CETI featured in Pontos de Vista magazine
The purpose of CETI is to treat patients and solve the problems of couples with infertility. This was the title of an article about CETI published in Pontos de Vista Magazine. Be sure to read this highly relevant article that we share with you here.
Infertility is now a disease recognized by the World Health Organization, with an estimated prevalence of around 15% of the population of reproductive age and affecting a growing number of people in the contemporary world. The scale of the problem requires concerted action by the various entities involved in health and social support, something that is not being done properly.
On this subject, it is important to start by analyzing a scenario, that is, using the latest data released by Eurostat, Portugal, in 2050, three decades from now, will be the oldest country in the European Union, and among the main causes justifying this prediction is a historic drop in fertility rates.
Therefore, it is important to understand and raise awareness in society about this dynamic, which means that it is essential to continue to put on the agenda the urgency of implementing the necessary support so that many couples can realize their dream of starting a family, especially because it is essential that Portugal increases its birth rate, otherwise we will become an increasingly ageing country, where the active population is unable to contribute to the needs and desires of a country that wants to be developed.
In this sense, Pontos de Vista Magazine wanted to know more about the panorama of infertility and fertility in Portugal, to learn about the existing support, the dynamics and initiatives created, without forgetting how innovation and the investment in cutting-edge technologies have been fundamental in this journey, among other important issues.
So, we met with experts in this field and spoke with João Silva Carvalho, Clinical Director of CETI – Center for the Study and Treatment of Infertility and Professor at the Faculty of Medicine of Porto (FMUP), and the author and coordinator of the AFRODITE study, the first epidemiological study on infertility in Portugal, which concluded that 9% of couples are infertile in Portugal, and with Ângela Ribeiro, Director of the Embryology Laboratory at CETI and with Rita Pinheiro Magalhães, Embryologist responsible for oocyte donation.
Today the world has changed, but not in all areas and areas, which was the starting point for this interview, that is, is infertility still a taboo subject in Portuguese society today? João Silva Carvalho acknowledges that this was a problem of the past, but that today it is reasonably outdated. This is if we talk about the so-called urban areas, “because if we go to the inland areas, the panorama changes, as there may still be greater difficulty in facing the problem”, he reveals, “assuming therefore that this fear, in the big cities, has been overcome and today people, thanks to the existing means of information and communication, seek solutions, learn about the problem, research specialists and forms of treatment and medical assistance, among other things”, he states with conviction, not without highlighting that the taboo on issues related to infertility arises in a more personal, familiar and close sphere. “Of course, it is not the same as saying that you broke a leg or a foot. In infertility, inhibitions still exist and people prefer to protect themselves and remain silent because, at times, they continue to feel diminished, especially in the area of social relationships.”
And what is the role of specialists and medical professionals in demystifying this idea? Our interlocutor has no doubts, and highlights that “we, specialists, also have this duty and clarify that pathologies of the reproductive system are the same as diseases of the digestive system, cardiovascular system or others. People cannot, and should not, assume a position of diminishment or inferiority because of this fact”, states João Silva Carvalho.
Promoting the dialogue is important
As we have already mentioned, there is currently a demographic problem in Portuguese society, as the renewal of generations is not taking place at the appropriate levels and pace and this will have an impact in the future, as in the short term, in a European scenario as well, there will not be an active population producing enough.
For João Silva Carvalho, it is important to remember that “average life expectancy has increased a lot and will continue to increase. In several areas of the globe, humanity, at any time in its existence, has never lived as well as it does today, with excellent quality of life levels.
We have reached very positive levels of health and longevity and the evolution will continue to be unpredictable”, says our interviewee, remembering however that although this aspect of longevity and quality of life is positive, it also brings with it difficulties, especially because longevity entails a greater number of elderly people, which will lead to higher costs in terms of health care, making it even more vital to promote and encourage birth rate policies in our country.
The question is, can fertility contribute to this imperative renewal of generations? “We must understand that first it is necessary to create a philosophy and policies in favor of birth rate, so that we can still have, in the medium term, a young and active population and, naturally, if there is dialogue between private companies and the State, fertility clinics can also play an important role in this renewal”, highlights the Clinical Director of the Center for the Study and Treatment of Infertility.
This is why our interviewee, when asked about the existence or not of a recurring dialogue between private entities, such as CETI and the State, regarding infertility treatments, cannot assume that it exists in such a fruitful way, assuming that currently “in terms of clinical practice or healthcare practice, the articulation between the State and private clinics does not exist.
We have to understand that the State has deficiencies when it comes to treating infertility, which is understandable, because in light of the Health Budget policies, it has other priorities than fertility. Serious illnesses such as oncological problems, among others, certainly take on a higher priority in the health sector in Portugal and I can understand that”, he reveals.
Ângela Ribeiro shares the same opinion, ensuring that there is no assistance coordination between the public sector and private entities in Portugal, although she recognizes that there has been a huge effort on the part of the regulatory entity, the National Council for Medically Assisted Procreation – CNPMA, “in establishing targets aimed at the public and private sectors, namely in access to Medically Assisted Procreation – PMA treatments”, added the Director of the CETI Embryology Laboratory.
As a body of the Assembly of the Republic, the CNPMA promotes one or two annual meetings with all public and private centres, which encourages and creates a joint vision of the problems, with a very important role from the regulatory, ethical and normative points of view. The CNPMA is also essential in the guidelines it provides for some procedures and is the only credible national source of information, because it collects all national data on the activity of public and private centres, explains João Silva Carvalho.
“Efforts to try to attract donors to the public and private system”
But are there economic issues related to this lack of coordination between public and private healthcare? Our interviewee has no doubts and admits that there is, but he stresses that it is necessary to look at the problem in more depth and explains. “The success rates of medically assisted procreation treatments decline significantly with advancing age and, for example, no public centres accept couples where the female partner is over 40 years old, as they know that the probability of success is too slim.
I can understand the state’s position, because if that were the case, we would have many people using health treatments that are not very effective, taking away opportunities from younger couples and wasting resources, which is related to financial limitations”, says João Silva Carvalho, corroborated by Rita Pinheiro Magalhães, who recalled that for “the State to be able to carry out protocols with private clinics, the amounts to be paid would be very high and someone would have to assume this expense”.
Donation is defined as a voluntary and altruistic act, although the law provides for compensation for this donation, namely for lost working hours, among other inconveniences, and this applies to both public and private entities. In Portugal, there are currently three public centers that do this: the Júlio Dinis Maternity Hospital in Porto, the Coimbra University Hospital Center and the Alfredo da Costa Maternity Hospital in Lisbon, three locations defined by the CNPMA to work with donors.
So far so good, the big problem, according to João Silva Carvalho, is the difficulty in recruiting donors, “where these three centers, for example, have difficulty in recruiting donors, something I understand, because doctors have a huge workload and cannot be the ones to perform this function”, explains our interlocutor.
Naturally, there have been valid and positive initiatives to change this course, as explained by Ângela Ribeiro, who recalled the launch of the “Give Life to Hope” Platform, “which had a great deal of involvement, including from the Portuguese media, in order to promote this platform, and which is being managed essentially by the Portuguese Society of Reproductive Medicine, which, once again, is a private scientific association. Therefore, there has been an effort to try to attract donors to the public and private systems”, states the Director of the CETI Embryology Laboratory.
The connection to the world of universities
If dialogue between the State and private clinics is still scarce, in the area of universities the outlook is clearly positive, as can be seen from CETI, which attaches great importance to its relations with the so-called knowledge buildings, as it maintains a close relationship with the Faculty of Medicine of Porto – FMUP, a reality that has allowed it, for example, to achieve several distinctions, including the Grant for Fertility Innovation – GFI, won in 2011 in Sweden, where 12 countries and around 40 centres competed, “and it was we, CETI, who won, in partnership with FMUP”, says João Silva Carvalho, revealing that there is currently an understanding in the area of research with FMUP, more specifically with the Department of Biomedicine, through Professor Henrique Almeida, and that has allowed, for example, to carry out several master’s theses and have three doctoral theses in progress”.
Ângela Ribeiro points out that this connection and level of understanding also extends to the publication of scientific articles and collaboration with European centers, giving a specific case. “We have a Belgian center, where one of our collaborators, Ana Catarina Gomes, is involved in a research project that has the strong support of the European Society of Human Reproduction and Embryology, in promoting access to medically assisted procreation treatments, through the innovative application of simpler and more accessible technologies, implemented in countries considered less developed and that do not have the capacity and possibility of having a laboratory structured according to Western canons”, asserts our interviewee.
This initiative is called “The Walking Egg Project” and is currently being developed in several countries such as Belgium, England and China, and in Portugal “we decided to take a break, also because the applicability of the method as a private center that we are, is not possible at the moment,” says João Silva Carvalho.
Infertility – a “game” for two
Going back a little to the beginning of our conversation, and to all the issues in the realm of taboos, we asked our three interviewees whether society today still views the issue of infertility as a problem that only affects women.
Rita Pinheiro Magalhães, assumes that there is still some difficulty on the part of men in admitting that the problem is theirs, remembering that donation is always a “more complicated process in men than in women”, a fact corroborated by Ângela Ribeiro, who remembers that the prevalence of the male factor is quite high and easy to diagnose.
João Silva Carvalho decided to demonstrate this dynamic through numbers. “Most of the time, 60% of the problem is caused by the woman and 40% by the man. But I prefer to put it another way. 1/3 of the problem is caused by the woman, 1/3 is caused by the man and in 1/3 the cause lies in both, because we cannot forget that there is a strong multifactorial component here, as we are talking about a “game” between two people who are always dependent on each other. This point is fundamental”, he explains, ensuring that the woman’s age is the fundamental factor, regardless of the clinical diagnoses, in the success of the techniques.
CETI at the technological forefront
There are many points that make CETI different, with the ability to be close and have a relationship with patients being crucial, as each case is different. We can also follow the path of innovation and the ability that CETI has had in aligning innovation and investing in cutting-edge technologies in the field of fertility to put them at the service of people.
Just look at some concrete examples, as the director of CETI was the main author of the first study on the prevalence of infertility and its causes, through protocols and collaborations with the University of Porto with research capacity that he is carrying out and producing master’s and doctoral theses, and through the connection and collaboration with international centers “we always try to be at the forefront in terms of the applicability of research to the clinic, to the treatment of couples”, highlights the clinical director.
“There is also a great effort to frequently have a member of the clinical or laboratory team participating in congresses and other scientific meetings, thus allowing an exchange and updating of knowledge, concepts and measures”, says Ângela Ribeiro.
When we talk about innovation, it is essential to talk about the technology known as time-lapse. We must understand that despite the technological advances of the last decades, the traditionally used method of morphological selection of embryos was not sufficiently predictive to allow the routine transfer of a single embryo. Therefore, new screening tools have emerged, such as time-lapse technology.
Time-lapse technology applied to Clinical Embryology consists of a non-invasive method of embryo assessment, enabling the Embryologist to more carefully select the best embryos to be transferred to the mother’s uterus. The time-lapse system allows continuous observation of the embryos and, therefore, decision-making without the need to disturb the embryo culture, which can benefit selection, offering a dynamic and detailed view of embryo development to improve success rates. “This way, we can enhance results and minimize stress on the embryo culture,” says Ângela Ribeiro.
CETI has been around for almost two decades and is one of the oldest centres in Portugal, but it has not stood still and seeks to improve and innovate every day. Just look, for example, at the Vitrification area, “which we started doing at a very early stage and was one of the most important advances we have had and which applies to the freezing of embryos and oocytes, and in the oocyte area we had an added difficulty factor because oocytes are large cells and very rich in water.
When so-called slow freezing was applied, ice crystals formed in the oocytes that destroyed the cell membranes, rendering the cell unviable. With the new techniques, this no longer happens and we are able to dehydrate the oocyte and proceed with rapid and ultra-rapid freezing”, reveals João Silva Carvalho, revealing yet another example of how CETI is always committed to innovation.