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Fertility Specialist Dr Devora Lieberman On Ovarian Ageing, Miscarriage And Reproductive Health

We asked Dr Devora about all things infertility – tips, treatments and misconceptions. This is what she wants you to know.

Dr Devora Lieberman is a fertility specialist with 25 years of experience. She is the Medical Director of City Fertility’s Sydney CBD clinic and co-author of Empowered Fertility. Her areas of speciality are IVF and fertility care, recurrent miscarriage, ovarian ageing (defined as having a low number of good quality eggs for one’s age) and genetic disease. Devora was incredibly generous in sharing her wisdom and knowledge with THE INARRA.

Hello Dr Devora! Can you tell us about yourself and what inspired you to pursue a career in reproductive medicine and fertility?

I was born and bred in New York, Brooklyn before it was cool. I was living and working in Boston as an obstetrician and gynaecologist when I decided to migrate to Australia in 1998 to marry my university sweetheart.

My earliest career aspiration was to become President of Planned Parenthood, the American version of Family Planning. From an early age, I recognised that reproductive freedom for women is inextricably linked to our ability to achieve and succeed. Faye Wattleton had that role from 1978 to 1992 – formative years for me. She led the organisation to expand its services and become more politically engaged. I wanted to be her.

Although I didn’t stay in the United States long enough to achieve that goal, I was President of Family Planning NSW for 12 years, so there’s that. 

 

Where did you complete your medical training and specialisation in reproductive medicine?

I received my undergraduate degree in Comparative Literature from Cornell University and went to medical school at the State University of New York. Residency training took me to Washington DC for four years at The George Washington University. 

After that, I was fortunate to obtain a faculty position at Harvard Medical School where I was able to work in the faculty practice as well as pursue a Master of Public Health degree, which I thought would be helpful in my pursuit of furthering reproductive justice. 

 

Where is your current practice located, and what services do you offer?

I became Medical Director of City Fertility’s Sydney CBD clinic in October 2019. We’re located in Circular Quay, so patients recover from their procedures watching ferries coming in and out of the harbour.

We offer the full range of assisted reproductive services from egg freezing and ovulation induction through to IVF with genetic testing of embryos. City Fertility also caters to LGBTQ+ people with fertility preservation prior to transitioning and surrogacy. We have a wide range of sperm donors and I’m seeing an increasing number of single women deciding to have children on their own.

 

How has your approach to treating fertility issues evolved over the years?

It might seem strange that one so committed to contraception and abortion advocacy would work in infertility, but for me, it’s the flip side of the same coin. I believe that all children should be planned and wanted, and that applies to those who encounter challenges along the way.

 

Your work covers the likes of ovarian ageing, miscarriage and genetic disease. Can you explain the primary factors that contribute to ovarian ageing, and how they impact fertility?

Getting pregnant gets harder as we get older. Our fertility declines a little bit at about 30, and at 37 the slope is very slippery. At 42, half of us won’t be able to get pregnant with our own eggs. Beyond 43-44, it’s almost impossible.

The most common problem is an increasing rate of chromosome abnormalities. This is why it’s harder to get and stay pregnant, and why there is an increased risk of problems like Down syndrome.

Also, while we struggle with quality, quantity declines as well. This means that in an IVF cycle in an older woman, we’re likely to get fewer eggs than someone younger. Fewer eggs mean fewer embryos, and with the increased rate of abnormalities, the chance of finding normal embryos diminishes. 

Another issue is the metabolic capability of older eggs diminishes – they run out of puff and aren’t even able to develop into a day-five embryo, let alone become a baby.

The ageing ovary also suffers from fibrosis due to collagen deposition. It seems to be due to the trauma and repair of incessant ovulation. I think that as we age, the collagen moves from our face to our ovaries…

 

What are the most effective treatments currently available for women experiencing ovarian ageing? Can lifestyle changes help?

Sadly, there aren’t any proven treatments to reverse ovarian ageing. People have tried innumerable supplements and diets, but none show consistent benefits. The latest rage has been injecting platelet-rich plasma into ovaries. We were quite keen on that for a while, but more recent research publications show that it doesn’t help women with what we call diminished ovarian reserve.

You can certainly diet and exercise your way out of fertility, but as I often tell my patients, being healthier doesn’t make you ‘fertiler.’ So it’s best to stop smoking or, better yet, never take it up. Maintain a healthy weight and eat a balanced diet. There’s some evidence that a Mediterranean diet can benefit fertility.

IVF is the best option for these women. Not because we make eggs or embryos better in the lab, but because we make more in any given cycle, increasing the odds of finding a normal one among them.

 

How do you approach treatment for patients with advanced ovarian ageing differently than those with other fertility issues?

I think it’s important to be open and honest with people. I start by talking about what we can do, what we can’t do, and then what people might want to do. Giving people false hope may seem comforting at the time, but ultimately, it’s really not in their best interest.

If we live long enough, ultimately we all get to a point where we are no longer capable of making healthy eggs and embryos. Egg donation is certainly a viable option.

 

Are there any preventative measures women can take to slow down ovarian ageing?

Give up bad habits, and maintain a healthy weight.

 

What are the common causes of recurrent miscarriage, and how do you diagnose these in your patients?

Almost always when a pregnancy fails, it’s about the embryo. It’s rarely about a woman’s ability to carry a baby. I’m an advocate for doing chromosome testing on all miscarriages. If the embryo is abnormal, the miscarriage is normal and people can be reassured. If it’s normal, then additional tests can be done to see if there are any identifiable problems that can be addressed.

Of course, having normal chromosomes is a necessary but not sufficient criterion to become a healthy baby. Embryos also have to develop normally.

 

How do you support patients emotionally who have experienced recurrent miscarriages?

I find what people need most is reassurance. There is just about nothing that a person can do to cause a pregnancy to fail, yet people may blame themselves. My list of things that don’t cause miscarriage is far, far longer than the list of things that do.

There are support groups around, such as Pink Elephants, that many people find helpful. Miscarriage and infertility can be very isolating, so it’s helpful to know that you’re not alone.

 

What innovative treatments or protocols do you use to help women with a history of miscarriage achieve a successful pregnancy?

People are often surprised that after even two or three miscarriages the chance of the next pregnancy going to term isn’t terribly different to a woman who has had no miscarriages, though that does change with increasing age.

Some women with recurrent miscarriages seem to have a problem with their quality control. Not that they make abnormal embryos, most embryos are abnormal, but some women allow them to implant and hang on for longer than they should. For these women with good ovarian reserve, IVF and chromosome testing of embryos may help.

 

Can you discuss any recent breakthroughs in the understanding or treatment of recurrent miscarriage?

I’ve been working in this space for over 20 years. When I first started, I did around thirty tests. Now I do maybe six. So many things that we used to believe were associated with recurrent miscarriage actually aren’t.

 

How do you tailor your treatment plans for women who have experienced multiple miscarriages?

Not really differently from others, though many patients in this group are anxious about transferring an untested embryo.

What role do genetic factors play in miscarriage, and how do you test for them?

Chromosome abnormalities account for 50-75% of miscarriages. We have to test the embryonic tissue itself.

 

Why does secondary infertility occur?

It’s about time. We get to a point where our ovaries aren’t capable of producing eggs that can make healthy embryos. You may have conceived your first child easily, but by the time you get to child two or three, time may have caught up with you.

It’s frustrating, and it’s challenging for families. I always ask my IVF patients what their ideal family size is, because that would make a difference to how quickly they start trying to conceive. In sex education, we should be talking about that. If you want a large family, you should start young.

 

How do you approach the treatment of patients who are at risk of passing on genetic diseases?

We can test embryos for the mutation and transfer only those that are unaffected.

 

Is fertility genetic?

Not necessarily. There is some familial association, but just because your mother had no trouble getting pregnant, doesn’t mean you won’t.

 

How do you incorporate holistic treatments alongside traditional medical approaches in your IVF practice?

‘Holistic’ can mean different things to different people. I do look at the whole person – their lifestyle, work and environment. 

A few years ago, I co-wrote a book called Empowered Fertility with Claire Hall, a life coach. Claire has been life-changing for many of my patients. There are sections in the book about dealing with unhelpful friends and family as well as the importance of self-care and being your own best friend. Because how you feel is one thing, but what you do with those emotions is another. 

Self-care is important, for example, not surrounding yourself with people who are pregnant, because going to baby showers and family functions can be challenging.

I think the question, ‘Do you have children?’ should be stricken from social interactions. Don’t ask them, and I promise that if they do have children they will tell you in the first five minutes!

As for things like naturopathy and acupuncture, there’s not much evidence to support their efficacy, but for many people they feel better in themselves, which can only be a good thing.

 

What holistic treatments have you found most effective in improving IVF outcomes?

Um, unpopular opinion, but not many. I do have a list of supplements for which I have a little bit of evidence. They are affordable and don’t have side effects.

 

What role do diet and nutrition play in your treatment plans for IVF patients?

I refer people with elevated BMI to a nutritionist or back to their GP. Weight has a dramatic effect on the ability to get pregnant and stay pregnant. Many studies have demonstrated that elevated BMI leads to longer times to conception, increased need for fertility treatment, and an increased risk of miscarriage.

On the flip side, being underweight, with a BMI<18.5, can also lead to an increased time to conception and the need for fertility treatment.

 

How do you balance the use of evidence-based medicine with alternative treatments in your practice?

I always try to support my recommendations with references and journal articles. I’m conscious that my patients can be vulnerable to misinformation and pseudoscience.

 

What are your tips for preconception care?

Lead as healthy a lifestyle as you can, but I’m a believer in moderation. I’d recommend taking preconception vitamins like folic acid, vitamin D and iodine two months before conception, not as a fertility drug, but for the health of the baby when you are pregnant.

In terms of diet, avoid ultra-processed foods. A Mediterranean diet can help. Be a normal weight. You can be too thin and you can certainly be too overweight, and if you’re overweight there may be an increase in miscarriage and pregnancy complications.

Also, when you come off contraception, you are most fertile within the first couple of months. Once the pill or the coil, for example, is out of your system, your fertility will return straight away.

 

What do you find most rewarding about working in the field of fertility and reproductive medicine?

Enabling people to have the families they want underlies all of my career choices. From working at Planned Parenthood of New York City during university through my advocacy for informed decision-making around egg freezing and, of course, assisted reproductive technology.  And helping people who can not be helped with technology come to terms with this reality.

 

How do you stay motivated and passionate about your work despite the challenges?

I try to celebrate the wins, even if it’s internal. The current political climate in the US and the threat to women and their health also keeps me fired up.

 

How do you handle the emotional aspects of working with patients who have experienced loss or infertility?

It can be difficult not to take some things home with you. I’m fortunate to work with an incredible team of people at City Fertility and we often share the load and debrief together. And, frankly, a glass of red sometimes helps.

 

How do you see the field of reproductive medicine evolving in the next decade?

Probably the biggest disruptor in our field is artificial intelligence. AI may help us decide which embryos to transfer or freeze, and which will have a negligible chance of success. Automation in the lab will streamline processes, improving outcomes and efficiencies.

At the end of the day, though, a robot won’t be able to give my patients a tissue or a hug when they need it.

 

What is a common misconception about fertility?

Doing a blood test to determine your AMH (anti-Mullerian hormone) level is not a test of fertility potential. There is no test that will tell us how easy or difficult it will be to get pregnant. AMH doesn’t tell us how fertile you are. It looks at egg count, not the quality of those eggs.

Lots of women get the test because they’re curious, and then they panic and become distraught. I use it because it helps me manage clients’ expectations about how many eggs they might get in an IVF cycle or during egg freezing.

 

What message do you want to share with THE INARRA readers who may be struggling with fertility issues?

I think it’s important to know that one in six couples will have difficulty getting pregnant.

First of all, look after yourself. Try not to take blame or responsibility. Avoid people and situations that make you uncomfortable or sad.

Second, seek reliable, accurate information. Get the facts and find a fertility provider whom you trust.  And I’ll shamelessly plug Claire Hall’s book, Empowered Fertility. It’s helped countless numbers of people coach themselves through infertility and its treatment.

 

How can people contact you?

Through my website drdevora.com.au. I’m also on Twitter and Instagram @drdevora. 

 

By Ellie Wiseman

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