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“You feel like you’re going around in secrecy, maybe we should start asking some questions, but who do we ask?”
Being in a same-sex couple, former Everton player Fern Whelan and her partner had to go through a fertility clinic to get pregnant. The only reason they chose their provider was because they had seen former England international, now Canada’s head coach, Casey Stoney attend the same one with her partner.
“I had no knowledge,” says Whelan, women’s football equality, diversity and inclusion/player services executive at the Professional Footballers’ Association (PFA), expressing how she felt isolated. “It’s so nice that now players do not have to feel like that.”
That is because on Wednesday, the PFA, the world’s largest domestic sportsperson union, representing 5,000 current and 50,000 former players, launched a first-of-its-kind for a UK sporting organisation partnership with Care Fertility, the UK’s largest fertility provider.
The partnership will offer male and female players across the Women’s Super League, Women’s Super League 2, the Premier League and English Football League access to clinician-led fertility education, assessments, preservation, including egg freezing, in vitro fertilisation (IVF) and family-planning support. The partnership’s priority is to educate players through webinars, in-person events, and a digital hub that provides information, reduces stigma around fertility, and signs players to clinics.
The Athletic spoke to fertility researchers, fertility clinics, the PFA, clubs and leagues to find out about fertility provision in England.
Former Brighton player Fern Whelan became a mother attending a fertility clinic with her partner (Jess Hornby – The FA/The FA via Getty Images)
There is a lot to learn: from high treatment costs to hormones breaching anti-doping regulations. The key message, however, for players is that a woman’s fertility decreases with age — it’s at its highest in one’s 20s, begins to fall around the age of 30, before significantly decreasing after the age of 35 — and as female athletes’ careers become longer, their peak competitive years often overlap with their peak reproductive years.
“Men are like factories of sperm manufacture,” says Alison Campbell, Care Fertility’s chief scientific officer. “Women just have the eggs they are born with. It frightens me (that) when they decide they’re ready to have a family, it’s often after their peak fertility has passed.”
Fertility timelines will not change but the sport’s infrastructure must.
Fertility support and player welfare
Although there are differences in each country’s healthcare system, the women’s game in England is far behind the United States in terms of fertility treatment provision. More than half of National Women’s Soccer League (NWSL) clubs started partnerships with fertility clinics a couple of years ago — Racing Louisville being the first to offer provision to its players in 2021.
In addition to club support, the NWSL’s Collective Bargaining Agreement also states they shall secure a vendor to assist players with family building benefits, including IVF treatment, ovulation tracking, fertility testing, genetic testing and surrogacy. The NWSL will pay for the administrative costs, while the player’s health insurance covers other fees, with any amounts not covered by insurance falling to the player.
Whelan believes the first step in England is to start the conversation before putting an onus on clubs financially.
When The Athletic asked the 12 WSL clubs about their fertility treatment provision, Arsenal were the only ones to engage. They view fertility support as a player welfare matter. “Clubs who proactively support fertility health are recognising the athlete as a whole person, not just a performer on matchday,” says Emma Saunders, Arsenal’s female athlete health physiotherapist, responsible for developing the club’s female athlete health programme along with head of performance Gary Lewin and a team doctor.
The PFA is unaware of any clubs other than Arsenal offering official fertility treatment support. The north London side believes that female-specific health support — including menstrual health, contraception, fertility, pregnancy, and menopause — should sit alongside nutrition, psychology, and physical performance. As they started to build their health strategy and conversations around women’s health became more open, players started to feel more comfortable raising different topics, including fertility.
Arsenal provides fertility education workshops, access to specialist fertility clinicians and individual consultations with the club’s medical team on demand. Collaboration between the player and club doctors, gynecology specialists, performance staff, and psychologists, as well as creating a culture in which players feel comfortable talking about their fertility, is key to their strategy.
Education and egg freezing
The PFA recognised a demand from players for education, security that it is OK to start conversations with their clubs and external bodies, and support when they return to play after giving birth.
Hannah Blundell, who was on loan at Everton from Manchester United last season, conceived naturally and gave birth to her daughter Romi last year. She had never received any education, nor even thought about her fertility. Conversations about an athlete’s fertility timeline, in her words, are still “very minimal”.
Hannah Blundell returned to action for Everton after conceiving naturally (Lewis Storey/Getty Images)
That tallies with findings of Professor Margie Davenport, the perinatal research lead for FIFA’s female athlete project, who has also worked with the NWSL and Women’s Tennis Association (WTA). She advocates for younger athletes, in their late teens or early 20s, to be informed of their fertility timeline so they can be empowered to make an informed decision. “Options are the most important thing,” she says.
The fertility treatment garnering the most traction among athletes, particularly in the United States but also globally, is egg freezing. This form of fertility preservation puts fertility on ice and has only entered the athlete world in the last couple of years.
The earlier in life a woman does an egg retrieval cycle, the more likely the collected eggs are higher in quantity and quality which results in a better chance of having a pregnancy.
Investing in fertility treatment reflects the evolution of women’s football. FIFPRO’s 2017 World Players’ Union survey found of the 3,295 women footballers participants, only two per cent of respondents were mothers, and 47 per cent felt they would stop their career early to start a family. “So you’re losing 47 per cent of all female players before they have fulfilled their career,” says Davenport.
“If doing egg retrieval or supporting pregnancy means they’re going to continue afterwards for a year or more, that’s a huge return on investment. (Think of) the loss of expertise and leadership, we should be finding ways to keep women in sport as long as possible.”
The egg freezing procedure involves appointments, around seven to 10 days of hormone injections to stimulate egg production, followed by a minor one-day operation under sedation for the retrieval of the eggs. It requires careful, but feasible, scheduling around the demands of athletes’ training and competition.
The challenge of fitting treatment around a professional football calendar was highlighted by Mary Earps in her book All In, when she recalled asking a medical expert: “I’ve got three weeks. Do you think I could fit in an egg-freezing cycle in that time?”
Some time away from training at a lower impact is necessary but exactly how long and at what intensity is much debated.
At a women in sport congress held in Australia in March, Davenport presented a paper, which is still under review, which found from an online survey of 216 recreational and elite athletes, primarily from the U.S., Canada and the UK, who underwent egg freezing and/or in-vitro fertilization in the last five years, patients were most commonly told to reduce their activity levels to walking or stopping completely for the one to two weeks before and after egg retrieval. But recommendations vary hugely.
Some fertility clinics in the United States that work with higher-level athletes recommend activity reduction for just one or two days around the time of egg retrieval.
The survey results concluded that: “exercise did not increase the odds of experiencing an adverse event during ovarian stimulation” but further research is required.
To tell an athlete to reduce their training without the evidence to support this is “not appropriate”, says Davenport. “There is no evidence-based standard available yet. When our baseline is nothing, we’re just guessing either way.”
Another interview study, conducted by Davenport but still under review, of 22 athletes who underwent egg freezing and were asked to reduce or stop their training for a very short period of time, had some “profound effects” on an athlete’s mental health.
“If you take away somebody’s athletic identity, take away a form of stress reduction and mental health support, it’s going to potentially cause other mental health issues as you’re going through the process,” she says. “Many athletes talk about this being a very stressful time because they’re going through this procedure that’s changing their hormones but they’re also stopping what they love, and they don’t know why they’re doing it or don’t feel they have the appropriate information to do it.”
Arsenal educates their players on the process and tries to use periods in players’ schedules where there is a natural break, if possible.
All those The Athletic has spoken to emphasise the importance of a transparent and confidential communication line with a relevant individual, such as a team doctor.
That’s especially important given drugs such as clomiphene or letrozole, which are used to induce egg production for egg freezing or IVF are banned by the World Anti-Doping Agency (WADA). Athletes must obtain a Therapeutic Use Exemption (TUE) to avoid breaching anti-doping rules. Under WADA regulations, athletes are also required to disclose any medication or procedures to their team doctor.
“Because there is still some stigma about egg freezing, some female athletes do not want people to know they’re undergoing this procedure,” says Davenport.
Saunders, who has worked at Arsenal since 2017, explains that from the player perspective, confidentiality builds trust, reduces anxiety, encourages early communication and allows better decision-making.
Meanwhile, from the club’s perspective, open communication allows staff to manage a player’s training load, anticipate physical responses to treatment, support recovery and plan their availability. “If players are comfortable in their environment and share their problems, it will benefit their performance,” says Saunders.
The picture is also more complicated than purely assessing if exercise can impact fertility. An understanding of an athlete’s overall energy availability and the impact of appropriate fuelling on reproductive health is missing.
The biggest gap, however, is most research on female fertility is based on the general population, not professional athletes. The PFA’s fertility partnership is a potential opportunity to build the data set to help future athletes.
Looking back, such a partnership, Whelan says, would have taken a “massive weight off (her) shoulders”. As the women’s game continues to grow, the support surrounding each individual must evolve as well, recognising them first as women, which in turn will benefit them as players.
