The motherhood question: Can a fertility MOT help tell me if I want children?

It was soon after I turned 30 that I first noticed my womb had become an open forum. Phrases like “future plans” and “catchment areas” began to be casually scattered into conversations like a trail of breadcrumbs guiding me to woman’s ultimate destination: the maternity ward.

When I got married, the dam opened and subtle-as-a-sledgehammer insinuation soon gave way to the alarmingly direct. “Are you two having kids?” was suddenly considered by many – at work and among friends – to be an appropriate question. “Time is ticking,” was delivered over Christmas lunch. Less White Rabbit, more Captain Hook. No longer an individual, I am now merely a uterus on legs.

More frustrating, perhaps, than the gross invasiveness of it all, is my inability to respond with any sort of conclusiveness. While the child-free movement has gained traction among millennial women proudly choosing to enjoy life without the burden of parenting — and the “anti-natalist” movement loudly extorts the virtues of eschewing child-rearing in the name of environmental responsibility — I stand in limbo, neither “child-free by choice” nor “childless for now”. You see, I don’t know if I want children. I simply cannot decide.

It was seeking the answer to this question that led me to having my feet up in stirrups one Tuesday morning in August as Professor Nick Macklon, Medical Director at the Women’s Fertility Clinic, wiggled a transvaginal ultrasound inside me and shouted out numbers like we were in a Bingo Hall. “Nine, 10 – ah yes! Thirteen.”

I had come to the clinic in Harley Street, dropping £300 I absolutely didn’t have to spare, to do a “fertility MOT”. A clean bill of fertility health, I reasoned, would allow me to delay the decision even longer. A less-than-perfect score on the MOT, however, might force the issue. And as I approached my 33rd birthday, I was well aware that the “scary age” of 35 — the foghorn age everyone tuts and shakes their head about when they talk (and talk and talk) about women’s fertility — was not too far away.

A fertility MOT — or fertility check, as Professor Macklon prefers to call it (“Women are not cars,” he reassures me) — assesses a woman’s egg and hormone reserves with a view to determining how successful her chance of conception is. The tests, which are offered at various clinics across the UK and range from £300 to £600, usually include a blood test to check the levels of anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH), as well as an ultrasound to count the ovarian follicles.

Produced by the brain, FSH increases follicle growth (follicles are the little pouches that hold the eggs and release them when they’re ready for fertilisation each month), whereas AMH correlates directly with the size of egg supply. AMH naturally decreases with age, so a low AMH number can be a sign of early menopause. However, both AMH and FSH levels fluctuate throughout the monthly cycle (the latter must be measured in the first few days of menstruation) so are not considered accurate markers of fertility in isolation. This is why most fertility MOTs also include a transvaginal ultrasound and a consultation that involves a brief discussion about lifestyle, period regularity and sexual and health history.

Tests such as the one I underwent were originally developed by IVF clinics to predict how a woman might respond to fertility treatment. But experts are skeptical as to the value of such tests as fertility predictors, with many seeing them as providing false reassurance, leading to snap decisions or even exploiting women’s insecurities.

Following my own test, I am told my AMH levels are very normal for my age and, aligned with the egg count, my medical history and my lifestyle (quitting smoking helped, I am told — and I think they should put that on the packet), Dr Macklon says there is nothing that he’s seen that would suggest I am at a higher risk of premature infertility than the average woman. He selects his words judiciously. “What I’m not saying is you can wait and you’ll be fine — there are many factors. It is just a snapshot,” he says, explaining that in order to fully interpret the results, I’d need to do another MOT in six months (conveniently costing me another few hundred pounds). “But there’s no obvious reason for me to say: ‘Gosh, you’d better get cracking’.”

He does add, somewhat ominously, that “your eggs in number and quality are never going to be better than they are today. The chance of having, say, two children without medical help would be greatly increased if you get started within the next year or two.”

But how accurate are the kinds of tests Dr Macklon just ran on me? A 2017 study from the University of North Carolina published in the Journal of the American Medical Association (JAMA) found that FSH and AMH levels had no bearing on a woman’s likelihood to conceive. The study looked at a cohort of 750 women aged between 30 and 44 with no history of infertility who had been trying to conceive for three months or less, and it found that a low ovarian reserve, low FSH and a low AMH level were not associated with reduced fertility. “These findings do not support the use of urinary or blood follicle-stimulating hormone tests or anti-Müllerian hormone levels to assess natural fertility for women with these characteristics,” they concluded, saying that women should be “cautioned against” such tests.

The British Fertility Society (BFS) also warns against the marketing of such tests as predictors of successful conception. “It is important to remember that these tests were developed to inform IVF treatment and not your natural fertility,” they say. “Many women with low ovarian reserve will conceive without any problems whilst others with a good ovarian reserve may take time and need fertility treatment. Their increasing use as a ‘fertility MOT’ test to reassure women that their fertility is normal or that they should considerer treatment sooner rather than later is open to interpretation.” The BFS says that age remains the ultimate mark of ovarian reserve.

Dr Channa Jayasena, Clinical Director at Imperial Reproductive Endocrinology, describes fertility MOTs as a Pandora’s Box. “Women can be pushed into something which on the basis of limited evidence can change their behaviour,” he tells me. “Fertility is a highly commercialised and lucrative area of medicine… Companies are very good at blinding us by science on how accurate these tests are, and we need to consider what the ethical implications are of putting undue stress on someone… or making them inappropriately freeze their eggs.”

He explains that if your AMH is very low, “it just tells us that if you were having IVF, you’d need more hormones. It tells us no more than your age about when you’re going through the menopause. You can still get pregnant with no AMH, and high AMH can be problematic as it can be associated with PCOS [polycystic ovary syndrome]”. Having said that, “The flipside is there will be rare problems you pick up through a fertility MOT.”

He adds that 35 probably isn’t the age everyone should be worried about: “Your fertility changes very slowly year on year downwards up until the age of 38. Beyond 38 to 42, there is a more rapid, steady and faster decline. I would prefer that people are empowered with this information — that they don’t think on their 35th birthday their ovaries are about to explode.”

Women are increasingly choosing to have children later in life. New data published by the Office for National Statistics (ONS) this week revealed that in 2020, half of women in England and Wales had not had a baby by their 30th birthday for the first time ever. And though the anticipated lockdown baby boom never materialised (the birth rate actually declined, with ONS figures showing an 8.1 and 10.1 per cent decrease for 2020 and 2021 respectively), fertility clinics reported a rise in demand when they reopened in the spring of 2020 following two months of forced closure. Enquiries to the London Women’s clinic alone doubled — partly, Dr Macklon says, due to pent-up demand and partly in anticipation of another lockdown. “We have seen a rise in interest in fertility services, whether that be egg-freezing for the future [or other issues], and it could be that part of that is a delay thing, people not wanting to have babies now because of Covid but wanting to freeze for the future. I think people want a bit more control over planning,” he says.

For 32-year-old teacher Clara*, seeking control is what motivated her to pay for a fertility test. “I know I want children but could happily wait a decade before having them, but I haven’t been with my husband for very long and I would love to know if we can enjoy some time together before starting a family,” she tells The Independent.

Clara’s MOT results said she had a healthy number of eggs for her age, that both her ovaries were working and her womb lining was of an optimum thickness. “The test showed I’m not at a disadvantage at the moment – and had I been, I would have planned to have children a bit sooner,” she says. “For me, spending £400 to not have a child at the moment feels like the best money I could ever spend, because I can now use my time and energy accordingly – to travel and focus on my career – and have children when the time feels right. It’s nice to know there isn’t quite the rush I was expecting.”

Genevieve Roberts had a fertility MOT when she was 37. Single and seeking reassurance (having previously conceived with an ex-partner, but later suffered a miscarriage), she had assumed her fertility would be fine. “When [the results] came back I remember feeling like the foundations of my whole world had been rocked beneath me,” she tells The Independent.

Roberts had very low AMH and was told she would be unable to conceive naturally. She underwent Intrauterine insemination (IUI) and became a mother to Astrid (now four years old). Two years later Roberts conceived Xavi, using IVF. “It did completely change my life for the better and it was the best two decisions I ever made. I think knowledge is power but you have to be prepared to act on it.”

For Roberts, the MOT enabled her to separate the decision of having children from finding the right partner. “It’s just as well [my fertility MOT] didn’t come out saying ‘don’t worry’ because I would have felt sad and waited a few years, met the right partner and it didn’t work.” Of course, because Genevieve acted on her fertility MOT, it’s uncertain whether she actually would have conceived naturally in the end or not.

I ask Dr Macklon what he thinks of people calling fertility MOTs a marketing ploy. He looks irritated. “There is a constituency of opinion that basically any innovation in fertility is driven by cynical profit-making and people like me do get upset about that,” he says. “I mean clear-eyed, private clinics make a profit, they do, but they’re manned by doctors and nurses who want the best for their patients — often the same ones working for the NHS come here in the evening — and with a fertility MOT I do believe it has useful information.” He refers to his clinic’s fertility MOT as “empowering to women” since it provides data they can choose to act upon.

I’m skeptical whether spending hundreds of pounds to find out hormone levels that are not yet conclusively proven to reflect fertility is empowering to women, but I can’t help but feel comforted that nothing appears glaringly wrong on my own MOT. The BFS says that, while a good ovarian reserve by no means guarantees a baby nor does a poor one suggest conception struggles, “there is no doubt that tests showing a good ovarian reserve are reassuring.” And reassurance, for some, is priceless. As for the big decision, I decide to nudge it down my to-do list, and fly in the face of the Pope’s wishes and get a puppy instead. Selfish? Possibly, but I am a millennial after all.

*name has been changed