“Read, learn, work it up, go to the literature. Information is control.”
– Joan Didion
In the span of a generation, the conversation around women’s health has improved leaps and bounds. Our mothers may have had hushed conversations but we have pastel-coloured apps. Period trackers, ovulation trackers, the list goes on. Google and Facebook now fund egg freezing for female employees and Australia’s first claim for ‘reproductive leave’ was recently backed by the ACTU. While we are on our way, though, we are not there yet. Stigma around pregnancy and miscarriage remains. Women and men rarely have open conversations around fertility, leaving many women waiting until their thirties before educating themselves on the science. Many men never do.
While there is so much we cannot control around our fertility, we can educate ourselves on the facts. As author Joan Didion famously said, ‘Information is control’. To clear up the common misconceptions around fertility and infertility, we spoke with Dr Devora Lieberman, the clinical director of City Fertility in Sydney.
Dr Lieberman grew up in New York City, studied at Harvard, and spent her first summer job at Planned Parenthood in Brooklyn. She moved to Sydney more than two decades ago and has spent the last 17 years working in IVF clinical practice. For more than a decade, she was also the chair of Family Planning New South Wales and jokes that she was “making babies by day and preventing them by night”. In 2016, she published her first book, Empowered Fertility, which tackles the physical, psychological, emotional and social challenges that often arise when dealing with infertility and IVF treatment.
We spoke to Dr Lieberman about her vision for an empowered approach to fertility. Here are the highlights from our conversation.
What does an empowered approach to fertility look like? What’s your vision for it?
“My vision is that couples get all of the information they need so they can come from a position of power when they’re deciding whether to have children or what kind of treatment to pursue. It’s really important for people to be realistic about what IVF or assisted reproductive technology can and can’t do for them. We tend to overestimate our fertility. So even at the tender age of 22, a woman will have about a 25 percent chance of conceiving each month, and by about 35, that’s down to about 15 to 20 percent. By 42, half of us won’t be able to get pregnant at all. So I think it’s really important to incorporate family planning, like real family planning, into the curriculum. When you’re talking about career planning to also think about family planning: Do you want children? Yes or no? If so, how does that fit into your career path? And how can you make that happen? To the extent that you have any control over that, of course.”
What are the basics we need to know around fertility?
“The language that we use around family planning, birth control, and reproductive choice makes it sound like fertility is a tap that you can turn off and on. When it is absolutely not. We human beings, as a species, are very inefficient in reproducing. The majority of embryos that are made, whether it’s in nature or in the IVF lab, aren’t normal. They’re not going to implant, let alone become a baby. It is family planners, like me, who have brainwashed people into thinking that every single act of unprotected sex is going to lead to a baby.
The only real test that we have of fertility is to try to get pregnant. I have no test that can tell me that a woman or a couple can have a baby. Certainly we can do infertility investigations of the couples having difficulty. Thirty to 40 percent of the time we find the challenge on the male side and 30 percent of the time we’ll find the challenge on the female side. But about 20-25 percent of the time we will not be able to work it out.”
What is your best advice around monitoring your fertility to increase your chance of pregnancy?
“I’m not a big fan of apps. I understand the desire to gain some control over a process over which you feel you have no control. I totally get that. The challenge is it can start to control you. There was also a recent study looking at those fertility apps, and a significant percentage of them are just wrong. Sometimes it’s just a question around getting couples to have sex at the right time. My best advice, if you’re trying to get pregnant, is to have sex every other day, in the typical 28 day cycle from day 8 to day 16. Sperm will live in the fallopian tubes for at least three days and are capable of fertilising an egg. An egg only has about a 12-24 hour window in which it can fertilise. You want the sperm to be waiting for the egg. An egg is surrounded by this fluffy cloud of cells and you actually need hundreds of thousands of sperm to break down that cloud for the one to get in behind.”
If apps are not a good way to count ovulation days and periods, is there an easier way to do this?
“Checking your temperature or urine sticks would be more predictive than apps, but you want to have sperm waiting for the egg. So it’s not like your fertility window is only open when you see the two lines. If you’re waiting for that, you may not have enough sperm sitting in the fallopian tube for the eggs. I will say one of my family members struggled with getting pregnant for many years and she told me that the worst piece of advice anybody ever gave her was to do days of body temperature charting. She found it so awful. Every morning, it was a reminder that she wasn’t pregnant.”
For female, LGBTQIA+ couples, should you check your fertility before embarking on the journey?
“I have no test to tell me if a woman can get pregnant. For my lesbian couples who haven’t decided who is going to be the egg provider and who is going to carry the pregnancy, then I think doing ovarian reserve testing, doing an ultrasound, just getting that basic information makes sense. Sometimes there can be disparate ages. Sometimes the older partner wants to go first to have an opportunity. And then the younger one. I think if a couple isn’t clear about which way they want to go, we just assess everybody and make an informed decision.”
Does the age of the sperm donor affect pregnancy?
“Male fertility does decline, but not quite to the extent that women’s fertility does. Probably not until about
50. And then we’re talking more about increased risk of miscarriage and single gene disorders like Haemophilia. There’s also an increased risk of Schizophrenia and Autism with older dads.”
What can we do to broaden the conversation around infertility at work to break down the stigma that surrounds both infertility and miscarriage?
“I think we need a greater understanding in the broader community about just how challenging it can be to get pregnant. The last thing my patients who have been trying to get pregnant for years want to hear is, ‘Oh, just have a holiday’ or ‘Just relax, it’ll happen.’ People need to understand that it is not a tap that you can turn off and on or something that you can control through diet or acupuncture or supplements or other – maybe not so helpful – suggestions that people might have.
For a lot of women and men who have always been very successful in their lives, who usually set their minds to do something and achieve it, bumping up against infertility can be quite confronting. Feeling like your body has failed you or you have failed it or you’re failing your partner – it can be particularly painful for high achievers. There is still a lot of shame associated with not getting pregnant. I encourage women who are feeling that to imagine that their best friend is going through it – and to consider what they would say to their best friend. Practice a bit of self care around that and be kind to yourself.”
Back in about 2014, some of the big companies like Google and Facebook started offering different policies around paying for egg freezing. What are your thoughts on policies like that and workplaces getting that involved?
“I think it has the potential to be fabulous as long as it’s part of a broader array of services and family-friendly workplace policies. But if it’s just because you’re working 14 hours a day and you can’t have a social life or take the time to find a partner, so they’re just going to bribe you to freeze your eggs, then that’s a different story. It also opens up the conversation about what egg freezing can and can’t do. A lot of women believe freezing your eggs is going to be some sort of cure for all the age-related decline and infertility. Unfortunately, it’s not.
You don’t know what a frozen egg is going to do until you try to get pregnant with your frozen eggs. And unfortunately, if you leave it too late when you use them, it may be too late to go back to retrieve fresh eggs. Around the world, less than 10 percent of women who freeze eggs come back for them. But having said that, for a lot of my patients, it’s not so much about using them in the future again, but getting back to empowerment. They feel like they’re taking some control back over their lives. That’s quite an interesting way to look at it.”
What are your thoughts on acupuncture, naturopathy and diet in assisting the IVF process?
“You can certainly diet and exercise your way out of fertility – so you can be overweight, you can be underweight. If you are reasonably healthy, being healthier won’t make you more fertile. About 10 years ago, there was a study that suggested that acupuncture would help improve IVF pregnancy rates. Since then, there have been many studies done. One very large Australian study done by some of Australia’s best IVF investigators in collaboration with the University of Western Sydney found no benefit in terms of live birth rates with IVF. Having said that, for many of my patients, acupuncture is the only time they stay still for 45 minutes and they find it helps them cope with the emotional ups and downs of treatment. So if you get that benefit from it, fantastic.
We don’t have any evidence supporting naturopathy. If you’re eating a reasonably healthy diet, there’s pretty good evidence that supplements are not going to improve your health. Having said that, many of my patients tell me they feel really great with the program that their naturopath has put them on. I certainly understand the desire to do everything you feel that you need to do. Again, it’s back to that control. Finally, there is some evidence that a Mediterranean diet can improve fertility. So good fats, olive oil, lots of fish. I support the Mediterranean diet.”
Does a Mediterranean diet support alcohol or coffee?
“I’m a big believer in moderation. A glass or two of wine, three or four times a week while you try is fine. There is no safe level of alcohol when you are pregnant. In terms of coffee, one to two cups a day is fine.”
How long you should you wait to try and get pregnant once you have an early miscarriage?
“It’s an old wives tale that you need to wait three months before you can start trying again. If you get pregnant in the months following a miscarriage, it’s absolutely fine and it will not increase your risk of miscarriage in the subsequent cycle at all.”
How long should someone keep trying before seeing a specialist like you?
“The general rule of thumb is if you’re under 35, 12 months. If you’re over 35, six months. My feeling is that six months at any age is a reasonable time to just get some basic testing done to make sure there’s nothing really obvious wrong.”
This conversation has been edited for clarity.
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