When COVID-19 entered the United States, it felt like a scramble to figure out what our next steps were as a field. Do operations continue to give patients the best chance of success? Or do the risks outweigh the benefits? Some clinics pivoted quickly, following the ASRM guidelines precisely. And some clinics panicked with feelings of apprehension of stopping treatment altogether.
On this episode of Inside Reproductive Health, Griffin talks to Dr. Oluyemisi (Yemi) Famuyiwa, the leader of a clinic who seemed to be well-prepared for the unknowns of the virus. Dr. Famuyiwa is the founder and director of Montgomery Fertility Center, an independent clinic located in Rockville, Maryland. Dr. Famuyiwa aims to provide state-of-the-art care based on emergent technologies and ongoing research. And this philosophy was truly exposed when COVID-19 first came on the radar.
Her ahead-of-the-game research got her clinic appropriately prepared for the emergence of the virus in her area, keeping volume steady--and even at the highest it has ever been. So what lessons can other clinics take from her experience in the COVID-19 era?
Learn more about Dr. Yemi Famuyiwa and Montgomery Fertility Center by visiting montgomeryfertilitycenter.com.
To get started on a marketing plan for your company, complete the Goal and Competitive Diagnostic at FertilityBridge.com.
***
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 0:06
Dr. Famuyiwa, Yemi, welcome to Inside Reproductive Health.
FAMUYIWA 0:11
Thank you for having me.
JONES 0:13
I want to talk to you today one because you're an independent practice that is in the backyard of a giant and I want to talk about what that sort of dynamic is like. And I want to also talk about when you have the resources of a smaller independent practice how you adapt to something that is crazy wrench in the works, like COVID-19 has been the last seven months. And so can you tell us a little bit--you're located in Bethesda, Maryland, you're--
FAMUYIWA 0:42
Yeah, I'm located in Rockville, Maryland, and it's just up north from Bethesda. And I've been in practice since 1999.
JONES 0:58
And so in that time, have you ever encountered--well, let me ask it a different way. Because I know none of us have ever encountered anything like COVID--what was the biggest operational surprise challenge you faced before COVID?
FAMUYIWA 1:14
Um, biggest thing before COVID? I wouldn't really say there was a big operational challenge, per se. I think we had a good flow going. We were, you know, a small practice. But we stayed busy. We were--we had enough work to occupy us. So it wasn't more of a challenge. It was actually fun prior to COVID.
JONES 1:43
And then so COVID happens and what was the initial reaction that you were going through? How, at what month does it start to get on your radar? And at what month, what timeline does it start to be something that you said were gonna have to change some things?
FAMUYIWA 2:03
Well, I'd been following the news, so I pretty much been following it since it started in Wuhan, China. I started paying attention in December. And I sort of suspected that it was on the way. And by January, I was convinced it was on the way. So I started actually preparing my practice and myself, I would say way ahead of most people. I started in January.
JONES 2:34
And what were those--what were the first things you did?
FAMUYIWA 2:37
The first things I did was to analyze what are supplies? What are we going to have--what would likely go out things like masks, things like disinfectants, IV fluids for our patients, things that we would need in the procedure room. So I started sourcing it. I started getting gloves in the quantities that would that we would need. The only error I may have made was based on what was going on in Wuhan. I thought, Oh, yeah, it will come but it'll probably be over in about a month or two. Right? Wrong. But I started preparing early.
JONES 3:17
I think for a lot of lay people it was--we've just heard so much with SARS and West Nile and H1N1 that we thought it was the same thing. And I was with a group of fertility doctors the first weekend of February and we're all sitting around a hotel lobby--and there's probably there was a lot of us--so this is what we were talking about, but it still didn't seem like the total response that we would go through globally was an inevitable future. It seemed like okay, here's a dangerous disease, it's gonna come to the US. But no one at that time was talking about that this was the type of lockdown. So you're seeing this ahead of time, you're keeping track and then you say, Okay, I'm gonna need some more PPE, I need some more supplies. Talk about the escalation. How does it ramp up as the news starts to develop?
FAMUYIWA 4:23
Yeah, so as the news started to go, I actually started implementing full masking in the office, believe it or not. I talked to my staff about we may need to get goggles. I was trying to read as much of the literature that was really spilling out from all over the world. And it sort of brought to mind a little bit of what happened with Ebola, right? In the sense that--I'm originally from Nigeria and I was aware that when Ebola hit in Nigeria, they rapidly shut it down, right? Because of the actions they took. And it did not become the overwhelming devastation that most people expected. So I knew was coming., of course, I didn't know the full extent of it. But I started to ramp up. And then I started to look for N95 PPEs, I would say, somewhere around February, when it started getting really bad. And believe it or not, I actually remember going to, at that time, Home Depot had N95 available for painters and everybody. And I actually remember going to stand in line at Home Depot at 5am in the morning, so I could get N95s. And believe it or not, when the door opened at 6am. We all made a beeline for where it was. And at that time, they were not restricting how many you could buy. So I was able to buy supplies for my office staff and for myself.
JONES 6:07
Was this early March?
FAMUYIWA 6:09
I would say late February, early March, I started doing that. Because really by--I would say by early to mid March, you couldn't find those supplies anymore.
JONES 6:23
So you stock up on supplies. As it's getting closer, you're getting more. At what point you make changes in terms of patient flow, in terms of workflow. Because I remember it was early March talking with my team and clients weren't really bringing it to us yet. We were saying as a team, we did talk about maybe not allowing [inaudible]. And early on--I remember the first time we said that. No, we can't. We can't do that. And yes, three days later, it was like Yes, this is what we're doing. So talk about those changes.
FAMUYIWA 6:56
Griffin. I didn't wait. I honestly did not wait. I already started--we started doing temperature checks in February, when people came in. I even gave my IT personnel who came to service my computers. I give them N95s to use when they're in the office. We started wiping down a lot of stuff. We started doing high touch--we've always done it anyway, we just ramped it up. Because usually around flu season in the office, I have wipes all over the office, I have sanitizers and it's just something that we've always done. So what we did was we just ramped it up, and we started doing temperature checks. We started spacing out our patients. I didn't let more than two people in the waiting room. And this was way in February that I started doing all those things. So call me a little paranoid.
JONES 7:58
So this is back in February, talk about some of the other safety protocols that you--
FAMUYIWA 8:05
We didn't really ramp up the rest of it till March, when it started getting really scary. So we were already distancing people. We were already doing wipes of everything. I would say we really, really ramped it up towards mid-March. However, if you recall, or maybe you're not aware, the American Society of Reproductive Medicine, as well as the Maryland State Department issued a letter or a memo saying, Hey, guys, we think you need to stop. We need to shut down. Non-elective procedures have to be stopped. I got an email from Maryland State Department of Health. And because I also have a DC license, I also got an email from the District of Columbia Health Department. And I think it was all within rapid succession of each other that all these came about. Somewhere on the 17th, 16th of March. So we did stop, we did stop. We finished any transfers that we had going on, but we did stop. Part of stopping was I felt that I needed to understand better this virus. I needed to know if what we were doing was enough. I think that the dynamics of the virus were just being highlighted. And not enough was known. So now, it doesn't mean everybody had to stop. I just felt that this was what I needed to do in my practice, to review everything.
JONES 9:53
I've been in the field for six years now, not nearly as long as you have, but in my six years, this dynamic that you're talking about with ASRM issuing the guidelines was the most controversial event that I've seen--it makes PGT and egg freezing look like...
FAMUYIWA 10:10
I understand.
JONES 10:11
...regular conversation.
FAMUYIWA 10:12
Yes.
JONES 10:14
And the spectrum was as wide as can be. How did you react to it?
FAMUYIWA 10:22
I am, I felt that I would go along with their recommendations because I felt that enough was not known. And they were doing it based on the knowledge they had, combining as many experts as possible, and trying to give guidance that would make patients safe. So and at the same time, you may not be aware of our governor in Maryland, was also very, very proactive. Governor Ogan started issuing guidelines, probably almost before anybody else did. So I felt that was helpful. Interestingly enough, he said that the federal authorities, NIH and CDC, they were asking him questions. So he had a team of people from Johns Hopkins, from University of Maryland Medical Center. Yeah, I felt that for us--it may not work for everybody else--but for us, it was the best thing to go along with those guidance at that time.
JONES 11:40
You wanted to pause, see what was really happening, get the data and review it. Most people felt that way, it seems or at least most people did that. I can't speak to how they felt. Some did not some kept going where they irresponsible in doing that?
FAMUYIWA 11:58
No, I don't think so. I mean, I think that this was evolving so rapidly, you know? Everybody had different protocols. So, for centers that felt that they had good enough protocols, and they wanted to keep going, that was the good choice for them. I think at this point, there really was no right or wrong answer. You understand? I think everybody had to evaluate themselves. So my responsibility is not for those centers. My responsibility first and foremost is to my patients and to my staff. So I felt I needed to do what was safe for us.
JONES 12:38
So you're getting this decision and then this is going through till when? Till the end of April when ASRM issued the updated guidelines? Is that when you started to come back online?
FAMUYIWA 12:56
What we went is we mostly went into telehealth mode. I read a lot. Attended a lot of webinars. I met with my staff, you know, telemed wise, twice a day. Talked to our patients a lot. And I listened to the updates that ASRM gave. In the meantime, I also did my own independent research, to get a better grasp of what's going on and how I can apply that for us. ,
JONES 13:36
Okay, so then you're doing the telemedicine and how did you adjust to that? Did you start doing video right away? Were you doing telehealth just over the phone? Zoom?
FAMUYIWA 13:49
No, we went straight to telehealth on Zoom. Yeah. And I already--I didn't start zoom with this pandemic. I have always done a little bit of telemedicine because I have a lot of patients that come from out of the country. And I have some patients that live in different states. So it has always been beneficial for us to have telehealth visits, you know, online. It's just with this, we really ramped it up.
JONES 14:28
Yeah. So what was that like? Did you find it as useful as being in an in-person consult, not quite as much in person? Do you like it better? How was that transition?
FAMUYIWA 14:46
Actually, we're still using telehealth right now. And we're doing an amalgam of telehealth and in office, and I like it better. And here's what I tell my patients, this is the only time you're going to see me without my PPE on. Right? So yes, we're going through a camera, but I'm going to stay with you, I'm going to take all the time that you need to explain things to you. I can even draw diagrams, I can show you articles. I didn't feel there was a loss of connectivity, in fact, they may actually get more. When we bring patients into the offices to do the actual physical, of whatever we were doing online. So we would do ultrasounds or procedures, but I'm not going to have a big long sit down conversation with you while you're here. You know, we will continue on Zoom. So we have really seamlessly integrated into our practice, and it works well. You know, for us, it may not work for everybody, but it works well for us.
**COMMERCIAL BREAK**
Ok, so here’s the skinny. Just as your fertility group has advantages over other groups, your competitors also possess advantages over your IVF center that you don’t have access to yet. Now you can say their consolidation model won't work or their lab sucks, or their doctors crazy, or that low cost model cuts quality, or who would ever get their fertility testing done from a food truck, but many of them are onto something.
If you're not maximizing your own natural strengths and adapting to what the new patient demographic is demanding, then they start to do more cycles where you are, get better rates from insurance and vendors, take your patients, and even your staff. We work to maximize those competitive advantages because Fertility Bridge is the only creative and business development firm that exclusively sub-specializes in the fertility field. We have an entire team of people who help fertility centers attract and retain the right patients and nothing else for a living.
So we can help only your competitors and then they have an even bigger advantage. Or we can help you, too. Our initial consulting engagement is the Goal and Competitive Diagnostic. It's only $597 and we equip your partners and leadership with the foundation to leverage your competitive strengths, not mimicking someone else, and not let your competitors have an unfair advantage.
There's no long-term commitment whatsoever and there's a 100% money-back guarantee. Send your manager to FertilityBridge.com, have them sign up for the Goal and Competitive Diagnostic, and I will see you and your partners on Zoom.
JONES 18:11
So what do you think will be the lasting impact of this? I'm guardedly optimistic that telehealth will stay. I hope that they keep the insurance reimbursement rates equal to in person, I hope that HHS and OCR continue to allow other platforms like Zoom and Skype, or at least makes make the ones like Doximity easier to use or less cumbersome in restrictions, because I think most doctors love it, most patients love it. I hope it's here to stay. What are some of the protocol that you think are not going to go away even three years from now after there's a vaccine and there's no cases--in a perfect world? What do you think are some of the things that might be that last?
FAMUYIWA 18:58
Well, for sure, what's going to last throughout this, at least we intend to do, is the frequent cleaning the high touch surface areas, because this is what you do when flu comes around anyway, right? Remember, the bad flu pandemics we've had in the past? So we've had those protocols since then. And we're doing more of it, and we're still doing it so that that will stay. You know, the use of PPEs is to some extent going to stay, and mixture of telemedicine probably will stay for the most part. Yeah, I think those parts will stay.
JONES 19:36
You and I are having this--we're recording this conversation in September. Do you find yourself now in September having to assuage patient's concerns as much as you did, in March and April, when everything was brand new?
FAMUYIWA 19:53
I think that patients come to us with varying levels of awareness. We've had patients who have been very upset and refuse to do any telehealth. And we're like, Well, you know what, this is a policy we have. So you know, I mean, you can't help everybody. But that's a policy we have and we have to abide by. I think--I think we're comfortable with what we're doing. And we'll probably continue most of it because it's worked well for us. Looking back, I never thought that it would be this long. I honestly thought it would be over by mid-summer. So we're switching into this new gear of we're dealing with something that's going to be protracted. So how do we keep our patients safe? We have a very strict protocol that we take the time to explain to our patients, we have it on our website and we actually give them a detailed, written explanation of what we do. One of the things that we do--and again, it may not work for everybody--but we bring patients into the office one at a time. If their spouses are going to come with them, we ask that they come with them on FaceTime on the cell phone. And one of the things we do do, which again, not everybody has to do that, you have to evaluate your office--we actually sanitize the exam rooms that patients have been in. We mop the floor with a quaternary ammonium compound and we wipe down every single thing in that room. We wipe down the equipment, we spray and let the contact time stay per manufacturer recommendation. And we mop the floor. It's exhausting. But we do that after every single patient and I think the patients realize it. You know, they feel safer. Another thing that we have done, we've always had a high purifier, air purifier in our embryology lab that has also the capacity to absorb volatile organic compounds, because we were using a lot of chemicals to clean the office. So we've always had that from time immemorial, but we had it in the embryology lab. So what I did when we paused actually--that was one of the things I was doing, getting ready to get started. We actually have the IQ Air, but not the lay one that patients might get, but we have the hospital industrial strength one. And we have about six of those throughout the facility. We have one in each exam room that we have the patients in. We have one in the front desk area. We have one in the procedure room. As I speak with you, you may not be able to hear but I have one in my office right now. And we have another one in the embryology lab as well. So we have these air filters and purifiers throughout our facility. In addition, I do know that the building owners have increased the exchange rate throughout the building. So we feel all these things help to keep us and the patient safe.
JONES 23:08
When this was all breaking out, I looked at it as the two buckets of concerns. The one bucket of concern that patients has is am I more likely to contract disease by going to see a fertility specialist and everything in the office. And the second is, is my child going to be in danger? Is this even a good time to get pregnant? I can-- Which of those two buckets do you find patients are bringing up to you more?
FAMUYIWA 23:37
Both! So the way that I addressed the first one? Yes, you know, I mean, I cannot guarantee that you can't go out in the elevator or you meet somebody on your way to the office or you know what I mean? What we can do is, essentially try to eliminate the risks of contacting anything in our office with the protocols that we've instituted, including sanitizing after each and every patient, including purifying the air constantly, including wiping down all the high-touch surfaces frequently--we do that, at least almost every hour and whenever anyone has touched it. Sanitizing things like pens, anything the patient touches. So yes, we had addressed that first one. The second one in terms of will my child get COVID-19 if I get pregnant now? Well, I did a lot of literature search. And I looked at articles--the first one that came out of China, they looked at 34 men that had recovered from COVID-19. And they found out they could not isolate the virus in their semen. We do know that the testes may have receptors for the SARS virus, but the virus itself was never actually isolated from semen. So that was the initial study. Then there was another study. The first study looked at men who have recovered. The second study out of Germany, I believe, looked at patients who had recovered patients who were actively infected, and patients who were asymptomatic. And when they analyzed the semen in all these categories, they were still not able to isolate the SARS virus in semen even in actively infected patients who were symptomatic. They were not able to. They did see that some sperm parameters concentration, motility went down, but the virus itself was never present. And then last but not the least, there's a seminal article coming out of Spain, done by IVI-RMA, and what they looked at was the gene expression for the receptors for the SARS-COVI virus. So they looked at the ace2 receptor that everybody's aware of. What you have to understand is the SARS virus binds to the cells using a spike proteins, right? `But the spike proteins have to be cleaved, they have to be cut off before it can actually bind to the membrane. What's the thing that caught it off, it's a protease called TMPRRS2. So you can look at the expression of that protease as well as ace2 in the endometrial layer, those are lowly expressed. They're not expressing high amount, however, ace2 does increase with age. Now, what they also did was they also looked at are receptors that the SARS-COVI virus can bind? And they search throughout the literature and then compared it to the DNA from endometrial biopsy that was already in the DNA database. And they found things like there's another protease called TMPRRS4 that helps binding in the gut. Well, that protease is also present, highly abundant, in the individual layer. They looked at things at cathepsin B, cathepsin L. These cathepsins, they aid the protease, they aid ace2 in binding the membrane. These receptors are highly expressed in the endometrial tissue, and increased throughout the menstrual phase, throughout the secretory phase, to around the time of implantation. And then lastly, they found another receptor called basigin, BSG, that was also present in the endometrial layer. And the way I look at it is if ace2 with TMPRRS2 is your castle gate, basigin would be the sally ports, right? Side entrances. And that's also highly expressed. Now does it mean that you're going to get infected? Those are just the receptor. It doesn't mean that they found the virus. So they're postulating that, Hey, maybe more research needs to be done about this. And these other helpers, and other receptors need to be evaluated further.
JONES 28:33
How do you share this all with patients in a way that they can grasp and in a way that gets them to stick with treatment if treatment is their best course of action? How do you get them to receive it?
FAMUYIWA 28:46
So basically, explain what we know. What we know is they have not isolated the virus in sperm, right? So it's not like you're going to go out and get it as a sexually transmitted disease. It's not been isolated in ovarian tissue, to my knowledge. They've looked at the receptors. I tell them, a lot is coming out that is not fully understood. There is some evidence that some babies there was a report in JAMA that a series of infants were born with the IGM antibody, meaning they may have been exposed in uterus, even though the nasal swabs on those babies were negative. So in general, any infection while you're pregnant is not good. And if you're pregnant, you could get sicker than if you're not pregnant. So I always tell my patients, please be cautious the same way that your physicians are cautious. If you're in treatment, maybe that's not the time to be traveling all over the place. Maybe you want to be careful with who comes into your home. Maybe you want to practice all the sanitary precautions that are out there, that we're telling people, that any article can give you. But by the same token, you have to understand there are some patients who they really cannot put off getting pregnant because they'll become menopausal, they're rapidly losing their eggs. So you have to balance the risk with the benefit. To tell the patient not to go through treatment is to condemn her to childlessness in some aspects. Because you're, you know, especially in our older patients whose ovarian reserves are rapidly depleting. So yes, you can go through treatment, but you have to be cautious and take precaution, not expose yourself. We do test patients before they go through retrievals. So far, none of our patients have tested positive but once they test negative, I tell them, Going forward, you need to be careful with what you expose yourself to.
JONES 31:11
So now that you've got a rhythm, you've got protocol, and you've got procedures and a way of communicating it. What do you see for the future of independent practices and the visions for yours now that this is the landscape? Because in March, I predicted I said this is going to dry up private equity money for a while that had been just dumping in the field and consolidating these big groups. And like you said, You were right, but you didn't get the timeline right. I thought it would dry it up for a year to two, two and a half years. And I think it did for, you know, three months. And I'm pretty sure it's back. And I do know of three deals that were squashed of groups that were on the one yard line that we're going to do private equity. But as somebody that's a single practitioner, and you're in the backyard of the biggest group in the country, what's your vision for your practice in the wake of all this for the next 10 years?
FAMUYIWA 32:14
You know, the funny part is we've actually been so busy when we started back up. And we're still very, very busy, I welcome busy. I would say my volume has actually gone up. If anything, I cannot speak for everybody, I can speak for myself. Even though our practice is small, I think that we serve a unique pool of patients who actually do want to come see us, who enjoy that one on one conversation, they have full access to us. I do my ultrasounds, I give them feedback right away. So there are a group of patients that actually cherish that, that welcome it. I also have a cadre of, believe it or not, international patients that come seeking me. So I think when you've been in the practice for so long, whether you're in a small group or a big group, if patients know who you are, they will seek you out, you understand? There are some patients that may go to a big group and feel they connect with one particular physician. Other patients may go to a big group and feel they don't connect and they'll say I can't connect, I feel like I'm a number. Those patients actually seek us out and they come to us. So I'm happy that we're very busy. So for the foreseeable future, we're very busy. I enjoy what I do. I love my patients, they're a unique set of people. So while I'm still having fun, I don't know--I'm going to keep it up.
JONES 33:47
That's always good advice. How would you want to conclude with our audience who's mostly practice owners, mostly your colleagues, some execs and managers as well, how would you want to conclude about the adaption to COVID-19 in the world thereafter?
FAMUYIWA 34:07
Well, I can tell you, it is exhausting. It's exhausting because we spend 45 minutes to 50 minutes to an hour sanitizing each single room after each patient so it's exhausting. I think that we're gonna--I think we have fun with what we do. I think people have to--they have to choose protocols that work for them and see what works for them, and how can they keep their patients as well as their staff safe. So I would say look for something that works for you. What we have works very well for us and I like it.
JONES 34:47
Dr. Yemi Famuyiwa, thank you so much for coming on Inside Reproductive Health.
FAMUYIWA 34:51
Thank you so much. Thank you very much. I appreciate it.
***
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.