions of couples, the inability to have a child is a personal tragedy and a large proportion of childless people are confronted with social stigmatization (blame) and personal frustration. Formerly assigned to women, infertility of a couple is nowadays equitably distributed between the two sexes. Among the methods used to treat male infertility problems, medicinal plants have been used empirically as extracts, decoctions, fractions or semi-purified compounds. These herbal products are used in the treatment of a dysfunctioning of the libido, sexual asthenia, erection, and sperm disorders. Pharmacological activities of many of these plants have been shown in vitro using cells, in vivo (on laboratory animals) and human studies. For instance, extracts of Panax ginseng, Panax quinquefolius and Lepidium meyenii have shown positive effects on sexual desire; while extracts of Astragalus membranaceus, Asparagus racemous, Withania somnifera, Andrographis paniculata and Acanthopanax senticosus improved sperm parameters. Plants provide a treatment option that is affordable and available for infertile couples, and phytotherapy is an essential form of treatment in our health system. However, herbal products are still anarchically used in many regions and countries, and a great proportion of medicinal plants used traditionally to solve male reproductive disorders have not yet been scientifically evaluated. Therefore in this review, we have summarized most of the data dealing with the effects of plant extracts on mammalian reproductive functions.