IVF: An Emotional Companion. Brigid Moss

has just plummeted?

      The accepted statistic is that one in 100 women has her menopause by the age of 40 (usually called premature ovarian failure, or POF). However, a new study from Imperial College, London, puts the number much higher, closer to one in 14, including those who have had surgery or treatment for cancer.⁵ POF can be devastating, even for women who’ve finished their families. A friend I interviewed, who had her menopause at 37, said, ‘Not only was I having hot flushes, feeling angry and putting on weight, but I was doing it ten or fifteen years before my friends, so there was no one to talk to about it. It didn’t seem fair.’

      Although, when you think of the menopause, you probably think of the typical symptoms my friend described, what it actually means for a woman is that she has gone through her store of eggs. ‘At birth, your lifetime supply of eggs — your ovarian reserve — is already determined,’ says Professor Bill Ledger, Professor of Obstetrics and Gynaecology at the University of Sheffield. You release one egg every 90 seconds — one of which matures each month — and when your store is gone, it’s gone. ‘Ovarian reserve can be reduced by ovarian cysts, surgery on an ovary, chemotherapy and radiotherapy. You also speed up the rate it reduces by drinking too much and smoking,’ says Professor Ledger. But, for half of all women who have POF, no reason is usually found. ‘My guess is that women who have an early menopause probably have a smaller lifetime supply of eggs to start with,’ he says.

      An early menopause often runs in families — so if it’s happened to your mother and grandmother, it’s more likely to happen to you too. Early menopause wasn’t such an issue for our grannies, of course, who tended to have their children younger, but the average age of new motherhood in the UK is now almost 30. ‘Mum had her babies in her 20s,’ says Toni, whose story is below, ‘so even if she had had an early meno-pause, it wouldn’t have made any difference to the number of babies she could have. I thought I had at least another five years until I needed to worry.’

      If you are showing signs of being peri-menopausal (you aren’t actually classified as menopausal until you haven’t had a period for a year), the first test your GP will usually do is for FSH (follicle-stimulating hormone), a hormone produced by the pituitary gland at the base of your brain. As the supply of eggs dwindles, this goes up. A result of 10 and under is usually considered fertile. ‘But it’s a very imprecise tool for looking at ovarian reserve,’ says Professor Ledger. ‘By the time FSH has reached over twelve, in many cases ovarian reserve has gone down very substantially.’

      Two more accurate ways of measuring ovarian reserve are the antral follicle scan, which counts the number of potential follicles in your ovaries each month, and a blood test for AMH (anti-Müllerian hormone), a hormone that’s directly released by the follicles in the ovary. Even if your AMH is low, it doesn’t mean IVF won’t work. ‘But it is a warning sign you may not have a good response,’ says Professor Ledger.

      • • • • • • • • •

      Toni, a sales manager from Manchester, had just married David when she was told, aged 31, that she was close to the end of her fertility.

      Two weeks after David and I got back from honeymoon, I called my mum, to say that my period was two days late. David and I had agreed to try for babies at some point in the next few years, but I was surprised it had happened without us trying. ‘Well, I’d rather be pregnant now than find out in two years that we can’t have children,’ I said, and we laughed. But my period came a couple of days later.

      Before the wedding, my periods had been very regular and I’d never even had PMT. Then, I started to feel really down, which isn’t at all like me. And I was having hot flushes, too. When I mentioned it to friends, they said I was probably having post-wedding blues, a comedown after the big event.

      I went to see my GP, and mentioned, jokingly, that it might be the menopause. I was only 31, after all. He did some blood tests and rang me the next week while I was driving to work. I put him on speakerphone and heard him say, bluntly, ‘Actually, it is the menopause.’ He told me that my FSH was 68, when it should be 10 or below. Then he said, ‘In fact, that level is post-menopausal.’

      It was such a huge shock. I remember it was pouring with rain, the windscreen wipers were going, and I couldn’t seem to see to process the news. At home, David comforted me, and promised me everything would be fine. But I couldn’t even look at myself in the mirror because I’d think: that’s a menopausal woman. How can I look so normal, when I’m not?

      My GP referred me to hospital for more blood tests and scans. The results confirmed what he’d told me: menopause. The fertility specialist told me there was nothing they could do. She said we could try IVF, but we probably wouldn’t succeed as my problem was going to be getting eggs. And there was no way I had two years of fertility left to wait on the NHS list. She suggested the Lister Fertility Clinic in London, as they specialise in IVF for women with menopausal hormone levels. ‘But if you want to get pregnant really your only option is egg donation,’ she said, ‘so I suggest you have counselling for that.’

      That was too hard to accept, that our only way to have a baby would be with someone else’s eggs. I knew David was upset, scared that we’d never have children too. But he didn’t show it; he just tried to be strong for me, because I was so completely devastated. The fact my body didn’t work was all I could think about. I felt half a person and guilty — as if I’d let David down, and I wasn’t the woman he married.

      I fantasised about running away from everyone, emigrating to the other side of the world, alone. But the sensible me thought, I want David to have a child, and I want my parents to be grandparents. I had told Mum and some of my closest friends my diagnosis, and they were brilliantly supportive. Between them and David, I managed to keep going.

      It was taking months to get appointments on the NHS so I went to see a private gynaecologist, who did more blood tests. For a change, a nice surprise: my FSH had gone down to 10. So I wasn’t totally menopausal. In fact, over the next year, my FSH fluctuated between 2 and 60. It wasn’t all good news, as my oestrogen was high when my FSH was low, another menopausal sign. But, the gynaecologist said, the official definition of the menopause is a year without a period, and I was still having some periods, which meant I was still ovulating, if only sometimes. So, in fact, I had what’s called premature ovarian failure (POF), and there was hope. ‘It just means it’s going to be very, very difficult for you to get pregnant and to keep the baby,’ the gynaecologist said.

      My next test was a scan of my ovaries, called an antral follicle count, where they look at the number of possible follicles developing that month; it’s an indicator of your ovarian reserve, how many eggs you have left. My right ovary was inactive and very small. (When I was 16, I had a cyst removed from it, and I don’t think it had worked since, even though doctors told me it shouldn’t have made a difference.) But, amazingly, the scan showed I was about to ovulate from my left ovary.

      We were delighted, and set about making a baby that night. Two weeks later, I did a test and I was pregnant. It was absolutely brilliant, a huge relief. I thought to myself: what are they all talking about? Menopause? What nonsense. Not only was I pregnant, but the pregnancy hormones overtook the menopausal ones so, for the first time in ages, I actually felt normal.

      At seven weeks, I had a private scan, and saw the heartbeat. But at 10 weeks, I went for a scan at the NHS fertility clinic and, after looking for a minute or so, the woman scanning me said, quite casually, ‘There’s no baby’. I said, ‘Oh yes there is, I know I’m pregnant, I’ve seen the heartbeat.’ ‘No,’ she said, ‘there’s no baby.’

      David wasn’t with me; I’d thought this was just a routine NHS appointment. It hurt so much, I wanted to scream, ‘Do you realise what this means? You’re telling me my only chance of getting pregnant has ended in a miscarriage.’ I put on my knickers and tights, went to the toilet, and threw up everything I’d eaten that morning.

      It turned out the baby had died around seven weeks, shortly after the first scan. I was given the choice of pills or an operation to remove what was left. I went home, took the pills and waited. The bleeding was