The great egg race

Bologna, the Italian city famous for having more arcades than anywhere else in Europe, also had probably the largest collection of fertility experts anywhere on the planet last week. A glance at the crowded lecture theatres of Bologna's conference centre would suggest they must be proliferating faster than embryo cells can divide.

If there is a growth industry within medicine, this is it. The European Society of Human Reproduction and Embryology, whose annual conference this was, was buzzing with the excitement of being at the cutting edge. Only 20 years since the birth of Louise Brown, the first test-tube baby, the technology has galloped ahead so fast that one baby in around 80 in the UK is now born with laboratory help, while in the Nordic countries, it is one in 50.

What does this say about human fertility? In spite of millions of years of practice, are we losing the ability to make babies in the ordinary way of the species? There are some who say we are.

Environmentalists point the finger at sperm counts, which some studies have shown to be dropping. There are huge anxieties over the effects of "gender-bending" chemicals - scientifically known as endocrine disruptors. These are man-made substances used in plastics, dyes, solvents, resins, paints, plastic containers, detergents and pharmaceuticals. They are highly pollutant, break down very slowly and accumulate in the fatty tissues of the human body.

Worst of all, they mimic the female hormone oestrogen or interfere with the male hormone testosterone. Birds and fish living in areas such as near paper mills, where quantities of these chemicals are released into the water, have been found to have reproductive defects. WWF (the World Wide Fund for Nature) believes that there is sufficient evidence to indict these pollutants for some male infertility problems, such as declining sperm counts.

But scientific studies have not yet come up with clear answers. Some have shown alarming drops in the numbers and motility (swimming ability) of sperm. Others have not. While some European studies suggest drops of 50% or more in the second half of the 20th century, a major American study from the Keck school of medicine at the University of Southern California, published in March, found nothing of the sort. Semen samples from 1,385 men who were seeking fertility treatment between 1994 and 1997 - a group that might be expected to have low sperm counts - turned out to have more than the usual amount of abnormalities in their sperm, but sperm quantities no different from the average in the 1950s.

Furthermore, all these men were blue collar workers who would have been more likely than most to be exposed to industrial pollutants in their jobs. The Medical Research Council's reproductive biology unit in Scotland is now embarking on a major study to try to find some definitive answers, recruiting 1,000 men to send in samples of their sperm by post for analysis.

There has been some evidence that sperm counts rise as well as fall over the years, and that high counts result in high birth rates. Some say particular professional groups are more likely to have problems - the wives of taxi drivers and lorry drivers whose scrotums overheat during the hours on the road are said to have more problems than most. But the same should go for any sedentary lifestyle. Tight pants have also been blamed. While there is every reason to worry about the effects of polluting chemicals on the planet, most fertility doctors tend to dismiss suggestions that falling sperm counts are a reason for their rapidly increasing workload. Lord Winston, in his book "Making Babies", says: "There is very little serious evidence at all that men are less fertile now than they used to be." Not only were sperm counting techniques entirely different in the 1950s - the period usually used as the baseline - but also the social and economic background of men that attended fertility clinics, he says.

Last month a study in the Lancet medical journal turned the argument on its head when it reported that couples were conceiving faster than they used to. Michael Joffe, an epidemiologist at Imperial College school of medicine in London, interviewed 646 men and 894 women aged 16 to 59, asking them to recall how long it took to achieve their first pregnancy. While he admits that asking people to think back four decades is not foolproof, he found a clear trend that more women were conceiving within four to six months of trying for a baby in the early 90s than they were in the early 60s - 80% compared with 65%. They are not having more or better sex (some experts believe orgasm is more likely to lead to conception), Joffe says - they have better timing. Couples today more often try to have sex on the days the woman is ovulating.

"Another conclusion should be that, at present, the near-panic sometimes expressed in the lay press about the effects of environmental pollution on sperm quality and male fertility is not justified," said an editorial in the Lancet. That was Egbert de Velde's view at the Bologna conference. The Dutch gynaecologist was deeply concerned that couples are rushing into fertility treatment that is not only expensive but can be dangerous. Women have died from hyper-stimulation - the effects of the chemical battering given to their ovaries to make them produce more than the normal one egg in a cycle.

"A lot of couples who have tried for half a year give up, thinking it is not normal and rush to do the fertility thing. Because infertility, especially in the US, is extremely commercialised, they are accepted with open arms. I think that is a development that is regrettable because a lot of couples, if they had waited - not for many years but for another year - would have quite a big chance of conceiving spontaneously without all the risks and complications of IVF," says de Velde.

Commercially, IVF is big news. There were more than 200,000 treatment cycles of IVF and ICSI (the technique where a single sperm is injected into an egg) carried out in Europe in 1997, at a cost to the individual or the state of around £3,000 a time. Organon, Serono and the other big names involved in fertility drugs were big sponsors of the Bologna jamboree.

If there is a panic rush to the clinics, as Dr de Velde believes, it is being fuelled by an awareness of the ticking clock. With every year that passes, a woman's chances of having a child get slimmer - especially past the age of 35. In the UK, fertility treatment is another postcode lottery - in some areas couples can have a cycle or two of treatment on the NHS. In others, there is nothing or an endless waiting list. The huge cost of treatment is to blame - health authorities blanche at the thought of the hole in their budget that would be created if everybody was to be funded.

Clare Brown, president of the International Federation of Infertility Patient Associations (IFIPA) and also executive director of CHILD, the UK support organisation, is wary of telling women to wait. "Up to 34, once you have been trying for a year or so and there is nothing, you should at least start to get the ball rolling," she says. "Over 35 you should not wait longer than six months or so. You are going to be investigated first. That can take time."

In her view, even if sperm counts are declining, it is just as likely that we are hearing more about infertility - and therefore assuming there is more of it - because of all the treatments that are now available. Couples with problems now come forward when they would have hidden away. "In the past, they wouldn't have said they didn't have children because they were infertile. They would have said, 'If it doesn't happen, it doesn't happen,'" says Brown.

At the IFIPA stand in Bologna, she was amazed by the doctors from Indonesia, Mexico, Iran and elsewhere who arrived to talk about the need for support groups for the infertile in their own country - not because there are more of them than there have ever been, but because the treatments are becoming available for the first time.

We have had them for 21 years now, when the UK led the world with the birth of Louise Brown. And yet now the UK has one of the worst records in Europe for enabling the childless to get help. Health authorities have diverse criteria for paying for treatment - if they do it at all. Some will bar a couple if they have previously paid for a failed attempt privately themselves - even if they spent their life savings or borrowed to the hilt to do so. "It is totally unfair," says Brown.

In the rapidly advancing world of fertility treatment, there is huge excitement, great promise and the most terrible misery for many couples. At Bologna it was clear that technology is advancing at a terrific rate. But how many of the infertile are going to be able to afford what the scientists have to offer?

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