Caitlin Blaney always dreamed of being a mom. But thoughts of having children got put aside while she pursued her education to become a clinical psychologist.
The 32-year-old lives in Winnipeg, away from her partner and family, who are based in her native Toronto, while she works toward completing her PhD at the University of Manitoba.
"I always thought it would be a lot earlier," she said of starting a family. "I never had intended to have any children past the age of 35." But having children without the support of her family, while immersed in intense clinical and research work, for Blaney, was not an option.
After completing 15 years of post-secondary education, Blaney will move to Ottawa in September to begin a year-long residency, one of the final steps to becoming a clinical psychologist. After that, Blaney said she and her partner plan to have children, but she's worried delaying until her mid-thirties could affect their chances.
For women seeking information about their fertility, a Toronto startup is offering a $219 home fertility hormone test as well as an "egg-freezing concierge" service.
The company, Lilia, was started by 29-year-old Alyssa Atkins, who says she created it after she began to consider freezing her own eggs and found the process to be confusing and time-consuming.
"We want to help women explore their fertility options and make it easy to take next steps should that be what they want."
Over the past month, fertility clinics across Canada have either decreased their services or shut down completely based on recommendations from provincial health authorities to suspend elective procedures and surgeries in order to slow the spread of COVID-19 and free up resources to fight the pandemic.
Atkins said in an emailed statement that "lab services have been deemed essential and (Lilia's labs) are still running," offering an alternative to women who are currently unable to access their local fertility clinic.
Lilia's fertility home test, done by finger-prick, checks an antimullerian hormone (AMH) level, a marker of ovarian reserve that gradually decreases across a woman's reproductive lifespan. A woman with a low AMH for her age could have a low "egg count," one factor that influences her chances of becoming pregnant.
Eileen McMahon, president of the Canadian Fertility and Andrology Society, said in an emailed statement that AMH can be "a useful test in someone who is considering freezing eggs for age-related fertility decline but it should ideally be done through a fertility clinic," with a specialist who would use other testing such as ultrasound, "and have a robust discussion about what the results mean."
McMahon also noted the test does not provide any insight into egg quality, "so even if AMH is found to be low, that in and of itself does not necessarily mean that person has infertility."
Low AMH can be an indicator of how someone will respond to assisted reproductive procedures such as in vitro fertilization (IVF), said Dr. Michael Ripley, a fertility specialist at Atlantic Assisted Reproductive Therapy in Halifax.
"You can think of ovarian reserve testing as measuring, for lack of a better term, the adequacy of somebody's backup plan if they're not able to achieve a pregnancy on their own," Ripley said. "However, for somebody who does not have infertility, ovarian reserve testing (is) not helpful at that time."
Ripley says a normal AMH level in an otherwise healthy woman who has not had infertility could provide false reassurance, as that person may have fertility problems in the future from other conditions such as endometriosis.
Lilia's kit also checks testosterone, prolactin and thyroid stimulating hormone (TSH).
"We chose those four hormones because they reflect common reproductive disorders," said Dr. Prati Sharma, a fertility specialist based in Toronto who serves as Lilia's medical adviser.
Women who order Lilia's fertility hormone test can usually get their results within a week or two, said Atkins. Clients are then offered a phone call or virtual visit with Sharma to discuss their results. Sharma said she is continuing to offer this service to Lilia clients during the pandemic.
Someone who receives an abnormal result from Lilia's fertility test is offered the phone call with Sharma, but unless they're pursuing fertility treatment or egg freezing, they would be referred back to their family doctor.
While having an abnormal TSH, prolactin, or testosterone level could affect a woman's fertility, Ripley said these are not tests he recommends doing in women who are otherwise healthy and not having symptoms such as irregular periods.
False positives for TSH and prolactin tests are also common, he added, and such a result would need to be repeated.
"I do worry that this testing is going to increase the burden on the health-care system," said Ripley.
Sharma acknowledges that for some women, Lilia's tests may not be necessary but says for others wanting to seek out information about their hormones, Lilia's test is a good place to start.
She points out they may pick up on issues such as a thyroid disorder or PCOS before a woman has symptoms.
"By no means is this a complete evaluation. It certainly does not replace seeing a fertility doctor and having a full evaluation. But these are the most common things and that's how we chose those parameters."
Women who are worried about their fertility should talk to their family doctor, because many other factors come into play -- such as fallopian tube patency and a male partner's sperm quality, said Dr. Delani Kotarba, a specialist at Ottawa Fertility Centre.
"Sit down with someone who is a specialist and can talk to you about your health history, talk about your plans for life, get you organized (for) blood tests and ultrasounds if they're needed, and it's less money than what (Lilia is) charging for this online."
Women approaching 35 who wish to have children in the future should get an appointment with a fertility specialist, Kotarba said. She noted the visit, with a referral from a family doctor, would be at no cost for Canadians. Some provinces do not cover AMH testing, which in Ontario costs around $75.
At Ripley's clinic, he said women can get an appointment without a referral if they pay out of pocket, a cost of $185.
Lilia clients who are interested in egg freezing are offered an appointment at a fertility clinic within a network the company has selected, some of which offer 10 per cent off the cost of egg freezing for Lilia clients. The cost of egg freezing will vary, but is usually around $10,000, not including yearly storage fees and the subsequent cost of IVF if the eggs are to be used in the future.
Ripley said for most healthy women, egg-freezing before the age of 32 isn't cost effective, because those women "are less likely to come back and you're more likely to be able to conceive a pregnancy naturally, at some point in the future."
But there are many women who are not as proactive about their fertility, said Carolynn Dube, the executive director of the non-profit Fertility Matters Canada, which provides resources and support for people struggling with infertility.
Women delay having these conversations because they aren't aware of health issues that may affect their fertility, don't have a family doctor they can talk to, or think that appointments with fertility specialists will involve long wait times and be costly, Dube said.
With respect to Lilia's test, Dube says it may be worthwhile for some women, but it's only a small piece of information that's part of a larger fertility picture.
Women concerned about their health should speak to a doctor or reach out to Fertility Matters, she said.
"Part of our mission is trying to empower the younger generation to take control of their reproductive health."
Rebecca Renkas is a family physician based in Winnipeg. She is a fellow in global journalism at the Dalla Lana School of Public Health at the University of Toronto.
