Fertility is increasingly, not only in Italy, a central theme for today’s society, where – with some exceptions – the cradles of states are increasingly emptier every year. A health issue certainly but also a political and social one. We asked Carlo Bulletti, Specialist in Gynecology and Obstetrics, former president of the Italian Society of Fertility, Sterility and Reproductive Medicine (SIFES-MR) and currently Adjunct Associate Professor at the Dept Ob/Gyn and Reprod Science of the Yale University, what the causes are, some advice for a natural conception and also what to do if the baby is late in arriving.

There has been talk of declining fertility for years now. What are the most frequent causes?
We must make an obligatory premise. As is known, the balance of births in Italy is negative for some years and will be negative for several more years, in the context of a world population that has more than tripled in the last 80 years but which has been declining again for 10 years. With a exception: AfricaThat in 30 years it will be the most populated continent (also from Asia and China). Fertility is decreasing wherever economic conditions are growing, because with comfortable conditions no one anymore wants the burden of looking after many children, due to what they take away from the rest of their lives, since today – unlike yesterday – a lot of attention needs to be dedicated to it. Today we have a fertility index of 1.2 children per woman while to maintain a constant population number we should have 2.2 children per woman’s lifetime. The problem is not of primary health (with the exception of some forms of male infertility) but of social customs and conditions of support for pregnancies, France docet.

Between most frequent causes we must count a cause not attributable to illness, but rather to age which has its own efficiency being optimal up to the age of 35, then a slight drop to 37, another drop to 39 and a more rapid drop from 39 and above. This efficiency is based on a genetic cause: oocytes have a potential to generate euploid (healthy) embryos of 65% at less than 35 years, 55% at 35-37 years, 35% at 38-40 years, 25% at 41-42 years and 15% at > 42 years old (Ata B et al., 2021) and in a poorly computable extra genetic. The average age of women who as a couple turn to assisted reproduction centers in Italy is over 37 years. Ergo, they are already subfertile regardless of the cause of infertility. It should be remembered here to those who believe that the search for offspring is a desire and not a necessity and its care an amenity and not a right, that “infertility” is defined as a disease first by the United Nations, and then by the World Health Organization (since the 90s) and more specifically “a condition of psycho-physical suffering” and as such a disease which – constitutionally – would be worthy of treatment.

Speaking of numbers. What is the right age for a couple to start looking for a child, wanting to take advantage of the maximum possibilities of natural conception and, perhaps, even having more than one child planned?
In an Anglo-Dutch epidemiological study the following was established: if a couple wants to have a child with a 90% probability of having one must start looking for it when the woman is 35 years old or youngerin case of any in vitro fertilization was an acceptable option. For two children must start at 31 years old and for three children at 28 years old. In case the option of in vitro fertilization was not acceptable they should start to try to get pregnant at 32 for a childto 27 years old for two children and from 23 years old for three children. If you accept that you only have a 75% chance these search start dates can move 4-11 years.

What is the evolution of fertility over the years in women? And in humans?
Age has its own reproductive efficiency being that:
a) the female germ cells (oocytes) have a reservoir at birth but have a variable speed of decay (apoptosis) with exhaustion of the gametogenic function long before the decay of all the other cells (somatic) of the body.
b) has a negative incidence as the same age progresses, regardless of the genetics she carries through her oocytes. We therefore have good efficiency up to 35 years of age, then a slight decline up to 37, another decline up to 39 and a more rapid decline from 39 onwards. In the’man There are many different causes of infertility but age plays a minor or at least not so stringent role as in women.

What are your tips and advice for increasing your chances of conceiving naturally?
• Have certainty of ovulation and one presence of adequate sperm population;
• Avoid basing your reproductive choices on tests of little use as the sonosalpingoscopy;
• Set up a relationship life that is not spoiled either by the urgency of targeted relationships or by the need to do portable ovulation tests on urine or saliva, but by have relationships when they come they come, possibly a couple a week, maximum 3;
• If you have a BMI suggestive of overweight or obesity establish a path, with the help of a healthcare professional, for one reduction of this weightuseful for the treatment of sterility and for the conduct of pregnancy itself;
Stop or limit smoking, alcohol, and other abuse;
• Diagnose presumption of endometriosis with your consultant (algorithm by C. Chapron predictive at 90% probability) and implement medicalization which may slow down the progression of the disease or, in rare cases, operate;
• Diagnose normal endometrial cavity, free and without polyps or myomas;
• Careful anamnesis on the possible causes of previous pelvic inflammation/infection;
Dose, on the 3rd day of the cycle, an AMH and FSH to evaluate the ovarian reserve (and with these how much haste one should have to start treatment) and lo state of ovarian responsiveness to pituitary signals;
• Finally, always keep in mind, in choosing a center together with your trusted doctorwhat the HFEA – English Society for Sterility – writes on its website on the “Choose a fertility clinic” page: “A great fertility clinic isn’t just one that can give you effective treatment, it’s one with compassionate staff, clear pricing, seamless administrative processes and exceptional emotional support.” effective, is the one with compassionate medical staff, a clear pricing policy,
continuous administrative processes and exceptional emotional support).

The months pass and the pregnancy does not arrive. What is the path that a couple can take to search for a child, turning to fertility centers?
When I 12 months have passed since the search for a child who does not arrive (6 months for women over 37), it is good to ask yourself why and look for a “free” and “independent” professional (not employed in any network but freelancer), with a good CV and good reputation, to work with counseling and start a diagnostic path to understand the causes and treat the problem. At 360°, not only necessarily with in vitro fertilization but also with this. Who is clear about the medical practice scenarios in Europe, the advantages and limitations of the procedures proposed as indications, clearly distinguishing solutions from national or foreign-driven commercial recalls. Not letting yourself be fooled by paid sirens of new Italian or foreign players. The times that elapse between becoming aware of a sterility problem and the implementation of solutions to resolve it constitute a parameter inversely proportional to the success of the treatments (Read the article: How time to healthy singleton delivery could affect decision-making during infertility treatment: a Delphi consensus, RBMO 2018)

Which fertility center to choose?
From the birth of Louise Brown to today, things have changed a lot. The public plants started in the 80s and 90s had the foresight of the politics of the time in foreseeing this reproductive health problem which affected 20% of the population and whose solution has led today – only in our country, with the existing plants reported the Istituto Superiore di Sanità – al 3-4% of newborns with in vitro fertilization techniques. But the health policy was not enough and the public facilities are few, poorly structured and poorly powered: often conducted with management logics of structures with low technical-organizational complexity while being highly complex; often led by directors of simple units and often deprived of a 360° management of the sterility problem (including surgery); almost all of them are in serious difficulty and with few prospects given the resources invested today. If you have to wait 12 months for a procedure and you are 38 years old, yours is not an offer of treatment but a sentence. If you are a candidate for gamete donation and have to wait two years, you are not a beneficiary of public assistance but you receive a crude invitation to desist from it. In private everything had started well with traits of virtue and vice, compensated. Where private individuals have an agreement, in the Regions with an appropriate fee (Lombardy), the treatment values ​​have been acceptable for years, while in those regions where the fee paid by the Regions was low the value of the treatments was poorer, as the property is a profit and not a Caritas of reproduction.
And being paid little per cycle, he had to earn in other ways to support himself. The possible deduction is rather easy to make. Centers had been formed in the private sector, among which those with at least 200 cycles per year were identified, equipped with an adequate case-mix and sufficient autonomy from hetero impulses of clinical and laboratory management. Then the advent of large financial groups attracted by the large global business that moves 22 billion dollars a year, with the merging of various centers into two or three large centers characterized – all – by the imprinting of a management aimed at reducing costs, maximization of profits and return to the market after 5 years with multiplication of profits compared to the purchase. This is in line with the objectives of large funds which must account to their shareholders for investments but not always with the necessary pursuit of lines of good medical practice produced by high profile doctors. Thus they monopolized the market by establishing pernicious rules of conduct (such as transfers of cryopreserved embryos with endometrial preparation through segmented hormone replacement therapy, without the use of natural cycles, or through gamete donation packages with guarantees of transfer of one or two blastocysts without no reference to the number of oocytes supplied at a higher cost than the previous one of 10 oocytes but with a lower yield) and by establishing powerful and aggressive marketing policies with ventriloquistic medical testimonials of the companies that we see in the media more than Vodafone advertising, or with promises of results unattainable, profiting from the emotional fragility of these couples. In my opinion, centers to be avoided by default today. It therefore remains for couples to identify a competent doctor with an adequate CV and good reputation who must be informed first, and decide together only afterwards, on the diagnostic therapeutic path to follow and the most suitable place to pursue it. Regardless of the media pressure of these large groups which mislead, in my opinion, from choices consistent with the primary interests of couples. Without any more hope in the recovery of a public health system that is already too exposed on other fronts and which continues – foolishly – to consider reproduction not a primary need, its treatment not a right but an amenity. While it is one of the many stones missing in the reconstruction of the building of positive demographic trends.