It took a major health scare for Wellington woman Mere Wilson Tuala-Fata to discover her own fertility issues - now she's speaking out to raise awareness for others. Katie Harris reports.
It started with blood, like a heavy period, but Mere was suffering internal bleeding which doctors said could have killed her.
"The only reason they said that I stayed alive was because I was fit, strong and healthy. Because basically my whole insides were full of blood."
She'd lost a child.
The Wellingtonian had suffered a ruptured ectopic pregnancy, a potentially life-threatening condition where the pregnancy occurs outside of the uterus.
Compounding the pain of losing the pregnancy and having a tube removed was the realisation that creating her family would be a whole lot harder than she anticipated and having no idea what that meant.
"I'm Māori, and my husband is Samoan, so we've got lots of families around us that have lots of babies. That made it even harder for us, to go 'oh we can't, why not us?'"
She says it was hard to understand why this would happen because she plays rugby, is fit and does not smoke.
Eleven years on and two beautiful boys born through IVF later, Mere says she's now happy with a house full of boys. They're now a family of six, including her husband Paul's 17-year-old son LeBron from a previous relationship.
But it wasn't plain sailing, and four months into her first IVF pregnancy Mere miscarried.
"His name was Matariki - because that was the time when he was born. So every year we get a nice reminder."
Determination is what kept her going, and after her fourth round of IVF, she gave birth to Beauden, and later Jackson.
Mere believes she's one of the lucky ones.
"We are privileged, we have good jobs, we have health insurance, we have an income that enables us to plan to have IVF. You can get a round free and depending what happens you can get another one."
Not everyone has the same support and financial backing to get IVF treatment, and Mere says our collective inability to talk about fertility issues, and shame of not being able to have children feeds a perceived inability for people to seek help.
Fertility Associates say as many as one in four New Zealanders experience infertility when trying to conceive.
Its Wellington medical director, Andrew Murray, says there is a reluctance for women to reach out.
"I think the greatest struggle is the stigma attached to seeking help outside their own immediate whānau.
"There are often preconceived ideas that seeking fertility help means that you're definitely going to need IVF or that you're going to be enrolled in some sort of treatment programme that will take months and months or even years."
He says while this can be the case for some patients, others may find they only need to pop in and get advice and that's all they need to straighten things out.
In New Zealand, public funding is available for some IVF treatments, but Murray notes that the criteria is ruling out a large number of Māori and Pasifika women.
These restrictions include having a BMI of 32 and under.
"A lot of Māori and Pasifika women have a BMI well north of that, and so that does have an impact on their accessibility."
As well as this, he says, the patient needs to be a non-smoker.
"Because we still have quite a high smoking rate amongst Māori and Pasifika patients, that's also a barrier to care."
While these restrictions do have clinical relevance, by impacting the success rate of the treatment, they are overall having an outside effect on these communities, says Murray.
Fertility Associates' science and information manager, Dr John Peek, says there are many studies showing smoking cuts a woman's chance of conceiving through IVF in half.
He says while there is considerable evidence that a higher BMI can reduce the chance of pregnancy through IVF and can increase the chance of complications, its use as an exclusion criterion has created controversy.
"Average BMI can vary between ethnicities. Also, the effect of BMI is less than the impact of smoking, and it is harder to lose weight than to stop smoking."
Data provided by the group shows public consultations for Māori and Pasifika run at about 35 to 40 per cent the rate for European and Asian women compared to what would be expected.
Canterbury University's Dr Kelly Tikao, of Ngāi Tahu, has a PhD in Māori birthing practices and says in Māori society, women's role in the survival of the culture is really valuable.
She says this is why the womb is called "Te whare tangata" - the house of people.
Because of this, she says, it can be difficult for wāhine that struggle with infertility as it comes from the very essence of whakapapa and who Māori are.
"To not be able to fulfill something so important, it weighs upon the hearts and minds of all of us really. My heart really breaks for those wāhine who are struggling to have babies and children because it is the continuation of a whakapapa or lineage."
For Tikao, the funding restrictions are short-sighted and fundamentally wrong.
Access issues are at the root of these problems, which date back to colonisation according to the researcher, compounded by assimilation practices.
"When you have that over generations and generations you get this accumulation effect. The only way you're going to get changes is to make funding available to all areas, but particularly for fertility."
Tikao says outcomes for these women will be improved if the barriers to childbirth are removed.
"You would have a greater uptake and engagement from our wāhine, because they want to go down this pathway but they are being blocked at the very beginning by a number."
As well as restrictions on funding for the treatment, Tikao says it's crucial for more investment in academic work as she says she can name on her hand the number of Māori researchers working in this space.
"We're ready, it's needed and we're keen, now we just need specific funding."
One of the most substantial pieces looking into Māori and assisted fertility attitudes was completed by Dr Marewa Glover more than 10 years ago, and she says the lack of research is concerning.
"When I did that research it was just incredible to me, and it's just stayed with me, that there are people out there who believe that children born via the use of these technologies are wrong.
"I've had to think about that - and you can see why people keep it quiet. Actually I've met lots of people who've had IVF babies but I'd be reluctant to say 'oh ring such and such'."
Although she doesn't work in the sector now, she says a common sentiment she heard in her research was that some women felt they weren't a woman if they couldn't conceive.
"One of the stories that stuck with me the most was a woman who was at one of the hui and she had a tiny wee baby with her, it was her sixth baby. And she just cried when she heard the kōrero at the hui of the people, that other women weren't able to have babies."
Glover says the woman was upset because she said it was the one thing she could do and other women couldn't.
Glover told the Herald on Sunday that criteria for funding was discriminatory, and said it would be a barrier.
NZME contacted Auckland, Canterbury and Capital and Coast District Health Boards about the restrictions but received different responses.
While Capital and Coast DHB says the Ministry of Health set the framework, Auckland DHB says it's already reviewing some of the BMI criteria and has increased the limit for initial assessments to a BMI of 35.
Canterbury DHB says provision of the funded treatment is done by a national tool and applied by providers.
However, Canterbury later confirmed that while it is not reviewing criteria like Auckland, it is interested to see what impact the Northern region's criteria might have on equity of access.
The ministry says it does not set the criteria, but it does have a threshold for the purposes of national consistency.
It says the service criteria is set by regional DHB funders and providers.
Eleven years on from beginning her fertility journey, Mere says her message to other wāhine is to get tested, even before you're planning children.
"Seeking help isn't an admission of failure, seeking help is showing strength and courage to persevere and build your family ... the family you want."