Associate Professor Vinay Rane believes that the problem of infertility in female athletes is ‘endemic’.
He says, “I’m finding it’s the rule rather than the exception, for physiological, medical, mental and logistic reasons. I’m treating women who want access to what is a fundamental human right, and I don’t believe our sporting systems are structured to let that happen easily.”
While he’s been encouraged by maternity provisions in Netball Australia’s and Cricket Australia’s recent Players’ Agreements, he believes more can be done. “For women to be able to have a baby, and then be welcomed back into a code is important. We celebrate that as we should. But there are still so many barriers to fertility to consider, and that we could have systems in place to manage better.”
There are a number of ways in which athletes and experts believe that the players can be better educated or supported about issues they might face with their fertililty.
Awareness and Education
The athletes and experts interviewed for this article believe that the first step towards supporting fertility is awareness. Sporting leaders, coaches, support staff, athletes and parents should have some understanding of why there is anecdotal concern.
At an All Athletes Alliance meeting – a group that represents a number of different sporting codes – some 18 months ago, female athletes spoke out about fertility issues in sport. Some of the male attendees were ‘gobsmacked’ according to Australian netballer Natalie Medhurst. “They didn’t even realise it was something that concerned us.”
Associate Professors Rane and Clare Minahan concur. Professor Rane stated, “We need a commitment from the leaders of our sporting codes to acknowledge that it is an issue and there are things we can do to help.”
Professor Minahan explained further, “We need to get that message out to a range of people. One of the difficult things is the sports scientists’ and coaches’ thinking is performance based. However, you can’t have good performances without good health.
“So we really have to work together with doctors, and have a shared responsibility to get that right. We need a very strong message coming from our general practitioners and sports doctors to say that it’s incredibly important for your menstrual cycle to be like this, and that for that to happen you need to be healthy first and foremost.”
However, Professor Minahan believes that communication is still a significant barrier to knowledge shared between athletes, coaches, sports scientists and doctors. “Why isn’t that conversation happening, why don’t athletes know what a normal menstrual cycle should be, how do we enable an effective conversation around it? Unbelievably we are right back at this stage when it comes to women’s health.”
Current English international Geva Mentor is firmly of the opinion that netball organisations and clubs have a role in educating players about their fertility. She says, “In the first instance, it has to be driven by the players, what we want and need. We need a strong voice from the playing group so that it’s not a wishy-washy topic but something that is very important to us.
“We’ve fought hard over the years to get maternity cover, and that is acknowledged in our contracts. This is another step prior to that, talking about fertility.
“We talk about the impact that sport can have on your cycle and your periods, but let’s fast forward another step and talk about why we have periods, because that’s what we do as women, we have kids. So to have that education around what sport is doing to you, and what plans you can make for the future.
“I’m currently doing a finance wellbeing module in a four week course that we’re doing with all the Suncorp Super Netball players. You talk about saving for the future and planning and investing, it’s exactly the same. This time you’re investing in yourself and your body, not just a house or property.”
Kath Harby-Williams, CEO of the Australian Netball Players Association, also believes that fertility education is ‘a story that needs to be told.’ She says, “Concerns from the players have been vocalised to me, and it’s a piece of work that we need to do.
“There’s enough evidence to highlight that fertility could be an issue, and from our perspective it’s important to educate players, rather than them getting to the end of their career and thinking they weren’t armed with enough information to make decisions accordingly.
“What we are looking at as the Players Association is working in conjunction with Netball Australia and the clubs to have a standardised induction process. Incorporated into that will be topics including fertility. We have to give the players enough information so that they can look forwards while playing elite sport, rather than looking back at the end with regrets.”
Former Australian netball captain and author of ‘If at First You Don’t Conceive’, Liz Ellis, agrees. “I just assumed that because I kept myself fit throughout my life that I would be able to have children whenever I wanted them. That was the case for my first baby, but I could have saved myself years of heartache if I had have taken steps earlier.”
So, what knowledge needs to be shared? Ellis points out that teenagers are taught how not to get pregnant, but very few women are educated about how to conceive. “I think sport needs to address how to preserve your fertility, although it is so much better than when I was playing.”
According to Ellis, the information presented should include, “How it all works, making sure players know when their fertile windows close, the risks that you are taking putting off your child bearing years, but also what can be done around preserving that.
“For example, clubs could help players out in terms of accessing services for harvesting eggs, for freezing, and that sort of thing, so they have options for later. It can be a controversial area, but I think it’s something that players need to be educated on, and I certainly wasn’t.”
Professor Rane strongly supports providing athletes with fertility specific education and helping them to access medical services. He says, “I’m happy to talk to them about how it all works, particularly when they are in their twenties and before they run into problems.
“Athletes may not be aware that we can do blood tests to give them an indication of how many eggs they’ve got, and what quality those eggs are. We can do additional tests to give them an idea of how easy it may be for them to fall pregnant spontaneously, or whether they’re going to need assistance and what that might look like.”
Medhurst agrees. “I think we need to be more aware of players’ needs as they go through the system. What conversation do we have when they are 20, and how would that be different if they were 25, 30 or 35? Check in with them, where they are at, what they are thinking, should they be speaking to someone and what specialists are out there. The last thing we want is players coming to the end of their careers and wondering why they didn’t have the knowledge to act earlier.”
Low energy availability
While Netball Australia doesn’t have a specific position on fertility, the organisation is well aware of the impact that low energy availability can have on menstrual function, bone health, iron deficiency and injury.
In 2016 they put the highly important daily athlete monitoring system in place, which includes screening for potential dietary problems. Netball Australia’s chief medical officer Dr Susan White says, “Where players have been identified at risk of low energy availability, we have worked with Suncorp Super Netball club staff to ensure we are progressing this further with the athletes.”
The program has been extended throughout the entire netball national pathway with athletes who are 16 and older. Dr White says, “Energy availability is more and more becoming a focus area for athlete education sessions.” Athletes have access to nutritionists and a range of specialists to make sure they are fuelling their bodies correctly, which supports good menstrual function.
Globally, there has been little research done on how low energy availability impacts fertility. However, it is known that if an athlete has an irregular menstrual cycle as a result of a nutritional imbalance, this is usually restored with an increase in food intake.
This isn’t always easy for an athlete, and as Professor Rane points out, can be fraught with emotional problems. “If I say to any woman, let alone an athlete, that I want them to go home, eat some junk food, reduce their exercise and put on three kilos, they will burst into tears. They find it very difficult to do.”
While a number of athletes are placed on oral contraceptives for premenstrual and menstrual management, Professor Minahan believes that younger athletes and their parents should be educated about the pitfalls.
She says, “I think we need to put an athlete’s health in front of everything. We need to get pre-menstrual symptoms under control so athletes aren’t having huge cramping or other dysfunctions that can impact them. We need to get them back to a healthy menstrual cycle, so that athletes aren’t missing their periods. I’d rather see any female, if they are going to take oral contraceptives, establish a normal, regular menstrual cycle before they even consider it.”
Egg retrieval and storage
With increasing concerns that a female athlete’s dream of having a sporting career may mean sacrificing her dream of having a family, egg retrieval has become a real option. Eggs can be stored for use when the athlete’s playing career has finished.
The process involves stimulating the ovaries with hormonal medication to produce a larger quantity of eggs than normal, retrieving the eggs, and storing them in liquid nitrogen. The very real advantages include being able to time family around sporting careers, having a better quality of eggs by having them harvested at a younger age, and having enough eggs left to retrieve.”
According to Geva Mentor, “Hopefully I won’t need to use those eggs (that I harvested) and I can conceive naturally, but they are a security blanket. And then if I did conceive naturally in the first instance and wanted a second or third kid down the line I might look at using those eggs, because they’d be my 35 year old eggs, rather than my 45 year old eggs.”
“Knowing that I’m still single, it’s given me comfort that I’m not just going out there looking for someone to start a family with. Instead, I’m looking for someone who complements me and I want to spend my life with. It’s taken the pressure off.”
With thanks to Associate Professor Vinay Rane, Associate Professor Clare Minahan, Dr Susan White, Liz Ellis, Kath Harby-Williams, and particularly Geva Mentor, Natalie Medhurst and Sonia Mkoloma. In sharing their personal stories, these wonderful women are our greatest advocates for change.
This is Part Two of the serialisation of Netball Scoop’s investigation into fertility issues among female athletes. To read the rest of the series, follow these links: