40 years ago, on February 24, 1982, France discovered "its" first "test-tube baby", a little girl named Amandine, in the line opened by Louise Brown, born in the United Kingdom on July 25, 1978.
These births have had a very strong impact on our collective imagination: for the first time, the fertilization of an egg by a spermatozoon could be obtained outside the woman's body, within a test tube in the laboratory, that is to say "in vitro" according to the technical term. The technique of in vitro fertilization (IVF) was born.
To measure technological progress, it must be remembered that at the time, medically assisted procreation (PMA) consisted solely of "artificial inseminations" (AI), that is to say depositing the Spouse's spermatozoa (IAC) or a Donor (IAD) at the level of the cervix or the uterine cavity so that they can naturally fertilize the oocyte in the woman's body, in vivo.
After the birth of Amandine, the history of IVF continued far from the media tumult. Where are we today and what has happened during these four decades?
Nearly 3% of children are conceived by IVF in France
Before the Covid-19 health crisis, IVFs in 2019 enabled the birth of more than 21,000 children. In relation to the number of births in the population, this represents almost 3 out of 100 children conceived by IVF (2.9%). In other words, on average, if you have a group of 34 children born in 2020 (mostly corresponding to conceptions in 2019), one of these children was conceived by IVF.
The impact of artificial inseminations is much lower (less than 6,000 children conceived in 2019), but the overall sum of these techniques leads to more than 27,000 children conceived following assisted reproduction in 2019, i.e. a proportion of 3, 7% of children conceived by PMA among French births. On average, among a group of 27 children born in 2020, one of these children was conceived by PMA.
The figures on LDCs for the year 2020 have not yet been published by the Biomedicine Agency. Nevertheless, a sharp drop is to be expected since the assisted reproduction centers closed their doors during the first confinement during the health crisis. Their activity gradually resumed from mid-May 2020, but the impact of the energizing of hospitals, in particular public ones, was probably a brake on the achievement of the PMAs.
40 years of almost linear increase in IVF
The figure below represents the evolution of the proportion of children conceived by IVF (red curve) and the proportion of children conceived by ART including IVF and AI (blue curve). Between 1981 and 1985, approximately one thousand children were conceived through IVF. After this start-up period, IVF progressed almost linearly. The proportion of children conceived by IVF increases by +0.5% every 7 to 8 years.
Evolution of the proportion of children conceived by medically assisted procreation in France.
This almost linear increase in IVF probably reflects the combination of several phenomena. Initially, of course, this technique had to be “diffused” among the population, that is to say, it had to be known and accepted. But its continuous progression over four decades calls for other explanations.
A first explanation is based on technological developments which have made it possible to broaden the “indications”, ie the type of infertility that can be treated by IVF. Indeed, initially, IVF was designed to respond to female infertility of tubal origin (altered or blocked fallopian tubes). It was quickly used for other indications, and its extension experienced a new dynamic from 1992 with the arrival of a new IVF technique for treating male infertility: the intra-cytoplasmic injection of sperm (ICSI). ICSI consists of selecting a spermatozoon which is introduced directly into the oocyte. Initially used for so-called “severe” male infertility, IVF with ICSI (or ICSI) is now very widely used since in 2019, two out of three in vitro fertilizations carried out in France were done with this method.
Beyond these technological aspects, the growing use of IVF undoubtedly reflects above all greater needs in the population.
On the one hand, scientific work warns of a possible alteration of human fertility in connection with exposure to industrial and agricultural pollutants, or tobacco for example. Such an alteration in fertility could be likely to lead to a higher frequency of infertility and therefore to greater recourse to assisted reproduction. On the other hand, demographers observe later parenthood. However, fertility decreases sharply with age, so that couples encounter more difficulties in having a child at older ages and therefore resort more often to assisted reproduction. Thus, in France, in one decade (2008-2017), the use of all infertility treatments (stimulations excluding PMA and PMA) has increased by 24% among women aged 34 and over, whereas remained stable in younger women.
More than 400,000 children conceived by IVF in 40 years
With this dynamic of recourse to IVF, what demographic assessment can we draw forty years after the birth of Amandine? The IVF carried out during the first twenty years (1981-2000) globally enabled the birth of 100,000 children. The movement then amplified since the birth of the next 100,000 children was obtained in just 8 years of activity (2001-2008). This period is further shortened for the next 100,000: 6 years (2009-2014), and finally 5 years (2015-2019). The IVF carried out between 1981 and 2019 therefore allowed the birth of 400,000 children overall. These French births are to be placed in the global dynamic where the number of children conceived by IVF was estimated at more than 8 million over this same period.
Behind this global global figure hides a high variability in the use of ART from one region to another, and from one country to another, including among European countries. There is no simple explanation for this high variability, it is likely that it partly reflects the cost of treatments borne by couples, the health care offer, the fertility dynamics of the country and the age at birth. parenthood. The level of recourse to assisted reproduction also seems to be correlated with the level of inequalities between men and women in the country: the lower these inequalities are (according to the gender inequality index of the United Nations), the more the recourse to assisted reproduction is developed. The study highlights the need for more research to better understand the meaning of this correlation.
The number of children conceived by IVF currently also includes children born following IVF carried out during the year 2020 and those carried out between January and May 2021. The disruptions linked to the health crisis weaken the projections that can be made, but by retaining Assuming a 30% decrease in IVF activity during the year 2020 and a stable activity in 2021 compared to 2019, this leads to an estimate of 420,000 children conceived by IVF in France on this fortieth anniversary of Amanda.
Cumulative number of children conceived by in vitro fertilization in France.
This increase in the number of children conceived by IVF is all the more notable since this number was formerly amplified by the phenomenon of multiple births, and since this phenomenon is in sharp decline. Thus, in the 1990s, 130 children were born for every 100 deliveries obtained following IVF. These multiple births were linked to the desire to increase the chances of obtaining a pregnancy. For this, doctors transferred a lot of embryos, often 4 or more at a time (39% of cases in France in 1988).
These practices were quickly called into question because of the risks to the health of children resulting from these multiple births. To reduce these risks, doctors gradually reduced the number of embryos transferred, going first to three embryos (about 40% of cases in 1997) then to two embryos (about 60% of cases in 2009), to finally transfer only one embryo (60% of cases in 2019). Currently, there are no more than 107 children per 100 deliveries following IVF, a frequency which remains even higher than that observed in the case of a pregnancy obtained without medical aid (101 children per 100 deliveries). This sharp reduction in multiple births has not, however, resulted in a fall in the number of children conceived by IVF, since the continued increase in the use of IVF largely offsets this effect.
LDCs invisible in statistics: LDCs abroad and outside medical settings
In the collective imagination, assisted reproduction is often associated with the idea of using a third party donor to have a child, whether through a donation of sperm, eggs, embryos (when those of a couple are taken in by another couple), or by calling on a surrogate mother (GPA). However, the reality of assisted reproduction in France is very far from this a priori idea: almost all children conceived by assisted reproduction (i.e. by IVF or AI) are conceived with the gametes of their two parents ( almost 95% of children conceived by assisted reproduction in 2019).
In the case of assisted reproduction with a third party donor, it is mainly a donation of spermatozoa (approximately 1,000 children conceived with sperm donation per year). Births by egg donation have increased sharply in recent years, but were still only 400 following the PMAs carried out in 2019 (compared to 200 children following the PMAs of 2013 and 100 following those of 2006). The reception of embryos is statistically negligible (37 children following the receptions of 2019), while surrogacy is prohibited in France.
Behind this use of assisted reproduction with an apparently very limited third-party donor in France hides a reality that is invisible in the statistics: French children born from assisted reproduction performed abroad or from so-called friendly assisted procreation (artificial insemination can practiced outside a laboratory because of its relative technical simplicity, and surrogacy on the basis of an agreement between the individuals outside the legal and medical framework).
Currently, there are no reliable data on the number of children born as a result of these LDCs. Despite the new bioethics law of 2021 opening PMA to single women and couples of women, it is likely that this phenomenon will continue. However, a call is currently underway (see image below) for people who have practiced PMA abroad or outside the French medical framework to participate in a scientific study carried out in collaboration with the associations accompanying these courses.
Scientific study, AMP sans frontières of INED.
From the testimonies collected in the questionnaire available on the Internet, it will be possible to provide initial data on these LDCs, but also to make visible these experiences and paths to forming a family.
_This text takes up and updates certain elements published by the author in 2018 in the journal Population and Society, n°556, "1 in 30 children conceived by medically assisted procreation in France".