History of anorexia

Minique Gutschow, a Cape Town-based 31-year-old project manager, is 12 and a half weeks pregnant after battling to conceive for more than three years.

After gaining six kilos, undergoing IVF and recovering from a miscarriage, she and her husband, Dieter, are awaiting the arrival of their first baby.

Dieter and I decided to start trying to have a baby in November 2003. We'd been married for five years and it was part of our plan. We'd travelled overseas, both completed a masters degree and we both felt the time was right. I consulted my gynaecologist, who said I should go off the pill and see whether my cycle returned to normal. I have a history of irregular, light and sometimes non-existent periods. For three months we waited, expecting signs that I was pregnant, but nothing happened. So, at each cycle, I went for sonar and my gynae found that I was not ovulating. By September 2004 I still was not pregnant and we were referred to the fertility clinic at Cape Town's Vincent Pallotti Hospital.

I was told that one of the factors contributing towards my inability to fall pregnant was that my body mass index (BMI) was too low. I was encouraged try to gain some weight. I have always been very slim and tall. I am a perfectionist and when stressed I forget to eat. I have also always been active and athletic. I started running competitively at the age of six, with my father as my trainer. I worked hard and I loved it. I saw healthy eating as part of the discipline. I did well as a sprinter and managing my diet became second nature to me. I realise now that there was a period of time when I became unhealthily thin. I injured my knees when I was 17 and was told I could no longer run. It caused me both emotional and physical pain. It was my love and I’d nurtured girlish dreams of running professionally. I never felt as alive as when I was running. Losing it created a void in my life.

I started to eat less and less but I still had a positive body image. I just didn’t feel like eating. I certainly wasn’t “stopping myself from eating”. But people began to comment on how thin I was becoming. I remember overhearing someone asking my mother if I was anorexic. I had never even heard the word. When I look back now I can remember the moment when it dawned on me that not eating gave me back the sense of power I’d lost when I had to stop running. Eating was something I could control. It didn’t present itself as a choice; it happened very gradually, over time. But when I made this connection, I realised that I had a problem. I’d become so thin that I had no energy and I was shivering all the time. My body was shutting down.

I didn't realise that I’d been slowly killing myself. For two years I was in and out of hospitals and clinics. And from the very first week I was admitted, I had the desire to get well, to regain my old strength and live a full life. It took about two years to normalise, but I recovered and regained a healthy relationship with food and my body.

A well-balanced life

By my twenties it was behind me. I'd re-discovered a full life and took up running again, though not competitively. I had to stretch the distance and slow the pace, to me a metaphor for my life: to become a long distance runner who lasts, rather than a short-distance sprinter.

In 1998, I married Dieter and we were very happy – until November 2003 when I found myself at the fertility clinic. I was told that picking up weight would "aid the process". It was very difficult for me. I knew that my eating disorder was far behind me and thought that although I eat leanly, I eat very healthily. I underwent seven artificial inseminations and one IVF attempt. My case was reviewed in September 2005.

By then I'd put on about two-and-a-half kilos but still wasn't pregnant. Then I was diagnosed with hypogonadatrophic hypogonadism (see below), and was put on an injection-only program and encouraged to gain more weight. It was an exhausting and emotional period, especially since we were both so used to being able to set our minds to something and achieving it. Controlling this outcome was not within reach. Knowing that it could help, I worked at gaining weight, tried to relax and remembered to eat – and to not be so rigid about the health value of everything that passed my lips. I'd eat sweet things, which I'd never usually do, and try to eat throughout the day. I tried to gain weight in a healthy way; it wasn't an option to gorge myself on cakes and junk food. I put on about six kilos, which I feel fine about because I know it's healthy weight and not unhealthy flab.

Something seemed to click inside me. I liked the extra weight and felt comfortable in my body. I felt a sense of peace, and that I was now living a well-balanced life. I think this was a very valuable learning curve and part of being better prepared for parenthood. I became more flexible, less rigid and probably a better role model for a future child. I realised that the moon and the stars weren't going to fall out of the sky if I weighed five or six kilos more, and it was a very good feeling.

By November 2006 I knew I would fall pregnant – and I did. But it was not to be. I had a miscarriage at seven weeks. But we tried to remain positive. The bright side, said our doctors, was that for the first time it was clear that my whole system was working “beautifully” and normally. It was heartbreaking and stressful but I made an effort not to fall into my usual food-avoiding habits. I gained another kilo. I told myself it was for the children to come. I finally accepted that falling pregnant was beyond my control. The pressure seemed to lift from our shoulders, and in a very peaceful state of mind we went ahead with another IVF. The positive result came back in March this year. We were pregnant!

I wasn't shocked to hear that my low weight was a factor in my difficulty to fall pregnant, but it was a warning light, an alarm bell that told me that I could try now to change, especially because being thin was suddenly in the way of a far greater dream. Priorities change. I think that other thin women should be advised that the world doesn't come to an end if you’re not in control. If being thin controls your life, you're not going to make the best mom. When your main focus is food, you can't even really enjoy your husband. Since I've fallen pregnant, all my selfish habits have gone. I'm not thinking about myself anymore. I've learnt that when you think you're controlling what you're eating, what you're eating and not eating is actually controlling you.

I believe that to be a good mom you need a well-balanced lifestyle. What you are "allowed" to eat and what you're not "allowed" to eat shouldn't stand in the way of happiness. I'm grateful to have learnt what I have. To be a well-balanced mom and a good role model, balance is everything.

Weight & conception

Was Minique's chief problem that she was too thin to fall pregnant?

Minique had two main problems, both of which create the same effect. Firstly, she had the condition hypogonadotrophic hypogonadism, which means the pituitary gland does not excrete the hormones FSH and LH necessary for ovulation. But because her BMI was less than 18, this problem was effectively doubled. When your BMI is under 18, there is exactly the same physiology as hypogonadotrophic hypogonadism. The excretion of FSH and LH is equally shut down, and ovulation cannot occur.

Does this problem apply only to anorexics?

We do not treat serious anorexics for fertility. We see what we can call “borderline” anorexia, or low weight not necessarily with the psychological profile associated with a full-blown eating disorder. It is among the most common problems associated with conception. When BMI is too low, the whole metabolic system is affected and the reproductive system is under great stress. In addition, other hormones, like lepton (the “starvation hormone”) come into play. We also see this in endurance athletes, who are exercising a lot. They have a low BMI, and their fat index is low.

In terms of conception, is it better to be overweight or underweight?

Both are equally serious; maintaining your weight between BMI 18 and 25 is the best option if you want to fall pregnant.

FOOD FOR THOUGHT

• Male weight can also impact on infertility, according to Dr William Hummel and Dr Michael Kettel of the San Diego Fertility Centre. They explain that low weight or weight loss can lead to decreased sperm function or sperm count.


• Studies show that women who don't gain enough weight during pregnancy risk giving birth prematurely or having a low-birth-weight baby.


• According to Akashia Anderson of Vanderbilt University's psychology department, "Roughly 80 per cent of anorexic women who successfully treat their eating disorder will regain their ability to conceive. Even a moderate weight loss of 10 to 15 per cent under ideal body weight can result in menstrual irregularity. It does not need to be the weight alteration of 30 per cent or more as seen in women with anorexia nervosa or bulimia."


• Studies suggest that 12 per cent of primary infertility is due to deviations in body weight from established norms, and that this infertility can be corrected by restoring body weight to within normal established limits.