NS EXCLUSIVE: Fertility and Elite Female Athletes

NS EXCLUSIVE: Fertility and Elite Female Athletes

By |2020-08-10T00:53:15+10:00August 4th, 2020|Categories: Featured, International, Uncategorized|0 Comments

This article has also been serialised, but appears in full format here.

 

Geva Mentor wants to have children, but, single and in the prime of her netball career, has been facing odds that are increasingly stacked against her. She recently went through an egg retrieval procedure in the hope of future proofing her dreams.

Natalie Medhurst considers herself lucky. She had fertility issues, and after going through a range of investigations and assisted measures she and her partner are expecting their first child.

Sonia Mkoloma is playing a numbers game, having had three miscarriages and three failed IVF cycles in the past six years. She didn’t start trying for a family until her elite career finished at the age of 35, and she’s anxious that it might not happen.

Aged between 35 to 41, the three athletes know about limitations. That their reproductive years, like their sporting careers, won’t last forever.  Given little concrete information about how sport could impact their fertility, they did their own research.

Each woman made a conscious decision to tread a pathway to assisted reproduction.  Littered along the way were physical, emotional, logistical and medical factors that complicated the process.

The trailblazers hope that by sharing some of their more intimate details, that people might gain a wider understanding of the problems they faced, and why all active females should consider their health as well as their sporting careers.

Mentor explains, “It should be a fundamental foundation topic that’s spoken about quite comfortably, and that we’re able to share.”

So what are the barriers that an elite female athlete faces to have children?

 

BARRIERS TO FERTILITY FOR AN ELITE FEMALE ATHLETE

 

Geva Mentor and Nat Medhurst sharing a moment at Collingwood. Image Kirsten Daley

 

Physical factors

Altered menstrual cycles are all too common among female athletes and can play havoc with their fertility. Research has shown that elite athletes are at far greater risk of menstrual dysfunction, with up to 65% of long-distance runners developing issues, compared to 2-5% of the regular population. Changes are generally caused by low energy availability, which happens when athletes aren’t eating enough to fuel their training loads.

According to an expert in reproductive health, Associate Professor Vinay Rane of the Melbourne Mothers clinic, “Unfortunately there is seen to be a significant performance advantage in some sports for not carrying extra body weight, and it is impacting fertility. One of the keys steps in becoming pregnant is being able to ovulate, and that is often suppressed when women don’t carry an adequate body fat percentage.”

Australian netballer Natalie Medhurst adds, “It’s related to the rigours of sport at this level. We push our bodies to extreme physical exertion that goes above and beyond regular exercise. While refuelling is critical, there is also an unnecessary emphasis on our weight and skin folds. It’s almost toxic at times.”

So how does weight impact the menstrual cycle? Reproductive hormones are stored in the body’s fat layers, and with a reduced body mass index, many changes can be experienced. These may include increased levels of androgens, and decreased levels of estrogen, progesterone and leptin. Problems resulting from these changes can include an inability to ovulate and secondary amenorrhea (loss of periods). Other symptoms can include reduced bone mineral density and iron deficiency.

Associate Professor Clare Minehan, of Griffith University, who researches the menstrual cycle in athletes says, “A lot of elite athletes think that if they miss their period, that’s fantastic, they must be training hard. And then if their period returns, they feel like they haven’t done enough.”

Medhurst agrees. “It’s scary to think that in sports such as gymnastics, for girls not to have their period is almost celebrated. It’s just shocking.”

Sadly, fat shaming is still a very real issue in sport and was never more pronounced than when sections of the media attacked swimmer Liesel Jones at the 2012 London Olympics. In the twilight of her career, Jones had a more mature figure than in her teenage days, resulting in mud thrown at her fitness to swim. Her autobiography, Body Lengths, tells of the shocking pressure on many female athletes to diet.

In addition to weight related problems, Professor Rane finds a number of elite female athletes have polycystic ovary syndrome. He explains, “This is an underlying medical condition that elevates androgen levels (male-related sex hormones). The athletes effectively have a competitive advantage throughout their lives, but it sadly comes at the expense of their fertility levels.”

 

Many female athletes have a low body mass index. Image Aliesha Vicars.

 

Oral contraceptives

The regular prescription of oral contraceptives to manage premenstrual and menstrual symptoms during training and competition is a source of concern for Professor Minehan.

The problem is two-fold: it can mask fertility issues and can have a negative impact on bone mineral density which may already be impacted by low energy availability.

Professor Minehan says, “Having your ‘bleed’ on oral contraception doesn’t mean you’re having a natural period. You may never have had a normal menstrual cycle in the first place, so establishing this should really happen before the pill is prescribed.

“There is also a problem if girls haven’t yet reached peak bone mass, and that doesn’t happen till their mid-twenties. By putting them on oral contraception, you are putting them at risk of poor bone health. That could be right throughout their life span, from being an athlete at increased risk of stress fractures, right through to osteoporosis as an older individual.”

It’s an issue that impacted Medhurst. It wasn’t until she underwent investigations that she found she wasn’t ovulating, a problem that had been covered up by her use of oral contraceptives.

“I was gobsmacked. It was my own decision to speak to a specialist about it, and I sat there thinking, ‘What have I been doing to my body? What could I have done differently?’ For all these years my body has been able to do X, Y and Z as an athlete, and now it can’t do the one thing it’s meant to do on its own. Had I compromised that in some way?”

 

Many female athletes use oral contraceptives to manage their menstrual cycle. Image Aliesha Vicars

 

Age

Female athletes are celebrating moves to a semi-professional era by staying in their chosen sport for longer. After years of existing on a shoestring, many can earn a comfortable salary for doing what they’re good at. And why not? says commentator and former Australian netball captain Liz Ellis. “You do want to extend your career for as long as you can, because why wouldn’t you want to have the best job in the world. But with that comes the idea that you have to be able to start your family.”

While many athletes are wanting to extend their career into their thirties, it’s the decade when fertility rates are plummeting. A forty-year-old has just a 5% chance of conceiving naturally, and an 11% chance of having a live birth after a successful IVF cycle. At this age, 50% of pregnancies end in miscarriage. Younger, bullet-proof athletes rarely know or stop to consider such frightening statistics.

English international Geva Mentor says, “While for me age is just a number, it’s not when it comes to my body clock which is ticking. I want to continue playing netball, but I’m facing the very real fact that things deteriorate.

“Your egg quality declines, the possibility of being able to get pregnant deteriorates, and there are associated health problems with age. Unfortunately, it’s not until now that I’m in this older stage that I’ve looked into it more.”

 

At 35, Geva Mentor is aware that her body clock is ticking. Image Kirsten Daley.

 

Timing

If absence makes the heart grow fonder, it doesn’t make conception any easier. Many athletes are competing, or travelling to compete, during the crucial hours of ovulation when they need to be having unprotected intercourse to conceive.

In addition, the cyclical nature of sport makes finding a big enough window for pregnancy and childbirth almost impossible. Professor Rane says, “Often I will have athletes walk into my office and say, ‘Right, I’ve got the Pan Pacs here, the Comm Games here, the Olympics coming up, so I need to have a baby on October 21 2022, and so I need to be pregnant on this day. They know they want to have a baby, but there just isn’t enough time.”

It’s an unusual situation, as many women can continue to work until late in their pregnancy. Unable to train or compete at elite level from around the three month mark of a pregnancy, until well after the baby is born, athletes are generally out of sport for almost a year.

Medhurst says, “The demands on athletes have increased so much in recent years. The international netball cycle runs for 11 months of the year, making it more difficult to take time out for a family.”

Fertility treatment also has it’s time difficulties. Medhurst was on fertility treatment during the 2019 netball season, having to take her medications with her and injecting herself while travelling.

Mentor was granted a break from her international duties with England, so that she could use the 2019 Christmas period for fertility treatment and egg retrieval, something that she says took four to six weeks to recover from. It was literally the only window in a twelve-month cycle that she could have managed, making the procedure a once per year option.

She says, “Physically and emotionally, there’s no way that I could have done weight training or court work during this time.”

 

Geva Mentor was granted a break from England duties for medical reasons. Image: May Bailey

 

Emotional factors

There can be significant psychological barriers to becoming pregnant as an athlete. There’s the balance between wanting a baby and wanting to succeed at sport. Medhurst explains, “Firstly there’s the concern that if you take time away from sport for a family, then you might not get selected back in the side again. Miss a year, and you’re done!

“Control is also a massive factor. For years you control everything you can around your performance – you train correctly, you eat appropriately, you do your rehab. But becoming pregnant is the one thing you have no control over. And if you can’t fall pregnant you then wonder if you’ve compromised that, if you’ve done something wrong.

“You feel like a failure. You blame yourself. To become a mother you are hanging on to so much hope, with no promises or guarantees on the end of it. That can be heart breaking.”

While Medhurst acknowledges that Collingwood have given her exceptional support she is worried that this may not always be the case in other situations. “Clubs are in the business of winning games, and I know when maternity provisions were put in the latest Players’ Agreement, that there was very real concern from the member organisations that more players would become pregnant and have a paid holiday.

“But it’s not that easy to fall pregnant, and given that there’s no assurances or support for players to come back if they’re out of contract, those concerns are skewed.

“Players have just as much right to have a family and receive maternity provisions as anyone, so sadly it highlights that clubs are more concerned about performance and less about the health and welfare of their athletes.”

 

Collingwood coach Rob Wright has been supportive of his athletes’ welfare. Image: Aliesha Vicars

 

Fertility drugs

One of the many dichotomies that Professor Rane faces is the use of fertility drugs to induce ovulation in female athletes. The World Anti-Doping Agency has banned the use of oral medications such as Clomiphene and Letrozole, while still allowing follicle stimulating hormone injections.

Rane says, “It’s invasive, and a far more costly process, partly due to the fees, but also because the athlete has to be monitored by ultrasound which means being at the doctor’s clinic every time it’s needed, which can be quite often during fertility treatment. That is incredibly draining, and difficult to navigate while they’re also supposed to be training or competing.”

“I don’t believe the oral medications belong on the banned list, as how can they give a performance advantage? But the WADA default position is that any drug can’t be taken unless proved otherwise.”

Simone Forbes, a five-sport international, took Clomiphene during her netball off-season for well-documented fertility issues. Captain of the Jamaican national team, she was banned just before the 2011 Netball World Cup, leading to her forced retirement.

Situations like this incense Professor Rane. “The notion of being banned for four years for taking a fertility drug – which is career ending – is heart breaking. It’s terribly irresponsible that more isn’t being done in this space to support female athletes.”

 

 

HOW CAN FEMALE ATHLETES BE BETTER SUPPORTED

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.

 

Players’ Agreements provide support for athletes/mothers like Laura Geitz. Image: Marcela Massey

 

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 Minehan 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 Minehan 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 Minehan 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.”

 

Geva Mentor believes that education about fertility is driven by the players’ needs. Image Danny Dalton.

 

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.”

 

As CEO of the Australian Netball Players Association, Kath Harby-Williams is highly supportive of the athletes’ needs. Her experience as a former international and Australian captain has given her insights into the issues they face. Photo: Simon Leonard

 

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.”

 

Former Australian captain and current commentator experienced fertility issues. Her book, ‘If at first you don’t conceive’ is a wealth of information on the topic. Photo: Aliesha Vicars

 

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.”

 

Energy availability is crucial for athletes to perform well. Image Steve McLeod

 

Oral contraceptives

While a number of athletes are placed on oral contraceptives for premenstrual and menstrual management, Professor Minehan 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.”

 

 

Geva Mentor learning to self-inject during her fertility treatment. Image courtesy of Geva Mentor

 

 

GEVA MENTOR – I retrieved my eggs

Geva Mentor is investing in her future. Looking to a life after netball, she is studying to become a teacher, learning – along with other Suncorp Super Netball players – how to invest her pennies, and has recently been through an egg retrieval process.

Using technology to preserve her fertility was a big, but considered, step. Geva said, “Having a family is something that I always just imagined would come. You get married, you get a house, kids and pets, and the whole family lifestyle. But once you have sport wrapped into that things change, a different order occurs.”

It was in 2019 that Geva reached a point where she went from wanting to be a mother in the future, to worrying that it might not happen. Her marriage had ended and it was proving difficult to find the right long term partner. “One that I can enjoy life with, work with, someone who is a companion and I can share everything with.

“Because for me, having a baby is about more than just bringing someone into the world, it’s about creating new life with someone you love.”

 

Geva Mentor in action for Colllingwood. Image: Kirsten Daley

 

Geva started talking to friends and teammates of a similar age, sharing information and perspectives. All her research gave Geva some very real concerns about her own fertility. She explained, “Being an athlete, sometimes you have a regular period but sometimes you don’t. I was thinking, ‘If I’m not having periods, am I losing my fertility?’”

Aged 35, Geva also knew that time was against her. “While for me age is just a number, it’s not when it comes to my body clock which is ticking. I want to continue playing netball, but I’m facing the very real fact that things deteriorate. Your egg quality declines, the possibility of being able to get pregnant deteriorates, and there are associated health problems with age.”

She made the decision to go through some preliminary tests; not to start a family at once, but to see how well her reproductive system was working and what urgency there was to take action. Geva made an appointment to see a gynaecologist, and was referred on to a fertility specialist at the Melbourne IVF clinic.

 

Read about Geva’s egg retrieval process below.

 

There was a lot to consider about her options, and it was a period of time that was highly emotional for Geva. Having decided on an egg retrieval process, it was during the evaluation stages that the enormity of her decision hit. She said, “At one of the appointments I had to meet the nurse, and she was talking me through my medication box and how to do my injections.

“I just started crying. I told her that I was so sorry, but I never imagined going through this process, and being here by myself. I have never felt so alone.”

“The nurse was really comforting, and I know I’ve got friends who would hold my hand through the process, but it’s not the same.

“You imagine that if you had to go down that pathway, that you’d be doing it with a partner.”

“I also had an emotional release afterwards, knowing that I was pretty fertile and that I may never need to use the eggs. That I had time to meet the right person, which makes me more comfortable dating.”

While Geva says that Collingwood have been highly supportive of her during the process, she “absolutely” believes that more needs to be done to educate players at a club or national level.

“It should be a fundamental foundation topic that’s spoken about quite comfortably, and we’re able to share. That the knowledge is put out there for all to share, and that it is encouraged. To know that if we want to explore further, the opportunities are there and that we are supported.”

“We’ve fought hard over the years to get maternity cover, and that is acknowledged in our contracts. Talking about fertility is another step that needs to happen prior to that. We talk about the impact that sport can have on our cycle and our periods, but 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 us, and what plans we can make for the future.”

 

Geva Mentor has been an English international since her teenage years. Image: May Bailey

 

Most importantly Geva wants the mindset around fertility management to change. She said, “It shouldn’t be seen as something you HAVE to do because you’re old and you’re single. I believe it’s something that you SHOULD be able to do for yourself, because you might want to continue your playing career while you still can.

“You might have a lovely partner at home to have kids with, but you should also have the choice of being able to use your 28 year old eggs, for example, rather than your 35 year old eggs, or what ever age they are when you finish your playing career.”

“I’d like to think that as athletes, we become well-informed, comfortable, and supported when it comes to talking about and managing our fertility.”

 

Geva talks about her egg retrieval process

 

I’m not on the pill anymore. After I stopped taking it, it took a while to start having regular periods. Once that was established I gave the fertility clinic a call on the third day of my period to start the process.

By that time I’d gone through some counselling sessions, which is sitting down with a nurse and talking through where I was at with everything, a double check to make sure I was of sound mind and doing it for the right reasons, and then some health and financial checks. I was given a medication box, and learned how to do the injections myself.

The first couple of days were pretty daunting until I got on a roll. I was injecting myself in the tummy, I did it in the mornings and it had to be at the same time every day. I did that for a certain amount of time – and every woman is different – for me I was doing it for just under two weeks.

The whole time during the injections I felt fine, although I was a little bit bloated with some major flatulence! I didn’t really feel emotional, which apparently can be like PMS symptoms.

After three or four days of injections I went in for internal scans to see how my eggs were developing. The injections were stimulating my egg follicles and trying to grow them to a size where they could be taken out and stored. They needed to be around 18 to 20 ml.

I went in for three internal scans, which is the most uncomfortable thing. You can have a laugh about it afterwards, because it’s like a wand that they put a massive condom over and put inside you. You get to see it all. You see your left and right ovaries and see what’s happening.

When the eggs were the right size, I had to give myself a trigger injection, and two days later my eggs were taken out.

The day that I went in for the surgery, I woke up with really tight stomach cramps, and by the time I got to the hospital I was literally bent in half walking through reception. I could barely get onto the table.

The specialist usually wants to take around 20 eggs, although it depends on whether they are getting frozen or whether they are going to be used for re-insemination. They need a good, healthy number to freeze, and they ended up taking 41 of my eggs. As they were all around 20ml, I was so uncomfortable and feeling like I had golf balls in my tummy.

The procedure usually takes between 10 and 20 minutes, and it’s done under a light anaesthetic. During the surgical preparation my doctor, who was the one familiar face in the theatre, held my hand, stroked it and spoke gently to me while I drifted off. I remember squeezing her hand and it was so comforting.

When I woke up in the recovery room I saw a clock, realised what I had just been through and burst into tears. Yes, my emotions were high, my hormones were through the roof, and I was thankful it was done. I remember being full of so much self pity that I was again here by myself, doing something I never thought I’d need to do alone.

 

Geva Mentor post egg retrieval. An emotional time. Image courtesy of Geva Mentor

 

The next day they gave me a ring to let me know how many eggs had survived the process and were able to be frozen, and that was 38 of them for me.

Because I was very fertile I got put on a watch list for the next week, and got a phone call from the hospital every morning to see what my symptoms were because I was hyperstimulated.

It was the few days afterwards that were the most uncomfortable and gross part of the process because I had to wear industrial sized sanitary pads for the bleeding and clotting. You can’t use tampons, you have to leave the whole area alone.

To get each egg they have to pierce the vagina wall, so I had my vagina wall pierced 41 times. I was meant to go to the tennis that evening and couldn’t. I was in bed horizontal for 2 days with heat packs. Everyone’s symptoms are different but I was probably on the higher end of it because I had so many eggs retrieved.

The first time I looked down at the pad I thought I was haemorrhaging. It was a sight that I hadn’t seen before and I didn’t know if it was right until I’d spoken to the nurses the next day. They told me that as long as the blood was dark it was okay, but if it was bright, then I could be haemorrhaging. But luckily it was dark and just old blood clots, so I was okay.

It took three to four days for the bleeding to stop, and then I was back to kind of normal, but I wasn’t myself for four to six weeks afterwards. It took a while to deflate so I felt bloated afterwards.

I had it done the beginning of January, and Collingwood didn’t start back at pre-season till the beginning of February. Physically and emotionally, there’s no way that I could have done weight training or court work during this time.

It was a pretty costly experience – somewhere between $8000 and $10 000, and then about $500 per year for storage. But I figure that I pay car and contents insurance, so this was another form of insurance for something that was so important to me.

I would go through the process again, for the overall outcome far outweighs any embarrassment or discomfort, and the feeling of knowing how many eggs I had frozen was joyous. I was proud of my body.

 

Geva Mentor at the 2019 Netball World Championships. A highly respected advocate for women’s sport. Image: Danny Dalton

 

 

NATALIE MEDHURST – pregnant after fertility treatment

It’s almost unbelievable to Natalie Medhurst, but at 36 and at the tail end of an elite netball career spanning 17 years, she is pregnant. Emotionally, she’s ‘excited, daunted, and everything in between,’ but most of all, she’s grateful. Facing fertility issues and struggling with the all-encompassing nature of elite sport, she wasn’t sure she’d ever become a mum.

In her earlier years, neither Nat nor her ex-husband wanted kids. On reflection, she said, “I think it was because we realised deep down that we just didn’t want kids with each other. When that relationship finished, my whole perception changed.”

In 2018 Nat met Samuel Butler and, the happiest they’d ever been, the pair quickly realised they wanted a future together. “We’d both been through a lot in terms of previous relationships, so we spent a lot of time talking about who we were as people, our goals and so on.

“The discussion around having a family came up really early, and he was the one who encouraged me to get looked at because I was on oral contraception at that point. So I made an appointment to see a doctor, and things progressed from there.”

 

Read about Nat’s medical experience below.

 

Across the next 12 months, Nat went off her oral contraceptives, had various tests and medical procedures, fertility injections, and played the waiting game to see what would happen. It was an unsettling time. She said, “You go through so many emotions when you are trying to get pregnant and you can’t, or it’s not happening.

“To know that the problem was with me was really hard. In sport, I’ve always got my body to do what I needed to do, and perform week in and week out. As females, we are the ones who procreate. While it’s an individual choice as to whether or not we do, it’s our purpose.

“So to think I’d failed in that department, after a career of controlling everything I could about my body, was really hard.

“Together with the issue of my age, the gynaecologist gave me no guarantees that I could become pregnant. That was a lot to digest – I felt as if I was on a rollercoaster.

“I remember being told by the specialist that being too active could work against me. So when she told me not to do too much exercise, I just laughed. It’s part of my job as an elite athlete, so I wasn’t sure how that was going to work.”

 

Nat Medhurst on court for the Diamonds against the Malawi Queens in 2013. Photo: Simon Leonard

 

Nat’s first cycle of fertility injections failed, and she remembers all too well the misery of its ending. It was the day of the AFL grand final, and as a former West Coast Eagle premiership player, Samuel was attending a function. Nat was at a girlfriend’s house when her period arrived.

“I was an absolute mess. I sent him a message saying it hadn’t worked, and next thing I know he was at home, ringing me to find out where I was. I hadn’t asked him to come, but for him to leave such a special function to be with me was pretty amazing.”

Almost unbelievably to Nat, the second cycle was a success. She was training at Collingwood when she received the news, and immediately let the club doctor and head of high performance know. Telling Samuel had to wait for four days until he returned from London.

“I’d developed a small cyst or some fluid that was picked up on the ultrasound, so if I wasn’t pregnant I was going to need surgery to see what it was, in case it was stopping me from becoming pregnant. I didn’t want to tell Samuel if I needed surgery on the phone, because then he’d know if I was pregnant.”

Collingwood told Nat to take some time off training so that she could enjoy telling Samuel her news. “I remember picking him up from the airport, and I hadn’t seen him for ten days. I was highly hormonal and very emotional, I was in tears when I saw him. But I waited till we got home to tell him.”

The first 14 weeks of Nat’s pregnancy were rough. She was exhausted, nauseous all day and often vomiting while trying to combine it with the rigours of pre-season training. She was also concerned about a tournament in New Zealand, where she would be expected to play five games in six days.

The Collingwood coach, Rob Wright, called Nat into a meeting. “He said that I didn’t look right. We’d previously spoken about managing my load, and he asked if I wanted to have a break from netball. When he asked how I was feeling, I said, ‘I’m feeling pregnant!’ His jaw just dropped.”

“I felt sorry for Rob, because I was the third Collingwood player who’d done it to him, but he was phenomenal, just so excited for us.

“I was also relieved that I’d told him, because he needed time to get his head around what it meant for the team.”

 

Nat Medhurst is appreciative of the support from Collingwood. Image: Aliesha Vicars

 

Nat feels incredibly fortunate that Collingwood offered her so much moral and practical support, but is also worried that it might not be the experience at every other club.

“The club, and Rob in particular, get that there is more to life than sport, and they are very family oriented. They’ve been so excited and ridden everything with me. It’s made my pregnancy so much more enjoyable, at what is a fairly emotional time.

“But clubs are in the business of winning games, and I know when maternity provisions were put in the latest Players’ Agreement, that there was very real concern from the member organisations that more players would become pregnant and have a paid holiday.

“But it’s not that easy to fall pregnant, and given that there’s no assurances or support for players to come back if they’re out of contract, those concerns are skewed.

“Players have just as much right to have a family and receive maternity provisions as anyone, so sadly it highlights that clubs are more concerned about performance and less about the health and welfare of their athletes.”

As Nat would be too pregnant to play 2020 Suncorp Super Netball, she and the club decided there would be no point in ‘flogging’ her during the rest of the pre-season. The club kept her involved in the program as best they could, but after so long at the top she found it difficult to sit on the sidelines. Nat said, “I really struggled with that.”

“I’d always been part of a team, you train, you play, you work towards something. So I suddenly felt obsolete. I was in the team, but not in the team, I was a player, but not a player. I didn’t know where to go or who to talk to. While the club was great, and it wasn’t anyone’s fault, it was just the reality of being part of a sporting environment.”

 

Nat Medhurst represented the Queensland Firebirds from 2010 – 2013. Photo: Simon Leonard

 

Nat still isn’t sure if she’ll return to elite netball. She’d always assumed that 2020 would be her last season, but she now has a sense of unfinished business. “As an athlete there’s no transition phase between having a working career, and having a family. There’s no middle ground.

“It would be awesome if I could come back and play, and the coaches have given some thought to it. But I’m going through something I’ve never done before. I’ve no idea what it will be like physically, what kind of birth I will have. Even if everything goes well, I may not want to, because becoming a mum might change all of my priorities.

“I do know that I’d never do anything that would put the baby or myself at risk of coming back, because I’ve got nothing to prove. But on the flip side, I might want to play on.”

During the 12 month period in which Nat’s had her fertility examined and gone on to become pregnant, Samuel has been with her every step of the way. Nat said, “I have taken so much strength and positivity from going through this process together. It’s been incredibly challenging and emotional at times, but he’s given me so much support.

“He’s given me my injections because he wanted to be part of the process. He’s been very hands-on and can’t wait to be a father. I think he’s going to be amazing at that.”

While Nat’s had the outcome she wanted, she feels that the topic of fertility is shrouded in secrecy for elite athletes. That there isn’t enough information readily available. That players feel guilty because they are trying to balance a sporting career with becoming mums. That some club staff may lack understanding.

“There’s no education on what the impact of waiting to have a family can have, or if you do want to wait, what are your options. What decisions can you control when it comes to your body, your fertility and your desire to have a family down the track.

“Very few women can have a baby at a perfect time in their playing career, and then come back without any detriment. While some players like (Laura) Geitzy, and Bec Bulley and Renae Ingles manage it and are sensational, it’s sad that there’s not more.

“There needs to be greater support given so that athletes don’t feel they have to sacrifice one dream for another.”

 

Nat Medhurst and Sam Butler announcing their pregnancy. Image courtesy of Nat Medhurst

 

Nat’s medical experience

The first step was to stop taking oral contraception.

I’d been off it for a while, and nothing was happening. So when I moved to Melbourne I went to see a specialist, and started by having some blood tests. Collingwood was at a pre-season tournament in Hobart (in 2019) and because of the timing I had to get a blood test while I was there to see what was happening with my ovulation and egg numbers. It came back that I wasn’t ovulating.

Samuel and I then sat down with the obstetrician, putting in the factors of age, what that meant, what it looked like, and working out a plan.

We’d flagged at the time that there was some medication that I could use to help me ovulate. But it was banned by the World Anti-Doping Authority, which a lot of female athletes wouldn’t realise. I only knew that because I remember Simone Forbes was missing from the 2011 Netball World Championships, because her doctor didn’t know. I told my obstetrician, he did some research and found that it was. I wouldn’t have known otherwise, so it was pure luck that I remembered that story.

We spoke about trying to get a TUE (Therapeutic Use Exemption), but the specialist said that even if we went down that path, if I had any blockages of my tubes, or endometriosis, that the medication wouldn’t work anyway. He needed to go in and have a look.

I wanted to get on the front foot straight away, and the club agreed that I could have surgery a week before the 2019 pre-season tournament in Brisbane. The specialist had a look through my insides, found that I had a blocked fallopian tube, and cleaned a few things up.

I probably shouldn’t have played six days after the surgery, and I know the specialist thought I was an idiot. But I didn’t feel comfortable taking that time off because I had a sense of guilt that I was looking after my own health and I didn’t have 100% of my attention on netball. The club was great, but it’s just that we don’t discuss these topics at that level.

From then it was a waiting game. I went through so many emotions, and that is true for any woman who is trying to get pregnant.

 

Nat Medhurst, in the early stages of pregnancy, with her partner Sam Butler. Image courtesy of Nat Medhurst

 

My obstetrician then referred me to a fertility specialist, and we had another thorough conversation about what treatment might look like and medication that was safe for me to use. It was so reassuring to have a plan in place.

I was put onto Gonal-F injections, which is a naturally occurring hormone used to stimulate a follicle to develop and mature. I was going to have to inject myself daily into the abdomen, in a process similar to IVF. The specialist didn’t know how my body would respond, so we started on the lowest possible dose.

Samuel was doing the injections for me when he could, but it was during the playing season so I would travel with my medication and inject myself in hotel rooms in private. I don’t even like taking Panadol, so it was amazing to have Samuel so involved and seeing what I was doing to my body.

After a week of injections I went back for an internal ultrasound, so the clinic could look at the size of the follicles and how they were developing. We were trying to force a follicle to perform so that I would then ovulate.

The first round took quite a while, and then we started increasing the dosage until the point where things started to respond. I was going for internal ultrasounds about every week until the follicle reached 10 ml in size, then I had to go in every three to four days after that, because the follicle can grow almost 2 ml per day.

They had to check so regularly so that my ovaries weren’t overstimulated and to make sure I’d only produced one egg. Once the follicle was big enough I gave myself a big injection known as a trigger shot. This made the follicle drop so that I ovulated.

Then I was given a piece of paper that mapped out our sex life. It told us to have sex on this day and this day, and that we could also have sex on this day. Then it’s almost a three week wait from the time of the trigger shot to the pregnancy test.

The specialist wasn’t going to give us too many chances for this to work, because my age was against me.

On the second cycle, my body felt so different after the trigger shot. I was exhausted – having dinner at 4.30 pm and going straight to bed, and that was fairly shortly after a three hour nap. I had sore boobs, I was really hot, and that’s pretty rare because I have Reynaud’s disease.

I did take a pregnancy test shortly before the blood test, but then I remembered that the medication I was injected with is what a body makes if you’re pregnant. So while the injections can give the same symptoms as pregnancy, it turned out that I was.

We were all pretty shocked that it happened so quickly, and it’s been pretty smooth sailing. It’s been incredibly challenging and emotional at times, but I take a lot of strength from having gone through the process.

I think sport is naïve if it thinks that fertility isn’t a serious issue for athletes. If they spoke to past players or some of the senior players, they would realise this, and hopefully take steps to make sure that younger players are better educated. I do have conversations with the younger players, telling them to keep on top of it.

Fertility needs to be an ongoing conversation, not a taboo subject.

 

Nat Medhurst pregnant and blooming. Image courtesy of Nat Medhurst

 

SONIA MKOLOMA – multiple miscarriages

Talking to Sonia Mkoloma about her fertility is like hopping into the ring with Muhammad Ali and receiving gut-punches that leave you winded. She’s endured an unfathomable three miscarriages – one of them with twins – and had three embryos fail after implantation. It’s been a brutal process, but Sonia remains cautiously optimistic about having children.

For almost two decades the English superstar was focused on her netball. She competed at five Netball World Cups – a record she shares with an elite handful – and her 123 national test caps a number that few others reach.

In 2008 Sonia moved to New Zealand, and then on to Australia in 2010, to further her on-court career. Busy with netball, and squeezing life into the gaps around it, she didn’t stop to think about her fertility. Sonia said, “Subconsciously I always thought having children would happen, but didn’t really pay it much attention. I wanted to be in a relationship before I thought about a family.

“And because I didn’t come over to play in the ANZ Championship until I was 28, I was quite late netball wise, so that was my priority at the time.”

 

Sonia Mkoloma moved to the NSW Swifts to further her netball career. Image: Simon Leonard

 

Leading into a pinnacle event, and just months into a new relationship, Sonia had an unplanned pregnancy. She chose to terminate, saying, “I was a professional athlete, so how could it happen? I almost felt embarrassed or ashamed, and didn’t know who to talk to for support. But I remember my life was so controlled: I had to train, to play, and I thought, ‘Shit!’ It was like a panic.”

Retiring from netball at 35, Sonia and her partner made the conscious decision to start a family, little knowing what was to confront them.

 

Read about Sonia’s medical experience below.

 

While the past six years have been filled with procedures and disappointments, it was Sonia’s first miscarriage that is remembered most vividly. She’d fallen pregnant naturally, and visited the doctor at nine weeks for a check-up. “I was told that they couldn’t find the baby’s heartbeat on the ultrasound. They then put a cold probe inside me, and found two sacs. So at that point I was pregnant with twins. But there wasn’t a heartbeat for either of them.

“I just said, ‘I’m ok’, and left. I found a quiet corner to sit down, and I phoned Mo’onia Gerrard. I remember bursting into tears. I just broke down.

“Everyone told me that it would be okay, but it was at that point that I realised how much I wanted the babies.”

Sonia’s most recent failed attempt was in December last year, and there is still no real explanation for what is going wrong. Both she and her partner have been thoroughly examined, but fall into a category known as unexplained infertility. Unhelpfully, it’s a diagnosis that isn’t a diagnosis.

“I’ve been in a weird place. If I knew there was something wrong, something causing the problem, I could try and fix it. It’s just my body is doing what is natural for it at the moment, and that is a real struggle for me.”

 

Sonia Mkoloma is one of England’s most capped internationals. Photo Credit ©Michael Bradley.

 

Fertility issues can tear some couples apart, but Sonia said it has strengthened the bond with her partner. “We were trying to time sex, time ovulation, or I’d ask him for his next sperm donation. Nothing has overwhelmed him.

“There’s been times when I’ve wanted to talk about it and be upset, and others when I don’t want to go over and over it. And he’s been amazing with that.”

Along with her partner, Sonia has spoken to counsellors and friends about her experiences. The latter don’t always know what to say, but Sonia has found that even when conversations are awkward, they’re generally coming from a good place.

“You are going to get people that are sad for you, or who pity you. If that’s not what you want, it’s fine to let them know that. From my own experience the best conversations are simple ones, like, ‘I hope you’re okay’, or ‘I feel for you.’ Then if a woman wants to expand and talk further, be there just to listen.”

Given her experiences, Sonia wants elite athletes to be better informed about their fertility while they are in their twenties. She said, “I never had anything when I was at school or when I was playing. We were educated on our career, on our netball, on how to stop falling pregnant, but never about what a journey into motherhood might look like.

“In this day and age, we should be educated about our fertility. We need experts to come in and speak to the girls, and let them know all their options.

“I know coaches might not want to hear this, and as a coach myself I understand. But players should be given the opportunity to put their eggs aside, and be supported with egg storage if they’re an international player and whether they are with a partner or not.

“It gives athletes the option and the choice. They might not be interested in having kids now, but in ten years’ time they might want to start a family, and that can be incredibly difficult.”

 

Sonia Mkoloma with her partner. Photo used, with permission, from Mkoloma’s Instagram account.

 

Sonia has recently moved to the Gold Coast to live with her partner, but prior to that she was in constant motion. “I was in Sydney, working, coaching an ANL team, coaching at the Swifts. It would take me an hour each way to drive to Olympic Park where the teams were based. I flew to New Zealand for the England tour. I was trying to fit my daily injections and medical care around work and netball commitments.

“So being up here is quieter, and during the Covid-19 situation I’ve had down time to rest and reflect. I’m going to be starting the medical process again soon. A friend asked me if I’d thought about a surrogate and I haven’t. But those kinds of questions will come into play.”

 

Sonia’s medical experience

Two miscarriages came after natural pregnancies.

My partner and I then had all the check-ups. Blood tests, checking my uterus, my partner’s sperm, and nothing was wrong. Sperm donation is interesting and even funny at times, because my partner isn’t allowed to ejaculate for up to three days prior to the procedure.

I started fertility injections, which in short pumped me up with hormones to assist with egg growth and stopped me ovulating. I had regular appointments and ultrasounds to monitor my follicles’ progress.

Because I was getting older, my specialist recommended that we try IUI. That’s short for Intra-uterine insemination, where my partner’s sperm was retrieved and injected directly into my uterus using a catheter. People often start with IUI before IVF, because it’s less invasive, and a lot cheaper – about $2500 compared to about $10-12 000 for an IVF cycle.

We tried that and I miscarried again, so we then went down the IVF route. I did a couple of frozen cycles, and it’s a real waiting game to see what happens.

 

Sonia advocates player education. Image: Simon Leonard

 

My eggs were removed and grown.

The clinic was great, and they called me every day while the eggs were growing. I might have started with ten eggs, and then I’d be down to eight. They’d ring to say another hadn’t survived and I’d finally be down to two or three.

I’m not an anxious person normally, but I felt anxious during this time because I had no control over what was happening. It was a weird kind of count down.

Once the eggs were big enough, they were fertilised and injected back into me. They had to try and attach to my uterus wall and grow. So that was another two weeks wait to see if it would happen. During that time, I just couldn’t stop thinking about what was happening, no matter how much I was told to relax.

After two weeks I’d have a pregnancy test, and a couple of times I was pregnant. I’d go back for a check-up, which was once a week, and at some point there would be no heart beat. My baby had died, and I didn’t have a viable pregnancy. I had three failed cycles in all.

I then had to sit back and pause. That toughened me. Even this last one, when I heard it didn’t take. I’ve begun to know when I’m pregnant, and I could sense that it hadn’t worked.

I have needed time to pick myself up after each loss, because I wanted each baby so badly, and I wanted it right now. As the miscarriages went on, it got easier for me. I still felt the pain, but it didn’t compare to that first time.

After three miscarriages, and three cycles that didn’t take, I’ve become stronger emotionally. I’ve had to.

 

Acknowledgements

With thanks to Associate Professor Vinay Rane, Associate Professor Clare Minehan, Dr Susan White, Liz Ellis, Kath Harby-Williams, and particularly Geva Mentor, Natalie Medhurst and Sonia Mkoloma. In sharing their personal stories, these three wonderful athletes are our greatest advocates for change.

 

 

About the Author:

Physiotherapist, writer and netball enthusiast. Feature articles, editorials and co-author of "Shine: the making of the Australian Netball Diamonds". Everyone has a story to tell, and I'm privileged to put some of them on paper. Thank you to the phenomenal athletes, coaches and people in the netball world who open a door to their lives, and let me tiptoe in.