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IVF Lab

224 The Best of Fertility Network C-Suite

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, nor does the Advertiser's sponsorship constitute an endorsement of the guest or their organization. The guest's appearance is not an endorsement of the Advertiser.


Since 2019, Inside Reproductive Health has conducted over 220 interviews, featuring prominent physicians and executives from numerous fertility companies.

Among them, nine CEOs continue to lead their respective Fertility Clinic Networks or chair their network’s board.

Together, their networks have overseen an estimated 1.6 million IVF cycles and other reproductive treatments that have resulted in over 2 million pregnancies,

This is an episode you don’t want to miss as we showcase:

  • Gina Bartasi and the only three things she believes matter in healthcare

  • Dave Burford sharing his battle-tested sales advice

  • TJ Farnsworth’s entrepreneurial journey and his perspective on the necessities of field wide collaboration.

  • Dr. Kshitiz Murdia’s reasoning on why doctors make good CEOs

  • Marc Segal’s perspective on private equity and its place in Fertility’s future

  • Francisco Lobbosco’s first 100 days as CEO and the power of listening

  • David Stern’s steps to finding the right financial partner (Hint: It’s like a marriage)

  • Lisa Van Dolah’s philosophy of transitioning nurses into executive leadership roles

  • Andrew Meikle discussing the power of perspective (Both patient & entrepreneur)


Dave Burford, CARE Fertility
Website

Gina Bartasi, Kindbody
Website | LinkedIn | Facebook | Instagram

Dr. Kshitiz Murdia, Indira IVF
Website | LinkedIn | Facebook | Instagram

TJ Farnsworth, Inception Fertility
Website | LinkedIn | Facebook

Francisco Lobbosco, FutureLife
Website | LinkedIn

Marc Segal, US Fertility
Website | LinkedIn | Instagram

Lisa Van Dolah, Ivy Fertility
Website | LinkedIn

David Stern, Boston IVF
Website | LinkedIn | Facebook | Instagram

Andrew Meikle, Fertility Partners
Website


Transcript

[00:00:00] Griffin Jones: Since 2019, Inside Reproductive Health has conducted roughly 230 interviews and counting featuring prominent physicians and executives from numerous fertility companies across the world. Among them, nine CEOs continue to lead their respective fertility clinic networks or chair their networks board.

Together, their networks have overseen an estimated 1. 6 million IVF cycles and other reproductive treatments that have resulted in over 2 million estimated pregnancies. 

Sponsor: This episode was brought to you by Organon, Organon is committed to championing care equity in fertility. By elevating education, expanding resources, and investing in innovative solutions, Organon stands with aspiring parents on their unique journeys. Learn more at FertilityJourney.com.

Announcer: Today’s Advertiser helped make the production and delivery of this episode possible. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, nor does the Advertiser's sponsorship constitute an endorsement of the guest or their organization. The guest's appearance is not an endorsement of the Advertiser.

[00:00:28] Kevin Ali: Hi, I'm Kevin Ali, CEO of Organon, and at Organon, we're committed to engaging with leaders across reproductive medicine. I'm proud to help introduce the best of Fertility Network's C Suite.

For the Inside Reproductive Health podcast. 

[00:00:43] Griffin Jones: Thank you, Kevin. Our best of reel begins with the CEO of Inception Fertility and the Prelude Network, TJ Farnsworth's vision emphasizes the power of collaboration among networks and clinics to advance the fertility field. 

[01:00:00]Now you're at the head of one of the largest fertility networks in the Western world, and it didn't exist five years ago, and so talk about that speed. 

[00:01:07] TJ Farnsworth: Yeah, so I think that, you know, we opened our very first practice from scratch. We didn't want to inherit, you know, ideas, not that ideas from established practices are bad. We've got some fantastic practices as part of our network that have been around for 20, 25, 30 plus years that bring a ton to the table.

But we wanted the opportunity to be able to experiment with things and ask the questions of why are things being done the way they are? And the answer being that's just the way they're done is always a bad answer. There may be a lot of great answers, but that's just the way it's always been done is never a good one.

So That allowed us to challenge what we can do and experiment. And then we also have the, we look at it as the best of both worlds. And then we have practices as part of Zora Network that have been around for, you know, with Eastern Fertility Specialists in Houston, which was our first acquisition practice.

They've been around for 25 plus years, you know, to the President's Network with RBA and TSC and NYU, bring a ton to the table. And the idea that we can bring the knowledge base From all of these places, people that are challenging the norm and saying, why can't we do things differently with de novo development from scratch operations to establish practices that have been doing it in such a way that really does work and those work for a really great reason.

And that way we can take the best of all worlds and combine them together. It's sort of been a unique approach. To how we grow the business, it's allowed us to grow into, you pointed out, you know, one of the largest networks in the world, and we're very proud of that. And mostly we're very proud of the fact that the way it came together, because it came together in such a way that lots of different people bring a lot of really great talents, really great experiences and really great processes to the table that we can blend to create the best of all worlds.

I'd love to see a whole lot more collaboration with our industry. You know, I think that coming out of a different specialty, I am surprised at all a return at how the lack of collaboration that exists between all of the big national networks and the independent practices in terms of sharing best practices, what can we be doing to make them successful?

You know, to the extent that the other national networks are successful to the extent that other independent practices are successful. That's good for me. That's good for inception. That's good for all of us as an industry. We want to see people be successful. And you know, we need to focus less on our competition amongst ourselves and more on our customer as our patient.

And that can be done through greater collaboration. 

[00:03:39] Griffin Jones: Rather than dictating from the top, our next guest engaged with staff across all levels, gathering insights to guide future life's growth. Hear how Francisco Lobbosco spent his first 100 days as CEO of FutureLife. 

So that leads you after your 100 days to recommend changes, and you said that they accepted all of the changes you proposed. What were they? 

[00:04:01] Francisco Lobbosco: So listen, so I went on by having, let's say, Um, one strong mandate, which was not imposed by anyone, but I could read it through my first a hundred days. Future life from a medical perspective is very well positioned and our medical outcomes are it. Fantastic. Francisco. Now you know that don't touch that.

Right? So let's, let's make sure that whatever you do, you don't mess up with the medical excellence that we're having in the business because that is what describes us. But then I went on and said, okay, so one of the things I'm asking is why are you here? And I'm getting different, different views, all great views, all great answers.

Um, and especially when I go around clinics, the purpose is there. What I was missing was this little trick on asking the same question around support center and saying, why are you guys here? And perhaps we were missing that, you know, to verbalize the, the purpose, the mission, the vision, the values of importantly, the values of future life.

So I went on and asked, why are we here? And then I went on and asked, what are we, uh, what are we setting ourselves to achieve? I, what our strategy is going to be in the next five years. And then finally, how are we going to. You know, just go through that strategy. So the why, the what, and the how. Um, so quite simply after my 100 days, the first thing I did is to grab, um, collect a number of associates across clinics, different roles, support center, different roles.

And we set ourselves with support of a, um, of an agency to define the future life purpose. Why is future life here? What's our vision of the world? What's our mission? And most importantly, what are our values? Um, and obviously we have clinics, as I said to you, that were quite independent and they are still independent for many years, very successfully.

And some of those clinics have strong statements in place. And my purpose is not to, my mission is not to change those statements. But to have a united voice on future life and why is future life here to, to, to drive that core identity. So we've done that. And actually, I'm not sure when, when this podcast is going to go live, but I'm flying to Barcelona tomorrow to the first global leadership summit, where we're going to introduce those.

Those statements to everyone, to all our leaders in clinics. And then obviously we're going to introduce the strategy. And the strategy, as you can imagine, is something that together with my management team, tapping into the medical advisory board, tapping into some key opinion leaders from country, we developed and we put on a paper.

And that strategy went through my supervisory board, of course, in June, and that was approved. And now we're going to introduce you, introduce a strategy into, into the FutureLife Society again at the end of this week. Um, and that is how we're going to go through that strategy and what is important for us to achieve.

And this question of why do we have a group? What is group going to do different than the clinics we're doing until now independently? That's a very important question that needs answering quite fast. Um, the synergies that we'll have a group. Those roles and responsibilities between, okay, clinics are doing this, fantastic.

How can groups support the clinics on, on being better at that, you know, at that quality of care? How can we help the clinicians in particular, the, the EMTs, the embryologists, the nurses to have more time with patients? Instead of having, you know, non value added activities or non value added time. So that's the purpose of group.

And that's what we're setting here to, to, uh, to achieve through the how. And finally, and with this I finish, um, it's all about, as I said earlier, to keeping that medical excellence in place. And therefore we introduced. Literally two months ago, our medical advisory board to the CEO, uh, which are 10 of our 10 of our great, uh, associates, you know, medical doctors, embryologists.

Um, and we'll get together once a month, um, and they have three different topics in the agenda that they need to help us, um, drive just as a final thought from my end, which is something I said to my team quite often. Um, I know that people like you Griffin, most of your listeners, if not all have been, have been in this sector in this space for, for quite some time.

And you're very familiar with it. Um, but sometimes it's good to have someone external timing, uh, reminding On how powerful it is to work that you guys do on a daily basis. And I'm talking about everyone working in clinics, right? So um, this goes for everyone working in a clinic, MDs, embryologists, nurses, receptionists, coordinators.

It's just fascinating what you guys do on a daily basis. I mean, your job is to put smiles on people's faces. Um, so my last words would be encouraging you to continue going. Um, I think what you're doing helps the sector in particular Griffin, uh, and for everyone else out there, just, just keep going. I think, um, we, or you in particular, uh, are changing the world one baby at a time.

So big thank you from my end. 

[00:09:16] Griffin Jones: Boston IVF says that in order to take good care of patients, you have to have a business model that takes good care of their providers and staff. Listen to David Stern discuss the vital steps to finding the right long term financial partner. 

[00:09:28] David Stern: And you know, one of the important things, it sounds a little corny, um, but the Boston IVF, our model is we want to do what's right for the patient first and foremost.

So we believe, and this is instilled because the physicians founded the practice and I'm not a physician, I'm an MBA, but I can tell you, I don't mess with the lab and I don't mess with the physicians. because those are the two most important assets that we have in our company. And I'm never going to tell an embryologist if they want to use a certain media and they want to use a certain microscope or an incubator because they get better success rates.

It's in my interest as a business person to make sure we get the best success rates that we can because our patients are going to be happy. Our referring physicians are going to be happy. Everybody's going to be happy. So I'm not going to cut corners and say, Hey, I got a great deal on this media. From A, B, C media factory, and it's not the same quality as Irvine or Cooper, but you gotta use it because we're saving money.

Same thing with catheters. We have physicians that choose different catheters. We don't have one catheter. We let the physician who's doing the transfer use the catheter they feel comfortable with. It costs us more, but the physician feels like they're doing a better transfer and they're more comfortable doing it.

So who am I as a business person to tell a physician how to practice or an embryologist how to practice? When you're dating someone, your first date is not about getting married. You have to date someone, see if it's a right fit and then get married. And I think we approach it the same way. We want to date our practices that we're going to partner with, see if it's a good fit, see if the culture is right.

See if we have, you know, commonality and an IVF center that's being approached by anybody, a strategic, a private equity, venture capital, whoever. Should be doing the same kind of due diligence. Is there a cultural fit? Do you agree on what the midterm and long term goals should be? Where do you see yourselves in five years?

And having a very open discussion about what that looks like and, and talking about who makes the decision. Does business trump medicine or does medicine trump business? And those are important discussions to have before, you know, on those dates, um, before you get married. I was, you know, with COVID, we've gone out and it's very important.

We go out and we do site visits. We want to look at the IVF center. We want to talk to the physicians. We sit down with them. I can't tell you the number of deals that we haven't won, where the other party that wins has never set foot in an IVF center that they're buying. They've never met the physician face to face.

It's all been on Zoom and they do a video tour. And if I'm spending that kind of money, Now, granted when private equity is doing it, it's not their money. It's someone else's money, but it's kind of like going in to buy a house and doing it on a Zoom video and never walking in that house. That's kind of scary.

Um, and so if a physician, if I'm a physician selling my practice and I never get to meet the person and they never come to see what my practice looks like, I would think long and hard about, are they the right partner for me?

Sponsor: Organon is dedicated to delivering impactful medicines and solutions for a healthier tomorrow. Guided by its mission of being here for her health, Organon proudly recognizes fertility providers around the world focusing on care equity. 

We believe everyone should have access to fertility education and treatment. By collaborating with providers, advocates, and communities, Organon is working to elevate fertility awareness, expand resources, and invest in innovative products that help more aspiring parents access the care they deserve. 

Every journey to parenthood is unique. Organon stands with you. Learn more about Organon’s resources at FertilityJourney.com

[00:12:39] Griffin Jones: Here, Chairman of U. S. Fertility, Mark Segal, delve into the enduring presence of private equity in the fertility sector, emphasizing the significance of aligning business goals with a genuine passion for solving critical issues in the fertility field.

[00:12:52] Marc Segal: Private equity is no question. Private equity is here to stay, right? It's not going anywhere. Um, and it will, there will [00:13:00] always be this need for capital and equity. Um, and I also, I also believe, you know, These innovative, uh, in physicians want to be something part of something larger than than themselves, right?

Um, and so finding the right fit. Yeah, is is, of course, paramount. Um, I would say that I've seen in my career again, uh, private equity. make very poor decisions and very poor business decisions and in some cases, you know, destroy practices, um, and, and, and the culture that they may have created. Uh, but I've also been very fortunate to be part of a group, be part of groups that I think have driven real value and innovation that's benefited both just both physicians and patients.

I believe, you know, the group that we are affiliated today called Amulet Capital is exactly that. I've been very, very impressed. And as I said, I've been involved with many different private equity groups. Um, I think there's this misconception about, uh, uh, that private equity, you know, what the does is.

drive down, drive costs and it's, uh, and therefore that impacts quality of medicine. I think that's a, that's actually a false. narrative. I think it's a false assumption. 

[00:14:34] Griffin Jones: You think it's false that it drives them up or because they're seeking profits or, or drives them down for efficiency? Which one of those do you think is a fallacy?

I think it's, I think 

[00:14:43] Marc Segal: it's a false narrative that, that driving down costs, driving down costs drives down quality of medicine. Um, Where I think private equity and again, maybe larger groups succeed is in the ability to drive to drive costs in an efficient through efficiency. Right. And, and, uh, and to me, driving down costs, which hopefully at the end of the day implies driving down price to patients or driving or driving access through increased payer contracts, etc.

Leads to better access to patients. And in fact, if you look at the larger groups, you look at, you look at the, you know, pregnancy rate outcomes, it completely validates the point that the larger groups are driving, driving innovation, driving pregnancy rates, doing different things that I think others are taking note of and trying to learn from.

Um, so, um, I, I do think it's, you know, at the end of the day, yes, you should do your homework and you should pick your right partner. Um, because not everyone's the same, not every private equity is the same. Um, but I, I, you know, I am a believer they're here to stay. I'm a believer, I'm a firm believer that they will, That they will continue to add value and make change in a positive way, not a negative way.

What is it that I need to do to kind of grow my, my practice? in order so I can maximize the valuation, uh, or potentially exit that type of thing. And, um, and what I think, and I would say this is actually all businesses in general, this is not specific to physicians or even healthcare, but, but, you know, when you've got, uh, when you've got a founder and entrepreneur that has started a business, it may be a family owned business,

If they are, if they start or have started having the conversation, you know, if they, if they're thinking about, I want to sell my business in a year's time, or even two years time, it's probably too late to have that to start thinking what I need to do. To maximize value, the conversation or the thought process about maximizing value has to occur much earlier on because it's part of a strategy.

It's part of a mindset, you know, of this is what I'm after. This is where I think I can build it. This is what I and so it's really to maximize value. It's a five year process. Now again, here's the calculus. Do I, do I spend, uh, do I spend the next five years building, hopefully, you know, doubling the size, tripling the size of the business that I have today and will valuations remain where they are today, right?

That's the big question. Because no one knows what tomorrow brings. No one knows what, what valuation, what interest rates and valuation and how much it's private equity will want to participate five years from now. Um, and so I think the calculus you have to make in all of this is, I'm either in it for the long term, if I'm only focused on, I want to figure out what the exit and how to maximize value so I can exit at some point, I actually think it's the wrong conversation to be having with yourself, right?

If I'm that entrepreneur, I think you've got to be driven by, you What are you trying? What problem are you trying to solve? What? What motivates you? What gets you to get up? You know, um, out of bed every morning. I want to do the kinds of things that you do. And you've got to love it. You've got to have a passion for it.

I mean, I know that I wouldn't be doing this for 25 years. If I didn't feel excited and passionate about it. 

[00:18:43] Griffin Jones: Our next leader, CEO of Care Fertility, Dave Burford, sheds light on the imperative of enhancing business processes to improve the patient experience. One of the biggest criticisms about so much external finance entering this field of medicine is the that there is a financial pressure and sometimes an oversight on operational quality.

There's operational improvements to be made for days in this field. There's, there's no shortage of those, but there is also the reality that there. It's a way of looking at things where it can be just looked at from a spreadsheet without the consideration of actually making the operational improvements.

And you had to at least experience some of the other sides. So what were a few of the surprises that awaited you? 

[00:19:37] Dave Burford: I think first and foremost, um, finance is very good on spreadsheets. Operations is very bad on PowerPoints and spreadsheets. Operations is about people and it's about process. And you only really can deal with one when you understand the other.

And so if I take us back to cares challenges at the time, it was very much around, um, a business that was geared up to, um, serve the clinic rather than the patients. And that's okay. When you've got a lot of demand and not much supply, but when, when that dynamic changes slightly and you've got more competition in town and you've got other people that are doing things in a more dynamic way, and actually.

The challenge is bringing in, um, supply or patients, then you've got to change your processes to adapt to that. And you've got to be more patient friendly and you've got to be more, um, Uh, adaptive and fluid in the way that you deal with things. And so, yeah, you can only really do that by talking to the people on the ground, talking to the staff, understanding what their challenges are, and then adapting the processes to meet the demands of patients and the needs of staff.

Um, So it was, for me, it was nice to get away from the, the laptop and the, and the, and the, and the PC and to actually talk to people and understand what is it that is the challenge here and that's best supported by a bit of data, if I'm honest as well, because sometimes anecdotal conversations only take you so far and you need to have a bit of skepticism about what you hear and then you need to look at the data and say, well, actually, look, we've got a thousand people calling us at The seven o'clock at night, you're telling me that patients don't have a demand for late night calls.

But why have I got a thousand, why have I got a thousand people ringing me when the lines are closed and it's just tweaking then some of those operational processes to meet those needs. Um, generally not that challenging, but, um, involved, yeah. Sales side device is critical and these advisors do an amazing job, but it's when it's a very fast six week process and highest bid wins kind of thing.

It might be perfect for some sellers, but in my experience, what you'll find is that there's sometimes a misalignment after the sale because you didn't really get chance to talk about what it is that you want and what it is that they want and how can you, it was a very quick, it was a very quick process.

And so this is. Quite often somebody's lifetimes work, right? They spent 20 years building this business. Why not spend a little bit longer just getting to know who it is that you're going to be partnering with after the, after the deal would be my main advice, really, to, to people. And then, as I say, my passion and, and cares passion, having done lots and lots of these acquisitions over the years is to really understand what it is that people want, uh, and then to try and tailor that deal to suit them.

[00:22:38] Griffin Jones: Dr. Kshitiz Murdia, CEO of Indira IVF's CLIPS, revolve around the importance of standardizing protocols across the entire network of doctors, emphasizing the need for consistency and quality. 

[00:22:50] Dr. Kshitiz Murdia: I think that brings me to another important point, Griffin, is around the doctor recruitment, as to how we have done it.

Because. Ours is a B2C brand and patients are coming to Indira IVF and not to a particular doctor. I mean, patients don't come with a mindset that I have to go and meet such and such doctor or get treated by such and such doctor. They just see Indira IVF, they would come to Indira IVF, and then they would get to know who is the doctor treating them.

And every other day we have a roaster, so somebody is consulting today. Their pickup might be done by a separate doctor. Their embryo transfer might be done by a separate doctor. It's as per the schedule or the roster in the clinic. Uh, so it was our responsibility to ensure that we have similar protocols, similar outcomes across all the doctors because that's what we were doing.

One patient could be meeting two or three doctors in the clinic at different points of time during the same cycle and the protocols should not differ. The language that they speak should not differ. And that's why we started this Indira Fertility Academy back in 2016, which is one of the world class setups in training in fertility.

Our training center has been recognized by, recently by British Fertility Society. Our training center is recognized by Merck Foundation in Egypt. They regularly send, uh, uh, African and Indonesian and Malaysian, Vietnam, all the Asia Pacific doctors for training. We run a fellowship program with them for three months.

And 99 percent of the doctors who are working with us, I've been trained through our own fertility academy and same with the embryologist also. And once we got a hang of it, uh, we understood that, you know, IVF is not so difficult. It's not a rocket science. You know, every gynecologist and a life science, uh, a postgraduate could be trained into either being a IVF doctor or an embryologist.

Uh, either ways. Uh, we developed a structured program and we understood that there are 15 or 20 steps during the whole IVF cycle. Once you have an SOP around each and every step, you just hammer in the training that you just need to follow the SOP. Don't bother about the final outcomes. Final outcomes are bound to come.

And we've been very successful. I think the average age of our doctors is 35 or 36 in spite of, you know, a few doctors being with us for almost 10 years now. Uh, so that gave us a very good handle on expansion because. See, expansion, the major limiting factor for any clinical enterprise or an organization to expand rapidly is not funds, it's not infrastructure.

You, everybody has deep pockets, everybody has private equity money. You can fund a hundred centers in one year. You have the infrastructure available. You can buy spaces, you can rent them, you can do. I think the critical bottleneck for any organization could be having skilled manpower, you know, and then there's always shortage of manpower in whichever field you go.

And we decided that we would not struggle with this part. Let us create our own skilled manpower and let us not depend on the market, uh, uh, to get skilled manpower. The idea was to select somebody working with the company for, for, for last few years, because. You know, when DA invested, we were only at 50 center, we were the largest in the country in terms of number of centers, in terms of doctors being trained, in terms of business and, and the overall top line.

I think the idea from DA's side was, uh, nobody has done, uh, good work in the country in India in the IVF suite apart from Indira IVF. Let us have somebody from the group internally, uh, and promote them to the, to be the CEO. And I think because of, uh, uh, some of the diligence is being done on the company before DA invested.

Uh, so there were a couple of private equities, uh, looking at us and in all the big force coming and doing diligence. So I got exposed to many more financial aspects, many more HR and marketing aspects as well. And, uh, so I think, I think it was. Because everybody, all these shareholders thought that I had a very broad based idea about the business and not just the medical function.

Uh, and, and, and obviously we are very strong believers that a medical organization should always be headed by a doctor because that gives you much more leverage. In terms of talking to the doctors, because ultimately all these, uh, businesses are built on the ground in the clinics and not sitting in the corporate office in your air conditioned chambers and working on excels or laptops or you can't build a business.

Their business is actually being done at the clinical level by the clinicians, by the nurses, by the embryologist. So you would need somebody who could have that wavelength of talking to these doctors who the doctors would also respond to and respect. Uh, and it's not just about number, number, number that you need to clock certain revenue.

You need to clock certain number of patients being treated. It's always more to do with the medical outcomes and how do you treat and how do you excel in, in the overall outcome. So I, I, I strongly still feel, uh, that a non medical person, uh, one sounds very commercial to the doctors. Uh, doctors would not give that much of respect because.

Again, they feel the other person has no knowledge about medicine and is just come here and just telling us all the numbers on Excel. And we feel it's not like that. And, you know, Patients are different. The actual clinical life is different. So I think a good balance, uh, uh, between the medical and the financial work is required when you want to control the doctors.

And when I say control, because ours is a very different culture and DNA, it's not doctors independently practicing in their own. world and they have a different protocol and they have a different business mindset. All of us, uh, all the two 50 plus doctors run on a single platform, run on a single protocol.

Everybody, uh, is, is, is in very. Close touch, I would say, and everybody's using the similar protocol.

[00:29:13] Griffin Jones: How many nurses, what percentage that you've worked with over the course of your career, which is a lot, do you think have it in them to be an executive? And do not say a hundred percent, do not say all of them. I don't want it. I want any kind of fluffy millennial feel good answer. I mean, if you work with a ton of people, ballpark, what are the percentage, uh, that you feel like really have it within them that they could be not manager, not director, but top C-suite?

[00:29:47] Lisa Van Dolah: Anybody that sets their mind out to do it can do it, but you have to be willing to, to learn, um, and step out of, uh, Kind of a comfort of a clinical based mindset. And I think, um, many nurses don't want to have anything to do with that. They went into the profession, um, to be a clinical focused expert and they should, that's amazing.

Um, and they should continue to explore that, how they can continue to contribute there. Um, you know, there's only so many individuals that went into nursing originally that then look at organizational, um, Uh, you know, goals and organizational, you know, success as being something that are even interested in, in being responsible for.

So, you know, we all can contribute at every level of nursing, um, to that organization success, whether or not you want to be the one that's. that's thinking about that 100 percent of the time is, you know, it's only an interest of certain, certain individuals. And, you know, but I don't think any nurse should limit themselves, um, to that possibility if that's something they're interested in doing.

If this is a role that you want to learn, we'll be here to support you. And so if it's something that you want As a nurse to step into something that maybe is outside of what you perceive to be your training. I think you need to seek that opportunity, um, and ask for those around you to support you, um, in learning things that maybe you don't have any experience in yet.

Um, and I think nursing, um, has tremendous foundation to offer you the skill set. Uh, in a variety of roles, whether it's administrative management, leadership, um, or, you know, like you said, project management, sales, marketing, business development, all of those things are, are, are ways training, teaching, um, for nurses to, to advance their career.

And so it's not just one path, but I think nursing has tremendous foundational, um, value that, that you can build on if you're interested in. 

[00:31:58] Griffin Jones: The three things that matter in healthcare are patient experience, patient outcome, and cost, according to our next leader, Chair of KindBody, Gina Bartasi. Here, Gina stressed the value of team collaboration and employee well being in delivering exceptional patient care.

[00:32:11] Gina Bartasi: Really? Only three things matter in healthcare? Any kind of health care, but specifically fertility, um, patient experience, patient outcome and cost. It's the only thing that matters to the patient, patient experience, patient outcome and cost. And by the way, it's the only thing that matters to the employer.

And what I have found after building and running the largest care navigation firm as a care navigation or middleman or an insurance company, um, Um, you cannot effectuate change in those three areas. An insurance company or care navigation firm cannot affect member experience. They cannot affect outcomes and they cannot affect costs.

Only the doctor's going to set his reimbursement rate. He's only going to decide how many embryos to transfer. Only he can decide how to give that patient bad news, whether that's, um, uh, diminished ovarian reserve diagnosis or a failed IVF cycle. But in order to really effectuate change. And really change kind of how patients go through the process.

You have to be in the doctor business. So today the employers are issuing RFPs. Um, I think in the beginning, uh, large tech companies on both coasts are really in the Valley kind of started this fertility benefit. But today you see requests coming in from very, very large employers in retail and manufacturing and automotive.

Like again, it's moved from kind of a nice to have to a must have benefit. Employees always come first. They have to because the employees will take care. If you take care of your employees first, they will take care of your customer. They will take care of your patients. And that's when we're talking to doctors, you know, and doctors say, well, I used to do that.

You know, we want the doctors to know that we can train and teach. nurses and front desk managers and practice managers to be just as kind and just as empathetic to that patient that the doctor can. So again, employees always come first as it relates to the lab. 

[00:34:11] Griffin Jones: Talk a bit about how you use the brand for culture.

[00:34:15] Gina Bartasi: Yeah, I think, um, a lot of it starts with humility, right? The brand is humble. It's not anybody's last name. It's not, you know, um, and our culture really starts with this humility, right? So those two things are ingrained. I think, um, it's not just humility to, it's a vulnerability to it. Um, you know, uh, It's also our brand and our culture.

We do embrace risk. You know, we tell our doctors, we're like, embrace risk, do something crazy on TikTok. Can you tell a doctor to, or a scientist embrace risk? They're like, whoa, whoa, whoa, whoa, whoa. I'm a doctor. I don't embrace risk, except that if you teach them, we're not talking about embracing risk when it comes to, a prognosis of an onco patient.

We're talking about taking risk as it relates to the brand, as it relates to culture, allow yourself to have fun, allow yourself to smile, giving devastating news. Another failed pregnancy test is hard. It's hard. And we're so glad you're empathetic to your patient. But outside of that, how can we make you smile?

How can you be cheery and yellow and optimistic? And so we believe that there's a lot of similarities that brand and culture do go together. And I don't think our brand would be as successful if our culture wasn't so strong. And I don't think our culture would be so strong if our brand wasn't so strong.

And there's a, I think the other thing that I would say about culture and brand is team. Right. Um, I think too often, you know, healthcare people and doctors in particular may think solo first, like I'm a doctor and hierarchical and solo. And those are not things that belong in our brand or our culture. We don't do anything singularly.

Not any of us. And, and Dr. Beltsos would say the same thing. And Beth Eschbach, Greg Poulos, none of us do anything by ourselves. And that's intentional. We make group collaborative decisions and same thing with our brand. It's, it's, it's, we invite feedback. We invite constructive feedback, constructive criticism, because we want to get better every day.

And again, that goes back to our brand and our culture. 

[00:36:25] Griffin Jones: Andrew Meikle, Executive Chairman at The Fertility Partners, challenges traditional paradigms as he advocates for financial awareness and entrepreneurship in clinic management. 

[00:36:33] Andrew Meikle: I think that, um, you know, the typical practice owner is not an entrepreneur, and they're not typically very business savvy.

Some are, and they're doing exceptionally well. This space has grown 10 percent compounded forever. And, and, you know, No disrespect, but almost anyone can do well in that sort of a setting, especially when supply is not meeting demand. So everyone's doing well. Um, almost everyone's doing well. I think there's another level.

It's not just about revenue and EBITDA, you know, our mission and, you know, I'm a healthcare provider at heart is to drive clinical outcomes to use science, collaborate with stakeholders and our group to, to drive clinical outcomes, to be more successful for our patients. And as well to improve, dramatically improve the patient experience, the patient journey.

So it's pretty simple. All of our decisions are made, um, You know, based on those two things. And I think there's a tremendous opportunity to professionalize some of the areas in the space. Um, when you look at, at management, for example, I think there are a lot of people doing a lot of great things, but it's, it's sort of doctor first, it's not patient first.

So we're flipping this, um, profession on its head and looking at the management and the operational efficiency and effectiveness of, of clinics. We're looking at Uh, you know, lean processing from a patient perspective. We're looking at, um, sort of value innovation from a customer perspective. It's gotta be driven by, um, by the patient.

We have to serve the patient. Um, and I, and I think it's largely the other way today. So we, we have a completely different lens and I think most groups, um, we're investing for the longterm. Um, we can get into private equity if you want. I am now. Back. We are now backed by private equity. You got to be careful who you choose, who you partner with.

You got to be careful who you marry. You got to spend time. You got to do your diligence. You got to go on dates. Um, and you have to be, um, ruthless in your due diligence because it is a life sentence. I don't know how to turn a physician into an entrepreneur per se. I think you have to have the fortitude for it.

You have to be able to delegate tremendously because you need to see everything from 60, 000 feet and not be too in the weeds. Um, I think an absolutely critical element and some Something that I see as a weakness generally in the space is a lack of, um, financial, um, awareness, a lot, a lack of operating the business, uh, with financial metrics.

Um, people in the space seem to look at it in the rear view mirror rather than in real time. You know, our organization, we provide a full P and L every month. Month by the eighth day of the next month. So our partners can see what they've done in their business and and uh, How it relates to the strap plan that we've worked on them for going forward.

Um, so I think you know We don't have enough time, but I you know, I mean a start would be Definitely start reading some, some books, you know, um, there's a ton of great information on entrepreneurship out there. Gerber has a whole series. Uh, uh, you know, those things are very helpful, but, but you really have to take yourself out of the day to day equation, be able to see it from 60, 000 feet, have the best, most independent.

You know, brightest people you can working for you, um, actually, you know, executing on things. And I think that's a big first step. There are tremendous opportunities out there to, um, to partner with various organizations if it, if it suits you. And I think it's just really important to, you know, Have your house in order before entering into that do your due diligence find the right fit um, and look this this profession right now, is it incredibly, um, is that an inflection point it is changing and If you want to change, you might, you might look to join an organization that, um, aligns with your values and they can help you.

They could support you, um, to implement changes in your clinic, to drive patient flow, to, um, to make your life easier so you can provide the best possible medicine. 

[00:40:56] Kevin Ali: In today's episode, we learned how various leaders are working to evolve the landscape of reproductive medicine. Working together, we can drive innovation to help improve the aspiring parent's experience.

I'm Kevin Ali, CEO of Organon. Thank you for listening to the Inside Reproductive Health podcast. 

Sponsor: This episode was brought to you by Organon, Organon is committed to championing care equity in fertility. By elevating education, expanding resources, and investing in innovative solutions, Organon stands with aspiring parents on their unique journeys. Learn more at FertilityJourney.com.

Announcer: Today’s Advertiser helped make the production and delivery of this episode possible. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, nor does the Advertiser's sponsorship constitute an endorsement of the guest or their organization. The guest's appearance is not an endorsement of the Advertiser.

223 The $1 Billion Project to Automate the IVF Lab. Updates on the collective progress in the R&D Pipeline with Dr. Jacques Cohen

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


When will embryologists be robots?

Dr. Jacques Cohen, Chief Scientific Officer of Conceivable Life Sciences, walks us through the research and development currently underway for the automation of the IVF lab.

Tune in to hear Dr. Cohen discuss:

  • The next potential game changing innovations in IVF

  • His opinion on time-lapse incubation and its future in the lab

  • What the FDA doesn’t like about AI solutions

  • The $1B project to automating the IVF lab

Dr. Jacques Cohen
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Conceivable Life Sciences
IVF 2.0
IVFqc
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Transcript

[00:00:00] Dr. Jacques Cohen: You don't go to a dentist hoping that your root canal is going to work or not. You go to a dentist and expect it to be a hundred percent successful. Maybe you got a little infection, but that can be treated, but you want it to be a hundred percent successful. And that's what we want in IVF. We want things to be a hundred percent successful, not 98%, not 80%, or what it is now in some clinics over 60%.

No, we want it to be a hundred percent. And we really want that as soon as possible. So, I think all this technology that we discussed today will play a role in that process. 

[00:00:33] Sponsor: This episode was brought to you by Future Fertility, the global leaders in AI powered oocyte quality assessment. Discover the power of magenta reports by Future Fertility.

These AI driven reports provide personalized oocyte quality insights to improve treatment planning and counseling for IVF ICSI patients. Magenta can help you to better identify the root cause of failed cycles and counsel patients on next steps to optimize treatment. Download a sample Magenta report plus four key counseling scenarios and see the difference it makes in patient care.

Visit futurefertility.com/ivf. That's futurefertility.com/ivf.

Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you, but the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health nor of the advertiser.

The advertiser does not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertiser.

[00:01:49] Griffin Jones: When will all the embryologists be robots? Soon enough, probably, but that's my speculation. For a more measured walkthrough of what's in the research and development pipeline, For the IVF lab, I bring in veteran lab director, veteran scientific director, Jacques Cohen, Dr. Jacques Cohen, as I should say. And many of you know him very well.

He is now the chief scientific officer of conceivable life sciences. They're working on fully automating the IVF lab. I have Jacques walk us through what they're doing at conceivable at other companies that he's involved with. And I have him walk us through what is preliminary, what's well established, and what's in between.

Is time lapse going to be a must have for embryologists within the next couple years? Dr. Cohen has an opinion. What does the FDA not like about AI solutions? Jacques tells me why and I never knew that. If PGTA and vitrification were among the biggest game changers in the IVF lab in the last decade, what are the next two?

Dr. Cohen walks us through what he thinks might easily be a collective 1 billion project in automating the IVF lab. Enjoy this conversation with Dr. Jacques Cohen. Dr. Cohen, Jacques, welcome to the Inside Reproductive Health podcast. 

[00:03:00] Dr. Jacques Cohen: It's a pleasure being here with you, Griff, and really looking forward to it.

[00:03:04] Griffin Jones: Maybe the pleasure should be mine because people say Jacques Cohen is a legend. Jacques Cohen is a legend. And I've worked in the field for nine years. And I think 2023 was the first year that we met in person. So I'm, I'm interesting to, to see if the legend lives up to the hype in this conversation. But many of our listeners are familiar with you already.

And I wanted to go through oftentimes, you know, sometimes I go into the past cause I'm curious about what led to the developments that got us here. I'm more interested in looking at what are today's nice to haves in terms of what's in the R and D pipeline in the IVF. lab that you think are going to be tomorrow's must haves and tomorrow might mean three years from now.

It might mean 11 years from now, but I want to explore that with you. And so maybe just give us a, maybe we just do a little bit in the past are what are a couple things that were nice to haves in the IVF lab a decade ago that are now must haves that any, that the vast majority of them. Embryologists wouldn't even, you know, want to operate in the IVF lab if they didn't have these things.

What are a couple things that were, were nice to have just a few years ago that are now must haves? 

[00:04:27] Dr. Jacques Cohen: Yeah, well, it all depends. Well, first of all, that depends, and it's a very good question, but it depends on, on where you are in the world. The philosophy, let's say in Japan, where there's a lot of IVF and a lot of programs, and they're very advanced.

It, it, it very much depends where you are. So, in Japan, they would focus on, on strictly single embryo transfer, nothing else is allowed. They would focus on minimal stimulation, which is done in this country, but only in a few laboratories and a few clinics. So it very much depends where you are. In the U. S., I think in the last 10 years.

The technologies have been kind of the same of the years before. It's always hard to give, to have a hard cut, right? Say it's 10 years, it's a 12 years, 15 years, but in, in that ballpark, I see, I think the most important things to do nowadays are, are, are fitifying at the blaster stage, incredibly successful that took, you know, honestly, that took from the early 80s, the first paper on, on, on, on, uh, Embryo fritification in an animal, in a mammal, that, that, that was, that was published in 1985.

And the results, frankly, were intriguing because nobody had thought it could freeze that fast, but the results weren't great. And that's why for many years, decades, really, nobody looked at fritification. And it's only in the last 10, 15 years that that's been implemented worldwide. Uh, and, and nowadays, uh, It's considered a must to have, not only for spare embryo freezing, but maybe freezing all the embryos.

Because one thing that is obvious and has become obvious slowly over time is that the cycles where the stimulation occurs are good for the ovaries and you get multiple eggs. Well, it's not good for the uterus and, or it's not optimal for the uterus. I should say, because of course there are a lot of fresh embryos that have never been frozen and are being transferred for like the stimulation cycles that just implant.

So that's one area. The other area that is very much now driven in, in, in. in IVF in the United States is of course PGTA, pre imaging genetic testing for aneuploidy. That has had seen a slow process as well. I think we're now close to 50 percent of all cycles where PGTA is being performed. So, some clinics, it's completely routine, and they do a big case as PGTA.

Other clinics are more careful or more selective, I should say, and do it maybe in a proportion of patients, whereas in some clinics, it may not be done at all, but the average is close to 50 percent in this country. It's very different from the rest of the world. There we kind of stand out, and this has not been happening overnight.

The data is very good. The data that we have gotten over the years is coming very slowly. There has been tremendous debate back and forth. Debate isn't finished yet, particularly internationally, on PGTA. But we see major advantages of this in this country, and particularly because it gives you a higher chance early on in your adventure as a patient having having MBLs transferred because what is striking with the, looking at the data now from, from SART, what is striking the, the, the, is that A lot of patients don't come back after one or two attempts, irrespective of their economic or insurance situation, they just don't come back.

And so you want to, you want to strike it when the iron is hot. You want to get an embryo transfer now, or the embryo is frozen and you get an embryo transfer in a couple of months or next month or three months from now. That is when people are not just motivated, but not exhausted yet, and yet unfortunately A very exhaustive process and most, and most, and most patients experience it like this.

Not everyone does, but most patients do. I think those are two areas where these are now considered must haves. You don't have to do PGTA in each patient. Also it's expensive and it's, it's, it's cumbersome. It's very time consuming for ambiologists and doctors and nurses. And so we want to maybe do it a bit more selective than some clinics do, but I do think it's of the total package.

It's not going to disappear anytime soon. So those two, fitification, PGTA, and, and they go hand in hand. I think PGTA wouldn't have happened on this scale without the success of fitification. They're very much tied in together. So those are two examples. 

[00:08:58] Griffin Jones: Your point that what is a nice to have in some areas might be a must to have, must have in other geographic areas and vice versa.

Makes me think of what I've been starting to learn about time-lapse incubation. I'm not a a scientist, I'm not an embryologist, so I don't know enough about the cost benefit. But all I can observe is that for some people, time lapse incubation appears to be an absolute must have for some people. It, it, they would, they would never work in a lab that didn't have TLI.

And there are many countries where TLI is the norm, but in the United States it seems like it hasn't really taken off. So can you tell me why that is? 

[00:09:42] Dr. Jacques Cohen: Yeah. Thank you for bringing up TL. I, I probably, uh, I'm, I'm more leaning towards the people who, who couldn't do without it. Not necessarily because I think it improves pregnancy, although I don't see a reason why it shouldn't.

It's nice to leave the embryos alone for the entire period. Um, you're, you're sitting in, you know, the embryos are basically in a, it is a robot, it's an incubation robot, and, and they're being photographed every few minutes or. Or every minute and each one at a time, you get a timeless video at the end. What is really, really good about this.

You have a permanent record of that patients and BOS at all times. It also, these incubators have been sought through with so much detail that they kind of are. on the high end side, and they have very, very good results. So, so why it hasn't happened in this country as much as, let's say, some countries in Europe, particularly in Scandinavia, and then England?

I think, I think that is because maybe of the expenditures, and also we are very much data driven in this country, and that's because we have the luxury of looking up our own data. The data of our competitors and clinics in SAR and the CDC, and that is something, don't take it for granted because there is only maybe five, six countries in the world where we have data reporting that is, that's mandated.

And, and, and in most countries, and particularly in Europe, you, you see some data reporting, but it's very, very cursory. And so when we look at those other countries that have data reporting and we compare it, we try to compare it, it's a difficult process because there's so many other factors involved when you analyze data.

But if you try to compare it. I think we're a little better per embryo. I think we're a little better than, than let's say most of the European countries. And I know I'm sticking my head out here and I hope, hope nobody from Europe is watching. But if you are, I think that is the reason why we haven't jumped onto time lapse because all the time lapse, the initial five, six, seven years all came from European countries.

And but I, I think time lapse is, is here to stay. I think this is now the norm. But the reason I didn't mention it is because you set that 10 year limit and time lapse is now 15 years. We've had time lapse for 15 years, hundreds and hundreds of papers. I think it's pretty convincing. Um, things have been discovered we didn't know about before and there's still a long way to go.

So I think time lapse is not going to disappear. Yeah, I think it's the standard to leave the embryos alone while they're being watched by a machine. It's just a wonderful thing. You don't have to take them back and forth to an incubator. It's, it's, it's, it's an absolute must, but you know, they're expensive and they have to be maintained.

So there's an extra cost as well. I don't know if clinics charge an extra fee for it. I would be, that would be unusual, but maybe, maybe that is the case. I'm not, I don't know enough about that, but yeah, at least it drives up the cost for the clinic as well. Definitely. It's not just the investment. 

[00:12:46] Griffin Jones: Is, is the use of PGTA somehow related to adoption of, of time lapse incubators to that other countries don't, or they use time lapse incubators more because they don't use PGTA.

I've heard something like that, but I don't understand, but I don't understand the rationale. Can you explain that? 

[00:13:07] Dr. Jacques Cohen: Well, there are a few papers that have suggested that if you look at embryo development using time lapse, not using, using the, the archaic manual systems, if you use time lapse, there is a correlation with euploidy.

is normal chromosome detection and abnormal chromosome detection. It's being debated. There's very few papers about this, but that's one of, you hear people, indeed, you're quite right. You hear people say, well, specialists say, you hear say, well, I do, I do time lapse. I don't need to, I don't need PGTA. I hear that less the other way around, but I hear, hear that, hear you say, hear that.

that occasionally, but I think, I think our reaction in this country of not using time lapse is mostly associated because we have the data to show we have so much detail. There's so much information going inside a CDC that's not published in the national report that you do not see in the individual clinic reporting of SARC, which is fairly extensive, very detailed.

It's not, we don't see that in any country, including, including the UK. But it has been data reporting for less, less time, but data reporting nationally has been happening in 1988. It's quite an, in 1987. I mean, it's, it's, it's unbelievable, 35 years of it. And, and if you compare it to our Southern neighbor, Mexico, where there are a lot of good clinics.

There is no national data reporting. That is the norm for, for 80 or 90 percent of all countries in the world, including the ones that do a lot of IVF, including China, where there probably now is much more IVF than anywhere in the world, and including India. But there's also an enormous ton of patients.

Tons of patients that are being treated there, although the accessibility for the country's population is very, very limited because it's all, it's all out of pocket. So it's still a small population, but because it's so many people, there's a lot of IVF cycles being done. None of that is nationwide reported.

We do not know how well these clinics do. 

[00:15:10] Griffin Jones: I want to make sure I understand this relationship between the comprehensiveness of data reporting and time lapse incubation. Is it that other countries where there isn't this national level of reporting where they can see other clinic success rates and the other data points?

Is it, is it they're getting something from time lapse incubators that, They're getting a level of data from time lapse incubators that that they need because they're not getting from a wider pool of data. Or is the United States, because we have a wider pool of data, we're not convinced by the value of time lapse incubators.

I'm, I'm, I want to make sure that I understand the relationship and I don't think that I do. 

[00:15:56] Dr. Jacques Cohen: No, no, and I think that maybe I've, I've slightly misled it, misled you, because, because listen, you need to know the data in order to go forward and understand how well, how, how, where you, where you lag or how well you are doing.

You need to have data, data feedback so that you can compare with your colleagues and other clinics. Time, that's data and actual fact. It's not really entered in the SART data reports in the, you know, that, that would overload the system so much because timelapse, as you know, generates an enormous amount of data on, on an M, on the individual embryo level, on the individual oocyte and sperm level, the data that goes into SART and other national reporting sites in other country.

is, is limited or none. So that, that data is very independent from, from the argument I made, which is, you need to know that data. And I think that data has driven this process. In our country, we've just looked at like, look how we are doing. We have a national report. And if we look at that national report, yeah, we are slightly better than other countries.

I only, Do the comparison looking at individual embryos, because if you look at it on a patient level, well, some patients will have two embryos, quite a lot still. Most will have now one embryo, which is what has changed in the last 10 years. But it's difficult then to compare. What you really have to do is compare on each embryo that's being transferred, how many led to live births.

How many implanted, how many led to live births. You're going to get a live birth rate per embryo that's transferred. And if you compare that to other dead populations that are out there, I think we are clearly better corrected for confounders and confounder is a factor that affects the outcomes.

Maternal age is the most important confounder, but there are probably hundreds. My colleague of mine called Rusty Poole from Texas has, has published this years ago and he came with more than 200 co founders and he was probably being modest. There are probably more, in other words, those are all factors that affect the outcome.

So, it is a little difficult to look at another country and say, well, this is what you're They're not doing as well. But if we just look at if they report on maternal age groups, we can make the comparison. And that's what we do. Often counties will only compare patients over 40 and lower than 40. If you look at it per age, 35, 36, 37, 38, they compare all age groups.

You see that drop off in panacea rate and an increase in abnormal chromosomes. and aneuploidy. Highly correlated with each other. That's why we have gone to the PGTA route. We, and also the sync. We think we're syncing PGTA because, yeah, you may be, you may be living in a country. So I'm originally from the Netherlands and in the Netherlands, you get three free treatments for everybody.

It's for everybody. You have three, three treatments. That is three egg retrievals. You can have 10 transfers, all included and free. So you could have 12. Okay. Also there, you see a drop off and how patients returning. It's just, it's just, it's striking that not everybody necessarily the pleats, all the embryos that have been frozen.

It's striking. And that may even be, they may, it may even have PGTA. So they know they have no embryos that look nice, that have normal chromosomes and they do not return. And so, therefore, you need to get, you need to get the first shot is the most important thing. The first and the second, the second attempt are the most important.

Some patients react differently to this. I'm, I'm, I'm not trying to generalize. Some patients say, well, no, I'm going to go for this. I will take a look at every embryo that I have and have that transferred one at a time. And if that doesn't work, I'll have another act of retrieval. But that's, that is not the norm.

[00:19:45] Griffin Jones: Do you think that time lapse will become the norm in the United States, that it will be a must have in the next some years that Embryologists will demand it if they if they've gotten a taste of it elsewhere And they then perceive it as the is the standard or do you think it will continue to be an option?

[00:20:06] Dr. Jacques Cohen: That, that is a hard prediction to make. I think, I unfortunately don't have the data saying, well, how many clinics out of the 400 clinics, how many of those have time lapse and use it all the time? 

[00:20:17] Griffin Jones: I'm guessing it's less than 20%, right? And I don't, I don't know. I don't know how much it is, but it's probably, it's maybe 10%, maybe between 10 and 20.

Yeah. That's, that's a, that's a guess. 

[00:20:28] Dr. Jacques Cohen: Yeah. But let's not forget that if we would know those numbers, which we don't, if we would know that number and would know how much it is in the Netherlands, right? So how many, how many time lapse clinics are there in the Netherlands? How many are there in the UK? Well, there are frankly, we don't have the numbers.

We think everybody in Europe is using time lapse, I can assure you they don't. And it's the same for them saying, well, every, every, every patient in the United States gets PGT-A. They were saying that about us 20 years ago, and it was only a few percent. Right. And now it's just climbing up to 50%. So it's hard.

So once you know those numbers, it's always striking to see that there's not necessarily the norm and that it's just the frequency. Their frequency is probably higher than ours. But I think, I think you have to, now, now we're driven by large clinic networks. And, and, and so they often look at the bottom line and time lapse is more expensive, not just buying an incubator.

The incubator is just one expense. It's just embryology spent more time analyzing the data that comes unless you have a fully automated process and data analysis, which, which, which involve AI, artificial intelligence, and those packages have been approved in Europe or are used. experimentally and they have not been approved in the United States necessarily.

So the European clinics have much newer versions of their software and AI analyses than we do. We, we still have to do it kind of by hand. I think that may be changing and maybe I'm a few months behind and it was approved, but it's very difficult to get. An IVF related AI or any clinical AI that's based on, on, on machine learning, uh, and neural networks.

It's very difficult. to get those, uh, approved by the FDA, simply because the FDA loves algorithms that are stuck. So in other words, it's the same algorithm that's approved, but if you're changing the algorithm because you have AI feedback, well, then you have an intelligence system. And that they, they haven't gone into that very much in that they're, they're, they're worried about it, I guess.

I, it's hard to tell, but I think that they're worried about it. So. The Europeans have that advantage over us. They have more updated time lapse software than we do. So that is a big difference. 

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[00:24:56] Griffin Jones: Is it that European regulators have accounted for the machine learning feedback in algorithms and they, they have a different criteria for, for algorithms where the FDA? prefers one set algorithm or, or what, uh, or already set algorithms as opposed, as opposed to adjustable algorithms.

Is there a difference in, in how the European regulators look at it? 

[00:25:22] Dr. Jacques Cohen: That, that I don't know. I presume there is. There's one or two countries, there may be more that have said, well, let's see, let's wait and see about this and accept it as it is. I see the UK is one of those, whereas in the U S it's no. No, no, we're interested and we will evaluate this, but we need to know more about it.

So I think the FDA is more conservative than the European regulators, but I don't really have numbers and it may be different from country to country, but I know some countries have said, well, let's, you know, let's look at, let's not panic, which is what we do about AI a lot. We panic and we say, well, this is going to take over from us, so it's going to do.

funny stuff. You know, you don't get checked GPT, you know, but it hallucinates, as they say, well, AI packages in healthcare do that too. And I think, I think you can avoid that because you can have a very solid mechanism that, that catches that. And those AIs are not comparable to the large language model, but I think the Europeans have a more, a little bit more open minded about AI than we are.

[00:26:23] Griffin Jones: As we look into the research pipeline, does it make sense to talk about robotics first or to talk about AI first? 

[00:26:31] Dr. Jacques Cohen: They go hand in hand. Yeah, they go hand in hand. So, so the, the, the time, some of the time lapse incubators, this doesn't apply to all time lapse incubators, but, but some of them have, have, it is a robotic system, right?

You put a little dish inside an opening and then that dish is taken away and goes inside incubator and it's photographed all the time. And AI is applied to it, at least to one or two of them. Or two types of incubators. And, and, and you got basically a reading tells you, well, we recommend that you transfer the following or freeze these four embryos and recommend that you can choose one of this is the best one.

According to us, but it doesn't mean you have to do that, of course, but that, that level is, is very different from what we have and where we are. I hope that answers your question. 

[00:27:19] Griffin Jones: So it, well, they, they go hand in hand and, and whenever there's a chicken and egg question, I remember that I remember a quote that David Sable told me like two or three years ago.

He said the entrepreneur's job is to solve the chicken and the egg. And so our, right now is our, where are we further ahead in your view? Are we further ahead in the development of the robotics or are we further ahead in the development of the AI? Bye. 

[00:27:48] Dr. Jacques Cohen: Okay. So just, yeah, no, very nice. It's a very good point.

We, I see, I think, uh, I think there's a lot of effort in AI and also now a lot of effort in robotics. Robotics started earlier. The first papers are from 2007, 2008. Uh, mostly coming from Montreal from new songs, a program professor, you saw at Toronto university, you know, at, at university of Montreal and, and, and he and his group have been building this up for the last 15 years slowly and more and more interest now, at least five, six efforts in companies that have started up in the last few years, starting different aspects of IVF or studying the entire IVF process and see if all of it can be automated or maybe should you just focus at one particular aspect.

AI is, has had a tremendous interest because robotics. It's on a different economic level, robotics is relatively expensive, whereas AI is very doable. And you can, you can develop nice AI packages for relatively limited amounts of money. And so there are a lot of AI companies, uh, David Sable, you just mentioned him, he and his colleagues calculate that the.

There was a few months ago, there were 35. Uh, I wouldn't be surprised if we're over 40 and also wouldn't be surprised that the researchers missed several of them because they are basically, basically not noticeable. These could be companies or, or clinics or university groups that are not noticeable because they haven't published yet or they haven't really been loud enough as a matter of speaking and they're being loud enough that you know about them.

There could be as many as 50. So that is an explosion and most of them focus on embryo selection. Well, I can tell you that, that, that it's going to end up in the typical civic and valley frequency, 95 percent of them will fail. Maybe higher, but this cannot be sustained, particularly because they're competing with established methods.

The established methods are time lapse, morphology analysis, development rate. If you don't lose time lapse, there are other methods and also PGTA. So you're going, going up against 40 years of IVF and to see that replaced overnight, it's just not going to happen easily. But what is nice about an AI is you can just ignore it.

I think AIs need to be either for free or affordable. It's very affordable. So if PCTA means that you charge, let's say, 100 per MVO, an AI should be a few dollars per MVO. Also free. That's, that's my opinion. Because all of this is just somebody's opinion. An intelligence system that's looked at a lot of data and has come to conclusions that are maybe holding up or not.

We don't, we don't have enough papers yet that it is really making much of a difference. I've been involved in one effort and that seems very interesting. But. That's just one and a couple more that have been published, but you know, the advantage of AI is it's simply to, it has to be simple in terms of installing.

You just download a program and you get an interface to work or your, or your system in the lab and it shouldn't involve hardware. So it's very easy. It's just like an app on a phone, but you need input of data, morphological data. You need Maybe photographic or video data input, but if it's time lapse, then you need that kind of input, more, more hard, more computer hardware needed.

If it's just still pictures, it's very easy to do, and you really literally could do it on your phone. And then you get an opinion, and if you don't like that opinion, as an embryologist or a doctor, It's usually nowadays that, that's a, that's a team decision which I'm able to transfer or which I'm able to solve first.

Then you, then you, you can use an AI. If you don't like it, you got another AI. And if you like them both for different reasons, and you have tested two, why not use them both? Then you have two opinions. That's all it is. It's an opinion and it's an assistant. It's not, this is not what you should necessarily be doing.

You, you're, you're, you're. You're the end point of hundreds of millions of years of evolution. AIs cannot compete with you, but they can do one particular thing, one particular thing very well, particularly if they are based on experience of other clinics and you may be in a small clinic and you could use that experience and that, that, so it is democratizing in a way the solutions that you're building in the IVF lab by making use of an AI or it is an assistant.

So that's. A very big, big difference with robotics, where you have to develop, you have to imitate what an ambiologist is doing, what the lab technician is doing. The lab technicians that we, that, that are nowadays, they have been trained for years and experience counts, and you can just see that in a lab.

You don't see many publications showing. results of embryologist expressed of how they perform in the, in the lab, but it can assure you there are differences. And of course, as a lab manager, a lab director, you try to minimize that, but it's, it's, it's, it's, it's amazing that the robot is basically being put in place, replacing that kind of experience.

I personally think it's doable and I think it's going to happen. The timeline, I'm not sure about. Some of these applications could be a couple of years away. Others may take longer. It's hard to say. I hear all sorts of numbers out there. Some people think it will take a generation or two. Others are saying it's going to be a few years.

The truth, the truth we'll find out later. This is going to happen. There are some procedures that embryologists either don't like doing. Or maybe not so good at, you know, you get tired in the lab. When you do a lot of procedures, you get tired and you have good days and bad days. A robot, if it's well developed and well tested, it doesn't have good base, good days and bad days.

It doesn't bring out what it's experiencing at home into the lab. It doesn't look at this phone and pick up the phone or text. It's not distracted. It's, it's, it's an idiotic system that's very, very focused on one particular task and, and that, and that's how you use it. And then it can be very, very helpful.

We developed the sperm selection AI. I don't see if you, once you have had that, I think that is such a wonderful thing to have. It, it, it actually makes your decision faster and you know, you know, you can use it all the time. But you can ignore it. And that's the beauty of AI, whereas if you have a robot in place, well, you would have to stop the process and go into the robot and take the embryos out, or the eggs out, and interrupt the process.

So a robot has to be very, very well tested before it's implemented on a routine basis. It's a very different process. I, I, I think it, it will literally take hundreds of millions of dollars to develop robotic systems. And it probably, if you add it all up, and once you're done, let's say in five years from now, you add it all up, what all our efforts have been, this could be a billion dollar project, maybe more.

So, so AI, where if you can get data from different clinics, you're in, you're in a good place to develop an AI product that could make, could make a difference. Thanks. 

[00:35:04] Griffin Jones: So, when you say that you think that the AI should be either affordable or, or, or very, very low cost or free, do you mean as, uh, as a pass on to the patient?

And do you mean for as long as it is simply as good as an opinion as, uh, an embryologist or a clinician? 

[00:35:27] Dr. Jacques Cohen: Yeah, it goes both ways, right? So if it's a, if it's an add on cost to the clinic, it often is passed on to the patient and discounted. I think this is on a level that it shouldn't be. I've always been surprised that if you are able.

at some point in time to make maybe a difference with a new technology in terms of success rate, whether that's higher fertilization, whether it means that you can get more embryos to develop by changing things in your culture system. We don't pass that on to our patients directly. But there's sometimes these, these develops, like PGTA is of course a good example because it's so labor intense and costly.

But there are others, like assisted hatching used to be in the past, and, and clinics would charge a fee for something that takes a few minutes. And I don't think, I, I personally never felt comfortable about that. I think that, that is, that's often a decision of administrators, but the practitioners may not feel comfortable about these things.

So, we need to tinker on the, with the culture system, which is still the major. research line that exists, right? We're talking usually about sexy things like robotics and AI, and gametogenesis, artificial syntax, making synthetic sperm and eggs. I mean, those are the big sexy projects out there. Most of our research is about how can we make things better and safer?

And those are spreading tiny little steps and suggestions in the scientific literature. And that's where we focus most of our energy. It goes back to your earlier question, because that's really, that's really improving the culture system is never going to change. We will always think of Mr. Culture system.

That is a research line. That's incredibly important. Big breakthroughs in the last 40 years in that area. But because You know, if you change the culture medium ingredients and test different culture media against each other, and I've been hundreds of those trials, people don't get overwhelmed by that.

The lay people out there, they don't, they don't see that as something they're necessarily interested in, but that's why we got better. The cultures making changes to the culture systems, why we have gotten better over, over the decades. That will, that will not stop. That's not going to stop. That's going to continue.

[00:37:44] Griffin Jones: Will the AI not get to a point where it's better than an opinion, where it's better than the average opinion of the average embryologist and average clinician? Will we not get to a point where the AI has the closest to certainty? 

[00:38:00] Dr. Jacques Cohen: Well, that's a loaded question. It all depends on, on what your end point is.

If your end point is helping an, uh, an ambriologist setting up instruments and timing themselves, uh, you could develop an AI. We have developed an AI that's tracking the ambriologist. And I think there, you're probably going to say at some point, well, this is your guide. It's basically somebody who's keeping the books, right?

It's telling you, well, that those tools are, this tool is not looking good. Get another tool. You know, you need to position this differently. Oh, well, one second. You don't see there's a hole in this zone of Pellucida, you know, their AIs can actually take over and, and, or take over, help you to, in such an extent, you're going to ignore it.

Definitely. The decision AIs, those that are not observing and just helping you, but are making decisions, not necessarily for you, but making decisions like this is the best sperm. This is the best ag. This is the best embryo in their opinion. That's an opinion. Is that going to be equivalent to what you would come up at some point?

Yes, I think it will be. I think it will not only be an equivalent, it will be better than what we have come up with. But this is a development. Is that going to be a year from now? I'll be very surprised. Five or 10 years from now. It's going to be, it's going to be there. And look how long it take, took to get PGTA somewhat accepted in this country.

It took 15 years, maybe longer. With AI, it's going to be in the same timeline. So for every, every clinician, every embryologist to be, to accept that technology will take a long time. Uh, but I have little doubt that it's going to be at least as good as what we do, if not better. 

[00:39:46] Griffin Jones: Are you using it right now in the IVF lab, or do you use it to grade cases?

[00:39:51] Dr. Jacques Cohen: Yeah, I'm not running an IVF lab anymore since, since at least a year. But when you're consulting? Yeah, definitely. Yeah, I definitely, I definitely suggest it. There are AIs you can get for free or for very little. There are some that are charging hundreds of dollars per embryo. I don't understand that. It's a changing algorithm.

And I, I don't understand why it has to be that expensive, certainly wouldn't have cost that much to develop. So, so I think, I think should be for very little or for free. And I, I am consulting people say, well, these should get for you for very little or for free. And you could use several of them. That's, that's my advice.

Don't, don't use one embryo selection AI, but use several. If it's, if it's reasonably priced or for free, then that's what you should do. And you got, you got, you got, and then you can basically keep track of that data. See what you thought as an embryologist, for instance, what did you think should be transferred?

What did the two AIs think? And then you can get some analysis later on. You've done a thousand of those after a year or two years and then analyze that data. See if it has worked for you. Are you just kicking AI out, right? It's just turning over an app, just turning over an app. It's not a big deal. I think, I think a lot of it should be for free.

[00:41:05] Griffin Jones: With regard to robotics, you said that this will end up being a hundreds of millions of dollars, possibly a billion dollar project to fully automate the IVF lab. How far into that billion dollar project are we? 

[00:41:22] Dr. Jacques Cohen: I think we're over 100 million, but they're probably between 100 and 200 million right now. I mean, if you just look at Overture, that's already 150 million, I think, so, so we're probably at a quarter, quarter, quarter billion or 300 million in that ballpark, and I really don't have figures.

You know, that's the amazing thing, really, really hard to find out, but we're already probably 300, 400 million up there. I'm changing the numbers as I speak, but, but, but it's, it's a, it's a guess. I think within a few years we'll be at a billion. That, that's, so that includes all the companies. That doesn't mean that the, that one company that is serious about robotics is spending hundreds of millions of dollars, that you could actually focus into robotics.

And if you only are interested, let's say in, in finding eggs during egg retrieval to automate that process, you're probably looking at procedures that probably could be quite inexpensive to apply. But if you're looking at a fully automated robotic. Existation, which doesn't exist yet, or at least has not been published.

There you're looking at a massive amount of AIs, and you're looking at very intricate, very, very subtle and tested robotics and automation. There you're probably looking at a relatively expensive instrument to develop. So that will cost you many, many millions but yeah, if you look at the total effort, really a billion is not so you know, I'm being pushed back all the time when I say this, but is it really if you're already up to 300 million now, by the end before it's fully automated, which I think will take a while, fully automated will take a while.

Easy to predict it will be. 

[00:42:59] Griffin Jones: And so within that system, what pieces have we established in the last two to four years? And what pieces are still missing? 

[00:43:12] Dr. Jacques Cohen: Okay. So what we have established are preliminary data in most procedures, except for one. And that is tomorrow, the tomorrow system based in New York City.

I'm on the advisory board and I've been associated with them since the early days in 2018. So they have developed two robots that will label embryos or their little devices that they're held in during the verification process and cryo store all the samples. So cryo storage, which was which has been notorious in terms of mishaps over time.

These, these refrigerators, we call them dealers. These refrigerators can fail as all machines can. And so they, they are under a very harsh and then a very harsh environment and they will fail at some point, but it could take 20, 25 minutes before, before these fail. When that happens, it's a disaster. Also, what happens a lot, it's a lot of errors being made.

Because there are all sorts of good reasons for that. Almost all labs will have errors, at least in communication or errors in, in, uh, in the data processing of individual embryos and eggs. And so it's very common. So we want a more secure method. And RFID chips, which is of course an electronic way of labeling, Each embryo separately.

That, that had to be introduced. And it has been done, and TAMUA uses that technology. And then takes, takes a tube filled with a device that has the embryo stuck to it, that's already fittified, keeps it cold. And then sticks it in a pre programmed place. The advantage for the clinic is that they have immediately a log.

If you tell ambiologists, let's audit our, our units. Doers. Let's order a cryo storage lab. It could be 60 doers. There could be thousands and thousands of patients, embryos in there. Everybody looks for the exit. All the ambiologists are looking for the exit because it's so much work. 

[00:45:09] Griffin Jones: Yeah. 

[00:45:10] Dr. Jacques Cohen: And you're going to find things you don't like.

And so. Here and all that is, literally, you take your, you take your, your phone, you take your phone, you click on it, you have done your audit. It doesn't matter if there are 10, 000 embryos there or a million embryos. It will be a second thing after audit. You know exactly where they are and that they are still there.

That system has been put together by tomorrow. That is a robot that is in place and that's available now. There is, there are two other robots that have been developed. for our field, except for time lapse, which of course is a robotic system. Two other robots which have to do with part of the fitification procedure.

Fitification consists of four or five parts, and one of those has been been available already from Overture in Spain and Genia in Australia. The Genia one is at least 10 years old, but because it only does one in four, of the aspects of the procedure and biologists, including me, frankly, have never been interested.

Why would you have a robot where you do the other three procedures and the robot does the fourth part? I want one that hears the dish, frees this, and I then want the frozen embryos to come out and go in something like a tumoral system also automatically. So I don't have to be worried about it, and I get the data in my EMR.

That's really what I, what I want as an embryologist, because that'd be very, very helpful. Fidification is one of these things where experienced embryologists get very, very good at it. But it's, it takes a while to teach somebody to understand all the little details. details of it, and really start being excellent about it.

And so there, robotics would make a major difference. And Xe would make a major difference in things like egg finding, sperm prep, all of those procedures, yeah, so it would make a difference. 

[00:47:07] Griffin Jones: Are there people working on each of those areas right now? Automating AXE, AXE automating, egg freezing, is that, are we in sort of a race to see which company develops that first?

Or is that in very preliminary stages? 

[00:47:24] Dr. Jacques Cohen: It's right now, if I'm to guess and going by the literature, which is maybe only a couple of dozen papers, it's in preliminary stages, but it's getting closer. I think we'll see entirely a series of robotic systems being published in the next year or two, the first stages of that, before robotics becomes really implemented on a routine basis.

also involving the regulatory aspects that are sometimes needed for that, depending on the situation, depending on the type of robotics. I think you'll see, you'll see that that will take, of course, always a lot longer before something comes in team, but within the next months or years, you're going to, you're going to get papers where people are planning.

I can do X finding, not find all that. And I should find out maybe finding more X than I thought that worked. So, so that those things are going to happen probably sooner than, than. And then later, because there are quite a few efforts worldwide. I mean, I said five or six early on. It may be more than that.

Maybe a lot of, a lot of things, but the, so there are two, there are two types of robotics initiatives, companies that are looking at every aspect. And then there are companies, uh, looking at particular application. I don't know what's the better, best approach, but that's, that's, that seems to be what's, what's going on right now.

[00:48:40] Griffin Jones: How about with regard to non invasive genetic testing, non invasive biopsying of the embryo? And I have to give credit to your colleague, Cynthia Hudson, for planting this idea in my mind, because after her interview, she said, shoot, I wish I Thought and talked more about that and, and so she gets credit for, for putting the, the idea in my mind to ask the question, but how, how close do we are, are, are, are, are there preliminary papers about that or, or are we really far away?

[00:49:12] Dr. Jacques Cohen: Now, I say about preliminary paper, Stephanie, um, what are two approaches if you have an AI that selects embryos based on the development of the embryo and, and use machine vision to analyze embryos, that is kind of non invasive, right? That's non invasive embryo selection. And, and that could be trained on, on, on whether embryos are genetically normal or not.

I mean, I've been involved in an effort, it's a company called IVF 2. 0 based in Mexico. We've developed an AI called Erica and Erica was trained, really only trained on embryos. On a lot of MBLs, looking at whether they were normally, whether they had normal chromosomes or abnormal chromosome counts. So whether they were euploid or aneuploid.

Yes. The data was also provided there, which one of those MVOs would make a pregnancy or not, and which one miscarries or not. But the basic training set was euploidy versus aneuploidy. And so that is a non invasive way of doing PGTA, but probably Cynthia was hinting not at that, but at taking a sample from the culture medium.

Where the blastocyst has been, provided the blastocyst was by itself. And then, and then analyzing that chemically or maybe taking a sample of the fluid that's inside the blastocyst, as you know, the blastocyst is fluid filled and the cells are on the outside. Taking a sample from that. Both of those approaches have been done.

Interesting data. But for me, the most interesting paper is if you find DNA there that comes from ambiose, you could wonder, well, why, why is that? Why did that DNA come there? And the group in Bologna in on the, on the Luca Girodi's leadership in Bologna, Italy, they have found recently and published that if you find DNA, The culture fluid that the chances of fantasy of dose ambose is actually significantly lower than the embryos that do not have DNA in their culture media.

And so embryonic, DNA in the culture media, so that tells you, you may be finding DNA and that may help you what anomaly you're gonna find, but it also means what the DNA is there, that's already not a good sign. The advantage of this finding is that you could just test for DNA and that's very affordable.

Just looking at DNA. Rather than getting information back, you have to confirm it has to be embryonic DNA. Once you confirm that, that's all you need to know. If that's there, that embryo probably should be chosen not up front compared to embryos where you could not find the DNA, the embryonic DNA. So, because why would they lose cells?

Well, that means something's going wrong in that embryo. That means that cells die. or lice, and all the, all the content comes out, including the chromosomes and the DNA. That's why they end up in the medium. It's probably not the best sign that it's there. So in my, in my opinion, that kind of non invasive DNA assessment, chromosome assessment, if you like, has a future.

Particularly if you can just, in an easy way, sample the culture medium, say, in a 15 minute test, there's embryonic DNA there, yes or no, and that has a future. To get details of that embryonic DNA, I think that is far, far short. I would, I would go with the AIs looking for embryo selection based on just data and morphology, PGTA data, and, and choose those AIs, and, and already have a dozen of them.

I would look for those. the answers that those have to offer. That's also non invasive PGTA. So whether it's a very good point, non invasive PGTA, getting rid of biopsy is something that we need to try. We really need to focus on that because biopsy is difficult. It's difficult and it's expensive. 

[00:53:09] Griffin Jones: So, it sounds like getting rid of biopsying is on the preliminary end of the spectrum, on the very preliminary end of the spectrum, whereas it sounds like something more like the robotic labeling of embryos and the cryo storage inventory of tomorrow is on the mature side of the, of the spectrum.

What's in the middle right now? 

[00:53:32] Dr. Jacques Cohen: Well, I think the efforts on ICSI, one of them has been published, the Overture Group in Spain, and MBA Tools Lab in Barcelona. They looked, there was an editorial with that paper, they looked and the editor calculated how many of the steps were actually automated. It was a modest number, but nevertheless, that's never been done before and had, had fantasies.

So this was published. Just a few months ago or half a year ago. And I think that that tells you that there is a lot of work done in that area. There's work done on all aspects. I think on the fertification side, I think there's work done to complete those procedures, not look at one part of the procedure, but the entire set of procedures, and it's the same of all aspects.

So we have done, the field has accomplished making culture, the culture system. Robotic. It has accomplished making the acquired storage systems through tomorrow robotic and, and, and it's, it's, it's looking, it's obviously looking at all the other aspects, which means sperm prep, automation, sperm prep, and, and that, that, that's going forward in strides or making it at least so simple that only involves one or two activities by embryologists on andrology donations.

At finding in the laboratory, there's of course an egg finding or egg retrieval. There's two. There's two efforts going on. It's the surgeon, it's the gynecologist or the, the IE extracting follicular fluid. And then the, that follicular fluid goes through the lab and the embryologist looks through the follicular fluid in very shallow layers, so they decant it into battery dishes and look very quickly for acts.

And sometimes those are hiding, sometimes they sit in blood clots. So it's a bit of an art. It needs to be done in, in a, in a. In a timely fashion, you can't take hours, you need to do this in minutes. So that can be automated, the laboratory part can be automated. I stay away from the clinical part, I think in true course that can be automated too.

But the laboratory part can be automated and you'll probably see the first data sets coming out in the next year. 

[00:55:36] Griffin Jones: How about the systems being developed by Conceivable for automating the IVF lab, where does that fall in the, in the spectrum of preliminary to mature? for listening. 

[00:55:46] Dr. Jacques Cohen: Okay, so Consiglio Rouvas is now 12 months old.

I'm the Chief Scientific Officer. So we are looking at trying to automate all aspects of the IVF procedure. And there's at least one other group out there that's trying to do the same. So we're looking at egg retrieval, sperm preparation, we're looking at, you know, Denudation, the process where you strip cumulus cells away from the eggs before they go to eggsheep.

Automation, the full automation of the entire eggsheep process we're looking at, we're looking at full fertification. We're also looking at automation in, in the embryo culture system because we feel that the culture systems are very expensive. So we want to come up It's culture systems and timelines that are much more affordable.

So we're working on that and we're, we're working on full certification with the tomorrow system at the end to cryo store the MVO. So it is, it is the idea is to do all of these processes and then string them together. 

[00:56:49] Griffin Jones: I feel like I've gotten a really good look into the pipeline today, and you've also made a few points to me that really educated me on why time lapse hasn't been adopted to the level that it has in other countries, why the FDA has not approved it.

Uh, AI algorithms. And so I want to give you the concluding floor. How would you like to conclude about the, the research and development pipeline in the IVF lab? 

[00:57:22] Dr. Jacques Cohen: Well, I think, I think overriding what we do in the United States is the fact that funding is so difficult to come by. The largest funding agency in the world is NIH.

And they found, found, what is it, 60, 60, 70 billion in healthcare research. Thank you very much. Why don't they fund the IVF lab? Since IVF started in the early 1980s in this country, I think the first lab is from 1981, the Norfolk lab. There has not been a single. experiment. A single observational set has been funded by NIH.

There's a moratorium on embryo research since the, since the late 1970s, since 1979. That's now by law. So there cannot be any public money spent on human embryo research. It's outrageous because Everything we try to do in IVF, we have to actually go and do this on patients and spend private monies rather than public money.

And so, yes, we can study IVF and do IVF related research in animal systems. But at the end, if you look, for instance, at chromosomal anomalies, there's no animal system that's helpful. You have to find out in the human. So embryo biopsy studies have been very slow to come by. It's because there's not been any.

NIH funding available. I think we have to frame it like that. People saying, well, this is going very slowly. There is progress each year. If you, if you look at the data analysis and, and two of my colleagues, Alex Bissignano and Mina Alikani and I published a paper in 2012, where we looked at fine combed, uh, um, SAR data and found that there is progression in outcomes per embryo of, of 0.

9 percent a year, year by year. That was only a 10 year analysis and it includes all the clinic, but I've, I've looked since then. And it's going up by 0. 9 percent a year. It's more profound in young patients. In patients younger than 35, it's one and a half percent per year, but it is going up. So in other words, we're doing a lot of good things, but it is very, very slow.

Do we have the patience? Do we have the patience to go, to go this slowly? to where it becomes as good as dentistry, right? We go to a dentist, and you don't go to a dentist hoping that your wood canal is going to work or not. You go to a dentist and expect it to be 100 percent successful. Maybe you got a little infection, but that can be treated.

But you want it to be 100 percent successful. And that's what IVF. We want things to be 100 percent successful. Not 98%, not 80%, or what it is now in some clinics over 60%. No, we want it to be 100%. And we really want that as soon as possible. So I think all this technology that we discussed today will, will, will help us.

Play a role in that process, but it's not only technology driven. It's not only technology driven that we go up by 0. 9 percent per embryo in this country each year in terms of implantation and life births. It's not just technology. It's also communication. So what you do, communicating to the community. Uh, conferences, other webinars.

Training is very important in this country. There has always been a lot of emphasis in training. Our doctors s are trained, that's very unique in the world. In, in other countries is usually usually an OB GYN or, or a GP that becomes an IBF specialist. And could they become good at it? Oh yeah, they could become really good at it, but it's a little bit more tedious to do it that way.

And so. So, I think training also of embryologists has changed a lot over the last 20 years. All of those factors, particularly the communication and the awareness, creating the awareness of all this and having a discussion and comparing our data and comparing our methodology, that is making as much a difference to just saying what's all driven by new technology.

It's not just new technology. But the new technology could be introduced a lot faster if we had NIH funding. And we don't. 

[01:01:33] Griffin Jones: Dr. Jacques Cohen, I look forward to having you back on to look at the updates on the research and development pipeline in the IVF lab. I enjoyed this conversation today. Thank you for coming on the Inside Reproductive Health podcast.

[01:01:46] Dr. Jacques Cohen: It was a pleasure. Pleasure. Thank you, Griffin. 

[01:01:50] Sponsor: This episode was brought to you by Future Fertility, the global leaders in AI powered oocyte quality assessment. Discover the power of magenta reports by Future Fertility. These AI driven reports provide personalized oocyte quality insights to improve treatment planning and counseling for IVF ICSI patients.

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Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health nor of the advertiser. The advertiser does not have editorial control over the content of this episode and the guest's appearance is not an endorsement of the advertiser.

This has been another episode of the Inside Reproductive Health Podcast. Tune in for a new lineup of episodes premiering in June, where we'll be taking a tour of the C suite with a powerful new series featuring CEOs from some of the largest fertility networks in the world. We can't wait to share these inspiring conversations with you.

Until then, stay informed of the latest fertility news with our weekly digest, delivering curated content straight to your inbox every Thursday. Stay tuned for more updates and thank you for listening to Inside Reproductive Health.

186 How Fertility Centers Can Save (Patients’) Money, Line By Line with Dr. Mark Amols


Let’s save you and your patients some money!

From the materials you buy to the software you invest in, it can be difficult trying to find where to safely and effectively reduce, replace, or eliminate to save money and maximize your practice’s bottom-line.

We talk with Dr. Mark Amols, founder of New Direction Fertility Centers, and he walks us through his low-cost affordable IVF model. He reveals where and how he invests, or doesn’t, to keep his practice thriving.

Dr Amols breaks down his four categories when purchasing materials and services:

  • Which line items can be completely eliminated

  • Materials that can be reduced or replaced with cheaper alternatives

  • Finding cost-effective versions of necessary commodities

  • How to know the expensive must-haves to pony up full price

Dr. Amols opens up his playbook and gives specific cost examples from his own practice, so listen in and see where you can cut your bottom-line.


Dr. Mark Amols’ LinkedIn
New Direction Fertility

Transcript

Dr. Mark Amols  00:00

There's nothing special we're doing. I mean, this is typical supply and demand type of economics and in when it comes to the vendors, I think one of the most important things that I do as a business person is I don't look at it as me trying to get the lowest price. I don't try and get the best deal. I kind of look to the vendor, I say, how can we work with each other?

Griffin Jones  00:28

Let's save you some money. Let's go through your income statements, fertility doctors, let's go through your costs and see how we can save you money by eliminating, replacing, reducing, negotiating. But before we do that, I have to fess up to some technical difficulties that messed up this interview a little bit. It was my part I know that breaks your heart, you're not going to get to hear all of my witty insights the same as you would if the recording for the audio went properly. But Dr. Amols who was our guest, Dr. Mark Amols from New Direction Fertility in Arizona, gave us so many good insights. I was late to the interview to begin with, but no good excuse just my carelessness, I didn't want to have to bring him back on for his time for the audio issues that were on my end, but my audio stopped recording about a quarter of the way into the conversation. So I re recorded my questions, I tried to do my best to match them up with how the conversation went. And the answers that Dr. Amols gave, if any of the answers seem off, blame it on me. But the insights in this episode are terrific. I asked Dr. Amols to walk us through his low cost affordable IVF model that he's had a lot of success with in the Phoenix area, I have him go through those things that he spends less money on things that he doesn't spend less money on in his system for approaching that I definitely wanted to have him back on for another conversation about top of license, not just the REI, but everyone in the fertility practice, going through the accountability chart and what that would look like. But today, we focus mostly on materials and services. And we break those into four categories. The first is those materials and services that you just don't need, you can eliminate those costs altogether. The second, which ones can you reduce or replace with cheaper alternatives? Because you're reducing them in some way? The third is those commodities that you need them. But there's a wide range of prices and not a wide range of quality. So how do you get the cheapest? And then the fourth, maybe there is a wide range on prices, maybe there isn't, but there is a wide range on quality. And you really have to pony up sometimes. So we break into those four categories. We also talk about things like software and professional services. And Dr. Amols is very generous. In this episode, he gives specific examples, he gives specific costs, he opens up some of his playbook very transparently. And he shares that with you. So if you talk to Dr. Amols, please tell him thank you because I want him to come back on and share more. But I also want everyone to come on and share a little bit more. And it always pushes the envelope when somebody's willing to just share a little bit more makes that episode that much more popular, more valuable. And then people want to mimic that and they tend to share more valuable information and give more value to the audience when they come on. So enjoy this conversation with Dr. Mark Amols, Dr. Amols. Mark, welcome back to Inside Reproductive Health.

Dr. Mark Amols  03:28

Thank you, I greatly appreciate it.

Griffin Jones  03:31

I thought to invite you back on because I was in a meeting not too long ago, with an older physician who was expressing distress in their voice, I could hear how troubled this person was that they wanted to reduce costs at their IVF center because they wanted more people in their area to be able to afford treatment. And they legitimately did not know how to do that they're already being squeezed on the margins, I could see their numbers. It's not like they're raking in a whole bunch that you know, it's just coming out of a inflated top line for them. And there's been a handful of people that have been able to do a lower cost affordable IVF model in the country, only a handful. And you're one of them. You've been on the show to talk about that for and that's still one of the most popular episodes. And I remember at that time we did it live and it was during the COVID shutdown and we had more people than we had capacity for in the Zoom Room we had we had to you know upgrade our our account. And so I wanted to have you back on and I wanted to go through with you how you select your partners, meaning your strategic partners, your vendors, because a lot of people would like to be able to lower costs and they just feel like they're getting squeezed everywhere. So how do you think about this challenge?

Dr. Mark Amols  05:06

Yeah, you know, it's interesting when you told me about the topic, I was kind of confused when he said, How do I choose my vendors, but it actually does all come together? I think the question isn't so much how we do it. But why other people can do it, there's nothing special for doing I mean, this is typical supply and demand type of economics. And in when it comes to vendors, I think one of the most important things that I do as a business person is I don't look at it as me trying to get the lowest price, I don't try to get the best deal. I kind of look to the vendor, I say, how can we work with each other. And so for example, like I understand the vendor has shipping costs. So if I want them to send me something every month, I realized that's gonna cost them more money. So I'll work with them say, hey, whatever, I just take like two large shipments a year, I'll take a huge volume, you give me a lower cost. Now you're not paying shipping all the time. And I'm, you're guaranteed dismount every time I'm again. And so that helps kind of like, you know, look at it as a relationship in that standpoint. But the other thing is, is I understand the point of volume. So when you're talking about low costs, I mean, it to go like Target and stuff, you have to have more volume, if you don't do more volume, you're going to lose. And the way that traditional IVF is set up is really this kind of, you know, we're gonna get 1020 patients in per month to do IVF. And so they rely on making a lot of the sale, and they don't have the volume. And so when you do have the volume, or at least if you're going to have that volume, you can go to these vendors and say, Hey, here's my volume, here's my projected volume, you can see how much growing each year. And I tell them I say listen, if you make a deal with me, and help me, I will stay with you. You know, even your prices go up a little bit, I'll stay with you. And so down to the vendor pick, like we were saying, so getting back down to how do I pick my vendors, you know, it depends on your product. So there are some products that are made by multiple vendors. There are some products that are not right. So if you think of, let's say, fairing, or you go up at the end of the men's out there, that's like the electric company, you really don't have a choice, right, you only have a choice between Gameloft and follistim. But when it comes to manufacture, you really don't have a choice. So for those type of companies, there's really not much you can do that the relationship is really just them being nice to you and your stuff to keep buying their product, but with Folsom and go limp off, so you can work with them to try to get better pricing for your patients. When it comes to things like product for the lab, you're a little bit limited, because there are quality differences. Luckily, it's been very standardized in their industry now. So you know, most we're using the same products now. But with those vendors, it comes down to, I think building some type of loyalty with them. So you know, you work with a company every single time they know you're going to come in and buy, you know, six ultrasound machines, you know, 620 incubators the same time, they're going to, you know, keep giving you better prices through the years because they know you're gonna stay with them. And again, building that relationship with them, you know, always sending stuff that way. And then the other vendors are going to be your vendors that have multiple vendors that do the same thing. So when you talk about things like speculums, or you talk about things like drapes, you can get drapes from multiple companies, there's stuff I buy off the Amazon, because it's cheaper for me to get them off the Amazon than it is through my suppliers like Henry Schein, they have tegaderm, which goes on the skin after you put an IV in. Bye bye for them. It's like 100 bucks for 100 of them or 80 bucks. I got off amazon for $15 the exact same things. So when it comes back to choosing the vendors, going back to that question of how do we make it work? So one of the things is, is I tried to find those strategic partners. And and I talked to them like they're a business, I don't talk to them, like I'm trying to buy their product. I taught them to say Listen, how can we both help each other? What do you need me to buy? How much have you need me to do? Because like there's things I want a lower price, I'll go to come I said I need this at a lower price. And they said, we can't go any lower, it's okay. But if you buy more of this, then they'll offset I can lower that price. And so again, it still ends up the same, right? We're still looking at the same thing, which is overhead, which is your expense versus what you make. And that's really all it is. It's just the differences. It's harder to do. So I'm not trying to say that about most doctors, most doctors don't want to do business. I mean, why would you still want to become a doctor, you want to go out and just make money. And so for most people, they see money in their bank account, they're happy, they're like, it's going up, I'm happy I see the numbers going up. But that doesn't mean they're efficient. That doesn't mean that they've actually at the point that they're getting the most amount money they make. I can almost guarantee you that if they went and got a person like you know, Scott Robertson, you know, from practice up, they got him to go through their practice, I guarantee they'll make more money just by him going through and finding out where they're wasting tons of money. And so in those situations where you have those practices that already have this high overhead they're trying to do this low cost model, but they're not efficient. And that's really that the main thing is you have to be efficient, and there's more to it, we'll go over that in a little bit more detail. But that's really the biggest thing is when you're looking at vendors, you're trying to make sure that, you know, you pick vendors that you can build that relationship with. So you can get lower prices and be able to offer things you know, better cost. So things like speculums. I mean, I, my spec homes costs, I think some like 10 cents. Whereas like, when I was at another clinic, it was a buck 50 per speculum, and it wasn't needed. And so again, there's things you can do to get better pricing, that doesn't matter. No one's gonna have a bad idea of cycle because respectable isn't great. But they aren't going to bear the IVF cycle, if they're incubators bad.

Griffin Jones  10:47

So I do want to go through those different categories of what's more interchangeable versus what you think is less interchangeable, and I want to break up those different categories. First, I want to think about how do you approach looking at this systematically? Or do you like do you do you just start to negotiate and look for different options? When you're ordering something? Do you go through your p&l at different points of the year and, and go line by line and say, How can I start with this and go all the way down the spreadsheet? How do you approach it?

Dr. Mark Amols  11:21

Yeah, every three months, I go through and I look at everything that we order. And I find out if it's one of those categories of where we can't change, right, there's no option. It is something that we can change, but we can have very little room because it might be something like an incubator, I'm like, I can't go for the crappy incubator, or is it something that's easily changeable, like a drape or something like that. And then what I do is I always go through and look for the best price. And so for example, like propofol is one of the drugs we use for anesthesia, I found a way for us to get propofol at 20%, the cost we originally paid. And again, it doesn't sound like a big deal. Because most clinics, if you're only doing 10, 20 cycles a month, you're not going to notice a couple of dollars here and there, when you started doing 100 Something a month. Now all of a sudden, that becomes several $100 Every month in that one product. And so those little differences make, you know, make a big difference. And so yeah, I go through every every three months, I look at things, I'm always looking for ways to reduce costs. Here's example. So one way we reduce our costs for bloods by 50%. So we made more margins was I know this, we were buying 10 milliliter tubes to fill the bloods up. And then one day, I was wondering, they make smaller tubes that cost less. And we went and found that they make like four milliliter or five milliliter tubes. And so we went and got five milliliter. And then later we found even made a smaller tube when we run like six tests in our clinic, so we realized we could use less blood, it costs half the amount and we reduced our costs overhead for those supplies by 50%. So just things like that, looking for things, looking at what do you need? And what are you getting, and you may not need what you're getting, 

Griffin Jones  13:04

I would love to have you back on for another topic to talk about top of license throughout the accountability chart. So you and I can go through the accountability chart of fertility center together, because we often think of top of license as just the REI. But the whole purpose of getting someone to practice at the top of their license is to get the next person to practice at the top of theirs down to the person that is checking someone in and bring someone to their room.

Dr. Mark Amols  13:32

So it means a culture, right. So as a culture as a clinic, we all believe in the same thing, which is making this affordable. So everybody knows that the better our overhead is the lower we can keep costs for patients. And so my lab, you know, will always look for the best price and other times they'll come to me and say this is all we can do. And I say okay, let me look at it, I might look into a little bit more. I have to be very nerdy. I love numbers. Like a dat in there. So I love that stuff. So I enjoy doing it. But yeah, I have other people who will do a lot of that for me. And then when they can't, they'll come to me and but I'm I'm always thinking of ways that we can reduce costs, just because our field I do believe has a lot of fluff and a lot of overhead. It's not needed. You know, we made some big changes just recently on just even staffing away I thought the box of we have staffing our clinic different where you know, medical assistants are very difficult now to find. And you know, I kind of looked into the legality of like, do we really need medical assistants for every little thing and so we found out that we could even just put greeters out there who can help us just you know, put patients in rooms and then again, that brought cost down so it's just it's not resting on your laurels and just saying hey, this is what we're gonna do. It's always gonna be this way we're always changing and adjusting. Same thing with vendors, you know, always looking at different things. Now, there's the point where again, once you have that relationship, you know, if you're constantly just changing for the lowest price, well then no one's ever gonna work with you. So I mean, there's a little bit of flexibility you have to have right so if someone's give me a great price now and then two years later that go up a little bit. And they're a little bit more than next one, I'll still stand with them. Because at that point, I know I've built that relationship. And again, that's an I'll talk to them and just say, hey, it was a little harder than we need. Is there anything we could do to get that down? Can we can we purchase more at one time? Can we do this stuff like that, but things like there was little things like shipping all those different things working with your vendor, you can get better pricing by just working with them and ordering more and committing them more. So

Griffin Jones  15:25

For the sake of this topic, let's break it into four categories, those costs which you can cut, eliminate entirely those which you can reduce significantly, either by replacing them with something else or reducing them by a lot. Third, that which is a commodity, you need them. But you can find a wide range of prices for not a wide range of quality and that fourth category, those things that really matter, there might be a wide range of prices. But there might not be and there certainly is a wide range of quality. And it's too significant. 

Dr. Mark Amols  16:01

Exactly. 

Griffin Jones  16:02

What are those costs that fall into the first category that you can eliminate entirely. 

Dr. Mark Amols  16:06

One of the things I when I was in other clinics, you know, obviously did this with one person training and then prior business I was with, is there was a lot of stuff we did to make, like a few dollars, but wasted a lot of our time, I think the thing that's most important understand is there's only so much time in the day, right? As a physician, I only have so much time, I'm probably when you think about when it comes to resources, the most scarce resource in the clinic. And so what happens is, is that there was a lot of stuff I was doing as a physician that made absolutely no sense. So we used to do what are called IVF consults, where we would sit there and go over the whole process with the patient of the IVF, we used even do a surgical visit the day before then make an extra dollar or two through the insurance. The problem is that same hour and a half being used for retrievals could do three retrievals. Or I could do two consults. And so one of the things that can be thrown away is really using people who can do things in their category. So for example, there are things no one else can do that I can do right as a fertility doctor. And so those are under my license, any nurse can do those things I was doing before those other clinics. And I can guarantee you there are claims out there today, where the physician is still doing a ton of stuff. And there's no reason to do that. It's a waste of money, it's a waste of your time, you'll never build do this low cost money, because you're looking at going, I gotta spend all these different employments eight payments, before I get to this point. Now you don't you have a team that that can do this stuff. And so part of what's important is, is you want to utilize people to the max they can be what's the most are allowed to do as a nurse. And then but you also don't want to waste their time doing things that you don't need to right because you're paying them too much. So when you look at overhead, so when you talk about what can you get rid of, it's for not getting rid of it, but adjusting it to out of the wrong hands instead of the doctor bringing it to the nurse, bring it to maybe you have a specialist, that's all they do is bring in someone, let's say off the street, you pay him 16 bucks, Darren, you're like, you teach them everything about IVF, you say this now is our IVF consultant, and they're just going to tell them about IVF. And you know what, they're gonna be pretty damn good at that job. You don't have to pay someone $80,000 a year as a nurse to do this every day when someone else can do it. And they'll do just as good because that's what they're specialized that that's kind of the way I look at things when you're looking at these models. I think one thing that's really interesting, though, about our clinic versus some of the others is that I think it's really important, though, to stay a high quality clinic, you know, not seeing other claims are bad, and I won't name the clinic. But there are a lot of people who do what I do, and have very poor pregnancy rates. And there are clinics like me who have very good pregnancy rates. And I think that's really important in this big thing. So when you're doing all these things, you're making these adjustments, you don't lose being a good clinic. You know, it's not about just getting low cost and having bad service, you have to stuff that service. So all these things I'm saying when they take them out. It's not that they're there's none important, like I said, so one of the fluffs I always talk about is like, most people don't want to sit there for an hour and hear about the idea of like, you know, the prepper rather read it on paper or give it to him in a text or something like that. So just stuff like that is how I've taken those things out product wise, is more just choice. Some physicians like use an iodine, you don't really need iodine. There are other changes you can do, but those are very small.

Griffin Jones  19:24

How about the second category that which you can reduce quite a bit or swap it out for a much less expensive alternative?

Dr. Mark Amols  19:31

Yeah, I mean, a lot of the things it sounds crazy, but like going from four by fours to two by twos for certain things, you know, we just did it away. We we always did it one way needles. You know when I'll give you example, one thing that a lot of clinics use, is they use other fine needles. Butterfly needles are really expensive. I mean, the best price you're gonna get for them. It's maybe a buck, but usually they're like a buck 52 bucks. You go to a regular needle mean the pennies and so Oh, you know, you think about your doing 1000 or 2000 needle sticks, you know, every few months as 1000s of dollars versus a couple $100. So that's something where, you know, we still had those if needed, but any phlebotomist knows what they're doing does not need to use a butterfly. But yeah, clinics use up you can get skinny needles that are still butterflies. So another example, too, was not only going from the five milliliter tubes was a big difference. But we actually found out that there are other brands of the tubes. And so a lot of people when they use like tire top tubes, most expensive from you know, Beckman, but you can actually get these ones caught we call McDonald tubes, or they look like a McDonald's franchise, too. And those are when I say lower costs, like 1/10 of the cost of the other tubes. And so again, something as simple as that can save a ton of money.

Griffin Jones  20:56

And how about that third category? Those things that you definitely need, but they're commodities, you can find them from enough for a number of different vendors for a wide range of prices? How do you find the best price for those?

Dr. Mark Amols  21:08

I think one is, obviously you have to have a company where you can keep looking at you have to look at see if they have multiple companies that sell that product. Now, here's an example of drapes, the pads the patient's sit on. So we were buying a certain size, but they were kind of too big. And I found if I just get a size, it was like two inches smaller, we see it like half the amount. This is like little things like that, and always ask them the question of do we need that, we obviously need the purpose of protecting the patient so that you know, but not sitting on a drape. But if it's falling over the sides, well you can wear when there's two inches smaller. And now you see a cat and mouse like little things like that that we look at. One was a male stands we used to use Mayo stands all times when you do surgery thing called Mayo stand up, put up a sterile drape over and then that way it protects anything on which you obviously want to have is sterile. But then one day I was I was wondering why why are we putting a male stand that we put a sterile thing on top of already when we open up the instrument. So instead, what we did is we took our instruments by a slightly bigger kind of like the truth that we cleaned it with, put it on there, we opened it up, and now that becomes kind of our sterile drape. And we saw at the same benefit, as if we were being the man stamp, but we're paying a fraction of the cost. And again, we're not losing a sterility, everything's still the same is that we just use the drape that it came with that we have everything cleaned in sterile area. I think of other things where we've we've made some changes to sorry, is that there's a lot of things I mean, but you know, those are kind of some of the big examples of you know, things where we would just look at everything. Here's another one, I just thought one was a probe covers. So when you buy pro covers, if you buy them in bulk, you get a huge difference in costs. If you just buy like the 100 pack every time you pay a premium, but you can buy like 1000s of them in bulk, and they're clean. And then that way you just put those in into your rooms and then use those. So again, another place you can save a lot of money. I think the big question for speculums is you have to ask what what your volume is. So if you're only doing let's say, five a day, you're probably going to save more money than using something like a reusable one and just you know, clean them but that takes money cleaning those it takes a person cleaning them in a busy clinic like mine, that could never happen. You have to use disposable. And like if you use the common disposable, you'll pay a lot of money. So here's one I'll give away. This is a good one people really like so if you buy Welch Allen lighted speculums they're very expensive. The light that goes in them are very expensive. Everyone loses those all the time drives me nuts when my nurses there were some because they're like 300 bucks for those lights. The speculums themselves cost about once you about $5 Each speculum. So Henry Schein makes another version of it. But the problem is, it's a wired version. So the problem is you have to put a wire into it which is which is horrible. You want to have it you know portable. So there's a company that actually makes a little light that fits into the Henry Schein when I figured it out. And so we were able to buy all the lower cost Henry Schein lightest speculums and use a disposable light. So the best part about it is, is that if a man loses a light, it was just 10 bucks on that light. And the second thing is we reduced the cost by half of our speculums. Just another thing I found by researching things though, it's not always just the supplies you use, but also the time committed to it. So for example, like a Sano histogram, way most clinics I've seen do it, they by saline models, they pull the ceiling up into a 10 cc syringe. And then they go and they do their solo histogram pushing with the st lame. When we used to do it that way. We had to do solid histograms about every 15 minutes. And then I found prefilled syringes, and I thought well if they're more expensive, we're gonna pay more, but then we'll have to To time into it and said, How fast can I do it? We're using everything prefilled we end up doing them every eight minutes. And so again, one of the things you also look at is not just the cost of them, but you're also looking at, does it make it more efficient. So we switched over now completely to prefilled ceilings. And back to that thing where I said about the 10 CC's. So we were just buying 10 CC's for everyone. And then I went spoke to the nurses, I said, Well, how much do you use, they go, Oh, we only use about three or five. So then I went looked up and found out they make three or five milliliter ones, or those lower costs, and they were so at that point, okay, oh, by the lower cost ones. And the same thing with like propofol, people, when I got the better price, one of the things I found out was sometimes when they're given propofol, they open up a whole nother bottle for just a tiny bit. I thought, well, one of the really tiny bottles so that way, we don't waste so much medicine. And they did. So we bought those. And so then and this is all just these need a little bit more use smaller bar, which cost less. And so it's not always just about getting a different product, but finding out are these these little areas that you're not using so much, you know, and stuff like that is really how you do it, even on the pay what you do each ESGs for, there's several bottles, and you'll find that there's one bottle, it's about a third the cost. So so back to that fourth category. Yeah, you know, again, I think it depends on how you look at your clinic. And that's why I made that point. They were the biggest difference or clinic, we have, we have to have high quality, I feel like what good is do they have a lower cost, and you're just gonna have bad rates. And so the things that I feel like you can't come away from are some of the main products, you know, good incubators, you know, you really have to be up to date on their incubators, I think there is some adjustments you can make between them. But you know, I feel like, Sure, you can get a cheap pair cell incubator, but it's not gonna be the same quality as a benchtop incubator. Same thing with things like gases, you know, I would love to be able to use cheap gas. But you know, you're not able to if we're using mix gases, we, you know, we have to have it certified, that we did find another company again, for cost again. So we always are working on that. And we're even looking at now mixing our own gas to save money. But but the point is, you can't, you really can't do much, you know, now there is like, like I said, when it comes to medicines of it, you can't change that. There's nothing you can do the company. But when it comes to things like incubators, you know, we look at a lot of things, we buy a lot of them so we're able to get good deals. But there's really not a lot of like I said adjustment. I mean, other than when you want to be one of the top, you have to use some of the top stuff.

Griffin Jones  27:29

What about other costs, particularly related to your tech stack things like your EMR, your payroll, software, other software, your billing and scheduling software?

Dr. Mark Amols  27:38

So EMRs I feel they all suck. I don't think there's a good one. If anyone says they have a good one, I want to know about it. But I don't believe there are any good ones. So when I looked at I said, well, listen, there's no good ones, I'm just gonna go with something that gives me the fastest speed. So we went with a system called Dr. Chrono. And what's unique about it is is you can do the whole thing on the iPad. And it's very fast. It's not made for fertility, we're actually trying to make a component for for fertility. But so we went with that, but it's free, doesn't cost me anything. So my EMR costs nothing, they do my billing for me as well. And take the same fraction amount and take it from any other biller. So we just use a company, sometimes there's some things that are cheaper to do when you outsource until your volume gets high enough. So obviously, like a big company, like Pinnacle or CCRM, right, forgive them when they charge and stuff. But for smaller places, it's actually cheaper to just find the company that will do it, than hiring someone to do it. So we do all that outside. 

Griffin Jones  28:36

How do you approach paying for professional services? Things like business consulting, marketing, consulting, accounting, financial consulting, legal expertise? How do you pay for professional services or think about costs, like, associated for those?

Dr. Mark Amols  28:53

So because I like the business side, I do a lot of it myself. Honestly, I only have so much time in the day, I do have a CPA. So my CPA does all my bookkeeping does that. We do have a legal firm that we work with all the time if needed. Luckily, we don't have to use them a lot, except for all the expansion we're doing right now. And through the other cities, when it comes to financial stuff like that. I do a lot of that myself. We don't do much for marketing. Luckily, we're very fortunate that we don't have to, but I do do my own marketing when it comes to things like Facebook, my podcast.

Griffin Jones  29:25

My recommendation for professional services is to separate them into sporadic engagements whenever possible. So sometimes you need professional services for execution, some marketing services, some things that you might need for legal help in terms of drafting documents that are pretty easy to do here and there. Just the drafting part of it. I'm talking about things that you might need accounting services like bookkeeping, those ongoing things. Try to minimize those costs as inexpensive as you can and then be willing to pay for professional services as at a high hourly rate. That's something thing that I do now I charge at a higher hourly rate. And I could do packages and things, but that allows people to engage us at a rate that works for us because they're paying high by the hour, but also works for them because they don't have to lock it in every month. So go ahead, pay for expensive business consultants, expensive legal consultants, but try to separate that from the ongoing costs of monthly implementation when possible.

Dr. Mark Amols  30:25

Recurring costs are one thing that can kill a company. And so you know, you're hitting right on your right things like consultations, you don't need recurring forever, but it's worth getting the best when you do it. And usually, that does cost more. And you know, now that we're doing all this expansion, we use lawyers more. And so we've been looked at potentially going to have an in house lawyer, but again, recurring costs get expensive. And so I agree with you 100%. on them,

Griffin Jones  30:50

You're still independently owned, I sometimes see independently owned fertility practices having more leverage because of consolidation. Because there are fewer people to buy services, there is more emphasis on those buyers that remain. And so even if you're not the size of the networks, as an independently owned, Fertility Center, do you have more leverage, because everyone else is consolidated? And people have to make deals with those that remain? Or am I fantasizing too much about this? 

Dr. Mark Amols  31:23

You know, I think, again, comes back to that slide the man or thing, right, so if you have a clinic that's not using a lot, I mean, I don't know how they're gonna be able to really get best prices and things like that. I think clinics that do more, you give example I see and why and you see why it's humongous, or I'm in the summer, like 4000 retrievals a year, they're able to get the best pricing just as big as like a pinnacle or CCRM. You know, and so I think I would tell someone, if they're trying to do what I'm doing, is I think the most important part is explaining, show them your growth, right? If you can show growth every year and say less number grow in play in expanding, then you become kind of your own group, you know, Purchasing Group, and you say, Listen, every client I opened up, I'm gonna still order from you. And that helps it one of the things that you I think you and I spoke about one time is why not all the little guys teamed together and make one group you know, and then that way, we'll be our own Purchasing Group. I think it's a little bit fantasizing, I think, as a company, if I was a company, and symbol was so low, and they were doing a lot, I wouldn't give them lower prices, you know, because that's the only reason you're given the lower prices at the bigger companies is because of the volume they're doing. And it just wouldn't make financial sense to give it to someone who is using very

Griffin Jones  32:33

Giving us really specific examples. You've also given us a framework for practice owners to go through their own books and see how they can lower costs, how they can increase profit for themselves and ideally pass on a lot of those savings to patients. How would you like to conclude?

Dr. Mark Amols  32:52

If anyone's ever interested in learning about this, I mean, I don't try to hide at this you know, I'd love for everyone to make fertility more affordable. And I think there's always going to be those niche, you know, offices that offers you know, that one on one the whole time process with with a doctor and those are going to do great, but if anyone's ever interested, I'm more than happy to talk to you if they want some of the ideas. I have the reduced money costs, you know, on their overhead, more than happy to talk to you about but hopefully I was able to help some people.

Griffin Jones  33:20

Dr. Mark Amols, owner of New Direction Fertility in Arizona. Thank you very much for coming on Inside Reproductive Health and I look forward to having you back on for another topic very soon.

Dr. Mark Amols  33:31

I look forward to it.

Sponsor  33:33

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health.

184 Mastering Efficiency in the IVF Lab: Strategies and Insights with Dr. Liesl Nel-Themaat


Are you seeking ways to enhance the efficiency of your IVF lab and improve patient outcomes? We invite you to listen to the latest episode of Inside Reproductive Health, where host Griffin Jones engaged with Dr. Liesl Nel-Themaat, IVF Lab Director and Associate Clinical Professor at Stanford University.

Here are some key takeaways:

  • Identifying and addressing common inefficiencies in the IVF lab.

  • The importance of standardization and its impact on success rates.

  • Strategies for optimizing workflow and reducing turnaround times.

  • The role of technology in enhancing lab efficiency and patient care.

  • Overcoming resistance to change and implementing effective process improvements.

  • Best practices and practical tips for managing patient flow and scheduling.

Stanford Fertility and Reproductive Health
Dr. Liesl Nel-Themaat’s LinkedIn

Transcript

Dr. Liesl Nel-Themaat  00:00

You don't have to spend 1000s of dollars to implement very expensive new technologies to become more efficient. You can start tomorrow in your own lab just by making some small adjustments in your own workflow or products that you pick staffing models, things like that.

Griffin Jones  00:24

Ask 23, IVF, lab directors and embryologist. What the biggest inefficiency in the IVF lab is and get 23 different answers that was part of the talk that my guest a vet PCRs Her name is Dr. Liesl nelta Ma. She's the lab director at Stanford's IVF lab. She has been an embryologist and lab director at different labs throughout the country over the last 20 years. And her model was about the inefficiency or talk was about the inefficiencies in the IVF lab. And I started the conversation off equating that with automation, we sort of got into a little bit of a semantic discussion, I hopefully still wasn't thinking that I perceived her as being anti automation. But I also didn't think it was entirely semantics, she was painting something for me where I could see that it's not just automating things in the IVF lab that is going to make it more efficient that you could automate quite a bit in the IVF. Lab. And you'd still have inefficiencies in different areas. So she made that clear to me. And it's I'm also on this cake that you hear me talk about with David sable a lot about when does it just make sense to replace a model entirely? You know, we could have made faster cars, but eventually you come up with something that replaces that entirely with aviation, for example, when does the existing IVF model just become marginal at best with the improvements, you can make an efficiency versus scrapping it and starting with something all together? And so I was having that like, philosophical question in my mind while she was thinking of the particular inefficiencies that she was isolating. So hopefully, that didn't mean she didn't feel like I thought she was anti automation. I certainly didn't. But I moved on past that part of the conversation for your sake inside reproductive health listener. And we got into specific examples talking about plastic where how that became worse. During the COVID pandemic, we talk about paperwork and what paperwork could be automated. We talk about those times sets or inefficiencies in the IVF lab that should be eliminated altogether, because you should never delegate something that should be automated. It also should never automated something that could be eliminated altogether. Then I made the sole say what she thinks is the biggest inefficiency in the IVF lab and extend that to globally as opposed to being in the IVF lab because in her view, it's something that affects the IVF lab is related to the IVF lab, but isn't coming from the IVF lab after this episode. I would love it if you email me or comment on any of the social media platforms that you came across the episode on what you think the biggest inefficiency is, if you think we missed anything. I would love your opinions of what you think are the biggest inefficiencies in the IVF lab. But right now enjoy it from the viewpoint of my guest, Dr. Liesl Melton on Dr. nelta mod, Liesl, welcome to Inside reproductive health.

Dr. Liesl Nel-Themaat  03:40

Thank you very much. I'm thrilled to be here.

Griffin Jones  03:43

I became aware of you at PCRs you are giving a talk about automation in the IVF lab or maybe about the lack of automation happening in the IVF Lab is a very comical talk, you involved a lot of people, you had a couple of different things in your giving examples of things that are all, you know, antiquated in the lab that could should be automated should be improved. At least I want to go into those examples today. But maybe let's start with just a synopsis of what was your talk about and what were you seeking to educate the audience about?

Dr. Liesl Nel-Themaat  04:19

Well, in essence, actually, it was not pushing towards automation. More what I was going for is the base back to the basic lab efficiency. So a lot of times these days people are getting excited about the automation, the new technologies, robotics, fluidics AI, things that make very cool presentations. But what I was trying to more convey to the audience is that the vast majority of labs are still working with basic things, basic skills, basic supplies. In the lab, and there is a huge opportunity to make things much more efficient. If you just look at the things that you already have and work with, you don't have to spend 1000s of dollars to implement very expensive new technologies to become more efficient. You can start tomorrow in your own lab just by making some small adjustments in your own workflow or products that you pick staffing models, things like that. Automation would be a completely the next step. You know, if you want, I think there's a lot you can do before the automation,

Griffin Jones  05:38

I want to make sure I understand this difference. So what would a couple of examples be of just those basic skills or supplies that could be made more efficient?

Dr. Liesl Nel-Themaat  05:46

One big example, go to your staffing model. For example, in my talk, I talked about all these different types of personality get in the standard IVF lab, and that is heavily influenced by the size of your program. So the more IVF cycles you perform, the more people you need in the lab and a basic small program, maybe would have five embryologist and maybe two juniors maybe to seniors and a lab director. But then at the as this practice grow, are you going to one of these larger networks where you have a hub and spoke model, you might end up with, like 20 Different people in your lap. And it's the range from on site lab director, there's managers, supervisors, team leads, seniors, juniors assistants, shipping coordinator per DNS. And all of these different roles have different costs associated to it when it comes to your staffing model, right. And I shown in my presentation, just by adjusting how you put your team together, you can have enormous savings, and bring down your lab expense significantly, just by being wise with how you build your staffing model. So that's one example. You don't need any technology for that. Right.

Griffin Jones  07:03

So what maybe we'll get into a conversation about it, if that's necessary because of automation. But first, let's dig into those examples a little bit if we've got a hub and smoke model with a need for 20 people in the lab, how do you restructure that team so that you don't need as many people are so that you're getting more out of each of them?

Dr. Liesl Nel-Themaat  07:27

So a classical example is, a lot of times, senior embryologist, you know, as a practice grows, they small practice have limited number of staff and they can do up to a certain number of, you know, cycles, same average is about 150 per embryologist starting with minimum of two. But then what happens sometimes is as this practice grows, we need another embryologist, we need another embryologist. But the reality is a lot of this stuff that embryologist have been useful these days is data entry, administrative tasks, filing paperwork, retrieving paperwork, shipping coordination, all these things that you really don't need a very expensive, senior embryologist to do. So by replacing some of your high high cost center neurologists by more specialized people, like a lab assistant or shipping coordinator, or even using some per diems for when crunch time comes, you can actually significant, reduce your overall, you know, expense on your staff, just by redistributing the tasks and the responsibilities.

Griffin Jones  08:37

So wouldn't the proponent of automation just say well, yeah, but you shouldn't be giving those tasks to even a more junior person, if you don't have to the if you could totally automate the data entry. For example, if you could totally automate the renewal of ordering of supplies, then why give that to any human being? Why not just to have that as a part of the system? So why is efficiency important if automation seeks to make the efficiencies that we would gain by restructuring, pale in comparison?

Dr. Liesl Nel-Themaat  09:12

So just to you know, if there was any misunderstanding, I'm not against automation at all right. But let's say my program, we decided, you know, what we're going to automate that How long do you think that will take for the companies whoever is working on automation to complete developing, tasting, getting approval, then bringing it to market? Implementing it like, Yes, great. If five years from now, I can eliminate four of my staff members by bringing some fencing automated automation unit into my lab. Right, but I have five years that I don't have it right now. vast majorities of labs are not automated right now. So what can I do until I did get that technology. Again, I'm not against bringing in technology, I'm just trying to make efficient what we have and what you can easily achieve right now, before these next big things come into the picture, you know,

Griffin Jones  10:14

so I guess it depends on which next big thing is here and how now they are actually now actually present and ready there. Because I'm guessing that concern that you have is, which is we can automate. But there are things that we can do right now to be more efficient. If I'm a salesperson for any one of these companies, I'm thinking you trying to be more efficient is the waste of time, you should replace it entirely with our solution, whatever if whatever that solution might be for a particular thing. I'm thinking of one example, where I was recently speaking with the venture capitalists behind this new solution, that closets to be able to build a lab that can do 500 cycles a year with five techs, and nothing more. And so if that is the case, then I guess where I'm struggling is, is how do you know if the process of making it more efficient is worth the squeeze whether rather than trying to eliminate and automate the process? And,

Dr. Liesl Nel-Themaat  11:22

again, I don't know why there's that idea that I'm against automation. I'm not trying to eliminate it.

Griffin Jones  11:28

I'm not I'm not starting any I'm not starting any rumors on on this pocket? No, I know that you're not I'm asking because I'm thinking I'm trying to make the MCAT that calculus because I imagine that many of your peers are thinking, say, Well, should we do something or not? And I don't know what that what that calculus is for deciding, okay, we should try to just restructure and spend some time trying to restructure or we should seek a different solution. And how you approach that I

Dr. Liesl Nel-Themaat  11:58

think you should do both. I don't think it's one or the other, I think and even if you get your automation, there's still going to be places that the automation is not really touching, that you can still be more efficient paper usage. Let's talk about that. The amount of trees we are killing by doing paperwork and not going more electronic, you can have a machine that can automatically make your dishes it's not gonna resolve your your paperwork, wastage issue, right. Or you can restructure your staffing model, but it's not going to do anything for the plastic ware that you're using. So there's no one solution that's going to touch all the different areas that you can make more efficient. Like I played video, where I had asked multiple experts across the industry, what is the biggest lab inefficiency, not two people gave me the same answer. And that's the point I'm trying to make is yes, there are big ticket items that we could bring in new technologies. But there are so many places where you can be more efficient can save money for your organization can make your processes more streamlined and be friendlier to the environment. If you just conscientious and have this overall mission to be more efficient in everything you do, not just the one or two big ticket items that companies are trying to sell us right now,

Griffin Jones  13:27

as those examples that I want to make this conversation about, maybe we got bogged down in semantics for a second. But the you talked about paperwork as one of these examples. Why what's stopping the lab from being paperless right now, and what specifically should be paperless? And

Dr. Liesl Nel-Themaat  13:45

I think change is hard. I think everybody knows and use less paper and transition to all electronic and a lot of groups are moving towards that. But it is very difficult to make such a big change in a lab that you are used to I have my patient chart right here. This is where I document everything I do. It's first of all a big expense on the program. And then there's something about having a hard copy. And people just don't like change. It's difficult. I think we are definitely steadily moving towards it. But it's not something that you overnight going to be paperless than any practice right. So but you can make small steps towards it. And you can maybe double copy some of the things that you have at the moment still paperwork maybe the practice is not comfortable going completely paperless yet, but if you have the right mindset, you can move towards it or at least cut your paper usage in half like every time you print something Do I really need to print this is there a way I can have this electronically but doesn't interfere too much with my that workflow because there's always a balance, right?

Griffin Jones  15:02

Are there examples that you can think of, of things that shouldn't be printed almost categorically that, that that's just a waste

Dr. Liesl Nel-Themaat  15:10

consents, definitely. And I think COVID actually helped a lot with some of this where traditionally, patients would have signed paper copies of consents and get it notarized if they're not in the space, or gonna be able to come to the clinic. And I think COVID has forced the whole industry to become more electronic from telehealth visits to online consenting to, you know, explaining the treatment cycles, everything, instead of now giving paper handouts or welcome packets, and all that everything is done electronic. So we actually have COVID, to thank for some really good things that have come to our industry, I believe, the paper forms, I think sometimes there's a lot of duplicate things that might be recorded on forms where you could make it more concise, or just maybe have, if you if you're not comfortable going completely paperless, you can be wise about what has to be on a paper and what does not. So I think it depends on each practice, what kind of forms they do have, you know, when I was surveying a group of embryologist online and asking them, you know, how many pieces of papers was on average it 15 sheets? That would be things like, you know, your neurology worksheet and then you have your individual in row tracking sheets, you printing out your order, because you want it Do you really have to print out the order, you know, if that's electronic PGT worksheets that the company saying you print that out? Do you need to have a print out of that and your own PGT worksheet? You know, this, it really depends on every practice. But again, it's it's all about the mindset and the the, the vision and the mission to try to become more efficient. I'm sure every lab can go and look at the paperwork they use and identify at least one sheet of paper they can get rid of, you know,

Griffin Jones  17:02

can you give an example of where else it would go? Like, if you think back to the last five years or so where you were using paper? And some example it did it was? Was it something that changed to the EMR? Or was it something in a different type of workflow software? How did you eliminate paper?

Dr. Liesl Nel-Themaat  17:18

So we have not, we're still using a lot of paper, in fact, my my Kayla bow about six trees a year at the moment,

Griffin Jones  17:28

do they now listen to your talk? Yeah, you don't just you don't just sit them down and play the same talk for them.

Dr. Liesl Nel-Themaat  17:35

Now we started mentioning it, I haven't given this presentation to my whole clinic yet. But that gives you an example. So we have not but we started the conversation. Because when I had to find out how much does our whole clinic use, obviously our practice manager, I told her why wanted to know and say how, you know, we started the conversation, how much paper do you use? And now he's on the table. And then I say, Do you guys realize we kill six days a year? And now we're talking about it? So yes, I like I said paper consent to something, I think probably the majority of clinics I've gotten laid off, we still get copies in some instances. But we should not that that's the easiest for me to think of is that anything that can be electronic. And the good thing is this is not a form that we are generating on our end, when it gets difficult is when you have to do data entry. But you're not sitting at your computer while you're looking at, for example, embryo grading, right? I have I'm sitting at a microscope and looking at each embryo one at a time, and I have to write it down. And then I can take the computer and put it in my EMR. Now you could argue well, if you have the AI technologies with the live imaging, you don't have to do that, which is true, but most labs don't have that yet. Right. So can you get around that? Can you get comfortable enough that you might be can use the iPad instead of a piece of paper in real time while you're writing your embryos?

Griffin Jones  19:01

Oh, did COVID make plastic were more or less of a problem if it made paper less of a problem? What did it do with plastic where because you know where it didn't make plastic were any better? The whole effing rest of the world, you know, plastic everywhere. Now we have now everything's takeouts in styrofoam, it's in their individual wrap masks that all go everywhere. And so it seems like the plastic were got problem got worse in so many other areas of the economic sector. Was it better or worse after COVID

Dr. Liesl Nel-Themaat  19:40

classic where we've gotten much worse but for a different reason. It's because suddenly we have such big supply shortages because everyone was buying it at such a rate because they were worried we're going to run into supply shortages and then we created this superficial shortage or this this it wasn't real


Griffin Jones  20:00

Do you toilet paper and yourself? The IVF? The the IVF? Lab field toilet paper themselves said it.

Dr. Liesl Nel-Themaat  20:06

Yeah, you were listening to my talk. It's my cousin's analogy. You know, yes, we, it's not like suddenly all the labs, were doubling using dishes, they were just not available because big, people were just ordering more than they actually needed because they were worried they were gonna run out. And then we created this to a certain extent, artificial shortage of plastic where so people were scrambling, trying, you know, just to find get their hands on what ever plastic they wish they could find not necessarily getting the true and tested and, you know, validated plastic containers and dishes and stuff, but just, you know, open it up more for whatever we can get. But I do think that it did make us or at least for myself, so thinking, you know, where can I eliminate some of this plastic usage in the lab. And so part of my presentation, also, I use an example of one of my previous labs, how many pieces of plastic we were using per cycle, and it was 27 pieces. And what can I do in my workflow? Where can I maybe reuse some of the plastics instead of throwing every you know, when you're doing retrieval? Do I really need a new tube for every follicle that gets asked to write it? For example? Do I really need to pour it into a new dish? Every time I search for an egg, you know, where can I reduce the number of plastic that I use. And by doing simple things like that, you can really make a big difference in that now, of course, again, people don't like change. And it's difficult to implement something like that, you might think it's such a simple thing. But if you have a shortage of whatever that thing is, you use you very quickly have to out of necessity, make that change. So I'm actually curious to know if labs started using less plastic due to COVID? Because of the shortages? And would they maintain that going forward?

Griffin Jones  22:04

As far as you can tell, are we still living with the consequences of that over ordering in the beginning?

Dr. Liesl Nel-Themaat  22:10

Now we've sitting with boxes full of expired product, because people over order, because they were worried they're gonna run out. And now, you know, we in during my talk, I surveyed the audience and several people raise their hands on ask how many of you have supplies that you ordered during COVID? Because you were worried you're gonna run out and now it's sits in your storage room, and it will expired? Which shows that it was really an artificially created partially at least crisis.

Griffin Jones  22:43

Is there any application for those expired product? Like, can they be used in different kinds of applications?

Dr. Liesl Nel-Themaat  22:50

Oh, absolutely. You can use it for research purposes. You know, we all know that plastic dish is not suddenly toxic. But because of regulations, you have to follow the manufacturer's expiration dates, but any research lab would welcome it, you could even try to sell it to, you know, the research labs, but what we would do is we just donate it to Stanford's, you know, whatever lab wants to take it, I have people that some of my fellows that do research in my lab, and I would just give it to them, and they would use it for whatever research they're doing.

Griffin Jones  23:27

How do you make some of that reuse some of that limitation of usage into a system into like protocols that and processes that staff follow? I think your example of freezing a retrieval tube for aspirating follicles are maybe one of the other examples you gave. Is that up to the individual embryologist to figure out is there a way of standardizing that. So that's a process to get the whole lab is using less plastic ware.

Dr. Liesl Nel-Themaat  24:00

And that's a very good point. Actually, it's not just up to the lab, right? It is really the whole clinic. It's the physicians, it's the nurses, it's, you know, everyone, it should be like a joint vision. But for example, when you do a retrieval, there is a physician amazing is the geologist, there's a medic or a nurse, you know, there's a team of people and, you know, putting your heads together and thinking, Okay, we typically use 25, round bottom tubes. How can we reduce that number? Is it possible to you know, we take the first five, we d canted and we give it back to you and you reuse those tubes. You know, this is just one thing I can think of we full disclosure, we haven't done it. But that is one example or

Griffin Jones  24:46

we're going to play this podcast episode for everyone that you work with the whole leadership team will pass on that will go to that will go beyond the division chief to the dean of the medical school or whatever they Is it Stanford circulate this, will LinkedIn, target everybody at Stanford and play this episode.

Dr. Liesl Nel-Themaat  25:07

I think when I show the financial part of it, then I would have some big fans on my side. And when I hit the green, the environmentalists, you know, so they are people that love me people that will hates me. But the truth that we can be much more efficient, especially with plastic use, I would even go as far as saying, Have you heard of glass? You know, do you know that in the good old days, we were washing glass tubes and autoclaving them. Now by no means am I saying we shouldn't be doing that. But just at least open your mind and think about, there was a time when we didn't have any of these things. Right. And it is my one year anniversary at Stanford today. Just FYI. So if I get fired,

Griffin Jones  25:48

often there's a two year anniversary after this episode comes, this is

Dr. Liesl Nel-Themaat  25:53

a big project. And it's something that you need to get buy in from many different parties. I'm not going to say that I have made or implemented all of the changes that I'm suggesting that it's possible, but I'm trying to throw ideas out there. Because every program is set up differently, something that might have worked in my lab, that's an easy improvement in efficiency might not work in the lab next door who has a different workflow, they use different products, or they'd like a different culture system. So that's why I say that every lab person has to walk in their own lab and look at every component and ask yourself the question, is there a way I can do this more efficiency? Is there a way I can do like, Can I not use so much paper towel? Can I get away with you know, switching off some of the electric components of my lab at night and but only only the person working in that lab, the lab director, supervisor, the biologist only they can really identify it. I can't identify in someone else's lab, what efficiencies they can implement. I can just give ideas and hopefully try to get people to think about these things more.

Griffin Jones  27:03

So plastic ware was a big area paper work was another big area of those. Yeah, I think you said 23 or something suggestions of what what the most, the biggest inefficiency in the IVF lab was and you have 23 different answers. What were some of the other ones that you can remember,

Dr. Liesl Nel-Themaat  27:20

time is like a half hour. But biggest resources as you know, and that's one of the things that we have the least amount of. And I think there are a lot of things that we do in the lab that takes a lot of time that we don't necessarily need to be doing. There are procedures, for example, trimming of your egg osios side cumulus complex after retrieval, just for background for you and an egg comes out. It's surrounded by these little cells called cumulus cells. Now a lot of labs routinely use syringe needles or some other device to trim it. And then later on, take all the cells off with the enzyme anyway, to make it clean or make it easier to strip is the term we use for cleaning of the egg. But a lot of labs don't do it. And one of my questions to the audience was, how many of you people are still trimming? And I think it was about half of them. And then the question is, why is it necessary, it takes so much time it takes resources, it takes more plastic, if you can eliminate that step, you can use your embryologist for something else, and eliminate how many ever minutes from that workflow. Another thing is how many times do you wash your sperm? Right? They are practices that wash everything twice after doing a gradient. They are devices microfluidic devices, that saves you a lot of time because it's you the way the procedure works, you basically put the sperm into this device, but even culture and you don't touch it again. Now that device is pretty expensive. So you have to decide for your own workflow. What is more valuable for me here to save my embryologist time, or to not make this big expense of using this expensive device? Right? So there's always a balance, but the main Time is money. We know that. But you have to think how much does it cost me to save this amount of time? Is it you know, Palin's a doubt?

Griffin Jones  29:20

So the the device itself it doesn't automate the process? Does it circumvent the process altogether to tell me more about that. It's just a different

Dr. Liesl Nel-Themaat  29:29

technology that instead of doing manual nation steps that someone have to come back repeatedly, you just can use this device and put it in the incubator and let the sperm swim through it. But there are cheaper ways to achieve the same thing. And I don't want to go into speaking about specific products or brands or anything like that and they are things that for example, changing out your biopsy. When you do low your biopsy fragments. They are programs have changed out that tip every single time between every single biopsy fragment. And there are groups that don't. And there hasn't been any apparent difference. If you just rinse it out, you're saving on plastic you're saving on time, because a lot of times, switch out these things. And then there are ways techniques that you can use when you're doing some of the procedures. For example, XE is a time consuming procedure. But if you look at how different people are doing xe, probably everyone does it slightly different the way you set up your dish, the way you move the eggs around the way, you know how many spam you catch at a time. And by adjusting some of those things, you can actually save a lot of time I actually showed a video during my talk of I actually wouldn't play unfortunately, the technical difficulties, but there's a way that this embryologist Lisa Ray, she she she manages to hold on to an egg and then just roll it with a very swift movement, like five, six eggs in a row, just injecting jig, it takes like two minutes where, you know, if you have a differently organized, it could take you 20 minutes to inject the same amount of eggs just by adjusting how you do that procedure.

Griffin Jones  31:14

So you're in that talk where you also asking for examples of things that still don't work was that was that a segment that I'm remembering correctly? Where you ask people? If for however many years you've been in the lab, what's one thing that still doesn't work properly or, or work the way you want it to was that was that a segment that you did

Dr. Liesl Nel-Themaat  31:35

to video was on pet peeves and frustrations that people keep doing that really can be quite irritating, for example, leaving bubbles in your culture drops, you know, or using the last of a pipette and not replenishing in the in the hood, or using too much paper napkins and put it in the Biohazard. Which when it's not biohazard, and just this again, small little things that can become really irritating or people that complain that they are always the only one that does this, or does that. And if you look at the distribution, no, really, it's not that these were just complaints or pet peeves of some of my peers that were quite funny. Not writing open data, little vials and, you know,

Griffin Jones  32:28

and so some of them might be sort of comical. But other of those might point to bigger process efficiencies, you know, the writing on the vial, for example, could be something that is, is changed or automated in some other way. And as you're going through a lot of these examples, I'm thinking of the acronym, eliminate automate delegate, I don't know if anyone's put that into an acronym that is more that sounds better than EAD. But, you know, you're you're focused a lot on the elimination or because while one could say well, don't delegate anything that should be automated, you could also make an argument that says don't automate anything that should just be eliminated altogether. Are there a couple other examples that you think of either from your talk or just from your day to day work that you think, are pretty easy to just simply eliminate in the IVF? Lab? And if so?

Dr. Liesl Nel-Themaat  33:26

Absolutely. You know, you talk about delegation and automation, and elimination. There are delegation, I think, is extremely important, not only for streamlining things, but also for team morale, I really believe you have to have a strong, solid, happy team. And if you give different people specific delegated duties that they can take ownership of, I think it's healthy for the team in general that everyone knows who's responsible for what, who is the go to person for any particular thing. But then I think a lot of the things that ultimately fell on the IVF lab to handle really should not be handled by IVF. For example, sort of data entry or sorry, the initial cycle initiation, when a patient's first come through, should really be falling on the clinical team and shipping coordination. There are many of these things that really should not be handled within the IVF lab and can be eliminated from the IVF lab. Now, if you don't have a person outside of the lab, to do it, then delegate it to someone that has protected time to do that role, because it becomes quite chaotic, and it becomes a sore point if, if no one has that specific role in the lab and whoever has time has to just do it and then people that well, I'm doing it more than this person and this stuff isn't didn't have a turn yet. If you delegate everything just becomes more organized. Of course, if you can eliminate it all together, if it's not something that appropriately should be in the lab. That's even better.

Griffin Jones  35:01

I can also see though, it's sometimes easier to know what to eliminate when you do a better job of delegating, because you're isolating that particular things. And one of the things that I've started doing with my own company in the last year is it just started jotting out and mapping it alongside our accountability chart, all of the outcomes that the company is responsible for doing, you can break those into more junior outcomes, and then section those off to more junior people. And then you could take bigger outcomes that are more complex and assign those to senior people. And those often require more resource. But by mapping it in that way, it's, it's clear what can be eliminated after some time. Because if if you just have it as part of someone's job, that isn't really part of their job, and it's also kind of somebody else's job, then you don't even really see what can be eliminated. Whereas if, if you start to parse these things out, you, it's easier to eliminate? Have you found any things like in the last year or two by ft after you delegated it that you were like, No, I think we could actually get rid of that altogether.

Dr. Liesl Nel-Themaat  36:17

You know, actually, but em our integrations with SAR has done that where, you know, in the old days, something like three, four years ago, you would have to manually enter data into sources, we talking about data entry, and you know, who should do that. But most of the EMRs now will talk directly to salt and will send the data directly to salt or to NAS. And that is actually a automation step. Yes, your data entry still has to happen somewhere, but at least it is. It's in one place. And these two systems talking to each other has made a huge difference, which is also why going to electronic medical medical record system is very valuable, because a lot of clinics honestly still don't or paper,

Griffin Jones  37:06

which is amazing to think about to begin with. But put please go off. Yes. But

Dr. Liesl Nel-Themaat  37:10

I'm telling you, it's a massive investment. It's not just oh, we're going to switch to EMR. And we're going to just do it. I mean, I lived through a transition recently where we had to start a brand new EMR and it is a very, very difficult process. And there's a reason why clinics are not just jumping on it, you think but it's such a no brainer. But yes, once you get on the other side, it's great, but it's a difficult process to go through. And if a clinic already doesn't have the bandwidth, people are hanging on edge. And you know, there's budget issues. And it's not that simple. And so again, back to my point is okay, well, if you don't if you're not ready for that big step, what can you do? That's easy, that still makes a difference.

Griffin Jones  37:55

But how do you model the costs? For example, like if you so you, we started the conversation talking about different staff models, and ways of making that more efficiency more efficient? How do you model the costs so that it's easier to see for someone that has to make that calculation of should we replace this system with that? Should we should we move from paper to an EMR? How do you model costs?

Dr. Liesl Nel-Themaat  38:23

Well, it really depends on the system you're talking about, right? And let's use cry storage as an exam. Because I know it's such a hot topic right now. And I'm sure some of these automations, you're referring to refer to that component. There are various different routes you can take if you want to restructure your price storage system. But there are so many different factors to consider everything from your staffing model, you know, does your staff have the capacity to keep managing it in house? Is your practice dependent on the revenue that you are hopefully getting from your patients, those that are in fact paying? You know, at what point does it make sense for me to outsource the entire thing, but then I'm giving up a big piece of revenue, but I'm also giving up a big legal liability. And we're actually in the process of that right now. And Stanford is building this future for our careers storage systems. And we haven't come up, you know, decided exactly where we're going to go yet. But it is a, it, there's so many different components. And at the end of the day, you know, you have to have your spreadsheet and say, Okay, this is this is what I'm gaining, this is what I'm sacrificing, but how do you put a monetary value on your legal liability, you know, and what your insurance costs you every year and like Stanford is extremely risk adverse, right? Every clinic has a different tolerance for that liability. So it's not a very simple question. Something that's more that's easier to do is like the use of plastic for example, Which dish do I want to use? And I showed a table where, you know, I have two different dishes. This is what these dishes cost. The one dish might cost more per He's but then the amount of volume of oil you use for this dish is this much versus that dish. But then the media that you use cost this much, and then how long it might it takes to make the dish that's a time component. And then then in the end, you make a table and you add it all up and say, Okay, what is the most what makes the most sense, economically? And is that what we want to make our decision on workflow wise? I mean, it's, it's complicated.

Griffin Jones  40:29

How do you factor people's time into that table? As an estimate? Is there any time tracking in the lab, like how a lot of client services firms, a lot of remote companies will use apps like Harvest? Or I think another one is tea sheets? And so harvest can go in your browser? Anytime you switch windows, it can say, are you working on a different task, you record at a time it integrates with a project management software, I suspect that it's it's pretty inaccurate, or at least that it's, it is it is far from purely accurate, because it still requires so much human use to say, this is what I was working on at this time. But you can get an idea, a lot of remote company, a lot of tech based companies, this is how long this task takes. And it's just once AI takes that over, then we could really get a good idea of what people are actually working on for how long is there any kind of time tracking like that happening in the lab right now?

Dr. Liesl Nel-Themaat  41:30

Are some of the witnessing systems or try starting to track that and look into that? Obviously, it can be met with some resistance. Because there is a balance, you know, I was talking the intro to my talk was really the difference between efficiency and effectiveness right. Now, when you start going down to that granularity, I think you do run the risk. If your staff knows they are being timed, every time they do a procedure, they may start going too fast, and then start making mistakes, or, you know, maybe you see more eggs per minute, but your fertilization rate goes down. So there's a sweet spot and my my hesitation to embrace this kind of tracking of staff is exactly that is I would rather have my staff workout is a comfortable pace. And not everyone is equally fast with everything right. But it doesn't mean one that is not as fast it's less effective in your overall outcome. So yes, it is that is coming into the market, I don't know how many clinics are actually using it. I know some of the bigger networks would have their staff much more a day much more structurally. With time, at 745, you can start doing this at 752. This should be done. Now you're going to do that I can see the necessity in very, very giant big programs and how that brings in that efficiency. I don't think any embryologist particularly likes working like that. And so that could touch your team at all.

Griffin Jones  43:11

The concern that you have is one that client services firm share with their own time tracking of that, if I'm am I being monitored on this because it's down to the billable hour, and you can err on either Sen, either end of the spectrum, you can err on work completely, we bill everything down to the hour, and everything has to be tracked. And that causes a lot of stress on the team. Because one they're worried about what it is that they're spending their time on. And it can affect quality, but too often just it can be inaccurate. And they spend so much time just doing the tracking itself and the logging of the tracking that it's it's it's futile. And then you could also err on the other end of the spectrum where you do no tracking and you just don't have any. So what we done in the past, is it say listen, you're not so we never aligned it with incentives, and we never aligned it with billable hours either. And I think that helped because it was just we're doing this just to get an idea just to be able to practice, but it wasn't against the billable hours. So they didn't have to feel like it was it was for that exclusive purpose. And I also didn't want them just every single time they were switching from one little task. Well now I'm checking email minute one, but I'm checking the project management software minute two, and I'm back to email minute three. And so if you did that in the lab, and you just kind of got an idea. What do you suspect is the biggest inefficiency in the IVF lab.

Dr. Liesl Nel-Themaat  44:46

Their biggest inefficiency is not based on a procedure. In my opinion, it's scheduling. The biggest inefficiency that I think is hurting our IVF lab the most is in with consistent scheduling on the clinical side, that the lab has to absorb, that you don't know how many procedures are going to come your way at any given day, which day they're going to fall on. We know there are ways that we can do this can be done more efficiently. But this is not up to the lab. You know, that is the problem. So I know you want me to say in the lab, the most inefficient thing is how we stripping our eggs, but I don't have an answer. But I think globally, what affects us the most probably, is inefficient scheduling of procedures. And that's a big pet peeve of many, many lab directors, where there is no template with X number of slots with only these types of patients can come through on this day. And once it's full, they have to wait for the next month. I think for me, that is a big one.

Griffin Jones  45:54

I could just say I will save that topic of how to fix it for somebody who speaks on scheduling. And that's their topic, but let's try to give them a little bit more to work with how, how do you suspect that can be improved? Yes. So

Dr. Liesl Nel-Themaat  46:08

what I have seen was very successful was when scheduling is outsourced, where it's centrally controlled by someone that is not emotionally pulled into the decision or have to make a decision on the spot. Because what we often hear is, Well, this patient is so nice, and she wants to go to Italy for her vacation, can we please add her. And now I'm standing there with the person making the request. And I have to make the decision right now. And the problem is for other very nice patients to scold three of the other doctors. And before I know it, I have five more patients than I can safely managing the lab. So by taking that off of the labs plate where this is centrally controlled, only the lab can make kind of proof an addition but I'm not dealing directly with the physician or the nurse or whoever has emotional relationship with the patient. You know, I think that has made what I've seen when, you know, during transition that I lived through that made a huge difference. When you

Griffin Jones  47:19

say centrally controlled, you mean like that scheduling function outsourced altogether, or simply concentrated somewhere within the clinic that it's not just the doctor doing here, the

Dr. Liesl Nel-Themaat  47:30

example I'm using is, you know, in a network and a big IVF practice network that was centralized by scheduling department that was not even on site where we were. But in a standalone clinic, you can have a person responsible for that. That's not part of the clinical team that doesn't have a relationship. And that person should have the authority to say yes or no and follow the rules. There's a reason we have a template, we know what would be an exception. For example, if I have a cancer patient coming through that starting chemotherapy next week, and we need to freeze her eggs 100% That is a legitimate reason for an exception, someone that wants to go to Italy and she doesn't want to wait till next month, that's not a reason, insurance expires, you know, but that needs to be written down in a policy. And if an answer to make a change, or to deviate from the rules is no then that should be no and everyone is on the same page. And it shouldn't come become emotional decision between the lab director or lab supervisor and the doctor

Griffin Jones  48:41

is that where the bulk of the problems are coming from with regard to scheduling and your view just from trying to fudge in different exceptions at different times?

Dr. Liesl Nel-Themaat  48:54

A lot of it is yes, also communication, you know, you hear of patients that suddenly appear on the schedule and that patient was never presented earlier or was not planned in advance. And somehow there was a communication gap that the lab somehow didn't know that this person was coming until the day before. Also just you know, the clinical practice. Now, I'm not a physician, I do not, you know, have no input in the stimulation protocols or the treatment plans at the patient's other than what happens in the lab. But we know there are ways to manage the volume of patients how many FTEs and which days they fall on by just doing program cycles, right? So and same with retrieval cycles, you know, do we do birth control or not we you know, some patient wants to be on natural cycles. But that is something that really the clinic should be everyone should be on the same page and the physicians, not everyone likes to change the way they've traditionally practiced medicine and there is still in the list. The chair, not there's not really an agreement on if if it affects outcomes or not. But I know that most of the large networks do have better workflow because they have these scheduling rules and templates. And the majority of the cycles can be predicted because they use program cycles instead of natural cycles. But a lot of divisions are are not comfortable with that yet.

Griffin Jones  50:32

Is this an argument for batching? Or is that something different?

Dr. Liesl Nel-Themaat  50:36

batching is something a little bit different. But for batching, you definitely need that's not natural cycle, right, because you have true batching, you do one week of basically, sometimes it's just two or three retrievals data retrieval days a month. And then the lab is very, very busy. But you know, what's coming your way you can plan accordingly. And then people can, you know, during the downtime, catch up on a lot of the administrative stuff, and, you know, ordering and setting up the lab and get ready for the next cycle. So true. batching is a little bit different. This is just basically managing if you're not a batching clinic, just managing the flow of your patients coming through.

Griffin Jones  51:22

Well, I want to let you conclude with what you how you would summarize remedying and efficiencies in the IVF lab where you would like to see things go we have a lot of lab directors and embryologist that listen to especially when we bring on someone to talk on a laptop, but we also have some CFOs listening that are responsible for p&l, and we have practice owners. And so some of that support on the clinic side. And we do have some DIVISION CHIEF So there are people thinking about how they can get through the red tape, but their health system? How would you like to conclude?

Dr. Liesl Nel-Themaat  51:57

Definitely saying that, you know, we talk now quite a bit about, you know, stimulation protocols. And you know, whether it's programmed on program cycles and how that affects scheduling, every clinic is different, right? What works, one clinic is not necessarily going to work for another clinic, which is why it's important that you have to within your own practice, put on the hat of what can I do to be more efficient in all these different aspects of my practice? What will work for me may not work for you, right? If if I say I can eliminate this process or delegate this process out of my lab, the way in a neighboring clinic is set up, it might not work at all. So the most important thing is to just be searching for ways that you can make your practice more efficient. The one is not right and the one is wrong. It is very individualized because everyone is doing things differently. Just wear the glasses off. I want to be more efficient. What small changes can I make sometimes mighty big changes, but what can I do right now to become more efficient? That could be my message.

Griffin Jones  53:09

Dr. Liesl Nel-Themaat, thank you so much for coming on inside reproductive health and sharing this for your lab colleagues and your colleagues and the rest of the field

Dr. Liesl Nel-Themaat  53:19

is a pleasure.

Sponsor  53:20

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

182 6 Barriers To Automating The IVF Lab, Featuring Eva Schenkman and Helena Russell



What is stopping IVF labs from becoming fully automated? Tune in to this week’s episode of Inside Reproductive Health, as Griffin Jones sits down with Eva Schenkman and Helena Russell of ARTLAB to breakdown the six main barriers to automating the IVF lab.

Listen to Hear About:

  • Why automation isn’t happening in certain areas of the IVF lab.

  • Risk and inefficiency of data entry.

  • Lack of trust that comes from business intelligence software.

  • Lack of adoption of the Vienna consensus.

  • Which metrics are meaningful for safety that don’t necessarily improve clinical outcomes, but are required to improve safety and productivity.

  • Delivery vs operations- what needs to be prioritized now vs. what should be prioritized for the future.

Website: www.artlabconsulting.com

Eva’s LinkedIn: https://www.linkedin.com/in/eva-schenkman-ms-phd-cc-eld-hcld-6121778/

Helena’s LinkedIn: https://www.linkedin.com/in/helena-russell-5aa60214/

Transcript


Eva Schenkman  00:00

They're missing the point that you know I think UCSF did some data where they showed that having an embryo scope in their lab saves them the equivalent of one embryologist time per day. And if you look at the cost of an embryo scope which is probably akin to about you know, one year embryologist salary that is becoming more efficient with these devices will in the long run, save you money, especially now when there is no embryologist to be found.


Griffin Jones  00:32

All of the change that is not happening in the IVF lab we talk all about the automation is coming to the field and seemingly every talk at every conference many episodes on, I want to know why hasn't it happened already? Why isn't it happening faster. And so I explore those obstacles and barriers with my two guests on today's program. That's Dr. Eva Schenkman. She was a lab manager for a number of years to different practices. She has been a consultant. She now runs a program called ART Lab. And I bring in her colleague Helena Russell, and we talk about the barriers to implementing automation categorically. In the IVF lab, we talked about the risk and inefficiency of data entry, we talked about the lack of trust in the data that comes from business intelligence software, if estimates that fewer than 10% of IVF labs have fully automated their data entry with business intelligence software, we talk about the Vienna consensus. Why has there been a lack of adoption in the Vienna consensus again, I asked Helena and Eva just a ballpark how many labs they think have adopted the Vienna consensus. And I'm asking them to do this off the top of their head, but they think it's about half that have adopted some meaningful level of the Vienna consensus. We talk about other metrics that are meaningful for efficiency and safety that don't necessarily improve clinical outcome, but are necessary for improving safety efficiency. And for activity. We talked about this person dynamic between delivery and operations where you are on the hook for doing a certain number of IVF cycles, you're on the hook for serving a certain number of patients, you have to do that to make payroll to keep the lights on to keep the patients happy. Meanwhile, there's the operational systems behind that which are another entity another chore to solve. And those two things are at odds of each other in terms of what is prioritized now in the moment, but what needs to be prioritized and improved for the future and for ongoing delivery. Finally, Helena and Eva say that some solutions are not ready for primetime and boy do they go to town on naming who those folks are? Now they don't try to get them to but of course they go hard and ideas and soft on people as is generally good advice. So it was a constellation for myself, I have to detail what they would like to see from RCTs what they think is missing from solutions that are coming to the via what they think needs to be proved in order for solutions to merit much wider adoption and what IVF centers could do in the meantime to help prove the concept. Enjoy today's episode with Helena Russell and Dr. Eva, Schenkman, Dr. Schenkman, Eva, Ms. Russell, Helena, welcome to Inside Reproductive Health.


Helena Russell 03:19

Thank you, it's great to be here.

Eva Schenkman 03:20

Thank you.


Griffin Jones  03:22

I've finally fulfilled the promise or I'm living up to a promise where I said it was going to create more IVF lab content than I have in the past. I think, this year, we've already done more episodes about the lab than we did in the first three years of the show, combined. So I'm starting to have a rudimentary level of knowledge to where I can maybe start to ask more interesting questions. And one of the things that I want to talk about today is the obstacles behind the automation for the lab. So at a high level, on the show before I've talked about the automation that's coming to the lab, and like to take advantage, speaking with each of you about why it isn't happening faster, and probably have you unpack and give specific examples as we go. But maybe we start at a high level, with just the automation that you're seeing in the lab happening right now that you weren't seeing five years ago, and maybe not even two years ago, what's happening with regard automation.


Eva Schenkman  04:25

Now, one of the ways in which, you know, I've been involved in some of my consulting activities in some of the automation is through data analysis. You know, we spend an awful lot of time in the lab, you know, crunching numbers. And in most labs, we still do it the same way we did 30 years ago, which is, you know, we've usually got two or three different Excel spreadsheets, we've got one for data, we've got one for cryo, you know, we may also be entering something 20 or more, and we used to sit there at the end of the month or the end of a quarter and spend, you know, 234 days to crunch all those numbers. So not only counting the amount of time that embryol Just spending putting in all that data, you know, risking all those data transcription errors, you know, now we've been using things, you know, business intelligence software, like Power BI, to pull that data automatically out of the IVF EMRs, to run that data in real time, so kind of call that real time analytics. So that I see is one of the key ways into which we can save, you know, an enormous amount of time making the labs, you know, a lot more efficient, is on a data analysis standpoint, you know, one of the big talks now with a lot of the meetings or on automation in the lab and efficiencies in the lab, and, and, you know, I think we can talk a little bit more more about that, what the roadblocks are, you know, to those. And, you know, to a long way, I think a lot of the roadblocks are One is cost, you know, a lot of these devices, things like, you know, an embryo scope, for example, are very expensive. And, you know, a lot of physicians or a lot of practices expect to see, oh, I'm gonna get this device, it's going to increase my pregnancy rates, oh, it doesn't increase my pregnancy rates, well, that I'm not investing that kind of, you know, money into it. But they're missing the point that, you know, I think UCSF did some data where they showed that having an embryo scope in their lab saves them the equivalent of one embryologist time per day. And if you look at the cost of an embryo scope, which is probably akin to about, you know, one year embryologist salary, that it becoming more efficient with these devices, will in the long run, save you money, especially now when there is no embryologist to be found. You know, and I think some of the other issues I see with the automation is things are rushed to market quickly, you know, at at a very high price, and they don't necessarily have you know, a lot of the data behind it yet, that you know, that it is going to be you know, just just to save for just the same as a senior embryologist. So I think kind of got, you know, a couple of issues there, you know, between the cost and, and the efficiency, and, you know, making sure that you know, that we can get get current staff to adopt, you know, this new technologies,


Griffin Jones  06:59

because you give me a couple of different avenues that I could further explore. Let's start with the spreadsheets. You mentioned, having two or three Excel spreadsheets previously, for which you need for your data analysis. What were they what what were their roles, those those spreadsheets and the information that they contain


Eva Schenkman  07:19

everything from, you know, you're doing your pregnancy rates, your competency assessments, also your CRO inventory, you know, we typically, for the most part, still keep paper worksheets in the lab, very few of us are using, you know, tablets or have gone paperless. So, you know, we've got that paper, you know, we're either scanning that paper into an EMR or, you know, retyping that data into an EMR. And then typically, a lot of the EMRs, don't do data analysis very well. A lot of them don't have reports that follow the Vienna consensus, you know, guidelines. So we're then keeping separate spreadsheets, so we're putting things into the EMR, putting things into, you know, Excel spreadsheet for data analysis, and then typically having a third sheet for, you know, cryo inventory. So we're entering everything, you know, typically three times, and then taking having somebody you know, typically higher up, then do all of that data analysis, like I said, usually typically the end of the month, sometimes at the end of the quarter,


Griffin Jones  08:17

how is QA done in this instance, when you have three different sources of information, but they're all in different places? How, how is QA done so that the duplicate of information is correct, because anytime you have information, different sources that isn't uniformly exported, you always risk you


Eva Schenkman  08:37

typically an Excel worksheet, you hope you catch it, there's not really a lot of a lot of formulas in there to kind of automate to to pick that up. You're always gonna get data, transcription errors, some of the things like Power BI can can pick that up for you. But I think, you know, honestly, a lot of times it gets caught when you're giving a patient data off of your cryo Inventory spreadsheet and a patient, you know, or nurse, correct shoe, you know, will will that's, that's wrong. That's not what we had, you know, so that that is a problem, you know, with data entry errors, is we really don't have a good mechanism to ensure that the data is accurate.


Griffin Jones  09:14

So when you have three sources of info like that, you got your spreadsheet for cryo inventory, you're scanning into the EMR, and then you've got a separate spreadsheet for the data analysis. There generally isn't like an overarching QA for the data entry to make sure they're all uniform. Now, okay, so even without regard to efficiency, there's still there's a risk there.


Eva Schenkman  09:36

Yeah, absolutely. You know, your data is only as good as the information you're putting in.


Griffin Jones  09:41

You mentioned that is an area where clinics are starting to automate more and those spreadsheets are being supplanted or that's something that you envisioned in


Eva Schenkman  09:51

the know there actually is is a few systems out there. Several of the EMRs have been using business intelligence software either through Tableau or through Power BI and linking those with their EMRs to that automatically pull that data out of the EMR. So as soon as you've done your first check, you know, as soon as you've done, you know, your, you know, your observation or the pregnancy data is entered in, it's pulling it into those Power BI sheets. And those not only that are automated, but they can even be set up to then watch you when there's a problem. So they can send you notifications that, you know, Hey, your XC three P and rate is starting to creep up. So you can, you know, definitely not only from an efficiency standpoint, but also from a troubleshooting standpoint. So I know, you know, recently one of the media companies had an issue with with some oil, for example, you know, and that, you know, typically tends to take a little bit of time until you're able to pinpoint what the problem is. And you know, the hope is that these automated systems would be able to pick up on something like that much quicker than you'd notice by eye or, you know, you got to wait till the end of the month, you know, obviously, something's killing all your embryos, you'll notice that pretty quickly, but let's just say you've got, you know, 25%, drop and blast conversion rates, that may not be something you pick up so easily, maybe you had some bad patients in there. But you can use a lot of that business intelligence software, it's been used by the, you know, financial industry and other industries for for years, you know, now we can kind of harvest the power of that, and and use for the IVF labs,


Griffin Jones  11:20

do you have even a ballpark guess, of what percentage of IVF labs are now automating their data entry with business intelligence software?


Helena Russell  11:30

Automating? I'd say, single digits?


Griffin Jones  11:33

That's a very, very low, yep. What's stopping it from being at 90 100%?


Eva Schenkman  11:39

I think one is trusting in the data. Two is, is, you know, we, for as much as we like to think we're ever changing, we don't actually like to change that much. You know, we don't want to let go of our paper worksheets, we, you know, this is, this is what we've done for 30 years, you know, we don't want to make mistakes, and what we do we know that, you know, an Excel spreadsheet, you know, as long as it's not, you know, sorted wrong or tampered with, you know, it will get you the, you know, the data that that you need, you know, a lot of the EMRs aren't necessarily don't necessarily have the best fertility modules. So, you know, even, you know, a lot of people in the lab, they're, they're still using the paper worksheets, and they're only scanning in their sheets. So one is, is, you know, if you're going to use something like Power BI or Tableau, you really have to have a dynamic EMR, to be able to use that with so. So that's something a lot of the clinics struggle with, you know, and I think just just trusting, trusting in the data is a bit of a learning curve, you know, to to get going with it. And, you know, I think slowly it's, it's starting to come come about, but, you know, slowly,


Griffin Jones  12:46

by the way, Helena, anytime that you want to jump in, I tend to just riff off questions, because I


Helena Russell  12:51

just want to say a couple of things to, to kind of, you know, kind of chime in with Eva, one thing, that's what's really challenging is learning curve, because it's not just trust, it's taking somebody who works with their hands, and putting them into a situation where they're going to have to be working with computers more. And that can be a little daunting. But again, having the right tool and the right support from that tool, helps us something else that even just said, is that they're not, not all of these EMRs are created the same. And that's true across healthcare industry, in general, you know, they're very unique, there are so many out there. And they do different things differently. And so there may be some that are a little bit better for gathering all the information that needs to be gathered, and also to be flexible enough. One thing that you may or may not realize about IVF is that not all IVF centers do things exactly the same way. So you have to be flexible. And the learning curve is one of the one of the things that I think is challenging for people and trust, like Eva said, another way of automating that kind of tails into EMRs. And specifically EMRs built for IVF is witnessing, which is an automated system these days with barcode reading or with radio frequency. And even might want to chime in on this one as well. She has a lot of familiarity with these. And those are also tying in with some of these IVF databases, or electronic medical record systems. And again, pulling a lot of really good valuable information from the lab into that system helps with once we get to that point where we can do the analysis via you know, Power BI, what we can then do is really target quality control, quality enhancement, and quality assurance.


Griffin Jones  14:56

Let's stay on that thread for a second before we get into workflow variance and And the barrier of change. You mentioned one of the issues apart from that is trusting the data itself. So what is the cause for mistrust and data? Or what is the risk of inaccurate or incorrect data in using business intelligence software for data entry,


Eva Schenkman  15:18

when you're pulling data from from an EMR, you know, one of the problems is, these EMRs are all structured differently, you know, they're usually large back end SQL databases, they may not be, so you can't take, you know, three different EMRs take the same Power BI software setup and plug it into these three different systems, they won't work, you know, so these things have to be customized, you know, unless it's something your EMR is already offering, they, they would then have to be customized to each setup. And a lot of it is just in that analysis, knowing you might have two or 3000 different fields on the back end, to pull from, you know, how are you? How is each lab recording that data? Where are they? Where is that data sitting in the SQL? databases for analysis? I think some of it might be generational, you know, I think, you know, the first first generation of embryologist, you know, even though we're we're, you know, we are pretty good at using computers, you know, we, for the most part for the last 30 years have done everything on paper, have done everything, you know, simply the second we have to trust, setting up those scripts and setting up something to to the IT department, you know, it's these things are very difficult to validate. So it's a lot of time, and one of the things we don't have right now is a lot of time in the lab. So I think part of that is, is having the time to validate these systems to trust them, it would be very hard for company to come in to develop, you know, a Power BI software, that's, that's applicable to all EMRs. Because the EMRs are all structured differently. So they need to be done, you know, on a customized or bespoke, you know, level between between each system. But I think it's just as I said, I think it'll be different with this new generation of embryologist coming through, I think they expect it, you know, they practically live with a phone, you know, in their hand, you know, I think they're going to be a bit more comfortable with with having this data. Automated?


Griffin Jones 17:11

Tell me a little bit more about what you mean, by the time it takes to validate systems? Does it mean to like pilot the program to check the…


Eva Schenkman  17:20

Yeah, you know, I'm actually involved with one, you know, right now looking at at some of these, these automated reports, and I have to go into the EMR and I put in test cycles, and I'm putting in, you know, different complicated ones with day one xe or with late for some with thaw biopsy, refreezes, combination cycles with fresh and frozen eggs. And all of these data sets are stored in different tables in the back end of the CMR. So that I have to sit with the IT people and structure each of these queries. And, you know, we tested on these cycles, and, you know, these, how do you tell an IT person, you know, when they're doing a competency for, you know, good day three cleavage rate? You know, for example, you know, what does the word good mean? You know, if you asked, you know, for embryologist, you're gonna get five different answers, you know, and that's part of why, you know, we rely on things like the Vienna consensus, you know, as a standard, you know, guideline to go through, but then, you know, each and every clinic, we roll these things out to, has to validate it on their own, because none of us are doing recording data the same way, you know, there's, you know, we all record it a little bit differently, we're all using different templates, we're all using, you know, different embryo grading criteria. So I think that's part of, you know, a bit of a problem with it, you know, I think but, you know, as clinic start to see the benefit of these systems, I think it'd be easier and easier, you know, we get these things validated, we get a couple of hopefully, key key labs, you know, incorporating them into their workflow. You know, I think we'll, you know, we'll kind of get the message out there, that the systems are, you know, are reliable or trustworthy. And, you know, that'll go a long way to really making the labs, you know, more efficient. Everybody's talking about, you know, lab on a chip and everything else. But, you know, I think, you know, when you're embryologist are spending a significant amount of their time being admins, you know, hand entering data is still using paper worksheets. Were a long way away from talking about, you know, lab on a chip.


Griffin Jones  19:18

How much chicken and egg is happening here, like, if part of the reason why labs are slow to adopt the technology, they're slow to validate the systems because there's so much variance in workflow, people report data differently, they grade embryos differently, how much of so that's the barrier, but it's also the result, isn't it? Like if you had the universal systems implemented, that you might have a more universal way of recording data, you might have a more universal Is that happening?


Eva Schenkman  19:51

We have the Vienna consensus, you know, the paper that was written for KPIs. I think that goes you know, along A great deal.


Griffin Jones  20:01

Okay, what is stopping people from categorically adopting this Vienna consensus across all labs?


Eva Schenkman  20:10

I think for the most part, it's been very well, you know, received, I think it's just it's that the woods that way, we've been doing it for 30 years. You know, it's, it's that belief, it's, it's worked for all this time, you know, this is, you know, in that belief that, that, you know, we're kind of all homegrown cooks in each of our labs, that, you know, we kind of, we kind of do it our way, these are the KPIs that, that that worked for us, there are still some labs that are doing d3 biopsy, you know, as opposed to, you know, blastocyst biopsy and slow freezing, it's just that ingrained, you know, because we don't want to make mistakes and in what we do, so in some ways, we're very reluctant to try new things. And, and part of that comes with doing it the same way it's worked, we don't want to change it, but and


Helena Russell  20:54

so much hinges on it, right? Yeah.


Eva Schenkman  20:59

And that first generation of embryologist is retiring. They're leaving the field. So, you know, I think it's, it's, it's important to, you know, this new generation, they're not going to sit there for the, you know, the amount of hours and hours and hours that we spent typing into three, you know, three databases, they want to enter things on a tablet, you know, they don't want to enter things on on paper and then transcribe so, you know, I think there is a lot of push from, from these newer embryologist to to automate things, you know, and, and hopefully, you know, we'll get some significant changes. They're


Helena Russell  21:31

more comfortable trusting the data, as Eva has said,


Griffin Jones  21:35

what percentage of labs is, if you can even ballpark it? Do you suppose have adopted the Vienna consensus to? If not to the letter, you know, 90%?


Eva Schenkman  21:46

I'd probably have to say, maybe, what do you think Elena, close to 50? Probably


Helena Russell  21:53

I still they're not accepting all of them. They're probably focusing in on a few Don't you think? Eva?


Eva Schenkman  21:58

I think so. I'm still surprised how many lab people I speak to who haven't heard of it. And, you know, as I said, each one typically has their own KPIs.


Griffin Jones  22:06

Thank you, Eva. Now, I don't feel as dumb for asking.


Helena Russell  22:08

Yep. It's unfortunate. And I think it's a lack of communication in our field. But I also think that what we're doing is very difficult. And so the challenge is making sure that we continue to be able to produce what it is our patients need. And to meet our patients needs. I mean, there, there's, there's no excuse for failure. And so when you have something working, it's difficult to hear what somebody else is saying, if it doesn't mean an improvement, which I think you've kind of hit on earlier, unless you can show a, you know, a positive outcome. And it may be that they'd rather spend that extra money to have somebody do something in a less efficient way, then trust in something that may not may or may not give them the outcomes that they are looking for. Yeah, is


Eva Schenkman  23:06

it’s difficult to trust in the scripts that are written by, you know, by someone with a computer background that, you know, you as an embryologist don't really understand. So as I said, that's why the validation of it is so important, get them seeing that this data is accurate, and is pulling correctly. And, you know, I think, you know, to be able to have an automated system like that, then alert you, not only when something is out of range, but as deviating towards being out of range, I think will be you know, will be invaluable. And, you know, this, you know, one issue that recently developed with oil is now resulting in a class potentially, you know, class action lawsuit. So, I think, you know, anytime we can develop something that would pick up on these things, not only tell us our what our pregnancy rate is and what our our individual embryologist competency rates are, but to be able to then alert us to any troubleshooting issues in the lab, that we don't have to wait six weeks, you know, now we see something in our data analysis. Now we have to try to figure out, you know, figure out what it is, you know, that's where we're using AI is also going to help at some point, you know, with analyzing this data.


Griffin Jones  24:11

So I'm understanding if there's not a clear clinical outcome that lab directors can see of in terms of success rates, that there often isn't the impetus to impose a change, and I see the agents working against change. We've done it this way forever. It's worked this way forever. We have a big variance in workflow from one place to another. So just because it worked for these guys over here doesn't mean that I know that it's going to work over here, but at this point, why isn't the shortage of embryol embryologist and the constraint on embryologist time enough to have made a bigger catalyst for change? seems like to me it seems like okay, if success rates are equal, but I can get back an embryologist day. Every time that we use this solution, or I can get back this many hours of embryologist time, why is that not enough of a catalyst to be seen way more automation than we're currently seeing?


Helena Russell  25:22

Part of it has to do with time, it takes time to train somebody to do something new. You know, if you're so overwhelmed in your lab or your IVF facility, and you don't have enough time to train a new person, you don't have time to learn something new, don't you think? Eva?


Eva Schenkman  25:44

I think so. And I think it's just that you know, exactly that you don't have time to train something new, it's that chicken and egg, you know, scenario, again, you know, I'm so overwhelmed, I not only have time to not train somebody, and then you say, Oh, well, you know, get this piece of equipment or whatever, for automation, there is going to be a period of time where that, you know, system is going to actually take you more time, until you you know, you wreck it, you know, you're able to be proficient at it and you're able to, to realize its efficiency. And, you know, not all people have the patience for that much time for adopting it and the cost, you know, all of these, these automated systems are very expensive. So getting physicians in groups and practices, it's easy to say, I need another embryologist and they'll pay, you know, six figures. Plus, for an embryologist who see a body sitting there, you know, to pay six figures plus for a piece of equipment sitting on the counter, you don't see the efficiency savings as easily as you see another body sitting there. So I think that's part of it. And without them seeing, you know, like, as I said it, you know, I go back to time lapse, you know, they there was just, you know, paper recently that, you know, basically is, you know, we shouldn't be, you know, looking at time lapse, because there's we didn't see an improvement in pregnancy rate, but you're missing, you know, the picture of it, you're missing, you know, the safety of it, you're not having to take the embryos out to look at them, you can monitor embryos remotely, you know, so if there is, you know, more COVID outbreaks or another pandemic, you know, you can check fertilization from from home. And, you know, just that


Griffin Jones  27:18

you could centralize embryologist could knew or at least part of that workflow,


Eva Schenkman  27:23

you could do you have offsite lab directors could monitor things remotely, they can log in and look at the embryos look at how they're growing, you know, pull the data, you can see these Power BI apps, you can see all of your data on your mobile device, you can even see the images of your embryos on your mobile device. So I think it's, it's, it's, it's that cost barrier, but it is that learning barrier, that it's just not something new that we've done. And, you know, I think you'll I think next years, there'll be some workshops, at some of the meetings that are going to be focusing on future of technology and innovation, and where where things are going to be, but not just theoretical, but actual practical, what's here, what's now you know, what can we kick the tires on now, and part of that is, is training and having these new innovative systems launched at the at training centers, and having a rail just come in and use them because nobody wants to practice on a real patient. You know, you need to be able to have a place that's comfortable, that you can go in and you know, learn this in an environment that's not stressful, you know, not while you're you're trying to, you know, to do real patient samples, that you have a place to get comfortable with these devices and, and to you know, learn how they work.


Helena Russell  28:36

And we're all monitoring is integrated. And I mean, yeah, looking at your incubator, your temperature, your co2 level, your oxygen level, looking to see if your liquid nitrogen tank is got enough liquid nitrogen tank, liquid nitrogen in it, making sure your refrigerators are performing up to par. And having those be part of your automated, automated integrated system so that you literally have every function that you would normally assigned to possibly, you know, an intern or a novice embryologist, somebody who's a junior who's just coming in. Instead, you can have continuous monitoring, which I think is extraordinarily reassuring. Probably there's a role for someone or company out there to help clinics bundle and to become efficiency experts. I think one of the things that our training center does is helped expose new embryologist and even in workshops where we're opening up our center to experienced embryologist to come in to have one or two day workshops, they will be exposed to those kinds of integrated systems as well. And you know, a lot of it has to do with you know, I can I can hear about it all day long. I can read about it all day long. But if I can touch it, and I can move the dials and nobody's sample is going to get hurt by that. And I can actually download an app and do it on my own phone or my, you know, my iPad, while I'm in this Training Center. You know, the


Griffin Jones  30:13

exposure that you're talking about in the training center accounts for some of the issues, the distrust in the data, the lack of familiarity, the validation of the system counts, for some of them. Some of the things that it doesn't like, what you've been talking about is something that I've been obsessing over with regard to my own business and business in general. And I think we can apply it to the IVF lab, and that is delivery versus operations. And often when you hear business books, or you hear business talks, operations, and delivery are almost used interchangeably, like delivery, meaning the fulfillment of the good or service, which we've sold or promise and operations is really the system behind it. So we're roofers, our delivery is we're going to have a new tear off roof on your house by the end of April. That's the delivery. And we have an obligation once that roof is sold to fulfill that deliver, you could use delivery and fulfillment interchangeably. But operations is the system behind that delivery. So delivery is getting the roof on the darn house getting it done by the date, we said we were going to get it done by but operations is what types of materials we buy the workflow behind it, who we assigned to the job, how the job is assigned and accounted for and reported on the QA that comes after it the what what we automate or don't automate. And, and all of that is operations. And there's a tension between delivery and operations, because you have delivery obligations that you have patients cycling through, and you have a finite number of embryologist that can work on those embryos, while those patients are being served while you need to make this institutional change at the operational level. So how do you solve for that how, in this specific to the IVF lab, how do you begin to relieve some delivery obligations, while investing in the operations that will ultimately result in a virtuous cycle.


Eva Schenkman  32:35

Part of what we have here as opposed to just also having, you know, kind of a training facility is is you know, our training facilities a fully functioning mock IVF lab. So one to have all of these different systems communicating here. So that when people do come and try them, it's not just trying one piece of it, it's kind of seeing, you know, the entire system working as if this, this was a functioning lab, the other thing we have to convince them of is, is you know what to do when it goes down, because that's one of the most common things, you know, I hear that if we're going to be entering things on a tablet, or we're going to be entering things, you know, when our mobile device, you know, data patient data is potentially going up into the cloud, you know, nobody trusts that. So, you know, it's, it's the redundancy that's built in, you know, are we going to do you know, backups to, you know, to, to our local desktop, or we're going to print out, you know, a daily report, because what are you going to do when, you know, there's a hurricane that comes through retreating, like, what are you going to do, if a natural disaster comes through, I always have my paper, I always have my paper chart, you know, but there's that trust and what you can't see. And you know, we're all used to the internet going down the Wi Fi going down. But as an embryologist, you still have to do your job. And if everything is up in the cloud, and you come in, you got no Wi Fi, you know, how do you know what patients to do the first checks on or how do you know what patients to, you know, to do the freeze on or which embryos to thaw. So, you know, we do need to get better at that, you know, ensuring you know, what we're going to do from redundancy standpoint, to be sure that those concerns are addressed. And, you know, I think is, is, you know, manufacturers out there, we need to play a bit better in the sandbox with each other, and, you know, working on ways to get these systems communicating better with each other, because each one, you know, is kind of fine on its own, but there are these own little islands that aren't interacting very well with each other. They're very clunky, you know, not not not very quick. So, you know, we do need a lot of development still in those areas. But and I think, you know, the only way is to have kind of testing labs, you know, where where we can kind of kick the tires on these things and bring embryologist in to use them?


Helena Russell  34:40

Well, just to add to the you know, a lot of what we see in other industries, like the banking industry, a lot of what they do is done in the cloud. And you know, they have to have their very, very strict rules and regulations and other health care branches of health care industry. These people are doing a lot of commerce in the cloud, a lot of data storage in the cloud, and those redundancies have to be backed up by a robust IT support system. So they do exist for some of the systems that, you know, we've been talking about, you know, sort of loosely, but the really good ones are going to have that kind of support and structure so that you can, you know, assure those who are using it, hey, that information is going to be there. And they have to have an offline, you know, like a holding place at their own facility, a server that that information can be stored on,


Eva Schenkman  35:36

I still see a lot of doctors practices, their servers are in a closet down the hall. Yeah, and, you know, a lot of clouds. Yeah, that, you know, and, you know, we don't really hear it's not really openly discussed, but you know, we get a lot of clinics, there's a lot of clinics that are hit with ransomware. And, you know, a lot of that is kind of kept swept under the rug. And that's something that we need to, you know, why why do we not have a strict regulations as the financial industry, as far as how we're keeping this data, you know, where we're keeping this data redundancy,


Helena Russell  36:05

if you're thinking about automating, and you're thinking about going down this road with an EMR ask the really important question. And that is, how is this stored? What is your security structure? How is it done and who's handling that? Because, I mean, you have to, you have to have a very robust system, and it has to be redundant, can't just be stored in one place and must be stored in multiple places. And how that is done is actually critical, not only to the, you know, the security of your data, how you trust your data, the validation of the systems, but also whether or not you can move forward and practice one day, you know, if somebody holds you for ransom, you're stuck.


Griffin Jones 36:47

Well, that solves for the issue of redundancy, it solves for a lot of the issue of implementation. But a lot of what you described is still the challenge of delivery versus operations. A lot of the reason why people have their server in a closet down the hall is because they've been so busy fulfilling delivery commitments, meaning seeing patients doing retrievals doing transfers, and all of the lab work on the other side of that, that they have not had the time, money energy, to focus on the overall operation systems, you happen to have a program that takes care of a lot of the risk that allows people to visit allows people to do this without putting their own things at at risk or and taking their own, you know, having to test everything within their own system. But they still have to say, alright, well, I've got you know, maybe I've got four embryologist and I need seven. And so how am I going to send you one of my foreign biologists when I'm already half staffed? And, and so how do you how do you begin to solve for that


Eva Schenkman  37:56

one of the things we've been doing is offering you know, several, kind of intensive lengthy courses a year, you know, we, we, you know, and Elena primarily has been going out to to the universities we have someone who's also worked with us doing you know, on tick tock, you know, doing tick tock videos of getting those students out here to, you know, for training, so they typically come to us for for 10 weeks and we teach them everything from Andrology to biopsy, you know, we don't expect that these these these, these new embryologist could go back to their clinic and you know, be doing biopsy on day one. But you know, the typical in the old school apprenticeship style, it would take between two and four years to train one embryologist then we're losing embryologist at a much quicker rate than we can replace them. So if not only, you know, the training school that we have, but the other ones that exist in the country. You know, we are we believe that we're able to now get that training, once they're at the clinic down to under 12 months, so that we can speed up their training. So if you've got four you need seven. Well we can send you you know, you know, we're churning out embryologist, every embryologist that has been through here. I know everyone else had been through, you know, the, you know, one of the other firms California has had a job offer, you know, they're all you know, getting employed. And you know, we need to to, you know, bring through more embryologist and you know, and replace somebody even even a faster clip and that's the only way you know, we can't any longer do this, this apprenticeship, where it takes two to four years to get one new embryologist it's, it's not it's not sustainable. You know, we need a better way of of bringing them bringing them up, bringing them through quicker getting them trained. And you know, the style that we do it here which is very intensive, you know, they spend probably close to about 500 hours, you know, doing every literally every procedure and you know, over the course about two and a half months,


Helena Russell  39:52

hundreds of times they do each procedure hundreds of time. So what we're doing is set adding them up to make it easier for those who are doing the training on site in the IVF lab, making it easier for them to get the embryologist they need. I do think that part of the operational pushback is there needs to be kind of somebody who could bundle I really do believe that there's a there's another role out there for it, an IT biologist or something, you know, somebody who could go into a lab and do a consultation and say, you know, an EVA really has that kind of perspective, she may not be the IT expert, but she has, you know, a really good perspective on, you know, hey, you're doing this, this, this, and this, here are some products and, you know, we can put all these things together and deliver them to you. And you know, here's our IT redundancy expert, you know, can come in, look at your system right now, and say what needs to happen? And what tools can we bring in here that are going to meet your needs? What need do you have? Do you want to do all your quality control remotely? Do you want to do your embryo analysis remotely your embryo culture analysis remotely? Do you want to bring all your data together so that you can meet your KPI with a click of a button, review your your KPIs, and then bring all of those things together, and act as a liaison between all these different groups? Because it is a little mind boggling when you look at what is happening in the IVF field. And you have you know, this automated system and this automated system and this automated system and this automated system, how do you bring all of those things together? That's the challenge. And not everybody's going to want all those things. So how do you do that? That's that part of that operation could be someone who's an expert at all these different things, helping to give advice, consulting, and charging a fee to bring it all together for them and stitch it together.


Griffin Jones  42:01

Helena, you were talking about the challenges in having so many different automation solutions, one solution to that problem of having so many is having a consultant or an umbrella solution of some kind that can bring them together. How much of the problem is also those solutions not integrating with each other not integrating with the EMR? How common is that


Helena Russell  42:28

it's happens all the time. And Eva spoke to that earlier that people in these different realms need to play well in the sandbox, they need to be able to open up their their systems a little bit, so that they can speak to each other push and pull data, because a lot of times you'll see, well, one company will let you do one thing, but not the other. And you need both. And, you know, I think it's a little that's an operational hurdle. And again, an integrator, somebody who really is quite savvy and knows, you know, how to communicate with these folks could hopefully bring some of this together, I know of, you know, at least one company who's doing things like that. I'm sure there are plenty of others that are attempting that, you know, it's it's a daunting task, we know that we know it's very difficult to change. But one of the things that the light at the end of the tunnel, you're never going to stop changing. And IVF though that's just plain and simple, it, you're not going to reach a pinnacle and say, Oh, we're done. Now we've reached the pinnacle, because something new is going to happen down the road, something new, some new way of doing analysis. And so you're going to always have to change you're going to have to learn to live with that. And like Eva has said some of the newer generation, they're used to maybe looking at things a little differently, maybe not so much always changing. But at least the electronic aspect of it doesn't seem like it's so that was daunting, not as daunting not as as much of a trust issue. Now I can't trust my computer gets viruses, right, or I can get malware. So I think that, you know, if you if you have the right systems and the right checks and balances the right security systems and redundancies, as we've said, you will begin to you know, get over that hurdle. That's one of the biggest ones.


Griffin Jones  44:20

But if they don't integrate, aren't we back to the same challenge of the spreadsheets?


Helena Russell  44:25

A lot of them are integrating. Yes, we are if they don't integrate a lot of them are seeing the handwriting on the wall. I think Eva, wouldn't you agree?


Eva Schenkman  44:35

I think so. Now,


Griffin Jones 44:37

seeing the handwriting on the wall and that they're not being adopted, if they don't integrate


Helena Russell  44:42

They’ve got to make themselves a lot more malleable in order to be adopted. Like you just said, if if we're trying to show people how to use a KPI and the system that is is giving you your best data and is not you No handing it over that you have to actually export it and upload it a different way that may be not as user friendly, you might do it. But if somebody else down the street will integrate, guess who's gonna get pot?


Griffin Jones 45:14

So there might be a market response that forces people to integrate more you had in the beginning of the conversation, you alluded to some solutions, maybe not coming to market, but not having the scientific proof that they have a great benefit. What are some examples of that?


Helena Russell  45:36

Well, I think even would agree that there are some products out there that we need to more closely scrutinize and names. I'm not going to do that. But I will say that their artificial intelligence base, but the the issue with some of these is, you know, the gold standard in scientific medical research is the randomized control trial. And some of these products, they may have them in progress, but as far as I know, not really have published as much as they should, or at all. And so one of the things that I think we need to as a scientific community, which is what IVF is a part of, is that before we fully buy in, or spend an awful lot of money on something, that I mean, maybe we volunteer to be part of that study, you know, if you're an IVF center, and you're interested, you know, say, okay, all I'll be part of this study in order to help advance this field so that we'll know one way or the other, what they're promising may not be that we have better outcomes, necessarily, but that we might have more efficient outcomes, which might lead to better outcomes, because maybe your embryologist won't be so incredibly stressed out all the time, because they can't function because they can't get all their work done. Because there's not enough of them. And this automation could become part of the workflow that holds an answer for them, at least part of an answer.


Eva Schenkman  47:13

And I think that I agree with Helena, you know, the biggest issue is, is you know, especially, you know, right now, you know, the flavor of the month is kind of anything AI. And you know, each of them have some some papers coming out that they're showing that that, you know, this system is the best or that system is the best. But there's really a lack of well, plans. Well, well, rigorous setup. Yeah, what very rigorous those randomized controlled studies. And that's really, because what happens is people that adopt it, and they don't see the same benefit in their hands. So there's a big distrust of it, when you have for profit companies, who are then also sponsors of these papers, we're putting out data saying that this is the best thing ever. And then when somebody pays the money and adopts the system, they're not seeing, you know, the same, you know, Return, return to there. And so, you know, I think, you know, that's probably the one thing in this field that that I think is hurt us that we don't do, you know, as many well planned RCT studies, that, you know, we do a lot of retrospective, a lot of, you know, prospective, but not necessarily a gold standard, you know, stuff, which is hard to do.


Helena Russell  48:22

I mean, in IVF, it's very difficult to do that. Now, it's very difficult to do certain kinds of randomized control trials, because you do not have, you know, that many chances for fertility, in many cases who are coming to you for treatment. You know, if you're going to do a randomized control trial, it's got to be planned in such a way to limit the harm or potential harm for the patient. What's harm harm is, maybe they didn't get pregnant. And so, you know, in these cases, when you're looking at artificial intelligence, as long as you have a good check and balance, like you're having, you're having your own technicians review, and re and, you know, respect what's coming out, but review what's coming out of the AI. And make sure that well, whatever it is, it's telling you, you have the human aspect that you've learned to, you know, know, you know, and love, and you trust, then, you know, oversight is good, but what does randomized control trial mean? And what is blinded mean? Because a lot of times bias, unfortunately, you know, enters into these things and how do you create a study where there's limited bias, meaning that you're not overtly influencing the people who are conducting the study? The doctors, the even the patients, and certainly the embryologist, how are you ever going to blind the embryologist? Probably not never, you're probably never going to blind them because they're going to have to keep the numbers straight. Somebody has to protect the patient's embryos and make sure they really truly understand they know this is embryo 1234. And this is embryo 3456 and make sure everything is working properly. So blinding, the embryologist is almost impossible.


Griffin Jones 50:07

Which RCTs? Would you like to see happen with regard to AI companies entering the lab space? Like, can you detail what you would like to see an RCT or a couple of RCTs?


Helena Russell  50:18

I mean, even you talked about this the other day with the AI that you were thinking about that, that I think one of the things that we need to see is more numbers, also consistency and how the training database is working. So how you build that artificial intelligence is by having, you know, a large enough number of input and outcomes, you know, so you have something that you're observing, right, and you're applying an algorithm to it. And then what comes out the end is, hey, do it this way, or, or select this embryo. And so if you have a large enough database, you could potentially apply that one of the biggest problems that we have, is applying it across the entire world, probably not doable, because in each and every lab or each and every IVF. Center, there may be some variables that we really have no control over, that we have to kind of focus in on that particular lab and having enough data to have an artificial intelligence algorithm built may not be possible on a center by central basis. So some of these things, I think it takes time to develop the algorithm and then apply that to a randomized controlled trial, where you're looking at either isolating the artificial intelligence and doing it with sibling embryos, for example. So you have to have a special population of patients who have enough embryos that you could put them into different systems and compare them, or potentially looking at, you know, larger populations, if you don't have those sibling embryos to look at, you could look at groups of individuals in those two different, you know, isolated, different ways of producing the embryo, for example. So it goes beyond what we're currently doing in the lab, which is observational, when we even when we look at time lapse imaging, we're looking at changes over time that those are very interesting markers. Because you could see slow development versus fast development versus abnormal development. And you can see all that in a time lapse imager, this is something that you could never see as a, the traditional way of analyzing embryos to pick for transfer is a, you know, a one, a particular time point. And looking at an individual, you know, time point is, is not as superior as looking at, you know, time time points throughout the developmental process over the five to six or seven day period, that we have them in culture. And what Eva's talking about is even more specific and more precise. And that is going after those molecular markers, where you look at gene regulation, you know, those kinds of subtleties are almost impossible to you may not see anything, but and they made the embryo may be developing perfectly well, you know, it's just looks like a normal embryo. But when you actually look at the molecular profile, and look at the genes that are upregulated or downregulated, compared to the perfect environment where you can't replace something like that, you know, and and in past times, some of the things that people have looked at are metabolomics. I don't know if you've ever heard that word, but it's okay, the embryo is growing, and we're looking at metabolites of growth, and you siphon off some of the culture fluid and you look to see oh, is it metabolizing? Well, but actually looking at gene regulation, and and looking at markers that are very fine detail of the health of an embryo could be a potential answer.


Griffin Jones 54:15

I appreciate you both giving these so much insight into the different obstacles that are inhibiting automation from fully taking the IVF lab by storm. How would you like to conclude with regard to what needs to happen in order for automation to take its full rightful place in the IVF lab?


Helena Russell  54:37

I think what we need to do are some very detailed studies, where we look at how the impact of these automations on you know, first adopters, you know, there's always going to be a group of people who say, I'm there with you, I want to go automation all the way I want to do these things that are going to assist us in in prevailing and thriving and And moving forward, those first adopters should be studied. And efficiency should be studied, we should study all aspects of, you know, their turnaround time for troubleshooting, they're, you know, catching things on the on the fly when there's a, you know, a detail that's out of place for their QC, their daily Qc is messed up and they get an automated announcement. And, you know, there are people who are malleable to this, you know, they will be early adopters. And so those are the folks that we really need to study we need to present at meetings, we need to maybe create the perfect training environment like we have here at Art Lab, where you can bring people in, expose them to this integration and say, Okay, this is how it could work in your lab. You show them something, and that barrier is may not be eliminated, but it's gonna come down a little bit.


Griffin Jones 55:55

Helena Russell. Eva Schenkman. Thank you both so much for coming on inside reproductive health.


Sponsor  56:01

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

174 The Rise Of In-House Genetics Counselors At Fertility Centers: Featuring Amber Gamma



 In-house genetics counselors may be on the rise among fertility clinics. Amber Gamma, genetics counselor at IVI RMA America, discusses why the profession is trending toward in-house positions, how to address the challenges of funding their placement, and why you might want one of them on your side when it comes to litigation. 

Listen to hear:

  • Which genetic counseling are more suited for in-house vs. external genetic counseling telemedicine companies.

  • How much these in-house positions earn, and how much they cost.

  • Tips on how to bill insurance for genetic counseling.

  • Amber’s response to Dr. Norbert Gleicher’s criticism of the overutilization of PGT-A.

  • What AI will take away from the genetic counseling field, and what will remain in their control.

Amber Gamma’s Info: 

LinkedIn: https://www.linkedin.com/in/ambergamma/

Transcript


Amber Gamma  00:04

One of the biggest barriers, I think, to having an in house genetic counselor is that genetic counselors are not recognized as providers by CMS at this point. So that can make billing pretty challenging. That being said, we do still see that genetic counselors across the country bill, if you're working in a state that has licensure for genetic counselors, you're going to have, you know, a higher chance of success with billing and with significant reimbursements. 


Griffin Jones  00:29

Does your fertility center have an in house genetic counselor? Are you thinking about having an in house genetic counselor? I talked with Amber Gamma. She's an in house genetic counselor for the RMA network. She has been in house elsewhere in the fertility field. She's been on the industry side. She has a master's in genetic counseling from Sarah Lawrence College. She is a board member of the genetic counseling professional group that subgroup within SRM. So I asked her what percentage of fertility clinics have their own in house genetic counselors, that number appears to be on the rise. She talks about the total number of genetic counselors there are in the field, I have her detail what those specific roles are versus which roles are better off for an external genetic counseling telemedicine company. I asked her what kind of revenue and in house genetic counselor brings in and how much they cost. She gives us tips on how to bill insurance companies for genetic counseling. I asked her to comment a little bit on Dr. Norbert Gleicher’s, criticism of the overuse of PGT-A. I don't get too deep into that, because I'm not qualified to but I wanted to see if she thinks that having more genetic counseling in house will utilize less testing or at least different kinds of testing. And then I needed that clarification from her that you may not need of the overlap between genetics counselors and genetic testing labs. I thought there was a lot more overlap. Maybe you do too. So I asked her to delineate that we talked about the advantages and disadvantages to genetic counselors, career mobility being in house versus with a much larger company. And then she concludes with the functions that artificial intelligence will probably take away from the genetic counselor in the next year or two. And what will have to remain within the genetics counselors purview enjoy this episode with Amber Gamma, Ms. Gamma. Amber, welcome to inside reproductive health.


Amber Gamma  02:16

Thank you. Thanks for having me.


Griffin Jones  02:17

I'm trying to think if you're the first genetic counselor that I've had on the show, and I'm gonna feel really bad either way, I guess that I haven't had one over 180 episodes, or that there have been one or two that I'm forgetting. And then I'm going to feel really bad. But welcome. I want to talk to you about genetic counselors in the field. And I want to talk to you about their role in external companies versus being in house for a fertility center, you are in house for e vrma. And can you give us some context about how many genetic counselors there even are in house in fertility centers in the US?


Amber Gamma  02:55

Yeah, so it is around, I would say 20, at the moment. So the National Society of Genetic Counselors does a professional status survey every year. And so in the latest professional status survey, there were about 50 genetic counselors that reported working in this field entirely. So that would encompass your in house genetic counselors, your PGT, labs, your gamete. Banks. So that is growing, it was about 40, a couple years earlier, so we're growing pretty rapidly. But in terms of the in house, GCS, that's definitely where I think we're starting to see a bit of an inflection point and some more growth


Griffin Jones  03:33

of those 20. Do you how many are with IE vrma? How many colleagues do you have at your own company?


Amber Gamma  03:40

So two, as of today, I was the only one before that.


Griffin Jones  03:44

And so the other 18 that might be out there? Do you have an idea what the kind of distribution is between if they're at large group networks? Or if that among independently owned Fertility Centers? Do you have any idea,


Amber Gamma  03:57

you do tend to see a fair number that work in academic centers? So within I'm based in New York City, within the New York City area, a lot of my colleagues are based at, you know, large academic Fertility Centers, you definitely will see genetic counselors in privately owned groups as well. So specifically on the West Coast, within the Seattle area, I have a few colleagues that work, you know, kind of in more private practice. And I will say it does tend to be pretty distributed to the coastal areas. At this point. I definitely do have some colleagues in South Dakota, Missouri, but largely, you'll tend to see that we do kind of fit along the coast a little bit more.


Griffin Jones  04:36

So we think that there's 50 in the field based on the National Society of Genetic Counselors survey, you mentioned that you've thought there's an inflection point going upward for in house Janet concert. That is say you think that there is a trend of more genetic counselors being brought in house tell us more about that.


Amber Gamma  04:58

I think that we're really reaching a point where reproductive genetics and genetics generally is becoming so important in the field of fertility medicine. And that is because of the technologies that are picking up steam within our field, but then also genetic testing technologies and other areas of medicine. So things like pediatrics, you'll have, you know, a lot more genetic testing that goes on for kiddos that have pretty complex medical issues. And then you may find a genetic cause for that child's medical issues. The couple still wants to have more children. So they're coming in for fertility care to be able to reduce that risk. So I think that we're starting to come across some more complex genetic situations where providers aren't necessarily feeling so comfortable dealing with those situations, and feeling confident in their counseling abilities to be able to guide that couple appropriately.


Griffin Jones  05:50

That makes sense why we would expect to see more genetic counselors in the field, you mentioned that it's up fifth, the from 40, a few years back, but why in house,


Amber Gamma  06:01

because for me thinking about an in house genetic counselor, it's really all about, you know, what you really deal with improving the patient experience, right? When we have a couple that comes in, and they've had previous genetic testing, for example, the genetic counselor that works at the PGT lab isn't really going to be focused so much on the appropriateness of the testing, how the how the results will be handled, what we would be thinking in terms of embryos that are eligible for transfer versus not eligible for transfer, the conversation that really happens with the genetic counselor, the PGT lab is more going to be focused on, you know, this is how we set up the PG TM testing this is the process that we're going to go through this is what's needed. But there is always a discussion that needs to happen about how is the couple wanting to use these results. You know, if you're finding things like variants of uncertain significance that are not black and white on genetic testing, how are we going to be handling those? Are we going to be testing for them? Are we not going to be testing for them? What are the couple's goals and testing for them? So those are all things that an in house clinic based genetic counselor can really explore thoroughly with a couple that may not necessarily be part of the PGT lab conversation.


Griffin Jones  07:18

How do you envision it being structured because if there is a an inflection point, and we start to see a growth there, then I guessing we would start to see divisions departments, or at least teams of some kind right now, you're with a really large company, RMA does several 1000 cycles in the US. And there's you said you have two colleagues right now. So there's three of you for this very large company, what will the structure go on to look like?


Amber Gamma  07:48

So there's just two of us at the moment? My second one is starting today. Yeah. So I think that's really going to be dependent on the company. And, you know, for example, obviously, working for such a large company, it's not like I've just been able to come in and take on all of the genetic counseling that happens, it's really been focused towards things that we feel like are more important to be in house versus things that could potentially be handled by genetic counselors that intelligent addicts companies, for example, right, those supporting the supporting organizations that can help bridge the gap if there are not in house genetic counseling services that are available. So over time, what we're really hoping to do as we build the team is be able to bring more in house to be able to provide a better patient experience that continuity of care. Because also in house GCS are very familiar with the clinic policies and how we do things and tele genetics companies, when you're working for multiple different clinics. Those genetic counselors don't feel like it's their role to really be able to say, well, this is what study your particular clinic. It's more this is the information that we have about this genetic testing results and the possible avenues that can be considered. So we're definitely hoping to build a team that can help improve, you know, the genetic counseling services that we provide by you know, potentially bringing more in house and be able to have the resources for our providers to go to you and for nurses to go to when they encounter situations and they need


Griffin Jones  09:22

guidance. Tell me more about those roles specifically and how you see them differentiating from the help that you might be augmenting with at Tella genetics companies, you talked about being a resource for the providers, being able to have more background for the processes that you're running at your clinic as opposed to here's just a particular type of tasks but as specific as you can be talk about what those roles will do versus what the external roles might do.


Amber Gamma  09:57

So for example, I think what a lot of people Little are facing right now is the issue of mosaicism on PG TA, right? So if, as an in house genetic counselor, I'm aware of what our philosophy is when it comes to mosaic results, what our transfer policies are, and our workflows. So things like consent forms that need to be signed, what needs to be in the patient's chart for our embryologist to say, Okay, this embryo is going to be transferred. And so it's a much more seamless process for our patients, right? They meet with me, I handle the consent form, everything is in the patient chart. And there's no questions along the way. If you're talking about, you know, an external genetic counselor at Atella genetics company, they're obviously working with many different clients. And as I said, as a separate entity, a lot of those genetic counselors report not feeling comfortable speaking to that particular clinics policy. So they're going to be saying, well, this is the information and this is the data that we have about transfer of these embryos, go back and speak to your physician and talk about what their clinic policies are, what pre transfer requirements may exist. And so as I mentioned, it just kind of creates that more seamless process for the patients, and having, you know, more of a way that they can feel, I think, supported through that process.


Griffin Jones  11:15

That makes sense to me, I'm trying to think of it in terms of economies of scale, and I'm comparing it to something that I know better, which is marketing firms, marketing agencies, and some corporations have in house marketing agencies, and some do it for reasons of cost effectiveness. And it's almost never more cost effective. So even if you think of very large agencies and very large corporations, you think of a Pepsi, and maybe they're with Saatchi and Saatchi, or universal McCann or group M, or one of these really large Madison Avenue agencies, there will be an entire division that's just on Pepsi, but they're employees of the agency. And so what about a genetics company that has a dedicated rep for a particular clinic or particular network where they are trained on that clinic groups philosophy that clinic groups, workflows, has access to put things in their chart notes, their transfer policy? Why wouldn't something like that be able to work?


Amber Gamma  12:23

I think that there are some questions to be asked about, you know, as a, as a healthcare entity, how much access you want to be able to give to external companies about things like patient information, etc. Right? So usually, in situations where we are referring out for those services, it may not be the case that that service has access to the entire patient chart, right? Because is that really appropriate? Do we really want to be giving that access just from like a HIPAA point of view and a regulation point of view? I think that this is more related to patient care as well, right. And so I know that having the relationships with nurses and physicians within the clinic and them knowing that they can come to me, and having spoken with patients and them knowing that I work for the clinic itself. Again, I just think provides a better patient experience overall. And we do see this reflected, you know, I there was a survey that was done at practice managers that was presented at ASRM last year about people that had hired in house genetic counselors. And the majority of those participants said we did it to try and improve the patient experience. And they felt like it had done that, you know, so we do tend to see that there is this feeling within the field as well that, you know, having the in house genetic counselor is beneficial to be able to improve patient care.


Griffin Jones  13:51

Are you working with all of the different offices of RMA right now, all of the providers across the United States? Yeah. How is that workflow managed.


Amber Gamma  14:03

So we have a very clear list of indications for which patients will come to see me and then we have workflows for other indications, you know, when May a patient be referred to an external service? And so we train our staff really, and we have resources available for the staff, and then it's just habit building over time, right. So, over time, the nurses and the physicians have learned, they can always reach out to me with a question, I'll always direct them in the correct way.


Griffin Jones  14:31

Well, that's how I mean so even if you have a policy of which patients you see and which patients are referred to an external agency, if you are the only person who this is their sphere within a very large organization, are you not getting pinged with emails constantly about what about this? What do you think about these things that aren't even part of your, your ticketed workflow?


Amber Gamma  14:54

Yeah, yeah, I do get a lot of those emails. And so that is a large part of my day as well. Well, it's just being able to provide that support to our providers and to our nurses. What are they asking you? They're asking me about carrier screening results. They're asking me about, you know, what do you think about this history or this genetic counseling note that we got? What do you think needs to be done for this patient? And yeah, I mean, depending on the day, it can be a lot of emails, right. But I think that's one of the beauties of having an in house genetic counselor is that those individuals know that there's someone that they can reach out to that they trust, and that they know is going to be very responsive to be able to get that answer.


Griffin Jones  15:34

You talked about There are criteria for which patients see you and which patients may be referred to an external company. What are the criteria for patients that are a good fit to be referred to me an external to an external company,


Amber Gamma  15:49

it's going to be your more routine things. So things like carrier screening results that don't show an increased reproductive risk. The it's the more complex things that come to me where those clinic policies really become important. So things like mosaic embryo transfers, segmental aneuploid, transfers, complicated PGGM cases. So your more routine stuff is going to be referred out and it's the more complicated stuff that we keep in house.


Griffin Jones  16:16

What kind of revenue does one in house genetic counselor bring in?


Amber Gamma  16:21

Yeah. So this is something that the genetic counseling professional group is working really hard on right now. One of the biggest barriers, I think, to having an in house genetic counselor is that genetic counselors are not recognized as providers by CMS at this point. So that can make billing pretty challenging. That being said, we do still see that genetic counselors across the country bill, if you're working in a state that has licensure for genetic counselors, you're going to have, you know, a higher chance of success with billing and with significant reimbursements. There's a few different strategies for revenue generation may be billing directly under the genetic counselor for appointments, a lot of genetic counselors and other areas, see patients in conjunction with a physician. And so the billing is done under the physicians name. There is also the opportunity to think about bundling in a fee. I know some of my colleagues at their institutions, there is a fee built into embryology fees as part of the IVF cycle that generates revenue and income for the position.


Griffin Jones  17:26

You mentioned some states where there is licensure for genetic counselors, do you know some of those states off the top of your head?


Amber Gamma  17:34

Yeah, um, so a lot of the states that I practice in New Jersey, California, Washington, Florida, Pennsylvania, New Hampshire, Connecticut, it's the majority of the states at this point, I think we're around 30 to 35. And then in a lot of states, like in my resident state, New York, there are active licensure efforts to be able to get bills passed and get licensure in place.


Griffin Jones  18:04

And so those are the states where it's easier to bill directly under the genetic counselor typically,


Amber Gamma  18:10

yeah, when you look at the data, you do see that the licensure does increase the chance of getting reimbursement from insurance companies.


Griffin Jones  18:19

And those where the genetic counselor is meeting in conjunction with the physician and billing on to the physician, does that typically happen in states where there isn't licensure for?


Amber Gamma  18:29

Yep, it'll it can happen as well. In states where there are licensure, it depends on your area of practice. So for example, if you're a genetic counselor working in pediatrics, all of your appointments are going to be happening in conjunction with the physician. prenatal appointments pretty often we see that and I would say it's less common within the field of infertility, but it's always something to consider. If you're thinking about getting a genetic counselor and thinking about billing strategies.


Griffin Jones  18:54

This may be a question for a billing person but I'll ask you in case you know it, do you know about the differences between the traditional insurance companies that united Blue Cross and how they bill genetic counselor time or don't, versus the employer benefits companies, carrot progeny kind body.


Amber Gamma  19:16

So we're really lucky actually progeny recently started to cover genetic counseling services. So we're seeing some changes there. You're big players like Aetna, UHC, Cigna. We do tend to see reimbursement from those insurance companies. I know in New Jersey horizon Blue Cross Blue Shield is a bit of a challenge, you know, to get reimbursements. And there are still some insurances that don't credential genetic counselors, but that doesn't necessarily mean that you won't get reimbursement. So sickness and example they don't credential genetic counselors as providers. But if you build genetic counseling services, we do see that you do get reimbursement in most cases.


Griffin Jones  19:57

I am going to do an episode soon. specifically about reimbursements and negotiating with insurance companies, I have a CEO coming on to talk about that topic. So we don't have to go all the way into a book, what other Can you give us for being able to get reimbursed for in house genetic counseling?


Amber Gamma  20:13

I mean, I think that as much as possible, if you're bringing in a genetic counselor, genetic counselors, it's a small community, we tend to be, you know, connected to each other. And one of the things that the genetic counseling professional group is trying to do is to be able to set up resources, that providers who want to bring an in house genetic counselor have access to on these types of topics. So being able to tap connections and these types of resources, always a good idea. I think the other thing when you're thinking about setting pricing is, you always want to consider that sweet spot of being able to try to get significant reimbursement from the insurance company. But if you're going to be balanced billing patients, and the case that the insurance does not cover the cost of that, you want to be able to have it be an amount that is so reasonable, you know, for the patient to be paying. So you know, when I've looked into this before, you'll see varying amounts I've seen, like around 100 150. And these are the types of amounts that people are playing around with to be able to see, okay, what do we get back? What are our patients being responsible for? So I would say it's an ongoing area of experimentation. And and there are federal advocacy efforts that are ongoing at the National Society of Genetic Counselors, to be able to try and get us recognized as providers by CMS. We're just working on getting ready to reintroduce that bill with the new Congress session. So, you know, I think once that gets passed, the billing landscape is really going to change.


Griffin Jones  21:40

How much does a genetic counselor cost? And what is the point where it's more cost effective than using someone externally? Yeah.


Amber Gamma  21:49

So you get when you look at the professional status survey data of the genetic counselors that are reporting working in this area, and this includes all settings, you'll see a salary of around 100,000 250,000 a year. I think one thing that we do have to keep in mind, as well as it's not just necessarily about revenue that has been brought in from the patient appointments. Having a genetic counselor in house also provides a level of protection for the practice. Because genetics is complicated, you make one mistake, and there's one lawsuit that's brought against, you know, a practice, that's going to be millions and millions of dollars. And so having a genetic counselor that can prevent that money from going out the door, when a lawsuit is settled, is going to be able to, you know, help offset some of the costs of actually having that genetic counselor in house. Also, we hear this pretty commonly, you know, the the concerns about the salaries of genetic counselors, there are other staff at fertility clinics that do not actively bring in revenue that are seen as crucial and important to patient care nurses being a perfect example. And over time, we've seen the importance of nursing within this field increase. And I do think that we are going to go the same way with genetic counselors.


Griffin Jones  23:06

I wouldn't say that nurses aren't tied to revenue, they're not tied to billing, you're not you're not billing for you're not billing the insurance company for the nurse. But if you have an REI that can do X 100 retrievals versus y 100 retrievals, the number of IVF coordinators that they use, typically variable to that. So I would say they're part of the capacity, do you for sure. Do you see genetic counselors is being able to improve the overall capacity in terms of the number of cycles that can be done with genetic testing?


Amber Gamma  23:44

I mean, I think that having a genetic counselor definitely reduces provider time and having to, you know, try and counsel on genetic tests, trying counsel on on results. And through that process, you're you're improving processes like informed consent, right. So when we think about just patient care from a genetic counseling role point of view, I would definitely say that it reduces provider time. We also know that genetic counselors within fertility clinics are not just limited to seeing patients, they're gonna have other roles as well. So this may include things like being part of a third party program, or helping to manage carrier screening workflows, or acting as liaisons for labs. And so all of these things can help reduce time that is spent by other staff within the fertility clinic on some of these matters. So if not about


Griffin Jones  24:35

revenue, but about scale, what size of practice group do you think is too small to bring in a genetic counselor again, III vrma is multinational RMA in the United States is still doing several 1000 IVF cycles and you now have one peer at your company. At what point do you think it makes sense to bring someone in?


Amber Gamma  24:58

I think if you're encountering a lot have genetic testing. And you are feeling like your staff does not have the confidence to be able to deal with that genetic testing and counsel appropriately on it. I think that's really when the discussion should be starting. So we're working on a an abstract for presentation that we're going to submit to ASRM this year, which has just been a survey of in house genetic counselors across the country. And when you look at the number of cycles per start, you know, in terms of the the clinics that do have genetic counselors, yeah, we're talking about clinics that do tend to be on the larger side, like more than 500 cycles a year, right. But you will see one or two clinics that definitely are on the smaller side that have genetic counselors. So part of it is going to be volume, but part of it is also going to be how important do you feel like having that in house support is for your patients? You know, as I mentioned, there may be more opportunities at academic Fertility Centers, if there are already genetic counseling resources within the institution itself to kind of form that relationship with those genetic counselors. But I think, you know, really, once you grow, and you're kind of encountering this more, and you feel like that level of confidence is coming down, that's really when you need to start having that discussion.


Griffin Jones  26:19

Does having genetic counselors in house and doing more of the genetic testing in house change the type of genetic testing that is done on the aggregate versus using a vendor. So


Amber Gamma  26:35

it, it will and it won't, the way that it won't, there is this common misconception or that has sometimes been encountered that as soon as you bring a genetic counselor in house, that all of a sudden you can do any type of genetic testing. And there's really two different types of genetic testing, you're going to have your screening testing, which is more like your carrier screening ahead of time. And that's definitely things that genetic counselors that are working with infertility clinics feel like it's within their scope of practice to order. One other thing that you may encounter is you may get a patient come in that has a complex medical history with a suspicious diagnosis, they haven't been able to make it into see a geneticist yet. And sometimes I do get requests about, you know, can we order this testing for this patient, but that's diagnostic testing, that's testing for the patient to be able to establish a diagnosis for them. So that is not genetic testing that you know, generally fertility GCS feel comfortable ordering, because it is not within our scope of practice. That being said, even on the carrier screening side of things, you tend to start picking up on things that may not have been picked up on before you were in house. And testing starts to be ordered for that. So a good example, you'll get a lot of PGDM cases these days for BRCA one, BRCA two, those two genes are associated with dominant conditions. But they're also associated with recessive conditions. So when you're meeting a couple, and one of them is positive for one of these two genes, one of the things that we usually think about doing is offering genetic testing for the reproductive partner, to be able to see if that partner is also a carrier, maybe he's not aware. And so those are the types of situations where you start to see more discussions happening. That may not have been happening before you had an in house genetic counselor.


Griffin Jones  28:24

How about with regard to the prevalence of even doing PG TA and reason I think to ask this is because I recently interviewed Dr. Norbert glacier. I think his episode will come out before this one does. But in either event, people should listen to that episode. And I want to make sure that I'm paraphrasing Dr. Glaciers argument, right. But in a nutshell, he views that PG TA is far over utilized for lack of scientific consensus and believes that at least in part, it's due to the influence of the lobbying for lack of a better term power of genetics testing companies that in his view, they have replaced the pharmaceutical manufacturers as the big spenders at the conferences and have a lot of influence that is based on their their sheer marketing power. And we didn't talk at all about genetics counselors being in house. So I wonder one if you share that view, if I'm representing it correctly, and people should listen to that to make sure that I am, but to if we might see a change in behavior, particularly with regard to PGA if it's not about being referred out to somebody else.


Amber Gamma  29:49

So I'm obviously very familiar with Dr. Fletcher's point of view on PG TA and I think it comes from I think he and I differ in our perspective. ofs, but we share a common criticism of PG TA. And that's really that if you're going to be bringing a test to market, you need to have a very good understanding about the clinical outcomes for all of the different possible results. So your chromosomally normal your PDT and negative embryos. We know a lot about that, because we transfer those routinely, your mosaic embryos, we've gotten a lot of data on those within the last seven to eight years. The one thing that we don't have a good understanding on for most of the labs, in terms of what they've actually published, is your whole chromosome abnormalities, right, you're plus 21, you're minus one. A lot of clinics don't transfer those. And when you think about the commercial PGT laboratories within the US, there's only one PG ta lab that has done a non-selection study, and has transferred over 100 of these chromosomally abnormal embryos, to be able to understand how many of them make babies, how many of them don't. So that was the Ashley TEKS study, they transferred over 100, and none of them made babies. So if you don't have a good understanding about the clinical validation of your PG ta platform, you can't say with confidence to patients, when you get and whole chromosome aneuploid results, what is the chance that that would make a baby? Right? I've worked with labs that have this information and that don't have it. My counseling with labs when they don't have this information is, yeah, I think there's a very high likelihood that that embryo isn't going to progress to a full term pregnancy. But because you can have these cases squeaked through, that's really what's fueled the glacier controversy, and sort of that perspective of things. But I think if we could get to a place where all of the PGT laboratories have this information, then I think that critique really dissolves, because we have the data to be able to tell us, you know, whole chromosome abnormal embryos with next generation sequencing technology, do they make babies? Do they not make babies?


Griffin Jones  31:58

But then the thought that comes to my mind as a dummy is why do they not have that information?


Amber Gamma  32:04

Because it's very challenging to do as a study, right? You know, when you think about the teak study, that was obviously, because there was a very close relationship between the PGT lab and the fertility clinic that was really working with them. So you know, other labs that don't have that type of relationship? How do you really build that relationship to be able to get that study going, and also, as a study, transferring the abnormal embryos, because we know that there is such a high likelihood that they won't result in successful pregnancies? So a lot of ethical questions that come up, right, and may not be something that all institutions are super gung ho about doing, even if we know that it is something that is so important to this field.


Griffin Jones  32:43

You talking about this? And what you said earlier about one of the advantages for genetic counselors being in house is that they know the fertility clinics transfer policy, they know that fertility clinics, philosophies on different things like mosaicism, how much influence will genetic counselors have over those things from the beginning going forward? And in other words, how much influence will they have over the transfer policy over the group's philosophy on mosaicism and other elements?


Amber Gamma  33:16

Hopefully, more. I mean, I know at my previous institution where I was before my current position. When I had first started there, the conversation about transferring mosaics came up. And the policy was set. And then two to three years later, I was monitoring the the research and the data that was coming out. And I brought it to the physicians and I said, Listen, our policy is not reflective of the data anymore. If we want to be an evidence based practice, we really have to reassess this. So I think that genetic counselors in house can be a huge resource for helping to direct clinic policies based on the evidence and based on understanding of genetic testing.


Griffin Jones  33:55

That brings me back to what you talked about with risk. And maybe that's one of the ways that you see in house genetic counselors being able to reduce legal risk. Tell us more about that. How would an in house genetic counselor team or even one help a clinic reduce their legal exposure?


Amber Gamma  34:17

Hmm. So I think embryo disposition is a pretty big conversation now with these intermediate PGT results. So I know some of my colleagues have been really important in discussions with their institution about what do we keep what do we not keep your third party risk assessment, so things like egg donor sperm donors, especially if you have in house gammy donor programs, they can be really pivotal and being able to, you know, assess family histories, and appropriateness of gamete donors, and also be able to interpret genetic testing that is being done for those individuals. And then just generally, you know, in your day to day practice, being able to make sure that everything is being covered from a genetics point of view, we're not missing anything, results are being interpreted correctly. Those are all ways that we can assess with that.


Griffin Jones  35:12

What are if it's so important, as you mentioned, then why are genetics companies closing their fertility divisions?


Amber Gamma  35:20

Genetic testing companies?


Griffin Jones  35:23

So why why did semaphore close their fertility division? Why didn't vitae close their fertility division? If this is such an important thing, and so important that we should bring it be bring more of it in house? Why are large companies parting ways?


Amber Gamma  35:39

Well, I think we have to separate out genetic testing versus genetic counseling. So that genetic testing labs are really the ones where we're seeing a lot of shifts at the moment. And that is having some downstream effects on tele genetics companies that those labs have working relationships with. But the challenge with genetic testing, especially when it comes to carrier screening, which we deal with a lot, has always been that there have been very, very thin margins for that testing. And things change, you know, around 2018 2019, in terms of how you can bill for that testing, you could no longer stack codes, your margins got thinner, we've also changed into an economic climate where capital investment is not as readily accessible. And so I think it's a combination of all of these things, right, and also individual business practice decisions, that are really influencing a lot of the layoffs that you're seeing across companies.


Griffin Jones  36:32

Well, maybe this is an elementary explanation that my audience doesn't need, but that I'm may have benefited from earlier, I thought there was a lot more overlap between genetics testing companies and the genetics, counseling services done by tele genetics companies. Can you talk about what overlap there isn't, isn't?


Amber Gamma  36:53

Yeah, so a lot of labs will have their own independent like their own group of genetic counselors that work for that lab. But then especially a lot of carrier screening labs, you'll see that they start to build these relationships, these contractual relationships with tele genetics companies. And that's just simply because they have such a large volume of testing coming in that their in house group cannot cover all of the genetic counseling demand. So they will contract with these tele genetics companies to be able to provide your results reviews for your patients. And so the lab is then directing money towards the tele genetics company through that contractual agreements, but they're separate entities.


Griffin Jones  37:35

Okay, so the closures and the reductions that we're seeing with genetics testing labs, we're not seeing that trend with genetic counselor companies.


Amber Gamma  37:48

So like I said, there are some downstream effects, right? Because if you have a contractual relationship with a genetic testing lab that disappears over a couple of months, then you're obviously going to have a gap right in terms of what revenue you're expecting as a company. So a good example is genome medical is a tele genetics company that had a relationship with in vitae when in vitae did a lot of their downsizing and their layoffs last year, there were some layoffs that happened at genome medical later on, right. So these are examples of things where we can see more downstream effects that hit tele genetics companies because of genetic testing lab decisions, but it's really all originating from that genetic testing lab,


Griffin Jones  38:28

not originating from what could be the origin cause one being Insurance Billing that if these lab companies are closing fertility divisions and citing the lack of insurance reimbursement, are we not seeing that same trend in for the counseling companies? Or for or for counseling period?


Amber Gamma  38:54

No, I mean, you know, because we talk about billing in terms of the billing codes, right. They're seen as completely separate services. They're built very differently. And, I mean, there are some areas of genetic testing where you see much more successful reimbursement. So oncology, for example, from a from a lab testing point of view, but we're not, we're not seeing the same level of increasing difficulty that we're seeing within the genetic testing world when it comes to billing for genetic counseling.


Griffin Jones  39:26

Is there a disadvantage to genetic counselors career mobility, working for a fertility clinic, as opposed to a much larger company, given all of the different tracks that a genetic counselor could go on to do?


Amber Gamma  39:40

I mean, the thing that I've always loved about my role is you can be a trailblazer. So I think this type of role is going to attract a genetic counselor that likes a certain level of independence and likes to be able to be very innovative. I always say I would have been a horrible pediatric surgeon had a counselor because even though we're all trained in the same way, the role is very different, right? Obviously, in fertility, I'm not working directly alongside a physician every single minute of my day, whereas when you're a pediatric genetic counselor, there's a lot more of that. So, you know, when you think about working for a large company, someone like maybe a tele genetics company, there are certain advantages to that role. You know, you tend to have a lot of patient facing moments. So if you're really into direct patient care, that's a good role for you. You know, your, your company can work with a lot of different clients, if you like being able to have the influence and the drive and have a hand in many different pots. That's where I feel like the in house fertility GC role is really good, because you have those opportunities, and your genetic counselors that PGT labs are also really wonderful genetic counselors that gammy thanks really wonderful, like all of my colleagues are, are very adept and very with it, it's just that our roles differ slightly right? Your gammy being GCS, they see their patient as being the gamete donor, not the intended parent. And so their role, even though we all work within the same field can be different from what I do on a day to day basis.


Griffin Jones  41:27

What specific functions will AI takeaway from genetic counselors in the next two years?


Amber Gamma  41:34

I mean, you're starting to see like some pretest, carrier screening counseling modalities coming up that are, you know, like videos, and I think are more primed to like aI involvement there. I think at the end of the day, genetic counseling is very much a process of building a relationship within a patient within, you know, half an hour to an hour, and being able to really connect with that patient and facilitate a decision about some sort of genetic test or some sort of genetic results. I question about if AI methods are going to be able to bridge that human connection. I mean, obviously, with chat GPT, things have evolved so quickly. But I think that at the end of the day, genetic counseling really offers an opportunity to be able to connect with a patient that I don't know that AI is really ever going to be able to provide in the same way.


Griffin Jones  42:26

Well, even with Chet GPT, it's like, how do we know that? That's real insight? You know, yeah, I think it's going to be a while before we can tell what insight artificial intelligence is able to provide, because we often can't tell what insight real intelligence is able to provide. And at the end of the day, you're helping someone to make a decision that isn't necessarily a plus b equals c, there's an excessively anti factor and people need help digesting it. And so what are actors envision the role of genetic counselor will become as more of the predictive analysis moves to artificial intelligence, what will the role of the genetic counselor become?


Amber Gamma  43:14

I think it's really going to be focusing on those more complex cases where like you said, the decision is very unique to that patient or to that couple, based on what their fertility history is, what their treatment journey has been, where they're at emotionally and financially, and you know, what their goals are in the short in the long term. Those are the areas that I feel like, genetic counselors are really going to be able to thrive and build that role. But I agree with you like there's more predictive things or more routine things, that I think there are opportunities for scale and opportunities for technological support, to be able to target the resources of in house genetic counselors, to the things that really need it.


Griffin Jones  44:01

There's probably a couple of AI companies listening, being like Go on, what are areas where you where would help to have more of that support.


Amber Gamma  44:11

I mean, if you think about how often we're doing carrier screening, there's a lot of you know, let's say that you have a couple where they're both negative on that carrier screening, what's important for them to know, it's important for them to know their results, but it's important for them to know that this test is not decreased all genetic risk, right. And those are the types of things where that conversation is going to look very similar from patient to patient. So that's the type of opportunity that you may think about creating technological support for same thing for low risk carrier couples. So one partner is a carrier or something the other partner isn't. That counseling session looks very similar, but just with some added information about the genetic results that was identified. And then again, risk is reduced if not eliminated, but again, those those types of conversations look very similar from patient to patient. Those are really going to be I think the first areas are the low hanging fruit for more technological support.


Griffin Jones  45:02

And we're How would you like to conclude knowing that of 180 episodes, this may be the first where I've even broached the topic of genetic counseling. And if there have been one or two others, I apologize, but knowing that most of our audience is probably not genetic counselors, I do get notes from them sometimes. And if there are topics that I'm not covering, please do reach out, because this is how conversations like this happen, and we're able to create more content and serve the broader audience. But the majority of our audience being Rei is being execs being practice owners, how would you like to conclude


Amber Gamma  45:39

just that genetic counselors are way more than just people that see patients, there are ways that can support physicians, practice managers, you know, clinical operations, directors, and many, many more ways than you think just by hearing about genetic counselors. So, you know, I think having a genetic counselor has been so beneficial for the people that have brought them in that I think it's really worth considering, okay, how can we make this happen in the future. And it's been an honor to potentially be the first genetic counselor that has been on the show.


Griffin Jones  46:12

And we're gamma. Hopefully, it's not the last time either. Thank you very much for coming on inside reproductive health. Thank you.


46:19

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 thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health



172 PGT-A Overuse And Misinformation In Reproductive Medicine, According To Dr. Norbert Gleicher



Dr. Norbert Gleicher breaks down why he believes PGT- A is overused, over-funded, and over-aggrandized on the latest episode of Inside Reproductive Health with Griffin Jones. Is the genetics testing industry the new “big pharma”? Could PGT-A be harming pregnancy chances instead of improving them? And if so, why isn’t anyone talking about it? Tune in to see where you land on this week’s topic.


Listen to hear:

  • Grif and Dr. Gleicher talk about IVF “add-ons”.

  • Discussion on the huge differences in practice patterns.

  • The failures at the early attempts of rolling up IVF centers in the 1990s.

  • Talking points on the efficacy, or lack thereof, of PGT.

  • Gleicher’s stance on scientific literature’s inability to support the use of PGT to the level it is being used. 

  • Gleicher explain why he believes Big Pharma has been replaced by the genetic testing companies, who also happen to be the biggest benefactors of PGT. 

Dr. Gleicher’s info:

LinkedIn: https://www.linkedin.com/in/norbert-gleicher-88101916/

Transcript


Griffin Jones  00:57

Its the same old song, since I've been in the field, or at least working in the periphery of it from my perspective, but I admit that I can't judge the quality of the debates. I can't even assess the arguments properly because I'm not a clinician. What interests me about this topic is because of my vantage point, as a lay person, it seems like there hasn't been a shift. There hasn't been a consensus. Dr. Gleicher is from the very first generation of fertility specialists. He did his residency at Mount Sinai in New York. He went to rush Medical College in Chicago to work on immunology and microbiology, and then he founded his practice the Center for Human Reproduction in 1981. With Dr. Gleicher to talk about IVF add ons, we talked about the huge differences in practice patterns. We talked about the failures of the early attempts at rolling up IVF centers in the 1990s. And we zoom in on the issue of this efficacy or lack thereof of PGT. I need to be careful of how I summarize Dr. Gleicher’s arguments because I'm at risk of getting it wrong, but I think it's safe to say that he feels that the scientific literature does not support the use of PGT anywhere near the utilization that it is being used at in fact that it could be harmful, and that many of the reasons for PG T's wide implementation are from economic and social pressures. Dr. Glasser says the Big Pharma has been replaced by the genetics testing companies and the MSOs the fertility networks that are the biggest benefactors that PGT as the biggest exhibition spaces at annual meetings, there's a limit to how much I can press Dr. gletscher. In this interview business people with no scientific and no medical training should not be doing that. That's your job. What I am interested in is why isn't there a consensus? And is it the case? And how is this impacting the business of reproductive medicine? There may be people that want to argue the counter argument, they're welcome on the show, it's very likely that you're going to hear genetics companies sponsoring this show that I would even let a genetics company sponsor this episode. But I'm not going to be the guy to moderate that debate. Not on this show. I could have someone moderate the debate if I felt like it was going to be meaningfully different from what we've heard at the conferences. I'd be open to that if some of you want to be guests on either side of the argument. But first, you should hear Dr. Gleicher’s argument and I hope you enjoyed this conversation with him on inside reproductive health. Dr. Gleicher. Norbert, welcome to Inside reproductive health.


Dr. Norbert Gleicher  03:25

Thanks for having me. It's a pleasure being here.


Griffin Jones  03:29

The pleasure is mine. You and I have known each other for a while but we finally made each other's acquaintance. Someone mentioned to me that you had mentioned our newsletter in your newsletter, I became aware of your newsletter, and read one of your articles. And such is the compounding effect, the compounding network effect of content creation. And one of the things that caught my eye had to do with the perceived overuse of PGT. And you can correct me if I'm not characterizing it correctly, we'll set that up. But I noticed a concern for empiricism and transparency in medicine. And I want to go through that argument with you today. But first, am I characterizing it correctly?


Dr. Norbert Gleicher  04:17

You are characterizing it perfectly. And I would say that the concern about transmission of information has increasingly become a central issue at our center in our internal discussions in our research, in our evaluation of the literature, and has not the least been a big impetus for the creation or I should say the expansion of our newsletter because if you may have noticed, a very important section of our monthly newsletter is A review of the literature that relates to reproductive medicine. In general, it can be general medical articles, but there must be relationship to reproductive medicine and research in our field. And that section of our newsletter has really grown the most, because the response to it has been really phenomenal. And so we are really addressing this issue very aggressively.


Griffin Jones  05:32

What would you say the issue is specifically?


Dr. Norbert Gleicher  05:35

The principal issue is that I think that, especially since 2010, the the impact on our field from external, often financial sources, has been increasing. And that has been to the detriment of outcomes in IVF. Best characterized by the fact that like birth rates in IVF, which until 2010 have progressively improved since 2010 have been plateaued, and then in more recent years have actually been declining. And this is not only seen in the US, but around the world. And seems to correlate with the addition of add so called add ons. This is a term created by British colleagues several years ago, describing new things introduced into IVF practice without proper prior validation studies, and probably the most significant or one of the most significant is indeed PGT. Specifically PGA I'm not concerned that other PGA formats,


Griffin Jones  07:14

why 2010? In your view, is there a catalyst event, as far as you can tell it? Did it just happen to be around that time?


Dr. Norbert Gleicher  07:23

Well, it's it's really the acceleration of what I and some of our publications have called the industrialization of IVF practice. I don't know if you know that. But I was probably the first to try to roll up IVF clinics in the late 1990s, during the physician management practice, bubble as it is now known. And very quickly, learn how difficult it was and what the arising problems. Become when when when you develop chains of Fertility Centers and try to integrate them and try to establish best practice. All of those things that, really since 2010, have, again, become Vogue and have accelerated. I mean, I don't have to tell you, because I've gotten a lot of my recent information from your newsletter, about what has been happening over the last 12 years, 13 years worldwide in terms of roll ups, and creation of large fertility clinic networks. I think that has played a significant role.


Griffin Jones  08:57

I don't want to take us too far off, but I do think is germane to the conversation as far as discussing IVF centers, workflows and different providers workflows. What were the greatest difficulties at that time, you said you were among the first in the 1990s to attempt a roll up of IVF centers, you very quickly found out the difficulties, what were the greatest difficulties,


Dr. Norbert Gleicher  09:22

huge differences in practice patterns between individual centers for a variety of reasons, and certain conservatism amongst doctors. Meaning, resistance to change. And then, of course, economic considerations. The facts The more you intervene in a physician's established practice pattern, the more of a decline in productivity you will encounter. And so, it, it becomes kind of a vicious circle. It is very, very difficult at least that was our experience to to change a physician's practice pattern. And so if you acquire an infertility practice that had a very distinct or different practice pattern, you will be successful in changing that practice pattern, at least in our experience, then only at the cost of losing significant revenue.


Griffin Jones  10:52

And specifically, as you can please give us examples of these types of practice patterns.


Dr. Norbert Gleicher  10:59

They're almost unlimited if we go into into presentation genetic testing, for example, which in those days already existed, was called pre Implantation Genetic screening. You know, some people then already believed in it, others strongly opposed it. I think this discrepancy if anything has increased over the years, but also the utilization of PG TA has greatly increase. You just have IVF clinics out there, that till today swear that it's it's the best thing that ever happened to IVF. And then there are others like us, who feel that not only is PGT a, useless for most patients, in terms of outcomes, but for many patients, it actually does the opposite of what is claimed it does and actually reduces their pregnancy chances. So this is probably one of the most dominant subjects where this kind of discourse exists today in our field, but there are many other major subjects, routine culture of embryos to blastocyst stage, for example, that the even ESRM considers that today, the routine embryology practice in IVF. But when you look at what is really behind it, the you have to question the routine, embryo culture to blastocyst stage for everybody because the people who initially promoted this did their studies in a very highly selected good prognosis patient population. And subsequent studies who tried to show the same improvements in general populations have universally failed. Yet, we as a as a field, have accepted the claim that routine embryo culture to blastocyst stage improves, improves pregnancy outcomes in IVF. That is categorically false. Yet still, like with pgpa. This is the main treatment that is being pursued in this country for most IVF cycles.


Griffin Jones  13:55

Are you familiar with these very large consulting firms that they're retained by companies in lots of different sectors, health care, energy commodities, and they have rolodexes of experts in different verticals, and then they call you and they pay you for an hour at a time to talk to someone identified. group on the other end, they ask all these questions. Are you familiar with those groups at all?


Dr. Norbert Gleicher  14:20

I'm familiar with them because I get a lot of calls asking, asking me to set up meetings. I rarely do it. But yes, I'm familiar with that.


Griffin Jones  14:32

So I get these calls, too. And I take some of them sometimes, and I often get the question about PGT about its implementation and about its use and if if the doctors view it as an add on or if they view it as necessary, and I tell them I'm not qualified to answer the question. I say the only thing that I'm qualified to remark on is that I've been showing up since 2014 to 2015 And it doesn't look like there's any more consensus than there was eight years ago, it seems to me like it's the same debate. And from my vantage point, it doesn't look like there's any kind of consensus. So that's what I tell them. I can't speak. I'm not I'm not clinicians, I can't speak on the issue of PG. Tea itself. But you said that some people even back when it was still called PGS. They thought that it was it was the great they swore by it. And and some people say today, that is the best thing to happen to IVF and where others, like yourself believe that there's no evidence for that. Why Why isn't there consensus if it's the same darn debate at SRM and PCRs? Well, first off, maybe I'm making an assumption, is it the same debate that's been going on for years? And two, if it is, how has consensus not been able to emerge?


Dr. Norbert Gleicher  15:55

It is the same debate. I would argue that there has been a shift, I think there's increasing recognition that that the hypothesis of PEGDA, which is that by removing supposedly chromosomally abnormal embryos, from the embryo, embryo cohort, before embryos are being transferred into the uterus, will improve pregnancy chances for patients. I think that this increasing doubt about this hypothesis, so that from my vantage point, is a positive development. At the other end, as you correctly stated, they are those who are holding on and if anything else, they even have become more aggressive in in defending PGT A, and I cannot speak to their motives. Um, but several months ago, I spoke to one of those economists who called me and he made the startling comments to me in our discussion of the field, and his comment was, if PG ta were to disappear tomorrow, a third of IVF centers would have to close or at least to restructure. And I found that that interesting, because what what he meant to say was that the profitability of IVF in the US is obviously marginal. I mean, this is not a huge, not in an industry with huge profit margins. And he suggested that, in in many IVF centers, that profit margin comes from PG TA. But without PG TA, there would be no profit and maybe even loss. And, and this, this makes sense, when you think that PGA is not covered by insurance, and so as as a cash payment on top of what IVF centers are getting from insured patient coverage, this is a significant addition to the average cycle revenue. And if that were to disappear, because let's say for example, the FDA comes out with a statement that it considers egta inappropriate in certain circumstances, that would have an enormous economic impact on the field, so you cannot ignore that. But yet at the other side, there are people who, who see PGD as a religion, you know, there are people who are just believers, and they are not convinced by studies. They are not convinced by the opinions of people who are much smarter than I am. And they just stick to their opinions. So the motivations are open for a discussion.


Griffin Jones  19:49

You can't speak to their motivations, but at this point, you should be able to speak to their arguments because you've been on the other side of it for many years. What are their arguments in the best way that you can run? Present them.


Dr. Norbert Gleicher  20:01

Their arguments have been shifting over the 20 plus years that this procedure has been promoted. The the, the original argument of embryo testing was that it would improve pregnancy and life birth rates and would reduce miscarriage rates that has been dismissed over the years by various studies and has been acknowledged by ASRM in policies they statements by Essure, the European counterpart of ASRM are both in repeated statements have concluded that there has been no evidence to show that it really improves outcomes. And so as it became harder and harder to make the argument for improvements in outcomes, the rationale shifted shifted to Okay. It, it makes. It improves outcome, maybe in some subgroups. And first, it was in younger people, and now it is in older people. And again, I don't want to go into technical details. But those in my opinion, at least, those arguments are incorrect and are contradicted by by many studies, then the argument became ei increases, it still reduces miscarriage rates, that was also contradicted by studies. Then the argument became, yeah, but But it helps with single embryo transfer, which is, again another subject that deserves separate discussion, because this is also an add on. That, in our opinion, is is not logical to do single embryo transfer on every patient, in our opinion doesn't make any sense. But that is again, an opinion that has evolved. And so the pro PGD, a crowd argued that by testing the embryos and selecting a normal embryo, it helps with single embryo transfer, pregnancy and life birth rates. Again, studies have shown that that is not true in my opinion. But what is even more important than this proving their argument for potential benefits with which have shifted so much over the years, is that in parallel, there has been increasing evidence that PGT a harms patients and harms many patients in their pregnancy chance. And let me give you only one example for that, which is probably the strongest evidence for harm by PGT. pgpa allegedly classifies embryos as transferable or not transferable meaning, yes, you can put them back in the uterus or you should not use them and even throw them out. And that's that's the whole concept of pgti. Now, we started to doubt this concept in 2014. And we in 2014, started transferring so called abnormal inputs selectively, initially only so called mono soulmates because they are known not to implant and we transferred them under the theory. Okay, if they are really mono Assamese as pgpa claims, then they will nothing implant no big harm there. And lo and behold, we started seeing normal pregnancies. Now, we just published a paper in human reproduction a few months ago, about 50 consecutive such cycles from patients who shipped the embryos into our center because their own centers refused the transfer because they were by PGT. A declared this abnormal So, if they could not have shipped them to us for transfer, those embryos would have been thrown out to not use these patients had even though they were very unfavorable with a median age of 42, which is quite old. These patients had a pregnancy rate in the mid 20s. At that baby take home arrayed in the iteams. Now, what does that tell you? That tells you that there are 1000s and 1000s and 1000s of patients out there who went through PGT, who ended up with embryos that were declared as not transferable and who therefore don't have those embryos transferred. Yet, those embryos have a decent pregnancy and life and life birthrate. And these 50 Women who I just described, they didn't even use all of their embryos, yet they still have over half of the embryos frozen here, and therefore have even higher pregnancy chances sitting up there, they are not used. Is that a better evidence for the potential harm of egta than that? I don't think so.


Griffin Jones  26:21

Is that also not an argument, though, against the financial incentive argument of PGT, that if it is the result that we're not transferring embryos, Fertility Centers aren't in the business of forgoing IVF cycles for nil is, is there not a counter business argument to be made that there might be incentive to not use PGT, because it may result in people not transferring some embryos.


Dr. Norbert Gleicher  26:54

The issue of egta and not transferring embryos leads to another problem. And that other problem is that a lot of women who go to through two or three IVF cycles and are told in every one of their IVF cycles, that all of their embryos are chromosomal abnormal. The next message they're getting is okay, yeah, the only remaining choice is to do donor x. Now, donor eggs are a wonderful option, because they have the highest the pregnancy chances of any IVF cycle that the woman can have, because nothing can compete with 20 or 25 year old eggs. But I always tell patients, and I think this is another thing that differentiates ourselves from from many others, that I have seen very few if any women who came to us and said, Hey, I want to get pregnant with donor eggs, patients usually come to us because they want to get pregnant with their own eggs. And therefore we see egg donation as a wonderful treatment, but only as a last resort. And that is not the opinion of many of our colleagues. They are very, very quick, in in moving into egg donation with their patients. And when you look at national IVF data in the US use the FSC very few patients after age 42 Certainly for the three who still are going through IVF cycles with their own X. At our center, the median age of our patient population, well, the last four or five years has been 43 plus. So I think that's a reflection of of the different philosophy that is prevailing in the field. In most centers and and how we look at what is happening in in the fertility practice today.


Griffin Jones  29:12

If I dig any deeper there, I will leave my scope of competence and and won't be able to contribute. So I'll instead ask each of us to leave our scope of incompetence. Let's each step out of our pay grade for a moment and speculate that if it is the case, that there is a financial incentive to increase PGT add ons because of the increase of insurance or simply because PGT is usually cash pay. And then even if someone is covered via insurance, it allows for a cash pay option that's more profitable. If that is the case. Should we expect to see that bear out one way or the other as we start to see payer provider models so the He's groups that are doing are the payer and contracting with employers, as well as buying existing clinics starting clinics de novo? Shouldn't we see on one end of their model, a correction? Or am I missing something? In other words, if it is to gain more, if it is to just to add more money, would they be? Would they be losing something? Because they're not getting that on the employer benefit side? Or is it in fact better for them to add it on the employer benefit side? Because then they would be that they would be getting better outcomes on their provider side?


Dr. Norbert Gleicher  30:45

So that is a very complex question. With an equally complex as the complexity comes from the question, what is benefits. And I think that is the core issue of the whole discussion. Because in the old days, of IVF, and as you can see, from my hair or lack of hair, I am still a member of the first generation of, of IVF people. In those days in Chicago, when when I started an IVF center, we were the first IVF center in the Midwest, and one of the first in the country. In the early days of IVF. We all competed based on our outcomes. And that was healthy. Today, outcomes almost no longer matter. Yes, they are being listed national reporting sites, but very few patients, take them as a guide. And today, the competition is at a very different level. The competition today is much more than economical competition, it is a competition of academia versus private. It is a competition between networks versus individual practices. It's an economic competition, it is no longer a clinical competition. You know, the issue now is to grow. The issue is no longer to to get better pregnancy rates and better live birth rates. And I think that is at the core of our current problems.


Griffin Jones  33:00

Why do you suppose that is the case, though, because there's still an incentive on the patients and to pursue better outcomes at a lower cost.


Dr. Norbert Gleicher  33:09

There is a an incentive, the patient's on this on a portion of the patient side because insurance coverage has increased. And therefore patients who are insured, the only incentive is to go to somebody who is in their insurance. That financial incentive exists only among the non insurance, a paradoxically, the very poor. And the very wealthy. And, and the very poor, unfortunately, simply can't afford it. And therefore they are not visible. They don't have a voice. And the very wealthy frankly, most of them don't have to care. You know, they go by where they feel they will get the best care and what they perceive to be the best care not only in our field, I think that is true every throughout medicine, most information patients still get from their physicians. Yes, the Internet has become very powerful and and has much more influence than in the past. We had a good example. Because if it wasn't for the Internet, we wouldn't have patients and their so called normal embryos. from Europe and from Asia. God knows from where to us for transfer. But but the truth is still most infamous addition, patients do get from their physicians.


Griffin Jones  35:04

Let's talk a little bit about the information that physicians are getting in your newsletter. You reference a scientist named Carl Bergstrom, who I believe is an evolutionary biologist. But Brookstone wrote a piece where he gives aid rules for combating medical misinformation and for reviewing literature and other sources of info I suppose. And I'd like to go through each of those eight rules with you and see where might apply in this case. And so the first rule that Dr. Bergstrom offers is be aware of the environment into which we release information, how would you describe the environment in which information about PGT is being released,


Dr. Norbert Gleicher  35:50

I'd be happy to discuss his very interesting article, which was based on an even more interesting book. He wrote a while back, but I want to preempt that by making the point that the reason why he wrote that article recently, was his concern for misinformation, that the permits, medicine, medical publishing medical information, etc, etc. And partially driven, obviously, by our environment, and therefore, we have se se correctly, I think makes the point we have to be aware of the environment in into which we are releasing information. If we're sending out a news release, it's a different story than when we are talking to a patient or when we are giving a talk to colleagues. I think that is very important. And and we need to recognize that information needs to be delivered differently to different audiences.


Griffin Jones  37:03

The second rule is avoiding hype and tenuous claims of significance with regard to PGT. You talked about a few of those and summarize that what is you talked about that they have changed that the claims have changed? What are they now?


Dr. Norbert Gleicher  37:21

Oh, that's a very good question. And I think it is a question that that nobody, nobody can answer. Let me give you an example that I think demonstrates that the best. And then just taking PGT as an example again, but it applies to other issues, other subjects and other things. Equally. As I noted earlier SRM released 10 years apart to policy statements or opinions, which clearly declared that PGD has not demonstrated any outcome benefits to those points. The first one was in 2008. The second one was in 2000, at ASHRAE, kind of similar yet, yet. SRM just announced that they will update a release on the interpretation of PGT a results. Now, explain to me how a professional organization logically can provide a document explaining how the results of a test should be interpreted. That same organization claim has no benefit. Where is the logic? And I think that's, again, a good example of that, we need to be careful in what we are saying to the public. You know, we cannot say to the public on the one hand, test X is useless, it doesn't give you any outcome benefits, and then go out and say, okay, but if you do test X, interpret it in this in this way.


Griffin Jones  39:38

The next rule is to recognize the importance of visualization in making figures stand on their own. Is there a way that's being used by the opposition argument, in your view to represent the information that they're trying to get across?


Dr. Norbert Gleicher  39:59

Yeah, I Think this is a this is a more or less technical issue, I'm not sure if it has the same importance as, as the first two, it's more a technical issue in the how you present that, again, you can you can manipulate everything. And and that includes how you how you present that, and how you present that graphically. You know, you can you can present a graph in different ways, trying to, to, to support you with direct message without without really being objective in presenting the data. And I think that's what the author said in this, again, technical aspects. I'm not sure it's a major issue.


Griffin Jones  40:57

Here Berg strim talks about the vantage point of the writer of the literature with trying to envision and head off in advance abuse of one's findings. But let's put ourselves instead in the position of the reader as opposed to the writer, what what abuses Do you anticipate potentially coming? If the arguments have changed multiple times? What will they change to next?


Dr. Norbert Gleicher  41:26

That's a good question. moving the goalposts does not only happen in medicine, as we know, they happen in many other areas of our existence as well. What comes next is, is it's hard to predict. And again, I do not want to concentrate our conversation just on PG TA, because there are so many other issues in involved, as well. But what I think he wants to say with that point is that what you write and what you read, needs to be both done with caution. As a writer, you have responsibilities towards your readers, in how you present your data, and how you present the interpretation of your data. It is not uncommon in our in our medical literature, and again, I'm not referring only to reproductive medicine or only pgpa. I think it's an issue all over medicine and all specialties. It is not uncommon that authors performance study, produce reasonably reliable, good results. But then, in their own interpretation of their own results. lose it. And I think that's what he's referring to. And on this other side to answer your question about the reader. I think readers need to be cautious, I would say maybe even suspicious, not only in reviewing the study design, whether the design is appropriate, or whether you selected patients or you did anything else otherwise inappropriate. But the reader also needs to, to think through the conclusions of the author, it is not appropriate, though I don't think it is smart to automatically assume that the author is right in his interpret, or her interpretation of their own data. Okay, we need to be more critical. And that brings me back to what I said before that's a big part of our newsletter in reviewing literature and providing our subjective acknowledged subjective opinion about papers we think are of interest, both in the good and the bad.


Griffin Jones  44:19

When I see this happening when I see someone give a very different interpretation of the data that they just that they themselves compiled. It's very often not for economic reasons alone. It's very often for social reasons. And those two things overlap. They can compound each other of course, because you can have socially and economically aligned incentives. And if you're really trying to achieve an aim, you do want those two things too, to intertwine. But even though they overlap, it seems to me that the social is a lot more powerful. And even if it's driven by economics, it's Social, not wanting to be a pariah, that often leads someone to giving a very different interpretation from what they know to be fact. Do you see social pressure happening in the field? And what is it?


Dr. Norbert Gleicher  45:15

Absolutely, absolutely. There's social pressure. At every level, there, I can tell you that, in the early days of our criticism of what Ben was still called PGS, I hate to come back always to the same subject. But as an example, again, in the early days, and I'm talking about 2008, we reanalyzed, some early studies on PGS, from Belgium investigators. And we concluded from those studies, that PGS probably doesn't work. And not only doesn't work, but that it actually in older patients may be harmful. And we wrote a paper and send it to every journal, in our field and in the general medical literature and couldn't get it published. Until Swedish colleagues published in the prestigious New England Journal of Medicine, a study that showed exactly that point, much better than we would have shown in our paper, at which point I was called by one of by the editor in chief of one of the journals that had rejected our paper, and had us to resubmit. And they then published our paper subsequently, the point I'm making is that our review process in medicine and again, this is not only in our field, this is universal. Our review process is based on what is called peer review. And peer review is the review of your submission by your peers in that particular field in which you have submitted the paper, the editor of a journal, takes your paper and sends it out to peer reviewers who are quote unquote, experts in that field. But what does that mean that they are experts in that field, it means that they have an opinion in that field. And they usually have the predominant opinion in that field, because that's why they became experts in that field. And if you then come into this with, with a paper that contradicts the predominant opinion, you have a hard time and and it shouldn't surprise, and this is not only a problem in medicine there, this is a problem in physics, this is a problem. In in every field of science, experts are biased. And philosophers have known this for centuries. And our editors, unfortunately, very often still don't understand. But let me kind of make one additional point. In next month's newsletter, we are indeed discussing a paper that that was recently published about the big scandal that has kind of shaking up the medical publishing industry recently. Because I'm sure you're aware that one hot topic in science in general now are fake, fake papers, fake photographs, manipulations. It's it's a it's a major problem allowed this coming out of China, unfortunately, but it's also coming out of local from local sources. So a very prominent journal, not in our field, was notified by some scientists about alleged fake figures, fake photographs, in a whole series of papers by a particular group of investigators, resulting in an investigation. But what that investigation revealed, which is at this point unresolved, it's still open and ongoing. But what they discovered is that the people who complain about those papers which related to the introduction of a new Alzheimer's drug, had shortened the company which produce that Alzheimers truck. So the people who claim that the papers were fake, really had an interest in bringing down the stock price of the drug that was supported by those people. I am mentioning this here. Again, it did not happen in our specialty. I'm mentioning this here, just to demonstrate how closely intertwined today, medical opinion, medical messaging, medical publishing, is with economic interest. And that is a major issue that we are not openly and transparently addressing here.


Griffin Jones  51:05

That impacts what type of information the patients receive, what type of information lay people receive both extremes. fifth rule is if submitting in unreviewed preprint, consider its reception by the public. Let me paraphrase this rule for for the question of the example, which is, when you're seeing patients come with information, where are they? Where are the sources of incorrect information? Most common, as far as you can tell,


Dr. Norbert Gleicher  51:37

today, unquestionably the internet?


Griffin Jones  51:41

Sure, let's try to be a little bit let's try to be a little bit more specific than that. Is that anecdotes from friends? Is it? Are they reading papers that they that have summaries that they just they can't read the scientific literature themselves? And they're reading a couple lines from the summaries? Are they deliberately getting information marketed to them by companies? What do you see as the most common?


Dr. Norbert Gleicher  52:05

I think? To answer your question, we have two separate information to whom, if we're talking about the public, I don't have to tell you that the longstanding controversy in the US has been advertising to the public's about drugs, for example, we are one of the few countries in the world that permits direct advertising of medications to to to the public. And they are you have a direct influence of the public by drug manufacturers and whatever they want to present. That is not our primary concern. Our primary concern is, I think, maybe even more important, because our concern is the influence on those who prescribe those drugs, and physicians. And, and, and I think we underestimate here, what is really going on, I find it ridiculous that the laws were passed that prohibit pharmaceutical companies, from bringing pens to doctors offices, when reps, or coffee cups to doctors offices, when when the reps come by to push a drug. While at the same time we ignoring all the other influences that strap companies have on us, you know, just look at what happened during COVID. And look at what happened to the influence of drug companies on health policy during COVID. I mean, we we we are because of of the trees not seeing the whole forest. Yeah.


Griffin Jones  54:16

Is that because of the necessity of that influence that financial influence in order for the institutions to conduct their business. So the pens, the coffee cups, that's two individual providers, but I tried to picture in SRM where there was no pharmacy support to look at Gold Ruby diamond sponsors or or any conference that we had, I suspect they would look very, very different. And where would that money come from? Where would the money come for? For many of these? And I don't ask that cynically, I asked that truthfully, I appreciate that everything is a trade off, and that there could be benefit to those companies paying for events and studies. And but it seems to me though, that The reason why that may not have been regulated out in the same way that the coffee cups the gifts the individual correspondence was, is because could you even have an ASRM without that level of corporates spot and I'm not picking on SRM. It's true for any society, any conference.


Dr. Norbert Gleicher  55:19

Absolutely. But your observations, very astute. But can I ask you who you saw having the big exhibits at the SRM recently?


Griffin Jones  55:28

It's still still the pharma company. They're not gone. But it's the pharma companies and its genetic testing companies


Dr. Norbert Gleicher  55:34

and genetic testing companies that need


Griffin Jones  55:38

more storage and more AI. And


Dr. Norbert Gleicher  55:41

that's exactly it. That's exactly it. So this is exactly what has been driving our field in recent years ASRM. And, and God bless them. And I can't blame them because they need the money. ASRM does not have the support anymore from the drug company that drug companies because of all the stupid laws that were passed in the in in the last two decades. And what happened, new blood came into the same business and that blood a genetic testing companies and again, not only in the infertility field, go to the oncology conferences, go to other conferences. The genetic industry is now the new drug industry in their influence on what is happening and coming back to your earlier question about social pressures, they determine who the speakers are, who are invited. They determine to some degree what medical journals are publishing, just like the drug industry was very, very influential, you know, 2030 years ago. Now, over the last decade, it has been increasingly become the position of the genetic testing industry. And that is why there is so much genetic testing going on.


Griffin Jones  57:25

I want to conclude with one summary question. When we conclude I will let you conclude with your thoughts. I want to conclude our summary of Bertrams rules by summarizing the last three because they all have to do with media, traditional media press releases social media. And one of them says if you're submitting an unreviewed preprint considered reception by the public, this is the point where you start to see the social pressure come to bear, isn't it when you first release something, it's when people get jumped on that they very often either reverse their opinion or they say, Oh, well, maybe I didn't. And they issue some sort of caveat. They don't express their findings as strongly. Or if they don't do anything to revise their findings, they simply just stop talking about it. They don't submit the posters and and so this is the point where it where you start to see social pressures when you release that into the environment. And you can see people recoil. So what advice do you have I suppose for someone who's going to produce something that that may make them socially undesirable for some time.


Dr. Norbert Gleicher  58:41

It is the political correctness question. Political Correctness exists in medicine, as much as it exists in the political realm and the media environment. If you contradict political correctness, you have to be ready for the social consequences. You know, there are Nobel Prize winners who couldn't get the papers published and had to publish them and some third class journal. You have to be ready for the consequences. You know, it is always easier to be part of the echo chamber. There is no question. That's what what will make you popular that will give you all the invitations to speak. If you are not part of that, you have to live with it.


Griffin Jones  59:47

Dr. Gleicher, I'd like you to conclude with our audience who's largely your peers, but it's going to be some of the folks that are executives of the genetics companies as well. And so we have many practice owners and physicians but We also have a lot of folks that work on the, quote industry side, how would you like to conclude our discussion today?


Dr. Norbert Gleicher  1:00:07

We are in our respective medical fields all together. Like in in politics, I have a very hard time accepting the notion that, that we are enemies that that just because we do not share in opinions, we we have to be antagonistic to each other. I'm a capitalist, I strongly support the profit motive. But I also like to believe that I have a such a social conscience that mandates that I as a physician set the interests of my patients at the very top of all of my considerations. And that just because it's the nature of the bees will at times contradict other people's opinion. But that doesn't mean that we need to be enemies. That doesn't mean that we cannot together fine, find solutions that will benefit all of us and most of us our patients. Dr. Norbert


Griffin Jones  1:01:37

Gleicher, thank you very much for coming on inside reproductive health


Dr. Norbert Gleicher  1:01:41

was my pleasure.


1:01:44

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 thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health


162 4 Principles For Abandoning The Travel Agent Model Of IVF Care: With David Sable and Abigail Sirus

Former practicing REI, David Sable, and venture capitalist, Abigail Sirus, deconstruct how democratization will change the face of the IVF field. Sable and Sirus break down the four principles of how this will be accomplished, perhaps sooner than anyone anticipated, on this week’s episode of Inside Reproductive Health, with Griffin Jones.

Listen to hear:

  • What Sable and Sirus believe will happen when the travel-agent model for IVF care is abandoned and patients are empowered to oversee their own care.

  • Griffin question what risks this evolution may introduce to both patients and practitioners.

  • What Sable and Sirus think may happen to incumbent REIs- whether or not they will  be phased out entirely.

  • Why Sable and Sirus believe, one day, patients will pay for IVF if - and only if- they have a baby.

Reference:

https://dbsable.medium.com/the-four-guiding-principles-for-democratizing-ivf-pre-asrm-2022-prep-notes-from-the-front-lines-of-2f2fd66e5d8d


Abigail’s info:

LinkedIn: https://www.linkedin.com/in/abigailsirus/

Company: AWM Investment Company Inc.

David’s info:

LinkedIn: https://www.linkedin.com/in/davidsable/

Company: Life Sciences


Transcript

Griffin Jones  00:26

Netflix? Or are you Blockbuster Video? Or are you HBO? Or are you some other analogy that should be applied to the fertility field as we talk about the massive change that is coming from venture capital to the field of reproductive health. My guests today are Dr. David Sable, who needs very little introduction to you all. This is his third time on the show former practicing REIi also teaches at Columbia University for classes on entrepreneurship also manages a fund for Life Sciences. Today, we bring on his colleague, Miss Abigail Sirus, who is a venture capitalist and investment associate for another life sciences Innovation Fund. She had at IBM for another number of years before that, today we talk about the four principles for democratizing IVF. We get so engrossed into these principles and the changes that might be happening in the marketplace and who might be executing upon them that we're going to have a part to where we go through some of the mapping where of the areas of biggest potential disruption for the fertility field, I felt that we needed this conversation to set up the next one, and I don't tire of having Dr. Sable back on the show, and you don't seem to either. So until you do, then these multi part series make sense today enjoy the four principles for democratizing IVF. With Dr. David Sable and Abigail service. Ms. Sirius, Abigail, welcome to Inside Reproductive Health. Dr. Sable. David, welcome back to Inside Reproductive Health.


Abigail Sirus  02:08

Thank you for having us.


Griffin Jones  02:11

I'm always happy to have Dr. Sable. Back on the show Abigail, this is the first time that you and I have met. And I want to talk about an article that David wrote recently based on work that the two of you have done together. But before we get into the article, just give me a little background. How did the two of you link up? Sure,


Abigail Sirus  02:29

I'd be happy to. So Griffin, David and I actually had the pleasure of meeting on a project at while I was at my previous company, IBM, I was a blockchain strategy consultant. And David was actually one of my clients. So we in that instance, we're trying to create a blockchain enabled system called IVF, open to really bring standards to the way that biospecimens are stored and tracked and traced along with chain of custody for in vitro. And I admit, you know, Griffin, I'm actually the product of IVF. So my twin brother and I were born via IVF. And it's it's truly a miracle that, you know, I really wouldn't be here without. And so it's always had a place in my heart and been special to me. But when I got to meet with David and several others across the industry now a few years ago, and do this project together, my eyes were really opened to the industry in a new way. And I'm a process minded person. And when I started to understand the inefficiencies across the space, it really started to inspire me and grow my passion for all of the opportunity that is here. And things that we can can kind of bring to light through innovation, which I know we'll talk about a little bit


Griffin Jones  03:42

later. But what came of IVF open?


Abigail Sirus  03:45

Absolutely. Well, I'll let David answer that question.


David Sable  03:49

Thanks, Griffin. Thanks for having us. having me back. And having Abigail on. Going back to the decision to bring Abigail on I try to endeavor to be the dumbest person in the room. Wherever I am.


Griffin Jones  04:00

It doesn't work when you and I are hanging out.


David Sable  04:04

Well, certainly when she's around, it's today. That happens. But now IVF open was we likened it to building drainage ditches for to let the IVF industry scale try to help you and I might have talked about it briefly trying to have one place that assigned identifiers for frozen eggs and embryos so that nobody ever was stuck someone's eggs and embryos for somebody else's. And nice thing is it kind of got it's been taken up by a lot of the private industry incumbents and made part of their kind of overall strategy. Training Group enforce these kind of rules by a nonprofit is a difficult thing to do. So having kind of the industry say yeah, this is a really good thing to avoid these problems. Let's go ahead and try and see if we can build into our her handling of specimens, a uniformity of labeling. And that'll evolve in a nice way kind of organically. within the industry, what we did is we tried to put all the incumbents together into a single, not a room and single single zoom screen. And, you know, it really it's it was great was that everybody got it. Everybody understood, and left the effort, which hats off actually to Risa Levine, who you know, who's a super patient advocate activist in this field for kind of getting the whole thing off the ground. And the other great thing that came out of it is I got to know Abigail, because IBM was a big partner of ours, in that. And then when I was looking for someone to join me, actually just having us if you know anybody, and she said, Well, how about me? I said, well, they knew you were available, I wouldn't be asking. So I brought her on as soon as I could. And that's been terrific. She's been with us for almost a year. Now.


Griffin Jones  05:57

Let's talk about the article that brings us here today, which is about the four principles for democratizing IVF, the four guiding principles for democratizing IVF. And this was an article that you published just before ASRM David. And there are four principles, I have a feeling that we're going to go into the third one disproportionately today, at least that's where my disproportionate interest lies. But the four principles for democratizing IVF are abandoned the truck travel agent model for IVF patient care, use the gravitational pole, foreign by incumbents making today's highest pregnancy rates, the floor of outcomes for the future. And fourth, using greater certainty uniformly higher outcomes and improve data collection analysis to actually quote, qualified data leading to better risk management, who will talk about the four of those principles? Let's start with the first one. What do you mean by abandoning the travel agent model of IVF? Patient care?


David Sable  07:05

Well, yeah, 30 years ago, if you wanted to take a grand tour of Europe, you call up a travel agent. And they would book your flights for you book, your hotel, book, your tours, make reservation restaurants for you add up the bill, put a big margin on top of it send you one bill, and he'd write one check. And it's a it was a way of getting things done. And it's a nice model, if you a can afford it, be have access to a great travel agent. And see they actually give you what it is that you want. For the IVF world. That's kind of what we have. Now you go to an IVF clinic, you say I'm having difficulty conceiving, and the incumbents in the clinic make all the decisions for you. And they charge you one amount. So your input really comes down to just choosing a clinic. And they make all the decisions for you from there. What the future of IVF as we foresee it, and the way things seem to be evolving, as we disassemble the cycle into different places, into geographies closer to where the patients live. Using our inputs more efficiently, not putting everything into a $2,500 a square foot laboratory is that the patient herself or the family themselves will be able to choose maybe being monitored one place, have their egg retrieval somewhere else, take the rigs store them somewhere else. In initiate contact with the laboratory, once the eggs are frozen, and maybe bring your reproductive endocrinologist into the process later on. Giving the patient the opportunity to choose to stay closer to home do some price comparison shopping. Really the way we purchase just about everything nowadays, there's no reason that IVF cannot evolve into that model, which will result in greater access, more price comparison we have more price choices, and an ability to kind of oversee one's own care the way you can do so many other choices now in the marketplace.


Griffin Jones  09:24

Maybe we'll bring this up a little bit when we get to the third point where we talked about dollars until baby and time until baby in life disruption to baby but is there a risk if you are abandoning the travel agent model the all in one model by choosing your clinic of having death by 1000 cuts like I don't think the airlines have added a lot of value the Spirit Airlines and the Frontier Airlines by having people choose if they want to bring a carry on if they want to pay more for that or if they want to pay more for not having a middle seat and maybe there's something to be said For the Southwest, and the jet blues and the Alaska's that have brought down cost without making people have to nickel and dime on an each individual micro choice. But what about that?


David Sable  10:14

Well, I think that if you're looking at people, yeah, if you're looking at the people who have access to air travel now, without a very, very low close budget airline, we have to pay for your seat choice and pay for each bag you bring on. And there's no food and there's no flight attendants, then it may not be very additive to them. But we have to ask ourselves, and you have to start every conversation the same way, what problem are we solving. And if we're solving for access for the next million, 5 million people per year that need IVF, that have no access to it now, then they may be more than willing to, at a price point in a geographic location that works for them suffer and endure some of those little cuts of inconvenience. Whereas if the choice is they have no access to IVF at all, then were you kind of opening that consumer choice up where it will matter, people don't want to buy an IVF cycle, they want to have a baby. And if I, you know, look at some of the inconvenience and the things that people endure now to go through an IVF cycle, including traveling 1000s of miles, and taking off at 40 hours of work, per cycle, in order to go back and forth to the clinic to be monitored things of that sort, then, you know, I don't want to make consumers and patients decisions for them. I think that as you expand the market, you know, our big goal is to go from 3 million cycles a year to 30 million cycles. We've got to give a lot of different patient experiences, put them into the market, and let the patients slash consumers themselves decide.


Griffin Jones  12:06

You brought up the point of I don't want to make the patient's decisions for them referring to the travel agent model, but I can hear a number of RBIs thinking I make patients decisions for them. That's what my job is. What decisions are patients qualified to make? And maybe perhaps they're not qualified to make? Like, are we talking about picking their own PGT? Provider? Are we talking about picking where they store their gametes and their embryos? Are we picking where they're pharmacy to? What are what are we talking about


David Sable  12:44

all of the above? It's so amazing again, when I met Abigail, who had not yet had another than professional reasons to learn about it. She was incredibly knowledgeable about the process, the science, the medicine, everything there was I remember thinking, what was your healthcare background in college, this is like somebody who's like a pre med that decided to go into data and analytics. Turns out years an accounting major, pretty good accounting major imagine my patients knew so much about what they were undergoing that, why not entrust them with the ability to comparison shop for the best IVF process that works for them. Rather than have us decide for them. You look at the range of pregnancy rates from one cycle from one program to the next. And through the United States and through the world. Here we're doing about 2.6 million cycles per year, worldwide, hitting about half a million babies, tells us that our efficiency is somewhere between 20 to 25% per cycle worldwide. We know we have clinics here in the US that are doing 65% per single embryo transfer, if that embryos genetically normal. So there's an enormous range. So to think that the de facto proper way to navigate your IVF cycle is to put all the decision making in someone else that may turn out to be the case. But why? Why do we assume that's the only case. And again, this is within the context of trying to expand the size of the marketplace, to people who really, really need IVF not to have a baby or to have a healthy baby or to get pregnant at all by a factor of five or 10x. So it's the putting different choices out there. It's we go back to our old metaphor of we have an IVF industry that's the hotel industry with just the four seasons Is the Ritz Carlton. But we got a heck of a lot more people that need a place to sleep. And essentially, their frame of reference may be give me a comfortable bed, and a clean bathroom at a price I can afford. And they'll get the same eight hours of good sleep that you'll get in the Ritz Carlton. If we keep people the same probability of having a baby. And we're transparent enough in the marketplace the same way all other consumer marketplaces are going, then why not interest this the patients, again, because a lot of these people would have choice would have no choice at all, it'd be out of the market. And so I think that the REI is have done a fabulous job of making these choices up to now. It's great, and they should Oh, this should always be a place for them. And high touch high hand holding, kind of decision making for you service is fabulous the same way. There's still great travel agents out there. But it shouldn't be the only choice.


Griffin Jones  16:02

Well, not to defer to anecdotes. But hopefully to give some context, Abigail, during your journey, were there. segments of the journey where you wish that you had decision making authority that you could have opted for the option that you wanted? Or did you choose any options that are now informing how you view this from a business perspective?


Abigail Sirus  16:26

Yeah, and just to be clear, I do not have an IVF baby. I was born via IVF. So I can't speak directly to the process itself from that intimate of a perspective. Although, you know, who knows, maybe I will, I will one day. And I'll come back. And you know, we can have another discussion. But what I can tell you is just from observing the industry today, as David said, not only about the hotel chain model of making sure that there are the Holiday Inn expresses as well as the Ritz Carlton's, really, for us as well. It's about geographic access, and making sure that, you know, a teacher in Des Moines has just as much of a chance as having the family that she so desperately wants as anyone who's right near our office in New York City. And it's only by increasing that optionality and bringing services to patients through you know, at home monitoring and other innovations that we're seeing that we'll be able to bring those models to bear, which is part of what I'm so excited about coming from IBM, where we were doing consulting projects with innovative technologies, like blockchain, and AI and quantum computing, and starting to see some of those models take shape in this industry as well, is just, it's just the tip of the iceberg.


Griffin Jones  17:35

You talk about that there should be a gravitational pull for incumbents. That's the second principle of democratizing IVF. But is there often an inherent conflict from incumbent, Dr. Harrington sent me a book by Clayton Christensen, who is the author of a theory of disruptive innovation, or at least one of the theories behind disruptive innovation where he charts out the corpse of blockbuster and other incumbents that were simply dis their disincentivized relative to their current model, their expenses, their profits, their current obligations, against someone that's coming into the marketplace that doesn't have nearly as many obligations, they don't need to make as much revenue. They don't have current infrastructure as expenses. So you talk about using a gravitational pole for and comments or at least ideally, there should be one. But isn't there not one very often almost by nature?


David Sable  18:41

The agreement? It's great question and when we mapped out the strategy for reengineering IVF. The second principle really came down to the best what knew in the best circumstances, this will be steered, managed and navigated by the income. It's the people that know it best. You know, the experienced Ori eyes the best embryologists, but recognizing that there is a natural, rational and perfectly reasonable, kind of, you know, inertia towards changing the way you do things like frankly, when I was running a busy IVF program, I was making a good living, I was employing a lot of people. And I was busy as all hell. So if you came to me and say, Okay, it's your job to, you know, open up the world. So that the next million, 5 million 10 million people have access to it. I'd say listen, it's a nice idea. But where am I supposed to fit that into my schedule? So going from anecdote to generalization. You know, Eduardo Harrington is as visionary as any young Rei out there. And you recognize that you can't really rely on incumbents. So To do all the heavy lifting for you. So the way we look at is we can do with them, we can do without them, we can do it with the existing Rei infrastructure. And we try to make it in their best interest by looking at their operational capacity, looking at the limitations of the inputs, where they're bottlenecks are in their process, and trying to come up with solutions that make them able to expand what they do in a less costly manner. And they can decide to triage that input any way they want, they may decide to expand their geographic reach. If we cut the IVF cycle to three parts, retrieval and freezing being one part, storage being a second, and then thaw fertilization, development and transfer. Third, they may decide to have retrieval stations all over the place. And they may take their existing satellite offices and use them there. They may do alliances with large OBGYN groups in rural areas. To do them there, they could do them. alliances with other programs, leveraging the real estate that they have, they can use decision making decision support software to put 10 times the number of people through stimulations. And so the army on duty Rei on duty only needs to look at four or 5% of the results each day because the computer will make the same decisions that they are, you're all different ways that we can facilitate their operations. So in that way, we like to think that the incumbents are going to be served by innovation. But if they choose to keep things the way they are, which is perfectly okay, if some of these programs are doing fabulous patient throughput, terrific care, great results, then we can use these technologies to reach patients that have otherwise no choices by bringing other people into the marketplace as suppliers. In a way that maintains the quality of care, because we're gonna be using a different engineering, different data analysis, and different process optimization, try to arrive at the well, the well run IVF kitchens that exist now. So we can do them with these people without a lot of what we do in IVF is repetitive things that over and over again, a lot of embryology will lend itself to automation, robotics, things of that sort. So that way we can build the kind of bigger parallel industry that can take that next 10 million people in that aren't being served. And the incumbents can choose to participate wherever they want to. We want to make it easy for them to do so without giving them absolute control over who gets to be treated worldwide. Because again, what are we solving for? We're solving for access. And the size of marketplace not being served is a lot bigger than the size of the market currently being served. To the incumbent people. We embrace them, we want them to do a fabulous job. But we don't want to be in a position. And if we're acting as advocates for the unserved we don't want to give them control over who gets to be treated who doesn't.


Griffin Jones  23:32

Incumbents can be served by the innovation or it can be done without them. It sounds like you had a I wasn't at your talk at SRI. But it sounds like you were a little bit more stern with that message at SRI, what are the consequence? What did you say their first second, what are the consequences if they if they choose not to be a part of the innovation?


David Sable  23:58

Oh, it's a it's a competitive marketplace. You know, the right now we've got a small number of suppliers, with a enormous reserve army of new patients that are trying to get in and more and more patients getting coverage as well. Their coverage from employers, state mandates, things of that sort. I guess the the downside to not participating is you're locking yourself into a model that we may or may not be able to replace that you go into, you know, what are the what does a patient look at when they're trying to make a decision to how to navigate their journey? And Abigail and I came up with three key performance indicators. It's using an MBA term, but it seems I just saw the patients silently make these decisions. For the 20 years I saw patients dollars per baby time until they have a baby and the life disrupt Should they have to endure to have a day, every patient is solving for those things. And those are our North Stars in trying to kind of navigate or map out how we reengineer, the IVF worlds. So if the clinic existing now is operating at capacity, and they have full control over the pricing, it's exactly what you want as a supplier in any industry, you want to operate, you want to be as busy as you want to be. And you want to be able to charge what you want to charge. And this is not a value judgment, every economic actor is kind of solving for that. But they're operating within an environment where there's a cost structure, there's an access structure. And if people have no choices, then they're the kind of a, you know, they're at your whim. They, you know, the there, they have to serve under the parameters that you set. Now the markets can change. And if we put out a, whether it's technology, whether it's using AI, whether it's finding alternative practitioners, whether it's opening of centers closer to them, we're suddenly those dollars per baby time to baby in life disruption are much more skewed in the patient's favor. and to hell with it, I'm no longer going to the ball of the ball to buy a bookstore, to buy a book, in a big bookstore, I'm going to do it online, I'm going to download a Kindle file, I'm going to have all these other ways of fulfilling my need for a text file called a book, I'm gonna have all these other ways of fulfilling my needs to build a family. And the incumbents if they don't fund either change their marketing strategy, change the way that they fulfill that or, you know, maybe they maybe they're still doing such a great job, that people that want that higher touch, higher cost, higher travel type IVF experience will continue to come to them, which is great. It's a really it just puts that competition into the marketplace. That, you know, it's all doctors always say, no, we want the free we want free market medicine. Well, this is free market medicine. But it's free market in a way that the patients have access. And the patients themselves have choice. Not were the providers can rely on monopoly power to keep their keep their practices the way that they are now,


Griffin Jones  27:32

Abigail, are there some segments of incumbents that you see more vulnerable as others going back to the blockbuster example, that's the example that's always used in every business course is used in mainstream everyone knows that example. huge corporation in blockbuster, within a few years being totally supplanted by now a titanic Corporation of Netflix. But I think the story that almost no one talks about I don't ever hear anybody talking about is no that was HBO. So HBO live to tell the tale. And as far as I know, they're still doing well, I haven't looked at looked at their performance or their stock prices or anything. But as far as I know, HBO is still doing just fine. But that Netflix space in the market was HBOs to take and somebody came out of nowhere. Netflix and did it. But HBO had the same considerations. They didn't suffer the same consequences as blockbuster but they lost the land grabs, are you seeing some incumbents that might be more vulnerable than others and, and in different ways than just you know, being being supplanted? Entirely?


Abigail Sirus  28:48

Yeah. And it's funny, you bring up the Netflix and blockbuster example, because that's one of the first cases I ever read in college. But I think about it informed two ways, in terms of incumbents first, who are not going to be willing to innovate, and bring in new practices or new processes or see things in a different way, which I think of as blockbuster. They're the ones who are sitting there streaming was coming to a head, we were seeing, you know, it becoming less and less expensive, with the compute power becoming more optimized, and they decided not to change their business. And because of that, they were usurped by Netflix. But then we have also the incumbents who do a specific part of the process or have their specific niche, just like HBO does, and creating their own content and being extremely good at that, and creating a name for themselves in that way, who will continue to have their corner of the market based on what they do well. And so I think that for the incumbents who are choosing not to innovate, they potentially might be at the most risk. Because, you know, I think it's good to see businesses growing and changing and adopting new modalities in ways that might be better than they ever were before. But then there will also be the HBO models who are very good at doing so. specific things, maybe they have a specific capacity where they have a number of genetic counselors on staff, or they can focus on specific, you know, more complicated journeys than others can like an HBO model, and they will be able to survive as well. But generally, you know, I think we keep focusing, you know, we've we've got Thanksgiving coming up this week on kind of this pie. And speaking about these incumbents who have really in the scheme of things, just a small sliver of the pumpkin or pecan pie, but the the pie is quite large. And so I think that there's vast opportunity for incumbents and new players to come into the industry together, and to create innovation that can improve the patient experience and make it more accessible for all.


Griffin Jones  30:39

Let's talk about the third principle then of what needs to happen in your view, in order for that to still be successful. That which is that today's highest pregnancy rates should be the floor of outcomes for the future, that it's not about delivering a lower quality product at a lower cost. It's keeping the main metrics of dollars until baby time until baby and life disruption to baby at the forefront at the forefront, excuse me. But aren't those three principles very often in conflict with one another that if you reduce the time to maybe you might have to increase the cost of AV or vice versa.


David Sable  31:28

One of the things that we learned when we started examining the IVF industry, as an industry that eight years ago, is that it's really characterized by outstanding science and really mediocre engineering. It's, you know, the you look at you in my career that pregnancy rates when I came out were middle single digits by putting back three and four embryos at a time. And we didn't touch the egg. So the idea of sticking a needle into the egg to do insemination with the sperm was just beyond us, much less doing things like genetic analysis. So the progress has been just remarkable. And the fact we have anybody that can have a baby, that can create a baby, more than half the time with one embryo routinely, on average, is that seemed like a million years in the future, back when I started being exposed to this in the 1980s. But that being said, that means that someone has cracked the code to get that high. And what is engineering engineering is just getting everybody on board to these best practices to do is to do things as well as everybody else. And if our goal is which we think it should be that anybody that needs IVF, to have a baby has access to IVF, say to a baby, then we've got to proliferate these best practices. Now, there are some people who are more talented than other people for manual procedures. And if we look elsewhere in cell biology, and we look elsewhere, in manufacturing and engineering, we see that these things can be standardized, to using robotics, using machine learning, two way that everybody can operate at the highest level, we will migrate to that it's unavoidable. Every industry that's tech based does that. And the sheer size, the sheer enormity of the demand for IVF services is going to migrate the best clinics to higher and higher pregnancy rates, they're much higher here in the US than they are in the world average, you're very high in areas of Western Europe and parts of Asia. And that will it's just a matter of time, get up there, we will collapse the pregnancy rates always upward finish. Now that said that means as we engineer and as you do more and more process optimization, those rates will be even higher. And that leads us to probably the biggest innovation, which is really going to disrupt this industry and I also think is inevitable, unavoidable and an unequivocal good. Is that shows you how bad I am at writing articles because I completely buried the lede. But I wrote that because the real big point that I was trying to make is that we're gonna get to a point where the expectation for outcome is very standard, no matter where you go. And is high enough that we can risk manage in a way using very simple principles of finance. And we turn things around and nobody ever pays for an IVF cycle where they don't. That is the ultimate democratization of the process. That's where we really change the way we deliver it. And it's very, very, it's very doable. Just a question of how much time in there indeed We do see a conflict turns real choice as to how you want to run your practice how you want to deliver this. And, you know, in the interim, we will see a splintering, of which clinics do suck, do certain things, well, which ones adopt a more convenient model? Which ones adopt a highest possible pregnancy outcome with a super high price point model. And this is all fine. This is the market working the way the market should, you know, if you notice, we're not talking about forcing the insurance industry to cover things that the basic insurance model doesn't say that they should cover. We're not talking about convincing governments to provide price support, or provide supplementation for patients. This is really trying to go through a free market model. These things may be accelerated by governments getting involved maybe because they're concerned about population shrinkage and things of that sort. But ultimately, the to the individual choices that the existing clinics are not going to stop the movement towards a much bigger marketplace marketplace with lots of choice. And that choice will ultimately include completely shielding, the patients were having to mortgage their houses two or three times in order to do that next cycle, are people draining the life savings, and never ending up with the baby. And you know, what's the big motive, the big driving factor, there is just this enormous, enormous market of people that really want to spend money, want to dedicate their time and effort towards building and all of us your grip, and certainly you included who interact with IVF patients, that you can't underestimate the size of that motivation. This is not consumer discretionary. This is not choosing to buy a book at a bookstore on Amazon or downloading video text file from HBO or Hulu, or going to your closet and having VHS tapes. This is one of the prime motivators in life. So there's this enormous, enormous marketplace out there that's going to find out oh, by people creating we means of fulfilling these needs.


Griffin Jones  37:37

Does that mean that we should expect one of the factors to to improve before the others? For example, should we expect dollars until baby to reduce before we see time until baby to be reduced? Or both of those to happen before we see life? disruption to baby? Are we? Is it more realistic to expect one of those dropping? And then that setting the standard where the value add becomes in the other two segments? Or are we looking at technologies that could possibly reduce the concern of all three at once?


David Sable  38:15

Yeah, I think it's a Venn diagram where the three circles overlap a lot. It's like dollars to baby if a patient has to travel 25 miles to the clinic every two days to be monitored or needs to travel to another state to have the cycle done needs to stay in that state, then that's a dollars per baby and time to baby and definitely a life disruption to the you know, when we develop new medications that can be given orally instead of by shots. Well, those shots are real life disruption to baby. They're also very, very expensive. And there's only two companies that make those sets of dollars per day. The fourth thing is well, so it's I think that as you as you move one, it tends to drag the other two along. And it's not so much a conscious choice because implicit in these are specific things you're doing. You're moving your retrievals from the big, unbelievably expensive lab to a procedure room, because the engineering system is closed up. So the for the egg never sees the ambient air or light before it's frozen. Or you move the retrieval to your satellite clinics 10s or hundreds or maybe even 1000s of miles away so that you can better leverage the enormous lab that you built. And you can kind of defacto increase the capacity of your laboratory without building out without spending another 2500 for another square foot of space. You may be moving your storage somewhere else. All of these things are going to improve your operational capacity, improve your ability to grow By the service you're giving now, in ways that can turn into translating into offering your patient a better experience that's more affordable, or more risk managed, or closer to where they live. I think it's just kind of a virtuous ecosystem, where you start attacking these things one at a time. And they show up at all of these parameters, both for the clinic themselves, and for the patients, as well as being a motivation for kind of ambitious entrepreneurs outside the fields that say, Hey, you got all these people newly insured, all these people who state mandates, all these people that may be in other countries now need the service. Look, Japan is doing everything they can to make IVF more accessible. Let's build it and they will come because right now they have nowhere else to go. It's kind of it's kind of like virtuous ecosystem, because


Griffin Jones  40:53

it seems like it should be a virtuous ecosystem. But there are clearly challenges to integration. If that's the case. And Abigail, I want to get your experience if you see if you've seen these challenges with integration in other areas, because it seems like there shouldn't be a Venn diagram that someone that can come in and improve the time until baby would also help be helping reduce the costs until baby and, and limiting the life disruption to baby. And there's all kinds of companies at ASRM that are trying to sell into clinics, and I see them struggling selling into clinics or a number of different reasons that can be an a whole podcast episode. And I've probably done one or two, but they are struggling, even though I see the value that they bring they they reduce nursing workflow, they reduce the the legality and other workflow, not all of the workflow much of the workflow involved in third party cycles. They reduce what Texans did ographers and other support staff have to do, I think of these companies, and I see the value that they bring, and there have having a hard time selling in two clinics, partly because of its it's seen as an added expense. But also because it is really hard to integrate given the variability of clinic workflow. So it seems like it should be a virtuous ecosystem. But there's some roadblocks, and I'm wondering what you've seen in other sectors that might be comparable.


Abigail Sirus  42:39

Yeah. And for me, it goes back to my background and emerging technology and how tech gets adopted, really, I mean, when we think about it, I started doing blockchain back in 2016, which feels like a long time and blockchain years are in any emerging tech where, yes, of course, in the beginning, when you're changing the status quo and introducing something new, there is that friction in that hesitancy, especially when the incumbent clinics have a great formula, they know what they're doing, they know how to do it well, and they know how to bring in an optimized value for it. So adding anything to that or changing anything, can be, can be met with a little bit of, of that friction that I mentioned before. But as we see with kind of all the traditional tech curves going into, you know, any business school case, yes, there's that friction in the beginning, and you kind of go up into the curve where over time, as the technology begins to be more widely adopted, it becomes status quo, and it becomes kind of bundled along and become standard of care in this case. And so I think that we're just in kind of the beginning of that cycle of seeing some of these new technologies starting to take shape. And as the value becomes more proven, and as it becomes, you know, these are some of the best educated patients, I think it throughout all of health care. And they know exactly, you know, what's going on and where their money's going. And if they hear that this clinic over here is doing something that might have better outcomes than a clinic down the street, I don't think they'll hesitate to, to make decisions based off of that, and to also encourage that kind of innovation. So I think it's going to happen organically and naturally at first, and then quickly and kind of more all at once once things start to become status quo. But as for integration, integration is always difficult. But what I think is important is, is patterns do start to emerge. And so once some of these early stage startups, you know, I had the pleasure of walking through the SRM booth just like you did, and getting to speak with a lot of them. Once they start becoming adopted, you know, a couple clinics at the time, and start being integrated into their workflow, they'll be that much better positioned to integrate into the next one. And you know, as well as we do in this industry, there is some pretty significant consolidation. So just winning over a couple of those larger chains could mean that a lot of innovation is adopted at a faster rate.


Griffin Jones  44:53

Well, I see that but I also see a lot of steps back and I see it being I see it also taking several years. So I think of one company that's been around for many years that probably has half of the market share and does very well. And, you know, they and so there's probably okay, we get a few of the early adopters on board that will try anything. And then that provides the case studies for us to increase the market share. And then, and then they've got some rapid growth for a little bit. But then either it just, it just stalls because whoever isn't adopting, still isn't adopting, and and they don't see the improvements as dramatic enough to to make the investment. Maybe they're just incremental, or the consolidation does happen, Abigail, and then they they go back, it regresses because the the new partners coming in are cutting costs and say, you know, what, we just don't see this as dramatic enough. So is, is incremental one year after another possible? If so, it doesn't seem revolutionary, it seems like it's taking a really long time for many of these companies, or does it have to be so dramatic and so obvious to that? This is now the standard. And if that's the case, what's necessary to do that be given the variability of clinic workflows, if something is really going to be that dramatic of an improvement, that means it has to affect a lot of the areas of the clinic and lab, presumably. And in order to do that, there's a lot of things that need to be integrated. So, David, you've said on the show before, that the entrepreneurs job is to solve the chicken and the egg. But what about this challenge of of improving incrementally? When? If, if the adoption, the catalyst for adoption, is seeing dramatic improvement?


David Sable  46:49

You Yeah, well, like, like a lot of things successful only be in retrospect. Yeah, and we're going to look back at one point and find that it's gonna be an awful lot of overnight successes after 15 years work. The kind of cul de sac that everybody drives into intellectually, when they envision, you know, this kind of a sweeping statement, but I often see, when I discuss innovation with an IVF, is it's always done within the context of the existing clinic structure as it is now. And it's always okay, how do we go into these existing clinics convinced them to do something different. And I think that we may find that the innovation really reaches critical mass. And you see those revolutionary steps, when we start building that industry alongside the one that's there now. Now, this may be one of the large consolidated chains, and these are terrific doctors, terrific administrators, they may decide, you know, we've really reached a limit of kind of the limit of growth of what we're doing under brand name of what we've got. So we've got the four seasons there, let's build a nother system for a different marketplace. Let's take a critical mass of these innovations. 4567 have put them together in a way that really adds up to a substantial change in cost of development delivering the service, yet with the same outcome probability, you know, take this, the, the old thought that lower cost or more convenient, has to be a trade off between lower probability of the baby that's unacceptable, you've got to have at least as good a chance of having a child at the end of the whole process. But you know, there is an enormous industry to address that doesn't exist, right. And trying to kind of force feed incremental innovation into the existing infrastructure, the existing clinics as they are, or as they are consolidating. Maybe too difficult a way to get these innovations into play. However, like I've been, I've been talking to founders now going on seven years. And watching them as they evolve their business plans. And it doesn't seem like it's been all that long. We've seen some really great changes the way people look at these things. Like if you're looking at you, and I've talked about AI. And if you're talking engineering in the 21st century, you're talking AI, which What does AI it's math, but it's a digitalization, of which previously were just kind of our teas and all processes. But the all the Ag companies a few years ago had the same business model. We're going to go We ended, we're going to optimize one part of the process one part of the IVF cycle. And we're going to charge $1,000 per click to do, or $2,000, a click to do it. Absolutely unsustainable business, great engineering, great concept, you are making the process work better. But the whole idea of building a business around, when really what we're trying to do is drive costs down, it was very difficult to demonstrate the value proposition. But if you take those same capabilities, and you say, Okay, we're going to talk to intact the entire process. This is just bringing the data collection, feed into the computers have computers tell us those things that really make the process work better, make it work more efficiently, and really feed into dollars per baby time to baby life disruption. And let's reengineer the system itself, let's offer IVF places where it's not available to people that have no access to it that really want it that can afford it at a lower price point. And let's build that places where it doesn't exist. And we're gonna start filling in a lot of the holes around the existing infrastructure around the existing clinics and the clinic networks. After that, we've got the existing clinics looking and suddenly, wow, there's someone else doing this. And it turns out that some of our people, some of our market, maybe want to do that instead, maybe it's closer to where they are, maybe there's they could do the same get, they get the same probability of an outcome. And they're willing to do the trade offs of not having quite the same experience that we've been offering. And that way, that kind of parallel industry is going to flow into the existing industry. This is what I'm not smart enough to be able to predict it. What are you already know, that incrementally looking at people with no access at all. And we're trying to one after another build systems that can deliver that access to them. And actually can do it in a way that we can measure and we can process optimize, iterate in a way that the current kind of artisanal system doesn't let us do that I think you're gonna see in retrospect, that these things had really revolutionary effects. But you just can't map it out. It's going to happen organically. And when you look at the proliferation of technology over the past 100 years, how did airplanes go from the Wright brothers to the first jet for two years later, to what we have now, which essentially the democratization of air travel, including airlines that charge you to pick your seat, and have no food on board, you have to pay for every single bag you bring. These are things that evolve, because the technology was built in let it evolve into that. And turns out there was a market segment, looking for the first eyeglasses were invented in the 1300s took about 300 years before everybody over 40 could see. And, you know, it's it's a very, very long time to put these innovations into a marketplace. it up if you can see it a lot faster. Because there's an extremely fast proliferation of knowledge. Consumers know where to go for the information. And given the information of the the way information travels over the internet, things of that sort. This a very, very savvy group of patients is waiting for access to the waiting for access. And again, we go back to the desire to have a family. He is one of those incredible, you just can't. It's just this is not consumer discretionary. This is not something you could like people give this out.


Griffin Jones  53:56

So it could be the case that the disruptive model coming from venture capital becomes not one that says we're gonna create something that sells to all of these people or even sells this to the patients as a as as a direct to consumer base, but rather all of these booths that are ASRM are at SRM trying to sell to the clinics to improve these envision they themselves are now the model we create a model running alongside the the current model. That's how I see the 15 year hard work the 30 year 40 year hard work potentially being an overnight success based on your insight.


Abigail Sirus  54:42

And I mean to me Griffin a great analogy and one that's obviously used quite often now is electric cars like Ford and GM. Chrysler everyone knew electric was coming but decisions were made not to pursue it until they were forced to buy a new entrant coming and doing things differently inspiring change and having customers or in our case, patients demanding that new kind of experience proliferate in other areas. So I think we're seeing this in other places, it will be modeled here, as David said, hopefully faster. And so we can get to more patients as fast as we can. But I think that


Griffin Jones  55:17

that's a good point. That's a, you just made me think of something, Abigail, which is that I suspect that that part of the reason why Tesla was able to come in as the entrant there were is from all of the different vendors and companies trying to sell to GM and Ford and Honda and Toyota over the years to develop certain technologies. And that made it possible for Tesla to come in faster possibly to acquire some of those to, to, to integrate some of those that weren't happening and build a whole new model, which could be the case of venture capital coming into


Abigail Sirus  55:49

exactly. And we're seeing, you know, new clinic models emerging where they're bringing in these technologies, almost as if they're within the clinic's DNA itself, they're getting off the ground while thinking about re engineering processes that still have yet to be optimized that kind of some of the larger the larger chains as well. And so they're starting off on that front foot of the innovation as they go, which I think is going to be really exciting to see how they can grow and progress and continue to innovate, since they're starting in that place already.


David Sable  56:21

In the kind of unspoken on talked about part of this, as well as there's an entire industry of cell biology, feeding into biopharmaceuticals, for example, and all sorts of new types of fluid engineering, that is not operating in a vacuum, like IVF is just one more area of cell biology. And a lot of these technologies are mature, they're in place elsewhere. And we just have to cart them or put them in the lab, plug them in. And it can really radically rattled radically change the way a lot of the IVF cycles performed in ways that can benefit the providers themselves in ways that can provide new founders who want to build different delivery systems of IVF. And all follow them benefit the patients, their mortgage, they're better engineered, so they're easier to scale. Since they're better engineer, they're easy to measure the benefit from these are things that are gonna go into bringing that IVF pregnancy rates higher and higher, towards the towards emerging of kind of the emergence of a best practices, and then give us a springboard to keep iterating to keep reengineering, to keep finding the thing that's working the least. So we can inch that pregnancy rate higher and higher. Then we bring in our actuarial and financial principles, we risk manage the whole thing. And we build an entire different IVF industry, where you pay for baby instead of buying IVF cycles. That's what you want to you want to get people's attention, you start totally risk managing the process. You will see the floodgates. So


Griffin Jones  58:09

that's your fourth, that's your fourth principle that you talk about in your article and talk about burying the lead David, I buried the lead as I read this again, and think oh, this, this will get people's attention. So the fourth principle recaps what you just said greater certainty uniformly higher outcomes and improved data collection and analysis leads to actually actuarial quality data, which leads to better risk management, which leads to pain and getting paid for outcomes, not cycles, you pay when the procedure works, you really believe that that's not only possible but inevitable.


David Sable  58:49

Yep, absolutely. It's too important. It's to the people that are consuming. People are also very yet it's the the optionality right now. It's just unacceptable for most the idea that someone talked to me for that five, six years ago, they say, Well, what's an IVF cycle costs like the cost of a small Toyota. What's the big deal of this? Well, you go into a Toyota dealer with 15 or $17,000, you drive out with a car, you walk into an IVF clinic with 15 or $17,000. And you walk out with a possibility of having a baby or a 35 to 65%, possibly of having nothing other than endured a lot of inconvenience, a lot of heartbreak and set your financial stability back quite a ways. Now, that is a a need in a marketplace that screams for someone to open up that market. So this is something you're talking about with incumbents or without incumbents. This is something that really plays right into the The underwriting insurance playbook. If the traditional insurers want to assume that, so far they have not. So we've seen the emergence of a secondary market, people doing IVF and fertility only underwriting insurance, which I'm thrilled about, we're seeing some of the practitioners start to re explore using risk management. And these kind of risk sharing strategies. This goes back to the late 1990s. But it was done very poorly. And as the numbers get better and better, frankly, it's an easy thing to do. If no one else does it, Griffin Newman, Abigail and I all started our own insurance company. It's just taking actuarial data, crunching the numbers using some very basic insurance principles, sticking the margin on top, making everybody else pay a little bit more. So the nobody pays to get enough. And it's really kind of trying to


Griffin Jones  1:00:59

think of where the precedent is for that, David, I see the actuarial principle. But I think of if we have a tumor removed, and we undergo chemo, if the if the cancer comes back, we'd still pay for that procedure. If we pay a landscaper to install drainage and and level our backyard and the flooding returns, we still pay that landscaper, we might write a bad review. But this happens all of the time, in other segments where people are paying to have a problem solved, but for whatever reason it it still happens. So what makes this possible in IVF? In a way that doesn't seem to have been possible yet. And oncology?


David Sable  1:01:45

Well, I don't know if we want to trade anecdotes. But why. But I practice that I did surgery, it's like until the problem was solved. You paid your surgical fee, and that was it. You know, follow up problems, things that complications that things have brought you back or part of what you're paying for upfront. Yeah, it's it's certainly there may be, you know, co pays and things of that sort along the way. But we really, you know, we're talking about risk managing in a way to make something affordable and acceptable, can take away the big optionality with whether there's some small, you know, it's like administrative fee that goes into paying for IVF. And certainly, let's say there's a late pregnancy loss in the third trimester, tragically, how does that get, you know, internal internalizing for the system, these are sort of details, what we're talking about is the, you set up a pricing system for your for your based on your outcomes, and you define the outcome, however you want. The same way, you know, it's maybe it's like a warranty. Maybe, as we've mapped out for the disease prevention, part of IVF, which is a enormous another enormous industry, when to be developed. Maybe the pricing marketing structure is essentially a gym membership for the family. You freeze your eggs early, you go on birth control, all of your pregnancies occur, using IVF and PGT. Him. And you have a zero risk of having a baby that dies of sickle cell disease, as 9% of babies born with a do have childhood. That you pay a certain amount for unlimited access to the service. And since we know what the service costs to produce, and we know the likelihood, and we build our business over selling your lifetime of access to disease prevention. Pricing is really just it's just taking the cost of production, looking at the enormous size of the marketplace, bringing some creativity, and a little bit of fearlessness into addressing a new market, rather than trying to just make a little bit of a change with the IBM ecosystem is one that most people are not served with really. We're really trying to build an industry that doesn't exist. And a big part of that is that this whole part of what was offered the possibility of having a child or family to people that don't have access to and making it affordable. And we're not going to make it affordable by just doing what we're doing now. And putting a lower price tag on although that's one one way of doing that. Wherever you address another 1015 or 20 million people worldwide, for a million to 2 million more people who in the US is by tackling price and the patient's own risk. We attack that with engineering, we attack it with certainty and attack it with numbers. And it's a, it's very antithetical to the idea of this produce now. And yeah, this is a big idea. But if you talk to all the people that don't have access to having families, you know, they're very open to big ideas. And there's not a room in this industry, both for the people that are doing such a good job. As well as people are going to cover and address those people in our research.


Griffin Jones  1:05:45

We spend so much time talking about the four principles behind democratizing IVF, that we didn't even really get a chance to go into the map, it could be its own topic. And I would love to have both of you back on the show to talk about how you mapped engineering solutions to IVF success because there is so much in the lab in the clinic. And you really give some of the main problems with labor, with embryology, with medication, with lab space and complexity, that I think it merits its own topic. So I'm inviting you back in front of everyone. David, your invitation is constantly standing. But Abigail, I'm explicitly inviting you back with Dr. Sable. To go over just the map in a sequel part to this episode, if you would oblige us in the new year.


Abigail Sirus  1:06:44

I'd love to absolutely looking forward to


Griffin Jones  1:06:47

it. I'd like to give both of you the floor to conclude and in a way that either summarizes what you talked about today, or what you want people to pay attention to, either within relation to the article or other things that they should be studying up on.


Abigail Sirus  1:07:08

So to summarize, Griffin, my perspective is is simple. We continue to talk about the small slice of the pie and how to cram as much innovation and new thinking and bring integration into that sliver. But I think that there's such a broad opportunity beyond that. And that innovation will come from all areas. And we're going to see different kinds of businesses entering the market, challenging incumbents learning from incumbents. And hopefully our goal is that over time, what it will do is increase access to anyone who needs IVF that they can happen and have the best outcomes of anywhere in the world. So that's how I would conclude.


David Sable  1:07:49

Yeah, just reiterate to what Abigail just, you know, this is a if there's a entrepreneurially healthcare entrepreneurial playground that's more interesting than this one. I haven't found it. You've got an enormous enormous life moving need, with a huge population of people. We've got a confluence of terrific engineering, information technology and great science. That is this this is yet having been the I look back at the last 30 years when we've done it IVF is breathtaking. It's absolutely spectacular. What we can do to scale that is, you know, it's it is just such an opportunity to take fearlessness, creativity, and just a lot of heart, your heart knows brain and is looking looking for comparisons. Don't look at healthcare. Don't look at the IVF industry. Look at what we've done. You know, my first computer, I love putting a picture of it one of my one of my talks, my 1988 Commodore PC 30, which was a fabulous $2,500 computer with 10 megabytes of RAM, and one male, half a megabyte of RAM, 10 megabyte hard drive, and a 286 chip. And it was a great computer wasn't connected to anything else. And to think what that computer does, what you can do with $2,500, the computing world now. That's where we are in IVF. Now where that computer was, which was about 40 years ago. Look at the IT industry, look at the transportation industry, look at communications. That's the kind of growth we're going to see to helping people get pregnant and families which argue is just as important. And the need there'd be the desire to suck that entrepreneurial effort up into an enormous industry is there and that's the opportunity. And that's the kind of growth that you're really looking for in the next 1015 20 years. And I'll leave it at that. In Griffin I will say this again. You are the only person that provides this kind of forum to talk about this. So I always like whenever I'm on your show, I always want to back it up by reinforcing what you're doing. Because this is not a insignificant part of. So, you know, I could stick myself in there and just a plug for what you're doing, which is really, really necessary, really important.


Griffin Jones  1:10:23

I'm grateful for the plug, I hope to be able to provide a lot more coverage in 2023, as inside reproductive health expands its scope. And there's certainly no shortage of material to cover based on what we talked about today based on what else is happening in the field. And I look forward to having both of you back on the show. To explore this more. Thank you both very much for coming on inside reproductive health.


1:10:52

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 thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health



161 Is Time Running Out To Sell Your IVF Practice? Advice From Financial Expert, Richard Groberg

 Long-time fertility financial advisor, Richard Groberg, joins Griffin this week to review a Yale School of Management paper and to discuss whether the time is right (or wrong) to pull the trigger on selling an REI practice. What factors should you consider about timing, taxes, keeping a piece of the pie you created- and everything in between- on this week’s episode of Inside Reproductive Health.


Listen to hear:

  • What it really costs to sell your fertility business.

  • What hidden caveats to consider when selling an (even profitable) REI practice.

  • The reality of compounding growth in the fertility field

  • What the long-term hold principle means for younger fertility specialists who are not yet owners, but who may be on the brink of buying in.


Yale School of Management resource: https://www.readkong.com/page/on-the-nature-of-long-term-holds-holding-a-business-for-5835798


Richard’s Information:

LinkedIn: https://www.linkedin.com/in/rsgadvisorsllc/


Transcript


Richard Groberg  00:04

On a recent fertility sale, one of the internal discussions was, how much do I bet on myself versus taking equity in my acquire, which diversifies my risk? Because now, my results aren't dependent on much just my practice, they're dependent partially on 5 10 15 practices around the country.


Griffin Jones  00:26

Is it time to sell your IVF practice? Are you getting screwed over by not holding on to your IVF practice? Are you getting screwed over by being a young physician who isn't building equity in their own IVF practice? To begin with? I visit these questions with my guest, Richard Groberg. Richard has been on the show before he's been a Chief Financial Officer, he's been a for-hire financial advisor to help practices on the sell side to sell their practices and devalue them. And together we review a paper by the Yale School of Management that visits the pros of a long-term hold of a business when it might make sense to sell though I think Richards’s commentary is a lot more in-depth and interesting than what the paper has to that particular point. And the different things to consider when you're building an asset versus just trying to flip one. For those of you that have practices that are thinking about selling right now, this paper and this review is hopefully good news to you. I try to get more advice from Richard for younger docs than is offered in the paper. And we also get Richards’s insights on what he sees happening in the marketplace. Now as practices are selling, are they selling at rates as high as they were? Are? Is the buyer side starting to slow down our volumes starting to slow down what returns some practices are still getting? We get those today. And so I hope you enjoy this visit again with Richard Groberg. Mr. Groberg. Richard, Welcome back to Inside reproductive health.


Richard Groberg  02:07

It's good to be back riff and thank you,


Griffin Jones  02:09

You are a popular guest the first time I wanted to do this in a live event with you. I've just been so busy. I tell you audience; I will do a live event with Richard at some point so that you can come on and ask questions directly. While we're talking. I still want to do that. But in the meantime, I had to have Richard back on, so I was chomping to talk to him before the interview starts. Richard says Hang on a second, how are you slow down and caught up for a little bit. But today we're going to talk about the nature of long-term holds, particularly talking about a paper that came from the Yale School of Management on building a business or buying a business and then holding it for a long time. This is mostly about building a business and then holding it for a long time, as opposed to selling it or flipping it. And so I want to go through this with Richard because I think a lot about the younger docs that are not building equity themselves by building a practice and again, getting multiples down the line. And I don't know how much this consolidation happening in the field helps or hurts younger dogs, I have heard arguments made for younger dogs that they are able to buy into things that will be worth a lot more and then sell for a lot more later. But I don't know. So we're going to review this paper together. So and bring up some points for all of you. And then we'll share this paper for you in the show notes so that you can review it yourself. But let's talk Richard, about buying and holding a business and then we might be able to also talk a bit about some things that are either accelerating or decelerating in the field. Maybe it's a good time right now. But in your view, how do you Scott, how do you do summarize the pros and cons of holding a business?


04:19

Oh, Grif, I'd actually unpack this article from two perspectives if I'm putting on my pure corporate finance numbers guy hat on. One is every year my business makes money. What do I do with those profits? Do I Do I pull it out? Do I invest in something else? Do I buy a new sports car or do I reinvest in my business? And the second aspect is when do I sell and I think whether you're in the fertility business or another business, to the extent that you can reinvest your profits to grow your business profitably. It always adds value whether you're adding another doctor to fund growth, you're opening a satellite, you're buying equipment, you're expanding your facility. If over a period of time, that endeavor generates a higher return than the cost, you've added value to your business. And some of the great success stories in the fertility industry, Shady Grove, Boston IVF, others CCRM, in its early days have added value by reinvesting in themselves and growing, as long as you can earn a higher return than the cost, or alternative investments, that always is a positive, especially in owner operated businesses. The second aspect is the whole concept of do I sell? Or do I continue to grow my business? And that's related to the first answer, if you can reinvest in your business and generate an incremental return above your cost relative to the alternatives, you're going to be better off in the long run. Now, there are some caveats that the article talks about, which I'll double back to in a minute. But if you continue to grow your business versus Okay, I want to sell like the article talks about I have to pay lawyers, I have to pay accountants, I have to pay advisors, I'm gonna have taxes, am I really getting what I think I'm gonna get. And again, some of the great success stories in American business and in the fertility industry, are companies that have held long term. Now that that can change. When you and I talked in January, the market for PE back groups buying fertility practices was heating up, multiples were increasing. And when someone wants to pay you 910 1112 13 times your profit. And there are other factors that make you think about selling, I'm getting older. I don't want to be left out of the corporate consolidation. I have leadership issues. I need help with renovations. It's hard to resist that. But as the market pulls back, which it is now, people, I'm sure are rethinking? Do I really want to do this now? Or do I continue to grow my business?


Griffin Jones  07:24

So there can be conditions to sell? And that is part of the second part of the equation that you're talking about is when do people make this decision? But you also referenced the first part of growing the business investing in the business every year it's making money, what do I do with the profits? Do I invest? Or do I take some of it out how much of each the papers starts with this thought exercise, and it's an anecdote, but it's useful for people to think about, which is, think about where you're from, and our audience is from 75% is from all over the US and other 7% or so is from all over Canada, another 6% or so is from all over India, and then everyone else is from all over the rest of the world. And so think about wherever you are from Think about the wealthiest people where you are from. Are they employees of larger company? Did they do they flip businesses one after another? Or do they have at least one major enterprise of which they're still the either the largest shareholder or some kind of plurality shareholder? And I think of Buffalo New York, there's only there's only three billionaires in all of buffalo Richard so my list is a lot easier than somebody from Dallas or somebody from Las Vegas like yourself. In Buffalo. There's only three billionaire families the rich family which owns the very fortunately named by the way right that owns rich products. There is the Pegulas who own who now own Pegula sports entertainment which owns the Buffalo Bills and the Buffalo Sabers. But they've held the interest in their energy company is escaping me at this point and the Jacobs family who some of you know, the Jacobs family for owning the Boston Bruins, but before that they own Delaware North, which is one of the largest concession companies in all of the world and they still do and so so that passes that sniff test but Richard, can you give us more to think about if not data then other points for the best pathway to wealth being holding a business other than just the anecdotes phrase like that in the paper?


09:38

Well, some further anecdotal examples in our industry. Most of the transactions going on in the industry. The sellers are taking some combination of continued equity in their own business and or equity in the acquirer. And if you think about some of the growth A success stories of people who've built businesses and sold them. Most of those people are people who've made great wealth outside of ownership, the first thing they want to do is look for something to buy. Investment bankers, pe people, when they make their riches, they then want to own their own business. People like Griff Jones, rather than being consultant and working for somebody else, you own your own business and continue to reinvest. And so the world evidence is that when people make good money, if they're not holding their business long term, most of them that are really successful the second time around, are buying another business reinvesting in themselves through partial ownership, investing in the company that's bought them looking for that long term value. Now, there are a lot of good, there's a lot of good information in that article about what it really costs when you sell your business, you think you're selling your business at x times your earnings, by the time you get done with the fees and expenses and taxes, you're not getting as much as you think you're getting. Which is why, again, from a pure mathematical standpoint, if your return on reinvesting in your own business is higher than what else you can do with your money, apart from the social, the social equity value of building community and building Employee Relations and building community relations, it's always better off to wait as long as there's not a prevailing alternative scenario.


Griffin Jones  11:40

So what you're talking about Richard is substantiated in the article with the 2017 version of the Federal Reserve's evidence from the survey of consumer finance, indicating that US wealth predominantly resides with entrepreneurs and business owners, the top 1% of wealth holders in the US derive the largest percentage of their wealth from business equity, and other financial health as as, as opposed to residential equity or retirement assets. And,


Richard Groberg  12:08

you know, are people people who who earn high salaries and, and get sales commissions, they don't build long sustained wealth, unless they become owners, or they reinvest those profits in something that gives them ownership or long term value.


Griffin Jones  12:27

So maybe, you know what I do want to go down this rabbit hole for younger Doc's listening, I kind of want to save being prescriptive or even not being prescriptive, but giving younger ducks more to think about after we get more into the paper. But it raises a good point, which is, sometimes people do get money from other ways, then being the capitalist from the beginning, and then they become the capitalist. So in other words, may be one route, is to build a practice from the beginning and and then you're building equity from the start. But another potential way is you go work for someone else, like a dog, and earn a lot of money and minimize your expenses, and then start a group you open up a practice or buy into another venture, do you think one is usually better than the other? Well,


Richard Groberg  13:27

it's hard to answer that without looking at the other factors that affect it. For younger physicians in the fertility industry, the cost of getting in business, the cost of operating is very high, and you come out of school and med school and your specialty, and you have so much debt. How do I afford to open my own practice? How do I compete with the big group down the street makes it more difficult, and we've seen that in other industries. So there seems to be a movement away from younger doctors coming out of school, opening their own practices, versus going to work for somebody else. And, and hopefully, and I'm seeing the PE back groups, granting equity over time and options to the younger physicians, so they do have a stake and can build wealth. And it's not just about maximizing my current income, but at the same time Grif I am seeing some groups starting, that are backing doctors to open practices from scratch. I'm working with one now in the southeast and for them, and hopefully for a lot of others. It's not about how much what's the most salary I can make. But how do I earn equity and build long term value? But as I said before, it gets difficult in an environment where the cost of getting in business and staying in business is very high. And I'm competing again. Hands roll up groups with hundreds of millions of dollars of private equity backing, that can spend on marketing and recruiting and opening satellites much more easily than a doctor just out of school can.


Griffin Jones  15:15

Okay, so we have major expense considerations for doctors just finishing training, we've got other considerations for ducks to think in the when do I sell question that are within a few years of retirement, maybe they're within one or two years of retirement, and it's just getting to be to be a lot and, and there are reasons to sell that you brought up earlier. But what about the folks in the middle? In your view? They're, maybe in their mid 40s. They've been a partner for eight years, and maybe they have one senior partner, then they have two peer partners and then two associates on the way What about that middle group here is this is that really who the paper is talking to about holding their that holding their practice?


Richard Groberg  16:07

Yeah, I've had a few situations like that this year, where you've got to practice with a few doctors who are significantly older and closer to retirement, and other physicians who are 1015 20 years away. And interestingly enough, in some of those scenarios, where they've sold to the roll up groups, the younger doctors have retained a significant equity stake in the business to bet on their future versus cashing out. Whereas the older doctors would cash out. I've worked with other practices where absent what I call stupid multiples from the buyer groups, they're like, Oh, I'm 45 years old, I've got 1015 years at most, my practice is still growing, I still have opportunities, I have no interest in selling now. And I remember in one of my former lives grift when I was in the veterinary industry, and I was tasked with going out and buying practices for a corporate group, I need some doctor who's making a ton of money. And I basically said, unless you're ready to retire, or have some strategic reason for wanting to sell, there's no reason for you to sell. Here's my card when you're ready, call me. Because they're making too much money, there's too much growth, they can reinvest incrementally, profitably, again. But doctor can open a satellite and a physician and generate enough incremental business and grow his or her practice or change your quality of life by not being the only physician. The value added there is better than I'm going to sell, pay all the advisors pay taxes. And then what do I do next? Where am I going to make this higher return as my business.


Griffin Jones  17:58

And that ties into performance. The paper also talks about compounding and of course, compounding capital as a surefire way to accumulate wealth that's discussed anywhere that wealth is discussed. But in the paper, they talk about the concept mathematically, and they illustrate it by depicting the growth of $1, over 25 years, at 15% interest per year, initially, barely any interest is paid. But over the 25 year holding period, the initial investment soars to over $32, the first 15 years representing 60% of the holding period, show the first dollar have grown to $8.10 20 for 24% of the total capital growth in the final 10 years, that $8.10 More than quadruple to $32.90. And a full 13% of the total growth occurs in the final year. So translate that for the rest of us that are not CFOs, please.


Richard Groberg  19:06

Well, that example is a little bit sort of mathematically theoretically static, in that if you're reinvesting your money, and you're earning 15% a year, that that's the case, unless you're investing in bonds or some interest bearing account. That's easy math. But that doesn't necessarily apply, if I'm reinvesting in my business, unless I can earn those kinds of returns versus pulling the money out and putting it elsewhere. But there are also some tricks of the trade if you're if you're opening a new satellite, there are expenses to open it that get deducted for tax purposes, that you're generating the incremental revenue. And if you sell a year from now with the same multiple you could sell now But you added $1 of men earnings than you're worth $10 more. If you wait two years, if you keep doing it over and over again, you get the same compounding effect. The unfortunate reality is that for the average fertility practice across the United States, and frankly, for the average roll up group, unless you're doing something unique, and you're adding services, or you're again, opening satellites, adding doctors, it's hard to generate a 15% compounded return year over a year. Again, unless you're doing things like some of the great success stories have done, or, again, companies like engaged MD and others that are increasing their number of subscribers and increasing revenues by reinvesting constantly in marketing and sales people and adding services. I hope that I hope that answered the question.


Griffin Jones  21:03

It helps to illustrate the concept in a way that isn't like the example that's often used just about compounding interest, how much money would you have if you compounded a penny every single day, if you just started off with one penny on day one, and on day two, you had two cents, and on day three, you had four, etc, etc, that by the end of that it's in excess of $5 million, I believe. But of course you're not you're not doubling money every single day in any kind of investment or owning a business or being in stocks or even writing the crypto wave really. But the so you help to give more context to that example of that. That's how compounding can work. But it doesn't mean that that is the way that it always works. You talked about what do you do with your businesses making money? What do I do with the profits? Is there a way of thinking about it? With regard to how much one should invest? Other than the other side of it, which is this is how much I want to withdraw for personal expenses. I want the Tesla now I want the vacation home, I want to go to Bora Bora. Is there a way of thinking about how much money to reinvest versus how much to distribute? And at what point?


Richard Groberg  22:29

Yes, the practices that I work with that are not sale assignments, but looking to grow and expand. It comes down and in any industry, it comes down to a fundamental, you know, a doctor says I want to add a doctor, but I can't afford it. So okay, how much is that doctor gonna cost you? And how many more cycles-starts? Do you have to generate a month to pay for that and be incrementally profitable? Or I want to open a satellite? Okay, well, how much is it going to cost? What's my overhead gonna be? How much more business do I need to do to be profitable? And what's the likelihood? Or I want to buy a piece of equipment? Not because obviously, safety and patient care is always first. But someone says I want to buy a piece of equipment because it can do extra me. Okay, well, how many more of those procedures will you do a month? How much are you going to charge? And is it profitable. And if it is, then assuming you don't have other things personally, you have to do with your money, it'll that investment will make your practice more profitable. And if today, your practice is worth a multiple of x, as long as that x doesn't change a year from now, if you're making $1 more than your cost, then your business is a bit more valuable than it was today by reinvesting in it versus taking the money out and doing something else with it.


Griffin Jones  23:59

I suppose that this could be an entire episode in and of itself, especially when we talk about satellite offices. You talk about forecasting of this is how many more procedures I expect to do this is how much more revenue I expect to Bill. Is there also a way in perhaps it's just going against those projections in real time. But whether you cut losses on an investment because I think that's one of the things that make people perhaps want to sell sooner is like well, I could invest in the business in this way. But if I am wrong, and I don't make $1 more than I did last year, because the expenses are more than that set on that satellite office then we expected that they would be how should one review that perhaps review the forecast to decide okay, this is this is something that we were right up out and we should keep going or, or, or bail on. Where? Because I think satellite offices. This is anecdotal. So I don't know if this is true, Richard, but it seems to me like they get let go more frequently than they make it a year or two. And maybe I'm wrong about that. But how can people make more informed decisions either as they're forecasting, or they already have forecasted and open, but they have to make a decision on to, to continue to investor cut their losses?


Richard Groberg  25:34

Well, any kind of decision like that there's a judgment call, people need to do their homework, if they're opening a satellite or adding a doctor, they need to weigh demand and potential demand and weigh the risk against the costs. They need to have the wherewithal to make the investment and bear the risk that maybe instead of taking one year, it takes a year and a half or two years. But that does need to be weighed against the alternatives. I mean, I could argue the other side of it, some people feel, you know, something, I work in this business, I make my livelihood, it pays my salary. Maybe I need to diversify. On a recent fertility sale, one of the internal discussions was, how much do I bet on myself, versus taking equity in my acquire, which diversifies my risk? Because now, my results aren't dependent on not just my practice, they're dependent partially on 510 15 practices around the country, and the ability of the corporate group to do some things, or, you know, something, I'm going to put the rest of my money in the stock market, I want to know a very famous broker, who would not buy one stock ever. Because he said, I make my living on the stock market, if the stock market goes down, my livelihood gets hurt. So my profits from the stock market, I put in real estate, so I'm diversified. So there is no one right answer. But I think it should be balanced. But I also think that there's another concept from from this article that I think is important is that if you're building your business to be fundamentally sound, and not be dependent on a flip, then you can weather a storm. You know, look what happened in 2020. With COVID, a lot of businesses that weren't prepared to weather the storm in various aspects of the utility industry were hurt 21, it rebounded 22, as an industry has been a little softer. So if you're fundamentally sound, and you've protected your downside risk, then it's not about what I'm going to get bailed out, because the next roll up group is going to pay me an insane multiple, you don't have to sell and when the time is right, and the factors, say this time, then I can choose that decision versus being forced to.


Griffin Jones  28:12

Let's talk a little bit about taxes. And I'll come back to other parts of the paper. But we talked about diversifying risk, we talked about compounding one consideration in how much money that one makes is how much they have to pay in taxes. And so can you talk a little bit about the advantages of holding business versus not with regard to tax?


Richard Groberg  28:37

Well, when you decide to sell, even though in today's market, people are taking some retained equity in their business stock in the parent, which usually can be tax deferred, the cash portion of what you get is going to be taxed. And that means that your net proceeds are less, there are always some strategies and tactics and things that tax experts and tax lawyers can do to minimize that. But you don't get what you think you're gonna get. Versus Holding, holding, holding. Again, you build a very valuable business, you always can borrow against it to create liquidity. There are things that you can do without selling, paying taxes and having a lower net proceeds. And again, depending on what state you're in, it can be painful California. If you're selling your fertility practice, between federal and state taxes, it's a pretty painful number. And a lot of people don't set up their corporate structure preparing for that. And then when the deal happens, they realize oh my goodness, I'm not getting what I think I'm getting. But again, it also comes back to why and myself Like, if I'm selling because I'm older, and I'm closer to retirement, and I need to diversify, I'm worried about competitors coming in my market need a big brother behind me. Multiples have gotten so high that I'd be crazy not to sell part of my business, I need to build a new facility or renovate, then you take into account the tax aspect. And you just understand that I'm gonna have to pay what I have to pay. I want to make another point there. To the extent you're reinvesting in your business in a way in which you get deductions, then when you sell some of your taxes or long term versus short term, if we go back to my example of I add a doctor, physician, and the physician costs me, let's say it's a major urban market, by the time I got them with salary, benefits and malpractice insurance, they're costing me over $400,000 a year. But I generate enough incremental revenue that I'm profitable, then my revenue and expenses are proportionally balanced, I've made $1 more, if my business is still worth 10x, then I've added $10 in value that will be taxed as long term gain versus income short term.


Griffin Jones  31:28

And I suppose there's also the benefit that a business owner has. And in order to be able to deduct some of the expenses that we talked about, in our previous episode, where you were advising on categorizing as one time expenses, these are things that maybe maybe it was a business trip, that was kind of a business trip, but kind of a personal trip. And and I don't even know if the paper is talking about that kind of tax advantage.


Richard Groberg  31:57

No, it's not. I mean, it's like, again, if if I had a doctor for Doctor cost me $400,000 a year, and I generate enough cycles, that my profits, my revenues are $401,000 a year, I have 401,000 of revenue, I have 400,000 of expense. So but I've added $10 of value to my business if my business is worth 10x, because I have $1 More net profit with that new doctor. So I've offset the revenue. So I've got no tax impact. And I've created $1 More of long term value.


Griffin Jones  32:36

To give some more context to the paper as well. They're not talking about businesses that are suffering for a long time that aren't creating value that have a poor investment thesis. They say that a business that is slog through for five to 10 years without really getting off the ground should be liquidated or exit even then I don't know that that's totally obvious of what that is, there could be some, there still is a line that says well, it's making a little bit of money is it worth getting rid of and moving on to doing something else. But what they're talking about is healthy business with a tenable investment thesis that is improving their revenue consistently should not be sold just because of a 60 month period of up and down what they are talking about in terms of really good business to hold on to is one that is capable of generating mid teen returns on equity for at least a decade with a path forward for equally desirable returns, in your view from looking at a lot of clinics, books. Are they doing better or worse or around that?


Richard Groberg  33:51

As a general industry? 2021? I would have said yes, in the post COVID recovery. Most of the industry statistics say in 2022 in general No. Of the eight practices that I'm currently representing one way or another, some are growing significantly. Some are relatively flat. And there's a whole host of reasons why. So every business is unique in that regard, but as an overall industry. They're not growing that dramatically. Which by the way is part of why recently the PE back roll up groups are starting to pull back from being as aggressive, lowering their multiples that they're willing to pay. And some of them have even temporarily paused in the market, because the growth does not support the valuations being paid because practices aren't growing double digit like they did in general in 2021.


Griffin Jones  34:57

So there's a bit of a Yeah. I don't want to call it, Jacqueline. No, I wouldn't. So there's a bit of a catch 22 in that if you want to diversify and reduce some risk by selling at a higher multiple, because you're not doing as well as you were last year, well, the buyers are also seeing that. And so there may have been a six month window, where there, people could have said, you know, what, I probably only have about two years left or three years left, and I don't know how long this slower growth or flatlining will continue. But now, buyers are potentially seeing that as well, from what you can tell.


Richard Groberg  35:43

Yes, I mean, if I'm a, if I'm a fund that invests in the PE back roll up groups, between the slowing economy and slower growth in general, the utility industry and higher interest rates, you know, how do I justify the valuations on paying? Now, having said that, the and we talked about this last January in our podcast, the premise that one of these groups will find some economies of scale, and value added, above and beyond an individual practice, that hopefully will make the corporate group and the underlying practices more profitable over time than just going it alone. But like any other investment, stocks get overvalued. And they eventually correct back to a rational place. And that's going on now. Because just like the individual practices, the corporate groups have to ask themselves the question, if I'm reinvesting all my profits to buy more businesses, am I generating a higher rate of return than doing something else with the money? It applies to everybody all the way up and down the food chain.


Griffin Jones  37:04

And from the seller side, we talked about taxes being one of the things that they have to consider. But there's also transaction fees that the paper discusses. So how significant is that? And How significant are transaction fees when a practice is selling their practice? And how significant is it when they're selling part of the practice that maybe they're not totally exiting, but they are selling a controlling stake in equity, maybe even a minority stake in equity, are transaction fees similar in each of those cases? Or do they vary depending on how much of the business someone is selling?


Richard Groberg  37:48

Well, if you're selling a minority stake to an associate, or partner leaving is buying out another partner, the fees are much less significant. And I have some of those clients and you manage it properly, it doesn't get out of control on on sales to the PE back groups, even when the selling doctors are retaining equity in their practice, equity in the buyer or both. The fees can can be very significant. The buyers hire an outside accounting firm that goes through your numbers with a fine tooth comb to make sure everything is recorded properly. A lot of businesses are on a cash basis and need to be converted to accrual basis, you have legal fees, you have an unbelievable burden of document requests that burdens the practice manager and other people. And if you and then of course, you have fees to the advisors, people like me and others in the industry that helped guide through the negotiation process. And then the lawyers and accountants, you know, it can get expensive, but you only do this once. So making sure that you've got good counsel and good accountants and good advisors is worth the investment if it's not getting out of control. Because if you're still going to own part of your practice afterwards, you got to wake up the next morning and know what the deal is with the person you're now working with, as opposed to being on your own.


Griffin Jones  39:24

Well, so do you only do it once? Or is there more transaction costs to consider if I'm selling a controlling stake in the practice now I'm selling 60% of the practice. I'm retaining 40 Do I have to expect the same transaction costs to be incurred the next time? When


Richard Groberg  39:44

what no because what typically happens is, let's say one of my recent transactions. That was a multi Doctor practice where two of the doctors were older and closer to retirement, but there were younger doctors. They sold the practice They took some equity in the parent and they took back 40% of the practice going forward, which differed a bunch of taxes, and gave them an incentive to grow their practice, but also gave them the diversification. The documents themselves were such that when one of them's ready to retire, or a new doctor physicians coming in, that they want to sell some equity to the documents were so thoroughly negotiated, that there might be a little bit of legal work internally, but not to the extent of I'm selling all over again.


Griffin Jones  40:33

Do you want to talk about the idle cash? Because I don't I want to I wanted to ask you about it. But I don't totally understand it. The idle cash part of the paper?


Richard Groberg  40:44

Yeah, I mean, especially if a business is expanding and taking risk, like you talked about before, I think it's important to keep reserves in the business. In case things don't go well. But if you keep too much reserve in the business, it's what's called dead money. So if if interest rates are one or 2%, you're keeping a whole lot of money in the business, you have to say to yourself, oh, if I pull that money out, what else could I be doing with it? Could I earn a higher return somewhere else, versus just letting it sit there and not be reinvested or in return. But again, it's very important. And I'm a big believer that businesses should have some cash reserves. Because you never know what's going to happen. You never know, when the next COVID happens, or you get seven feet of snow in Buffalo, and you can open for a week, or, you know, I had some businesses in Staten Island where they had the hurricane come through a few years ago, and they got flooded and took six months to get insurance money. So again, there's no black and white there. But cash just sitting there not doing anything isn't earning your return.


Griffin Jones  42:02

So I think what the paper is talking about here is that there's also risk of have the opposite of that wretched. So if once you if you do sell a business, you don't want to just have it do nothing and not compound. But there's a risk in the redeployment of that cash that finding a new business to start or purchase is hard work requires a lot of time. And there's also a high possibility of false starts. So you have something right now that's making money, maybe it's making 10%. Maybe it's making 5% compounding year over year, maybe maybe some years, you're doing really well. But if you sell it, and then you have to make the decision of well, it's not it's you know, it's gonna make one to 2% in a savings account. What do I do with this money? Now, in terms of how I redeploy it, it takes a long time to start another business or even find one that's worth buying.


Richard Groberg  43:02

Yeah, that's what I was thinking about the other aspect of idle cash. But that's true. And you and I both know, some people from the industry who sold their businesses for a significant amount of money. And then they're scratching their heads, what do I do with it? Do I speculate, where can I reinvest it? It's not earning much for me anymore. And some people make colossal mistakes in that regard. It also depends on where you are in your life. You know, if you're 60 years old and closer to retirement, you're going to be more prudent with it, then, you know, I just cashed out and I'm 35 years old, and what am I going to do and there are some great success stories and there are also some people who've gotten in trouble making rash mistakes.


Griffin Jones  43:54

So that has to do with the the redeployment risk of the money, there's also redeployment risk in choosing a venture. So if you have a practice that's doing really well, and you think you know what, I can sell the practice right now. And then I can start a company that is maybe I start a surrogacy agency or I start an AI company or I start a finance company for fertility cycles, that I'll just take that money, and I'll I'll start the next venture. But this paper talks about the redeployment risk in doing that, that that is far from a guarantee that just because one person was successful at an untrue entrepreneurial venture in one area, that they will be in another for a prolonged period of time.


Richard Groberg  44:50

Right. And you just brought up a good point, which is the redeployment of human capital versus financial capital, someone who started and ran their business and may have A lot of money. Getting there are two aspects is what am I going? Where am I going to redeploy it? But where am I going to redeploy my expertise, and my passion. And sometimes those two can be in sync. And there are some great success stories when that's happened. Think about Mark Cuban are some people in our industry who've done things successfully one time and then redeployed in a different area, and there are others who were doesn't translate.


Griffin Jones  45:29

So now let's start to explore when it is time to actually sell. So we talked about risks to selling we talked about the compounding benefits of holding on to a business, the paper says that we think keeping a business that is performing well has a durable investment thesis is a privilege and is an economic golden goose that should be nurtured, pampered and retained for as long as possible. Doing so provides a few other primary benefits, like we talked about avoiding transaction fees, avoiding tax fees, and or avoiding certain taxes at certain times. But as you mentioned, there still can be a time to sell. So let's pretend all of these things are the case, Richard, that that things are still going well, is there? Is it still? Is there still a time to sell. And let's pretend everything was like how you saw it in 2021. And it was year after year after year, is there still a time to sell? If things are mid teen compounding returns every single year,


Richard Groberg  46:41

I think there are a combination of factors which lead people to sell. And this year, even with the market now pulling back, there's still people doing and it's usually not one reason but a combination. physicians who are getting closer to retirement, thinking about retirement diversification concerned that they don't want to go it alone. The some of the big groups are going to come into my market. And while I'm still growing, and doing well, I need a I need a strong partner to help me. I need to renovate my facility or build a new one. I'm having a hard time recruiting. There are some practices where you and I know where a doctor was 60s partner was retiring, he had a hard time recruiting, he wasn't ready to leave. So he sold part of the practice. Or the practice has problems that the current leadership can't solve that perhaps. And then of course, if you take any combination of those factors, and then valuations are high, you know, if I've got practice growing double digits, and that's a multi Doctor practice. And someone's only willing to pay me five or six times, well, I might as well keep going. But if I have a multitude of those factors that are weighing on me, and valuations are still strong, and some of the subjective factors meet my objectives. While it is still time to sell. And even with multiples coming back to reality, there are still practices that I'm working with that are selling because they want a combination of those factors. And then they figure out how do I minimize my taxes? How do I diversify my risk? How do I still own part of my business so that because I still believe in it. And by the way, some of the practices that I'm working with are still on double digit growth paths, but meet some of those other objectives. And their attitude is, well, if the price is reasonable, and I have the right partner, and I still retain part of my business, it makes sense to do it. If not, I'm growing 15% per year, so I don't have to sell I'll wait.


Griffin Jones  49:03

That level of growth. And those concerns seem like they should address each other meaning for practices that are growing 10 12% 15% year over year, it seems to me like it makes sense to solve for a lot of the issues that you talked about while they're having that level of high growth meaning they get to a point where they don't want to face competition. They are there. They're getting close to retirement but they're having a hard time recruiting ducks to come in. Maybe they're having a hard time recruiting other staff like embryologist it seems to me like solving for those issues investing in the the company while they're doing that well make sense to do because a lot of times people will say, Well, we're growing so much anyway, why do we need to invest in these areas? because eventually you get to a point where that might force your hand to sell, it seems to me. And it seems to me that if they do invest in those areas that they're not as pressured by this sale and an answers to some of the question of how much do I reinvest in the company right now?


Richard Groberg  50:22

Well, in most cases, when they're getting that kind of growth, unless there's a very strong other factor, it probably makes sense to wait. I have a few situations where the combination of factors is such that okay, I probably could wait. But because of my growth, I'm going to get a higher valuation and cut a better deal and get the help I need but still own part of my practice. So, you know, I like to say there's a reason why they're 31 flavors and Baskin Robbins, everybody likes it differently. So depending on which who the group is, the answer might be a different answer. But again, the longer you wait, if you're growing, the more valuable your businesses on a pure economic basis, the way this Yale study is calculated, which is, which is an accurate way to do it.


Griffin Jones  51:19

I'm stepping away even from the sales question for a second, going back to the reinvestment section for or the reinvestment thought for a moment, which is, if you have a practice or a business, whether it's in the fertility field or anywhere else that has mid teen returns compounding year over year, and really isn't the investment, just making sure that that thing goes on forever. Don't you just want that to go on forever. And I guess it gets to a point where if you start to see some growth, that's a lot higher, like a lot of people saw in 2021, a big jump in the end of 2020. over the previous year, doesn't it make sense to say, you know, what, what we're trying to do is preserve our 12 13% growth year over year, anything after that is going to go back into investment into making sure that we're that we're doing that for the next five and 10 years,


Richard Groberg  52:16

if you have a valid place to put it. Yes. So let me give you an example. I'm working with a company in another industry that has a bunch of retail locations. And last year, the business was at breakeven, the business has tripled, it's making a lot of money. Every dollar has been reinvested this year, to open more locations to replicate what it was doing. And by the end of the year, it'll have twice as much revenue and be twice as profitable. And instead of pulling out $3 million, that $3 million is being reinvested and probably created $10 million in value to the owners. Now, a year from now, the investment proposition may not justify reinvesting. So there's, you have to reevaluate all the time, whether I can make more by reinvesting then doing something else with that money.


Griffin Jones  53:14

So those things are immediately obvious in terms of where you could reinvest your money. There's other things that maybe work but aren't as obvious as if we open up in this location, we'll get this many more patients right now. Or we can hire this doctor right now and see this many more patients and do this much more volume. But I think of things like, Oh, if you were doing really well, in 1996, maybe you didn't need to buy a website and invest in having a website, but by the year 2000, you you needed to have it. So do it in 1996, even though it's not a place where you have to put your money right now, but in a few years it will be or social media in 2012, let's say but then by 2017 or 18 is you're not attracting nearly as many patients if you don't have that and or all of the things that are necessary for recruiting young Doc's that might not be a place that we have to put our money right now. But in order for us to not become the older group that has a hard time competing for the newer talent, we have to make a couple of changes. So what about those investments that good point that aren't as immediately obvious.


Richard Groberg  54:39

So if I put my financial geek hat on, and someone says Look, I need to hire Griffin, I need I need to build a new website. I need to have a marketing campaign. I need to figure out how to convert more of my leads into interest into actual cycles, new patients and cycles. At the end of the day, while there's not a black and white answer you still need to die would do the financial analysis, what's it going to cost? And over time, is it going to generate more more patients for me, which results in revenue, which results in profits, which makes my business more valuable. And those often are not short term decisions. But if I've also seen the other side of the equation where someone spends money on something that feels good, but if it's not good, either improve the quality of medicine, improve the quality of customer service, or bring more customers or revenue in, you have to question the economic validity of making the decision. That makes sense,


Griffin Jones  55:48

it does make sense and to me, it hits the nail on the head of what makes the best visionary entrepreneurs is they can navigate those decisions, when the clearest, and most obvious data isn't in front of them in that people can err on the side of well, I can't make that calculus right now. Because I don't know what the return will be. And then they end up not investing in the things that allow them to continue to appeal to the people that they're trying to recruit to come work for them, that people that can that become their patient base in the future, because they're doing well attracting patients right now. And then just over time, they become the less desirable group and their volumes decrease and, and then you get to the 2022, end of calendar year where they are in the group that you're talking about that isn't doing as well, because they didn't make those decisions five or six years ago, and or maybe even two or three years ago. But you can also err on the other side, like you said, of people that just throw money away. And, and there's a lot of faux entrepreneurs that do that. Because this lol This is an investment. And it never pans out to be one. And I think the best visionary entrepreneurs are the ones that make those decisions without airing too far on either side of the spectrum.


Richard Groberg  57:18

Right? Typically those kinds of decisions, you're going to be 51% right or wrong. But you've got to think about what happens if I don't do it, well, I lose business. If I don't make this investment. If I don't update my website, if I don't figure out how to convert better. If I don't improve my lobby, am I going to lose business. That's the same economic analysis, it just works in reverse. Not how much incremental revenue and profit am I going to get? How much I gotta lose, if I don't do it. And great leadership, you can't great leadership, you can't just live by the numbers, you can't just live by the seat of the pants, and I'm gonna hold my finger up in the air and see which way the winds blows, you have to look at both and make balanced decisions. And if you're taking a huge risk, you better have the wherewithal to withstand the storm.


Griffin Jones  58:17

And I would define a huge risk as something that that bets the farm. And if it has to do without, do I just take out a bit more profit this year, and you don't really need to take out a bit more profit than my gut tells me to reinvest back in the business. And that's if it's, if it's something that's if you're if you're kind of on the fence, and you don't totally, you don't really need the profit, then if you make five of those decisions, it's likely that one of those is going to have a Pareto effect distribution where it's truly significant for the business.


Richard Groberg  59:00

You know, again, without revealing anything confidential I know over this last year or so you've done that you've reinvested in staff and other things to expand your business and make your business more valuable by being a more robust greater depth service provider to your your clients.


Griffin Jones  59:21

I think about the the building the business in this way of having a hold asset and that's why I wanted to go over this paper with you and and like you said that applies to me with what I'm doing with my business. It applies to a lot of practice owners. When I first wanted to talk to you about it, I thought of the younger Doc's that have not bought in yet that are about to buy in. And I don't think this paper really speaks to them. So what do you what do you think this paper means for those folks? So that's who I was originally thinking of the folks that are me Be they've been in associate for two year three year, they have the chance to buy, they either have the chance to buy in, start something on their own or, or buy in or work for a new network group. And so what do you think this long term hold principle means for the folks that are not yet owners, but are on the cusp of potentially being owners,


Richard Groberg  1:00:26

I think in the fertility industry and other health care businesses, where the practitioners are the primary drivers of the business, in the long run, if you have any kind of ownership mentality, you care about your business, you want it to do well. And it's not just the job, you're not going to build the same kind of wealth, just taking a salary, maximizing your income, as having a piece of your own business, whether you're starting your own practice, you're starting a practice backed by one of the groups and I've got a client doing that, or you're opening your own business, the concept applies if you're, instead of making $500,000 a year, if you're making $400,000, you're here. And that other 100,000 is building equity in your business. If you believe in yourself, and you're building business value, then somewhere down the road, you're going to be worth much more money. And frankly, from a from an self appreciation standpoint, you've built something that's partially yours, you're better off. Now that needs to get balanced against do I open my own practice? And where do I get the money to do it? Or do I work with one of the groups and make sure that they give me equity or options or those kinds of things. But again, I've worked with physicians who want no part of that. But for the most part, physicians in this industry and other practitioners are so dedicated to the craft, that why would they not want to own a piece of what they create?


Griffin Jones  1:02:03

I think it is okay to not want a piece of it too, even though the evidence that we've gone over today is dictated that the people that make the most are the capitalists, the owners of the capital, doesn't mean that everyone has to do that, and you can't have a really good life. If you don't do that. I also think it's true for some business owners that as long as they don't walk away with lots of debt visa, as you make some money for a while, you can still go back to the to the employment path, if you decide, you know, what, I have now made myself a much more senior person I've been I, I have put myself on a track to now be number six are the number four at a much larger organization. And I never would have been able to build that career capital had I not been the number one of this smaller venture, and I can walk away from that and then go be somebody else's number four, number six, I think that's a reasonable. I think that's a reasonable career path. And I think it's it could also be the case for people that if they start their own practice, and maybe it's just them in a partner, and they do okay for five years. But maybe that makes them the opportunity to be a senior partner at a much larger group after that, as long as you're not going into debt. Or if you're making more money than than what you're borrowing or spending, then that still can be a part of the Career equation.


Richard Groberg  1:03:38

Yeah, not everybody wants to be an owner. In my former industry in the veterinary industry, there are now statistics that more than half of the veterinarians coming out of school don't want to be practice owners don't want to work full time, and the burden and stress of starting a practice and the debt in the ownership, which plays into the corporate groups. There is some of that in our industry. Not everybody wants the burden, financially and mentally of being an owner. And I'm fine. But even then, to the extent they can have a small piece of the equity, whether it's options and equity in the parent company or a piece of their practice. There are ways that roll up groups are making that happen now. But again, there's no one right answer because everybody's different.


Griffin Jones  1:04:29

But I would love to have you back on for a live event where people can ask questions in real time, but for concluding this thoughts on the yellow paper, which we will include in the show notes, what would you like to summarize for the audience?


Richard Groberg  1:04:45

I think the premise of the paper is, is that if you can reinvest in your own business, and it doesn't have to be at a 15% return at a higher return than you can do elsewhere with your business. You You're building value you're building community, you're building loyalty amongst your employees and constituents. And your business will be more valuable when the other factors say it's time to sell. But every micro and macro decision should be made with some thought process of what are the financial implications, and the non financial implications? Not one or the other.


Griffin Jones  1:05:27

And I suppose that valuing one's time would also be a tiebreaker for that, isn't it, Richard? So if you could have a business that's doing well, but if you're working 80 hours a week, and you feel that you could be doing as well working for someone else, it at some point, one's time is is valued in that not just for earning potential, but also quality of life and, and their time with their family. And


Richard Groberg  1:05:54

that is one of those factors that would lead someone to say, you know, something, let me let me get the benefit of selling to another group and having them help with certain things. Take some pressure off


Griffin Jones  1:06:08

me. You had a few people that reached out last time we shared your email address. Are you comfortable with doing that again? How can people find you?


Richard Groberg  1:06:17

Absolutely, I can be reached at Richard Groberg and outlook.com. I'm on LinkedIn as well. And your podcast is so well viewed and received, that I had a number of calls, I picked up a number of assignments to work with fertility practices, both in the United States and surprisingly from Europe. So I think that's a testament to your reinvestment in your business to continue to grow it.


Griffin Jones  1:06:43

I appreciate that very much, Richard and I appreciate being able to cover these topics and I look forward to having you back on to cover them some more. Richard Groberg thanks for coming back on inside reproductive health.


Richard Groberg  1:06:58

Thank you. It was my pleasure.


1:07:01

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 thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health



153 Elizabeth Carr: What is U.S. IVF’s First Born Working For and What Is She Doing Now?

 This week on Inside Reproductive Health, Elizabeth Carr shares her experience from birth to where she is today, at TMRW, and everywhere in between. Born quite literally into the industry and its spotlight, Elizabeth has chosen to be an advocate for IVF, working to change public education, and further ‘industry’ advancements. 

Tune in to hear:

  • What Elizabeth Carr is doing to give back to the community that made her existence possible.

  • How her relationship with Dr. Jones and his family contributed to her life and ultimate career path.

  • What she wishes people in the industry would push harder for. 

Elizabeth’s information:

LinkedIn:https://www.linkedin.com/in/elizabethc

Twitter: @ejordancarr

Website: www.ejordancarr.com


Transcript

Elizabeth Carr  00:04

My speaking up and out has always been kind of my love letter to the industry as a thank you and to all the patients. As a thank you for saying thanks for not giving up and making sure that I got here.

Griffin Jones  00:17

unlimited human potential Do you ever think about the line of work that you're in, in those terms, unlimited human potential. That's what I think about when I think about the in finite or at least in depth finite number of IVF babies that can be born or babies born from art in general, my guest is Elizabeth Carr, you know who she is because she was the first baby born from in vitro fertilization in the United States, through Dr. Howard Jones and his Institute. And we talk about what that was like to always be in the limelight. But I think the reason why you'll get an interest in or you'll take an interest in this episode is because partly the relationship that she talks about with her family and Dr. Jones and, and then what the other IVF babies that she knows from the institute, what their relationship was like, and their fondness and even the way she thinks of Dr. Jones's colleagues, and that weren't there at the institute, but But everywhere. And so I think as you think about what kind of legacy that you're having, maybe we take a little break from the private equity and the hiring and the marketing and the business development and all of the this stuff, the important stuff that we do have to do we take a break for a second, so that you all can reflect on the legacy that you're leaving from someone who had one is very good about speaking about it, but to at least in this country, has been living it for the longest. So now she's with TMRW Life Sciences. And I get to talk a little bit about that, and a little bit about advocacy and an opening up. But think about this episode with regard to your legacy. And enjoy this interview with Elizabeth Carr. Ms. Carr. Elizabeth, welcome to Inside reproductive health.

Elizabeth Carr  02:23

Thank you so much for having me. It's great to be here.

Griffin Jones  02:26

You are the United States of America's first baby to be born through in vitro fertilization. So does Louise Brown, like ever? Just Does she ever throw some nationalistic crap at you that the UK beat us to it? Or does the stet you know, does that Steptoe Jones legacy does it? Does it manifest itself as a rivalry decades later, or was it the whole world collaborating to? To try to do the right thing?

Elizabeth Carr  02:57

Yeah, no, no shade, definitely no shade from Louise. And yeah, my doctors Jones actually worked with Steptoe and Edwards to kind of understand what they had success with, and then tried to replicate. In the US, of course, my distinction versus Louise, where maybe I'm throwing a little shade is that I'm really the first IVF baby, that, you know, when we think of modern IVF, I'm it so Louise was a natural cycle, whereas I was the first baby born using all of the, like, hormone protocols that we're also familiar with now.

Griffin Jones  03:35

Wow. So well, that's another reason why whenever somebody says, and normally there's playing around, but our country did this first or our team, our university, whatever did this versus like, but yeah, they did that one step first. And then because you did that one step and you help somebody out, they figured out another step. And then the other guys and gals over here figured out another step and as much better to think collegially Exactly. So. So when did that start to become a part of your life? Because it was always a part of your parents life, but But for you, it definitely wasn't, you know, in the first couple years of your life, in terms of like you knowing that, you know, at least age two and three

Elizabeth Carr  04:25

you Well, I mean, yes and no. So I let me put it this way. My first press conference ever was at three days old. So while I may not have had the cognitive realization of what was going on, I have always known that I was not like all of my other peers, you know, other kindergarteners weren't going on Good Morning America, but I was, you know, think things like that. So I may not have realized until I was older. What this meant: But, but I knew that my parents went through something different in order to get me here. That was kind of like my understanding when I was very young.

Griffin Jones  05:10

My assumption was no, it would have taken a few years before some of the to be able to explain it to you. But you were just never out of the limelight is what you're saying.

Elizabeth Carr  05:19

Correct? No. I mean, it was a media firestorm from the day that it was announced that there was a pregnancy even before I was born, just even a pregnancy there and woman impregnated was the headline that my father recalls reading. And he was like, yep, that's my wife. So yeah, it's always been a subject of media spotlight and scrutiny.

Griffin Jones  05:45

And so how long did that last for? You said you went to? You went to kindergarten, and then

Elizabeth Carr  05:54

I made its last my whole life. Yeah, it still happens. It's lasted my whole life. Basically, every reproductive milestone, somebody will want to talk to me about what this means, or you want to check in and make sure I was developmentally just like everybody else, because this was, you know, had never posted, by the way. Yeah, I mean, you know, mostly abnormal, I

Griffin Jones  06:19

think, crazy as everybody else.

Elizabeth Carr  06:22

Exactly. I don't think there's any real normal out there. But yeah, so I mean, it's been a constant. limelight. I mean, I had a camera crew here last week at my house, and I'm, you know, I'm just living my life. So

Griffin Jones  06:37

were there. Were there points in your life where people were less aware the media was less interested, like, oh, 13 year olds are gross. Let's bother again, when she's old enough to vote? Like, Were there ever lows in? Were there? And, or maybe at least lows compared to the peaks?

Elizabeth Carr  06:58

Yeah, I think, yeah, the ages that were less exciting, right. So like, nine was not a big deal. But 10 was a huge deal. Because it had been a decade since I had been born. You know, when I turned 16, it was like sweet 16. Right? When I turned 20, when I got married, when I had my son, when, you know, it's like, all of these kinds of life milestones that people go through. Mine had an additional level of media interest that I don't think many people realize until we start talking about it.

Griffin Jones  07:29

Hey, are you gunning for centenarian status? triple digits, because

Elizabeth Carr  07:35

I know that the running joke is, you know, this year, I turned 40. And I was like, you know, I can't lie about my age. Everybody knows when my birthday is exactly how old I am forever. Never. That's, you know, that's what I'm stuck with. So yeah, it's, it's crazy.

Griffin Jones  07:52

So when did this notoriety start to get you involved with the fertility field, like the fertility field had always known about you? The doctors knew who you were, and they certainly knew our Jones was. But at what point? Did it start to get you involved with them?

Elizabeth Carr  08:22

Yeah, so I mean, aside from the media attention, and all the interviews that I've had, over the course of my life growing up, I, I've always had an interest in science, I'm not good at math. But I've always liked to explain the science. So I've always, and I always, I think I was probably 10, when I started really paying attention to the industry and seeing what was going on and developing. So I've always paid attention to the reproductive field. But I also started realizing that because I had this weird platform in life, that I could use my voice for good and for change. And so I've really, from a pretty young age, started speaking up about different reproductive options out there, and became kind of like a junior advocate, you know, Junior age, probably 1011, I really started paying attention to what was going on with insurance. And I'm still actively fighting those insurance battles and testifying in front of various committees and on state by state basis and paying attention to all the laws and, you know, looking into just helping people understand their options. So I started really paying attention to that stuff, probably when I was 10. And then I went on to be a journalist and wrote, not surprising to many I don't think primarily about health and science and again, stayed up on everything going on. And then I've worked for a few fertility startups and done a bunch of free then to writing and social media for various companies. And now I'm at TMRW Life Sciences as director of marketing.

Griffin Jones  10:07

So you started off as a journalist, were you ever kind of covering just a regular beat? Or was it always Health and Science?

Elizabeth Carr  10:16

Yeah, so I did a range of things. When that you, when I started out, I worked from age 18, at the Boston Globe. And I actually started out as an obituary writer, because you can't label a dead person, believe it or not, so they let you start there. And then I did a lot of general assignment. And then I went into health and wellness was a writer, then I became a health and wellness editor. And so I've done you name that you name it, it runs the gamut in terms of journalism,

Griffin Jones  10:47

what made the switch or the transition from journalism to marketing.

Elizabeth Carr  10:53

So I spent 15 years of my career at the Boston Globe. And I actually jumped from the editorial side of the business to the marketing side of the business, because I wanted to learn, you know, the dirty little secret of newspapers is that you don't make money selling a newspaper, you make it doing events, and marketing, and in house advertising, and all these other kinds of modalities that a newspaper has available to them. So I just wanted to learn soup to nuts, the business. And so that's why I jumped to the marketing side. And then I figured out that, you know, this was an important skill in the fertility world for, you know, anyone looking to grow their practice or understand the business of infertility services or reproductive technologies as well. And, you know, it's hard, it's, it's complicated, right? If you don't understand the reproductive field, it's hard to translate it into plain English for people sometimes. And I that's, that's a skill that I wanted to learn and adopt very early, that I wanted to be able to explain something very complex in a way that people could understand it.

Griffin Jones  12:05

So what areas of marketing did you experience both at the Boston Globe and then afterward?

Elizabeth Carr  12:12

So I was one of the first digital reporters, you know, back before anybody knew what a blogger was, I was blogging, doing social media, tweeting, you know, doing kind of the early days of podcasting, where, you know, we did audio over stills, it wasn't really movies back then. But audio over stills kind of storytelling. You know, things like that, basically anything I could get my hands on and play around with I was experimenting with.

Griffin Jones  12:46

And then and then what happens after the Boston Globe.

Elizabeth Carr  12:51

Let me see, after the Boston Globe, I actually went to work for Runner's World Magazine, I was an editor there because in my free time, I am an endurance runner, and I run marathons. And so again, kind of still in that health and wellness bent, was a was a writer and editor there. Then I went to work for over science for a very short period of time, I then I worked for genomic prediction, I've done nonprofit fundraising, and leads kind of all the way up to today, TMRW.

Griffin Jones  13:27

All the while that you're doing like that you're at the globe that you're Runner's World. Are you? Are you involved in the advocacy? You said? Yeah, surance passion never left you. So what were you doing during that time?

Elizabeth Carr  13:42

Yeah. So it's all the stuff that nobody sees, right? It's all the stuff behind the scenes that we all know, hopefully we all know is going on, of, you know, fighting to get insurance mandates in various states where there aren't mandates and coverage, as well as making sure that bills that are being proposed have language that is protective of all, not just some seeking reproductive options. So all of the nitty gritty stuff that's behind the scenes that nobody really, you know, it's not visible, but it's critical work. So I've kind of always been doing that, since I was very young. It's just not something that people see.

Griffin Jones  14:23

So then how did you when did the logical or now seemingly logical conclusion of starting to work with startups in the IVF space? When did that happen? And how did it happen?

Elizabeth Carr  14:38

Probably. I don't I'm trying to think how many years ago probably 10 years ago, I think is when I started. Sorry, my dog is drinking water loudly off camera. Miracle. Thank you. So probably about 10 years ago, is when I started working in the infertility slash startup space in a in a professional capacity as opposed to just in a patient advocacy capacity? And how did it happen? You know, I'm not really sure I've just always kind of known a lot of people in the space. And I happen to have this like weird digital tool set to or skill set in my tool belt of various things I was good at. And I understood the needs of patients as well as the needs of clinics or providers as well. And so it was kind of marrying all of these various skills from journalism, marketing, patient advocacy, kind of all into one. You know, one multi tool, I guess you would call it,

Griffin Jones  15:47

as you've established, we all know how old you are. This took place about 30. Why not? Until then was was it? Was it just because you were just another person doing other things in your career? Or was it because there weren't as many startups in the fertility space at that? I think,

Elizabeth Carr  16:05

yeah, I think it was both to be honest with you, I think I was just kind of still, I felt like I still had a lot of growth to go at when i i left the globe, and I was 33. So I still kind of had this mini city of people to learn from and that was, I was really grateful that I spent a majority of my career there because I have learned so many different skills from so many different people. And then yeah, I think also, yes, we have seen more and more fertility startups survive those early days, to be honest with you. I think it's there's there's many, many out there, but not many of them become known until after they survived that first few bumpy like six months to a year. Right. And so that's kind of when I feel like people rise to bubble up to the surface.

Griffin Jones  17:02

What was it? What were people working on at that time that you found interesting in the fertility space?

Elizabeth Carr  17:09

I mean, back then, you know, it was a lot of the early days of pre Implantation Genetic testing, which is fascinating to me, because it was not even in the realm of possibility. And when I was born, I mean, this is really dating me, but they had a statement written, or my doctors had a statement written in their pocket about how it was a sad day for infertility that they had on backup, just because ultrasound was showing that I was really, really small and they were worried I was going to come out with birth defects because I was only five pounds 12 ounces. And ultrasound was so bad back then. Right. So people forget that, like the things that we take for granted now. vitrification I remember when vitrification became possible, and that was like, the catalyst and game changer in the field. You know, egg freezing was I remember being probably my late teens and touring a facility that had done the first egg freezing for fertility preservation for cancer patients, because that was it was very niche back then. And it was like groundbreaking that they figured out that, you know, we can freeze eggs and and they can still go on to become viable pregnancies. People didn't know that that was possible. So it's kind of like all of these milestone moments that I remember growing up with industry really in, in my view.

Griffin Jones  18:37

And then what, what landed you TMRW, and how long have you been there for?

Elizabeth Carr  18:44

So I'm trying to think I think I've been here six months now. I saw TMW at ASRM, actually. And I just thought, wow, this is the kind of safety and transparency that I hear from a daily basis that patients really are kind of clamoring for that they want, you know, they want more information. I know that we we all think it can be information overload because it can be right we didn't my my mother always jokes that she was kind of grateful that there was no Dr. Google back then when she was going through IVF. Because it is so overwhelming the amount of options and information out there. But I hear from people you know, I really wish there was a way I could just stay up to date on all of my eggs, embryos, health information, everything I needed to know and not wonder where things are or what the status of them is, in in the moment really, to know that everything is safe and I've worked so hard to you know, get these eggs or embryos that I want to protect them at all costs. And I think that you know, TMRW unique digital chain of custody and patented technology is just It's just, you know, so interesting in kind of leveling up that transparency and peace of mind for patients.

Griffin Jones  20:08

I don't know exactly when a startup becomes not a startup is.

Elizabeth Carr  20:13

I don't either.

Griffin Jones  20:16

Do we still call TMRW a startup?

Elizabeth Carr  20:18

I mean, I don't know. That's a very good question.

Griffin Jones  20:22

A lot of money, a lot of people.

Elizabeth Carr  20:25

We're all working very hard roster

Griffin Jones  20:27

at this point. So yeah. So in your director of marketing,

Elizabeth Carr  20:34

that's your director of product and clinic marketing,

Griffin Jones  20:37

clinic market? So do they pull you out like a dog and pony show? Yours? Which is, which is partly the role of marketing director anyway. But given your status, how was that used?

Elizabeth Carr  20:55

No, I mean, it's really kind of, I'm always the one saying like, Oh, I know them, or or, you know, like, let me I want to help or, you know, I'm really the one who kind of said, I want to help move the needle in whatever way I can for the industry. That is kind of my that is my, like, personal stake in the ground aside from TMRW, or any other company I've ever worked with? It's really how can I personally move the needle? For the better in the industry at for patients? That is, that is my end game. And so everything I do is kind of with that mindset, you know, moving forward? And no, it's really my job to kind of, again, translate all of the complex things about the about this technology that we have, and explain it to people in a way that makes sense. And let people know, you know, why it matters.

Griffin Jones  21:50

So our director of clinic and Product Marketing means of what TMRW is marketing to clinics, yeah, helping

Elizabeth Carr  21:59

helping clinics so that they can level up their practices in terms of having our cutting edge technology at their practice. And then as well as explaining the product itself, like soup to nuts, nuts and bolts in a very, you know, non technical way to understand.

Griffin Jones  22:16

So what are you doing to, to talk to practices now?

Elizabeth Carr  22:22

Yeah, so essentially, you know, my job now is to interface with all of our current partners, and help them explain to their patients, you know, this is the TMRW platform, this is why we're using it, this is what it means, you know, that kind of stuff. So I help them explain to their own patient populations, why this is important, and it matters as well. And then again, explaining the product to the clinic so that the clinic can then explain the product to their patients as well.

Griffin Jones  22:49

We're talking about lessons learned in owning a practice or owning a business in the fertility field and things that you may want to learn how to do or learn about before you go and start your own venture. Another thing is some of the systems that are used, and oh, people that can give really good recommendations on the different EMRs. They've shopped in the depth and scope of functions. But I would ask someone that you know, that uses engaged MD, if you're not already, if you don't use engage MD, and you're CISM, you're thinking I want to open my own office within my own group, or I want to open my own practice, I want to go join somebody else, and I want to be able to add something to it, engage them D is one of the surest bets that you can do, but you don't take my word for it. Ask someone that you know, because more than half of your colleagues are using engaged MD and more than half of your colleagues are extremely delighted with engaged and be because they got real informed consent. They don't have stacks of papers that people have to sign in then account for and then keep an eye out file cabinet somewhere. They have true informed consent from patients that have a module at their convenience, so that the staff isn't overburdened with questions that they don't need to be getting that they can help the patient with the attention that needs to be devoted to that patient's case. Because the elementary the rudimentary is covered, and now it's just what that patient is stuck on or what's unique to their case that the care team can focus their care on. That's what personalized care is. And more than half of your colleagues have seen the benefit from engaged MD that way so just reach out to any of them Hey, guys do use engage in the people you want to fellowship with people that you see it ASRM Hey, do you use engage them D What do you think I hear Griff talk about it. But he doesn't want to practice. What do you guys think? And see what they say but if you want At every workflow assessment want to see what other practices are doing, you want those insights that engage them D has, and you want to see how your practice stacks against that ideal workflow, then you go to engage them. the.com/griffin. And you mentioned that you heard them on the show, you mentioned that you heard them from me, and then you're gonna get that free workflow assessment. So ask somebody else, don't take my word for it, but go to engage md.com/griffin Or say you're on the show. So you heard from me, so that you can get that free work assessment for you. That's one of the biggest system wins that you could have right off the bat. And you can verify that just by asking people you already know, I hope you enjoy the rest of this episode about things you need to know for the fertility business you might start. When you're at SRM, especially like if you're either talking or you're involved with a session, or somebody invites you to be the guest. They're the guest of honor at their party, and you meet fertility doctors, what do they say to you?

Elizabeth Carr  26:05

Oh, it runs the gamut.

Griffin Jones  26:08

I want to hear the game I want to hear all the time, I want to hear

Elizabeth Carr  26:12

all of the games. I mean, I've heard everything from the very young embryologist who are like you're in all my textbooks, which makes me feel really old and weird, but in a good way. versus you know, some of the older physicians who remember by doctors, Dr. Howard and Dr. Georgiana Jones, and comparing notes to like, what it was like back then versus what it's like now. I've had people ask me really odd questions such as, Do I have a belly button? Spoiler? Yes, I do. I was born just like everybody else.

Griffin Jones  26:48

Doctors are asking that question. And doctors and patients have asked

Elizabeth Carr  26:51

me that question. I kid you not which it's always shocking when a clinician asks me that question. Mostly OBGYN so I have to be honest.

Griffin Jones  27:02

I wonder if there's what the reason that they're asking that question because

Elizabeth Carr  27:05

there's because in the early days of IVF, the slang term was test tube baby, right. And so the, the image in everybody's head was that I was grown in a test tube, which is just wildly inaccurate. Also, fertilization happened in a petri dish. And there were no test tubes involved in any way, shape, or form. So I always found that very amusing. And I've always hated that nickname.

Griffin Jones  27:30

But I thought there might have been like, but they didn't know that you that you went through gestation in utero, they didn't know that. They are a lot of people. A lot of people vitro fertilization also means grown

Elizabeth Carr  27:43

in a lab, like literally. Yeah. And I have to, I often have to remind people that that, honestly, the only difference was that fertilization happened in in a petri dish. And then I was placed back in my mother's womb. And nine months later, I came out just like everybody else does.

Griffin Jones  28:01

I mean, a lot of people think that, you know, like, Alaska is a country or that. Queen Elizabeth lives in Brazil. So like, it could, it could be, you know, I could see a lot of people thinking anything about that. But it surprise surprises me that OBGYN ins have

Elizabeth Carr  28:23

not awesome just to fit. You know, I'm just not I'm not saying everybody. But yeah, I mean, it's I think that's the one thing that surprises me still to this day, is that I have to do so much still basic education on what IVF? You know, I only primarily speak about IVF, because it's what what got me here, so I know it intimately well. But in terms of education on what exactly IVF is, there's still a lot of baseline education that needs to happen on a on a general level for a lot of people, many people have maybe heard about it, and think they understand what it is. But a lot of people there are still misconceptions about it. Yeah.

Griffin Jones  29:05

Unfortunately, it doesn't happen to me as much now that that generation is mostly gone. But I used to meet people that that knew my grandparents, I would meet older people that knew my grandparents, and they would talk about how they, how they knew my grandpa's. I guess that happens with my parents generation, too. But I guess I know more about my parents generation. So I'm just Yeah, a couple years ago, my brother and I were at a neighborhood bar in the neighborhood that were for the working class outside of Buffalo neighborhood for generation two, and we're at a neighborhood bar where like, all of the Irish working class stereotypes are coming together like our second cousin is our attending that we don't know that was oh, yeah, I know. And then there's this older couple there and that oh, and I know who your who your family where they were the Burns is and they were like telling me about my grant. parents and their family and great grandparents. I wonder, do you ever get that vibe from from older physicians like, who were maybe just behind the Steptoe Jones generation? And, like, do they want to tell you about Dr. Jones or duck, maybe even Dr. Steptoe, even though he wasn't in this country, like do they want to tell you about them in the same way that your grandparents friends would want to tell you about your grandparents?

Elizabeth Carr  30:33

Absolutely. And the grandparent analogy actually is a very good one, because that's how I've always referred to the Jones is my second set of grandparents. Our relationship for my whole life until they died was very, very close. Phone calls, emails, writing all sorts of correspondence. When I had my son, Dr. Howard wanted to make sure that I was going to a hospital with a level two NICU just in case, you know, all these kinds of things. So, yeah, people definitely want to share their stories with me of Oh, I was a fellow I was a Jones fellow or I went through the program, or, you know, I learned from so and so who was on the original team, or, you know, all those kinds of things, I actually really appreciate when people share those stories with me, because, you know, those were, those were kind of the Wild West days back then. Right? They were trying to figure out what was going to work, I don't think people realize that my parents you know, they didn't realize they were going to be the first until my mother got pregnant. And then the Jones were like, by the way, you're the first. And my parents, I think, naively assumed that there had been success, like it didn't dawn on them that there wasn't success. beforehand. And they weren't the only couple going through this. There were a group of other people going through this process at the same time, my parents were, but all the couples had a different protocol. And so none of the couples knew like, are we going to be the ones that the protocol works? Or is it going to be somebody else? And they weren't really allowed to share notes or talk about, you know, how their protocols were different. So it was kind of like, you'd pass in the hallway and wave and but you didn't know like, are they? Are they pregnant? Are we pregnant? What's going on? So yeah, it as I said, it was a wild west. So it's always interesting to hear those stories from from the very early group.

Griffin Jones  32:33

And so Dr. Jones passed away, like when I got into the fertility business, I started working with that, our first fertility client in 2014, but moved back to the US in June of 2015. And he passed away that summer. And how much correspondence did you have with Dr. Jones throughout your life?

Elizabeth Carr  33:00

Oh, as I said, so much correspondence. I mean, when I was little, we had a Mother's Day reunion every year at the Jones Institute in Norfolk, for the first 100 Babies essentially. And when it got to be 1000, and 1001 babies, that was our last reunion, because it just got to be too many people. And that was just from the one, you know, clinic. So throughout my life, you know, he would come to the airport and pick us up, or he would you know, I've got Birthday, birthday cards and phone calls every Christmas and on my birthday from them. I when I interned as a writer at The Virginian pilot newspaper, Dr. Howard actually helped me figure out my housing and I stayed with one of his fellows. And he and I had a standing lunch date every Wednesday. Well, I was there for the entire summer. He was one of the first people I told when I was pregnant with my son. He was invited to my wedding, you know, they were invited to my wedding. You know, anytime I had a newspaper article that made the front page or something like that, he would send me a note. So if people I think don't realize that we had such a close relationship, and they really were like a second set of grandparents, as I said,

Griffin Jones  34:23

so I just had a client asked me today, they were like, because we're doing a photo shoot for them. And we have a part of that where we we have just like an open period where people can come in and they can take their pick, they can bring their kids and they can take a picture and and they asked me what's the age limit because we just had someone in their early 20s who reached out to Dr. Toe and toe and said that they're now beginning medical school and as like there's no age like Yeah, that's great. That's incredible lady Yeah, like, that's it's not just a cute chubby cheeks that that is the whole story like, and you could argue that that's like, that's the story like, you know this, more broadly speaking this unlimited human potential you don't know what the human potential is, but we know that it wouldn't have existed if not for. Right. And so you like you were a part of of of that growing up. So I want to ask this question that has to do with the infertility community. If you think it's personal to me, I'll edit it out. I think it's, I think it's germane to the conversation. So sure. Did you go through infertility treatment

Elizabeth Carr  35:44

for everybody asks me that, no. So that was the other the other interesting thing about my mother's fertility journey to have me, she actually didn't have traditional infertility. She like where it was unexplained, or, you know, something was going on like that. It was scar tissue from a botched appendix surgery when she was in her teens. And she actually had three ectopic pregnancies before having me and so her fallopian tubes were removed, which, then that's where her fertility issues really came in. Because you, you know, back then you couldn't have a child unless you had fallopian tubes. So ironically, my mother could get could always get pregnant, she couldn't stay pregnant, the reason she couldn't stay pregnant was because of that scar tissue. So she was kind of the ideal candidate for this IVF program. And then No, I had no fertility issues at all. And I had my son at the same age actually, that my mother had me I was 28 when I had my son.

Griffin Jones  36:46

The reason why I asked is because I wonder what that's like the fertility community is such a tribe in many, in many cases, partly because they have at least some, some similar roots to draw upon. Like, even though the journeys are different, there's, there's some common threads, and sometimes those common threads are so distinct from the rest of society, that's where they form their bond. And, and you don't have that with them, you have a different kind of bond with them. It's like it's, it's as though they're, it's like their kids, you know, the the ones that have gone through treatment and been successful, are gone through time. Fast forward to be a grown up and now are with them in that community. So what what is that like, like to be to be not one of them at all, in one sense, and to them? And to be like, the most proud I know, there's so yeah, right, and product and and others? What's that? Like?

Elizabeth Carr  37:49

Yeah, so I mean, that's where, to me, I've always been very cognizant of that. There's like, I cannot speak to what it is like to exactly experience infertile infertility or trouble with your family building, right? I'm very aware of that. So I never speak to what that is like, what I can say is I can relate to what my, my parents went through, in their very unique situation. And that is where it has become my goal, that I am very humbled and privileged to be here. And I realized that I am very humbled and privileged to be here. And so my work as a patient advocate, or, as somebody who can be a resource or connector for somebody else going through this, my goal has always been for people to know what their options are before they need them. Because my parents really, you know, we're kind of given this option in a moment of crisis of like, Oh, my God, what do we do we have, we can have a child of her own, what are we going to do, and I never want anyone to feel like they don't know where to turn. And so my speaking up and out has always been kind of my love letter to the industry as a thank you and to all the patients. As a as a thank you for saying like, Thanks for not giving up and making sure that I got here. Because it took everybody it took all of my parents willpower of fighting. It took all of the scientists and lab technicians and embryologist and nurses, and even receptionists answering the phone and all the billing folks, it took so many people just for me to be here talking to you today. And so that's where I'm going to keep keep using my unique platform and voice to keep moving the needle ahead in this industry. And it's it's just it's it's honestly my only way of saying thank you because the words thank you seem wildly inadequate.

Griffin Jones  39:48

How old were you when you started meeting other adults that well, maybe now I won't even ask the question adults. How often How old were you? You when other people started introducing them to themselves, do you say I'm an IVF? Baby, too?

Elizabeth Carr  40:08

I mean, I think I'm a bad person to ask that question only because I have a magnet right at the end. And, you know, we had those reunions from from when I was very little with a Mother's Day stuff. So, so I always had other IVF babies around me, always. The only difference was, you know, when I was little, we would all introduce ourselves using our numbers. And so, you know, a friend of mine would be like, I'm never 10 and be like, I'm number one. You know, so nice to meet you. Where's number five? We don't know, like. So but then, you know, to have friends of mine. Now my age saying, Oh, I'm going through IVF or I'm having an IVF. Baby, myself. And they often say thank you. And I'm like, you know, I appreciate that sentiment so much. But like, honestly, I my, my joke is that I didn't really do anything I just showed up. It was really everybody else did the hard work, you know, I had no control. And whether I was here or not, it was everybody else.

Griffin Jones  41:06

Because you've got this passion, because you got this unique perspective. Are you ever asked to? Or do you take it upon yourself to be a public relations force when something bad happens, like when there is the the rare tank leak or embryo mix up? Or some sociopath in some, like OB GYN clinic from 30 years ago that fathers, how many embryos like when that stuff happens, and people are looking at the fertility field? Like, wait, what like, is that witchcraft? What's going on over there? And we know how rare that is, we know how much of a sliver it is to, in comparison to the good in the hundreds of 1000s of lives now over a million IVF babies that have been born from the treatment. But like, do you see yourself in in a unique position? Like do you feel an obligation to to be a counter voice when that stuff starts to get a larger share of voice in the public sphere?

Elizabeth Carr  42:23

I mean, yes and no. So obviously, especially with with my role TMRW, we're always trying to move the needle ahead for safety and you know, best practices and upping the standard of care, right? And so on, on that kind of mission level, I'm always saying like, this is why this technology is so desperately needed, so that in the rare circumstance or whatever that it happens, this is this is not a possibility, or the risk is mitigated to, you know, such a degree. On the other hand, I also know, because I grew up in this industry, how deeply IVF clinicians and lab techs and embryologist and everybody care about what they're doing. And, you know, I come at it from a very different lens of like, nobody would ever do anything on purpose, right? Like this is, as you said, like, these are catastrophic mix ups that I don't think anybody obviously ever wants to have happen. And so therefore, like, let's come together, link arms, let's talk about best practices, let's make sure that we're all doing everything in our power to make sure that this never happens, right, that this this is, this is the one thing we all collectively have agreed that we want to avoid from happening. So let's figure out how to do that together. And it is not from a place of, you know, fear mongering, it's, you know, we had a practice in place that was the best at the time. Now there's a new option, you know, let's let's go forward with the new option. Because it's new, it's a new standard. And it's just like, you know, kind of same thing with how the industry itself has grown up, right? We used to use certain hormones in the early days of IVF that now we don't really like my mom was on personnel, they don't make personnel anymore. There's now a new version out there. That's the next best, latest, greatest right? So we're always iterating we're always moving the needle. Again, even vitrification wasn't it was a moment in time where they were we were moving the needle, right? We went from fresh transfer to now we know we can vitrify and we can flash free. So what does that mean for moving the needle? And so that's where I always am kind of coming from like, what do we have to do now to move the needle? From an advocacy standpoint, from a safety and technology standpoint? What can we do together?

Griffin Jones  44:53

I'm curious a little bit while we're talking about that, I do want to conclude with you sharing what you think the field should be paying attention to. But I want to ask with regard to the extent that you're able to talk about what, what is TMRW’s vision or potential outside of just the IVF space? Like, I got to believe that this company is, is also going to do other things with this technology. So what's on the horizon?

Elizabeth Carr  45:25

Yeah. So I mean, I'm actually a terrible person to ask. Because I am so ingrained in this in this particular field and this particular dish that I'm like only, like a horse with blinders on that this is our goal right now, this is our mission, this is our drive. I'm, I'm the wrong person to talk about future looking, because at this point, it's we just want everybody to understand what we have going on. Right now. That's in the marketplace for patients and clinics to move forward. But I am excited about where where the potential of this could go. Although I don't necessarily I'm not the person that's necessarily involved in those discussions. But I am excited about yours, knowing about the person perceived benefits of this technology in, you know, potentially other fields. Who knows?

Griffin Jones  46:20

Well, let's talk then about what you think that the field should be paying attention to. And so let's maybe start this conclusion with what do you think that people aren't paying attention to enough of that, that you see, from your vantage point from having worked for all these different startups from our comfort mile from having talked to so many doctors and been involved in the institutional structure? What do you think that people just aren't paying attention to enough of right now?

Elizabeth Carr  46:55

I mean, that is such a hard question. For me, I think it's always the coverage and insurance landscape. We have known for many, many years that, you know, in many ways, reproductive technologies are cost prohibitive for so many people. And that continues to be a really tough nut to crack to make it more accessible to more people, and, and that is something that I know, we're all striving to change, but it's so hard, and it's so slow, that I think that that, you know, in this Roe v Wade overturned landscape, it's really come to the forefront even more, you know, as as a, as a worry that, you know, it will become less accessible, as opposed to more accessible. So I think, for me, personally, that's always one that I'm like, you know, if everybody can really pay attention, not just to the technology and best practices going on in the world, because we know that's going to continue to march forward. But really the landscape itself and, and making sure that everybody has access, and, and that is so key, and I don't think we can ever stop paying attention to it. Truthfully, like, if we take our eyes off that ball for one minute. I think it can be really harmful in the long run.

Griffin Jones  48:32

Well, then I'll let you conclude, however you want to clean our audience of practice owners and Doc's and fertility execs. Maybe it's it's a call for how you'd like them to get involved with that. But how would you like to conclude?

Elizabeth Carr  48:46

Yeah, I mean, I think, you know, for me, it's always, it always comes down to what do we think we need? And how do we think we need to get there. And I grew up in an industry where everything was highly collaborative, right? That was what everybody that talks about the Jones remarks how collegial and academic and collaborative they were, back then, that they, you know, wanted to share the latest and greatest research, they wanted to share best practices. And I think we all still need to kind of especially in this current landscape, continue to link arms and and kind of look around and say like, Yes, I know, we're competing, maybe for customer acquisition and those kinds of things. But let's make sure that we all agree that we want to provide the best care that we can to our ability, period, full stop, and whatever that looks like in the current day, landscape, technology, whatever it is, if we can all say that we're all driving towards the utmost best patient care. That's really all that matters to me. And I think that that's really all that matters to patients as well as they all want to know that we are marching in the same direction, you know, towards the best care and I think wholesale, you know, all of the practitioners that I've come into contact with, you know, embody that, which is a lovely thing. And it's very rare to have a whole industry care so deeply about, you know, their patients on it on a very human level. So I just hope that we continue that, and that we don't let any political landscapes or law changes kind of derail us from from really providing the best that we can.

Griffin Jones  50:34

And then we'll have a few more million Elizabeth cars. Oh, God. I'll be guests on the show. Maybe not me. But we'll, we'll do like every every million dollars or maybe 100,000. That can can be a guest.

Elizabeth Carr  50:50

That's that's the running joke of why my parents never had another they were like we were good with you. We decided to stop after you,

Griffin Jones  50:58

Elizabeth. Karen, thank you very much for coming on inside reproductive health.

Elizabeth Carr  51:02

Thanks so much for having me.

51:03

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 thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

125: How to Attract Per Diem Embryologists

On this episode, Griffin Jones and Giles Palmer, the executive director of a group called the International IVF Initiative, discuss  what’s happening in the lab and why clinicians, managers, and other folks should pay attention. Giles holds webinars for embryologists and other fertility professionals, attracting over 800 people each session. Tune in to this episode to hear more on the shortage of embryologists and how automation could be one key to increasing your embryologists’ capacity and quality of life. 


Listen to the full episode to hear: 

  • Giles perspective on hiring young embryologists

  • How automation will affect lab efficiency

  • Giles viewpoint on corporate IVF

  • How Giles is able to attract large crowds of embryologists 


Giles Palmer: 


Company name: International IVF Initiative

LinkedIn Handle: https://www.linkedin.com/in/giles-palmer-52461531/ 

Twitter Handle: @IVFLIFE

Facebook: https://www.facebook.com/giles.a.palmer 

Website URL: https://www.kosmogonia.net/ 


Want to make your company irresistible to new talent? Let’s start the conversation at fertilitybridge.com



Transcript

[00:00:00] Griffin Jones: So I think what I'm saying is the cycle of life is continuing, but yes, it seems to me that the trajectory of most things is consolidation and fragmentation happens with countries, happens with businesses. And so we're seeing consolidation right now, but I also think we're seeing fragmentation and, and niching as well. 

 

[00:01:00] Griffin Jones: On today's episode and back in the lab and I'm across the pond. I haven't had too many guests from the UK or from Europe and on today's show, I have an embryologist, someone with lab experience, someone running an initiative, that they'll talk about from the UK who has also worked many years in Europe.

This is Giles Palmer. He is based in Cardiff Wales at the moment. And now he's the executive director of a group called the International IVF Initiative that he formed with some other lab folks in the start of the pandemic. And now they have audience. Like several hundred people, not just embryologist and lab staff, but also clinicians.

And in this episode, we talk about what clinicians, managers and other folks who aren't in the lab have to worry about what's happening in the lab because it's coming for them so enjoy this show with Giles.

Mr. Palmer Giles. Welcome the Insider Reproductive Health. 

[00:01:57] Giles Palmer: Thank you very much. We meet at last, I think we occupied the same you know, virtual university, if you like, but it's good to see you, you know, So it's great to be on the show. Thank you very much.

[00:02:09] Griffin Jones: Well, I like to give you the ability to decipher some of my audience. I'd like some exposure to yours because I got to confess. I have not had too many guests from the UK on the show of 125. You might be number three, maybe number four. And so that's fine. We are having to recruit a, too many guests. And so I felt we need more representation across the Anglosphere and here you are. 

[00:02:37] Giles Palmer: Well, thank you very much. I shouldn't be offended at all. I mean, I only moved to the UK only about six years ago. Yes. I was born in Britain, but I've worked most of my life in Europe. Okay. And I came back to the UK, you know, only a short time ago, so although we're out of your work. I still like to think of myself as European. But certainly from across the pond. So yeah, perhaps I can give a different perspective in things in the IVF world, in that respect. 

[00:03:02] Griffin Jones: So having worked in Europe for a number of years now, working in the UK and the initiative that you're involved in that we'll talk about.

That sounds like you have a good exposure to both the UK and Europe. And I want you to give us just a little bit of state of the union of what's happening over there. So here in the US and Canada last year and a half is you're probably aware most centers have just been slammed. Some have not. If they're in competitive markets or they haven't updated their business in a long time, but I would say 75% centers have been slammed.

I might be starting to change now. We'll talk about that in a little bit, if that might be the case, but what's been happening in Europe and the UK post covid.

[00:03:43] Giles Palmer: Oh sure but what's the word you use slammed was that? 

[00:03:47] Griffin Jones: Very busy. It means very busy. 

[00:03:49] Giles Palmer: Very busy. Okay. 

[00:03:49] Griffin Jones: To be at or exceeding capacity. 

[00:03:52] Giles Palmer: Well, thank you very much to clarify that marvelous. Yes. It is incredibly busy.

Both in Europe and in the UK. And you can see this from the posts, you know, everyone is hiring, and that's from the countries that I've worked for and in the UK. But yeah. But why is that? It's not just that there's been like a bottleneck, you know, and people haven't been treated over there pandemic.

First of all from the patient point of view, I think that people have thought, you know, they're like reassess their live and they say, yes, I want to have IVF. So yes, there's been a small amount of people that couldn't be treated and now they're being treated, but there's a lot of people that are thinking, yes, you know, I want to start a family.

So I think there's been an increased demand. Also, you know, the life of the embryologist has changed dramatically over the past few years. I mean there's more free cycles. Okay. Which means you have to have a devoted person to do that in the lab, it's not so much, you know, like full rounded, like, in the IVF lab, you'll have an egg collection, you'll fertilize, and some days later you'll then have the transfer, you know a lot of people are freezing the embryos and transferring them in a further cycle.

So that means that there's a lot of you know, force to be done as well. Which means as well for like the dynamics of a clinic as well. And I don't know if you've touched on this in some of your programs, but you get a higher throughput through your theater. If people are just having egg collections, when people are having egg collections you know, egg retrievals, but also embryo transfers, then there's going to be some time that you've got to sort of a lot for that, but I think the dynamics have changed in the clinic. And even within the inner workings, people are working a lot more and continuing on for that, of course you know, PGT and biopsy. You know, other techniques are being used as well. So I just think in a way it's a great time to be an embryologist, but it's a very tiring time to be an embryologist. 

[00:05:45] Griffin Jones: Is batching common in the UK and in Europe?

[00:05:51] Giles Palmer: Not so much, no in your Europe and especially where I was like in the Mediterranean which is quite shocking for people in the states. I know that like using summer, we wind down and there's a reason for that. Like, you know, for example, I was in Greece and there was no treatments in August, okay,, but that meant that, you know, the whole staff could be taken you know, could take a holiday.

You know, the clinic could be shut down. It could be just, you know, like maintenance done on that period of time. And then, you know, back up again after August or so that was like in that sense, patching, but in the UK, you know, there's no distinction between, you know, summer and winter there, mainly because of the weather, I think, but there's none of that that goes on, obviously in large air, you know, larger countries like India, there is a lot of batching just because it's such a wide expanse and the such a demand for embryologists that they cannot be treated in that sense.

So there'll be a clinic which will open in like a remote area for, you know, for a certain amount of weeks, but I wouldn't say batching has done. No, no. The only time it may be done, I think is in clinics that treat HIV patients. And then we sort of have a certain time where they'll treat HIV patients you know, for risk of contamination and whatever they like bachelor in that sense. But now it's, work all around the year. I think a few days of in holidays, but it's busier than ever. 

[00:07:09] Griffin Jones: So what are people doing to meet the increased volume? You said everybody's hiring, which means that there are not enough people coming in and filling those positions as quickly as possible as it is here. And so what are people doing?

[00:07:23] Giles Palmer: I mean, the desperately trying to find staff, and it's not always the solution that you can find a trained staff, okay, there was effect, I was giving a talk in Arizona, that was the start of January this year. And I've talked about mental health, which was a study we did which was the international study. We did actually with the group that I worked with and we looked at burnout. So ita lot of embryologist who are suffering or on the verge of burnout.

There's so much work that's going on. But that said it's very difficult to recruit younger people that have the skills, now it takes investment to train people. And the ideal thing is of course, to find someone who's like pretty well-trained or at least knows the basics. Now there's a lot of masters courses all around the world going on teaching at various stages, some are treating practical aspects.

Some are treating just theoretical. So there is quite a large pool of young embryologists, but it's being accepted to sort of join a team because as I said, there is an investment that needs to be done plus, and we're sort of changing tack a little bit. There's a growing workforce, especially in the states.

There's a lot of embryologists who have worked in clinics for over 20 years or more. This again was a finding from our study and these people will be retiring soon. Okay. And leaving the workforce. So there is I think a crisis coming perhaps when we have to find the men, you know, the members of staff to actually fill in this space.

Again, you mentioned, what are people doing to alleviate this? Two things I'd like to mention one is that there seems to be more and more what I called locum, but you call per diem embryologist,. okay. And it's a supply in need. I mean there are many more that are coming out and they can actually move from clinic to clinic and give their skills to a clinic who for many reasons needs to have more staff.

Okay. They have to be mobile. They have to be very well trained to sort of go to another lab. In fact cook in another kitchen, if you like, okay. They have to know all the equipment, they have to know all the protocols and they have to assimilate very quickly into a lab. So there's many more per diems coming into the fray, if you like.

And one thing which is changing is that now that the clinics are sometimes in chains, you know, the corporate companies which are coming out the advantage of those is that they can in fact relocate or they can move around their staff. So now I'm terrible at the geography of the states.

But you know, let's say that it's spread across the nation. If there's a shortcoming in one of the clinics, okay. In some kind of conglomerate, then they can effect, you know, move around people to sort of care for that. So that I think answers, that's my long answer to your, the question, but there are ways around everything again it's a good time to be an embryologist because there are many jobs out there.

[00:10:15] Griffin Jones: That's right. It's a seller's market at the embryologist, the seller in this context, though, people are, they're recruiting, they're using per diem folks. Is there any acquiescence to the burnout in, from the side of the clinic and the lab in that? Okay. Well, we just can't hire enough per diem folks, or we can't replace the folks that are being burnt out.

Our current staff are telling us they're burns out and we're so afraid of we lose even one that will, our problem will be compounded that much more. Is anyone saying, okay, well, our waitlist for patients might be two months to start IVF. Well, sorry. We're going to have to make it three or two and a half because otherwise we're going to burn out our embryologist.

Is anyone acquiescing as far as you? 

[00:11:02] Giles Palmer: I know of one example that slowed down there are treatments and that's a clinic in the UK actually who through staffing reasons they just had to. Okay. And. It's all power to them to be able to do that because you kind of went to clinic, you know, on a shoe string and you kind of when a clinic, you know if there's not an adequate number of staff.

So I think that has been the case. But it has been the case, even with the pandemic. If you think about it, the way that they've had to slow down in the UK, they couldn't have had to stop completely. I know in the states that wasn't the case. In every single state in North America. But you know, there has been this like management of staff just sort of keeps them furloughed if you like.

Okay. And sort of like gear them up again to be done. What has happened in the pandemic is that there's been a lot of like a, transfer's a bit like football. There's been a lot of you know, key players that have moved from clinic to clinic. And that's been the case, not just in the IVF world, but also in any kind of industry.

We've found people have reevaluated their values and their job. And if they haven't happened, if they haven't been happy in their in a particular job and feel a bit disgruntled with that company, then they had a great opportunity to change. We see a lot of fluidity over the last few months.

But then if you've noticed as well, there's been a lot of changes going on. And of course that goes fuels. Why people have been advertising so much. So there has been more change going on in that market, you said it's a sellers market. Well, I kind of took about salaries. You know there are clinics which are offering, like sign up bonuses for that, which I think is a great incentive.

But salary isn't everything and that's very easy for me to say, but you know, there are various things in your working life, you can look at as opposed to just salary being the reason why you leave. We know the embryologist are, are the greatest asset to a clinic, but if they're so good then you always have the danger that they're going to leave.

Now I was in lab management, I'm an embryologist, but I've been in lab management for, many years over 30 years. And some of your staff maybe like headhunted, you know, maybe taken away. Well, that's Inevitable, you have to be gracious when that happens. There are wheels within wheels.

We're still a very small community embryologist. I don't know how many thousands we are worldwide, but we are quite sociable and we all meet up, you know, even more so virtually, so is to be gracious. And if they have to go, they have to go. But there are many ways that you can keep an embryologist and it can be an, and you refer to burnout.

It can be just a flat fact that you, you give more amicable working hours or flexible hours. 

[00:13:36] Griffin Jones: I was having this conversation with Dr. Tony Anderson from Texas, and he was saying the exact same. You said, but I pushed back and said, well, how do you give people better working hours or fewer hours? When the queue of patients is figuratively around the corner and if you do that, then you're either pushing back treatment for people or you are putting the workload onto another embryologist. Say how do you do that when the demand is so high? 

[00:14:09] Giles Palmer: Well, I'm sure there's no company that's going to give someone, you know, extra time off if that's at the detriment of their lab staff.

Okay. But it's all part of management, you know, it's all part of lab manager. You have to have redundancy anyway. Okay. that is a day-to-day thing that a lab manager has to cope with. There's always going to be, there's always going to be someone in your large chain of clinics that, you know, you're going to be ill for one day. I'm going to have to take time off for like personal reasons. So you should always find that you can fit people to their abilities. You have to have younger staff. I'm not saying you can't and you have to train them and you have to train them on the job. Like I said, there are many training colleges around.

Okay. Especially in North America that, you have someone who has the competencies to sort of start with a less learning curve. Okay. When they join the lab, it is a commitment to the lab manager to actually see that everyone is competent and everyone starts off. But you know, it has to be done in the UK in fact, there's a new sort of subset of embryologists. Think they're called lab practitioners. I could be wrong, but they just do egg collections and semen analysis. So they do, let's say You know, limited workload, but it can be like a job which would take an embryologist, you know, hours away from doing other work while the other more experienced people will do.

You know, the embryo biopsies, the ICSI, makeup the culture medium. So, you know, there are ways around that.

[00:15:33] Griffin Jones: What do you think should be eliminated Giles and in any workloads, there's priority is eliminate, automate, delegate. And when you're getting so busy, you have to be extra scrutinous. What do you think could be eliminated or automated readily that you still see many labs not doing?

[00:15:56] Giles Palmer: I think you know, a lot of it is the paperwork. Okay. Now you don't have to be paper free, but you can be paper light in a lot of the clinics. A cornerstone of clinical embryology is of course quality control. Okay. But you still see people walking around the lab with, you know, pieces of paper you know, with a little tick box.

 Okay. There are now electronic means reflections where it's an outweighed and just electronically typing all these numbers you have to do. And they're forgotten about in a way until you want to actually retrieve them and reflect on them for any number of reasons. Okay. There's lots of things that can be done around the lab, which again, can be automated.

You do in fact, have these alarm systems on most of the critical pieces of equipment, but you still have to visually check them every day. Okay. I'm not saying that you shouldn't. But there's a lot of paperwork that goes on now, embryology as well. And we've spoken about this many times between the peers is there's a lot of admin work that is done with embryology.

Now that is a root of great concern because when an embryologist is trained, he doesn't realize that he's got to do another quality control assessments and he's got to do stocktaking and the, and the inventory to look after the, you know, quiet back. Okay. Even speak to patients. A lot of people are unaware that they have to do that when they train to be an embryologist.

And it could be that the embryologist wants to spend time on the bench work. So, you know, automating all this interaction with the patients, if you don't want to, or the admin, it could be done and there's not an efficient EMR at the moment, which can help with that. You've got to take yourself out of your working routine and type things in.

But you know, that will change. We often speak on our initiative about, you know, like smart devices now in the future, there'll be, you know, like perhaps smart dishes where you haven't got to use a sticky labels and there'll be voice to action certain ways that you can witness things in that sense.

But technology is coming just to take all the admin away from the embryologist. So that will be a good thing. 

[00:18:01] Griffin Jones: Well, there are some life sciences companies out there now. With replace a lot of the manual systems and both with storage and managing if they're not cleaning up right now on the heels of labs needing to become more efficient because they can't fill enough embryologists, then they don't have a very good sales platform.

I think there are some solutions out there I'm not qualified necessarily to speak right now. The pros and cons of each, but are these, some of the things that you talk about in your initiative that you call Ifree, which is the international IVF initiative. Tell us more about that. What do you do there?

[00:18:41] Giles Palmer: Sure. Well to answer your question about, does it, does it fill the void? Well, it's certainly a space which has been filled up by many companies. So, obviously you know, there is work for everyone to do making things automated and one is with the, you know, like quite a storage. It's a no brainer just because why should we have to check ourselves visually every year that we've put something in the right place, if it can be done automatically, then it should be done. You know, once AI of course has perhaps been overused these past few years. I mean, you know, everything is AI at the moment. But it's like tangible benchtop AI, which is going to come out and actually help us.

It'll rank things first it'll help us choose embryos a little bit better, but we'll still have to have embryologists that will actually look over the results. You know, it's like, a driverless car, will we allow complete control over it? You know, like a driverless car, we'll still have to look at this you know, this data to help us. That will be an improvement because now, you know, you'll know about time-lapse and time-lapse imaging, which is a fantastic way forward is a better way to incubate, it's undisturbed, but to choose an embryo, an embryologist may spend, you know, a much longer time if they have time looking over these images and trying to choose, which is the best embryo, it may call over one of his colleagues and have a debate purely because you have the luxury of seeing the video of that sense. So all these new technologies we talk about in our initiative. But it, talks about so much more it's really addressed to clinic staff We have a slight majority of embryologists, but also clinicians and lab managers follow this initiative.

We usually have them once a week. It's become very popular, but we do the whole gamma of the IVF industry. So we do like the cutting science. Okay. What's happening with new articles and practices. We can then do about new innovations. So again, we do about what's new on the market, but we've also touched on the field of embryology and looked at things that concern them, like quiet governance which is of course affecting everyone with a recent or failures, which are happening, everyone's paranoid to say the least about getting things right. We've looked at staffing levels. We've done a survey which was awarded which has been awarded at the fertility 2022 for its work.

We looked at mental health in an international survey, which I think I sort of touched on beforehand, but there's a lot of data in there. There's a lot of data that we know now about the psyche of the clinical embryologist. And then of course we've done a few webinars as well, which have looked at animal reproduction.

Okay, cloning stuff, which you know, is interested people. I think they do our job, which can, if can add that to your daily speaking with the patient, giving you a weird and wonderful, explanations from nature, then that's quite good, really. And we've even gone off piece and had people from NASA that had spoken to us because as you know, every five minutes people are popping into space nowadays and there will be productive houses with that.

There's micro gravity. There's a radiation problems and it's not been discussed. So people are doing experiments on sperm and embryogenesis in space which I think are interesting, not just as an embryologist, but the lessons they learn can she help some of the medicine here on earth as well.

 So we've done about everything cause you can see.

[00:22:02] Griffin Jones: When did you start? 

[00:22:04] Giles Palmer: We started just as the pandemic hit, actually the start of 2020. And it was Dr. JacquesCohen who got us all together. He felt, you know, and is a great visionary. So he thought that embryologist would need someone to talk and and to discuss things, especially as you know, there were like furloughed in, at home and in this uncertainty.

And he got together with Thomas Elliot of ivf.net. Who's a bit of a it wizard and he set up a website and they had the idea to have these like webinars. And of course, everyone has been doing webinars, but I think we've done something a little bit special. They've been very popular and to go with those two, Dr. Zsolt Peter Nagy.

Okay. And they look at like the scientific content of everything. And then we've had Mary Ann who's been with us in the IVF industry for a long time. Shaista Sadruddin as well. She helps out and Colin Howles, of course, who's quite a well-known figure in the pharmacy world.

So that's the core band, if you like, but we've been helped with, you know, so many people in the IVF industry, so many people have wanted to help us.Dr. Liesl Nel-Themaat has helped us out, Dara Berger, Alison Campbell, another person from the UK. And two others, Alison Bartolucci and Kelly Ketterson have all sort of helped behind the scenes to make these things a success.

[00:23:24] Griffin Jones: You mentioned that you have it's embryologist heavy, but you have a number of clinicians and physicians and lab managers, what kind of crowds are you? Are you getting now that the pandemic is now that people are on zoom every second of the day, like they were in March and April of 2020 about what's a average crowd for you?

[00:23:45] Giles Palmer: Well, we got about an average 600 to 800 people, every webinar I'm told is pretty good, especially as like companies that hold webinars you know, don't do very well at all, but it's because it's because it entertaining, you know, yourself and then your interview skills are fantastic.

You have to make people buy into the time that you want to give them, you know, they're working hard, it's their own personal time. Okay. You know, it's gotta be something that they want to listen to. And you know, and we have topics where I think people want to listen to, you know it's got the scientific core but it's also entertaining as well.

You know, no one wants to finish you know, like a long day and listen to like a commercial yeah. You know, on a certain project, you know at the start of the pandemic, of course it wasn't much higher. We were having over a thousand people attend but it's like leveled off to the numbers, which I've said.

And then of course it's put on the website afterwards and then many thousands watch it on demand as they say. Yeah. 

[00:24:40] Griffin Jones: Are they mostly coming from the UK and Europe? What's your distribution? 

[00:24:45] Giles Palmer: I'd say it's over half from North America. Okay. And then after that it sort of pretty similar numbers, but I wouldn't say that you know, too many people from the UK, watch it shame on them, but I say it's like north America and then the rest are all very similar.

You know, we've got UK as well, obviously. We've got a great following from. And now in India, usually the tone that we show these webinars, it's like 11, 12 o'clock at night, but thankfully that, you know, they stay up to listen to it as well. We do have them on other times if you never time to time, but the time we usually have them, which is 3:00 PM Eastern it's sort of our slot.

So we're quite pleased that we've got, you know, like a global following. 

[00:25:24] Griffin Jones: So, what are some of the insights that you've gleaned in the last few months? Because on this show, I talk about the business side of the field. And when I have lab folks on and talk about the business side of the lab, but I'm not having any sort of topics on about the latest techniques on ongoing to date by her beyond glasses.

And I'm not, you know, I'm not covering hatching. 

[00:25:47] Giles Palmer: Yeah, I'm not sure, but you know what it is though, but you know what it is you see, and that's the thing. And we'd still have people who own a clinic who we may want to dip into you know, webinars, just because it's much more practical experience. So you'd have someone talking perhaps about hatching blastocysts isn't it, you know, as you said, but it will say, it may be in a. terrible discussion where you've got people from, you know, leading clinics all over the world and they're talking about, well, I do like this and I do like that. So it'll perhaps, you know, help them sort of manage either their workload or their sort of plan about how they want their clinic to go.

 So that's what they gleaned from it, you know, that, you know and we have a large, we have a very large, let's say following, we have over 18,000 members, but that doesn't mean that they watch it every week. Of course, you're going to have like a subset of people that are going to be interested in, you know sperm and similarities.

Now, even if. 20% of those watching it, then that's a very, that's a really big number. You know, other people who are interested in like the tech side of it are going to be that and other people, which are medicine are going to fall from that field. So, you know, by having a large net, if you like and being global, we can get the numbers, which are quite envious in anyone's book I think.

[00:27:00] Griffin Jones: Especially for people that want to talk to embryologists right now. So who can join? Is this, is this a membership that people have to sign up for?

[00:27:08] Giles Palmer: Anyone can join. It's completely free and heal and it will always be free. We have an electronic membership card, which is quite good that you can put it on your phone.

So we've noticed that you know, that Evan has email overload and sometimes, especially with webinars. So we have a lucky little app if you like, but it's, but it's a membership card which will tell you where the next session is coming up and there'll be various offers on. And you'll be first to know about certain things.

So that's what we do and that's how they hear about it. We've got the website, which is IVFmeeting.com, which has the back lobby of all the talks. And we don't just have the, like the whole webinar. We also have them sort of cut up into each single lecture. So we're finding that even like master's students or I should say in a master's course, the teachers is telling the master's students to actually, you know, go and watch session 66 or go and watch you know, the topic on this.

So, you know, it's quite an archive of like, current topics there. And we do delve into, you know, the, you know, the business side of things sometimes, you know, the management side, as you said, within a very successful. 

[00:28:14] Griffin Jones: Yeah, but session coming up it by the time this episode is out, your session may have aren't fast, but I see you have a session coming up on corporate IVF.

[00:28:23] Giles Palmer: Yeah, I think it's very exciting. It's a very exciting time that we live in and you know, the clinics are just the preserve of like a single doctor or a group of doctors anymore. You know, these, you know, this is big business and to be quite honest, I think it does need to go into the biotech arena.

So we're getting these large companies more so in North America, but most centers in the UK now are, there's only about three or four, you know, like groups, if you like small in comparison, perhaps to ones in the states. 

[00:28:52] Griffin Jones: Is that across the board of Giles? Now there's three or four major groups, but are there still boutique centers in different markets or it's almost everyone owned by those three or four groups?

[00:29:04] Giles Palmer: There's still a boutique. There's still boutique in Europe. There are very much boutique markets now. Okay. Save a few, you know, like IVI, and Eugin still, they are the, you know, the end of the preserve of like a group of doctors. But I think the writing on the wall, you know, I think it's a good model.

It's a good business model. It's good for quality. It's good for results. It's also good because you know, all the research nowadays is going to come from private companies in the states. There's no money, which is given to embryo research at all. Okay. Although there is funding, you know, for other forms of medicine.

So it's going to be the antidote is going to be the conglomerates that are going to have the mic to do this, you know, and that again is going to be like a coward that is going to attract, you know, like embryologists that want to do that work, big data, large number of patients. That's where the, you know, that's where the research is going to come from now a days.

[00:30:03] Griffin Jones: That's the argument for corporate IVF. There's also arguments against it. And I have both perspectives come on my show. are you going to have a debate in your topic on corporate IVF or what are you going to cover? 

[00:30:18] Giles Palmer: We don't usually have the format of a debate now, you know, there were many other webinars and even, you know, the courses conferences, which do have like a debate.

[00:30:28] Griffin Jones: Neither do I, by the way sorry to interrupt because I want to sidetrack on this because so many, I would love to have a debate on my show because so many people will email me after a certain topic. And they'll say, I can't believe so-and-so said that when I think they're full of it. And I said, well, why don't you come on and share your perspective. No, you know, I can't, well, it would be great if people would.

[00:30:55] Giles Palmer: Well, I mean, I want to hear the, what are the arguments against it now? I'm sure they are, and I can guess that, you know, people think it's not gonna be personalized and whatever. But I just see the writings on the wall, you know, That's the way it's going to be.

[00:31:09] Griffin Jones: So this is the way it's happening over here. And I actually don't know if these metaphors work. Europe or the UK, but in the United States for a hundred years ago, you have a brewery in every city, in town, in America. There was Goebbels in Detroit, there's Genesee and Rochester. There's old style in Chicago and, and some of them are still around and some of them aren't, but every city had its own brewery or a couple.

And then as the century progressed, you had MillerCoors Anheuser-Busch merges the three conglomerates. Then you had south African brewing by Miller and then they walked coolers together. And then, so then you have SAB MillerCoors. Actually, I do think this analogy works in Europe because InBev comes from Europe and then merged with Anheuser-Busch. So now you've really just got two conglomerates that control most of the group, but what did we start seeing in the mid two thousands? The emergence of craft breweries, again in just about every city in America, and then some of them grow and they get bought by the bigger guys and then the middle of the new middle guys are buying the smaller guy.

And then people are starting brand new breweries. And it happens with breweries that happens with local and regional banks. And we also see some of it with fertility centers that this doc was a partner over here, or they worked in an REI division and they got bought and then they went off and they started their own thing.

And now they're growing again. It gobbled up.

[00:32:33] Giles Palmer: So what's the answer. Yeah. So, yeah. So what's the answer, no, I mean you know, you could say if there are these conglomerates. And with your beer analogy, you know, is their choice. But of course there's choice because there's market forces. That's what I think.

And you know, someone's going to offer these things. And you mentioned about like the emergence of these microbreweries. Well, you know, that'll happen again, maybe with IVF, so, you know, all that we are seeing.

[00:32:57] Griffin Jones: We are seeingg it. So I think what I'm saying is the cycle of life is continuing, but yes, it seems to me that the trajectory of most things is consolidation and fragmentation happens with countries, happens with businesses. And so we're seeing consolidation right now, but I also think we're seeing fragmentation and, and niching as well. 

[00:33:18] Giles Palmer: Yeah. But like, while these companies are big, then they get super efficient and they get this big data and that can help the smaller ones in the long run afterwards, you know, it gives them the opportunity to faction out if you like.

[00:33:29] Griffin Jones: If they provide efficiencies. And so come on my show and say, they're not so good at biting efficiency. I've gotten accused of being both. I'm neither. I do think there are pros and cons and I let people say which they think is.

So we've covered a lot. How would you like to conclude most of our audience right now comes from North America, about 75%. But there are some folks outside, I think after the US and Canada, India is our biggest listenership, but we've had listeners from Australia and central Europe.

You speak far more to the lab side, whereas our audience has some lab folks reach out I, how we got connected. But a lot more on the clinician side and the business side. How would you want to conclude with our audience either about what you see happening in the field and what like see, or what you'd like people to know about?

[00:34:22] Giles Palmer: I have to take a moment to think about that. I would just think about saying that what you've said to me now is you know, that you think that you are catering for an audience, which is just mainly north America, perhaps, and many conditions. And I think that we cater for people from the lab side of things, but as our hashtag is, it's like hashtag share the knowledge.

And that's what we did. You know, first of all, and people are watching it because whether it's legal aspects or it's business aspects, as you mentioned yourself, it is coming their way. And you know, we've got 180 countries that follow us and I'm sure you have as well, because they're going to learn something from what you're saying, and they're going to learn something from what we say as well now, maybe they've got different laws and a thing that we have seen. Not just with my, with my day juggles with is that every clinic works differently. Okay. They may have similar protocols, but every clinic works slightly differently, but they have these common problems in each country and each region has a way to solve that.

But you know, the issue of, you know, quiet governance. So what are you going to do with your non-compliant embryos, for example, what are you gonna do about safety? What you know about quality control, what are the legal aspects? What are you going to do about staffing levels? As we mentioned whatever it is, it's coming their way.

We've had some sessions on Treatment of same-sex couples. We've had successes on trans folk, which applies to perhaps my country, UK and yours, more where it is more open and it's more accepted, but as a service towards that many other countries in the world that's an opportunity for many of these people, but it's coming their way.

You know, this globalization is happening and they can learn from you know, like reaching out and having programs like yours, like mine and like others, where they can just see the writing that is on the wall and what is coming up in the future. 

[00:36:11] Griffin Jones: Well, I thank you for coming on to share some of that with this audience.

I hope our audience will come and check out your initiative the international IVF initiative at IVFmeeting.com and we'll link to that in the show notes and hope that they benefit from the insights of the things that are coming their way. Thank you very much for coming on  the show, Giles. 

[00:36:35] Giles Palmer: Thank you very much.


IVF Conversion Strategy

IVF Conversion Strategy

Fertility centers often set new patient appointments and IVF retrieval goals without examining their relationship together. When we ask practice owners to state growth goals for new patient appointments and IVF retrievals, the difference almost always equates to a decrease in current IVF conversion rate.

90 - The Best of 2020

As we head into a new (and hopefully better) year, we wanted to take a look back on all the wonderful, inspiring guests we had on Inside Reproductive Health throughout the year. We talked about affordable care, mentoring new staff in the clinic and the lab. We learned about independent clinics and how they thrive despite heavy network competition, networks and how they continue to provide personalized care even after becoming publicly-owned. We talked about reducing physician burnout and increasing patient communication. And so much more.

On this episode of Inside Reproductive Health, we highlighted your favorite episodes and compiled the best clips into one episode for you to enjoy as 2020 wraps up.

86 - Embryo Disposition: Implications and How to Protect Your Clinic, an interview with Igor Brusil

The disposing of embryos has long been a controversial topic in the world of IVF. Clinics can’t afford to keep embryos around when patients have stopped paying their bills. But the ethical and legal implications keep embryo disposition from being a simple decision. Plus, patients aren’t really properly educated on what the limitations of cryopreservation are and clinics aren’t always fully prepared with proper consents and contracts when the time comes to freeze embryos.

On this episode of Inside Reproductive Health, Griffin spoke to Igor Brusil, attorney-at-law and per diem embryologist and legal counsel for the American College of Embryology in Houston, Texas. After working as an embryologist, Igor became interested in the ethical and legal implications of lab procedures, specifically embryo disposition. This led him to pursuing a legal degree and working as counsel for a variety of clients, but his focus remained in healthcare law, risk management, and professional liability.

He brought his unique experience to the show, sharing his thoughts on what clinics can do to protect themselves when it comes to the issue of embryo disposition.

55 - Easing the Strain of Embryo Disposition on Patients and Clinics, An Interview with Andy Gairani

Embryo disposition is a sensitive topic for patients even long after they’ve left a clinic. However, there can also be a burden placed on clinics when it comes to making space and cryopreserving embryo, eggs, or sperm for an extended period of time. On this episode of Inside Reproductive Health, we learn more about how one company is working to alleviate the burden for both the patient and the clinic. Listen to Griffin talk to Andrew Gairani of Embryo Options, a web-based application that provides patients with disposition education and resources, along with other features that make storage easier for everyone.

53 - Has Mentorship in the IVF Lab Suffered Due to Strained Staff? Interview with Bill Venier

Are you struggling to retain your lab employees? You are not alone. Retention is a commonly-discussed issue across the field of reproductive medicine, but no one is hurting more than the lab. On this episode of Inside Reproductive Health, Griffin talks to Bill Venier, IVF Lab Director at San Diego Fertility Center. Together, they discuss what SDFC is doing to keep their employees in for the long haul, as well as some ideas to ease the training process of new reproductive biologists.

51 - All About the Sperm: Testing Standards, Accessibility, and Anonymity - An Interview with Dennis Marchesi

Donor gametes are a crucial pillar of the field of fertility, but what happens behind the scenes? On this episode of Inside Reproductive Health, Griffin talks to Dennis Marchesi, Director of Laboratory Operations at Xytex, a sperm bank located in Georgia. Together, they talk about the nuances of different labs working together, how Xytex is dealing with cultural changes that are affecting anonymity of donors, and the impact mail-away testing kits are having on the lab.

48 - David Wolf, Do Regulatory Restrictions Hinder or Help Innovation in the Fertility Field?

“...I think fighting consolidation is not going to be a winning strategy in the long run. That being said, I think there's still lots of room for creative, innovative, entrepreneurial operators whether they’re at the clinic level or the supplier level and... as the field gets bigger and gets more interesting from a public capital markets perspective, there's going to be a lot more opportunity for funding those exciting innovations.”

Consolidation, IPO, publicly-owned...all words that weren’t a part of the fertility world vocabulary 10 years ago. Now, they are becoming more and more common, which can be both exciting and nerve-wracking to entrepreneurs in the field. On this episode of Inside Reproductive Health, Griffin Jones, founder of Fertility Bridge, talks to David Wolf, President and CEO of Hamilton Thorne. They discuss the implications of consolidation coming into the fertility world as well as the pros and cons of both publicly- and privately-owned clinics and suppliers.

Click here to learn more about David Wolf and Hamilton Thorne.

To get started on a marketing plan for your company, complete the Goal and Competitive Diagnostic at FertilityBridge.com.

46 - Can Innovative Practice Culture Drive Patient Satisfaction? An Interview with Dr. Alan Copperman

Building and growing an IVF practice can have numerous benefits for both the owners and the patients they serve. But growth can sometimes lead to loss of patient-focused care. On this episode, Griffin Jones, CEO of Fertility Bridge and host of Inside Reproductive Health, talks to Dr. Alan Copperman, Co-Founder and Medical Director of RMA of New York, one of the nation’s largest IVF centers. Together, they discuss how RMA of New York was able to retain their patient-focused culture while exponentially growing the practice. Their approach to delegating important tasks, understanding the “new” patient, and finding the right, compassionate employees has greatly contributed to their success today.

To learn more about Dr. Copperman and Reproductive Medicine Associates of New York, visit their website at https://www.rmany.com/.

Visit fertilitybridge.com to learn more about what Griffin and his team can do for your fertility clinic and take the first step in building your marketing system with the Goal and Competitive Diagnostic.

42 - Insights from a Futurist: Genetic Engineering, An Interview with Jamie Metzl

Preimplantation genetic testing has opened up a world of helping families have successful pregnancies. But when does the testing and selection of embryos go too far? In this episode of Inside Reproductive Health, Griffin talks to Dr. Jamie Metzl, author of Hacking Darwin: Genetic Engineering and the Future of Humanity. They discuss the implications of advanced technologies such as the future of embryo screening and gene-editing. More importantly, Dr. Metzl discusses the significance of understanding the coming technologies and how those in the fertility field can help prepare their patients and the rest of the world for these changes.