On July 12, 1984, Barcelona registered the first birth in the Spanish State thanks to in vitro fertilization. It was the fourth time in Europe, and the sixth in the entire world, that conception was successfully launched, uniting a female reproductive cell with a male one outside the uterus, before being able to follow the natural gestation process of this embryo in a woman's body. Thus, on that day, the Catalan capital ---at the Dexeus University Institute in Barcelona--- wrote the first chapter in Spain of assisted reproduction, which today is responsible for approximately between 3% and 6% of all births in Europe. It is estimated that around 10 to 12 million people worldwide have been born thanks to this medical technique.
The biologist, researcher, and university professor Anna Veiga is today the director of the Barcelona Cell Line Bank and head of the research group in advanced therapies with pluripotent stem cells in the Regenerative Medicine Program of the Bellvitge Biomedical Research Institute (IDIBELL). In this same institute, in the summer of 2020, Veiga was appointed Ombudsperson, with the responsibility of ensuring good professional practice in research at IDIBELL. Anna Veiga also directs the Probitas Foundation, an NGO created by the company Grifols to improve access to health in the most disadvantaged regions of the world.
--- On the verge of commemorating the fortieth anniversary of the birth of Victoria Anna Perea Sánchez, the first child born thanks to in vitro fertilization, what do you still feel today when you remember that July 12?
--- It was truly a very special moment professionally, obviously. I was very young, 27 years old, and for me, work was, and has always been throughout my professional career, a very important part of my personal life. Victoria's birth marked the beginning of assisted reproduction in our country, and from there, techniques evolved.
--- What do you know about Victoria, have you kept in touch with her?
--- Yes, we maintain contact and friendship. We see each other often, even though she lives in Madrid, where she works in digital marketing for a company.
--- Since that birth, how has assisted reproduction evolved?
--- It's not that today it has nothing to do with what it was at that first birth, but many things have changed. The results have improved a lot, and the type of patient is now a different scenario. At that time, we were opening the doors, starting the specialty, and today in vitro fertilization and assisted reproduction are totally consolidated worldwide, and, in Spain, with more activity because there have been very good groups that have done a good job.
--- What has made the work of these groups in Spain more prominent and intense?
--- Mainly, egg donation, which here has some particularities compared to other countries, especially in the recruitment of donations. Because in our country, economic compensation for donation is allowed, which is not allowed elsewhere. Although Spain has always stood out in Europe in the matter of organ donations, in general, and in egg donation, too.
--- The successes of assisted reproduction are increasingly seen also in older women.
--- This has been the other big change that has occurred. When the technique was established, donation was done for relatively young women who had lost reproductive capacity and, instead, today the recipients are women who have already exhausted their reproductive capacity and are unable to conceive.
--- Does the older age condition the technique or the process in any way?
--- The treatments are always different, but at a clinical and laboratory level, the essence is the same: to achieve egg production from the same patient or from the one who makes the donation and put them in contact with sperm in the laboratory, to get the embryos to develop and transfer them to the uterus.
--- From a bioethical point of view, is it clear what the maximum age limit for this medical aid to conception should be?
--- The legislation does not set a maximum age, it only sets a starting age, which is 18 years old. But in a consensus at the level of medical centers and scientific societies, we established 50 years as the maximum, although it is very possible that this figure will be extended. The 55 of now are the 45 of before and we have to know how to position ourselves in many elements of the environment where motherhood is considered.
--- It is a change of mental and social paradigm.
--- All of this has changed a lot. The average age to have the first child now in Spain is around 31 years old. Not in assisted reproduction, but in motherhood in general. It is one of the highest in Europe. And it is a social phenomenon caused by a series of issues, such as the incorporation of women into the university world and work. Women want to complete a period at a professional level before having children, they consider it more, for economic reasons. Until you have economic stability, it is postponed. Before, either economic stability was reached earlier, or we launched ourselves more cheerfully into having children. Today's young men and women, before deciding, weigh many issues taking into account that economic precariousness is absolutely evident. It is much harder for them to leave their parents' home, because they do not have the means to do so. They leave to live with other young people because they cannot afford the rent or the purchase of a home. And this has its repercussions on starting a family and having children.
--- So does deciding to be a mother at 50.
--- I think it is very important to reflect, given a certain tendency to think that nothing happens if I don't get pregnant when I'm young, because I've decided to travel the world, do a master's degree, or because I haven't found a partner, and that they will help me in a clinic to achieve it. In vitro fertilization can help you get pregnant if you use the eggs of a young woman, it does not rejuvenate your eggs. This is increasingly understood, people know it, but we have to make the effort to ensure women have all the information. Also about freezing. Freezing eggs and storing them is not something everyone can do, it involves an expense, but there is increasingly more and clearer information about this possibility.
--- And personally, what do you think of motherhood at such advanced ages?
--- I had my son at 31, and I was already older. But today a 40-year-old woman is not the same as those 40 years ago, they are much more in shape. The entire population in general lives much longer, and these are issues that we must put on the table. We have always ensured as professionals, and I say this in the past tense because I no longer work in assisted reproduction, but we have always tried to foresee the guarantees that that child would be born in the best possible conditions. We took into account any suspicion of a problem in the couple that could foresee the birth in an environment not favorable to their quality of life, both physically and mentally, and we took all precautions when doing a treatment, and this is what I believe must always be taken into account. But it is difficult to decide what to do if a 53-year-old woman who comes to a consultation because she wants to have children and is in good physical and mental condition and has economic stability, should we tell her yes or no?
--- And who should answer this delicate question?
--- This would be much easier if it were regulated by law because, otherwise, it ends up being an issue controlled by the criteria of professionals and with the support of more or less sensible scientific societies.
--- But fertility clinics are private, and they are companies that live and grow thanks to people's desire to be mothers and fathers.
--- In any case, money cannot be a criterion for deciding the maximum age to help a woman become a mother; it must always be the well-being of the child to be born. We know that in the United States, treatments have been done on women aged sixty and over who have had children. Being a mother at that age, like Ana Obregón, who is my age, is no longer a question of whether it is natural or not, because in vitro fertilization is no longer natural, just as the use of antibiotics or an appendectomy is not natural; when you intervene, it ceases to be natural. Assisted reproduction is artificial, the concept is no longer natural, but reaching certain extremes makes me uncomfortable. We started by solving fertility problems for men and women with a medical problem that prevented them from having offspring. At this moment, a large part of the treatments that are done do not derive from a medical problem; we are facing a problem of social origin, because people consider having children very late, this has been the change.
--- Barcelona receives many couples and single women every year who come here to treat their difficulty in getting pregnant. For example, Italian women who are not allowed to do so in their country.
--- In countries where there are no donor eggs or where legislation does not permit it, there is a movement of patients towards the rest of Europe, where goods and people can circulate freely, and they can come to Barcelona, Madrid, and Valencia, where there are very advanced centers where they can do it.
--- Technology has also played its part in the evolution of techniques.
--- The tools available today in the laboratory and in the clinic for treatments have improved a lot. When we started working, it's not that they were precarious, because we had the best possible, but now there is a whole industry behind in vitro fertilization, such as machines to assess whether embryos are of good quality or not.
--- There is already talk of human embryos produced entirely in the laboratory, in China.
--- These are embryos that do not have implantation capacity and are not made to create children, but to study implantation models to understand development. By themselves, they cannot give rise to life, they do not have the capacity to do so, they are only models. In any case, everything that is done is not only subject to bioethics, but also to legal regulations.
--- Where are we now in regenerative medicine? What can we do that was not possible 20 years ago?
--- In regenerative medicine, a lot of progress has been made. The tools are now much better than many years ago, and treatments with stem cells are being considered to solve degenerative problems, such as macular degeneration, cardiac or pancreatic pathologies, and to create blood cells to treat ailments. The first clinical trials have been underway for some time with good results in many cases; it is a field where a lot of work is being done. It is also helping us to understand the problems derived from aging and how they can be solved.
--- What are the fields in which we will be able to see, in the short term, progress in real patients thanks to the reproduction of stem cells in the laboratory?
--- Already in ophthalmology, neurology, and cardiology there are many clinical trials underway and the results are appearing, and many of them are very promising.
--- In all this, what place do Barcelona's research centers and groups occupy?
--- I believe we are very well positioned. In Barcelona and throughout the State, work has been done since the beginning of regenerative medicine, and now we are in a very similar situation to many other European cities. At the Centre for Genomic Regulation, at the Barcelona Research Institute (IRB), at the Institute for Bioengineering of Catalonia (IBEC) very cutting-edge research is being done, at the same level as in many European countries. There is access to European funding, and this is an unequivocal sign of the good level we have. Very good research is done in our country despite funding problems, because not enough money is dedicated to research in our country and the importance of research should be taken more into account from a regional and national perspective.
--- Throughout your career, what progress, besides the birth of Victoria, do you highlight as a before and after in medicine?
---- The birth of Victoria marked a before and after in my career, and it was from then on that I decided to dedicate myself to stem cell research. I was lucky enough to be able to participate in the beginnings of both fields, and this is a privilege because you are part of the first steps in certain disciplines. In stem cell research, the first clinical trials are already being conducted to determine the scope of the techniques in the treatment of degenerative diseases, such as macular degeneration, heart problems, and neurological processes like Alzheimer's and Parkinson's, where a lot of research is being done.
--- What would you like to see happen?
--- In assisted reproduction, truly very relevant advances have been seen over these years. In regenerative medicine with stem cells, I would like to be certain that the treatments we are proposing with stem cells solve problems as well as we want to solve them. We are close, in certain diseases and cases, to these cells ending up curing patients. Curing, or improving their quality of life, because finally, the theory is that, from stem cells, we replace some that do not work and make them work. We do not cure, but we repair.
--- In contrast, in gene therapy, how is it done?
--- In the case of gene therapy, what is done is to modify the genome. In genetic diseases, an attempt is made to correct the genetic mutation that causes it. Worldwide, treatments are being carried out to solve genetic problems successfully. It is a discipline that is just beginning, but treatments have already been done with which leukemias in children have been cured.
--- Can stem cells be trained to do everything?
--- Pluripotent stem cells can give rise to many functions, but not all. We try to replace cells that no longer work with those we manufacture in the laboratory, where we convert them into those that are deteriorated. Regenerative medicine appears because aging pathologies appear. 50 years ago, macular degeneration was not talked about, or its scope was not known. We see that our cells stop performing their function; the aim is not to achieve anyone's immortality, but rather, if people live longer and these diseases appear, we try to alleviate them and make the quality of life better, not that they live eternally.
--- Right now, what are you working on?
--- I direct the Barcelona Cell Line Bank where, among other projects, we are manufacturing stem cells that can be used in a large proportion of the population. It is a European project for which we have received funding; we work from a consortium of countries to agree on what types of cells we need to manufacture for a relevant population. Stem cells, as happens in transplants, cannot be used if I don't have immunosuppressants to achieve maximum compatibility. If we manufacture cells that are usable for a relevant proportion of the population and we make them in the laboratory, in the same way that medicines are manufactured, they will end up being like medicines. And now the objective of many centers together, which we lead from Barcelona, is to agree on what types of cells we want to produce. We are not thinking, for now, about specific treatments; this will be done by researchers who want to develop a specific treatment from these cells. Each one will do it; we prepare the raw material to be as compatible as possible with the largest number of patients. First, we have to agree on what the raw material is to then move towards the treatment.
--- You are also the director of the Probitas Foundation. What does the entity do?
--- Its objective is to help improve the physical, psychological, and emotional health, as well as facilitate equal opportunities, for people in vulnerable situations, both locally and internationally. Projects are supported in Africa, Latin America, but also in Catalonia. In 2008, the managers of the Grifols company decided to allocate 0.7% of their annual profits to this foundation that they themselves created.