The decline in births does not depend only on the economy. Increasingly advanced age, poor information and diagnostic delays make reproductive health one of the great healthcare challenges of the next decade.
In the In 2024, approximately 370 thousand children were born in Italyone of the lowest levels ever recorded. Of these, 17,660 came into the world thanks to Medically Assisted Procreation (PMA): means today almost one child in twenty was born thanks to reproductive medicine techniques. It is a fact that until a few years ago would have seemed exceptional and which is instead becoming an integral part of the Italian birth rate. It not only tells of the evolution of medicine, but above all of a profound change in society: people are looking for a child later and later, reproductive difficulties increase and the number of people who come to specialists when biological time has already reduced the chances of success is growing. It is from this photograph that the Fertility Manifesto 2030presented to Montecitorio byItalian Fertility Association (AIFe). More than a document dedicated to medically assisted procreation, it is a proposal to change perspective: stop considering fertility as a problem that emerges only when faced with a diagnosis of infertility and start treating it as a component of public healthexactly as happens for cardiovascular or oncological prevention.
“We must shift attention from the sole management of full-blown infertility to the early protection of reproductive health,” he declares Laura Rienzi, President of AIFe. “Fertility must become a permanent part of public policies. Informing earlier, recognizing risk factors promptly and reducing delays in accessing treatment means offering people greater possibilities of choice and allowing reproductive medicine to offer more timely and appropriate responses, without presenting it as the only solution to the birth rate.” The basic idea is simple: today medicine has increasingly effective tools to help those who are unable to have children, but they continue to arrive too late. Many people are unaware of how age affects reproductive capacityunderestimate pathologies such as endometriosis or varicocele, or postpone checks for years. When they finally turn to a specialized center, often the margin for intervention has already decreased.
The missing prevention: inform earlier to treat better
The topic does not only concern the PMAbut everything that comes before. Specialists are increasingly talking about reproductive healtha concept that includes education, prevention, early diagnosis and protection of fertility throughout life. Age remains the main biological factor, especially for women, but it is not the only one. Obesity, smokinginfections, chronic diseases, gynecological and andrological disordersin addition to some environmental factors, can progressively compromise reproductive capacity. Many of these elements, if identified early, can be addressed before they become an obstacle to pregnancy. For this reason the Manifesto proposes to introduce programs of reproductive literacy already during school and in local medicine, with the aim of providing correct information on biological time and the main risk factors. A proposal that arises from the observation of an evident “fertility gap”: many young people know perfectly well how to avoid an unwanted pregnancy, but much less how to preserve their fertility in the following years. The problem, moreover, is not just a health one. The choice to have a child is often postponed for economic, work or housing reasons. Increasingly precarious careers, difficulties in buying a house, insufficient childcare services and the still complicated reconciliation between work and family end up pushing the age of the first child ever further forward. When the right moment arrives from a social point of view, however, it does not always coincide with the most biologically favorable one. In this scenario the Medically Assisted Procreation represents a fundamental resource, but the specialists themselves advise us not to consider it a solution capable of completely compensating for the effects of time. In 2024 they were carried out 115,455 PMA cycleswith a cumulative pregnancy rate of 34%, numbers that confirm the growing centrality of these techniques in Italian healthcare.
“The preservation of fertility must be fully included in the paths of information, prevention and protection of reproductive health,” he underlines Rocco Rago, Head of the Reproductive Physiopathology and Andrology Unit of the S. Pertini Hospital in Rome. “It does not represent a guarantee of future pregnancy nor can it replace welfare and conciliation policies. In selected situations and after an adequate clinical evaluation, it can however offer the opportunity to protect reproductive potential before age, a pathology or certain medical treatments can compromise it. This is why correct information, clinical appropriateness and accessible paths are needed”.
From cryopreservation to single women: the debate widens
Among the aspects that are changing reproductive medicine the most there is also the fertility preservation. In 2024 the cycles of oocyte cryopreservation for non-medical reasons registered by the National PMA Registry increased by 44% compared to the previous year. An increase that reflects a growing attention towards the so-called social freezingthat is, the possibility of preserving oocytes when fertility is still high. Specialists, however, urge us to avoid misunderstandings. Egg freezing does not represent insurance on future motherhood nor can it replace support policies for young couples. It can instead become a useful tool in selected cases, especially when there are clinical or therapeutic conditions that risk compromising fertility or when, after adequate counseling, one decides to preserve one’s reproductive heritage.
The Fertility Manifesto 2030 it also addresses some issues intended to fuel political debate. These include the request to include fertility protection pathways in a more organic way Essential Levels of Assistancethe reduction of territorial inequalities in access to care, investments in research and the opening of a reflection on access to PMA for single womencurrently excluded from Italian legislation. The discussion, in reality, goes far beyond reproductive medicine. It concerns the model of country that Italy intends to build in the coming decades. Why the birth rate it does not depend on a single factor and cannot be corrected with a bonus or a single reform. It requires policies capable of bringing together healthcare, work, welfare, research and family support. This is perhaps the most important message that emerges from the debate opened by AIFe. There fertility it can no longer be considered just an issue to be addressed when a clinical problem arises. In a country that continues to record historic lows in births, it becomes an indicator of the health of society itself. And if medicine can offer increasingly sophisticated tools, the real challenge begins long before entering a ART centre: it begins with information, prevention and the possibility, for men and women, to truly choose whether and when to become parents.
