Is there a human issue more sensitive, thorny and obstacle-strewn than fertility? What our reproductive bodies are capable – or incapable – of, and why, can be a confusing business. Sometimes babies happen quickly and brilliantly. Sometimes conceiving is slow and emotionally gruelling. Sometimes we need help from science. Sometimes it doesn’t work at all and science cannot tell us why. What is clear is that, although the fundamental nature of human breeding is simple, the realities of fertility are textured and complex.
If we are contemplating having a baby, wondering if we can have one or are actively trying, there is a conveyor belt of news stories regarding fertility adding to the uncertainty so many of us carry. The discourse is cacophonous. Whether it’s concerning how women choose to try and gain a sense of autonomy over the ticking of their biological clocks or what it “means” to become a parent in your forties, facts and opinions swarm like bees. Sometimes, it can be helpful to strip things back to basics and work from there. Let’s start with a brief biology recap.
By definition, “fertility” refers to a person’s ability to produce offspring. For women, this commonly concerns ovulation: the monthly release of an egg. For men, it’s the quality of semen: the fluid containing sperm that is ejaculated during sex. Women have what’s known as a “fertile window” each month, a day or two either side of ovulation, although, as we’re taught in biology lessons at school, we can get pregnant at any time during our cycle if we’re having sex with a man without contraception.
Millions of us are now using cycle-tracking apps and know roughly when we’re ovulating. I use Clue, but am not, er, having the kind of sex that requires being aware of optimal pregnancy conditions. I track my cycle to be in tune with my hormonal fluctuations and their significant effect on my mood. It helps me feel more in control. I’m currently finishing a book on hormones and our mind-body relationships and have met many women who feel the same. I’ve also spoken to women who have used fertility-tracking based contraception apps like Daysy and Natural Cycles and fallen pregnant.
Such apps are, as Dawn Foster wrote in the Guardian, “simply the Vatican-favoured rhythm method repackaged in shiny, Silicon Valley jargon and a slick interface”. They have met considerable scrutiny. A remarkable paper by a scientist called Chelsea Polis was published this year, showing how fatally flawed the analysis behind Daysy’s effectiveness was. These apps offer a kind of medical intervention. If they are making health claims, they must have good evidence. As Polis argues in her paper, “marketing materials on contraceptive effectiveness should be subjected to appropriate oversight”.
In order for two humans to reproduce, a sperm cell must enter an egg cell so their genetic information can merge. Once this has happened, the fertilised egg is called a zygote. Cell division then begins and the dividing zygote gets pushed along the fallopian tube. Around four days after fertilisation, the zygote has about 100 cells and is called a blastocyst. When the blastocyst reaches the womb lining, it bobs around for a couple of days before nestling itself into the uterine wall – usually six or so days after fertilisation. This is the beginning of pregnancy.
The sperm-and-egg reproductive basics are as binary as almost everywhere else in the natural world. Some species are known to be completely asexual, however, and have no need for a male to reproduce – some species of whiptail lizards, for example. There are also some animals that are designed to make babies with a male but don’t always choose to. The phenomenon of virgin births, or “parthenogenesis”, is as spectacular as it is unnerving. In 2015, “virgin-born” sawfish were seen for the first time in the world. The same year, a study published in the journal Animal Behaviour suggested that female prickly stick insects might prefer to embark on parenthood alone because sex with males can – make your own comparisons – be damaging to them. All offspring produced asexually are female, too, so if the females carry on going it alone, the males could be effectively wiped out. They have been known to fight off amorous males, first squirting them with an anti-aphrodisiac chemical, then, if they won’t back off, they’ll aggressively kick their legs. I clench my fists in frustration at not being able to interview one of these sticky iconoclasts.
Alas, we female humans cannot make babies by ourselves, as much as some of us might like to. But how an embryo ends up in a woman’s womb, and, indeed, where the constituent parts of that embryo came from or when it was “made”, is, thanks to advanced technology, a variable thing. We have options: donor sperm, Intrauterine Insemination (IUI), IVF. As a woman who dearly wants children and also falls in love with other women, those options are important to me. But the beginning of a new human life can only, for want of a better phrase, come about one way. Another unavoidable fact, constantly shone in our eyes like an optician’s torch, is the use-by date of our eggs. Our “ovarian reserve” – the number of eggs women are born with – declines from conception to menopause.
Our ovaries may be small, looking a bit like a pair of new potatoes suspended in the lower abdomen, but they are powerhouses. They don’t just produce sex hormones; they contain hundreds and thousands of eggs. We are born with them all; a staggering fact, when you consider how small the ovaries are at birth. Obviously, we are not going to have hundreds and thousands of babies, but nature gives us a big back-up system. However, no new eggs develop after we enter this world.
A study in 2010 was the first to actually collate women’s fertility decline. The research showed that, on average, women are born with 300,000 potential egg cells per ovary, but this pool decreases at a much faster rate than first thought. The model showed that, for 95% of women, only 12% of the maximum ovarian reserve is present by the age of 30. Only 3% remains at 40. At the time, newspapers bellowed that this research was “the latest to warn women that they must not leave it too late to conceive”. However, if we shelve the oppressive headlines and probe the research a little deeper, the story is more nuanced.
Alas, we female humans cannot make babies by ourselves, as much as some of us might like to
What this study (with its relatively small sample size of 325) also showed was how enormous the difference can be between individual women’s ovarian reserve. Some women had as little as 35,000, others more than two million. Although it is extremely prudent to consider the fertility drop we have in our mid-thirties, women do have children into their late thirties and forties. Even fifties. Women who have been told by doctors they unequivocally cannot have kids end up getting pregnant. I know some of those women. Nature doesn’t always follow its own rules.
Many women worry about whether they’ll be able to have children in the future, particularly if living with conditions known to potentially affect fertility, like PCOS or endometriosis. Often, until we start trying for babies, we have no idea how easy or hard it will be. If we do find it hard to conceive, we might wish we’d started looking into things earlier. These concerns lead many women to have what is known as a “fertility MOT”; a blood test that measures a hormone known as anti-mullerian hormone (AMH), which gives an idea about a woman’s ovarian reserve.
For women who feel out of control regarding their fertility, an MOT offers a delicious sense of reassurance. However, they’ve been reported as “a waste of time and money” by the NHS, cost hundreds of pounds and, many doctors argue, are a way for pricey fertility clinics to exploit women’s fears. Particularly given that the blood test cannot assess the quality of your eggs – the most important part of the picture and something that, again, we don’t really know about until we start trying for a baby.
An American study, published last year, found fertility MOTs did not predict a woman’s chance of conceiving. Instead, the results showed that it doesn’t matter how many eggs a woman has in reserve to get pregnant, as long as she's still releasing eggs (ovulating) regularly. So, just because your MOT results come back “normal”, there’s no guarantee you’ll be able to conceive a baby. Equally, an “abnormal” MOT doesn’t mean you won’t be able to get pregnant. Given the evidence, it is not merely cynicism to suggest that Harley Street doctors are profiting from our anxiety, selling us compelling-sounding “evidence” that doesn’t hold up.
We are sold fertility reassurance all the time. Egg-freezing is another contentious subject. Barely a week goes by without a headline relating to the process. I should know. I am infertile due to scar-tissue damaged fallopian tubes following the spectacular rupturing of my appendix. My womb is fine, but I could never conceive naturally because a fertilised egg couldn’t move through my blocked little pipes. I was offered egg or embryo freezing in 2015, after my infertility was confirmed with a dye test during surgery to remove pelvic adhesions. I opted for embryo freezing with donor sperm. They’re on ice at my local hospital. Since writing about my own experience I have been asked every month by a different TV producer to speak on various panels when a new perspective or study is published somewhere. The last one was with Katie Hopkins, and they seemed surprised that I’d said no. But there is something big happening out there.
Sometimes babies happen quickly and brilliantly. And sometimes conceiving is slow and emotionally gruelling
The first official report on egg freezing in the UK from The Human Fertilisation and Embryology Authority (HFEA) shows an astonishing increase – 460% – in women freezing their eggs since 2010. The report also shows that, despite the surge, egg-freezing cycles still only account for a tiny 1.5% of UK fertility treatments. In 2016, only 19% of egg-freezing cycles were funded by the NHS for medical reasons, like preserving the fertility of women who were undergoing chemotherapy or, like me, are infertile due to organic cause. The 81% carried out in private clinics were likely down to what are referred to as “social” reasons, i.e. not having a stable partner or having financial or professional concerns. To deem the reasoning of a woman who isn’t ready to be a parent just yet, but who is aware of her declining fertility, as “social”, is pejorative and ripe for judgement. Prominent gynaecologists have said as much.
Egg-freezing is a huge commercial practice: 81% of cycles in 2016 that were carried out in private clinics set women back, on average, £3,350 a go. These women are not stupid. As those researching the phenomenon have pointed out, the process is often done with clear-eyed realism. It is true that improvements in egg-freezing technologies now means a far better chance of egg survival. It is also true that women who have not found a partner shouldn’t be penalised with childlessness, nor pressured into finding one because their fertility is declining.
Egg-freezing extends the window of opportunity, but it can also be mentally and physically taxing, requiring hormonal stimulation of the ovaries by daily injections and surgical retrieval of the eggs under anaesthetic. It is IVF, just without the embryo implantation at the end. Success rates are not high and, while women embarking on the process should absolutely be supported in their decisions, they should also be made aware of how realistic their chances at future pregnancy are. Egg-freezing is not, by any means, a foolproof safety net, and regulating bodies must start to engage more fully with questions around the growing commercialisation of this process.
As well as the efficiency of our gonads, our choices and attitudes towards baby-making are loaded with cultural and societal meanings. Hierarchies. Embedded in the layers is abundant stigma and shame. New research suggests that many women may have gone through the invasive process of IVF because of the lack of historical focus on male fertility. On the face of it, this arguably tells us something about whose feelings we’ve protected more.
The whole thing can feel like a disorientating web of expectation, and we still talk about so much of the reality of it all in hushed tones. Women who have used a surrogate, donated sperm or embryos, for example, are talked about behind the palms of hands, as if they’ve somehow bucked the “natural” ideal. I have seen this happen firsthand. But what is natural about desperately wanting children and not being able to conceive? Which god decides that this woman, or that loving couple, are “destined” to not have children when it’s perfectly possible to make it happen a different way?
I have, even in discussions with friends, felt my own shame at having to do it all a bit differently burn like a sciatic spasm. Intellectually, I know this is wrong, but years of historical, heteronormative stigma in society obviously hangs out in my fibres somewhere. And let’s not even talk about those women who say they don’t want children at all! As a society, we still often seem to find it incomprehensible that, just because she is equipped to, a woman doesn’t want to have children. We say things like, “Oh, she’ll come around in the end.” But why the hell should she? I still often think about Giles Coren saying “go fuck yourself you barren old hag” to a female journalist on Twitter and the layers of poison in those words; as if the true measure of a good, worthwhile woman is her fecundity.
It is one of nature’s cruellest tricks that not every woman who wants to have a child can. For those with that primal, language-eclipsing yearning in them, the fear of having it unmet is sadder than anything. However, although our collective species may have been hardwired to want to reproduce, our big clever brains give us the individual ability to choose whether we want to or not. That choice should be celebrated. Also, families take so many different shapes. Babies find their way into loving arms in many different ways and what’s most important, above all else, is that love. The only unassailable truth when it comes to fertility is that it wholly depends on the individual. Let’s get better at talking about that.