Infertility is easy to diagnose, since if after one year a woman does not become pregnant and has regular, uncontrolled sexual activity, this is the conclusion. This is according to Carlos Calhaz Jorge, Full Professor at the Faculty of Medicine, Director of the Department of Obstetrics, Gynaecology and Reproductive Medicine, as well as of the Centre for Medical Assisted Procreation at the Northern Lisbon Hospital Centre (CHULN). The Department consists of two services: Obstetrics (Director: Professor Diogo Ayres de Campos) and Gynaecology, which the Professor also directs. This Service, in addition to the Reproductive Medicine Unit, has five sectors: Urogynaecology (the only unit in this area in the NHS in the south), Mastology (which conducts about half of the breast cancer interventions at the hospital), Surgical Gynaecology in general, Oncologic Gynaecology and Medical Gynaecology (with the largest outpatient area). In total, the Department has 32 specialists and about 11 permanent interns. In the Reproduction area alone, the Service receives close to 700 couples for the first time per year. Among those who have just arrived, and with whom new consultations are taking place, and those already being treated, we can say that there are over 8,000 (annual) consultations of couples who want to have a child and cannot naturally have it. It is at this time that they go to CHULN, where their paths intersect with those of the Professor, who has been at Santa Maria Hospital for 44 years and been a specialist in infertility diseases for 32 years.
Calhaz Jorge always thought to take up Endocrinology, as he was fascinated by the complex and interactive mechanisms of the organism. But then he decided that the area of infertility was even more attractive and broader, and had a huge endocrinology component. His specialty was coming to an end when in vitro fertilization emerged in Portugal. This allowed him to "experience history from its very beginning", as he says. Looking at Reproduction with special interest, catching this new twist of science innovation, not only about Reproduction but also Genetics, has made him fully devoted to this area of Medicine. Carlos Calhaz Jorge was thus part of the group that started the treatments with this technique using the Reproduction laboratory installed, with financial support from the Gulbenkian Foundation, at Santa Maria Hospital.
Advising member of scientific committees for several years, he will be, in 2021-2023, the Chair of the European Society for Human Reproduction and Embryology (ESHRE), currently serving as Chair-Elect.
Why not become familiar with the behind-the-scenes of his Service, in an interview that allows a guided tour of reality, which is still little known?
Discrete enough, and disliking marketing himself or the role he has been playing, he is strictly methodical in everything he does, and good time keeping is no exception. Thus, being rigorously convinced of principles, he does not know how to embellish data or fictionalize reality. However, in his mission, he does not turn his back on adversity. I am looking for the Professor in a month when a Colloquium of the National Council of Medically Assisted Procreation (CNPMA) is organized, of which he has been a member since its inception. We talk about the problems of those who want to have children and cannot, the emotional pain of trying to make a big dream come true, and the concerns that remind him that the CHULN Reproductive Medicine Unit welcomes people from almost all over the country and beyond. Indeed, with the end of each hospital's catchment areas, access is geographically free. If we add scant investment in health and the lack of human and technical resources to address so much demand, then this translates into long waiting lists for sophisticated infertility treatments. The good news is that, for now, less complex treatments still have no waiting time. Given this formula, where there are so many misfits, we fully realize that almost everything becomes complicated.
Who are the people who seek you the most?
Calhaz Jorge: As part of the National Health Service, we welcome everyone here. Those coming from Portuguese-speaking countries, others with immense difficulties and unable to complete the treatment due to the very high costs of medication, even those from a higher class and who decide to enjoy the same right as all others. And all this demand means there is a problem, which is the size of the waiting list.
How long is the waiting list?
Calhaz Jorge: Between 15 to 18 months for the most sophisticated treatments. Because infertility is not synonymous with needing in vitro fertilization or microinjection in all situations. About 30% to 40% are cases that can be solved by medical means without the need for a complex laboratory, or by surgery, or even some couples with infertility problems whose cause is never known eventually resolve the problem spontaneously. But when treatments are the most sophisticated, they include a lot of costly medication, which means that some couples can access them only if they have social support. That is why, with existing waiting lists, those who have more resources sometimes end up going for treatments in the private sector.
Can we get a real idea of the cost of one of these more sophisticated treatments?
Calhaz Jorge: The fraction of the drugs is equal in both the public and private sectors, around €500/€600, despite the 69% contribution. The remaining 31% already reach these values. Then the techniques themselves vary depending on their complexity. There are still additional sub-techniques, but in vitro fertilization costs approximately € 4,000 and microinjection € 5500. Then, there is the cost of the drugs
These treatments may not work well the first time.
Calhaz Jorge: Sometimes not even the third time... The overall probability is about 30%, depending on the age of the ladies. If they are younger, it is closer to 35%/40% success, if they are older (but before 40 years of age), it is between 25%/30%. Then we have to take into account the restrictions of the NHS, according to which the most sophisticated treatments are only possible before the ladies turn 40, until the day before their 40th birthday.
One of the themes we tried to understand this month is the issue of pain. Can we talk about pain in both its physical and emotional senses when we talk about these treatments?
Calhaz Jorge: Talking about pain, it's really about existential anguish. Of course infertility is a major contributor to this. But physical pain... There are diseases that cause infertility and are associated with pain, but I would say it is a subpopulation of the area, essentially of endometriosis (when the cells that make up layers in the uterus are outside their normal location), a situation that manifests itself often through pelvic pain. Other than that, physically speaking it is not usual for the person to suffer significant discomfort.
From reports I have come across of women undergoing infertility treatments, at some point some say they quit because they cannot stand the physical treatment itself. Does it cause pain?
Calhaz Jorge: In such cases, I think this withdrawal is mainly a result of tiredness, frustration. Even the ones who talk about the treatment process that becomes hard to endure? Calhaz Jorge: Then what we are talking about are treatments where women have to have belly injections every day for a period of time. Of course, there is a needle that is inserted into the skin, but it causes the same pain as a diabetic person who has to have insulin injections every day has to endure. Surely, they are uncomfortable, but I would say that they are experiencing the moment they are going through in a negative manner. I would place I this pain in the psychological area. Not being pleasant, the injections, which are subcutaneous, as in diabetic insulin, are made with minimal needles and sophisticated systems, and the nuisance usually lasts a total of two to three weeks, then it is over. If we talk about mental pain, it changes a lot from person to person. It can almost come to obsession. It may also be caused by the simple difference in commitment between the couple's elements. Did you know that there are couples who come to the end of treatment and when the woman gets pregnant, they break up? There are still cultural issues of women from some ethnicities who, if they do not get pregnant, are repudiated by the community, even if the cause lies in the male. In fact, often the question couples raise is whose fault it is as a way of minimizing their own pain. But ultimately, all infertile people feel a disability of their own and of course this brings great suffering.
Are there currently cases of women seeking to be single mothers?
Calhaz Jorge: The legislation changed 3 years ago. As such, there is legal access for women without a partner, and women married to women; all are entitled to have access to these techniques. So, they need a sperm donor. In these cases, and in the NHS, this is extremely complicated, because there are no donors, an issue that has worsened, especially since a year ago, when donor anonymity ceased. Female donors, in this case of eggs, have shown a higher level of response. I can tell you now that I have about 12 couples waiting for sperm, but the public bank is failing to respond. It has to be said that as these inseminations do not have the high costs I mentioned earlier, some candidates are able to resort to the private sector and may import sperm from abroad.
When is the decision "with this couple we can't try more" made?
Calhaz Jorge: We have three criteria: age, the one that states that only three treatments can be done per couple, and finally, used only with great reflection and not so often, the clinical criterion when it is found that the ovaries do not respond to treatment, or that the eggs do not have compatible quality. But these latter situations are very rare.
In the face of a vast demand scenario where everyone comes here, with a 4% investment in Health up to 2019 and which is then diluted by various areas of this vast hospital, how do you continue to run such a service?
Calhaz Jorge: There are three ways of dealing with this matter. One is to shrug shoulders and let go, which is not compatible with me. Another is to say goodbye and leave because there are more than enough reasons for that, which is not part of my personality either. Therefore, the last one is to actively try to resist, although realizing that the prospects for improvement are absent on the horizon. For over 10 years, we have had laboratory expansion plans, as well as for the most sophisticated techniques, our major limitation. But there was never money for the works, nor for the equipment needed, nor for hiring more people. There is even the lack of replacement of leaving and unsubstituted clinicians. We have been at the limit of our response capabilities for years as a result of efforts to maximize procedures as much as we could. Now, we will have to decrease this capacity with the leaving of a specialist.
What is happening in Health?
Calhaz Jorge: I don’t know. I am a realist and I know that Reproduction is very important for people who need it, but from a broad social perspective, it is clear that cancer or transplants are more visible and receive most investment. In fact, this area consumes little money because the fraction of the population is relatively small. Although they are costly techniques, they are comparatively still much less expensive than others. And it must be borne in mind that our couples are those who want to have children and not those who, for legitimate life choices, have decided not to have them. Not being the resolution, we are a contribution to the mitigation of low birth rates.
Professor, did the Colloquium that took place on the 22nd of this month and which had as its theme "The technical, ethical, social and legal perspectives of medically assisted procreation" help to send a message out? Because it wasn't just a peer meeting.
Calhaz Jorge: It was not really a medical meeting. It was extremely fruitful in addressing technical, but not medical, and social and ethical issues, as well as the political dimension. National and international speakers provided a very broad view of the MAP and the discussion was very lively. This is already the third colloquium we have organized and, like the previous ones, was attended by representatives of political parties. The problem is that the politicians who usually participate are already involved in the area, know the problems and say what we hear, as a regulator, when we go to the Parliament’s Health Committee. Despite a relatively low participation (just under 100 subscribers), these colloquia are always very interesting and a way for the CNPMA to show its dynamics to non-specialists, because the behind-the-scenes work is immense, and if those within all know how we work, outside this knowledge is unclear or does not exist. This year, the presence of the Minister of Health at the closing session was an especially important manifestation of the Ministry of Health's appreciation of the MAP area.
What messages do you want to convey to the general public?
Calhaz Jorge: That there is a regulator in a complex area that is under very strict European directives - the CNPMA. Infertility is a larger field than it seems. For example, the European Society for Reproductive Medicine, the largest society in the world in this area, organizes an annual meeting that has about 12,000 participants. They are not all doctors, because it also involves research and basic and applied sciences, but it is truly great. Still, infertility often tends to be considered unimportant and even almost a luxury, which is unfortunate.
Professor, despite all that we have said, none of the negative factors has kept you from continuing in the public sector.
Calhaz Jorge: No, I won’t quit. And I don't do that because I have a self-destructive nature. None of that (smile). I have always dedicated myself to treating people and that is what I will continue to do. I still think the NHS is one of the best things the country has but it is misused and poorly structured. I will continue to make my contribution. I currently have no expectations of improvement, but I intend to try to contribute to prevent further deterioration. I want to tell you, however, that this general framework I draw does not specifically refer to our centre, it mirrors the NHS and within that reality, we are still among the best able to meet the needs of the people.
There are many women from other nationalities who come to Portugal, and even though they have rarely come to the country, many have a number of NHS users. As such, their health costs are almost entirely borne by the NHS. In the last year alone, the entire Department of Obstetrics and Gynaecology lost 3 experienced specialists whose replacement has not been made. Next year, three more doctors will leave for retirement reasons. Of the younger ones, those who leave seek greater financial stability as well as the expectation of being able to treat patients more adequately, because they have all the means to do so. The hospital has opened competitions for newly trained doctors, but when new blood is needed it is also essential to maintain the experience standards.
Despite this scenario, Professor Calhaz Jorge reiterates that this quality has not diminished, but also warns that waiting lists tend to increase even more. In addition, factors outside his remit cause general concern, the low birth rate allows us to predict that by 2030 Portugal will be the most aged country in the world. And although it is a low percentage, the fact is that Reproduction treatments are a birth aid, with a contribution of about 3%. “Helping a woman in a timely manner will be very different from putting her on hold for a year and a half”, he insists. After this wait and with the possibility of not being successful in the first treatment, it is possible that she approaches a limit age that no longer allows her great leeway for further treatment. The Professor knows that, while not addressing all the reasons for the low birth rate, if he could help all those who seek the Unit he leads, in due course, this rate would increase, becoming a clear benefit for eager parent-seekers and also for the country.