Shaping Our Future
The subtitle or theme of these conferences is always, and sometimes even unintentionally, significant. In this case, ‘shaping our future’ could refer to how young couples might shape their fertility by relatively simple lifestyle measures. Or, it may refer to how the professionals “shape” up to the increasingly complex demands of ART and all those HFE add-ons in fertility units.
At a more worrying and societal level, it may also imply the need for governments and healthcare providers to ‘shape up’ to global fecundity challenges (AKA falling fertility and birth rates almost worldwide).
And finally, as well, we all have to “shape up” to the inevitable consequences of declining fertility, specifically to the health and wellbeing of the next generation.
This conference was notable for three very significant invited lecturers, from people of great standing, learning and knowledge. The first of these was my friend Professor Richard Lea from Nottingham University, who gave the eponymous Anne McLaren lecture. The title was ‘Born Exposed’. This pointed to the ubiquitous chemicals in the environment that are known as environmental chemicals, or more specifically as endocrine-disrupting chemicals. He pointed out the effects of the mixtures of these chemicals and that it was very difficult to define a single agent, except in research terms, but he gave a very well reasoned and clear argument for the effects of exposure to these chemicals on our reproductive health. He used the excellent analogy of guide dogs, whose environments are well controlled until they go to live with and help their new owners, and of course at this stage they are exposed to the same environmental chemicals as are their owners and the rest of us, and as the generational gap is far less than with humans, it allows the possibility of exploring between the generations the measurable effects on the dogs’ fertility. So one can get the effect of environmental exposure in three generations of guide dogs which would have taken more than fifty years to explore in three generations of humans and, surprisingly enough, these environmental effects seem to be very similar. So, once again, we cannot prove in an evidential sense the deleterious effect of the environment, but the associations are so strong that they can no longer be ignored.
The second, excellent presentation was by Professor Niels Jørgensen. This was looking at semen quality and lifespan. This presentation was first given in the ESHRE conference in July of last year, and there were only slight modifications in this particular presentation, but once again the kernel of the issue is that the Danish healthcare system managed to follow 78,284 men for the best part of 50 years, and the findings were that as the parameters of the semen analysis got worse, then the healthcare outcomes were worsened across the board. These healthcare outcomes included more hospital admissions, higher rates of cardiovascular disease and stroke, higher rates of hospital admission for fractures, higher rates of certain cancers including specifically colon cancer and high-grade prostate cancer. Once again, cause and effect is difficult to prove and Professor Jørgensen was, as many academics are, a little reticent to point to more than an association, but if one is dealing with 78,000 men followed for that length of time, it is difficult to see how you could get more data and larger datasets which would translate better into evidence. Of specific interest was the fact that the worst healthcare outcomes (but we should point out that this only included a reduction in overall lifespan of approximately five years) were in men who were diagnosed with azoospermia. Professor Jørgensen did point out that this particular diagnosis was perhaps not as precise as it could have been in terms of classifying obstructive, nonobstructive and genetically related.
Finally, great credit must be given to my friend and colleague John Aitken who gave the eponymous Bob Edwards Memorial Lecture. The title of John’s presentation was ‘Declining global fertility and our future dependence on ART’.
This was a masterful presentation building upon John’s lifetime work in charting the effects of declining male fertility and increasing DNA damage to sperm. John has long had regard for the effect on the next generation and this lecture took us into the effects on the generation after that, because of course for whatever reason that male fertility is declining, there will be epigenetic and therefore transmissible defects to the next generation. It matters not that we cannot precisely measure these. What matters more is that we have regard for the possible consequences of what we are doing now.
John also combined the physiological and biological fertility effects with the undoubted economic effects of a reduction in worldwide birth rate and fecundity, because of course if there is a sensible and responsible resolution amongst an increasing number of couples only to have a small family, then across a community or population the important effects of natural selection are inevitably lost, once again adding some damage to the pool of favourable genetic characteristics. Whether or not we are in fact enhancing the less favourable characteristics is once again almost impossible to measure, but it is not impossible that the consequences of our economic success, coupled with our reproductive failure, have created a perfect storm for future generations.
It is certainly important not to end this blog either as a diatribe or as a doleful story like the Handmaid’s Tale. This is because elsewhere in the conference, there were many signs that we are beginning to understand properly some of the puzzling features of fertility failure which have confounded everybody’s best attempts at proper diagnosis. It is undeniable that the power of AI will not only produce algorithms to direct better management, but that also in terms of diagnoses, particularly those that touch on genetics (accompanied by future prospects of gene editing), it will help us all to understand, so that the all too commonly heard refrain ‘ICSI (plus or minus another variety of add-ons) will sort it out’ will become a thing of the past.
So I wish all of you, current patients, past patients or future patients, all the best, either with your families or with your current or future treatment, and I will of course as always, with the help of Alison, do my best to accommodate your appointments in good time.
