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What is the future of fertility?
Professor Brian Cox and our expert panel explore the science of fertility.
Biology has come a long way, but when it comes to fertilisation, pregnancy, and development, our knowledge is still surprisingly limited.
In this episode, a panel of researchers, scientists, and ethicists discuss emerging technologies that could shape the future of fertility and pregnancy. They also tackle audience questions on declining sperm counts, egg freezing and the ethics of genetic screening.
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Brian Cox: Hello, I'm Professor Brian Cox. Welcome to A Question of Science, recorded at the Francis Crick Institute here in London. This is the podcast where a panel of experts tackle your questions on the biggest scientific challenges facing society today. From what is consciousness? To can we build a human, who owns space? And every debate is framed by you.
Now, today we're talking about fertility. The fertility rate is falling globally. Here in the UK we've hit our own all time low. The average age of new mothers and fathers has been steadily rising and both are now in their 30s. Now, given that fertility declines for women in their 30s what does the future look like? And what might science have to offer? I'm joined by four experts who can help us get to the answers and they are.
Joyce Harper: Professor Joyce Harper, from the Institute for Women's Health at UCL, around the corner.
Güneş Taylor: Dr. Güneş Taylor, Developmental Biologist at the University of Edinburgh.
Naomi Moris: Dr. Naomi Morris. I'm a group leader here at the Crick, studying embryonic stem cells and how they can help us understand human development.
Lucy van de Wiel: Hello, my name is Lucy van de Wiel, and I am a senior lecturer at King's College London. I focus on the social study of reproductive technologies and wrote a book about egg freezing.
Brian: And this is our panel.
Now, Lucy, I thought I'd start, I said an introduction that fertility rates are declining, so what are the main reasons why that's the case today?
Lucy: As you also mentioned, the fertility age at which people have their children, their first children, but also children on average is going up quite significantly. So now in this country it's for women about 31 years old, for men, about 34 years old. Of course, reproductive ageing is a bigger issue for the women. Their chances of conceiving decrease particularly after the mid 30s.
And also with men, if they get older, their testes become softer and they get fewer sperm and they are less motile and less successful at creating a conception, but they still have a chance of conceiving much later in life.
Brian: So Joyce, that was an outline of some of the reasons why fertility is becoming a problem for many people. What are the standard treatments as of today?
Joyce: The main treatment that people probably heard about is in vitro fertilisation. And I started my career when I finished my PhD as an embryologist, working in one of these fertility clinics and working in the lab and doing all the magic that happens. Then I ended up being the other side of the table and had my three children by IVF. It is quite involved for people to go through and I spent a lot of time crying when I went through it myself.
It's quite easy to get the sperm from the man. You can think about how that happens really easy. They go into a little toilet, very glamorous with a little pot and do their magic there. But for women to get the eggs, we have to get the eggs out of the woman. We have to stimulate the woman. She has injections and then she has a minor surgical operation to remove those eggs. The embryologist will look after and nurture those eggs and sperm. Hopefully they'll help create some embryos and then those embryos can be transferred to the woman and then we hope that she gets pregnant.
But the success rate in the UK for IVF, even if you are under 35, which is the optimum group of patients we like to see in the clinic, you've got a just over 30% chance of getting pregnant if you are young. If you are over 35, so between 35 onwards, your chance of getting pregnant each month goes down and down very rapidly. By the time you get to your early 40s, the chance of getting pregnant by IVF is just a few percent. And by 43, 44 it's zero. It's almost impossible to get pregnant by IVF, which definitely reflects what happens naturally.
So IVF is the main technology. We've got things like egg freezing, we've got genetic testing, but we're gonna talk about all of those later on.
Brian: And that decrease is to do is to do with the egg. So Güneş, your area. Could you give us a brief introduction to the biology of the human-
Güneş: Yeah, of course. With pleasure. The fun fact about the female ovary is that I think most of us will have heard the phrase "you're born with all the eggs you're ever gonna have". Yeah, I'm seeing some nodding, that's great.
For human females that's true. You're born with all the eggs you're ever gonna have. Each ovary is estimated to have about 1 million eggs stored in a sleep like state at birth, about a million of them per ovary, okay? And the average age of entering the menopause, which is the time at which you effectively run out of eggs, no longer can be fertile, is about 52. So any of you who are quicker than me at maths will be thinking, well that doesn't quite add up because doesn't the average female ovulate one egg per month per cycle? Sometimes you can ovulate two and that's how sometimes twins happen. But on the whole you have one egg that's good enough to go every single month.
Now the fun fact about female ovaries is that for every one egg that is ovulated, you unfortunately have to bring a 1,000 eggs out of dormancy and then they all start growing. And I describe it a little bit like "The Hunger Games," because only one gets out at the end, right? 999 of them don't make it. So it's remarkably wasteful. There's a lot of losses in the process.
And the second fun fact that most people don't know is that this process starts from the moment you're born in fact. So you can't ovulate eggs obviously until you reach puberty. But that's because eggs take a long time to go from their dormant state in which they're stored during early embryonic development to being mature enough to be ovulated. Again, in humans that's estimated to take about a year, which should make you appreciate your mothers a little bit more because they were busy growing the egg that became you for a year before that point.
And so basically you're born with a million, they start activating immediately in batches of about a 1,000. And by the time you reach puberty, you've actually depleted 50% of what's called your ovarian reserve, that first starting pool. So you're down to about half a million and that's why from half a million onwards 1,000 at a time, you'll end up at about 50 years.
Brian: And as Joyce described, why is there that decline in the success of IVF?
Güneş: There's two main reasons for that. One of them is to do with the fact that these eggs are put into long-term storage. Before you are even born, those eggs are set aside if you're a female. Okay? So those eggs sit there for decades and they sustain environmental insult basically. They get damaged. That's why the IVF rates that Joyce is talking about is predicated on the age of about 35.
There's also the rate at which you use these up. And so I said about a 1,000 a month and about a million. There is some natural fluctuation between people basically as to how many you have to begin with and how fast you deplete them and various other health conditions also interface with that kind of stuff as well as lifestyle. And so it's all very approximate and realistically nobody knows how many eggs they have, nor how many of them are good enough. And that's the other dark side of IVF and these fertility things that we don't talk about, which is ultimately you could have many eggs but they might not be good enough for a live birth.
Brian: And then Naomi, we talked about fertilising the egg, but your research is in embryonic development. So after fertilisation and you use a technique using something called model embryos. So could you give us an outline of your research?
Naomi: Yeah, of course. So I think one of the problems with fertility is of course you have to make an embryo when you're doing IVF, you put the sperm and the egg together, you form a very early embryo in the clinic and we don't necessarily know how to grow those embryos properly. We don't know why they fail to give live births when we implant them back into women. We don't know why sometimes the embryo doesn't implant properly and that leads to early miscarriages and we don't know why certain malformations of the embryo can lead to congenital abnormalities. So there's a huge amount that we just don't understand about the early embryo.
And of course the best way to study the early embryo would be to look at embryos. But there are all sorts of challenges associated with studying human embryos in particular. So there are ethical challenges, there's challenges of getting access to them. But there's also, in the UK there's a rule against using embryos beyond 14 days in culture. And after that point is when the embryo does a lot of its interesting stuff. It's when it starts to form the body plan, it's when it starts to organise. And really that's the time that we would like to be able to understand better.
And so the approach that we take is to use pluripotent stem cells. So these are cells that have the ability to make all of the cells of the body. And you can either get them from early embryos or embryonic stem cells or you can reprogram cells back to that state. So you could take a skin sample or hair sample or blood sample and reprogram them back so that they're in a kind of embryo like state. And I guess the magic is that when you put those cells together in culture, so in a dish in some fluids, but allow them to be in suspension. And what they end up doing really remarkably, is that they end up forming something that is a little bit like an embryo. And so we call these embryo models, although they haven't come from sperm and egg, they've come from stem cells.
Brian: Wonderful, and I think we're gonna talk a bit more about that later on in response to a question which brings me neatly to the first audience question.
Sim Scavazza: Hello, my name is Sim Scavazza. What is the best stage for a woman to freeze her eggs and how safe is it? Does egg freezing empower women given that it allows them to remain economically active during the prime of their lives? Or being a commercial enterprise could it exploit women too?
Brian: Joyce, you'd like to take that?
Joyce: Yeah, so in the main, in the UK the average age women are freezing their eggs is age 38. And that does worry me because they are now in that age range I talked about where the fertility rate is really going down. So I would say that if a woman wants to freeze her eggs, she should really do it under age 35. There is a little bit of a difference between 30 and 35 for example. And we just don't know that. We do not have any tests to say 'you are super fertile', 'you are fine', 'you can wait another five years', 'you're not, you better do it'. Now we don't have that test. So I would say somewhere between 30, maximum 35 is optimum.
Brian: Lucy?
Lucy: I think there's... You always have to balance a number of different risks when you freeze your eggs, right? So you can do it early and so maybe as Joyce suggests then you have better chances biologically, although the decrease in fertility doesn't happen that much earlier on, say if you're 25 and you're going to go through egg freezing, which as Joyce explained is effectively the same as IVF, you're gonna have to inject yourself between two to five weeks. You need surgery and you need a lot of money for it. So in London for example, it's about £4,000 to do it at that age. And you may not need it at all because it's very hard to know in your 20's whether in five or 10 years time you're going to have the conditions that are important for you to have a child. So you run the risk of medicalising your own concern really early on.
And when we talk about the commercial companies, there seems to be a trend particularly by companies that are focusing on egg freezing to try and encourage that early egg freezing. Because that means that you can get a much broader group of women, but also that it guarantees income year on year because you need to pay the storage fees every year. So if you are freezing your eggs for 15 years, you're gonna have to pay every year that storage fee because you don't really wanna throw them away, right? However, on the other hand, if you do it much later then you might have to do many more cycles to get the same amount of eggs. You might get eggs that don't actually fertilise.
But just to round that off, if you can freeze embryos, that's maybe a better idea. 'Cause you already know then whether your eggs are good enough to fertilise and embryos freeze a lot better than eggs. So if you freeze eggs, you might lose some in the freezing and thawing process. But if you can fertilise them straight away, you don't lose as many. The downside is that you then need to know where the sperm comes from. So if you have a partner, you may break up, then you get an issue about, you know, does he still want you to have those embryos? Maybe he wants the embryos, you know, that's gonna be part of your settlement. So you get more security early on with your success. But there are of course social consequences in terms of who the genetic father is going to be.
Joyce: As Lucy said, with the egg freezing, we still need to do the injections and the surgical procedure. And that is really, really traumatic 'cause we're injecting ourselves with high levels of hormones and it's really an emotional rollercoaster. So I think in the media they portray both IVF and egg freezing as really easy procedures. This is becoming plan A. I don't want my students at graduation to march off to the fertility clinic and freeze their eggs at age 25 as they think this is a guarantee that they're gonna have a baby. There is no guarantee that it's going to make a baby at the end.
Lucy: I've had students from the US who came up to me and said that at their career fair there were stands for internships to be, you know, to go into medicine or into law and then stands for egg freezing next to that. If you wanna go down there then you know you can come and freeze your eggs as well, so you can make sure you can focus on those things. And a lot of the information that's on offer reflects the fact that it's expensive to get people's attention and the people who have the money to do that are the people who are investing or have something to gain to share that information.
So often that's through ads or information days, you know, done by people who are effectively marketing but presenting the marketing as education. So I mean, Joyce is doing a great initiative on fertility education, but we need to have some kind of literacy as we do with every part in our lives at the moment to see where the information that we're consuming comes from and who stands to gain from the message that's being shared in there.
Brian: Well thank you. So let's go to the next question.
Jenny Jiang: Hello, my name is Jenny Jiang. I'm heard about a hypothetical scenario where a woman's menopause could be delayed, thereby creating an extended period of fertility. If this is possible, would it be preferable to use eggs frozen earlier in life, in one's 20s or early 30s rather than the eggs that were produced during this extended period of fertility given the risk of chromosomal abnormalities will increase with maternal age?
Brian: Thank you, so Güneş.
Güneş: Thank you so much for your question. So I don't think that anybody is suggesting that we should delay the menopause to try and get better quality eggs for longer because frankly that isn't going to happen, right? From the hard biological facts that we just told you. So the longer an egg sits there, the longer it is damaged by the sands of time basically.
And so even if we find ways to delay the menopause, you would not be well advised to use an egg that has sat there for 48 years and you should probably still consider using an egg in the sort of 30 to 35 year range ideally. But I think it's really important for us to also address the fact that there's a question of like why, right? Why do we want to delay the menopause? And for those of you who can't see us in the room, somebody is shaking their head.
Brian: Well I wonder whether Joyce is agreeing or disagreeing.
Joyce: I'm disagreeing.
Brian: Oh, disagreeing.
Joyce: Yeah.
Do you want me to go for it? This is one of my things.
Brian: Please.
Joyce: One of my things. Okay, any postmenopausal women in the room who want to delay, like keep your hands up. Who wants to delay the menopause and keep carrying on with your periods and your menstruation and your menstrual cycle? A few of the hands went down, right?
I have a real thing, I've done a lot of work with postmenopausal women and they tell me that this phase of their life is the best, most fantastic. The hands are going up. Hooray. No, it's not gonna be for everyone. I know we're ageing, but many women will tell you this is the best time of their life. They feel more powerful, stronger.
Brian: If I'm right, where you agree is that it in specifically about the question of fertility it is not in any way desirable on that specific question, but for many other reasons that you mentioned to delay menopause, that is not an answer.
Güneş: I think that if you are pre-menopausal, the menopause is like Damocles's sword hanging over your head, right? Especially in these times where we are expected to have careers, right? It's a race against the clock. That's kind of, I think for me at least that was what the question was kind of capturing. And that's also why there's this appeal to the narrative of like, can we delay the menopause, right?
It's actually not meant to throw shade on the menopause, but rather it captures an anxiety about the fact that females are running against a clock, they're running outta time. And I think it's really, really important to acknowledge the fact that in this day and age, so many of the careers that women have been encouraged to go for, the career progression moment and the moment where your eggs are at their best and or going past their best clash, they coincide.
Brian: Well actually part of the discussion is about older eggs. And we have a question specifically on that.
Jennifer Franich: Hello, my name's Jennifer Franich. Are there any advances in genomic science that could improve the viability of eggs in older women in future?
Güneş: Yes, this was a really cool paper that came out recently actually. So this is still very exploratory. You remember I said that you're born with all the eggs you're ever gonna have and they're dormant, right? They're stored in these structures called follicles where they have supporting cells around them that look after them.
And there was a very recent paper that came out that showed surprisingly if you take eggs from older females and then remove their supporting cells and replace them with younger supporting cells, there was some evidence to demonstrate that there was some rejuvenation occurring. So this is all very like, you know, early stage research stuff and I'm sure that we can develop tools to turn back the time for these kinds of eggs. But the real question is do we actually need those tools? And I think that that's something that we should all think about a little bit.
Brian: In terms of these technologies, Naomi, the things you're finding out about embryonic development, would they be related to these technologies that we'd like to develop?
Naomi: Yeah, I mean I think that the, you know, the egg quality is a really important factor in live birth rates, but it's not the only factor. And of course you, once you've made the embryo, there's not a guarantee that that embryo is going to lead to live birth. You've still got to get through early development, you've got to implant correctly, you've still got to get it through the rest of development without any problems. And so there are lots of technologies that are coming out to try and improve that whole process.
So for example, these embryo models that I was talking about earlier where we use stem cells to try and model early development. One of the benefits of using stem cells is that we can make thousands of- tens of thousands of these models. So obviously embryo research we're limited in the numbers that we can get. We can't do screens to effectively work out the best way of culturing embryos, but with embryo models you can chuck some chemicals on them, you can change the way that we grow them in the lab. We can try and adjust conditions so that we can get better quality embryos. So when those embryos are implanted back, they can hopefully have a higher chance of success. So that research is going on at the moment that should be in the clinics fairly soon and hopefully it slightly improves year on year the IVF success rate.
Brian: So we've talked about eggs and sperm, but mainly about eggs so far. We do have a questionnaire about sperm.
Lyn Lacey: Hello panel, my name is Lyn Lacey. We hear that the male sperm count is on the decline. How much is this a factor in the fertility issues that couples commonly face?
Brian: Joyce, you'd like to take that?
Joyce: Yeah, so there is many reports, it's quite controversial, that the male sperm count is decreasing when that will have an effect on our population, it's not in the wings at the moment, but Lucy did say that the quality of the sperm does decrease. So over the age of 40, partners have more chance of miscarrying. It can take longer for them to get their partner pregnant if they have a younger partner, it doesn't affect it quite so much.
Brian: Lucy?
Lucy: Yes, and also that's where we get back to the social aspect that many on average people in heterosexual couples have older male partners. So men are an average three years older in their partnerships. Whereas if women are having children later or those couples having children later, women should be dating younger men so they can get more chances of conceiving.
So if you are on the older side of reproduction and think, oh I don't have a partner, I'd like to have one to have a child with, opt for the younger man so you have a better chance or opt for younger donation, donor sperm, which is generally younger anyway and it's well tested.
And of course the downside is if the sperm isn't of great quality, it's the woman who has to undergo IVF. So we see that 20 to 30% of couples who come to the IVF clinic have a male factor reason for being there. But it is the woman who needs to undergo that whole IVF cycle as a result to mitigate male infertility. So it's still a major issue in that sense.
Brian: So Reithian advice there, go for the younger man.
Güneş: I was gonna say, I mean speaking as an individual now rather than professionally, I think that that's really important though to flag that there is a substantial proportion of people who undergo IVF because of male factor infertility. And I think, you know, to the point about the question, I think it is kind of important that we talk about fertility as not just being 'a female problem', basically.
I personally think a good number of women end up having to do IVF and egg freezing because males think that they have endless time and they don't want to make those decisions and they don't have to, according to them. And so therefore by changing the dialogue to being a bit more like, well fertility is an all of us problem. It makes it a little bit more pertinent for the male side of the population to also engage. If I may be so bold as to say. Thank you, yeah.
Brian: If you'd like to applaud, you're welcome to applaud. So we now have a question about IVF treatment and embryonic screening.
Shahid Rowles-Khalid: Hi panel, my name is Shahid Rowles-Khalid. My question is, how might artificial intelligence be used for IVF treatment in the future? How will the balance be struck between selecting traits that enhance the health of the embryo to present, prevent disease with those that enhanced traits like intelligence and strength?
Brian: Naomi, you could set the scene in terms of screening embryos and what we can and can't achieve.
Naomi: Yeah, I mean there's a lot of options out there. There has been some research into imaging of early embryos. To try and predict whether we can tell just by looking at an early embryo which ones are likely to be a lead to successful births or not. It's been shown by the HFEA and Joyce I know has been working on that. But actually that's no better than just not doing it, right? It has no sort of tangible impact on the success rates of IVF. So in that sense, imaging them possibly not.
Whether AI and those sorts of technologies might help us better select which ones are going to lead to live offspring is kind of yet to be seen. I guess the question is, is also kind of genetic, right? Can we select genetic traits that would lead to particular features? And I think we have to be really careful there. 'Cause of course genetics is very clear when it comes to eye colour or hair colour, but very, very obscure when it comes to really complex traits like intelligence, which I think was mentioned by the question. So we should really be very cautious about anyone suggesting we could select for complex genetic traits like that.
Joyce: So, I worked on this procedure, the main procedure that we use at the moment called pre-implantation genetic testing for decades of my career. And how we do this, we take those embryos that I was talking about when they're- What they do nowadays is do it at what we call the blastocyst stage, which is about day five of development when the embryo's made up of about 120 cells and we just what we call biopsy a few of those cells, about five of those cells. And then the geneticists at the moment can do quite a lot. It's really improvement. When I started doing this in the '90s, we could just look at cystic fibrosis and we could sex the embryo to see if it was male or female. Now we can do a growing number of diseases.
So if a couple are at risk of transmitting a specific genetic disease to their child like cystic fibrosis or beta-thalassemia or sickle cell, that test now has become quite routine and it's governed by our authority, the HFEA, Human Fertilisation And Embryology Authority in the UK.
But we are now doing this because the parents desire a boy or a girl that's being done worldwide in many, many clinics, not in the UK, it's illegal and in Europe. But also there are clinics now that are offering maybe your predisposition to height, eye colour is one that's being offered. Your predisposition to diabetes or to cancer or to heart disease. And I put predisposition because these are multifactorial genetic diseases and you may never get them. And we are really on the cusp now of being able to measure the full genome of an early embryo before we implant it. So where that will go.
And for those old enough to have seen the film 'Gattaca' where everyone in the film was reproducing that way because it was economically more important to eliminate so many diseases from our future offspring, well we are on the cusp now of being able to do that. And I think genome editing is somewhere bubbling under as well. What about if the couple didn't have the right genetic makeup to want the child they desired. Maybe they wanted a very sporty child or a very musical child. Well would people want to just edit their embryos so that they can have their desired child? Who when they grew up probably never wanted to be a pianist, they wanted to be a footballer. And that brings in lots of social issues about where we go with the future of fertility.
Brian: There are two parts to this ones there's the ethical parts and the scientific parts. As you mentioned, Naomi, well you said, playing the piano for example. You mentioned in passing that we're a very, very long way away from being able to identify genetically even I suppose height maybe I don't know what?
Naomi: Yeah, I mean some of these really complex traits, there's no real evidence that it's possible at the individual level to ever predict from genetics those sorts of traits.
Brian: So just eye colour, yes.
Naomi: So very simple things. 'Cause obviously a gene encodes a protein and when that protein codes for something like the sort of pigmentation in the eye, that's a very easy one-to-one relationship, right? The genetics is... Or many to one, Güneş is nodding now. relatively simple to unpick at the genetic level. But when we're talking about characteristics, personality traits, I mean that's so much more than genetic.
Güneş: I think that there's this real appeal that we have that technology gives us control against the face of the chaos of biology. And you have to ask the question, is that the right tool? And do we really care that much about it, that we're gonna do that, you know?
Joyce: People will, because there's lots of money in it. So, the about the question is about AI as well, and I've just come back from Switzerland where I talked about the future of AI in reproductive health and we are not there at the moment, but people are talking about it. You mentioned imaging earlier, about imaging embryos, and there's this term that one of my colleagues said in his talk, which was "garbage in, garbage out".
And the trouble with any AI is we have to program it with information that's going to help us with our outcome. And embryology is not binary. And also fertility's not binary. So there are many, many factors that the... Even for female fertility, there's the egg, there's the womb, we've got the sperm and what the sperms doing. We've got the womb, we've got the health of the woman. There are thousands of different variables that affect whether that couple or woman will have a baby.
We've got technology that doesn't improve live birth rate. If we put that into the AI, is the AI really going to make anything better? Because that's not good data. It's not improving live birth rate. But maybe the AI will figure out something, some connections that we can't figure out. But it is all complex. I think we really need to be very careful in the next five or 10 years about where we go with AI and the future of fertility.
Brian: Well we do have a question from the audience that speaks directly to some of the issues that you raised, Joyce.
Lorna Jacobs: Hello, my name is Lorna Jacobs. I had a number of miscarriages at between eight to 12 weeks after a successful pregnancy. Is there any progress being made on understanding what causes these early miscarriages?
Joyce: The reason why someone has a miscarriage is really complex and it could be the genetics of the egg and the embryo or it could be something to do with the womb and hormonal. There's many, many reasons. So people are doing lots of work on this, but I think we're going very, very slowly unfortunately, which is terrible for the one in four people who have a miscarriage.
Brian: And Naomi, this was a question specifically about the eight to 12 week period in development.
Naomi: Yeah, and we just know so little about it. I mean, thank you for the question. I think we need desperately to understand early human development. We just don't have a really good way of exploring questions like that. Why is it that some embryos fail to implant or that they start implanting and then can't complete the process? Why is it that some embryos begin to form and then aren't able to kind of sustain their own development?
And of course for people who experience miscarriage, they often don't get answers to that question. They don't necessarily know why that's happened to them or whether it's a genetic cause or whether it was just, you know, cellular in some way. So we really need better ways of studying that process. And hopefully things like embryo models allow us to explore, right? We can start to play with the genes. What happens if I turn this gene off? How does that affect the ability of the embryo to implant? What happens if I slightly tweak the conditions in some way? Does that somehow improve implantation?
So for example, neural tube defects for example, when the spinal cord doesn't form properly, we now know that the addition of folic acid really helps to kind of prevent and to minimise that. It could be the case that there are other compounds or other drugs that we could take that could improve implantation or slightly improve the kind of development of the embryo. And we just don't have enough knowledge at the moment. So there is a huge amount of research going into just studying the fundamental biology of how the embryo forms and what happens when it goes wrong.
Brian: Well we have a question. Yeah, the note here says that this might seem truly outta this world, so.
Will Sharkey: Hi, my name's Will Sharkey. Will it be possible for women to produce children without any biological input from males? And secondly, could two people of the same sex have biological children together?
Brian: Joyce?
Naomi: At some point in the future, we don't know when, we could make eggs and sperm from someone's skin. And there are numbers of people that are doing research on this. One of my students runs a company and he wants to make an egg for him and his husband so that they can have their genetic child. So we are not sure how soon this procedure would be possible.
Some people think it's science fiction, some people think it may happen within the next 10 years, but if this happened, this would totally revolutionise female fertility and totally revolutionise IVF. Maybe we wouldn't need to freeze our eggs anymore because we could just make someone literally thousands of eggs from some of their skin.
Brian: Now Naomi, maybe you could just describe the... Give me the one minute introduction to how a cell from someone's skin could become an egg.
Naomi: Yeah, so it is a very similar technology to the one that I was describing earlier, right? You can take skin cells for example, or hair cells and reprogram them back so that they're in an embryo like state. And as I say, these cells have the potential to make any cell of the body. One of the cells of the body is of course sperm and egg. And so effectively what you're doing is reprogramming them back and then pushing them forward to make something like either a sperm or an egg.
And it's been done in mice. So in mice you can do this process of reprogramming back and making sperm and egg and in fact those sperm and egg are viable. They can form offspring, they can live healthy happy lives. It's never been done in humans. So it's not really clear, as Joyce mentioned, it's not clear if this is on the horizon or if it's not possible. There's some sort of technical limits to stop us from doing this. But like you say, if it is possible, it would completely revolutionise fertility.
Brian: Joyce.
Joyce: So, at some point in the future we will be able to make eggs and sperm for a woman but also eggs and sperm for a man. So your face is- It would be off.
Güneş: I really love Joyce's optimism about these things because I mean science is nothing if not optimistic. So perhaps we could, you know, if we can do it for a mouse, maybe we could do it for a human.
Brian: Lucy.
Lucy: I think there it's really important that we think about not just what is possible technologically and biologically, but about who is doing this research and who has an interest in this research. Because we see this particular research happening both in the context of Silicon Valley with high profile investors from big tech sector. And we see it happening within universities, much more in a public health context in which people are asking very different questions, have very different projected timelines to clinical application and are under very different kinds of pressures to do the research that they do.
So I think it's very important that we think about not just do we wanna do this technology, but also who's going to do it and what are the implications of that for who can eventually access the technology and who will benefit from it financially. So you know, if there's something that's going to basically make IVF, egg freezing, all the things we've talked about obsolete, then it's very important then who holds the intellectual property To that.
Brian: The next question from the audience.
Alan Burnell: Hello, my name is Alan Burnell. What impact on the growing child's identity could different forms of conception have? And how should children be told about them?
Brian: Lucy?
Lucy: So I mean there's a number of different technologies we could talk about, but when it comes to donor conception, there's been - so using donor eggs or donor sperm - there's now more of a consensus that it's a good idea to tell the children as young as possible so that they're not surprised at a certain point or have to adjust their sense of their parental kinship relations. But when we talk about some of the technologies that are maybe on the edge of what we are used to ethically. For many things a child cannot consent.
So when we're talking about, for example, whole genome testing or selecting embryos on the basis of information, that's then information that that embryo if it becomes a child, will also be made aware of. And they may not have the right not to know certain things. We are very much focused on the intended parents who presumably have the best intentions for the child. But when children live with the consequences of it, we need to think about their effects as well.
Brian: Joyce?
Joyce: When I started working in fertility in the '80s, if you were helping a couple conceive with a donor egg or donor sperm, you were advising them not to tell their children. And I've always thought that was not right. And through the years I've done a lot of work with the Donor Conception Network who are a brilliant group in the UK and they were really against this. And now in the UK, we have a registry and donors can be traced. So I'm really pleased now that in most countries, but not all, most countries, there is the encouragement that we are honest with our children about how they were conceived. If different gametes were involved, if a different womb was involved through surrogacy. I think we need to be really, really honest.
Brian: Essentially, the question was how should children be told about these issues? Whatever the procedure was that you went through at the moment.
Joyce: Yeah, we did some research on this as well. The Donor Conception Network makes wonderful books called "Our Story," that cover so many different ways of making a family. And these are stories that they encourage people to use from birth. From birth we read to our children. So read to your children at night, the "Our Story," you put your pictures in about whoever was involved in generating this child. So there was no conversation, there was no day when you were 10 or 16 or 25 that your parents sat you down and said, you are not who you think you are. They always knew that the egg or the sperm came from somebody else or the womb came from somebody else.
Brian: Well we have a final question and the final question is about the future.
Deb Lancaster: My name's Deb Lancaster. Louise Brown, the first IVF baby turned 47 recently, conceived in my hometown of Oldham. In the circa 50 years since her birth. Would the panel have expected more in the way of advances in this field. And are there any advances that you think might happen that we haven't covered already?
Brian: We could go around the panel actually. So the future, so why don't we start with Lucy?
Lucy: Yeah, thank you very much. One more thing that I can add to that which we haven't discussed directly is in relation to the AI question. There is an opportunity to use AI for many different aspects of the IVF cycle, the embryo selection, sperm selection, egg selection, as well as completely automating the embryological process. So what is now being done by hand, what is being done in Oldham at the time, automating that process. And we've seen in Mexico the first clinic that has completely automated that process one year ago. And so a lot of this is being done to really reduce labour and managing the clinic as a business than about necessarily increasing success rates.
And I think that's where we have to think about the future as well. The future is not just about what is technologically or biologically possible, but what is going to be invested in? Because we see now a lot of cuts in public funding but we see this across the world including research institutions, healthcare institutions and education institutions. All of which have played a major role in creating the technologies that we have today.
If that funding is moving away from governments and if the funding is coming more from the private sector, there may be a different agenda that is directing the future of these technologies. And when we see that the investments are mostly going to the technologies that are going to aid the people who are wealthy enough to afford them and not so much to the public health technologies or women's health more broadly that affect people more widely. We need to take that into account as well. So we have it in our hands in the way now, not just to choose the ethical limits but to choose the kinds of equitable futures that we want to create through these reproductive technologies.
Brian: Naomi?
Naomi: Well it's a great question. Thank you. I think, you know, we've talked a lot about how IVF has transformed the clinic and has transformed fertility but of course IVF and then the ability to make an embryo in the lab in vitro has also transformed research. So we have been able to move beyond mice and start to think about how the human embryo develops. Can we understand particularly the first, one of the first cells that the embryo makes is called the trophectoderm which goes on to become the placenta. And that's obviously really key for the embryo to set up the placenta properly so that it can interact with the mother, it can implant correctly.
Of course Louise Brown and the birth of IVF also affected our kind of ethical questions because now we can create embryos in the lab. Where should we draw the limits? Where should we put those lines? So in the UK for example, we've got this 14 day rule that stops us from being able to culture human embryos beyond 14 days. And I think now that we're just about at the cusp of being able to grow them for that long, we're starting to say well actually should we extend that limit? We've learned so much about that first kind of seven days, very early development, should we be allowed to grow them for much longer? And I'm hopeful that that will be in the future, we'll start to think about either using real embryos for longer or indeed using embryo models to begin to unpick really how does the embryo form and how can we better understand those early days of life.
Brian: Joyce?
Joyce: The 40 years I've been in the field, yes we've seen an increase in the live birth rate, but I don't think it's been that huge. What we have seen is an increase in the technology that has been developed that's been trying to improve the live birth rate. Only one of these IVF add-ons out of 42 we looked at, when we did our European recommendations that are actually being shown to help live birth. When I started in this field, the majority of IVF cycles in the UK were being paid for by the government. And now it's way over 70% of people are having to fund- So nevermind about trying to fund your egg freezing. If you're an infertile couple, can you afford the 10,000 or so to have fertility treatment?
And if they stick loads of add-ons on yeah, extra treatment, unproven treatment onto your cycle, it can go up to even much more than that. So I feel very sad that we haven't really brought in any new technology. I think that significantly helped the chance of having a live birth. So I think we just have to finish thinking about being cautious about where we go with technology in the future.
Brian: Güneş?
Güneş: As a developmental biologist who's interested in the ovary, the thing that I would like to see going forward is more basic knowledge about how these organs are formed, how eggs and sperm are formed in the first place. The dream is to be able to understand the mechanisms of how these organs work well enough that we could steer them how we'd like to basically, I think the Daily Mail headline equivalent of what I've just said is 'let's make ovaries in dishes'. But I like my version better. That's my professional answer.
My human answer, as a female at the age of 35, is more aligned with what Lucy was saying. Namely, the biggest thing that I would like to see changed about this space is the cost. Because I don't know how many females at the age of 30 to 35 can afford to get 20 eggs frozen down. 'Cause you need at least 20 in a freezer to be able to have a successful live birth- a chance at a successful live birth. And 20 eggs is two rounds of egg freezing at approximately 4K per round. I think that's actually the biggest limiting factor as a human being.
Brian: Well thank you, that is all we've got time for. So all that's left is to thank our panel Joyce Harper, Güneş Taylor, Naomi Morris, and Lucy van de Wiel.
