Kypros Nicolaides: "I am against private umbilical cord banks"

BarcelonaKypros Nicolaides (1953, Cyprus) is a doctor and professor at King's College London, from where he has led important advances in prenatal diagnosis and the prevention and treatment of complications during pregnancy. Considered a leading figure in fetal medicine, among his achievements is the creation of combined screening to detect chromosomal abnormalities, such as Down syndrome, which has become the international standard for pregnancy monitoring. L'ARA interviews Nicolaides in Barcelona, where he received the XX Dexeus Dona Foundation International Award, a recognition of his career.

You are a pioneer in a field that revolutionized obstetrics, as it moved from looking only at the mother to knowing the fetus's condition directly. How did you specialize in this area?

— I was a medical student at King’s College Hospital in London in the seventies. I came from Cyprus. At that time, as now, there were many problems in the world. In Latin America there were revolutions, and the United States, in the name of democracy, imposed dictatorships. In Cyprus we had an attempted overthrow of the government by Greek military, and then we were invaded by Turkey. As a student, I wasn't interested in medicine. I was more concerned about the world. In 1979 I finished my studies without really knowing what I wanted to do. I was more involved in demonstrations than in anatomy or pharmacology. But a professor arrived, a pioneer in ultrasound, and when I saw a fetus moving inside the mother, many questions came to my mind. How does it grow? What happens when it gets sick? And if there is a conflict between the mother and the baby, whose side am I on? Is there anything we can do to diagnose problems in pregnancy? Can we do anything? From being a revolutionary, I found a purpose in life.

And transforms prenatal diagnosis.

— I was lucky, because I was there from the beginning for all the changes we have seen and sometimes I was able to influence them. One of the important areas in which I was involved is in the diagnosis of Down syndrome. Before, the only way to do it was to say that if a woman was over 35 she had a high risk and needed to have an amniocentesis. But most women with babies with the syndrome are young. We were missing most of the cases. One day, while doing an ultrasound, I saw a black space behind the neck, a fluid accumulation. I conducted a study with 100,000 pregnancies to find out if it was true or not, and what the relationship was between the fluid behind the neck and Down syndrome. And this led to the nuchal translucency ultrasound, and instead of waiting until sixteen or twenty weeks to know, now we can see it at twelve weeks of gestation. And the same happens with other chromosomal abnormalities, more than 100 genetic disorders and heart defects. But there is still a gap between advances and their implementation. From the time I proposed this screening until it was accepted, sixteen years passed.

It was also key in the creation of non-invasive prenatal tests (NIPT), which is a faster test with no risk of miscarriage.

— We realized that a blood sample could be taken from the woman and the DNA coming from the placenta could be examined. This is the basis of NIPT. Now in many countries [like Spain] people do the combined first-trimester test and, afterwards, if the risk is high, they do NIPT. But the question is: if it's so good, why isn't it offered to everyone? Well, because it's still expensive, and there's no reason for it to be. In fact, I argue that it should be used as the primary test, regardless of risk.

Now there is a debate about conscientious objection to abortion. Does your opinion change depending on whether there is a genetic disorder?

— In England, 20% of women, if we tell them that the baby has Down's syndrome, continue with the pregnancy. But 80% do not want to. Then there are other milder things or, if I go to the extreme, in some countries having a girl is not positive, as in India, and there is a risk that parents will terminate the pregnancy. Is it acceptable? Personally, it is not. But is it my responsibility to decide which conditions are acceptable and which are not? I can give an opinion, but in many respects I am irrelevant.

How is fetal medicine imagined in twenty years?

— We now have many medical advances. One is molecular biology. It is very likely that for many disorders that we do not understand now there will be a molecular basis that is completely or partially responsible for them. As we advance in molecular biology and understand more and more disorders, it will become an inherent part of our way of approaching the diagnosis and screening of these anomalies. Another area is imaging. In 1992, when I first saw this black space behind the neck, the imaging was very poor. And I was very lucky because it was easily visible. But now there has been a spectacular improvement in imaging. Not only with ultrasound, but with magnetic resonance imaging. Many fetal disorders we can now diagnose in a way that we could not before. And Barcelona is very lucky because it has some of the best specialists, such as those who use neurosonography. They are specialists who only study the fetal brain and can define anomalies that many people do not see and characterize the degree of intellectual disability associated with certain disorders.

And artificial intelligence?

— Ultrasound will require many years of experience, but it can help to capture images and interpret them. In addition, a current problem is controlling fetal growth. Many babies die because we do not detect that they are not growing well. Now I am working with Bill Gates on the use of AI so that with a simple device basic information about the fetus can be obtained. Only with a phone, making four vertical and horizontal passes over the mother's belly. This will make the technology accessible to developing countries and also to places with a lack of trained personnel.

In recent years there has been an increase in families storing umbilical cord blood from a child in private clinics to ensure they have stem cells in case the child develops a disease.

— I am very much against it. Many companies exploit families, in some countries in a more ruthless way than others. There are companies that frighten mothers by telling them that the child may have cancer. Doctors receive commissions. This is corruption. But in reality, the most likely scenario is that, if the child develops leukemia, the worst possible donor is the baby itself. On the other hand, I fully support the development of blood banks, national and international, so that if someone develops one of these disorders, they can easily find a donor.

Do we have a birth rate problem?

— There is a decrease in the desire to have children. In Greece, births have fallen sharply. In London, too: at my hospital, King's College Hospital, we used to have 5,000 births every year, and last year we had 4,000. After covid there has been a drop. Women have changed. They used to marry young and have children. When I started, 5% of pregnant women were over 35 years old, but now they are 40% or 50%. So what has changed drastically is that women are no longer just baby producers, they are professionals, they are independent and ambitious. This is positive. There are also economic problems and changes in relationships that make it difficult. Many men have difficulty adapting to intelligent women.