Choosing when to retire, or more simply, whether or not one should retire, is a difficult question. It takes lots of reflection, looking back on one’s journey throughout their professional life and whether or not they feel like they’ve left no stone unturned as their journey comes to an end. In the field of fertility, it can be even more difficult to make that decision.
On this episode of Inside Reproductive Health, Griffin talks to Dr. Selwyn Oskowitz, founder of Boston IVF and heads the Rwanda Fertility Initiative, an organization with a mission to provide affordable fertility services to every citizen of Rwanda. Dr. Oskowitz retired in 2016, leaving behind a legacy that left its mark across the entire field of reproductive medicine in the United States and beyond. In addition to sharing what he’s been doing with RII, Dr. Oskowitz also discusses why he chose to retire and what he sees are the biggest positive changes to come to our field.
Learn more about the Rwanda Fertility Initiative at www.therii.org.
To get started on a marketing plan for your company, complete the Goal and Competitive Diagnostic at FertilityBridge.com.
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Welcome to Inside Reproductive Health, the shoptalk of the fertility field. Here, you'll hear authentic and unscripted conversations about practice management, patient relations, and business development from the most forward-thinking experts in our field.
Wall Street and Silicon Valley both want your patients, but there is a plan if you're willing to take action. Visit fertilitybridge.com to learn about the first piece of building a Fertility Marketing System--The Goal and Competitive Diagnostic. Now, here's the founder of Fertility Bridge and the host of Inside Reproductive Health, Griffin Jones.
JONES 0:57
Today on Inside Reproductive Health, I'm joined by Dr. Selwyn Oskowitz. Dr. Oskowitz is the former Medical Director of Boston IVF. His long standing career included many firsts that impacted the field, both in the state of Massachusetts and elsewhere, some of which include being on the team that was the first to establish a live birth from IVF. Dr. Oskowitz also developed new IVF protocols and taught them to other members of the fertility field across the world. These teachings and other research efforts resulted in additional firsts in the state of Massachusetts, the first baby from gamete intrafallopian tube transfer, the first baby from a donated egg, first baby from a frozen embryo treatment, the first baby born from the ICSI procedure all in Massachusetts and many others. Dr. Oskowitz is also the founder of the New England Fertility Society and is widely recognized for his patient-centered medicine and philanthropy. Dr. Oskowitz, Sel, welcome to Inside Reproductive Health.
OSKOWITZ 1:52
Thank you so very much. You're certainly making me feel welcome.
JONES 1:55
Well, I think we're doing a new segment now that I've just decided and it's called where are they now in the fertility field? And so for those that haven't heard from you, I think that this bio resonates with a lot of people, so is familiar to a lot of people better said my project manager on this podcast, Katelynn, said that she had to--it was very hard to shorten your bio down because she said, “This man is amazing.” I can see written in my notes. And a lot of people know you for this, but I think a lot of people have also missed you for the last four or five years. So for those that are familiar with you, and I'm going a little bit backwards, but for those that are familiar with you and haven't seen you since you've retired, what have you been up to the last four years?
OSKOWITZ 2:41
Well, I happily retired from full-time Reproductive Medicine in 2016 and I moved from Massachusetts to the west coast, which was a major transition. So it's a whole new country out here and very interesting, wonderful people, beautiful sunshine. And I was able to, I'm able to enjoy that. And of course, I invite all my colleagues who want to come say hello and have a coffee or you can have a meal, too, with me out here in California!
JONES 3:16
Why did you decide to make that move? You had been in the northeast for a long time. Why did you decide that once you were freed up professionally, that you wanted to move physically as well?
OSKOWITZ 3:29
Well, I wanted to be close to my two sons. So my eldest son, Adam, is a vascular surgeon and he's working in UC-San Francisco. So it's not exactly--at least it's in the same time zone, so I'm happy for that. My youngest son is in the movie industry, in of course, California, Los Angeles, and we're able to see him so much more and that's what I wanted to do with the time that we have.
JONES 3:56
So you move out to the west coast to be with family, to have a bit of change of pace. What have you been up to professionally, philanthropically? I know that you're involved with an organization in Rwanda. Talk a little bit about that.
OSKOWITZ 4:10
Now, having retired with all the useful skills that we all develop over the years, I felt it’s very important to utilize some of that background to help in reinventing oneself. And I was inspired by other colleagues in the field, including Melvin Taymor who was my mentor or one of my mentors up in Boston. He was a professor of OB/GYN and he did a lot of work on hormone research and he was a skilled surgeon. And when IVF came on the field, he reinvented himself. He started, sort of, a new career, restricted to in vitro fertilization. I thought that's fantastic and really nice to be able to use your previous experience to enjoy a different pace and still contribute to our world. So Rwanda happened by a relationship that was started through Brandeis University. They had a fellow from Rwanda--
JONES 5:10
An REI fellow?
OSKOWITZ 5:12
No, this was a fellow in Sustainable Global Health. Her name is Angelique Rwiyereka, a wonderful lady, a daughter of 10 siblings from Rwanda. And to Brandeis, she had received a Fellowship Award from my wife's foundation there, Laura Oskowitz Foundation, and so we became friendly with her and I just said, Listen, if you ever need help in Fertility Care in Rwanda just let me know, so that created the avenue for us and she helped set up a relationship with the hospital, Rwanda Military Hospital, where they have OBGYNs and dozens and dozens of patients who need fertility care and no recourse for them. There was a private clinic, but no one could afford the fees, but for a few people. So the idea was to offer fertility care to all patients, no matter the income, no matter what they are able to afford and so on.
JONES 6:08
Is there an IVF lab there?
OSKOWITZ 6:10
Yes. Dr. Catherine Racowsky, who is currently the President of ASRM, generously donated her time and energy to this project and donated laboratory equipment including two incubators, microscopes, instruments, and a host of other things and came out herself to Rwanda to set the lab up and test, QC it, and start teaching the process. Our idea is, we wanted to be sustainable. We don't want to just move in and do a few cases and then come back out, that isn't sustainable. We sort of teach people to fish if you will. And she was part of the volunteer--she still is, of course, involved in teaching the Rwandan technicians basic laboratory, not embryologist yet, but now we are training them so that they can do it themselves.
JONES 7:04
Are you only training while you're in Rwanda? Are you also doing retrievals and transfers and doing some cycles while you're there?
OSKOWITZ 7:11
We are doing some cycles in the training mode. So we’re there with the doctors and some residents, as well as some students, too. But we are training the doctors, virtually hands-on, to do the stimulation, the retrieval and the transfers. And at the same time, we have laboratory volunteers. So these are all volunteers who give up their time to come and do hands-on training. And I have to mention, Keith Isaacson on the clinical side is an expert not only on IVF, but hysteroscopy, laparoscopy which is essential, you know, I can go on and on about how one introduces a new procedure in a country that doesn't have one. It's not simply a one-off procedure. You know, there's a whole infrastructure that needs to be developed in order to sustain a high tech procedure. In other words, patients needed the basic surgery, they needed to have their tubes corrected and needed fibroids removed. And they needed to be done as modern laparoscopic techniques. We had to introduce all of that--
JONES 8:27
And the people that you're training, these are Rwandan OB/GYN physicians?
OSKOWITZ 8:34
Yes, they are Rwandan OB/GYN physicians. Some of the doctors are from nearby countries, there’s one doctor from Nigeria and so on. That's not unusual where professionals may move to an adjacent state, but they’re Rwandan, they’re Rwandan trained physicians. It’s a critical thing as out of 12 million population, they're barely 50 OB/GYNs. And that's a very small number as you can imagine. And they do all OB/GYN--they'll have a patient who is bleeding in labor, which is an emergency, and they’ll have to do emergency cesareans. One of the things about early IVF that all colleagues who started IVF programs in the United States was dedication of OB/GYN to reproductive endocrinology. In other words, they basically stopped doing the obstetrics and the deliveries to focus on the reproductive endocrinology which is a seven day a week process and requires a lot of dedication and time. You know, you cannot postpone the retrieval because you were called away to do an emergency cesarean. So that's still a problem we’re struggling with in Rwanda is a lack of autonomy and a lack of resources. They have a lot going on, they have--when I say lack, it's compared to the United States--they also have a lack of physician expertise and time. So we’re working hard with that to try and improve that situation.
JONES 10:12
So there's a population of 12 million, there's about 50 OB/GYNs in the entire country?
OSKOWITZ 10:19
Entire country.
JONES 10:20
So what does that mean for regular gynecological care? I imagine a lot of people are going without--I imagine a lot of people are going without basic primary care. For those that are somehow able to receive some type of OB/GYN care, or gynecological care, are they typically going to a primary care physician for that if there's only 50 for 12 million people?
OSKOWITZ 10:46
Well, they have midwives, so they have a whole cadre of midwifery services. And Rwanda has done a lot amongst the African nations to improve maternal mortality, which is one of the criteria that you judge obstetrical care. So they have outreach programs. They have lay educators that teach women about where they should go when they’re pregnant. And they get the counseling by using nurses. And they do this all at the local village clinics. They have a hierarchy system of once the clinic feels they've done all they can and they needed their intervention, they get referred to a regional center, which is a more advanced clinic, if you will, then Regional Medical Centers and then the major centers which are in Kigali and some of the bigger cities.
JONES 11:40
Is this program the only REI training in this part of Africa?
OSKOWITZ 11:46
No. This is in Eastern Africa, so we have Nigeria, which is a huge country and they have ongoing IVF programs there and in fact, some of the patients prior to our arrival, some of them had to go there to Nigeria, Kenya, Ethiopia, some even go to Tanzania. These are all countries that border on each other. I do think we are one of the very few, if not the only one in East Africa that takes care or is attempting to take care of all-comers. This is our idea of the philanthropic approach. And the small number of patients can afford a private clinic in which there's one in Rwanda, that is fine for them, but we wish to provide the service. And that's what we’re starting with to all patients, regardless of the ability to pay.
JONES 12:38
How often do you go?
OSKOWITZ 12:40
Well, I--initially on retiring I used to go there about four times a year. And now I go a lot less maybe once a year to work with our volunteers. Some of the doctors including Joe Gianfortoni, who is also retired, does a lot of philanthropic work, and after just going out once, he said I can't wait to go again. Of course Keith Isaacson, been out there a couple of times with him. Of course he gets very busy because he has to do both the REI side as well as the surgical component. There’s a big bottleneck of patients who need surgery. They can't do IVF yet because they might have a submucous myeloma, they might have a hydrocele,that's even difficult to diagnose laparoscopically, and etc. So he has to help them get those patients ready for IVF. Then there's a wonderful character--he’s going to be angry with me for using the word character--Eduardo Kelly, he used to run Serono in the United States. And he's now a fully accomplished laboratory advisor and each one has volunteered his time, he's been out there on two occasions to help with training of the endocrinology lab people. We even had--we brought Rwandan professionals to the United States, we brought them to ASRM. Eduardo has actually brought Felicie Nyinawabali--sorry about the pronunciation. She came out for three weeks to study under his tutelage in California.
JONES 14:18
Did this idea of I'm going to go help get this program underway, I'm going to train. I'm going to be active using the skills that I've practiced my entire career--did this help make retirement more tenable of an idea for you?
OSKOWITZ 14:36
Yes, it did. It made it more tenable, but that's a word that we need to keep in abeyance. Because retirement means a whole host of things. I've been told that retirement in the romantic languages means jubilation, there's so much that one can do and I want all people who have considered retirement to think about the books that they can read, that I'm enjoying now, I also enjoy a little bit of painting. I'm not that good, of course. So I can rely on my social security rather than painting to make a living. Yes, so staying engaged in your area of accumulated expertise is helpful. It's not essential, but it's helpful. And one example on how to retire is to look at the one of the four doctors that started Boston IVF, Erwin Thompson. He was one of the first founders with us, me and Mike Alper and Merle Berger. And now Erwin Thompson retired in his early 60s, and he said I'm retiring from medicine as well. I want to do all the things I love doing, besides my love for medicine, and I'm disengaged from that now. He is a painter, he's had several one man shows, he's also a poet, and he also loves life and his time off and that's his form of retirement--very intellectual, cultural approach to society. And he doesn't do any medicine at all. And he loves that.
JONES 16:10
But I like exploring this and I like starting the conversation backwards because it gives you, also in the way you mentioned, the kind of gynecological roots of REI and gives us a sort of flashback to bounce to and forward, but I want to explore this idea of retirement and the reason why I wanted to talk to you about is because I hear so many people thinking about it. And I think it sounds like they're just unsure about a lot. I can't counsel on it. I hope that I'm pretty far from that point in my life, but I see just people weighing a lot of different options. One of the things I hear is, well what would I do? Would I go golfing? They're entertaining offers of their partner buying them out or they're entertaining offers from private equity and maybe it's the timing, but they just don't know what they do? How many days can they go to the golf course? And it sounds like between you and your colleagues that you found some different meaningful things to do.
OSKOWITZ 17:13
Right. And I think the whole question of retirement is so complex and so intricate, and so on. And I think that the whole session can be devoted to that. And I do think it's very important, not only because of the things that one can do, but I think for some people, one shouldn't retire. That retirement may not be for them. There are some people who really miss the cultural support of the people that they work with and love every day, and the enormous professional feedback that you get from finding out new things, sharing expertise, and of course, most importantly, the relationship with patients who you're struggling to help, who you help sometimes, and others who don't, that part of life is so intense. And for some doctors, if you have your health, you know, those doctors should continue with what they’re doing because they will miss it enormously. I fortunately don't miss it that much because of what we just discussed--my work and all the other things I enjoy on the west coast.
JONES 18:27
How did you discern the decision? How did you know it was time?
OSKOWITZ 18:31
I really wanted to do some volunteer charitable work. And it was very difficult being in full time practice and it's also difficult to do that in the United States. At the same time that I was thinking of retiring, the theme at ASRM was access-to-care, over and above all the wonderful research that's being done in terms of vitrification, genetic analyses, and non-invasive analyses of immune, etc. The one thing that became very important at ASRM is access-to-care. And just in summary, it's a very difficult area. No one can do--you can do a one off where you make a donation or every time there's a successful pregnancy, make another donation. And some people do that. There's some papers about starting a nonprofit organization to try and raise some money. It's very difficult. And also, there's a lot of opposition. It's a struggle between what's made medicine in America successful, the capitalistic incentives and connections and energies that derive from that versus taking care of those who cannot afford it with the current infrastructure that we have. So just to say it's very complicated. My feeling always, I want to do--I want to help all comers, I don’t want to be restricted by the Massachusetts insurance, which is better than just about every other state in the country. But I wanted to be successful in a place where you are more likely to be successful, which is a place like Rwanda, where they just love the idea, of course, and where it's just a natural, where one doesn't get pushback from industry, because industry is constantly trying to enable their products to be sold and sold more efficiently and you know, enormous amounts of being competition that way. I do not want to take away from the way the system is developed in terms of marketing and so on. But I thought if I could be successful in Africa, then I can take that to start in America, because America needs charitable work or access-to-care, they’re different things, but access-to-care is something that is really a big challenge in a lot of states.
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JONES 22:50
Well you brought up a lot of the capital interests that are present in the field, that built the field to the level of industry that some would call it today, some don't like that term, but to the level of all of the different companies that are involved. And that, I think is a reason why some do sort of want to retire, for better or worse, it just isn't the same field that they signed up for some time ago. And I came into the field 2014-2015 and I've imagined it will be a very different place in 2035-2045. And it might not be something that--it might not be the same thing that I signed up for and it might bear very little resemblance to what I signed up for in 2015 or 2016. So you came into a time where this is one of the first private practices in the country. You join up with Harvard pretty early on to have that academic affiliation, but by the time you exit in 2016, by the time you retire, you're the co-founder and medical director of one of the largest fertility groups in the entire continent. So, I guess, you know, does that play into one's decision as well? How much did it change to where this isn't what I signed up for, and I don't like this anymore versus, you know, I'm still excited because it's something new? Describe the balance or lack thereof between those two?
OSKOWITZ 24:40
Yeah. So I retired when I was still really excited and I still am very excited about the field that we're all in. It's a wondrous field with the things that are changing, with opportunities for improvement, and human engagement, and that is wonderful. And that is continuing. Most of us feel like this is what we signed up for and and even better than what we expected. I just need to make further clarification that I was medical director in the first five years or so of Boston IVF, getting it started, introducing the new protocols, and then it was handed over to Erwin Thompson, Merle Berger, and then Michael Alper, who's been the medical director for the last couple of decades or so. The size of Boston IVF, it was related to initial thrust and value of the insurance mandate. Boston IVF started in 1986. We were all part of the Harvard Medical School association with Beth Israel Hospital and the department was run by Melvin Taymor and we were doing research on the various aspects of IVF under Mel Taymor. And then there's another story that we can tell you about as to how the first in vitro baby was conceived in a state where they had forbidden it illegal to do research with embryos as a law, which I believe is still on the books, that one cannot do research on embryonic material. But right now, the way IVF is done, the Attorney General feels that it's not in contravention of that law. But initially, before doing IVF, we had to deal with a legal component, the so-called ethics that surrounded that whole process.
JONES 26:40
So for you, there was this change, you were excited about the changes that were happening, you ultimately decided to retire because of some other things that excited you, including, but not limited to volunteering in Rwanda. If I can put you on the spot for a second and ask you an on the spot question, how would you describe, If you had to summarize it briefly, the best of the changes that you saw in the field and the worst of the changes you saw in the field?
OSKOWITZ 27:13
Well, the easier question is the best of the changes because there were so much positive and wonderful gains that occurred in terms of the medication that we were able to use starting off in the early days with Clomid, and then adding hMG. And our industry was able to do the research to give us much more refined products. Serono was very big in research in those days. That's another reason why I think that we enjoyed the wave of success in Massachusetts and grew so big in that Serono was headquartered in Massachusetts. Serono used to have a special division, which was independent, called Serono Symposia. Their mission was to educate patients and doctors and researchers with teachers from the best in the world. We'd have people like Bruno Lunenfeld, who was a close friend of Mel Taymor, he did research in Switzerland, Israel and Serono Symposia used to bring these experts out to us to teach us new techniques. So talking about the best, medication was difficult initially, they were intramuscular shots every day, you'd get a shot and then some patients needed twice a day shots. It was a very difficult, intense process. So another good thing is how patient-friendly, a lot of IVF has become. And I'd say that our group at Boston IVF was very focused on patient-friendly IVF. We were the first to move into a subcutaneous approach when the first subcutaneous gonadotropins came out like Metrodin, Fertinex, Bravelle, and other nice developments that came out, of course, finally we have Gonal-F which is even given by a cartridge--it's a lot easier, you just dial up the dose so these things all became much easier for patients. And the learning curve on this became much easier with all these opportunities, including the development of the computer or computer informed consent. It became available and made much more streamlined and patients would spend less time away from their work and their families, their husbands and children if they had them having secondary infertility, for example, patient-friendly IVF. We also introduced subcutaneous HCG triggering, the human chorionic gonadotropin, traditionally had been given intramuscularly. So there was another painful shot to do the final maturation of the eggs. And we learned from the Canadians that you can give it subcutaneously quite successfully. And we took that information, introduced it subcutaneously. There's always pushback whenever you move in a different direction people have become stalwarts. They like the intramuscular, it’s a good dose and that's a good route. But with a lot of pushback we still managed to finally get everybody to agree subcutaneous HCG works very well. We also adopted vaginal progesterone as supposed to intramuscular progesterone. Intramuscular progesterone is quite brutal, it's an oily solution nowadays, although I'm hearing now that there's a new aqueous solution a lot easier to give. So a lot of good stuff. And nature's been very forgiving in terms of having embryos that thrive in the various media that have developed over time and then the development of global media by John Biggers who is a giant in vitro fertilization from the Laboratory of Human Research and Reproduction--LHRRB. So we had staff and colleagues who came out of that institution, including Catherine Racowsky, who developed the global media blastocyst culture came later in the earlier years. We grow the embryos for two or three days, then blastocyst culture came out, and they were all kinds of thoughts of how are we going to have the correct media to nourish this more advanced embryo. And Biggers and Racowsky developed this global media and then generously shared all this information with industry without going the patent route, which I'd say--if I put that on the negative side is the the development of patents on this wonderful research that comes out.
JONES 31:50
Yeah, I wanted to ask you about that because just hearing the experiences of your career, it's very much a highlight reel of the field and has been overwhelmingly good by that view and I wonder, patent sounds like it could be one, but do you also have concerns about where the field has ended up or where it's going?
OSKOWITZ 32:12
Yeah. So law concerns about the involvement of patenting of information, patenting of biologic material. People suddenly deciding that they own a gene that they discovered. Now, there's some complex stuff. I mean, you know, Columbus discovered America and claimed it for himself. And that's fine and that's how things work and that's wonderful. Should we do it if you discover a gene and chromosomes? We all have genes of that nature and these belong to mankind and all those animal species, vegetable species as well. So can one claim them? And If one wants to put their name on it and get the recognition they deserve, and they really deserve these research searches do it, but the name on it, but the economics of patenting can become a problem, can be toxic and the classic example is with the BRCA gene where one becomes higher risk for breast and ovarian cancer. And, you know, the cost of doing that test was high because of some patenting issues.
JONES 33:31
I wanted to bring you on the show to talk about retirement, to talk about a career and building a career over the field that sees these tremendous accomplishments and then other concerns and to get your experience on that because when you and I first met, it was at essentially your retirement party at NEFS. And I had only been in the field for probably less than two years at that point. So I was pretty new and you and I hadn't met previously. And the people that came to speak and did your slideshow and the stories that people were talking about you for the rest of that meeting in Vermont at that hotel were just really fond of you. That everyone had nothing but good things to say and that you had also touched their career in many ways. And I looked at that and I watched that and I thought, Damnit, I want somebody to make a slideshow and be crying about how much I touched their career in 30 years. That's the type of career that I want to build. And if I don't do that, I will feel like I haven't unturned every stone that I could have in my professional life. Sel, how would you want to conclude with our audience about the career that they can build, the legacy they can leave, and when they know they might be satisfied with it?
OSKOWITZ 35:01
Well, I'd like to tackle that--that's a wonderful question. And one of the things I admire about you is your observation of life's happenings pertaining to people. Let's focus on--I cannot focus the answer on the joy of who one is in one's profession, because profession is a large part of our lives and that brings up a lot of other issues in terms of gender issues and profession and so on. It's an enormous part of our lives and the most successful components of professionalism is your relationships with people. We can't do this all on our own. There's not a single development in infertility modern care that was developed by a single person without cooperation, collaboration, validation, and so on. And the spirituality that comes with it and spirituality is a tough subject, but there’s an enormous human, spirituality and collegial relationships. Giving the recognition to other people, sometimes talking with them, quoting them, sharing time with them is so valuable and so constructive in what we do, and the research we do. We get ideas just by an intimation by a colleague and we then develop them, even though the idea may have gone in a different direction from the first person who thought about it. So that's a wonderful part of our lives. And I also want to mention that retirement, even though that's when we first met was when I was retiring, it's not the victory lap, if you will. It used to be. I think, in the old days, when one had back breaking work and literally lugging bales of coal and things like that, I think retirement was more of a blessing. Today, there are so much network relationships that we have, and so many other avenues of contributing to medicine in spite of our skills declining. So one has to change, of course, one's contribution to research and patient care, depending on your skill sets and so on, which just do decline with time. And there--let me just emphasize--there are nice, lovely, creative ways in one's humanity to continue professional activity. And of course, retirement has its own joys, but it's not the be all and end all for everybody. And I wanted to emphasize that and one of the things about retiring that I'd like to caution against is that sometimes one gets cut off from all those wonderful relationships that mean a lot more than medicine, but are essential for medical care and medical progress as well.
JONES 37:56
And it hasn't happened to you. So thank you for continuing to collaborate both with your programs, via philanthropic efforts, and here on the show, on Inside Reproductive Health. Thanks for letting us know, Dr. Selwyn Oskowitz, what you've been up to, and letting everyone who's missed you the last few years letting them know what you're up to because I think many of them would like to contact you and I hope that they do.
OSKOWITZ 38:20
Thank you so very much, Griffin.
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You’ve been listening to the Inside Reproductive Health Podcast with Griffin Jones. If you're ready to take action to make sure that your practice drives beyond the revolutionary changes that are happening in our field and in society, visit fertiltybridge.com to begin the first piece of the Fertility Marketing System, the Goal and Competitive Diagnostic. Thank you for listening to Inside Reproductive Health.