Clock ticks for us all

“THE pressure to have a child starts soon after being married.

Couples are frequently asked ‘Any news?’. There is a presumption that you will have children, so outside of the pressure of infertility itself, you have the social pressure, the pressure from parents and parents-in-law who are looking forward to being grandparents.”

So says Helen Browne, chair and co-founder of the National Infertility Support and Information Group (NISIG), who is speaking from experience. After seven failed IVF treatment cycles and a decade of trying for a child, she and her husband finally called it a day.

“I felt depressed, angry, bereaved, anxious and guilty and it was very difficult for me to see a future without children in our lives.

“Infertility treatment had taken over 10 out of 12 years of our married life. I was exhausted mentally, physically, emotionally and financially.”

Helen’s response to her devastating journey – establishing NISIG – was motivated by her own lonely experience; she saw a need for a forum where couples affected by infertility could share their pain and offer one another advice. That was in 1996. In the 14 years since, there have been many advances in the treatment of infertility, but some issues remain largely unchanged.

“Infertility is still a closet subject. The fertility clinic is the last place anyone wants to be. Everyone knows why you are there but no one speaks about it and everyone keeps their head down,” Helen says.

“With infertility, everything is taken out of your control. Nobody goes to the clinic singing and dancing. Sometimes in the media, clinics are portrayed as offering treatments for the rich, but the reality is infertility affects every social strata,” Helen says.

Infertility is more discerning when it comes to age and the cohort of women most affected are over the age of 35, the point at which experts agree female fertility generally starts to decline. However, some unfortunate women are affected at a much earlier stage.

“Two years ago I got a call from a guy who was driving home. He and his wife had got the news from their GP that she was menopausal. He was in bits and didn’t know what to say to her. She was looking in the mirror and seeing a young face but she had an older person’s condition,” Helen says. Fortunately, this experience is not the norm and the couple in question underwent donor egg treatment and went on to have twins.

Unsurprisingly, age of the female is a recurring theme in fertility clinics around the country and with the average age of first-time mothers at its highest in 50 years, the demand for fertility treatment is set to increase. Dr Mary Wingfield, clinical director of the Merrion Fertility Clinic in Dublin, predicts an increase of IVF in Ireland of at least 23% over the next decade based on population size – before taking into account the effects on infertility of sexually transmitted disease (STD) and increasing maternal age.

Central Statistics Office figures show the average age of all mothers giving birth has been rising steadily since the early 1980s. The average age of the 15,334 women who gave birth in the first quarter of this year was 30.9 years, up from 30.7 last year.

This growing trend towards deferred motherhood is not unique to Ireland. In Britain, fertility experts are calling for a public health awareness campaign and/or a schools educational programme, to sit side-by-side with lessons on safe-sex, to counter the perception that technology has evolved enough to overcome infertility irrespective of a woman’s age. This is a perception largely fuelled by mass media coverage of high profile Hollywood stars who give birth in their late 40s and who may or may not admit to using donor eggs. Some British fertility experts have also suggested women undergo a “fertility MOT” in their early 30s to measure ovarian reserve – the number of eggs they have left – which may help inform career or relationship choices.

Here at home, fertility experts also see the need for some form of national fertility awareness campaign and some believe it should start in school. At the Galway Fertility Unit in Rahoon, medical director Dr Declan Egan believes there are “a lot of messages” that should be incorporated into safe-sex education in schools “and fertility is one of them”. This is against a backdrop of a general lack of awareness that a woman has a finite number of eggs. While sperm form throughout a man’s reproductive life, a woman is born with all the eggs she will ever have. Over the years, her supply is depleted; of one to two million eggs present at birth, only 400 make it to ovulation and the remaining eggs age, diminishing their reproductive capacity.

“We go around talking to GPs trying to get the message out there that we need to see these women before they get to 40,41,42,” says Dr Egan, “but it seems to be a social problem now that women don’t get married until they are in their mid-30s and they don’t come along to us until they are 40 and we have a battle on our hands.

“So I think it’s a huge educational thing. People come here at 46, 47, 49 and are amazed that we can’t get them pregnant and that the only card you can put on the table with any realistic chance of success is egg donation,” Dr Egan says.

At Clane Fertility Clinic, consultant obstetrician and gynaecologist Dr Osman Shamoun says the majority of women don’t realise age 39 is a “bit late for fertility” and that the school biology class, with a captive audience, may be a good place to start to build awareness.

“I think if these kind of facts, the small facts, not the detailed facts, were given to students, I’m sure it would stick in their heads and they would be aware of it when they graduate or when they start a career and they would think of it as a priority as well. I think we would see more women coming forward for fertility treatment at a younger age if that message got through.”

Dr Wingfield, who is due to address a fertility conference in January on the topic From School to IVF, feels schoolchildren need to be made aware of how lifestyle choices and general health can impact fertility eg obesity, smoking (if either partner smokes it can reduce IVF success rates by 20%), the fallout from sexually transmitted disease, (particularly chlamydia, which, if left untreated, can lead to infertility) and the fact that women have a finite number of eggs.

“Women, if they want to have children, should be thinking about doing so in their late 20s and early 30s. They shouldn’t defer it for the sake of careers or building houses. Once you’re in your 40s, you can’t roll the clock back,” Dr Wingfield says.

Dr Egan agrees a fertility MOT at around the age of 30 may not be a bad idea. “Certainly, advice could be given on ovarian reserve because in some women their ovaries may be failing at 30 and they have no idea.”

However, Dr Edgar Mocanu, consultant-in-charge at the Human Assisted Reproduction Unit (HARI) in Dublin, points out that fertility/infertility “is the sum of two individuals” that try to reproduce and that any such testing should be performed from a couple’s perspective. He also points out that an abnormal test “does not automatically imply infertility, no more than a normal test guarantees fertility”.

Dr John Waterstone, medical director of the Cork Fertility Centre feels school is too early to introduce lessons on the biological clock. “The kids going to school are probably more pre-occupied in avoiding getting pregnant,” he says. However women in their 30s may need a wake-up call.

“The big message that needs to get out there is that for a woman, you can’t get away from age,” Dr Waterstone says.

“We do see women who are quite unrealistic in their expectations: on the one hand you see women who start panicking and they are only 32 and others who are 35 who say ‘Doctor, I’m getting very old’ and we say to them ‘You are young by our standards, relax, you have plenty of time’. And then there are other women who come in and they’re already 42 and when you say to them ‘I’m afraid your age is a problem, your ovaries don’t look good, your hormone tests indicate your ovaries are not working well,’ they get affronted and slightly insulted that you are being ageist.

“They don’t realise just how important the age thing is and they think, ‘I feel young, I look young, I exercise, I’m in good shape’, but they don’t realise that the ageing of the ovaries is inexorable. It doesn’t matter if you look young or feel young, this is beyond your control. Your ovaries work less well as you get older and is a serious issue on average after maybe age 38.”

Dr Mocanu believes the education system should include male and female reproduction classes.

“It is important for school children to understand that fertility is a finite opportunity and one should consider having a family young rather than when it’s too late. Career is important but should be developed in parallel to achieving the desired fertility potential. This cannot be achieved unless society understands and accepts this. Look at other countries where maternity leave is paid for two years.”

Both Dr Mocanu and Dr Egan believe men also need to be made aware that fertility declines with age. Dr Mocanu believes this decline “is poorly understood and talked about, even in specialised circles”.

Dr Egan points out that sperm count gets worse with age and environmental factors are also having an impact.

“Your best sperm count is in your teens and your 20s and it goes downhill from there. Male fertility and sperm counts have been falling in Europe and it’s due to toxins and the environment and it’s due to estrogens in foods, and so they are also on a timeline.”

Dr Waterstone believes some form of public education policy aimed at increasing female awareness of their fertility should be aimed at women age 30-35, although he acknowledges that personal circumstances can largely dictate the time in your life when a person is in a position to consider having a baby.

“It’s hard to tailor your personal commitments and relationships rigidly to ‘I must have a baby now’ because there may not be a man in your life, and what do you do?” Dr Waterstone asks.

It may be time, he thinks, for a Health Service Executive-type campaign to raise fertility awareness.

“Something along the lines of the approach taken in their drink awareness campaigns, or the campaign highlighting the need to use contraception. That kind of advertising would never have happened 10 years ago, now we have these health messages on national TV and there’s no reason why they shouldn’t do the same for reproduction.”

‘I talked to Karl about adoption. I came around to the idea before him, and this can be hard for a couple’

MARRIED at 20, Martina Horgan knew earlier than most that she had fertility issues.

Her efforts to overcome the obstacles to pregnancy began as young as 23.

“I had some gynaecological problems so I went to see my gynaecologist in Cork. I did actually become pregnant, but it didn’t take off. We had one of day of ‘hurray’ followed by ‘oh no’. But that gave us hope. At least it meant I was capable of getting pregnant.”

Four to five years and two surgeries later to address the problem of polycystic ovaries, there was no sign of the longed-for child. Martina says at no point during this time did her consultant mention that maybe she and her husband Karl should consider other options. “There just didn’t seem to be any information available,” Martina says.

In 1995, Martina travelled to Galway for her first round of IVF (in vitro fertilisation) – the treatment wasn’t available in Cork at the time.

“It didn’t work, but I didn’t find it a negative experience. It was as if any guilt I had felt that my body was failing me was taken away; and I also felt more in control because I understood each step of the process, that we got through egg recovery and embryo transfer. I felt with the first IVF that we had taken a positive step and for us, emotionally, it was probably what spurred us on to continue with treatment.”

Martina underwent a second round of IVF in 1998 which she found far more punishing both physically and mentally. “I think at that stage the realisation kicked in that my body had gone through enough and I think both of us knew I would never go for IVF again.”

Ten years into their marriage, the possibility of adoption was discussed.

“I came around to the idea before Karl, and this can be hard for a couple. It probably took him 10 to 11 years to get his head around adopting rather than having his own child.”

It took up to four years for the adoption process to be completed, and eventually, after 15 years of marriage, Leah joined the Horgan family from China.

“It was tough. People assume when the child arrives that it’s a fairytale ending, but that is when some of the real struggles begin. I had been married 15 years, was a very independent person and suddenly I found myself in a room in China with a nine-month-old baby who refused to drink milk. It was one of the scariest moments of my life.”

Ultimately, Martina says every minute of her journey to become a mum was worth it. “For us, it’s the most amazing thing in the world, to be a mum and dad.”

Martina is co-founder of the National Infertility Support and Information Group (NISIG).

‘I was getting apprehensive that I wouldn’t have any and even though I had a very loving husband and a good job, I could see this terrible long road of loneliness...’

BROODINESS was not an emotion Nicola Bradwell ever identified with until her mid-30s.

Her 20s were packed with travel and adventure, she had a very full life and a job she enjoyed.

It was only after she met her now husband, Feargal Courtney, that she thought about putting down roots and having a child.

“Most of my friends were late getting married and I think we were of a generation when we all had careers and I hadn’t given much thought to motherhood. Then suddenly, in my 30s, a switch came on, I felt hollow, and where once work had fulfilled me, I now had an ache. I didn’t realise what it was at the time, but now I think it was my body telling me what I really wanted,” Nicola says.

She married Feargal at 35 in 2002 and spent two years trying for a baby with no success.

“I was getting apprehensive that I wouldn’t have any and even though I had a very loving husband and a good job, I could see this terrible long road of loneliness stretching ahead of me. I did get very, very depressed.”

Eventually, she opted for IVF, with the support of her husband. “He obviously wanted children but he never put any pressure on me. He knew things were difficult and he totally supported my decision to seek help.”

Initial treatment with fertility drug Clomid at a clinic in Tralee, Co Kerry, was unsuccessful. She followed up with acupuncture to no avail.

“After two years of treatment I thought ‘God, I’m not very fertile’. I suppose I had never really been in tune with my own body, I was never very aware of my ovulation cycle the way other women would be, I had never really suffered from the hormonal shifts. I wondered if I had been infertile for quite some time.”

Nicola’s consultant in Tralee suggested IVF.

“I felt a sense of relief going for IVF. Before that, the waiting was just awful, instead of sex being enjoyable it became mechanical and set to deadlines. I started to feel that I was not a real woman. In the end, I just wanted someone to come in and help.”

They were successful on the first attempt. “I felt elated, but extremely apprehensive. I thought ‘this [the pregnancy] is not going to last’. I suppose you get to a stage where you don’t trust your body any more, it has let you down so many times.”

She was not let down. At age 39, following treatment at the Cork Fertility Centre, she gave birth to Luke in February 2007. She was back at the clinic seven months later trying for her second child. David was born in December 2008.

“We were both just so relieved and so delighted. Both of them are my miracle babies. I genuinely didn’t think that after 38, I would be able to have children and suddenly I had two.”

Nicola said she did not find the IVF process difficult and her advice to those contemplating the same journey is to “stay positive” but also not to give your whole life over to trying to have a child.

“Keep some perspective if you can. And always remember that if IVF is not successful, there are other options such as adoption or egg donation. Keep all avenues open but keep your life going at the same time. It is very, very important to hold onto your hobbies and your friends and not to get too consumed with trying to have a baby.

“It is also important to have people to talk to about what you are going through. I know a lot of people are frightened of it but I had tremendous support from my husband, family and friends, I never felt there was a stigma attached to what I was doing and it helped that I was surrounded by such a lot of positive feeling.”

‘Rituals such as my children’s christenings, confirmation and marriage were denied me’.

DIAGNOSED with endometriosis in my 20s, I knew I would have difficulty conceiving. My fallopian tubes were blocked and I opted for surgery to have them unblocked. Unfortunately, it was unsuccessful. IVF treatment was quite new in Ireland – it was the early 1990s – and I didn’t know too much about it. There was just one treatment clinic at the time and no internet. But I knew that in order for me to have my own child, I would have to go the IVF route. To be pregnant, give birth and have the opportunity to breastfeed my baby was so important and fundamental to me.

Following our second unsuccessful IVF treatment, I felt very low and alone. The feeling of isolation was so overwhelming that I decided to go for counselling. After five minutes I knew this was not for me: what I needed was to meet with, and share my pain with, those who knew what it was like. That was when I co-founded National Infertility Support and Information Group (NISIG). Sharing experiences, pain and disappointment helped me immensely.

Three women set up the group, each of whom had a different outcome following fertility treatment: success, adoption and acceptance. My own experience was that following seven treatment cycles and miscarriages I had to deal with not ever having my own child/children. When all I ever wanted was a family, it was a devastating blow.

After each treatment cycle, I felt depressed, angry, bereaved, anxious, and guilty.

Infertility treatment had taken over 10 out of 12 years of our married life. I was exhausted mentally, physically, emotionally and financially.

I felt socially excluded; my friends had new friends through their children. Rituals such as my children’s christenings, confirmation and marriage were denied me. I will never be a grandmother.

Although I’m a positive person it was exhausting keeping up a front and I withdrew from a lot of activities. Our decision not to pursue further treatment or adoption evolved over many years. I can look at it reasonably strongly now but deep down I am still angry at the unfairness of it all.

Acceptance can take a while, if not a lifetime. To come to terms with the idea of life without your own children, especially if it’s something you’ve always set your heart on, is a horrendously lonely and isolating grief, and one not acknowledged by society.

Insensitive remarks stick out in my mind, surprisingly often made by mothers. I have now learned to deal with it. I continue to smile, look elsewhere, count to 10 and make an excuse to leave.

Everyone assumes fertility. As you grow up, people say to you, “When you get married and have your kids...”.

Infertility shatters your identity. You have a picture in your mind and in it you are married, living in your dream home with a lovely back garden. But where are the children? Infertility shatters your rosy picture.

A person with a chronic disease or terminal illness gets support from all those around them, but to a couple struggling with infertility, these same people offer platitudes. “Count all your blessings“, or a couple who has kids will say “Take mine!” or “Relax, it will happen”.

Infertile couples suffer a similar level of heartache as those who are dealing with serious illness and they need to be treated with compassion and care.

Having a very kind and patient husband helped me to be where I am today. I will always miss deeply not ever being a mum and us not being parents.

I ask for people to be more empathetic towards other people and to those who don’t fit the mould: those who have left their 20s and are not married, those who are in their 40s and have not had a longed-for child, older people who cannot tell tales about their grandchildren. Stop and think before you speak.

Helen Browne is co-founder of the National Infertility Support and Information Group. To contact NISIG, phone 1890 647 444 Monday-Friday, 7.15pm 9.15pm. Mobile 087-7975058 (anytime)

Single women put babies before Mr Right

A NEW and growing trend in some fertility clinics around the country is the number of single women coming forward seeking assistance in getting pregnant.

Clane Fertility Clinic has seen 14 single women in the last year and has noted a “significant” rise in the number of enquiries in this category. The Sims Clinic in Dublin says it is seeing circa five single women per month and that the figure is rising all the time.

Some of these women are lesbians but others have simply not found a suitable partner. At the Cork Fertility Centre, nine single women sought treatment in the last 12 months. At the Kilkenny Clinic, about a fifth of IVF and intrauterine insemination (IUI) treatment cycles carried out in 2009 were for single women.

Kilkenny Clinic medical director Dr Martine Millett-Johnston (right) says the majority of single women they have seen have reached their late 30s or early 40s and have not found a suitable partner. “They are aware of their biological clock and we check their egg reserve and we will tailor a treatment plan to suit them. They will get full support and counselling, for these patients it’s mandatory. They also have to fill out appropriate Child Welfare Forms, as central to all our treatment is child welfare.”

In Clane, fertility unit manager Gladys Leyden says some single women have come to the clinic with elderly parents to support them. Consultant obstetrician and gynaecologist Dr Osman Shamoun, the person responsible for the Clane unit, says recently a single woman came to him and said “Mr Right can wait, but the baby can’t wait. I’m running out of time and I want a baby now, so Mr Right can come later.” Most of the single women that come to Clane are aged between 35 and 40.

Galway Fertility Unit treats less than five single women a year, but medical director Dr Declan Egan says he tends to be sympathetic. “Because if you’re 38, 39 and you’re a woman who’s had a relationship that was going for eight years and has broken up, you’re either going to have no children, or have them like this.

“We usually get a social report to see that all is well and that there are sisters or somebody around to help and that the woman is not going to be trying to mind a child and hold down a job with no one to help.”

The Cork Fertility Centre started treating single women about 20 months ago. Medical director Dr John Waterstone says the “most striking thing” among the single, heterosexual women who come to the clinic is that often they say: ‘Listen, this [donor sperm] isn’t what I would have chosen to do, but the fact of the matter is that I’m in my late 30s, I’m worried about how much time I have left to have a baby, Mr Right hasn’t come along and I want to have a baby’, but the depressing thing is, they may already have left it too late.”

For those worried that Mr Right may never come along, some women are looking into the idea of social egg freezing, currently not available in Ireland. The HARI unit does offer a medical egg freezing service for patients with a cancer diagnosis, but no baby has yet been born in Ireland following egg freezing and thawing. It has been done successfully elsewhere. At the Midland Fertility Services in Britain four ‘frozen egg babies’ have been born to three women who elected to freeze their eggs for non-cancer treatment reasons. To date, there has been more than 1,000 births worldwide as a result of egg freezing. In autumn of 2009, the American Society for Reproductive Medicine said egg freezing held “great promise” and that from the limited research performed to date, there did not appear to be an increase in chromosomal abnormalities, birth defects or developmental deficits in the children born from frozen and thawed eggs.

Dr Waterstone says that although egg freezing is a “theoretically attractive idea” it is technically difficult and that while a lot of clinics around the world offer the service, “very few of them are actually producing babies”.

“In our clinic I have pressure put on me be people in the laboratory who say ‘Wouldn’t it be nice to have the first baby after egg freezing in Ireland?’, and of course it would, but I don’t want to try and do something that doesn’t work, I don’t want to give false hope.”

Dr Waterstone says occasionally people ring the clinic and ask “Can you freeze our eggs?”

“I have to say ‘no’, because we don’t do this yet, and I also have to say to be a little bit cautious about where you go, I wouldn’t go on the internet and find some commercial London clinic that says ‘We freeze eggs’ because they may never produce a baby.”

Dr Egan believes there is little point in a woman freezing eggs in her late 30s because “they’re not going to be very good eggs and you’re not going to get very good results”. “You’re talking really about a woman of 30 deciding she’s going to freeze her eggs who might then meet somebody at 32 and get married and have three children and so you could waste a lot of money and time and effort.

“But if you are going to vitrify your eggs, you should do so at as young an age as you can and then go off and do your career and get married or whatever you like and get your partner’s sperm injected into the eggs and hope you get pregnant like that, that might be the future.”

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