For 12 years, Komal and John Appleby tried desperately to have a baby.
The Auckland couple suffered through eight miscarriages, three cycles of intrauterine insemination (IUI), five rounds of in-vitro fertilisation (IVF) and one devastating stillbirth.
Though she was diagnosed as having hypothyroidism - in which the thyroid gland does not produce enough thyroid hormone - there was no explanation for Mrs Appleby's recurrent miscarriages and each one was a cruel blow to the couple's dream of having a big family.
"We fell into the whole unexplained infertility bracket," she said.
"There were no answers."
Unexplained infertility and recurrent miscarriage are two of the five types of infertility focused on in this year's Fertility Week, which starts today.
Mrs Appleby was 23 and her lawyer husband 44 when the pair began trying to conceive in 2000.
As time wore on and she was unable to bring a baby to full term, she said she felt like a failure as a woman.
"I cried, had moments of darkness and dreadful feelings. I had them just about every single night."
But she "parked" her emotions to prepare for IVF, battling through four cycles before the stillbirth of son Kaden at 24 weeks' gestation in 2009.
Mr Appleby said the word "grief" was not strong enough to describe how he felt.
"Each time we created a life my heart pounded with joy and exhilaration," he said.
"The death of my children was the death of part of me."
Then in March 2011, after six months of research, they flew to Thailand to find a gestational surrogate.
There, a doctor at their chosen clinic persuaded Mrs Appleby to try one more time to carry a baby to term.
They went back to Bangkok in November that year and underwent IVF but the specialist insisted Mrs Appleby rest for a few months before a frozen embryo was transferred in February 2012.
By then Mrs Appleby had quit her high-flying career in corporate sales at a bank, and spent the first 15 weeks of the pregnancy in Thailand under the careful watch of her specialist.
After she flew home Mrs Appleby remained on bed rest until the couple's son, Amarin, arrived safe and healthy in October, 2012.
Mrs Appleby said their little boy was a miracle.
Treatments to conceive cost the couple $49,000 and earlier treatments cost $150,000, but it was not the money that has Mrs Appleby hesitant to try for a second child.
The couple have seven frozen embryos remaining, but the emotional scars of 12 years of infertility mean Mrs Appleby, now 38, is comfortable being a stay-at-home mum for the moment.
The Applebys reflect one in six Kiwi couples who strike infertility.
A national awareness campaign marking Fertility Week aims to educate New Zealanders about five of the main causes of infertility, how to spot the conditions and how to treat them.
Fertility Week: Meet the Usual Suspects focuses on endometriosis, male factor infertility, polycystic ovarian syndrome, recurrent miscarriage and unexplained infertility.
Fertility New Zealand president Nigel McKerras said Kiwis were not often aware of the five common causes of infertility unless a friend or family member had been diagnosed with one, and even then it was often difficult to talk about.
Mr McKerras said seeking help early, discussing infertility and using support groups was imperative, as he and wife Catherine found out during their own infertility journey.
"We have a daughter, but it took 10 years of treatment to get her."
The Bay of Plenty couple were diagnosed with unexplained infertility and went through numerous miscarriages, two stillbirths at 18 and 20 weeks' gestation, and two rounds of in-vitro fertilisation (IVF) before Abigail was finally born premature but healthy in 2010.
Clinical director at fertility specialist company Repromed, Dr Guy Gudex, said unexplained infertility accounts for between 10 and 15 per cent of cases in infertile couples.
"It's very frustrating for couples because although there is nothing seriously wrong as far as we can tell with sperm or ovulation or fallopian tubes, sometimes couples find it even more frustrating at not being able to say what's wrong."
A big concern with unexplained infertility is the long wait for publicly funded fertility treatment.
In New Zealand a couple with unexplained infertility face a five-year stand-down period before they can even join the public waiting list, which in some areas is 18 months, to access treatment such as IVF for free.
If they don't find out they have unexplained infertility until their early to mid-30s, the long wait means their chances of getting pregnant are reduced because fertility declines with age.
About half of Kiwi couples accessing fertility treatment go public, with the average age almost 37, while the rest pay for it.
One cycle of IVF starts at $12,000 and only two rounds are publicly funded, unless the first cycle is successful, then couples have to pay.
Treatments for unexplained infertility include fertility drugs such as clomiphene, to increase the number of eggs a woman ovulates per month; IUI, where sperm is injected into a woman at ovulation; IVF; and lipiodol flushing where the woman's fallopian tubes are flushed with poppy seed oil.
The usual suspects
A complex but common condition involving hormonal and immune systems. Cells that resemble those in the uterine lining grow outside the uterus such as on the ovaries, fallopian tubes, pelvic lining, bowel, bladder, appendix and other organs. Women of all backgrounds and ages including teenagers can have endometriosis. Symptoms such as painful or heavy periods, bowel problems, fatigue, bloating and immune system issues vary greatly and women with severe endometriosis might only have mild symptoms. Treatment ranges from surgery to remove it, to hormone suppressive drugs such as the contraceptive pill. Many women alleviate symptoms through diet.
2 Male factor infertility
When a man's sperm numbers are low or the motility or morphology (shape) is impaired, this is known as male factor infertility. About 50 per cent of cases are believed to be inherited though it's not known what genes are responsible in most cases. Other causes include sperm duct defects, infection, ejaculation issues, tumours, undescended testicles, hormone imbalance and chromosome defects. Lifestyle choices such as smoking, alcohol and drug use, obesity, and environmental pollutants can contribute to or worsen it. Treatments include IVF using a micro-injection to inject the best sperm into the egg, known as intracytoplasmic sperm injection or ICSI.
3 Polycystic Ovarian Syndrome
PCOS occurs when the ovaries produce more smaller follicles than usual that stop growing, which means the ovaries are often enlarged. It is associated with higher levels of male hormones (androgens). When PCOS causes infertility, ovulation does not occur and an egg is not released as with a normal menstrual cycle. The cause of PCOS is still uncertain but it is often inherited. Treatment includes exercise and weight loss, medications to help the body use insulin, and the drug clomiphene to induce regular periods. Surgery using ovarian drilling is considered a last resort because it can lead to adhesions in the abdomen that can also cause infertility. PCOS is associated with a higher risk of the development of Type 2 diabetes.
4 Recurrent miscarriage
Defined as being three or more consecutive early pregnancy losses, before 13 weeks, or two late miscarriages, between 13 and 20 weeks, it is associated with reproductive problems with the parents, chromosome abnormalities, autoimmune disorders, infections, and structural problems of the uterus such as uterine anomalies or fibroids. But there is no definitive cause identified in about 50 per cent of cases. Treatment is difficult to determine and varied but can include low-dose aspirin, progesterone therapy, and fertility treatment. Symptoms include early bleeding. Recurrent miscarriage can occur before or after a successful pregnancy.
5 Unexplained infertility
Seen in 15 to 30 per cent of people failing to get pregnant after 12 months of trying. It's likely to have similar causes as explained for infertility, but the problems are more subtle, so that test results on a man's sperm and a woman's ovulation and fallopian tubes do not pick up the reason. There are no symptoms except for the inability to get pregnant. Fertility treatment such as IVF can help couples with unexplained infertility but in New Zealand the stand-down period to join the wait-list for publicly funded IVF for a couple with the condition is five years. The wait-list itself is up to 18 months.
• The number of women over the age of 40 having a child is up 70 per cent from 1997
• Women in their 20s having a baby has dipped 15 per cent
• A 35-year-old woman has an 18 per cent chance of conceiving a baby naturally each month
• That increases to 42 per cent with IVF and women aged 35 or under are more successful
• By the age of 40, natural conception drops to 6 per cent each month, and 3 per cent at age 42
• About 20 per cent of women who have IVF are over 40
• The average age of a woman having IVF has increased from 33 in the 1980s to 37 now
• A woman must be under 40 to be eligible for publicly funded treatment.
Source: Fertility Associates.