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218 Compounding Clinical Efficiency Through your EMR with Dr. Mark Amols and Elizabeth Lee

DISCLAIMER: Today’s episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free, to you! Here, the Advertiser has editorial control. Feature sponsorship is not an endorsement, and does not necessarily reflect the views of Inside Reproductive Health.


Ever wondered how much your fertility clinic could achieve with just a 5% increase in efficiency?

In this week's episode of Inside Reproductive Health, we explore this question with returning guest Dr. Mark Amols, Medical Director of New Direction Fertility Center, and Elizabeth Lee, VP of Wellnest Fertility.

Join us as we dive into:

  • The impact of your EMR on your clinic's performance

  • Where a 5% efficiency boost can generate 25% overall clinical improvements

  • How enhanced efficiency can unlock patient access to care

  • A brief demo of Embie, spotlighting its clinic-streamlining features


Dr. Mark Amols
LinkedIn

Elizabeth Lee
LinkedIn

Embie Clinic
LinkedIn
Instagram

Transcript

[00:00:00] Dr. Mark Amols: I think one of the reasons that everyone needs to demo this, regardless if you're looking for an EMR or not, it's going to open your eyes to realize that there's more to the EMR than what you've been looking at. You've always looked at the EMR as a system that just tells you the information that you want, but this system actually works with you.

It's a marriage where you're not working against each other, but you're working with each other. 

[00:00:20] Elizabeth Lee: This is really the clinic operating system that we've all been wanting, but never could find. Think about how, if we started to think about clinic operations like this, in this type of succinct, smooth way, think about how many more patients we could help.

[00:00:37] Sponsor: This episode was made possible by our feature sponsor, Embie Clinic. Is your EMR holding you back? Is an Excel sheet your one true source of data? Are you wasting your time with disconnected point solutions? Embie Clinic's unified solution for the clinic and patient provides a single source of truth. Our suite of tools helps you flex and scale your fertility practice from clinical care to the lab, administration, and beyond.

From onboarding to baby in arms, Enby makes sure your patients are informed, Educated and supported every step of the way. Say goodbye to the old and welcome a new standard of care with Embie Clinic. Visit embieclinic.com/irh now to book a demo and take the first step to modernizing your clinic. That's embieclinic.com/irh.

Announcer: Today's episode is paid content from our future sponsor, who helps inside Reproductive Health to deliver information for free to you. Here the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of Inside Reproductive Health.

[00:01:57] Griffin Jones: Could it be that this is the Chosen One? Is this the promise that has been foretold? The Slayer of EMR? The Trident of Triumph? That allows you to finally start getting some meaningful clinical efficiency and stop doing all that junk you hate? I have no idea. I'm not a clinician, remember? That's why you have to check out for yourself and why I brought on two clinicians.

It's worth it. Elizabeth Lee, who's been a fertility clinic nurse for many years and is now the VP of operations at a new fertility clinic network called Wellnest Fertility. And Dr. Mark Amels, who's been on the program a few times now, despite the annoying technical difficulties I've thrown at him more than once.

Thanks Mark. Before we even talk about EMRs, we talk about how a 5 percent efficiency in one area of your clinic can lead to a 25 percent efficiency or greater and have impacts. in every area of the clinic and the lives of the people touched by the clinic. Yes, including patients. Yes, including providers.

Yes, including staff. If you've already decided that you're only going to listen to half or a third of this episode and all you care about is what is this revolutionary EMR slayer, skip to the last third. I think this conversation about compounding efficiency is really valuable because whether it's this solution or another, this is what we've been asking for.

It's the direction that we have to go in. I did a teensy tiny baby demo with Elizabeth in that part of the episode. I can appreciate you're probably going to want something longer form. We're putting those links in with the show notes with this episode, in the places where this episode comes out. Click on that, schedule your demo with Embie, and let me know.

Because I'm not a clinician. Are Elizabeth and Dr. Amos just sugar high on pixie sticks? Or is this the technology that you have been clamoring for years? Your input really matters to me. Please. Let me know what you decide ms. Lee Elizabeth. Welcome to the inside reproductive health podcast Dr. Amos mark.

Welcome back to this darn podcast 

[00:04:01] Elizabeth Lee: Yes, thanks for having us really excited to be here 

[00:04:04] Griffin Jones: There's a particular angle that I want to get in today because of a previous episode that I had recorded where I had a number of REIs from many different parts of the world email me after that episode and I want to get into what that was about.

I first want to broached this concept of thinking about how marginal efficiencies can have a compounding impact and maybe like the efficiencies themselves aren't marginal, but I'm talking like if you make your clinic 5 percent more efficient, if you make it 10 percent more efficient, that There is a compounding benefit to that.

And, and so Mark, you are someone that I think lives it's, this is now your probably third or fourth time on the program. It's at least your third. The first time I had you on was during COVID. It was a live episode. We had over, We had maxed out the zoom limit for the people that could attend. And I was like, people are going to have to do things this way.

I thought that it was going to have to be, I thought it was going to be sooner because I didn't know how many trillions were going to get pumped into the economy. That bought people some time to not be crazy efficient. But now as I, but now where I see things are going, it's okay. The way that Dr. Amos and a handful of others are approaching this.

That's. Just the way it's going to have to be to expand access to care. So what about this idea that increasing efficiency by 5 percent or 10 percent or something, what you might consider small can have a much larger impact.

[00:05:45] Dr. Mark Amols: Yeah, I mean, absolutely. That's how I run my whole business is efficiency, getting rid of the bottlenecks.

I think one of the interesting things about this show is when it comes to this product MD, that is really the center of your entire. Practice, right? So everything goes through it. So when you talk about bottlenecks, even a 5 percent increase in efficiency, if it's at the EMR might actually lead to a 25 percent efficiency because now different departments can talk to each other faster, different things are happening versus like you're saying, if only a 5 percent or 10 percent efficiency occurs on one area, let's say at nursing.

That only helps at that nursing portion. So there's different things that have downstream effects that also make the full clinic more efficient. And so this is what's unique about this system, which I'm excited about. And we've been working with now for a period of time, is its efficiency for the whole clinic, not just one area.

And so most of my focus has always been on individual areas, how to make nursing more efficient, how to make room and patients more efficient, all those little things. I look at everything in time. So as the old adage goes, time is money, I look at everything as time. And so that is one of the efficiencies is time, because the one thing we all don't have is, is more time.

And so we're all working on the same rules there. And so the ones that can find a way to improve the time efficiencies are the ones who are going to come out ahead. 

[00:07:06] Elizabeth Lee: Yeah, it doesn't count. It doesn't take that long to count to a hundred. It really doesn't. And so I want to even posit that 1 percent efficiency gains over time are the reason why people like Mark are able to run his practice the way, uh, that they are.

Mark and I actually know each other really well, and I helped him build a, Getting things really going in terms of being very high volume. And what he and I found was that same thing. It was these little areas that really added up quickly, just the costs. And one of the ways Mark's able to offer the costs he is because he really cares about looking at each line item and saying, okay, these consumables are too expensive.

We don't need to be spending this much money on syringes or something. So I think 1% Little 1 percent gains are all that's needed. And I think people think about it in much bigger chunks and that makes it harder to swallow. 

[00:07:59] Griffin Jones: Why don't we talk a little bit about what it is that you do in helping other clinics?

And I understand you're the VP of ops for a brand new clinic network. And I want to talk a little bit about that because before. We started recording and you said that you and I had met. I didn't remember. And I'm, and I thought I would have, it seems like I would have remembered that because I know who you are.

Like I've heard your name in a lot of different places and people are like, Oh, you got to talk to Elizabeth Lee. Elizabeth Lee is over here doing this. And so I've, I've. I've seen some of the activity that you've had in a lot of different places, and more than one person, it's probably three or four, have directed my attention to you.

What is it that you're up to? 

[00:08:44] Elizabeth Lee: Yeah, thank you for that. That's having started as a little baby IVF nurse with Mark many years ago. It's very humbling that anybody would mention my name. I spent the last year or so really doing consulting and trying to bring this topic that we're talking about, this idea of minimal efficiency gains to create big change.

But working with some big clinic groups, some donor banks, just some different groups that were really looking to make that type of shift. In their thinking to realize some of their goals. And I really spent the last, like I said, year or so working with CEOs really trying to help to shift that mindset and to help see on the ground level or the direct level.

Patient to staff communication level where some of the improvements could be made. That's not an easy thing, right? To say, Oh, you need to make improvements here. No one wants to necessarily hear that. And it's certainly not an easy thing to tell people, but when, you know, this, some of the biggest successes I've saw from organizations was, were ones who said, Bring it on.

How can we change? How can we shift our mindset? But since then, I got offered the opportunity kind of a lifetime, which was to start a clinic from de novo, from scratch entirely. And so that is with wellness fertility, which you're right is a new network of clinics. And we're really looking to bring care to places that there is none.

So Griffin, you talk a lot about it. Mark talks a lot about it. We all three talk a lot about access to care, which I think has become a little bit of a buzzword. Something that I'm looking to tackle with my newest venture at Wellness Fertility is actually looking at how do we really do that? And part of the way we are doing that is we brought on a consultant from Johns Hopkins who actually wrote his PhD on how to improve access to care.

across the U. S. Like he and his wife went through fertility treatment, and he just so happened to be very passionate about this topic. And so he actually helped us do some really deep dive analyses to figure out where to put these clinics, right? Where are these white spaces where there are population densities sufficient enough to support a clinic, but there isn't a clinic there.

And then how do we show up Yeah. To serve communities like that. So that's really what I'm up to now. I thought I was going to just continue talking and geeking out about operational efficiency for the rest of my life. When someone says, Hey, you want to start a brand new clinic? It's hard to say no. 

[00:11:15] Griffin Jones: Yeah.

It turns out if you have good enough ideas and you can communicate them to people specifically enough, somebody is going to say, I want you to do that for us, and you decided to say, yes, Mark. Before you said that. In some areas, a 5 percent efficiency might just be a 5 percent efficiency, but in others, a 5 percent efficiency might actually lead to a 25 percent efficiency.

You mentioned the EMR as an example of that. One, why is that principle the case that a 5 percent efficiency can lead to a 25 percent efficiency? And then why is the area of EMR a good example? 

[00:11:56] Dr. Mark Amols: Cool. Yeah. So like anything, there's a central part, right? So let's think of like a computer, you have a CPU, right?

You can make, you can add on better parts of your computer. And the end of the day, if your CPU is slow, the computer is going to be slow, right? Everything has to go through that portion. And so my example would be like, if I went in and improve, let's say making calendars for a nurse, I might improve that 5%, right?

But it doesn't make me any faster. It doesn't make my front desk any faster. But if I upgrade my CPU. So now the central portion, which everything goes through, improves even just by 5 percent there. It could make the entire clinic increase in productivity because each department now improves. And that was my point.

I think we're a really good example of a clinic that will benefit a lot from a better EMR. I like my EMR. I don't want anyone to think I don't like my EMR. My EMR is not made for IVF. And so one of the issues that we deal with my EMR is that there's a lot of fragmentation. So like anyone who's in the EMR that wasn't made for IVF, there are workarounds you have to make them.

The workarounds usually add time. They usually create a second or third step. And so to become more efficient, you have to get rid of those steps. And one of the things that an EMR would allow me to do if I have one that was made for IVF. is we could skip those steps, get more efficient. And obviously I'll let me talk for themselves.

But one of the things we've been looking at is, and I'm sure if you ask anyone, no one's going to say there's the perfect EMR because just as it exists, because no EMR is made for just one clinics made for a bunch of clinics. But of all the EMRs I've looked at, most of them have one thing that's Not the focus, and that is efficiencies.

That's the one thing you don't see in most EMRs. It's more about documentation, which is important, all the important things you have to have, prescriptions, billing, all that, but they really don't focus on efficiencies. And that's why EMR we've used for a long time is it has been very efficient in certain areas, but it's definitely not efficient in others.

And that's why we're looking at this, and that's why I look at that as the CPU. I look at it as, everything has to go through the EMR, and if that's efficient, it makes everyone else efficient. Does it 

[00:14:09] Griffin Jones: have to be that way? Is the reason why EMRs don't focus on efficiency, it has to do with something that the other outcomes for which they're responsible precludes them from being efficient?

Or is it simply that they have other priorities and efficiency isn't at the top of the list? 

[00:14:29] Elizabeth Lee: Yeah, I don't mind taking that. I think, as Mark said, like his EMR, for example, wasn't made for IV, other EMRs aren't made for a specific clinic, right? And so what happens is, I think, I don't think that any of the EMRs don't necessarily think that efficiency is important, but clinics are having to back their process up.

Into the way the E. M. R. runs. For example, you might have something we're really looking to focus on. It must is trying to tee up our patients so that when they get to the R. E. I. They have all their diagnostic testing done right now. The E. M. R. S. Don't really entirely support that diagnostic front end. Why?

Because not a lot of places do it. I don't know. But at the end of the day, I think what we do have in common is that all E. M. R. S. Serve patients, Right? As different as our clinics can be, we all do the same thing, and that's serve patients in some way. I think that might be what makes Embie special, or have that spark that has caught both of Mark's and I, and my eye, is that it was actually created by a patient.

And it shows, it really does, does show in the flow, in a lot of the headaches that patients experience are, those things are gone. So if there's smooth communication with the clinic, there's ease of scheduling, there's ease of data portability, ease to see your data. You don't have to call the clinic and ask them to release your follicle count to your portal.

It's really a seamless two way communication so that the patient can actually be the center of the care team. I don't know if that answers your question, Griffin, but I think, I don't think it's a matter of not wanting to necessarily focus on efficiency as much as it is that a lot of the EMRs are just really set in the way that they work.

And you can either fit into it or you can do something different. I actually think a little bit different view.

[00:16:24] Dr. Mark Amols: I do think that they are set in their ways. I do think that one of the things MD has in any EMR coming in today is they now have the foresight of what's coming up, right? The one thing we all know is.

There's just not enough positions out there, right? And everyone's looking at different ways to fix that. Some of us look at efficiencies. Other of us look at, we'll just pull in more money and take another doctor. But at the end of the day, there's only so many doctors, so much time. I think Griffin, when you look at what an EMR is, you're right.

There's like a basic portion of EMR that says, okay, I have to be able to do this. I have to be able to do this. What the original EMRs came in with was looking at how do we make things fit better for IBM? For example, is, oh, we can make the partners match up. You can't do that. Most EMRs. So people, oh, that's great.

But again, that's not a very efficient feature. Sure. It helps a little bit. Right. But it doesn't really make you more efficient. It's just, okay, now I don't have to put in there a little note that the husband is this. EMRs used to be able to now track certain lab things that you would have in a lab. But again, doesn't make it efficient.

And when the EMR gets a bunch of people, at the end of the day, this is, these are all businesses. I think the thing we always forget about is everyone's trying to make money, right? We all, we're all just trying to make money. And so when these EMRs get enough customers, they're like, why do we need to make it more efficient?

Everyone's using the program. It's doing the job they need. That it's like a card. It's from A to B. But no one knows that there's more efficiencies there. For example, like a Tesla now, you don't have to drive it anymore, right? It just takes you there. So it's efficient. You didn't even know you needed, but you're like, I really liked this.

Now I can just pop in the location. It takes me there. I think MB is very fortunate. They're coming in at a time when there is this change in our field and this change of meeting efficiencies. And one of the things that, you know, that Elizabeth has, because most of them talk about the selfless and said it, she's extremely smart person.

So just so you know, when I met Elizabeth. I met her and she was, I think you were only a nurse in IVF for what, three months I think it was? I think it was only three months with the clinic you were at. I met her and she had more knowledge and more understanding of fertility in three months than nurses I worked with for, been in a year or two.

And when we met, one of the things that, Really, I got about Elizabeth. We both got each other. We realized that we had to be efficient to make this process work. I told her what the goal of my clinic was, what I wanted to do and the obstacles we're against. And we were coming up with many things. And I'll give you an example of efficiencies that you don't think of.

So back before there was programs like Clara, OMD, all these different kind of text to patient message things. When we first saw it, we were just like anybody else going, Oh, it's extra costs and help us. But then we started thinking about it and we thought about how long do we have to stay on the phone every time we talk to a patient because there's no such thing as a five minute phone call.

Every patient, Oh, it's five minutes. It's 20 minutes. And when Lisbeth and I talked about it, I said, Lisbeth, how long are you on the phone for? I'm on 15, 20 minutes, even for a simple question. And I'm like, wow, if we think about it, we look at the cost and we figured it out, we would save not just a ton of money, but efficiencies.

And so before we had this system, Liz would be there maybe till 5pm or something. We got this message system, and all of a sudden now, Liz would leave at like 3pm because the work was done. We were able to answer 50 patients in an hour. And so the point is, like I said, not everyone realizes, There's a benefit.

Just like we didn't that day. I didn't know there was a benefit, but I'm always looking for it. And that's where I think Envy is so fortunate. And like most companies, they're coming in at the right time. They're coming in at a time when we now are becoming like the primary care, where we have to see more patients in a short amount of time.

And it's the only, not everyone at CCRM can charge a million dollars for a cycle and get away with it. Most of us aren't going to be able to do that. And we're gonna have to do volume. That's how most are going to have to do, especially if it becomes a mandate, when you look at like a Boston IBM, right, they have efficiencies.

And so they're coming in at the right time when efficiencies 

[00:20:26] Elizabeth Lee: are needed. There's really something there that we don't think about our staff burnout levels and what contribution that. Our tech stack or lack thereof is making to those burnout levels. And actually some of the efficiency gains we've talked about earlier, where 1 percent actually may have more of a compounded effect, that's where I think this is because the EMR is every interaction you're having with a patient must be.

Put in the EMR. And so if we're able to create the efficiency gains in that Avenue, then I think our staff become less burned out. They become more engaged. Then they have more to give the patient. Yeah. 

[00:21:08] Griffin Jones: I don't think you can totally bucket efficiency just as this metric for productivity or profitability.

And, but I, and I encourage people to think about it, that your, your Team or your perspective team simply will not use the old fashioned tools over some time because it's asking too much of them. It'd be like asking a landscaper to do an entire football field with just it. a set of shears, right? It's like, we have giant industrial size lawnmowers for a reason.

And once you have them, there isn't any going back to saying, Oh, just use these shears. And, uh, it'll take you about four months, but, uh, have fun with that. It's the same for operations in the clinic too. How did Embie come about though? Which of you two discovered it first?

[00:22:08] Elizabeth Lee: I did actually, I was working with a client while I was doing some consulting work and.

They were getting a presentation over lunch of this new EMR and I was like, okay, blah, blah, blah. And then as soon as I saw it, I was captivated. I was like, wait, what is this and how do I get it? And then very shortly thereafter, I'm texting Mark going, have you seen this thing called Embie? You need to see this new direction.

This would make every impact on new direction. So then that he started to become excited about it at that time. at that juncture. 

[00:22:41] Griffin Jones: Why did you get excited about it first though? 

[00:22:45] Elizabeth Lee: Me, because I could see the drastic difference in, in efficiency, starting with just right upon login, being able to see this sort of bird's eye view of the, the clinical picture.

So Mark will probably start nodding his head here when a patient calls. He and I actually have really good memories as memories go, we remember some strange things, right? But not everybody is that way. And I'm a real believer that systems and processes drive behaviors, right? Things aren't going to happen by accident.

I need to be able to see at a quick glance what the picture is that I'm looking at, who the patient is, who their partner is, what sperm, eggs, uterus, tubes look like. And Embie immediately showed me that in one glance. I didn't even have to try. To find it. And then just as I started to go through it, it just, I could feel the intuitiveness of it.

And at the time when I first saw it, I didn't realize, I didn't know that it was made by essentially from a patient who had gone through eight cycles of IVF and ultimately found success in the cycle where she demanded, not demanded, that's probably too strong of a word, but she insisted on triggering at a different timeframe.

Then her doctor was indicating and why, because she had her own data set from all of her cycles and did some predictive modeling, right? Patients like Mark and I are, and we can remember things patients don't have all don't have that capability, but it just was very clear to me quickly. Not only does it have a beautiful aesthetic, but it's just so intuitive in terms of how to navigate.

And it finally, I found something that could templatize. The things that became very routine, but where mistakes become a big deal, for example, prescriptions. If I order something incorrectly for a patient, everybody's going to be okay. Everybody's going to be safe, but that patient might have spent an extra thousand dollars on a medication that she can't return.

And so Embie also really does a lot of that systematizing. Right? So if systems and processes drive behaviors, then we can build those systems in and Embie really seemed to me to be the first product that I've ever been exposed to that did that, that started to bake some systems into how the clinic should flow.

[00:25:12] Griffin Jones: Will you show me some of this? I want to do a little mini demo because after the previous episode that Embie did sponsor, but it was not a feature sponsor episode. So what that means to the audience is that this, for example, is a feature sponsor episode. If I say Embie’s meh. Embie can ask me to cut that out because it's a feature sponsored episode.

And we tell you the audience that in the disclaimer brought to you by sponsorships do not work that way. They are, we try to match advertisers with relevant topics, but they have no editorial control over the episode. So someone can say something's mass. Um, somebody could refer a competitor, even though that particular advertiser is advertising in that episode.

And after that episode where. And we just had the little mention and an ad in it, there were a number of people that scheduled demos with Embie. And then they emailed me telling me, this thing is awesome. I heard about it on your podcast. And then I booked a demo with them and I'm blown away. And so that kind of gave me the idea for wanting to see some of this today.

And, and I like the idea of having Mark on, because I was saying prior to our conversation that. Dr. Amos is the guy that will try everything and be impressed by not that much of it, is the impression that I have of him. And so, the fact that you're into this makes it intriguing. 

[00:26:45] Elizabeth Lee: That was one reason why I attacked him, because I was like, you know what, he'll bring me down from the clouds.

This is too good to be true. It can't. And so that was really one reason that I wanted to loop the bend, besides just seeing the benefits of his practice, was knowing that he really does have that sense of filtering things out. And I knew he would bring my head back down from the clouds if, if I was over seeing more in it than was actually there.

[00:27:08] Griffin Jones: Will you show me a little bit? 

[00:27:09] Elizabeth Lee: Yeah. Yeah. I would love to. Let's see here. This is your general patient chart. And this is what I was alluding to a moment ago about having all of the relevant data right in front of you. I need to know who this patient is partnered with, right? Cause that makes all the difference.

And then there's just a few key pieces of data that I need to see in order to form the clinical picture. Because Mark, Mark will nod. When you pick up the phone, you have such a brief amount of time to put that picture together before you start losing trust. Because the patient does expect you to remember everything.

And again, Mark and I are like, okay, luckily we remember things pretty well, but not everybody does. And you want to be able to convey trust to your patient that you understand what's going on with his or her picture. And this was really what struck me initially was having this high level overview, but then having the ability to dive under the hood where needed and have all that relevant data.

And Right at my fingertips, but that was a patient chart specifically. This is the clinic dashboard that sort of that practice management hub where. You can also get a bird's eye view of what your day looks like. Oh, I didn't know we had a monitoring today. Who is that? Oh, shoot. Who's the, let's say there's a transfer there and you didn't realize.

There's a lot of reasons that having these, these types of C's are really helpful and then it's just, it's really pretty and that helps, it helps. It's very easy to navigate. If I want to go dive into this patient, I can just double click her. There I go into her chart. If I want to hop on a telehealth with her, I can right there.

Click a telehealth button. I'm not looking for a zoom link. I can immediately. Present the option to just hop on a telehealth. Maybe there's something so you can see within here. I'm not sure if it's ultra mirroring it, but that ability to just right in the moment, hop on a telehealth with a patient. See here, sorry, zoom was covering the ability to exit out.

[00:29:12] Griffin Jones: Sorry, Elizabeth, I want to ask Mark, because I've never worked in a clinic before, right? Explain to me like what Elizabeth has shown us so far. What is the impact that it's having these different features? What is the benefit that it's having on the way your clinic operates? 

[00:29:34] Dr. Mark Amols: Yeah. And I think this is important to understand what area you're looking at.

So for what she was specifically talking about, and this is where I think it's huge is when a patient calls in. And you have to answer a question, even if it's not calling, let's say even just a situation where they send a message through the message system. In most EMRs, you have to go looking through the chart for things.

So maybe you don't see a cycle they did. And so you're talking to the patient and you say, Oh yeah, when you did this, they go, I didn't do that. You're like, Oh, you're right. I'm sorry. And then it makes me sit there and go, what else? 

[00:30:03] Elizabeth Lee: That moment in that moment, you lost a nugget of trust, right? 

[00:30:08] Dr. Mark Amols: Exactly. It's that meme where it says at that moment, you realize you effed up.

That's that moment where you realize. Crap. I just said something wrong. 

[00:30:17] Elizabeth Lee: And that's a lot of stress to put on your staff, right? 

[00:30:20] Griffin Jones: So that brings it up as soon as the person calls or leaves a message. Yes. All their information is right. I just, okay. So now I'm making the connection of what you're talking about, Elizabeth.

If I had the, it's almost like a CRM function, a customer relationship management function. If I had that, I wish that I had that for every time, you know, somebody, Texts or calls me, it's like, Oh gosh, what was the thing that we were talking about? Where's their information? 

[00:30:48] Elizabeth Lee: And I like to think about Embie.

What I think is so beneficial about it is it's really a suite of tools. So instead of having this CRM over here, and this is our telehealth platform, and this is our RCM tool, it's really aggregated all under the same roof because all of those platforms need to share the same data, but typically they don't do a very good job integrating with one another.

And so this is really pulling it, just allowing you to have really. One source of truth, one single source of truth without having to manually redo data. I know for me, one of the big bottlenecks that I saw in clinics was lots of spreadsheets, right? And why? Because it's, as Mark said earlier, it's, I think, I don't think you said a band aid, but it's a workaround, it's a workaround, right?

And Envy really took all of those workarounds and put them into, we don't need a workaround anymore, here's how you'll access that. So here's that overview that I was showing you. One of the things that Mark and I think is really cool about Envy is its ability to visually show data. In a way that really is syntonic with the way we think about it.

So we think about cohorts of follicles and we think about actually the stem sheet will be a little bit better. Um, we think of cohorts of follicles and we think about, um, those developing over time with, in relation to lab levels and just different assessment values. But usually those pieces of data are all in separate places.

Where Embie just brings it all together so that you can see at one glance, once again, this patient started stimulation here. She had her egg collection here. This is how many embryos we reach or eggs we retrieved. Here's how many were fertilized. Of those that fertilized, here was their ongoing culture development.

Uh, here's what was frozen on day five. It's just really this intuitive view of, Oh, what was her estrogen that day? I can hover right over and say, that was her estrogen that day. I don't have to go somewhere else. And look for it. So this was another area that really sold me on the efficiency piece because typically your staff are really left to put all these pieces together and this just puts it all together the right information for the right people in a way that's understandable and in a way that it clicks.

Do you want to say more about what you like about this piece, Mark? Because I know you really like the SIM sheet. 

[00:33:24] Dr. Mark Amols: So I want to make a couple points because I think Griffin was So I want to go stay here, but I want to talk about the last page was, so I was saying how the nurse could look at that page and now they don't have to say something dumb.

They take a look at everything. But as a physician, when you are going through a chart and trying to make a decision, having all that together in one page, your decision making changes. So if I'm thinking something, I look at the anterofocal count and I go, wow, that's a low focal count. I'm really worried about her.

But then I can see the AMH on the same page that says, Oh, our AMH is three. That might change my, my view now that may change what I may do. And so that's having all that in one place makes me more efficient and more accurate. But I want to show you one of the things I just, I was going to tell you, if you asked me, like one of my top things I think so great about this place is the intuitiveness of that.

So when I was at Mayo Clinic, we had a system very similar to this where it had dots and the dots were just a way you could watch everything grow. What's intuitive about that is we're not very good with numbers. Meaning like when someone hears, Oh, 22, 18, 16, 14, in our mind, we hear a cohort. But when we see it, it's so simple.

You look at this page, you go, there's the cohort, there's two that are hired. But they show you the intuitiveness of this program. I don't know if you even know this, but what do you notice about the colors? The purple represent the left ovary, and it's on the left. The blue represent the right ovary, and it's on the right.

They even positioned it anatomically correct. So when you look at it, you have to sit there and go, wait, is that the left or the right? Are those both of them? I You get to make that decision, right? That intuitive, that putting that thought into this is what makes it so great. And every step of the way, that's just how it is.

I love, like I said, to me, that little detail makes it so easy that I don't have to sit there and ask, well, which one's left, which one's right? I know I looked at the screen once on the left and left ones on the right are the right. Those are the type of things that, like I said, speed up the process. 

[00:35:13] Griffin Jones: Yeah, I wanted to ask you about how it normally looks.

And by normally, I mean in most EMRs. Yeah, not like this. Usually it's a number. 

[00:35:23] Elizabeth Lee: Yeah, it's usually a number in a cell, as Mark said. So you'll have the follicular size in a millimeter, and it's just in a cell. And you're usually having to look to see is that left? Is it right? Is it even different? So it's certainly not is not given in the, in a picture that actually just intuitively you can look at and go, okay, I have a really good sense of what happened in this cycle.

Can I show you something else that I think is really cool? It's. Something that the physician has done speaking with the patient, they're going to enter a plan. And that was something that Mark and I, we struggle with sometimes because there was no really great area to communicate a plan within the EMRs.

As the nurse, as the patient calls and reports their cycle day one, that's a, cascade that gets everything flowing. But in, at that moment, at cycle day one on the phone, I can't go find all of the relevant information that I need in a typical system without saying to the patient, let me call you back.

What's really neat about Embie is the physician can enter the plan. And then when the patient calls, I can click one button. That says activate cycle and then right within here I can begin making any adjustments that are needed. Maybe I've heard from Dr. Amels since the patient was seen that maybe they actually need PGTM.

They need something more than we thought or maybe, maybe she's actually going to be using some donor eggs. So there's the ability to craft or to, to fine tune. But then once we save the cycle, now this is another brilliant piece. The system knows. That we do monitorings on specific days relative to the start of the cycle.

And so all of this is baked in to where I can click one button again, systems processes, now I don't have to remember how does Dr. Amos like to do it? Does he like to see them on day five or day six? And then even within here. Being able to make adjustments to the lab orders for that day. Maybe we wouldn't draw a specific lab that day or something like that.

But these are the types of intuitive features that I know really were exciting to me because it was the ability to not have to think through all of this, but have a system in place where I can just let that cascade roll out. 

[00:37:45] Griffin Jones: And so how does this part normally look like? Is there, normally 

[00:37:50] Elizabeth Lee: there isn't, normally this doesn't really exist.

So what you would do is you would build a calendar for the patient somehow. Some people do it in Excel. Some of the EMRs have that ability, but you're going to build a calendar and try to put all of the relevant information that the patient's going to need. And then you have to transmit that calendar to her somehow.

But all of this that you see us doing is all being sent to her app right now. Okay. So this patient can right now see, Oh, my cycle's active. Here's my doses. Here's what I'm doing in the traditional EMR. Now, after the calendar's done, now I have to give the calendar to somebody to schedule all the appointments.

That's super inefficient, right? Who do I hand it to? And what were they doing when I walked up to them? So in the traditional EMR, there really aren't tools like this that allow you to, in a templatized fashion, repeat things based on protocols. Would you agree with that, Mark? 

[00:38:43] Dr. Mark Amols: Yeah, when I first saw this, I thought, did they steal this from our clinic?

Because basically what we do at our clinic is, Elizabeth and I came up with the idea to make all the calendars ahead of time. So when someone's going through IVF, we just pull out the calendar that they're going to be doing. We know the days where I see them, they walk up to the front, they make all the appointments.

And again, it's, it's efficient, but this is more efficient. And the thing that came from a, from a standpoint of, uh, someone who's inputting data, One of the nice things about that too was, I don't know if you noticed that Griffin, you can adjust things even on that page before you hit send. A lot of the programs I've seen, it's pre made and that's how it gets sent out, but there you can actually, even before you hit submit, you can change every little part to it that you want.

Delete things, add things, which now makes it a simple click and you're going. And again, it's just so many steps to remove. 

[00:39:31] Elizabeth Lee: There's just a lot of feeding the staff, the next step, right? Cause like how easy would it be to forget a step to forget to order the meds? This is prompting us. To actually go in and sign the various orders.

Let's say the patient wanted to she was going to go do outside monitoring somewhere These are all of her lab forms that I that are just auto populated The data is transferred over and now one click and this order is gone. I didn't have to write anything I didn't have to pull any data from anywhere else.

So it's really that Continually prompting you. Okay, what to do next and then bringing that information to the patient. Something else that I think was I really liked about this and I would encourage people go to the app store and download the patient app because I really don't think we can overstate That a patient created this and that it really speaks to the needs of patients.

So the educational needs, the mental health and emotional needs of patients. Go look in the app and you'll see that's a little bit of where the secret sauce on the patient side comes, but being able to integrate it across is. To me is a really brilliant piece. I

[00:40:44] Griffin Jones: want to, I want to jump on that for a second, because I've thought there have been apps in the past and maybe, and I think that there's still are that do add a lot of value to the patient in terms of information, in terms of even helping to a certain degree as concierges, but there's always been something missing.

And we've seen app after app come in and either have to change business model. Or they burn through tens of millions of dollars and without ever, like really finding what the business model is. And I've constantly asked, what is it like, how, what needs to happen in order to make this work? And it could be the case that the limit to those apps is that they just never connected to the other side.

Like never really fully integrated with the clinic that there was. It's okay. We can give you this information. And we can. Monitor stuff about your menstrual cycle and maybe even some of your treatment. But then there is a wall once, uh, once we're interacting with the clinic and we have to try and leap over the wall.

This to me seems to be two different sides to the same coin. 

[00:41:54] Elizabeth Lee: You bring about a great point. And it's just, I think It comes down to where is the value ad? And it also depends on what your clinic needs are too. Right? As Mark was saying, we haven't mentioned this, but this tool specifically, something else I thought was really brilliant was the customizability of it.

So the ability, like maybe Mark always likes to see, I don't know, a certain value, and it's not naturally displayed in the app. It's very easy to, to see. To pull that beta in and to customize it for how he works. So, so not only is it just very intuitive and efficient on its own, out of the box. But then you're able to further create refinements to, to make sure it runs the way that, that your practice runs.

We haven't shown this site at all yet, Griffin, but we, and Embie thinks this is really cool. I think this is really cool. Mark and I talked about. Implementing Clara, that use of the bi directional communication tool with the patient, but this bakes it directly into the EMR and it provides that remember that 30, 000 foot overview of contacts.

that matters when I reply to a patient, right? Oh, that's right. No, they're not using a surrogate or, oh, that's right. She's on her 21st cycle or something like that. On our side, on the clinic side, we can see it all aggregated in one thread. So we can see who sent it. And then each of the patient's responses on the patient side, however, they see it as individual conversations.

So they have that ability to send to financial team or send to maybe send Dr. Ams a question. So this is really, I think, quite brilliant in terms of, 

[00:43:37] Griffin Jones: so in a normal pa, in the typical patient portal, how would that look? Would it just be just that? 

[00:43:43] Elizabeth Lee: Usually it's message gets some individual. Yeah, it's usually like an individual message itself.

So if I want to go back and look and see, I may have to click in and out of 20, 30 messages to get the whole thread where I can just scroll up, go, got it. All right. I know what's been said off I go. And yeah, in a traditional EMR, you'd be opening up each individual message from all the different teams.

[00:44:10] Griffin Jones: This is almost like a group. 

[00:44:12] Elizabeth Lee: Yeah, yeah. It's like a WhatsApp group thread. Yeah. So on our side, I can easily say, see, Oh, fantastic. Finance has touched face. The admin has touched face. The counselor has touched face. I can see all of that. And the system allows for tasks to be fired based on the cycle that patient's doing.

So we know every patient is a financial consultant. Every patient needs to sign consent forms, every patient needs to do on and on. And this allows you, when we activate that cycle, it cascades all the tasks out to the right departments to say, okay, we know now she needs a financial consult. We know now she needs these things.

And that too is. I have never seen that in the EMR space. That's always what we're seeing here or what I have traditionally seen people build workarounds for. 

[00:45:06] Griffin Jones: I feel like for so long we've been saying, man, somebody ought to build this. Like somebody ought to I'm not gonna, I'm not a builder. And I think I've known Ravid and Josh for probably a year or so now.

And I don't think that I've fully appreciated what they've done until now. 

[00:45:28] Elizabeth Lee: Griffin. I don't know if you know this, but obviously it was started as a patient app and really looked, they wanted to join forces with the various EMRs and offer this, their platform as an overlay for the patient portal. Right.

Let us give your patients this really intuitive, pretty experience, but none of the EMRs wanted to play ball. And so they looked at each other and said, okay, let's just make it ourselves. And that's exactly what they did. And it's to look at this and to know that this was built less than a year ago and to see the progress with which new changes are coming about.

Something we haven't gotten a chance to mention yet, Griffin, is the AI component. It's not live yet, but it's still in, in, we're still working on it. It actually helped, we created an abstract to submit to Esri to show the data, the accuracy of the data from AI is there. So I'll give you an example. In Embie, we're going to have the ability to click a button and have AI generate the progress note for the day.

[00:46:30] Griffin Jones: You know, who's going to love that mark beyond your team, not having to look at your digital chicken scratch anymore, but your, your family is going to love it. My wife's a physician and she's not in, she's not an RAI, she's not in women's health, but she, it sucks. Like when she's on service week and she has to.

Come back and do notes. And she's just, should I stay at the office and do notes? Should I come back and put the baby down and then do notes? And that's how it would be a lot nicer if that could just go away. And I've been trying to tell her that it will go away someday. And finally, somebody is at least doing it.

[00:47:08] Elizabeth Lee: Well, now she should, now she should just become do be a fertility doctor and she's got a platform. 

[00:47:13] Dr. Mark Amols: I didn't know a step further. And again, this is where I go back to that point. We all think around us. We don't think about everyone else. I'll go a step further. It's not even just about my time. Now, notes are going to be more thorough, right?

I mean, when I read a note and I'm dictating it, I'm not putting every single thing that half the time patients get Dr. Emeril talked about this. I'm like, well, we don't see the note. Cause I can't put out. I got to get home and see my family now. Not only do I save time, but now a complete note is there.

Every little detail is there. And. What AI is going to allow us to do, and which is one of the reasons I'm, be honest, I'm mostly sold on them is because they want to add AI. Is it's going to make things just more efficient, but also it's going to be more thorough. And so I think it's not just about the physician saving time, it's the better quality of notes, the better documentation, the speed of it.

Now more time for the patient, right? So now it's not even just about me. Now I can spend a full hour talking to the patient versus having to spend 30 minutes and the other 30 minutes having to chart. You brought up a point earlier about. Programs. And this is taking everything in. There's a program. I'm not trying to diss on it.

It's a program. I think it was called Sal. I saw it at ASTM one year. I remember what I saw. I was like, wow, this is really pretty. And the reason it came around wasn't because no one could do it. It's because it comes back to that principle again, as an EMR. You have to make decisions. Am I going to make this?

Am I going to make this? People are already using our product. Right? Why do I need to make this? So South came in and said, listen, I'm going to solve a problem. I'm going to give this beautiful, interactive tool between the patient and the clinic. But the problem was, it's a workaround. You're still not going to the EMR.

So what's great about Embie is, they're taking all those things like you said about why don't they put this in a thing and they're putting it into a program, but they're always looking to go ahead. And I do. I think it's perfect. I'm not going to lie and say there's nothing that can't be perfect. But what's interesting is when I talk to them about things and they hear about the efficiencies, they make the changes or they at least think about them.

[00:49:17] Griffin Jones: I want to ask about that because we have, and maybe Dustin will make me cut this part out, but we have seen EMRs in the past come in and to your point, Mark, maybe be more in the time of this digital revolution, starting off with cloud based, starting off with a lot of the digital technology that we have now.

And you've even seen some clinics adopt them, but then some other clinics try to adopt them. And it's just, this doesn't work. There's way too many. Bugs and glitches, and they had to even go back. Imagine how much it sucks to switch in EMR and then having to go back. Yeah. So, so what are the glitches here?

What's the, what are the things that. Aren't ready for primetime. 

[00:50:06] Elizabeth Lee: Yeah. I think that the AI component is really still very much in production. It's not, I wouldn't say today, if somebody were to pick up and be up as their clinic tool, do not expect that's going to be available today. It's something very much still being massaged.

[00:50:20] Griffin Jones: But that's an add on that's being incorporated. What about the core functionality of this? 

[00:50:25] Elizabeth Lee: Is what the biggest opening for opportunity is really to pull their reporting capabilities together. Cause they're all there. But it's just, I think, about finding what are the reporting tools that are going to be really important and then extracting those out.

So I think that's the, in my mind, where I see the biggest area of opportunity is that the ability is there, the framework is there for all of the reporting, which is amazing. But I want to dig a little deeper on how am I going to get the exact reporting that I need to do my best work. 

[00:50:59] Dr. Mark Amols: There, there's a couple of things that when you're looking to look at EMR, right?

You mentioned about adding a product, right? So if you look like Windows, for Windows to be able to keep where it is now, they had to scrap everything and start from scratch. And you're right. A lot of these EMRs might not be able to do this stuff. The way things were written, the way it's coded may not be allow it to.

So this is actually coded in a way that is very HTML5, that's what I'm looking for. It's able to be adaptable a little bit better than some of the EMRs. But. Where the question you were asking is, I think we're the biggest drawback to going to the Amari is the amount of work that's going to it. And I know one of the things they're working on is ways that be almost a turnkey approach where you hit a button and it pulls all your data and goes into it.

And, and that's really the biggest. drawback of going to another EMR is, okay, these are great functions, but are those functions worth the headache of going into a new system? 

[00:51:53] Elizabeth Lee: And I think this is where I like to equate it to a marriage, Mark, right? You've got to be certain, for you, this is such a vital part of your business, that you really need to be certain.

And it is very much like a marriage, and the longer that you are with it, a certain EMR. The scarier it is to think about making the jump and is the data portability there? I think that's what you were speaking to, Mark, is how do I get, how do I not interrupt my clinic operations? And that's actually something I think is quite brilliant about Envy.

And it is, it's just very simple. It integrates with either your Google Calendar, your Outlook. So it's very simple in terms of getting implement, getting implementation up and running. There's not a lot of back end. I think the biggest thing is like customization, right? Where Ravid sits down and she says, okay, give me all of your form.

Give me all of your workflows. Show me all, show me at all. Right. And then she helps to create those little tweaks. 

[00:52:47] Dr. Mark Amols: And it's not AI, right? One thing is you're talking about, everyone can put AI in it, but how you do it matters, right? Just because something has AI doesn't mean it's going to be useful for you.

There is the potential here when you have a company that's really willing to integrate it to make efficiencies, that again, it's not going to be the same as someone saying, Oh yeah, you can get an AI to dictate your notes for you. Like I said, they're looking at it from a different perspective. Which is what makes me excited about them 

[00:53:14] Griffin Jones: to your marriage analogy Elizabeth prior to a marriage You typically go on a few dates a first date might be a demo Do you know the demo that I know reviewed does demos for perspective clinics that do you also do them for?

Perspective clinics, or am I just getting a special treatment right now? 

[00:53:29] Elizabeth Lee: You're just getting, it's you Griffin. But Tiffin, you really, what you have seen is just very much a scratching of the surface. And I do want to make that clear. This is not a full demo. There's so much more to see. And Mervy does an amazing job at walking you through really line by line, the magic of it.

Yeah. You're getting, you're getting me, but Mervy really is happy to give those, those demos. And then the second, third, fourth date is something like what you see here. And that's a sandbox. So Mark's had the ability, as have I, to really dig under the hood and play with it and look at, okay, for my patient flow, how will this work?

How will that work? Seeing what it looks like on the patient's side, right? So we can actually, through the sandbox experience, link, A patient to say Dr. Emil's phone. So he can actually see what the patient is seeing. I think that's really valuable because especially if you, part of your business model is an amazing patient experience.

I think that those kind of the information gleaned from those second and third dates as it were, it's really valuable for them for the overall 

[00:54:30] Griffin Jones: decision. So I'd like to conclude then is why someone should spend the time to do this demo, to go through this demo and probably tying back into the, where the conversation started in the first place of how some efficiencies in particular areas can lead to much greater improvements in many other areas.

And the whole time that you each have been talking about, I'm thinking of. We have to do this as a field, whether it's this particular solution, whether it's other particular types of tech solutions, we have to, there's no other way where there's no other way to get Gen Z's and millennials to, to get even the productivity that earlier generations of docs had been doing much more.

All of the rest of the patient population that needs to be served without these kind of improvements. And, and I'm thinking like, there's just, this has to happen. It's got to happen yesterday. But so I, but I'll let each of you decide of, of what people should be considering about what they test and why this makes sense to think about.

[00:55:42] Dr. Mark Amols: Yeah, I can go first and then Elizabeth and really summarize everything. But I think one of the reasons everyone should do this demo is to realize what they don't have. I think it's going to open their eyes, whether they decide to go with this product or not, it will open their eyes to realize, wow, I didn't realize how much I'm leaving behind of efficiencies, of benefits, just to name a few programs that this would get rid of.

Things like Clara, EngageMD, Salve, All those different things easily gone. Potentially billing. Potentially using AIs right now for dictation. It even gets rid of nurses in some ways. I hate to say that, but I may not need four nurses. Now I may only need three because I don't need someone to double check everything because the system's already double checking it.

So, I think one of the reasons that everyone needs a demo desk, regardless EMR or not. It's going to open your eyes to realize that there's more to DMR than what you've been looking at. You've always looked at DMR as a system that just tells you the information that you want. But this system actually works with you.

It's a marriage where you're not working against each other, but you're working with each other. And the part that we really have not delved into, and I think you just hit on Griffin, is the patient side. We're in a different world now. The old days of sitting down with a patient for an hour or calling them up and set up an appointment, those are gone.

Very few people want to do that anymore. Most people want to point, click, have an appointment, get their information via email. Text versus getting it through the phone. And so, you're right, these changes have to be made. But the problem is, no one realizes what they're missing because they've only seen it through one view.

And that's the view of the old antiquated EMRs. And I don't know if NV is going to be the best forever. There may be something else that comes ahead. But one thing I can tell you right now is, They are definitely far ahead of the other EMRs I've seen, and I work with what I think is one of the more efficient EMRs, and I'm even seeing it have progress over what we're doing.

[00:57:37] Elizabeth Lee: Yeah, for me, Griffin, I think why everyone should go book a demo is because this is really the clinic operating system that we've all been wanting, but never could find. And I think that it is this suite of tools that now finally brings the all of your clinic operations under one tool again, like that single source of truth.

And I think we talked a little bit about it earlier about Access to care being a really important sort of North Star for Mark and I both, I know, Griffin, you talk about access to care a lot, but think about how if we started to think about clinic operations like this and this type of succinct, smooth way.

Think about how many more patients we could help. Right. Think about all of the wasted time, like the massive efficiency tax of just clicking from program to program, just even reorienting yourself. There's a lot of studies that show that is, is very counterproductive. So having that single source of truth, I think allows because we can start to get rid of a lot of that.

That's yeah, that efficiency tax from our current systems. I think 

[00:58:48] Griffin Jones: the financiers would definitely like that topic, Elizabeth, as well as the patient advocates and yeah, and oh, I would love to have you back on in the future for another episode. I also think this is a segue for a topic that I want to have Dr.

Amos back on for which is talking about that top of license. being applied to every different role in the clinic, not just the REI. This has been a pleasure having this conversation with you. Thank you both for coming on the Inside Reproductive Health podcast. Thanks. Thank you. 

[00:59:20] Sponsor: This episode was made possible by our feature sponsor Embie clinic.

Is your EMR holding you back? Is an Excel sheet your one true source of data? Are you wasting your time with disconnected point solutions? Embie Clinic's unified solution for the clinic and patient provides a single source of truth. Our suite of tools helps you flex and scale your fertility practice from clinical care to the lab, administration, and beyond.

From onboarding to baby in arms, Embie makes sure your patients are informed, educated, and supported every step of the way. Say goodbye to the old and welcome a new standard of care with Embie Clinic. Visit embieclinic.com/irh now to book a demo and take the first step to modernizing your clinic. That's embieclinic.com/irh.

Announcer: Today's episode is paid content from our feature sponsor who helps Inside Reproductive Health to deliver information for free to you. Here, the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of Inside Reproductive Health.

217 A Cold VC Climate, an IVF Start Up Incubator, and 15 new fertility companies with Dr. Santiago Munné

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.


You have an idea for a start-up that will completely revolutionize the fertility space and need seed money, how do you attract investors to believe in your idea?

Dr. Santiago Munné, Co-Founder of Homu Health Ventures, offers up the investor side of that question as he gives an honest look at the venture capital landscape in the fertility space.

Tune in as Dr. Munné:

  • Introduces us to a different kind of venture capital in the fertility space

  • Tells us the start-up must-haves for his company to invest

  • Discusses AI: Tool or complete business solution?

  • Reveals Homu Health’s target ROI multiple (And their ROI timeline)

  • Speaks on the current climate of the VC Market (Hint: Winter is coming)


Dr. Santiago Munné
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Homu Health Services
Website
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Transcript

[00:00:00] Dr. Santiago Munné: The funds have dried out completely. The ones that were lucky that, had investment, before. so now they had to preserve it, significantly. for instance, a company that were, was developing a couple of products will have to focus only on a single one, things like that. 

[00:00:20] Sponsor: This episode was brought to you by Mind360, where psychological evaluations become effortless. As an exclusive offer, all IRH subscribers will receive their first evaluation free. Visit www.mind360.us/irh to sign up and reserve your spot on our list. Elevate care, reduce wait times. Mind360 is psychology made simple.

Sponsor: This episode was brought to you by Family Inceptions. Join the Family Inceptions surrogate referral list at familyinceptions.com/irh. Connect with intended parents by using our exclusive surrogacy roadmap and elevate your practice today.

Announcer: Today's advertisers 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 advertisers. The advertisers do not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertisers.

[00:01:40] Griffin Jones: You have an idea for a startup that will completely revolutionize the fertility space. You need money. You might want some guidance. You might want some collaboration. How much of your company would you give up in order to get those? My guest talks about the average percentage of equity that his firm takes in startups, and he introduces us to a different kind of venture capital in the fertility space.

Dr. Santiago Munné, HOMU Ventures, is an incubator. They currently have 15 companies in their portfolio, all in the reproductive health space. They're developing companies at different parts of the fertility treatment chain. Dr. Munay talks about the ecosystem that they all fit into. You might know Santi as the founder of Recombine, the founder of Reprogenetics.

I believe he sold both of those companies to Cooper, where he was the chief scientific officer for a couple years. He's co founded a number of other companies and operated some of them. He was on the other side as the investee. Now he's the investor. We go through what is their target return on investment multiple?

What's their target return on investment timeframe? What do these companies have to have and have to prove before Dr. Munay's team will invest in them? Why don't they invest in AI companies? Is Santi right about AI solutions being more tools than complete business solutions? Or is he missing the bigger picture?

We go into more detail about the automation that needs to happen in the IVF lab, beyond storage and witnessing to automating ICSI, automating egg freezing and others. I asked Dr. Monet, what's the appropriate level of proof of concept for companies in these stages? They haven't sold anything yet. How do you know anybody wants it?

And Santi shares what it's like out there in the current venture capital market. I don't know Dr. Monet too well beyond this interview, but one thing that I think you're going to like about him is that he's not a pitch man. He gives very straightforward answers. And as far as I can tell, it doesn't sugarcoat anything.

Enjoy the episode. Dr. Munné, Santi, welcome to the Inside Reproductive Health podcast. 

[00:03:24] Dr. Santiago Munné: Thank you. 

[00:03:26] Griffin Jones: Nice to be here. I've gotten to know you a bit from your involvement in different companies. I've gotten to know a little bit of some of the companies that you've invested in, and I'm not here to necessarily talk Too much about those individual companies, but I am interested in how you invest in them and how you've chosen to invest in them.

I want to get to all of that, but your background is first a scientific training. You, your PhD is in genetics. I believe that you also have a degree in biology. And so when did business come into play? When did investing come into play? Did that come in very early? on in your career as you were studying genetics and biology or did it come much later?

[00:04:14] Dr. Santiago Munné: No, actually, so I, I, developed the first genetic test to, screen embryos for chromosome normalities and accidentally that became, it became a company and then it was, one after another. we created our companies or I got involved in, investing and so on. And at the end it was, I had a little bit too many at the same time.

So we decided to create an incubator and with some help, then, now we have this incubator among health ventures, in which we have about 15 companies, all in reproductive medicine. 

[00:04:55] Griffin Jones: So you said you had a couple too many. How many companies did you have before you formed the incubator? 

[00:05:02] Dr. Santiago Munné: one thing is to, to be the CEO.

I've been only the CEO of, ReproGenetics. and then I, helped found, several other companies. and yes, between The day to day of these companies, so it was getting too complicated. So we decided to, that we needed more help basically after, I sold a couple of them to, to Cooper, surgical, I funded, two, three more companies and as we have thought of ideas of potential companies, but it became, too complicated to manage all those.

So with a friend, we decided to get some more help and create an incubator where we put all these ideas and emerging companies, mostly on proceed stage. and this is come how these incubators started up. 

[00:06:06] Griffin Jones: In the beginning, were you involved as an operator in all of those businesses you said you sold two or three companies and were you either CEO or chief scientific officer or chief operating officer of all of them?

Were you deeply involved in the operations of all of those companies? 

[00:06:24] Dr. Santiago Munné: yeah, I've been reprogenetics where I was the CEO, then I've been CEO and chief scientific officer of a couple more, including overture. The last one. 

[00:06:35] Griffin Jones: So there's a difference between being an operator and the investor. And I guess we'll get to that.

But when you had those, companies with reprogenetic or, any of the other companies, did you have a venture capital funding for any of those companies? 

[00:06:58] Dr. Santiago Munné: yes. Yes. represent no repression ethics. But we had, that was all organic. But all the others have been funded by private equity. Sorry, right by VC.

[00:07:13] Griffin Jones: so you did have experience working with venture capitalists with private equity, right? with investors before you became one yourself, was there a process that you went through, while you were still at, the operator level of those two or three companies that was like a transition to an investor.

So you were like a part investor in your own companies. Did you become an accredited investor during that time? Talk to us about what that process was like. 

[00:07:44] Dr. Santiago Munné: No, that happened afterwards. so first We got funding in, several of these companies, Recombine, Phosphorus, Overture, and after that, we funded these incubator and started investing in it.

[00:08:03] Griffin Jones: What year did the incubator start? 

[00:08:05] Dr. Santiago Munné: That was only, three years ago. 

[00:08:08] Griffin Jones: So you've had success in building the businesses. You get some capital to do it. You have some. the experience with venture capital. but tell us more about how the incubator came to be. 

[00:08:26] Dr. Santiago Munné: Basically, we think that when you are starting a company, the investors, or the market will push you to develop a single product.

and you're lucky you will develop this product and you may be successful. And if you're successful, you may create other products after that. But usually you have to focus on a single product and In order to change reproductive medicine as we know it to make it more affordable and more efficient, you really need to change a lot of things.

You need a whole ecosystem of companies that are synergetic between themselves. And this is really very difficult to do with from a single company. I don't think any of the ones that are there. or that we have invested, they can do it by themselves. The idea or the leitmotif of, the incubator is, to create this ecosystem of companies that are synergetic and together, they may be able to, change and improve the, field of reproductive medicine.

[00:09:31] Griffin Jones: How do they work together in that ecosystem? 

[00:09:35] Dr. Santiago Munné: so for instance, we have, a company, that's called Sama that it's, developing, basically monitors patients remotely. But then we have another one, Genome embryonics that develops a genetic test to screen embryos, for the no mutations doing whole genome sequencing.

So we put them together, and gene embryonics will develop a test that. will be a companion, test for hormone stimulation. So that will help some, better monitor patients, for instance. Or, for instance, we'll have another company butterfly, that is developing a system to retrieve X, from by flushing, the, uterine cavity.

the need of surgery or an anesthesia. And on the other side, there is Overture that has developed egg freezing, in a very small, device. So if you combine them, you could put them, both systems in an OB GYN office. you wouldn't need an OR. and the idea is that, then Fertility preservation would be much easier, would be done in an RBGY office instead of having to go to an IBS center. we're looking for companies that, that, combine, can change the, the field. 

[00:11:02] Griffin Jones: So are you keeping all of this in a sort of hub? is there a hub for this ecosystem? Or you're connecting these companies together and are they just connecting with each other so they can learn from each other a little bit?

Or are you viewing this like a map? And here's where each of these different players. plug in and you have some sort of centralized way that they are all working in towards the same manifestation of the ecosystem. Yeah, 

[00:11:30] Dr. Santiago Munné: no, it's, more like a map. Yeah. And we're, trying to find, actively find sometimes, companies that feed some gaps in these ecosystem, but yeah, it's not a physical, place.

[00:11:47] Griffin Jones: Did you start with that map three or four years ago when you started the incubator? How differently does that, how differently or how diff, similarly does that map look today than it did four years ago? 

[00:12:04] Dr. Santiago Munné: it looks much better. I think at the beginning, we thought it would be easier. and it's not gonna be so easy.

It takes much more funding. And yeah, there are a lot of things that you don't predict. but yeah, I think it looks better. but also more complicated. so I think we're, getting closer, but we were not expecting, to be so difficult. 

[00:12:32] Griffin Jones: What specifically did you think would be easier? 

[00:12:38] Dr. Santiago Munné: we thought, that, things will happen much sooner and then you get the dynamics of, small companies, investors, funding and so on that derails, a bunch of these products and companies.

[00:12:52] Griffin Jones: When you say, things would happen much sooner, do you mean, fundraising would happen much, certain fundraising rounds? Yeah, 

[00:13:00] Dr. Santiago Munné: absolutely. We had very difficult two years for funding. So all the companies basically had to, to be much more conservative, with the money that they raised previously. because it's, very difficult right now still to, to raise funds. 

[00:13:19] Griffin Jones: How do you as an incubator, work with other venture firms? 

[00:13:26] Dr. Santiago Munné: Basically, we, try to, co invest sometimes, but mostly we, are trying to, yeah, to sell the companies or to, basically. Advertise that these companies are doing this work and that they need funding, more than coinvest.

Usually we, we find the companies that we like and then we try to, find people that would coinvest, but, not, at the contrary. 

[00:14:01] Griffin Jones: So I'm probably a little bit ignorant as to how incubators work. I think I assumed that incubators will do some angel or some maybe seed round investing in all of the companies in the incubator.

Is that the case? have you invested at the angel level at each of them? Have you invested beyond the angel round for any of them in the series a or 

[00:14:23] Dr. Santiago Munné: yes. So we did the angel proceed and seed. and some are at the level of, a, but yeah, we, try to, to invest at the very early stage and, get about 10 percent of the company.

[00:14:43] Griffin Jones: And so what in your estimate, why has it been difficult in, your view to this fundraising environment in the last two years, because the last year, while we've seen interest rates skyrocket relative to what they had been, the, the capital that was just floating around for two years is started to, To not flow like that.

But, the prior to that there was a lot of money going around. And so in your view, what has been the challenge in fundraising for these companies? 

[00:15:20] Dr. Santiago Munné: Yes, no, that, the funds have dried out completely. And the ones that were lucky that, had investment, before, so now they had to preserve it, significantly.

for instance, a company that were, was developing a couple of products will have to focus only on a single one, things like that. 

[00:15:46] Griffin Jones: That was going to be my question in terms of what does this do to their commercialization? Does it, does it delay it or does it make it happen sooner because they have to start selling?

[00:15:59] Dr. Santiago Munné: in a way it makes you, to be more, agile that, so far all, most of them have survived that process and are still, at it. but yes, it has delayed. going to market, and make things more difficult. 

[00:16:19] Griffin Jones: Are all of these companies in similar stages? Did they all start with you four years ago or some started four years ago?

Some started two years ago and maybe in the last couple of months you have somebody else tell us about that. 

[00:16:34] Dr. Santiago Munné: Yeah, most of them are at similar stages. So either they are all past proof of concept so that they are working on products that, they will reach the market in maybe a year, two years. a couple are have products already in the market, just starting selling them very early.

[00:16:59] Griffin Jones: So tell us, how do you, decide which companies are worth taking on? 

[00:17:05] Dr. Santiago Munné: Yeah, so we want companies that have IP or that they are developing IP, so not very interested in marketplaces and things like that. And that will, that they could return, let's say, 20 X, Roy in 6 to 8 years, and in, in which we can really contribute ourselves also.

So we like to be very involved in these companies. So we have to understand it. and also we want to contribute. That's, the fun part to, to be involved with them. not just Silly money. 

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[00:18:50] Griffin Jones: How do you determine what degree of intellectual property is worth it or, do they even have the intellectual property? Like you might look at something and you might say, that's not really.

That's not IP. how do you, determine that? 

[00:19:07] Dr. Santiago Munné: Oh, it's, they should, develop patents. They should file for patents. And for instance, it's very difficult to get patents in AI. So it's one of the areas in which we're we haven't done anything because I think, you just need big data.

if you're a network, have the, data organized, and any network can create their own AI to select embryos, do an algorithm for hormone stimulation and so on. That's why we haven't touched that. Also, it's very difficult to protect it, algorithms.

[00:19:44] Griffin Jones: I want to talk about that. I want to get into, to what that actually might entail.

network being able to create their own AI algorithms. But first on the on the patent side for IPS, are you looking at folks that already have technology under patent? Is patent pending sufficient to you? How do you look at that? 

[00:20:07] Dr. Santiago Munné: No, patent pending will be sufficient, provided that we understand the patent and we think that it may go somewhere.

[00:20:14] Griffin Jones: As you're building out this, map, tell us more just at a high level, what do you think is, missing most in the fertility space? You've been in the field for a long time now. You've gotten to see both incumbent fertility companies and fertility clinic networks. You've gotten to work in it.

You've gotten to build and sell a few companies and now you have these new young companies and you're, mapping together the needs that. that are missing. What are those needs in your view? How would you categorize the biggest two or three needs that are currently missing or are big challenges in the fertility space?

[00:20:53] Dr. Santiago Munne: Definitely. it's a big focus on automation. so the whole IVF lab should be automated. not because we're going to get rid of the people that were there. there is a lot of steps that are manual, just pipetting, in which the only thing that you could do is, make a mistake. It's not very rewarding to do it.

initially embryologists were scientists, now are becoming technicians. so if, the routine part that's where you can make mistakes, can be, automated, that will be great because it's great variability between clinics, and between. people working on the same clinic, from, for instance, I have a paper on, genetic abnormalities in embryos, in egg donors.

In theory, all egg donors are young. So you have, you should have a similar rate of, from some abnormalities in those embryos, but we had from 20 to 60 percent unemployed rates depending on the clinic. So obviously this means that there is too much variability. The problem with variability is that then when you launch a product, let's say when we launch PGD, for instance, some people would say, it doesn't work because they don't do it.

and it's very difficult then that a new technique catches on because everybody does it differently. And the results are not consistent. If you have, let's say you launch it in a platform, then it's much easier to see if it works or it doesn't work on. If it works, then you can innovate far faster and faster.

So these platforms, it's what we really need to innovate much faster. So yes, one thing is, Automation. I would say that's the, key. then there haven't been any, new developments in, drugs, for a long time or how those drugs are, delivered. We are not investing in that because it's a lot of money.

So for us at our level, we cannot invest in, in drugs. But there is a, it's a, it's an area where, there is not much innovation lately. and how the drugs are delivered also. Why do you suspect that is? The patents, from those drugs expire and it seems that the, those companies are, not interested in developing new ones.

I really don't know. but, yeah, there is, not much, innovation there or. People developing new drugs and deliveries of those drugs. 

[00:23:47] Griffin Jones: So you're not aware of too much innovation happening on the drug side for pharmaceuticals. so then we'll go back to where you are more familiar with the innovation happening that you're trying to do, the automation in the IVF lab.

I want to describe to you how I understand the IVF lab and you tell me what. is being automated or can be automated. And this is what I understand as someone who does not have any clinical training or any scientific background. So that, the egg is retrieved, and goes into the lab through a window, typically in the OR, the embryologists then put the oocytes in media, and, and then think, I don't know if, there's something else that happens to it.

They grow it to day five blastocysts. they need to label, everything up where all of the specimens come from the, sperm, the oocytes, the donor trails. I don't know exactly where it's stored during that time. And then once embryos are created, the Most viable embryo is transferred back to the uterus and the other embryos are stored.

And those embryos can be stored on site or they can be stored off site. some may need to go to deposition and be discarded and, and there needs to be labeling and monitoring across that chain. but that's the extent. To, which I understand our audience understand this a lot more deeply, than I do.

But tell me in that chain, what isn't automated now? What needs to be automated? 

[00:25:32] Dr. Santiago Munné: So right now there is very little that it's automated. The, we have probably two or three products. So for instance, you have the embryoscopes or incubators. with some time lapse that can capture images continuously. So you don't have to take the embers from the incubator to check them.

that's been a great events. And this really has as a platform that became probably the first platform that we had. And thanks to that, now we have, we can develop AI to select embryos. so that was a great. invention and, it's one of the few things that it's basically automated before we had to take the embers out of the incubator every, day to check them, that created changes in temperature and pH and so on.

so it was, a little bit detrimental for the embryos. and then we have, yeah, there are some machines that, that, can track where the eggs are frozen. so that's like tomorrow, for instance, and then you have a witnesses. So before, you had to have two people, watching each other, so you don't lose track of all these dishes, because mistakes were done and are done very commonly.

So you needed a witness system. now with, with these tags, you can, it's called a window system. And, by tagging all the dishes, you know where they are and it doesn't let you make mistakes when you are handling a bunch of dishes. but these are essentially small things. you still have to, for instance, do, ICSI.

So inject the sperm inside the egg. That's, is a company overture working on that. It's not commercialized. freeze eggs. Also there's no commercialized yet, but are people developing that overture? you could, for instance, when you do the transfer of the embryos, about 10 to 20%, it's thought that, those transfers don't go well.

because of, basically you are doing the transfer blindly with an ultrasound, but it's blindly. So now there is this company, Butterfly, that has put a lens on the catheter at the end. So we'll be able to see exactly where you put the, the embryos when you do the transfer. and. So once you start automating each one of these steps, then you can think about putting all these steps together in a machine that does the whole thing together.

But first, or at least how some of these companies are working is just, having technological blocks. that solved one problem first, and then you, once you solve it, then you put them together. 

[00:28:40] Griffin Jones: That brings me back to your original thesis of having the incubator because there's all of these different problems and it's hard for one company to to solve for all of the individual challenges and this way you have an ecosystem of people that, can come together and fill in that map.

What about someone that would say, why not create just one massive company and have this one massive company do all of that from start to finish? What's the argument against that? 

[00:29:20] Dr. Santiago Munne: No, there is no argument against that. It's that, you need a lot of financing and then your vision may not be the right one, right?

You may have a way to do it, but it may not work. So if you have, let's say, a competition of ideas on how it should work, I think it will be more successful at the end. 

[00:29:46] Griffin Jones: So it either way you need a lot of financing, so that seem yeah, you'll need a lot of financing. either, whether it's a, number of different companies solving different problems or one aspiring mega lift company trying to, solve, it all themselves.

Seems like either way you need a lot of financing, and you could have errors in the vision one way or the other. But are you saying with. with having multiple smaller company or not necessarily even smaller, but starting smaller in scope, we're starting more focused in scope. Are you saying that it allows for more iteration?

[00:30:25] Dr. Santiago Munné: Because I think it would allow for, yeah, if let's say this big company tries to solve everything, but it fails in one point and doesn't know how to solve it or financing finishes or. Then the whole project goes to meanwhile, if you have a bunch of companies competing in each one of the technological models, some of them will succeed.

And then at the end, you'll have the whole pipeline. 

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[00:31:40] Griffin Jones: So you talked about these areas for automation that you see is important and part of the reason that it fits with your investment thesis is because they've And Got patent pending. That sounds like that's one of the reasons why you haven't invested in a I companies because there's not a patent to be filed for their, and so I want to explore that a little bit more because you said if your networks could be able to create their own a I create their own algorithms and.

I'm wondering how accurate or how easy that is. people said the same thing about software for years, right? It's not until people said Oh, we could, we can create our own workflow software, we can create our own CRM and it's like in. The vast majority of cases, it's a lot better to use somebody else's software.

And so tell us about how this analogy either applies or doesn't apply with AI. right now, 

[00:32:43] Dr. Santiago Munné: AI has been used mostly for MBU selection. And really, it seems that there is like a plateau around 70 percent or under the curve about. distinguishing which embryos will implant. and there are like probably 10 companies or more working on the same.

basically all of them had access to some network of centers where they got the data. so it, it seems that there is very little differentiation between one product and another. and to us, as I said, I think that if you have enough data, and a team of five or six people experts in that, you can do the same.

[00:33:34] Griffin Jones: So who do you think will win that race? 

[00:33:40] Dr. Santiago Munné: I, think that, it's what they had to develop. It's been developed. As I said, we wouldn't invest on it right now, because there is not enough differentiation. and I think it's very easy to enter that market, right? That you have enough data. 

[00:33:56] Griffin Jones: So it sounds like then they're missing something because in one of the things that's missing sounds like patents and it And you know a particular differentiator, but it's almost there It seems like it would be almost certain to me maybe I'm wrong that many of the technologies that you're incubating today will will be powered by A.

I. In some ways in the future. what would certain A. I. Companies need to evolve to the next? Would they need to incorporate with some kind of hardware or just something that requires a patent as you all start to incorporate? AI more, what do they need to do on their side? 

[00:34:42] Dr. Santiago Munné: No, I, see AI as a tool, so it could be mathematics, physics, AI.

for instance, in Overture, so we develop, an automated XE device that, that uses AI. we have a couple of developers and that was enough to, for, the device to find where the sperm was, where the needles were, and injected perfectly. but it was a tool. It was not, it was just. Part of the, toolbox that we had to, develop the device.

So it's, I see it more as, as a tool, more, than a company or an entity itself. 

[00:35:28] Griffin Jones: you talk about, the involvement from the incubator in the companies that you're selecting. What type of involvement do you have with them? 

[00:35:40] Dr. Santiago Munné: for instance, I am, sorry, in addition of, other duties, but basically I'm, in the board of, three of the 15 companies that we have in incubator.

and I'm in contact every week with them meetings, introduction to investors, to clients, networks, going through, through the business plan, the whole thing. 

[00:36:10] Griffin Jones: And so what type of advice are you giving them, let's say when it comes to forming the business plan, that this is a, company that's, in your incubator, they have something that you've liked.

How are you typically coaching them? 

[00:36:27] Dr. Santiago Munne: Usually we're looking for either, products that fit the story. And sometimes they come from scientists that, that are, they have a very good idea. they know how to develop the idea, but they are not very good. Executors. And in those cases, what we've done in a couple of, instances was to then to put A-A-C-E-O, that, that was more executive than, a scientist.

It, the, combination of being a scientist and, a good, CEO, it's quite difficult. there are not too many examples. So usually either we find, these people or if not, then sometimes we had, help, we put CEOs, sometimes for a limited time, to just to help them. 

[00:37:28] Griffin Jones: How often is it the case that people are seeking you out because they want that help with?

different business leadership. I'm of the bias that most founders want to remain in control of their company, but I guess it could be the case that there are some scientists out there that say, listen, I want to be a co founder. I want to be the chief scientific officer and I want to have a huge role in this, but I know that I'm not going to be the one to build out the company.

How often is it the case where people are pursuing new leadership and looking for your help with that versus you really have to. To encourage them to do it, I would say, 

[00:38:07] Dr. Santiago Munné: all the starts up wanting to be the CEO and manage the company. But then they realize that I'm a scientist. What I enjoy is to developing products, discovering new things on the day to day.

It's a killer. And I don't like that. so I some of them rather better. Become want to be become a justice chief scientific officer and not have to deal with all the other things. 

[00:38:37] Griffin Jones: And so you talked about, patents is one of the things that you're looking for in companies and if they don't have that differentiator, that's one of the things that maybe isn't a good fit for your incubator, but what else is a no go for you if you're looking at a, a new company that it's like, if it's like this, then probably not something we want to get involved with.

[00:39:01] Dr. Santiago Munne: One, it has to, by itself, it, needs to, be big enough the idea that it could sustain a company. So we don't want little things that, that we don't think, by itself would be, a viable company or a large company. Individuals are very important. so we need, to have a good, and I, guess it's more a feeling that person, has the vision, the right vision, to take it to, to the next level.

and yes, it, it, needs also to, to feed the, vision as I said, that we have. 

[00:39:46] Griffin Jones: How about the appropriate level of proof of concept for your incubator? One of the things that I feel like I wouldn't necessarily be a great VC at is, I think I typically want to see more proof of concept from just about anything.

I want to see sales. And in many cases, that, you're dealing with technologies that aren't ready for that. That's why they're pursuing VC. That's why they're Pursuing being in an incubator, but my bias is to want to see something that says the only way that I know that the market wants this is because the market has paid for it.

People in the marketplace have parted ways with their dollars and that's what proves concept. My threshold is probably too high for, venture capital, but what is the appropriate level of proof of concept for companies in this stage in your view? 

[00:40:42] Dr. Santiago Munné: Yeah, right now, I think we would be satisfied, with looking for companies that can solve a problem.

we know if they solve that problem, eventually they will sell. We know the whole market. we know all the other networks. we can help them to sell to these networks. and so if we think that the solution will be good, then we think That, then we would invest, we don't need to see sales.

[00:41:20] Griffin Jones: I guess that's why people like you exist, and then if you win big, and, and maybe I don't have a high enough risk tolerance yet to be a venture capital myself, and, but that's, also why I probably wouldn't be getting a 20x ROI either. that's why certain companies get. 20 XR wise, because they're investing at an earlier stage.

And, you've seen the, the venture capital, marketplace change a lot in the last two years with regards to funds. What do you see on the horizon now? Is it getting worse? Is it, staying steady? Is it, starting to improve? What do you think is going to happen in the next six months? 

[00:42:12] Dr. Santiago Munné: it seems that, there was still some investment in, early stage and, now it seems that it started to, to change, and that's what I read because I haven't seen the change yet, but it's, it seems that, later stages will start to get, funded again.

But, right now at this stage that we are, it's still, difficult to get funding. so the, this change hasn't occurred yet.

[00:42:50] Griffin Jones: What are you doing to your strategy? Just hoping the market changes? Are you approaching new people, going to new different geographic markets? maybe if you were Looking at VCs in, in London or New York or Silicon Valley.

Now you're looking more at Singapore or New Delhi. I don't know, but, how, has your strategy changed? 

[00:43:12] Dr. Santiago Munné: yes. so we, because I was, Living in, in Europe, we focus mostly on raising funds in Europe and it's much more difficult even to raise funds in Europe than in the U. S. So we are opening a chapter in the U.

S., to facilitate, more funding from the U. S. I know that the U. S. it's easy right now, but we hope to, to get a wider network of potential investors. 

[00:43:46] Griffin Jones: you've given us a very honest look at the, the venture capital landscape in the fertility space at what it's like to incubate companies in that stage, the need in the marketplace that they're filling.

How would you like to conclude with our audience? 

[00:44:08] Dr. Santiago Munné: yes, I think that most of the innovation in this field is gonna happen in the startups. Basically, there is little funding from government to invest in. Infertility and reproductive medicine. And now with, traditionally, most of the innovation happen in, in the clinics themselves, a lots of my ready doctors, innovating, scientists, but now with the consolidation in all these networks, all these be funded networks, I think that one of the first thing that it will go will be research and development in these networks.

So really, all the innovation it's going to happen probably, in these startups. 

[00:44:58] Griffin Jones: Dr. Santiago Munné, thank you so much for coming on the Inside Reproductive Health podcast. 

[00:45:03] Dr. Santiago Munné: Thank you. It was a pleasure. 

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216 One Fertility CEO's Plans After 100 Days of Listening with Francisco Lobbosco, CEO of FutureLife

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.


The first 100 days are often the litmus test of leadership, and this week’s guest rose to the occasion.

Francisco Lobbosco, CEO of FutureLife, spent the first 100 days of his tenure hopping country to country, clinic to clinic, clinician to clinician while asking one set of questions. What he learned from his listening has created the blueprint for the future of FutureLife.

Tune in to hear Francisco reveal:

  • The questions he used to create his growth strategy.

  • How his first 100 days inspired FutureLife’s current mandate.

  • FutureLife’s 4-Pillars driving the company forward.

  • A clinic’s sweet spot for FutureLife acquisition [And the KPI’s they look for]

  • His philosophy on Quartile Growth

  • Some of the solutions FutureLife is implementing [Including a new CRM]

  • FutureLife’s growth trajectory [And if they’re expanding beyond the European continent in 2024]


Francisco Lobbosco
LinkedIn

FutureLife
Website
LinkedIn

Transcript

[00:00:00] Francisco Lobbosco: I took my first a hundred days to just go around and listen. But after that, I went through probably the key opinion, all the key opinion leaders that we have in the business in all 10 countries, and I started proposing changes. And to my surprise, they said yes to all of it. I think it's a matter of communication.

I think it's a matter of explaining what would happen if we were to do things differently. And most importantly, it's a matter of making sure that you don't mess up with the medical freedom that they have. 

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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.

[00:01:32] Griffin Jones: 45 clinics, 1500 employees, 450 physicians, according to their website, and he may have said 250 FTE docs, 55, 000 IVF cycles amounting to the second largest fertility clinic network on the continent of Europe. At least with regard to number of locations. That's according to our guest, the person that has found himself at the helm of this network.

The organization is Future Life. The CEO is Francisco Lobbosco. At time of recording, Francisco has been in his post for the last six months. He spent the first three and a half. Going from team to team, doc to doc, country to country, office to office, asking one set of questions. He tells us what those questions were.

He tells us the mandate that future life has come up with since those 100 days. He says he didn't propose any changes within those first 100 days, and since, all the changes that he proposed have been accepted. tried to dig into what those were and he tells us about future life's four strategic pillars.

Medical excellence, patients, associates, who we on this side of the pond would not just consider associate physicians, but associate physicians, partner physicians, embryologists, lab directors, all staff. All employees. Finally, growth. Francisco shares what puts a clinic in the sweet spot for future life to want to acquire.

He talks about which KPIs they're measuring, including but not limited to, take home baby rate, net promoter score, employee net promoter score. Francisco says that he's systems agnostic, but coding obsessed. I said, I don't know, man, we'll see how long that goes. They have seven EMRs. So I press him a little bit on that.

Are you really going to be able to keep seven EMRs? You're going to go down to one. What's that going to be like? What's your philosophy on that? And he shares his response. He shares his philosophy on quartile growth, which clinics and providers you focus on the bell curve. Francisco shares some of the solutions they're implementing now, including a new CRM, who that is and who they vetted from 17 options.

Will this be the promised child CRM? I don't know. I've been hurt before. And then I asked Francisco to conclude on trajectory of growth for future life. Are we going to see future life expand beyond. the European continent in 2024. Please enjoy all of these answers and more with Francisco Lobbosco, CEO of FutureLife.

Mr. Lobbosco, Francisco, welcome to the Inside Reproductive Health podcast. 

[00:03:46] Francisco Lobbosco: Thank you, Griffin. It's a pleasure to be here today. 

[00:03:48] Griffin Jones: It took me 200 some episodes, but I finally have the CEO of a European network. We've had Canada. India, the United States, the UK, but never mainland Europe. And you are our first, thank you for obliging us as we continue to grow the global audience.

[00:04:07] Francisco Lobbosco: My pleasure. I'll try to represent Europe in the best possible way. 

[00:04:10] Griffin Jones: I hope so. You're the CEO of Future Life. That's been your job for the last six months as of this recording. And tell us a little bit about Future Life. Is it, in the, as far as the. network sizes of Europe, where do you all rank in terms of volume, in terms of doctor size, and maybe just a little bit of, background and I'll cover the rest of the background in the intro.

[00:04:35] Francisco Lobbosco: Yeah, sure. So we have 45 clinics, we're present in 10 countries. We are ranking number two in Europe in terms of locations. We do 55, 000 cycles a year, 2, 300 associates from which 350 are MDs, medical doctors, that's head count. 250 full time equivalents that could be, and we are very, proud to say that we are part of, helping this world, receiving a new baby every 45 minutes.

So that is probably our, best stat yet. 

[00:05:08] Griffin Jones: You came from outside of the field. Tell us about how you found yourself in this post. 

[00:05:15] Francisco Lobbosco: So yes, so before, before coming here, I was in veterinary health and I was approached by a headhunter and I, do have a personal past connection with IBF and when, they call me and they started sharing this material, read material about the industry and the company, we at home together with Margot, my wife, we felt so passionate about it and they share, I think in total 500 pages.

And, we went through it, I think it took us two night and it became a topic of discussion on my wife is a marketeer and the journey and how many touch points do we have and is this a place where you would harmonize or not having 10 countries, it was a very good interview process and the funny thing about that interview process is that it was slightly different.

Because one of the shareholders invited me here to Prague, where I am today, where we have the head office, and instead of coming straight to the office, we stop up the Prague castle, which if you've never been in Prague, it's a beautiful, it's a beautiful scene, and we start walking towards the office, and that's a good 40, 45 minutes walk.

Through the, old Prague is fascinating. So I was already, fascinated about the scenery and then I arrived to the clinic and this is my first clinic visit ever. And, I go into the lab and I make a million questions around the way, but when I got into the laboratory, that's where I saw magic happening.

And I was just in time to see on the big screen an X ray process being carried out by one of our great embryologists. And I look at him as a. I, this is fascinating. What you guys are creating here, life is just fascinating. So I felt quite strong already in my first interview. And after, I think it was in total of nine interviews, I was lucky enough to be offered the job and I'm very pleased where I am today.

[00:07:13] Griffin Jones: What was in those 500 pages? Was it a sales pitch to you to come and be recruited? Was it their pro forma? Was it a mix of things? What was in those contents? It 

[00:07:26] Francisco Lobbosco: was the BBs from past acquisitions. So Future Life is owned by main two shareholders, Hartenberg and CBC Capital Partners. And CBC entered last year or at the end of 2020, but I think they finalized the transaction in 22.

And therefore there was a lot of quite recent data for me to go through. And it was quite good really. 

[00:07:49] Griffin Jones: What made it attractive as a business person, as a business leader that. said you could have gone to a few different companies and maybe been in the one, two or three spot, but you had this offer and you're looking at their history.

What made it attractive to you to where, what did you look at specifically and say, this is something that I can really be a part of? 

[00:08:14] Francisco Lobbosco: A couple of things, but I will start with the most important one. as you just said, I had the opportunity working across. Different businesses, different industries, great companies, great experiences.

But none of them have the strong sense of purpose that future life has. And of course, this is not just exclusive to us here in future life. Of course, this is across every single clinic within the fertility space and every single person working at an IVF clinic. And I'm probably, you've been quite a long time in this space.

But Hey, let me remind you and everyone who've been part of this for a longer period of time. We are so lucky to be working where we are already. We are able to spend our days working on something that is truly amazing. Something that makes a huge difference to the world, really. And our job is to bring smiles to people's faces, to make their dreams come true.

And there is nothing more powerful than that. 

[00:09:13] Griffin Jones: How about from a business perspective in terms of what growth potential did you see? What role, what did you see yourself being able to add? 

[00:09:24] Francisco Lobbosco: it's a very good question. So here at Future Life we're quite lucky because the clinics that Hartenberg at the beginning and then CVC together with Hartenberg have been acquiring over the past years are very good clinics.

And I'm sure you will come to, what challenges do you face? this is one of them. The clinics are quite good. the medical outcomes are very strong. Financially, they are very successful. Wherever I went before, you always had a car crash, right? Something to turn around. In this particular case, when my 45, the worst thing I had is a single bidget.

it's fantastic financially speaking, so it's very difficult to come with new ideas when something's been working for such a long time, right? And let's not forget that you have the founders of the clinics, which are still present in most cases in our clinics, 99 percent of the cases. So engaging with them on saying, listen, I know what, brought you here over the last 20, 25 years is being great.

But what if we were to do things slightly different so as to maintain that medical side of the business, which, I believe in medical firm, but to give it a different tone to professionalize certain areas of the business, of the support centers, of the functions that are supporting you guys to deliver that highest quality of care possible, and there is, there are opportunities.

Outside Griffin, there are opportunities in the marketing area. There are opportunities on how we connect with our patients. we have, and we still have incredibly good, very strong, isolated clinics. we started last year to generate a community of clinics within FutureLive, but we are far away from where we want to be in the future.

And I think the synergies that 45 clinics can create, that's the goal in here. And from a business perspective. That's where really you can quantify the possibilities. 

[00:11:17] Griffin Jones: It's interesting that sometimes the fact that it isn't a car crash on the PNL in many cases, in my view, is part of the reason why parts of the field haven't advanced that much because I said, why would I, our patients are getting pregnant or at least enough of them are, and we're doing great.

And lousiest social media presence or office space, or even if we are. Using paper and EMRs, we still have people coming out of the woodwork, offering us X multiple of EBITDA. We're still taking plenty of money home. We still have lots of people telling us that they love us. and I feel that's been the reason why the venture capital.

Was probably 10 years later than it would have been like 10 years ago, there was no venture capital. There was private equity. I don't want to say there was none. There was very little venture capital. I've really only started to see venture capital in the fertility space, three, four years. And I feel like we would have seen that 10, 12 years ago, if there was just more of a.

of, impetus to scale. Do, what's your view having been in here six months? Are you starting to see, is there any external force that you see starting to cause people to change more or is that external force still going to take some time to build? 

[00:12:41] Francisco Lobbosco: I think you just described it really well.

And I think partially the drivers about having a very strong financial performance are there in terms of stopping development. However, I must say that I was personally very surprised. After my learning process, I took my first a hundred days to just go around and listen. But after that, I went through probably the key opinion, all the key opinion leaders that we have in the business in all 10 countries.

And I started proposing changes. And to my surprise, They said yes to all of it. I think it's a matter of communication. I think it's a matter of explaining what would happen if we were to do things differently and most importantly, it's a matter of making sure that you don't mess up with the medical freedom that they have.

And I'm very respectful of that. But when it comes to how can we improve at supporting the business from a finance, from a marketing, from an IT, from an HR perspective, I think there's a lot to improve there. Before we even get to the medical area from, a medical perspective, I have great advisor, so I don't need to get into that terrain.

[00:13:54] Griffin Jones: Did you propose any changes in those first 100 days? 

[00:13:58] Francisco Lobbosco: Not in the first ones. no. So I am very respectful of. Coming into a new sector and so what I've done is I just went around, I visited every single clinic, I spent loads of hours talking to all our associates, not just the key opinion leaders in each of the clinics or the founders or the GMs, but I just, just wander around talking to.

Our embryologists, that's where I really enjoy spending my time if I visit a clinic in the lab. so talking to embryologists, learning, how they do things, talking to nurses, talking to the onboarding coordinators, even in the call center, I enjoy spending time because they want to know why they are calling us.

so I have a million questions on what I've done, which is something I always do. If I go around with my defined questionnaire and I just ask the question, the same question to different people within the same clinic. within different clinics, and then I go back and I ask the same question to the same person in different moments in time.

And what usually tend to happen is you get different answers and that helps you to make up your mind on assessing where the business is today and what do we think we need to do to improve the business and bring it to the next level. 

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[00:16:16] Griffin Jones: I was hoping you were going to say you went in with a disguise like undercover boss with the glasses and the big fake plastic nose and the mustache underneath it. And see, you didn't undercover boss them. You went in and you had a questionnaire. What was on that questionnaire? 

[00:16:32] Francisco Lobbosco: Why are you here? So that's my first question that I always ask when I go into a new place.

Why are you working here? So you usually start with, what's your name? What do you do? For how long have you been doing that? And why? Why are you with us for the last 10 years? Tell me what's different in this clinic versus the clinic next door. And to my surprise, our attrition rate is very, low. And people have, quite a lengthy period of time with us.

And therefore I'm fascinated to know, why do they stay? so that, that's my first question always, and you have so many different reasons. And that makes our job as a newly, my job as a new leader of a business slightly more difficult because you want to make sure you attach to the reasons that are keeping people happy and engaged and motivated.

But at the same time, you want to improve certain processes and SOPs and ways of working with an athlete. And therefore it's quite interesting when you ask the why are you here? It's never in this sector in particular, different to the prior businesses I worked for, perhaps. It's never about money, I'm still to get the answer saying they pay really well, which I think we do by the way, markets market rate.

But the point being is no one's here because of the money they're all here because of the patients and what they get to deliver for them, which is fascinating. 

[00:17:54] Griffin Jones: Are you using that question to find out what processes can be changed or what you need to know before you change a process? So if you're finding out that, a number of people really like a specific person or, a really specific way of doing things that you take that into consideration when you're making a process change, or is that just to, is that for rapport building?

And then you start to get into more granular questions after that. 

[00:18:23] Francisco Lobbosco: Yeah, but I don't take that question as the only question, to make up my mind. Of course, if someone tells me within a coordinator or the call center, right? So if I go into a call center and they have six people and I ask why you're here and everybody tells me my boss or the environment here is great.

I take that as a very good positive. So I try to learn what is that person doing to keep these people motivated and engaged and so on. But yes, the team, they usually gimme the team. The team is great. the team is great. and, then is, I get to help people and we are very, respectful about the quality of the service, the quality of the care that we provide.

So those are usually the two or three answers that I get. Within the very different versions of that. 

[00:19:07] Griffin Jones: So that leads you after you 100 days to recommend changes and you said that they accepted all of the changes you proposed. What were they? So 

[00:19:17] Francisco Lobbosco: listen, so I went on by having, let's say, 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, that don't touch that, right? So let's, make sure that whatever 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, views, all great views, all great answers. 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, to verbalize 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, 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, just go through that strategy. So the why, the what and the how. So yeah. Quite simply after my a hundred days, the first thing I did is to grab, collect a number of associates across clinics, different roles, support center, different roles, and we set ourselves with support of a, 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? 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 drive that core identity. So we've done that. And actually, I'm not sure 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 and 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 the strategy into the future life society again at the end of this week And then it's 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 were doing until now independently? That's a very important question that needs answering quite fast. The synergies that we will have a group, those roles and responsibilities between, okay, clinics are doing this.

Fantastic. How can groups support the clinics on, being better at that, at that quality of care? How can we help the clinicians in particular, the EMTs, the embryologists, the nurses to have more time with patients instead of having, 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 achieve through the how. And finally, would you say a finish? 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, which are 10 of our 10 of our great associates, medical doctors, embryologists.

And we get together once a month and they have three different topics in the agenda that they need to help us drive. so yeah, so I'll pause here for a minute because I think I gave you a lot there. 

[00:23:19] Griffin Jones: Was there no medical advisory before, board before? Was every clinic just operating with their own medical director?

[00:23:28] Francisco Lobbosco: So there was a scientific advisory board before, which was great, but I think we were missing parts of what I'm expecting the medical advisory board to do. So when in the medical advisory board, you have three areas that we predefined. So scientific research, now it's part of the medical advisory board.

We have education that it was perhaps not tackled before. And then the third one is what I call the business drivers. And that could be procurement, could be total reward strategy for the business, could be M& A, could be no thanks, right? 

[00:23:59] Griffin Jones: So you're involving them in the comprehensive growth strategy of the company.

Tell us what about what, does that strategy look like? You talked about some of the questions and I want to start asking those questions is to see what answers are in place thus far here. By the time this podcast episode comes out, you will have already shared that strategy with, you will have already released that strategy.

So it won't be news, but for the sake of. context of the conversation, tell us about what it, what is this strategy for the next year? 

[00:24:33] Francisco Lobbosco: Yeah. So we have four main strategic pillars. So we have medical excellence, we have our associates, we have our patients and we have growth. So those are our four pillars. In addition to the four pillars, if you were to think about a house, the typical house that you see in business.

You'll have the foundations and for me, the foundations are to make sure that we have the right reporting timely and accurate, and let's make sure we go through to have the right digital tools in place, right? I think there was an episode a few weeks ago that you guys, published it was fantastic.

I certainly enjoy it, but for us is to start the journey on this digital transformation, what are the basic initiatives that we want to land across the whole of future life? So those are the foundations. From a financial reporting and from our digital infrastructure. And at the end of it, as an outcome of it, we'll have our financial performance.

Okay. So we want to make sure that we have a strong and predictable results over the years up to 2027, but that's the outcome. And I'm convinced, as I always say to my team, that if we were to have strong success rates or medical outcomes, as we currently have on a strong patient satisfaction, the financials will come.

That's a matter of time, but I've seen places where actually financials are really good and patient satisfaction is poor or the medical outcomes are poor and that in the long term will take a toll. So for me, it's incredibly important that we stick with those medical outcomes being very high and patient satisfaction being very high.

I gave you the four pillars. So again, medical excellence, patients, associates, and growth. And within each of the pillars, what you have is a strategy. So medical excellence, our strategy is quite simple. Enable a quality and patient safety culture focusing on improved outcomes. Every strategy has a goal and a way to measure the goal, and then we'll have building blocks within those strategy pillars, right?

So again, medical excellence, for example, you have quality leadership, transparency, learning, and safety culture, advanced data usage, and clinical standard and outcomes. And then at the end of it, what is going to be our 2024 corporate objective? Because we wanna set this five year roadmap, but with milestones that we are set to achieve over the upcoming, midterm, short term, midterm and long term.

so that's how we set the strategy. 

[00:27:01] Griffin Jones: This might just be my own ignorance. Why is medical excellence its own pillar as opposed to it just being the. It being the result of the providers and patients pillars, I 

[00:27:14] Francisco Lobbosco: think it needs attention by itself. I think obviously when we talk about associates, we're talking in general about our, I think this is where you're going.

So we talk about associates. We're talking about clinical associates in general. When we talk about patients, it's the outcome, it's how happy they are is by the outcome of the medical excellence. When we're talking about growth is organic growth and inorganic growth. And there are cross.

But one of the things that perhaps. We did not have Griffin and I think we were very lucky on the way we've been acquiring over the last couple of years is this minimum medical and minimum lab standards across future life. But whilst we go on and on in this journey of, inviting more clinics to be part of the future life family, we need to make sure we have those minimum standards ready because, high quality clinics.

It's great, but are we going to have the same number of high quality clinics in five times across Europe that we're going to, go on and pursue to join us? Maybe not. So let's make sure we set the minimum standards right now. And I want the medical pillar to be a reminder for us of what we're trying to achieve all day long, doesn't matter the size, it doesn't matter the financial outcomes that is a pillar, the medical outcomes are a pillar for us.

[00:28:31] Griffin Jones: And when you say associates, I want to make sure we're using the words correctly, because in the U. S., associate would mean an employed physician. It typically would not mean an embryologist or a lab director. It also would be different from a partner physician. in Europe, does associate refer to all clinicians and all scientists?

[00:28:52] Francisco Lobbosco: All employees, from a receptionist to, the chief medical officer, everyone is an associate, but it's just terminology. 

[00:29:01] Griffin Jones: So then on the growth side, what do you plan to implement for the growth pillar? So you have a couple of things, right? 

[00:29:09] Francisco Lobbosco: So you have. Organic growth and inorganic growth, and obviously from developments that we've seen lately, inorganic growth is very important.

So perhaps I should start there. We have a great team, a great MNA team that they go out and source and talk to the best clinics in Europe about future life. With my arrival, the first thing we did is we put minimum requirements of clinics that we want to pursue, right? We want to have a conversation with.

And those minimum requirements could be as simple as, size of the total clinic, number of medical doctors, the size of the lab and potential capacity for, number of cycles, success rates. So by setting the minimum requirements, then our M& A team actually had what we call clinics within the sweet spot.

and then we go on and proceed the discussion with them. So inorganic is incredibly important. And then of course you have organic, we have organic coming from, a couple of building blocks. Productivity, you'll have synergies and you'll have advanced data usage, which is linked to probably productivity.

so productivity for us is not to push more work to our doctors or our nurses or our embryologists, but to understand how can we help them to have more air time with our patients. What is it that they are doing that perhaps these non valued activities, can we reduce them? Can we help them to reduce them?

I think you were pointing out into paperless before, I think you were referring to that, that, that's one of the drivers, right? So how much time are you spending on daily basis on printing forms and filling them out and in that are not required by law because every country is Understanding how we can help our clinicians and productivity is incredibly important.

And then understanding how we can leverage the group synergies across all our clinics is also very important. And then data, when, I came here in April, we, didn't have a very automated way of getting data, frankly speaking. And I think the team have, done a great effort over the last six months.

And now we have daily. Insights that are reporting for every single clinic that we have operational marketing and medical data coming, in an automated way, accurate way to us that then we share back because that's the intention. So every member of clinic leadership teams will be able to see not only their numbers, their dashboards in ways that they haven't done until now, but also they will be able to see what the others are doing.

Because the intention here is to share best practice. So if I'm struggling in an area of my business and I see that clinic A is doing fantastically well, we are actually pushing clinic B to call clinic A to see what they are doing. So data, has been incredibly important, but also we have. One of the most modern in, in, in house, lab facilities here in Proud, and we want to benefit from it.

We have one of the strongest marketing teams that we are building as we are speaking. So we want to make sure that we provide support to the clinics from a marketing point of view. Education, I talked about it before. We have a meat bank, right? So we want to make sure that we, prioritize our future life clinics when it comes to the donor material and so on.

[00:32:27] Griffin Jones: I want to dig into a bunch of these. I'm deciding which one to go first into. Let's talk about the insights because you're getting operational marketing, medical data every day. What are some of those KPIs that you're looking at every day? 

[00:32:40] Francisco Lobbosco: Yeah, very good question. So we started getting the data only a couple of weeks ago, and again, if you were to ask me about the challenges that I'm facing, these are challenges that I faced also in my prior positions where I went from having not much visibility and just reports that were manual into automated, and accurate reports.

And the risk with that, Griffin, is that you are overflowing the organization with data and KPIs and reports and so on. So it's just at the kick of a button distance for us to have loads of KPIs. So answering your question, I am a big fan, not us, us from many years ago to have a maximum of five things we really want to push.

So if you're a part of a leadership team, probably you're looking at the many, KPIs, which is great, but up to five is what you should push and reward for. and as you can imagine, deciding which five we're going to publish is quite an interesting discussion. And I'm quite open about the discussion and I want my executive team to have a say about it.

So we're actually looking into it, but of course, I'm not going to lie to you. So coming back to that strategy, right? So I talked to you about the four pillars and I talked about our digital journey, so most probably we will end up with at least one KPI for each of the pillars to be consistent with what we're saying that we want to achieve.

Now, if you want to dive into a particular pillar, of course, you will have loads of data, right? So I guess the first KPIs that come to mind, and again, with the caveat of this hasn't been decided yet with between me and my management team, NPS, patient related, take home baby rate, medical excellence related, EMPs, Associates related.

And then I had two more, one related to demand creation and one related to operational excellence. But those are still under discussion. 

[00:34:42] Griffin Jones: So those acronyms for those listening, NPS is net promoter score. EMPS I'm guessing is employment engagement score. what does that stand for? 

[00:34:53] Francisco Lobbosco: Yeah. 

[00:34:54] Griffin Jones: Employee net Promoter score.

Oh, okay. Oh, ENP. Okay. Yeah. So you got your NPS for patients and your ENPS Got it. Correct. And, then you talked to, you told us that initially this data wasn't being gathered and, or at least wasn't automated. Maybe it was being gathered, maybe it was here or there, and Correct. It was gathered.

[00:35:12] Francisco Lobbosco: But in a manual basis. So now it's a lot easier to access that data and to make decisions based on the data. But as something new, you may get overwhelmed. but that's where we are today. And we're incredibly happy with what the team, as I said, have achieved over the last six months. And now is what we're going to do with that.

And, this is the fun part of it. 

[00:35:32] Griffin Jones: What did you do to automate that data intake? 

[00:35:38] Francisco Lobbosco: We made it a topic, we made it a recurrent daily topic. Of course, we hire an external consultant to help us with it. So we have a number of EMRs in this, in the business. We don't have a single EMR. We have a number of them.

[00:35:52] Griffin Jones: and, that sounds horrible. I've never met one person that likes their EMR. Yeah. I've met people that like their EMR better than other ones. And they like the people that make the EMR and because they do their best, but I've never met. someone that's this is 100 percent my favorite thing to use ever, and you have multiple EMRs.

is that going to be something that, stays over time? Or how do you get, how do you get multiple EMRs to equate into one source of truth? 

[00:36:25] Francisco Lobbosco: Yeah, great timing for a great question because I just came this morning out of a management team meeting where we allocated 60 minutes to that discussion.

and listen, so one thing I learned years ago is that I am system agnostic. But I am coding obsessed. So if I can take the data in the right way out of an EMR and my medical doctors, nurses, embryologists, coordinators are happy with the system, but we can tap into it and generate these definitions, equal definitions in the cloud, and then just, spread the insights across.

I'm happy with that. But obviously as we expand the question is how many do you want to have? Because every new clinic most probably will come with their own EMR. So there's a decision to be made there. But so far we are okay with the seven EMRs we're having. and especially because as I said, this, this third party consultant company help us to tap into every single one of them.

And now we have access to the insights that again, it's not just for us at management here at group level, but we're cascading that down for, the clinics to make decisions as well. 

[00:37:41] Griffin Jones: So I've seen all three approaches with regard to when you acquire a number of clinics and then you adopt different EMRs, or they have different EMRs, I've seen the approach of everybody, you can keep your EMR, decide for yourself, we're going to make a recommendation of what EMR we should use, and here's our SOP, but you decide if you're going to implement it or not, and then I've also seen, and probably even more recently, we're going to all go to this EMR.

This is the way it is for everybody in the network. This is what we're doing. It sounds like right now you're choosing the approach of one of the first two. why not make everybody, you said your system's agnostic. I get that. But even from a coding obsessed perspective, doesn't it? I feel like I would, I just know there's going to be some pain in your.

In the future of this isn't coding the right way because they're not actually coding equivalents in these systems. And, especially when you see one group having a low NPS because of their EMR and another group having a higher NPS because they really like their EMR. So why are you not going with the third option now?

Not the right time for sure. 

[00:38:51] Francisco Lobbosco: I think we have other priorities. I think the current DMR systems that we have in place give us what we need today. And again, for every decision, every initiative that we implement and we create a group level, most probably it will have repercussions at the clinical level.

And what I do not like to do is to overwhelm the clinics with projects that then will have an impact on the way we treat our patients. And changing EMRs, as or developing EMRs, you need to tap into that, you need to work with clinical associates. And I think today is not the right time for it, but I'm not saying no for the future, but I think today is not the right time.

[00:39:33] Griffin Jones: So you're getting these insights and not just the KPIs in the form of insights, but you're getting wisdom in the sense of asking the questions, what can be. Removed in order to add more value, what non value added activities can go? What can we do to give more time back to our associates? You're a smart guy.

You've been asking these questions for a hundred days. I assume you have a couple of, answers by this point. what are a couple of those things that you can do to remove non value added activities for associates? 

[00:40:09] Francisco Lobbosco: Yeah. And I think every clinic is different and every, the starting point for every single clinic is very different, right?

So with data now we can see, volumes going through productivity metrics going through, and as I said, you can sit on daily basis or intraday if you wanted to. And if you see a clinic that is, I'm a big fan of quartile and everything, right? So you have in a regular bell curve, you'll have Q1 two, three, and four.

So if you think about the quartile one and two, they are below average. So you wanna bring them to average, right? So you'll probably get a better impact from doing the, a bigger impact from doing that than pushing Q4 into, the 98 to the 99%. And as I said, every clinic is different. But there's one thing that I learned, which is my MDs, our MDs, our nurses, our embryologists are flat out is they're not playing Tetris in their consultation rooms.

And therefore, if they're delivering a lower productivity levels than the clinic next door within future life, that means that they're probably doing something else that the other clinic is not doing. And in most ca, in 99.9% of the cases. The MDs are looking at us saying, help me because I want to see more patients, but I have to do all these things that are stopping from, they are stopping me from seeing more patients.

And I think that's, the area that is very different clinic by clinic. So if you ask me for an answer now, I don't have an answer. I have many answers and they're very particular to the countries, to the clinics. There's some legislation in some places where everything has to be paper based. So it's quite different clinic by clinic.

[00:41:50] Griffin Jones: That brings me to, it's jumping ahead to a question about the EU in terms of, I'm sure there's some things that are, standard across the board, but then I imagine that there are many differences country to country. And, what's it like navigating those differences? What stood out to you in terms of particularities between different governance?

[00:42:12] Francisco Lobbosco: yeah, it is different, but one of the things I experienced here that I didn't experience in my past experiences is fertility tourism, and therefore patients are willing to actually move to the next clinic in the next country to access whatever they cannot access at home. And that is one of the biggest things that here at Future Life we need to start leveraging.

And, that referral within our own family is something that is missing. It's something that is going to drive growth as we were talking about growth earlier, definitely. But most importantly, something that our patients are asking for, because if in clinic A, I come to clinic A because I heard great things about clinic A.

But you cannot treat me because I'm a single man, for example, where can I go? Or, a homosexual cop, where can I go? we can definitely help you here and here and here and here, and we'll, make it happen for you. So that is one of the biggest benefits from having this community of Canine Excel across 10 countries that we think, I think we need to leverage a 

[00:43:15] Griffin Jones: And that's helpful in having a lot of this data aggregated and having the, teams working together too, because then you can build that infrastructure of, it's not just, Oh, I think our clinic over here does that.

It's, we have, let's take you over to the portfolio and let's see where. Where you're going to be able to be helped on the solution side of the elements, 

[00:43:41] Francisco Lobbosco: sorry to jump in, but one of the elements I think is close to your heart as well as we're implementing a common CRM system across every single clinic.

And that actually will help us as well with that transition and to offer, the right treatment for, all patients across independently on the borders. 

[00:43:59] Griffin Jones: Is it a CRM we would know like a HubSpot or a Salesforce, or is it a different kind of CRM? Creation. 

[00:44:04] Francisco Lobbosco: I'm not sure if you heard about it. I'm not familiar with them.

[00:44:08] Griffin Jones: And how did you vet them? They're based out of London. The CRM topic is, interesting to me because the reason why. I don't advise most small clinics to do it is because it's just too much work. The bigger groups have found a way to make Salesforce work and the big networks, but it's still not what I would want.

If I had my druthers, I would want a CRM that fully integrates within EMR because otherwise there's just too much duplicate work. So how did you vet this solution? 

[00:44:40] Francisco Lobbosco: So we obviously have lots of requirements at the moment of selection. We worked very collaboratively between the digital team, the operations team and the marketing team, because everybody has a say on what, what conditions we want to drive out of a CRM.

and we started with, I think it was 17 potential options. We went through meeting each of them, making sure that they could. Cope with our requirements, different to what it may sound. Our requirements are, is it going to be simple to use? Am I going to get just, what I need? I don't need a Ferrari to drive through the streets of Prague.

I need something that would take me from A to B. Is that going to take me from A to B? But potentially having the potential to go to C if I wanted to go to C after. So we were quite picky on our requirements. And, some of the names you mentioned there were. Definitely within the top five of our consideration, but in the end, we decide for creation, which I think they are based out of London.

[00:45:41] Griffin Jones: Do you plan to use it just for patients, new patient sourcing? Do you also plan to use it for referral providers? Because I've seen CRMs used both ways, where you use it as like the digital CRM, the marketing CRM, but also as the sales CRM for referring providers. How do you plan to use it? 

[00:46:00] Francisco Lobbosco: there's a phase one for sure on phase one is to make sure that we use it for marketing purposes, but we have the, what I was saying, let's go from A to B and then potentially let's go for C.

can you take me to C? these guys can take us to C and C is precisely what you're saying. I think eventually there are some functionality sitting in the EMR that potentially can go to the CRM. It's becoming a bit technical. Definitely it's a second phase of the project. 

[00:46:27] Griffin Jones: Maybe we stick with the growth theme For the last couple minutes of our conversation, you mentioned you've identified a sweet spot.

Some of those clinics might in this, in your sweet spot, might be listening and maybe future life is a good partner for them. Tell us a little bit. More about who's your sweet spot of clinic to come into your portfolio. 

[00:46:52] Francisco Lobbosco: first of all, we are very keen on having reputable clinics, right? So we're not in the business of turning around clinics from a medical point of view, we just trust our medical community in every clinic that we acquire, and we believe that they're up to the quality that we want to be proud of offering.

Answering your question, it will depend. And the reason why it will depend is because if we're talking about a new country, probably you want to go with a clinic that is slightly larger, that if you want to go into a country where we already have presence and we have a half clinic, as we call it, because from a half clinic, you can provide certain services as a great marketing team, as a great IT team, and so on, which is what we do, Again, it depends on the country, but if we were to enter a new country, we'll be looking into a clinic that, does around, as a minimum 600 pickups a year. We'll be looking into is there succession planning? I, do I have four or five at least FTEs in place? I'm talking about medical doctors.

What about the founder? How important is the figure of the founder? Is there succession for the founder? How is it being managed from a support perspective? can we utilize those great resources coming from the support functions in that clinic that we are acquiring to potentially expanding within that country, relying on the marketing individual that sits in that particular clinic or the finance individual that sits in that particular clinic.

We're looking for certain minimum square footage or square meters. Obviously we're looking into. EVDA as a consideration, because based on turnover EVDA, if the clinic has opportunities or not financially speaking, but that is usually the last consideration for us is all about success rates, which are in general here in Europe, they are published.

And therefore you can see the medical excellence or the medical quality that clinic has to offer. And then we send our teams out there. We send our operators, we send our chief medical officer. So we have one in West New York, one in Central Europe. They go and see the clinic and they come with a report.

And usually I'm also going out, seeing the clinic meeting, meeting the people that will potentially partner with us. Oh, in most cases, we don't acquire a hundred percent because we like them to have skin in the game and to continue with us partnering and so on. So therefore that partnership and the quality of the partnership is incredibly important for us.

[00:49:18] Griffin Jones: all right, so you're not taking 100 percent stake in, are you taking a majority stake in most of the clinics? 

[00:49:24] Francisco Lobbosco: Yes. Yes, definitely. and again, we're open for, a hundred percents, but in general, people are very proud. Founders are really proud of what they built and they want to keep going, which is great for us.

They want to keep going, but we better support from a digital perspective, but support from a finance perspective, from a marketing perspective, and that's what we can offer. 

[00:49:45] Griffin Jones: The pick, when you said 600 pickups, I wasn't familiar with that term. Does that refer to ag retrievals? Is that referred to? Yes. Okay.

So at a minimum, you're talking about not the smallest. I would say the, where it starts to become a mid sized practice as opposed to a small practice. Do you have the opportunity in the year to place docs in, to have docs go from some countries to other countries? Like in the U S one of the biggest challenges for single doc.

groups is that it's hard to get other docs to come to that area if they're in a small market. There's at least one group in the U. S. that I know of that has been taking advantage of it. They have bought a couple of these single doc groups because they can take some of their docs and fly them out there for a week or two at a time and batch cycles.

Do you have the opportunity to do that in the year or does the regulation between countries prohibit that? 

[00:50:41] Francisco Lobbosco: It depends on the country, we do have examples, we, have Hans who was working in Spain now, he's the chief medical officer for, reprimanding Ireland. we have Tomas in Slovakia coming from Czechia.

So we do have examples, it's just, it is a bit more complicated to, to have that freedom of movement when it comes to doctors, but definitely it's an area that we need to explore a little bit better, especially when it comes to embryologists. 

[00:51:08] Griffin Jones: That could be its whole episode in of its own talking about being able to use a bank of embryologists, and there's a lot of questions that I haven't asked you that I will be happy to ask you bringing you back onto the show.

With Growth is international. In your near horizon, now that we're seeing, we, saw the East Asian cohort by Indira and IVF, we see ginseng fertility own HRC in California. We saw care in the UK for the first time, make an acquisition in the United States. And in the end of 22, are we, should we expect to see future life moving beyond the continent in 2024, 

[00:51:52] Francisco Lobbosco: so we see many opportunities in Europe for us to continue looking at.

Also, we need to remind ourselves, especially that ourselves here at future life, that we're a new team with loads of initiatives being carried out as we speak. So focusing on the 45 plus the ones that will come from Europe next year, probably is the right thing. With that being said, we're always looking at what the market has to offer.

And, definitely the U S is a, is a market that, is attractive from different considerations, definitely other parts of the world as well. So I'm not saying no to it. I'm just conscious that we are incredibly busy at this precise moment. Delivering what we have to deliver here in Europe.

We also see opportunities for expanding here in Europe as well. 

[00:52:45] Griffin Jones: Francisco, it's been a pleasure talking with you. I want to give you the floor to conclude with your vision for growth, your vision for why, what we need to do to help the people of, why we're here. The floor is yours. 

[00:53:00] Francisco Lobbosco: thank you. I think I really enjoyed the conversation, perhaps just as a final thought from my end, which is something I said to my team quite often, I know that people like you, Griffin, most of your listeners, if not all, have been in this sector in this space for quite some time.

And you're very familiar with it. Sometimes it's good to have someone external coming, reminding us. 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 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. your job is to put smiles on people's faces. So my last words would be encouraging you to continue going. I think what you're doing helps the sector in particular, for everyone else out there, just keep going. I think we, or you in particular, are changing the world one way at a time.

So big thank you from my end. 

[00:54:02] Griffin Jones: you have helped with the impetus for more international content because I think it was earlier this year, maybe end of 22 when you first messaged me and said, I'm coming into the space and I'm, using your media to, to learn more about it. I said, Oh, maybe we should start creating more international content.

So you're among. among the reasons why we're expanding coverage for the global audience. and I'm thankful to those people that, that send me notes like that. And I echo your sentiments for people, because I'm not a clinician. I've, barely passed high school biology and, I often forget to, to sometimes stand back and say the same things that you just have.

So Francisco Lobbosco, thank you for saying it. Thank you for saying it on the Inside Reproductive Health Podcast. Thank you, Griffin. 

[00:54:52] Sponsor: This episode was brought to you by AIVF. Maximize your clinic's potential with EMA by AIVF slash end-to-end embryo evaluation time by a staggering 97.8%, freeing your staff to focus on what truly matters.

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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. Thank you for listening to Inside Reproductive health.

215 Minimizing IVF Patient Dropout with Empathic Communication with Dr. Alice Domar, PhD

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.


IVF patients are dropping out and it isn’t just about the money.

Dr. Alice Domar, Chief Compassion Officer at Inception, discusses empathic communication and its role in minimizing patient stress and physician burnout.

With Dr. Domar we dive into:

  • Her definition of Patient Centered Care

  • How she measures patient stress (comparing against retention rates)

  • An example of a study she ran (the 67% difference in patient dropout)

  • Her format for teaching empathic communication

Common trigger points for patients (And their impacts on your reputation as a physician)


Dr. Alice Domar PhD
Chief Compassion Officer, Inception Fertility, Director, Inception Research Institute


Inception LLC
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Prelude Fertility
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Transcript

[00:00:00] Dr. Alice Domar: The clinics should worry because if patients drop out of treatment, they're not going to get the income. Pharma's not going to get the income. And I worry because the patient's probably not going to get pregnant. by the time she gets to IVF, and she drops that IVF, the chances of her conceiving spontaneously through sex are pretty low.

And so it breaks my heart to think that people get to treatment, may even have insurance cover for treatment. And find it so stressful they drop out. And that's, where we are doing something wrong. People should not be dropping out of treatment because they're too stressed to continue. 

[00:00:37] Sponsor: This episode was brought to you by Prelude Fertility, where top REI physicians find their calling.

Practice anywhere with Prelude. The Prelude Network is the fastest growing network of fertility clinics in North America. With more than 90 plus locations, we're ready to support you and your individual career aspirations, wherever they lead. To learn more, please visit rei.preludefertility.com. That's rei.preludefertility.com.

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.

[00:01:32] Griffin Jones: IVF patients are dropping out and it ain't just because of money. You can't help people get pregnant. You can't help people have a family. You can't scale fertility treatment. If people are dropping out for reasons within our control. If you own or operate fertility clinics, what does that mean for your business?

And if you're a fertility physician, how does it all come back to the way that you communicate? What does it even mean to train fertility physicians in empathic communication? My guest today has studied all of this more than anyone as far as I know. She's Dr. Alice Domar. Now she's the Chief Compassion Officer at Inception.

And she's working on reducing patient dropout by reducing patient stress. And she's working on reducing provider and staff burnout by reducing provider and staff stress. Allie talks about the studies that she's done and other studies that have been done on psychological interventions and patient centered care.

I make her define patient centered care. We talk about how she's measuring patient stress now and how she plans to compare those to retention and dropout rates. We talk about an intervention that she did in the past of a sample of 166 women where half were given this intervention, half were not. It's one variable and there was a 67 percent difference in patient dropout.

I ask her to describe the format and how she's teaching fertility physicians empathic communication. What does that training look like? And I push Allie a bit on the tension between alleviating patient burnout versus alleviating provider and staff burnout. I think there's a natural tension there and anybody who says otherwise is lying.

I'm not saying that it can't be managed. And I think Allie has a way of managing that. Tell me what you think about her suggestion and tell me what you think about physician communication as it relates to IVF patient dropout. Join my conversation with Dr. Allie Domar. Dr. Domar, Allie, welcome back to the Inside Reproductive Health podcast.

Dr. Alice Domar: So good to see you. 

I don't remember if this is your second or third time, but you were on one of the earlier episodes. You're someone that I've gotten to speak with at events before. I love seeing you speak at events. I love interviewing you. You're a chief compassion officer right now. And I am. One of the things about me is I don't like a lot of C titles.

I think C titles are way overused, but If there is a chief compassion officer and someone is qualified to be one, that is you. And so I want to talk a little bit about what it is that you do in this role at a network level that is a way of thinking about how we introduce things that are necessary for patient care and for patient retention.

But having somebody oversee at least some of the critical elements of that, Cross the scale of the organization. So what is it that you do at a, network level? 

[00:04:19] Dr. Alice Domar: Nothing. I'm just, I just goof off now. I, we really, when I went down to Houston to meet with TJ Farnsworth and the rest of the executive team, no one really remembers who came up with the job title.

I think it was TJ. He thinks it was me anyway, doesn't matter. But it really is a perfect title because, I've spent my whole career working to decrease the stress level of infertility patients and people who work in the infertility clinics in the sector. And so I've since added another title as I'm director of research for Inception, which probably adds another 50 percent of my life.

But I think to summarize it. I spend a lot of time trying to create and provide programs to our patients on how to decrease stress. So for example, tonight at nine o'clock Eastern time, I'm doing a webinar on, for family and friends of people who are going through infertility on basically do's and don'ts, like how can I best support someone I love with infertility?

And so I do monthly webinars. for patients. This is my first one for non patients, but I do monthly webinars for patients. I, if there's a patient in crisis, I talk to the patient. I write blogs on how to reduce stress. And I basically am just there for all of our clinics if there are any issues with the patient.

And as I said, I, talk to patients directly. And then another hat I wear is I try to provide programs to employees. Like in the last year, we've gotten a free subscription to the com app for all employees. I do this ask Allie column in their weekly newsletter. I'm starting a podcast this month for employees and how to reduce stress.

And if an employee is in crisis, either HR or their manager or the employee contacts me and I talk them through it. 

[00:06:16] Griffin Jones: So you've got these two different sets of programs, one for decreasing stress for patients and the programs that fall within that line, and then the other line being for decreasing stress for employees.

Are there indicators that you're ultimately responsible for or looking at that, that help you to decide that govern what those programs become and how you measure their success? 

[00:06:42] Dr. Alice Domar: Not yet, but that's in fact, I think one of the reasons why I'm running the Inception Research Institute because we're actually doing studies on the efficacy of different psychological interventions.

Although right now our research is mostly trying to understand. So for example, I have a study funded by MD Serrano where You know, for 10 or 12 years, researchers in Europe have been talking about patient centered care. And research actually shows that patients prioritize patient centered care over pregnancy rates.

women who are going for treatment right now really want to be cared for by compassionate, empathic physicians, nurses, and the team. And so everyone is always saying, oh, this is what patients want. But no one's ever really asked patients what they want. So we're doing a survey right now where we mailed a questionnaire to our patients to say, what are your priorities?

is it communication? Is it how to handle finance? everything. And so we will have the data hopefully released soon because I'm presenting it at PCRS. So we'll have the data soon. We're also on a LARC, gave the same survey to our physicians and asked them, what do you think your patients want?

And we're going to compare what the physicians think patients want versus what. patients say they want. And so once we know what the patient's priorities are, then we can make changes in the clinics to respect and reflect on what patients say they need, as opposed to you or I saying, Oh, I think this is a good idea.

This is what patients need. We're actually asking the patients what they need. 

[00:08:21] Griffin Jones: How do you juxtapose what patients say they want to need versus what their behavior suggests they want and need? And I'll give you an example that I'm thinking of. I remember, it was probably like 10 years ago or 8 years ago or so, Wash U Fertility did a survey of fertility patients.

And they might have done it in connection with Sirona. I don't remember who they did it in connection with. But they interviewed patients asking them what they liked and what they didn't. Want to see in social media. And what they said is we don't want to see pictures of babies. We don't want, we want tips on fertility, but then I could pull up all of our different clients, Facebook and Instagram analytics and say, it was almost like reverse alley.

It was like the pictures of babies did ridiculously well. And so you can say I don't want to see this, but then they're clicking on it. that's what they're, that's what they're paying attention to. That's what they're being driven for. And so I, I see. I've, seen this, with, employees, I've seen this all over the place.

It goes back to that Henry Ford quote of, if I asked my customers what they wanted, they would have told me they wanted a faster horse. Don't know if he actually said that or not, but, people can get the idea. how do you juxtapose like what people say they want versus, making sure that the, tail isn't wagging the dog.

[00:09:46] Dr. Alice Domar: first of all, I think a lot of the data that's been collected in the past was done in focus groups where you have, six or eight or 10 people meeting with somebody who asks them. And I don't tend to believe results from eight or 10 or 12 people. In fact, this morning I was asked to review a study that included 13 patients and they drew all these conclusions from 13 patients.

And I said, that's. That's insane. You can't draw conclusions from 13 people. And so we've already collected data, I think, from at least 500 patients. We're hoping to have at least a thousand. And when you have numbers like that, you can relatively safely assume you're actually getting real data. And then.

Before we actually implement these changes, we're going to do another study where we're going to take two of our comparable clinics, like maybe two of them in Florida or two of them in Texas, and take all the suggestions that patients said they wanted and make those changes at one of the clinics. And then compare patient satisfaction, patient dropout rates, things like that to see, yes, you're right.

People do say things that they want, but you also tend to get more. honest answers from these anonymous questionnaires versus talking to somebody, especially somebody who works at the clinic. 

[00:11:06] Griffin Jones: Yeah. I think that's a good way of looking at it too, is can you see from their answers how well do they line up to some of those numbers like dropout or conversion or retention?

Is there a way to do something like this, Sally, I remember there was a conversion rate Specialist that I follow in marketing, I think his name's Brian Massey, and I was at one of his workshops and we were going through this type of thing. And very often when people are trying to workshop a new campaign or a new website, they'll ask questions like, was this website clear?

Was this website appealing? Whereas he suggests. studies that show, show, did people buy it more or not? Or in the case of, if you're trying to get some kind of brand messaging over the line and it can't be tied to a particular conversion, he'll still suggest asking people what is it that this website does, or what is it that this company does after looking at the website homepage, as opposed to Asking people if the website was clear, is there any way to do that in your survey mechanism?

[00:12:18] Dr. Alice Domar: I think you're right. it's, tough to assume that people report exactly what they want. So for example, in all this research, because in Europe, they're way ahead of us in this patient centered care. But they did, I don't even know how they got the data, if it was focus groups or what, but they, said there are five things that patients want in terms of patient centered care.

And I don't remember what three of them were, but two of them were more information on the semen analysis and more information on the impact of a high BMI. I've been in this field for 36 years. I have never had a patient say, I want more information from the semen analysis. And most of my patients. don't want to know the impact of the BMI because they know that being heavy or too light, impacts their chances and they don't want to hear more about it because they already know it.

So I think we have to be very careful how we collect data. it's if you look at some of the old data from like before 2000 on the psychological impact of infertility, there were a number of studies that showed that women with infertility had the same level of anxiety and depression as did anybody else.

Yeah, but they were also. being asked to rate their anxiety or depression in their clinics, sometimes with their doctor present. And they would want their doctor to think that they were fine, that they could handle treatment just fine. Cause they didn't want the doctor to know how upset they were. Cause then the doctor would say, Oh, you're too upset to do treatment.

And so a groundbreaking study happened in 2004, where they actually had. a psychiatrist, interview, do a structured psychiatric interview before patients saw an infertility doctor for the very first time. And 40 percent of them met the criteria for anxiety, depression, or both. So sometimes these self report mental health assessments, let me rephrase that, many times these self report mental health assessments are not very accurate.

And if you go to countries like Scandinavia where People don't tend to talk about being anxious or depressed. You're going to get scores of zero from people who in fact are probably very distressed. 

[00:14:26] Griffin Jones: So you're working on getting some more of this data right now with the studies that you're doing.

In the absence of this data in the meantime, how do you decide which programs that you want to usher in and that you think will have the biggest impact? 

[00:14:43] Dr. Alice Domar: I look at the research. there's been, I don't know, a hundred randomized controlled trials on the efficacy of different psychological interventions.

obviously I started the MindBody program in 1987, so I'm a little biased towards MindBody, but in fact, there's been a group in Denmark who've done two huge meta analyses on the efficacy of psychological interventions with infertility patients on both psychological symptoms and pregnancy rates.

And both of their meta analyses have pointed to, mind body stress management interventions as being the most effective. and that's not me doing the research, that's them doing the research. It just makes me feel good because that's the intervention that I'm most familiar with. 

[00:15:28] Griffin Jones: tell us more about the programs.

What programs developed from that? 

[00:15:32] Dr. Alice Domar: So the MindBody program, it used to be an in person 10 session program. Obviously, now everything is remote. But we've also shown, I had a graduate student from UVM who took the in person MindBody program. And we've done a bunch of randomness control trials on it.

But she took the in person program and made it into an individualized online program. And this is before COVID, and this was her PhD thesis. And we found that women who did the MindBody program by themselves on their computers, not only had massive decreases in depression and anxiety compared to the control group, but their pregnancy rate was four times that of women who were on the waiting list control group.

I could talk for two days about The efficacy of these interventions. We know that our patients are distressed. We, know that a lot of them are anxious. A lot of them are depressed. Their partners are anxious and depressed. And, I was at a conference last year in Boston. I don't remember if you were at the same conference.

It was over Valentine's day. And it was on reproductive medicine, I think in women's health. And I actually got up at the end of the conference because they're all talking about all these technologies and all, AI and everything else that can be used in reproductive medicine. And I stood up at the end and I said, look, I'm the only mental health professional in this entire conference.

No one has mentioned. The emotional health of our patients. But if someone is really distressed, we know for a fact, they're not going to go see an infertility doctor. They're not going to start treatment. The more depressed a woman is before she starts IVF, the more likely she is to drop out after only one cycle.

all of us should be caring about our patient's mental health. I, as a psychologist, because I don't want these women to suffer psychologically. But the clinics should worry because if patients drop out of treatment, they're not gonna get the income, pharma's not gonna get the income, and I worry because the patient's probably not gonna get pregnant.

by the time she gets to IVF, and she drops that IVF, the chances of her conceiving spontaneously through sex are pretty low. And so it breaks my heart to think that people get to treatment, may even have insurance cover for treatment and find it so stressful, they drop out. And that's, where we are doing something wrong.

People should not be dropping out of treatment because they're too stressed to continue. 

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[00:20:17] Griffin Jones: I want to come into how this impacts dropout. I wonder if one of the reason why they didn't mention that at that tech or that innovation conference, perhaps two reasons.

What are people in that sphere obsessed with? One is measurables of certain metrics and they want very specific attribution. And we talked about some of that thing that you're working on. The other thing that they obsessed with is scalability. it's got a scale. And so are there. Technological solutions.

You mentioned that one of the things that you all are doing is getting subscriptions to the comm app for your employees. are there technological solutions that scale to reduce stress for patients? 

[00:20:55] Dr. Alice Domar: I haven't seen a whole lot of research yet. I know that Jackie Boyvan in Europe. is working on an app called Metaemo.

And the, at Esri a few years ago, she presented data that showed that women who use the Metaemo app were twice, who did IVF, were twice as likely to come back and do a second cycle than women who didn't use the app. We did a study, I, did it with Jackie. maybe six years ago, I don't remember how many years ago, where we recruited women, I think 166 women, who are about to do their first IVF cycle.

And we mailed half of them a stress management packet. So it was like cognitive behavioral skills. It was a relaxation CD. It was teaching them how to do mini relaxations. So we mailed them a half of them and then sat back for a year, didn't contact them, and then looked at retention rates. And the woman who got the packet, we don't know if they opened the packet, we don't know if they used the packet, the woman who got the packet in the mail reduced dropout rates by 67%.

Wow. And that packet cost 12. 

[00:22:00] Griffin Jones: And there was no other control? So we know that, 

[00:22:06] Dr. Alice Domar: no, we had a control group. We took 166 women. 

[00:22:09] Griffin Jones: but otherwise the groups were identical, like demographics, where they lived, and Absolutely identical. That 

[00:22:15] Dr. Alice Domar: was the only variable. Randomized controlled study. And then we just published a paper last year, and we tripped over this.

in my previous job, I was very interested in dropout rates. I'm in Massachusetts, six cycles mandated coverage. And we noticed that a lot of patients came in for a first visit and didn't come back. And I'm like why wouldn't they come back? They have insurance coverage. So we actually just sent them an email to say, Hey, we noticed that you saw an infertility doctor three months ago.

We noticed you haven't come back. We're just wondering why do you not like the doctor? Are you pregnant? are you taking some time off? what's going on? And we got a lot of answers, but. My research assistant noticed that a lot of the patients who got the email were coming back, like a lot of them said, Oh, I'll come back.

And then she went on maternity leave. So we didn't send the email out for four months. So we were able then to compare. When we sent the email out just asking, why didn't you come back versus when we didn't, massive increases in people coming back simply by getting an email saying, hey, we noticed you didn't come back.

So the conclusion I draw from those two studies, it takes very little to support patients to come back or to stay in treatment. And yet most clinics aren't doing anything. 

[00:23:41] Griffin Jones: There's a bunch of rabbit hole questions I want to ask you, but I'm making notes of them because we'll get to them if we get time.

The audience probably isn't as interested in those as I am. We'll get to the meat and potatoes first, and then if we have time, we'll, get to some of that dessert. So I, you're painting this picture for me. You've got 166 women in your mail. Half of them, stress packet, and half of them don't.

And then you have a 60 seven percent decrease in dropout for those that did get the packet. And then you've got this other, it wasn't a, it wasn't a study, but you could at least see in practice from the response rate that you were getting from emailing patients, asking them why they chose not to come back and.

Versus the time when your research assistant was out and didn't send that. So how does, what are the factors as far as you can deduce that impact patient retention? 

[00:24:41] Dr. Alice Domar: it's interesting because at my previous job, I spent about 10 years studying patient retention. And so we ended up interviewing maybe 250 or 300 patients who had insurance coverage.

for six IVF cycles and dropped out and didn't go to a different doctor. They just dropped out. And we asked them why. And most of them said because of communication, either from their physician or someone from the nursing team or whatever. They just had a conversation that just upset them so much.

They realized they couldn't keep up with treatment and they dropped out, which means, as I said, they're probably giving up genetic Parenthood by dropping out. And so then I got on my, my, whatever you want to call it. And I thought, okay, we need to teach people how to communicate more empathically.

And so one thing I've been doing at Inception for the last year is holding dinners for our physicians and teaching them empathic communication. And I do it in a, I don't want to say a mean way because none of them have, we go to dinner and it's, the physicians from the clinic and often the practice, the clinic manager, whatever.

And we, we're at like an ice steakhouse in a private room. And then I talk about empathic communication and all the things that indicate empathic communication. And then I give them vignettes. And I'll have a physician in a difficult situation practicing with either another physician or someone who works in the clinic.

And then I criticize them and it's gone over really well and they've learned there's some insanely easy ways. I, we, we're doing some training videos now at Inception where we just recorded last week training videos on how to communicate the six most difficult conversations that physicians have with patients.

And again, for both scenarios, I talked about how to. communicate empathically. And one of the easiest things you can do is to make eye contact. And so when I was trained in empathic communication, the tagline is never have a conversation with anybody unless you can walk away and tell anybody else what eye color that person had.

[00:27:00] Griffin Jones: Say that again, never make eye contact with anyone, never have a conversation with anyone unless you can walk away. 

[00:27:08] Dr. Alice Domar: So I noticed right away from what I can tell on the computer screen that you have brown eyes, right? Okay, that means I made eye contact with you.

[00:27:16] Griffin Jones: I barely know what color my wife's eyes are.

I'm thinking like, am I that crappy at talking? It's, something that wouldn't occur. Not something that would occur to me to pay attention to necessarily, or I guess better said, I would have to make a point to pay attention to someone's eye color. 

[00:27:37] Dr. Alice Domar: But that's one of the ground, the basis of empathic communication, that when you talk to somebody, especially if it's a physician talking to a patient, they need to make eye contact.

They can't be on their computer. They have to look at the patient and make eye contact. And that has enormous meaning. And if you look at the data coming out of Empathetics, which is an offshoot of Mass General Hospital, they've all this data on the efficacy of empathic communication. When you communicate empathically, patients perceive you spend far more time with them.

One of the number one complaints right now about physicians is that they don't spend enough time with their patients. 

[00:28:17] Griffin Jones: So is, with regard to eye contact specifically, do you find that older physicians are better than younger physicians in that particular regard? Or because I think very often it's said, the older physician is, might be the closer they are to.

[00:28:37] Dr. Alice Domar: That era where the doc was the authority and it was, it's really interesting 'cause I was in Dallas and then Nashville last week recording these physician training videos and we talked a lot about age, like our older reiss, better at communicating, better at being empathic than, for example, fellows. And I think you can't generalize because yeah, older physicians.

Don't tend to look at their computer screen as much because they are more, but some of them are maybe a little bit stuck in their ways. But, it was interesting. So the way we did these training videos, we had these six scenarios. Like one of them was, how to tell a patient that she was miscarrying.

she just had a prenatal scan. There's no heartbeat. And so for each physician, we had them record a non empathic interaction. Or an, a non compassionate one and then a good one. And we had, either, like usually it was an employee of the clinic acting as the patient. And even though it was fake, obviously the employees would say to me, wow, like I could viscerally feel different when the physician was talking to me in a cold, aloof way versus when they were making eye contact and leaning forward and not crossing their arms and things like that.

Millennials demand. Patient centered care. 

[00:29:59] Griffin Jones: Tell us a little bit about some of the gentle corrections that you made, some of those specifics. you told us about, about making eye contact and the way people pose, but what are a couple of specific things that you've said to people? 

[00:30:12] Dr. Alice Domar: I know, one of the most difficult conversations for physicians is telling a patient that she's above their BMI cutoff.

And the instinct for a physician would be to say, I'm really sorry to tell you, if, again, if I'm sitting behind them and they know they're being empathic, they say, I'm so sorry to tell you, but, your BMI is too high. I'm going to refer you to a nutritionist so you can lose weight.

and get your BMI below the cutoff, then you can do IVF. And that is an effective conversation. If I hear them do that, I would probably say, okay, so maybe we could do it a different way. how about, how would you feel if you said to the patient, something to this effect, there are a lot of things that can contribute to IVF success.

And we, I, the lab, everybody, we're doing everything we can to increase the chances that your next Psycho will lead to a healthy pregnancy and there are some things that you can also do that can increase or decrease your chances and one of the things that we look at is lifestyle habits and you're doing great with this and this but you know your BMI is a little high so how about we talk about ways that you can eat more healthfully to get your BMI below the cutoff so you can move ahead and do IVF.

No, which way would you rather hear it? 

[00:31:35] Griffin Jones: my, my preference is probably contrary to how a lot of people want to hear it. But it, the point is that it's not what you say. It's what people hear. And I remember when we were doing online reviews for fertility clinics or helping them with their online.

reputation management, I would look at the reviews and I would see very often she called me fat. He called me old. And I'm like, I wasn't in there. I wasn't in the consult room. I know that person. I don't think. I doubt, maybe she did, but I don't think she did. I think that she said something that in a vulnerable state was too close, too readily interpretable as I'm fat or I'm older, I'm not good enough in some way.

And, so I think that communication is clutch to be able to do. You have to be able to communicate in that way. And that was always something that And when we would help docs with this, it's I can't help you with that part. And so you're starting to. And so you're starting to do dinners. Is there plans to scale this, like beyond dinners and having this be like something that every doc goes through?

[00:32:44] Dr. Alice Domar: I think that's why we're doing the training videos because it's really, we have clinics. It's all over the US and Canada. And so having me go to every single clinic and do this and, not every physician can make every dinner. So it just seems more practical for us to do these training videos.

And I felt that, it was so interesting last week when we were doing them again, hearing the impressions of for one of the training videos in Dallas. the physician's MA was her patient. And she told us later that, she was faking it. She wasn't an infertility patient. She was probably, way too young for that.

And she said, when the physician spoke to her in a classic, somewhat detached, very factual manner, that she felt herself just feeling Like this doctor doesn't really care about me. And then when the physician followed through with all the empathic training and the skillset she has in communicating, the MA was like, I felt different.

I could feel myself reacting to how this physician was communicating with me. And it's, it's not hard. And it saves time, it's interesting because, Liz Grill, she and I once a year teach a course on a cruise ship for physician burnout prevention. And it's actually really fun. We get to go on a cruise together.

And one of the things that I, teach, one of the classes I teach for that course is empathic communication. And the physicians, these are not REIs, these are, all kinds of physicians and they come in yeah, blah, blah, blah. And then I list all the data on empathic communication. And it makes sense.

[00:34:26] Griffin Jones: It just makes sense. So I want to, bridge these two things because, and I don't want easy answers because sometimes people give me easy answers when I'm trying to reconcile the tension between patient burnout and, patient fatigue and, the needs that patients have versus the needs that staff and providers have.

And the answer that a lot of. Leaders give me ally is, oh, they're both, they both have the same interests. They both wanna do great. It's like bull crap that they don't have interests that are at odds sometimes. I'm not saying there's no way of being able to align their interests, but I'm saying that it, when you have patience that have certain demands that costs something on you when you're trying to, be able to deliver that.

And we could make patients really, happy if we answered their calls all at all times of the day and, like sped, didn't have dinner with our family to make sure we got them what they wanted. And, but then, Providers and staff are facing the burnout on that side.

And, you talked about inception a lot of who's your employer, but they are not a feature sponsor of this podcast episodes, which means they don't have editorial control. So you can say whatever the heck you want about them, your own consequences, consider those, but on my show, I don't have to do a damn thing.

I think one of their brands is, the brought to you by a sponsor, but. They don't get, they don't get editorial control. So how do you reconcile this, the needs that patients have versus the needs that the people providing those needs have? 

[00:36:10] Dr. Alice Domar: when I got to Inception, as I said, almost two years ago, it was a little overwhelming because they have almost 2, 000 employees.

And I don't know, at any given time, what, 100, 000 patients. And so I was trying to think through Where would I start? And it's, and I still say this, it's very obvious. You have to start with decreasing patient distress, because if you can decrease patient distress, patients will be easier to work with, and that decreases employee stress.

So I've spent a lot more time trying to design ways. To make our patients have less psychological pain because that will then have a domino effect and make it easier for the employees. 

[00:36:52] Griffin Jones: How do you incentivize the employees to do that when they're already feeling burned out? So if, one of the things that de stresses patients is maybe either more communication about finances or more communication about some of the things that you need and you could even come up with scalable ideas like Modules for the patients, but that takes staff time and provider time, and you have to take some of those staff and providers away to do that.

how do you incentivize the staff and the providers to say, listen, I know you've got needs here, but if we don't de stress the patients, then your needs are only, the burden on your needs is only going to get worse. 

[00:37:37] Dr. Alice Domar: it's, a separate thing because I provide a lot of entities for patients and for employees.

And so I feel like it's, on me to do that. obviously teaching empathic communication is a good thing, but for example, I've spent the last year and a half going to our clinics. I think I have three more to schedule and I do what I call a stress lunch at each clinic. And most of it is talking to them.

about where infertility patients are coming from, about how depressed they are, how anxious they are, how it impacts every area of their lives. And I talk about the unbelievable jealousy they have when anyone else gets pregnant and how agonizing that is and how hard it is to be part of a partnership.

where two members of the couple don't feel the same way at the same time and that puts them into crisis and their sex life goes to pot and they can't go home for holidays because their sister or brother has a baby and they can't be in the same room as the baby and you know I think when you explain to them where patients are coming from and why they seem so demanding and irrational and everything else it makes it easier to care for the patients because they then understand the patients.

It's different from pretty much any other aspect of medicine. You have a patient population who are as depressed and anxious as cancer patients and AIDS patients and heart disease patients, but they're young and healthy. And so when I talk about where patients are coming from and what their triggers are, I think it helps the employees because then you have compassion because you understand.

[00:39:16] Griffin Jones: I think that I could benefit from something similar in my own business and a lot of businesses could. benefit from something similar where you're training your team. This is what our user on the other side, whether it's a customer or a client or a patient is going through on this side, and I think that allows them to take better care of the patient that or the customer or the client That that reduces the burden on the team. I think that could be. I think that I think you have threaded the needle in that way. It still starts with the end user and it starts with educating your team. But if your team is educated on the needs. Of the user, then they can, in this case, the patient, they can reduce, the amount of stress that comes their way down the pipeline.

[00:40:09] Dr. Alice Domar: But it goes, I do a lot of couples counseling. I still have a small private practice. And I think the key with couples counseling is your partner can't read your mind. And you guys are not going to feel the same way about things. And you have to distinguish between what they. Can't do versus what they won't do and so the key to a successful relationship in any relationship is learning to understand Where the other person is coming from whether it be a marriage or a parent and child or being a nurse or doctor in a Fertility clinic you have to understand where the other person is coming from and what their triggers are 

[00:40:49] Griffin Jones: I think sometimes it goes too far one way and like in 2021, it was like, this is what employees need.

And, but then you had a bunch of employers get burned out. It's always, whenever you have more than one person, it's not just what wives want or what husbands want. It's wives and husbands or husbands and wives, whoever it may be, employees and employers. I think that's a really good point.

I guess some of the, I wonder, do you see. Is it helping in a way where you're starting to see turning the corner for reducing the stress in providers? Because I think of the companies that used to be really good at knowing what the customers needs were and servicing them. I think of companies like Apple.

I think of companies like Southwest. I think of companies like Trader Joe's. And I think with the exception of Trader Joe's. They have decreased. you go into the Apple store and they are not as nice as they were five years ago. And I think it's perhaps like what you're talking about. It's a two way street, and that niceness has been presumed upon too much.

[00:41:57] Dr. Alice Domar: But see, that's why every company needs a chief compassion officer. 

[00:42:01] Griffin Jones: Yeah, maybe. I really think so, because you're able to come in and balance this. And how are the providers responding to that piece of it? 

[00:42:11] Dr. Alice Domar: I have to say, I think I have probably met 95 percent of Inception's physicians, I'm guessing. And they've been lovely.

Like, really lovely. Like when I go to clinics, they hug me pretty consistently. And as I said, when I started doing these empathy dinners, I thought I was putting myself out there. I'm putting my neck on the chopping block and they've responded really, well. And it's been so much better and so much easier and so much more rewarding for me working with these physicians, because, as I said, they went into medicine to care for their patients and, some of them are, it's harder to work with millennials who are like, I was here at 730, where are my blood results?

And so I think, you They also respect the fact that I'm a researcher, and so when I talk about stuff, I don't just say this is what I think. I'll cite 16 different research projects that are randomized controlled studies that have been published in peer reviewed journals back up what I'm saying, and that's what you have to do.

You have to, you can't just pontificate what your thoughts and feelings are. You have to back it up with science, especially in this field. 

[00:43:26] Griffin Jones: Is the retention and dropout for third party a different animal? Does it all fold into this, but is, or is there something else that needs to be considered for retaining patients in such a way that allows them to then move on to third party IVF after failed cycles if they need it?

[00:43:46] Dr. Alice Domar: the transition from, for example, cycling with one who owns eggs to egg donor, when you transition from, treatment with each partner's eggs or sperm and the woman carrying that embryo that they've created, that's a different animal than third party because then you get into big bucks and a lot of mourning and grieving, excuse me, that is involved.

I think most clinics or all clinics follow ASRM guidelines. Or that those patients all have to see a mental health professional to, or hopefully they do, to help them process. Because you can't just say, Oh, my cycle didn't work. Let's do egg donation next month. You can't do that. So I think at some level, these third party patients can be more challenging to work with because the financial stakes are so high.

And because a lot of them have moved into it before they're really ready. And so they can be prickly. So there, there are a couple of things. On the other hand, they're highly motivated, but it's tough. I think third party is almost like a different kind of patient population. 

[00:44:56] Griffin Jones: Yeah, I think so. Are there special interventions that you've noticed for them, like, the sending of the email to, to ask why they didn't come back?

Is there anything equivalent to that you've noticed with third party? 

[00:45:09] Dr. Alice Domar: It's been very little research. It's interesting because I'm about to submit a grant for the first time. No one ever has looked at this, is what about patients who come in who want to electively freeze their eggs? Because when patients come in for that first consult, half of them don't come back.

And we're going to be doing an inter, hopefully if it's funded, an intervention site to see if we can better support them. Because what the research shows is women who freeze their eggs, very few of them regret freezing. Women who don't freeze their eggs, the majority regret not freezing. And so again, I as a psychologist want to see what can we do to support these women to make the decision that they are least likely to regret.

[00:45:54] Griffin Jones: I want to ask you the rabbit hole questions of where psychology meets neuroscience, but people would be less interested in that. And you got to go. But if people see us talking, sitting down at a bench someplace at the next conference, that's what I'm asking Allie about. Allie, I wanted you to conclude based on how you would like to conclude about empathic communication, about reducing dropout and increasing patient retention for either providers or staff or any of the threads that we talked about today.

How would you like to conclude? 

[00:46:28] Dr. Alice Domar: I think we all need to accept the fact that patients need to be cared for in a different way than they needed to be cared for 20, 30 years ago. That we have to learn, as you said at the beginning, what patient centered care is. But it starts with empathic communication. 

[00:46:47] Griffin Jones: Dr. Allie Domar, thank you so much for coming back on the Inside Reproductive Health Podcast. 

[00:46:53] Dr. Alice Domar: My pleasure. Always happy to see you. 

[00:46:56] Sponsor: This episode was brought to you by Prelude Fertility, where top REI physicians find their calling. Practice anywhere with Prelude. The Prelude Network is the fastest growing network of fertility clinics in North America.

With more than 90 plus locations, we're ready to support you and your individual career aspirations wherever they lead. To learn more, please visit rei.preludefertility.com. That's rei.preludefertility.com

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. Thank you for listening to Inside Reproductive health.

214 Grow Donor Egg IVF Programs While Increasing IVF Lab Capacity with Betsy John

DISCLAIMER: Today’s episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free, to you! Here, the Advertiser has editorial control. Feature sponsorship is not an endorsement, and does not necessarily reflect the views of Inside Reproductive Health.


Capacity, Reach, and Concierge Service.

Betsy John, Business Development Manager at My Egg Bank, shares how these three systems are necessary to growing your 3rd party IVF program.

With Betsy we discuss:

  • What Concierge Service looks like when serving your patients

  • The burden 3rd party nurses have (And how you can alleviate that burden)

  • The diversity of egg donors required for fertility practices to grow their 3rd party programs

  • What fertility practices should avoid when working with a new egg bank

  • The trends she sees on the horizon for donor egg IVF (Including AI for facial recognition)

Why offering both fresh and frozen donor cycles is necessary (and how My Egg Bank helps with each)


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MyEggBank
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Transcript

[00:00:00] Betsy John: To be honest, it is more one on one. So I guess more so in the vein of the concierge service, that it's not, something that we do. And it really is more so about to meet those intended parents where they're at in the journey. As I mentioned, some of them are coming to us, all of this is brand new. They feel so confused or overwhelmed by the process.

but I think that's where the personal touch really matters. That maybe a module or a video wouldn't be able to afford the same, open communication that a conversation with that person might have. 

[00:00:34] Sponsor: This episode was made possible by our feature sponsor, MyEggBank, the premier network of donor egg banks.

Enhance your clinic's fertility services with MyEggBank. By joining our network, your clinic can broaden its horizons, offering aspiring parents a diverse range of fresh and frozen donor egg options, each backed by our demonstrated success rates. Together, we can bring the joy and hope of parenthood to more families.

Discover the benefits of partnering with MyEggBank by visiting myeggbank.com/irh. That's myeggbank.com/irh

Announcer: Today's episode is paid content from our future sponsor, who helps Inside Reproductive Health to deliver information for free to you. Here, the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of inside reproductive health. 

[00:01:33] Griffin Jones: Capacity, reach, concierge service. Those are three themes that come to mind when condensing what's necessary. To grow your third party IVF program. And can you grow your third party IVF program, not just without straining your capacity in the clinic and the lab, but adding to your capacity in the clinic and the lab, I explore how fertility practices are leveraging these systems to grow their third party programs, particularly.

They're donor egg IVF programs. And I do so with Betsy John. Betsy is the business development manager of MyEggBank. She's worked there almost 12 years. And I think she's someone you'd like to know. I think she's someone that in some years time, you're going to enjoy saying. Oh, I knew her from that podcast episode.

I connected with her after she came out on that podcast episode. Here's what we talk about. We talk about what concierge service looks like when serving your patients. We talk about quality controls. We talk about the burden that third party nurses have, third party coordinators, third party directors have, and what you might be able to do to alleviate that burden.

We talk about my bank's massive capacity, nearly 200 egg donors in any given time. Not an application phase ready to go. We talk about the scope and diversity, the fertility practices need from their egg donor population in order to be able to grow their programs. We talk about how being able to offer both fresh and frozen donor cycles is necessary and how MyEggBank helps with each.

We talk about embryo banking. Being able to purchase all the eggs from a donor. And we talk about MyEggBank helping with embryo creation, which I found very interesting, because if you're growing your third party IVF program, you're taking away capacity from your lab. But if you have someone else that you trust doing the embryo creation, you are getting capacity back.

We talk about things that fertility practices want to stay away from when they're working with a new egg bank, when they feel limited. When they feel concerned about where other banks are recruiting their donors, about not having a commitment of how many donor eggs you need to order from. We talk about having resources that you can use to educate patients, help retain them, help convert them to third party IVF if donor egg is indeed a need of theirs.

MyEggBank has a starter kit that they use for all of their affiliate centers. We'll have a link to that. I would get it. It's free. It's useful for your patients. And we talk about the trends that Betsy sees on the horizon for donor egg IVF, including artificial intelligence for facial recognition and some other applications.

Enjoy this conversation about advancing your third party IVF program with Betsy John from MyEggBank. Ms. John, Betsy, welcome to the Inside Reproductive Health podcast. Thank you for joining me. 

[00:04:15] Betsy John: Thank you, Griffin. It's a pleasure to be here. 

[00:04:17] Griffin Jones: You're a person that when we were talking about having you as a guest, I was like, I want the fertility field to know who Betsy John is.

I've gotten to know you a little bit. I think five or six years ago, just via email. And then you meet it is, then, you keep in touch from making content and on LinkedIn and stuff. And then, you get to meet at a conference and I'm like, this is somebody who I think is. I want people to know who you are and to pay attention.

I think you're a rising star in this field and I've enjoyed getting to know you and I want to crawl into your brain today to really understand what's important to intended parents, what's important to donors. And then, and through that lens, What's so important in the relationship between an egg bank and the clinic because you've been at this for a little while and my bank has been a growing operation.

So what type of feedback do you get? from affiliate centers that you work with. What are they telling you that their needs are? What are you telling, what are they telling you that they like and don't like? 

[00:05:26] Betsy John: Yes, absolutely. Thanks again for the opportunity. And just to give you a little bit of background about MyEggBank.

So we really are the middleman between the clinics that give us. egg donors, egg donor profiles that we display on our website. And then we have a network of about 250 practices around North America that are purchasing those eggs from us. so our relationship with the two practices is slightly different.

The affiliate network, the clinics that are sending their patients to purchase eggs from us. I guess the key points that they really mentioned that they appreciate about MyEggBank is that we are a smaller team that we're able to offer a more concierge service to the clinical team there at the practice, but also to their patients individually.

we pride ourselves on really having a personal relationship with those patients. To us, there is a great deal of education that goes into the process when the patients are coming to us. They're further along in their IVF journey. They've tried it on their own most often, and at this point come now to realize that they need an egg donor.

And a lot of them honestly don't understand the process. They don't understand egg donation. What does that mean for the donor? What does that mean for me? So to us, having that relationship, having that level of communication with the patients really is. is what we prioritize in that process and they're with us for a shorter amount of time.

So truly when the patients come to us. find the right donor, they match, then they go back to their practices. So that short span of time that they're with us looking for a donor really is critical for us to establish that level of trust with the patients that they feel comfortable to ask questions and that we can help guide them through the steps along the way. 

[00:07:23] Griffin Jones: You mentioned that in that short span, they're looking for concierge service. They're looking for education. What does concierge service look like? What is it that they need special attention for? 

[00:07:35] Betsy John: Probably just in the donor search and just understanding the levels of complexity there that a lot of the intended parents come in with those general ideas of, I want to find someone relatable to me, a donor that.

maybe has my background, either racially, ethnicity, or looks like me, looks similar to me or my partner. And then also in the essays, I think to really feel that connection with the donor, that you get a sense of their personality, you get a sense of how would it be if this person was part of your family.

And then also the genetics piece, I would say that's probably very big in the patient's understanding of what's compatible, what's not, what do I need to look out for? Is there something with the blood type, something with the family medical history that I need to be concerned about? So there's various touch points through the process that I think we're able to really hone in and guide them through, walk them along.

We assign the majority of the clinics with a specific coordinator from MyEggBank. So it's a very fluid relationship. 

[00:08:43] Griffin Jones: How do you do that? Meaning when in these different touch points, because your user interface is such a way that it seems like it would be, it's pretty easy to find the donor that you want, that looks like you and to see the background from you.

But it sounds like they just need a little bit more attention, a little bit more where that concierge service comes in. So what do you do in those touch points? 

[00:09:07] Betsy John: So I think it's a good opportunity for us to explain to the patients what our screening for that donor involves. There's going to be various points through the process that we are educating the donors, go through a rigorous screening, but we're also following.

Our standard of protocol, along with ASRM, ACOG guidelines, we as my ag bank have our own guidelines that the centralized team that's reviewing all the applications that come through is really able to hone in on our gold standard of what's acceptable criteria. So getting the patients to understand that while everyone may want to apply, not everyone's going to make it to the point of.

Being able to donate was the reasons of what that exclusionary criteria might be, that if it's a question of health or their response to the medication, that we're doing everything we can from a medical standpoint to be sure that egg retrieval or that egg donation cycle is going to go seamlessly.

[00:10:08] Griffin Jones: How do you scale that education? Is it, it just an onboarding session with each patient? Do you have learning modules for them? Do you invite them all to an info session to do it once? Tell us about that. 

[00:10:22] Betsy John: Yeah. To be honest, it is more one on one. So I guess more so in the vein of the concierge service that it's not, something that we do.

And it really is more so about to meet those intended parents where they're at in the journey. As I mentioned, some of them are coming to us, all of this is brand new. They feel so confused or overwhelmed by the process. but I think that's where the personal touch really matters. That maybe a module or a video wouldn't be able to afford the same open communication that a conversation with that person might have.

So we really do. With every order that's placed, we're reaching out to those patients with a phone call or an email to start. Just, hey, I see that you've matched with donor 123. Did you have any questions that we can help you with? Let's talk about next steps together and see if there's any just general questions that we can answer.

[00:11:16] Griffin Jones: Tell me more about what the talking about next steps often entails. 

[00:11:20] Betsy John: Yeah. So even for the patients, it is a blurred journey. I feel they go into this, not really understanding the steps. So we really like to highlight, you'll get the access to the website by just signing up on our site, my eggbank.

com. once they create their patient account, they'll be able to see the full donor profiles, but we do leave the responsibility of granting access for patients to place orders on the clinics. Okay. So we want the clinics to say, Yes, Jane Doe is my patient, and she's cleared to move forward to make a donor egg purchase.

So once they've flipped that switch of a button, the patients will have the ability to place an order. They're making a selection of how many eggs they want to purchase and also which program option they want to purchase. So it's a level of a guarantee. Do you just want egg survival? Do you want an embryo blast guarantee?

And they can read through the different offerings that their clinic offers through us on our ordering page. Once that's completed, we have a 5 7 business day window of consent forms, payments that need to be made, and that's also the point that we look for any genetic screening. So if the donor is a positive carrier of a condition, we're going to request additional genetic testing for the sperm source just to ensure that there's compatibility there.

There's no, once that clearance takes place, then we would connect directly with the patient's IVF lab at their local center to coordinate for that egg shipment. 

[00:12:56] Griffin Jones: So it sounds like you're staying with them the whole time, which is useful because when people drop out of treatment. Very often it's just because there's nobody staying in touch with them.

I don't know if her episode will come out before or after yours does, but I just interviewed Allie Domar and she was telling me about one intervention of reaching out to patients where just reaching out to them, asking them, Hey, how's it going? Where are you at right now? had 67 percent less patients drop out than those that didn't.

And so it's about having somebody that can liaise with the patient the entire time. And it's just from a clinic standpoint, it's hard to do that with man hours. If you have a third party coordinator that maybe that's not even her only job. Sometimes, it's just too much. And so you, for patients. Coming to MyEggBank, do they have one case manager the whole time?

Did the, does, is there like a navigator? How does that work? 

[00:13:58] Betsy John: Yeah. So we do assign a coordinator per order. Of course, that person's going to have multiple orders at a time. We do just offer our general coordinator line. Either through phone or through email that if they're not able to reach their primary person, that someone would be available to help answer any and all questions that I would agree with you on your point that we're in this digital age that we're also trying to automate.

so many things, right? And so much of this process, but to us, it's very important that we've never compromised that piece of it, that sure, we could send the next steps via email, but we're also going to make that phone call as well, just to read all the information can be daunting. And that if there's any questions that we can answer along the way, just to make that smoother, that's ideal for us too.

[00:14:46] Griffin Jones: It changes even if your preference is email, like even if your preferences is, I'll read it on my time. And even if you never actually talked to the person, but you get a voicemail from a kind assuring voice that makes the email mean something more. 

[00:15:04] Betsy John: Absolutely. And I always joke, it's not the same as purchasing T-shirts from J. Crew, right? this is a pretty hefty purchase and it's an expensive one at that. So to know that your investment is coming from a trusted source mutation, all of that is so critical for us. 

[00:15:21] Griffin Jones: You were telling us about what happens in the middle of the process with how the intended parent goes through their selection and how does, talk to us about the beginning and the end of that short pathway between them coming from the clinic and then going back to the clinic.

How does the clinic interface with you when a new patient is, you're starting to work with them and then sending them back to the clinic? 

[00:15:47] Betsy John: Yeah, this is also a point that we really try to emphasize to the affiliate centers that we want to take as much of the burden off of their third party nurses to explain all of the options to their patients, that if they just make that referral, hey, here's an egg bank that we're working with one that we're comfortable with, feel free to reach out to them with any questions.

As I mentioned, we do have several program options. available and we can't expect the nurses to remember all of those things. So it is our preference that they would have the patients reach out. They're going to create the accounts. They would reach out to us directly with any questions they have. We touch point with the clinicians just to say, Hey, Your patient has created an account on our site, and now they've placed an order.

So there are several points that we would reach back out to the practice just to let them know the patient's made a selection, they've made this program option choice, and now we're ready to do the egg shipment. So we try to work with the patients all during those steps, but informing the clinicians on an as needed basis throughout the process.

[00:16:57] Griffin Jones: You talked a little bit about the burden that third party nurses have. Tell me more about that. Tell me, what are they struggling with? 

[00:17:05] Betsy John: Yeah, it's interesting in the last couple of years, I would say, we've had a lot of the centers that have newly joined with us just say, we can't manage the load, right?

We're just having more and more patients that are needing egg donation. Of course, we're one of. Several egg banks out there. So they have various options. Not one of us are the same. in instructing patients or guiding them in the process of where to go and what to do, I think it's a lot for those nurses to carry that, level of information they're referring to the best of their ability.

we also, don't want the patients to be running back and. Forth between us and the nurse to ask opinions or thoughts about their donor selection maybe. So as much of that as we can alleviate with the understanding their third party nurses, so they're likely not only dealing with donor egg.

They also have donor sperm, gestational carrier cases. Some of the smaller practices are just managing IVF patients in addition to third parties. So having a full scope of what these nurses are potentially dealing with and hearing it from them directly, it, it is a priority of ours to minimize that stress and how can we intervene and make this easier for you.

[00:18:19] Griffin Jones: Do you still liaise with practices or you're big time now? You got people for that. 

[00:18:25] Betsy John: No, you yourself. That is my primary role actually is the business development side. So I'm on the lookout for centers that need more help in this way. If we can be an option for your patients for egg donor, happy to sign up new clinics all the time.

And then with turnover as well. So if it's a nurse. at a practice that I signed up with two years ago, I'm still going to check in to say, Hey, do you have staff turnover? Do we need to do an onboarding call of our process with anyone? And then also setting up that training for our embryologist as well. So that's still very much my role in the process.

[00:18:59] Griffin Jones: So you're talking to clinics that are newly joining you as well as those that have been with you in the past, but for those that are newly joining you, what few things are they bringing up to you? that generally indicate why they're there having that conversation with you. Like back when we were doing marketing for fertility clinics, it would be a handful of things if it would either be, they had some need, like we're just not seeing as many new patients as we used to be, or we are seeing lots of new patients, but we need help converting more to IVF.

Or they would, maybe you'd say we're doing well in those areas, but we have an office or a couple of docs over here and we need help getting these particular docs up to capacity. That would be on like the proactive, need side. And then I would see a category of people coming from reactive needs. Like they were working with a different marketing agency and, would be usually they're not bringing us ideas.

they can't really report to us on the results that they're achieving, or we are asking for types of content or campaign updates, and they're really slow or unable to do that. So I would have these buckets, proactive needs, reactive needs. Let's start with the proactive, what proactive needs indicate to you why you're having that conversation with them?

[00:20:21] Betsy John: Yeah, I think for some of those clinics. that maybe have an internal existing egg donor program themselves. Internal meaning they're bringing donors in house and selling them to their own patients directly. Oftentimes in those cases they just don't have the diversity is what I'm noticing. That maybe their patient population isn't necessarily matching that of their donor population and they just simply need more options.

That would be one point. Secondly, I would say if a patient wants to do a fresh egg donation cycle, but they only have frozen or vice versa if they offer fresh donation, but they need frozen egg options. So the fact that we're all encompassing of those, I think is very helpful to them as well, that each patient's needs are different, as I mentioned.

If they are looking to do more embryo banking, they want to purchase all of the eggs from a donor. We have all of those different program options available. So I think having that variety is critical, the diversity of egg donor. And we also offer embryo creation programs. So sometimes it's that if the IVF lab doesn't have the bandwidth for these cases and they're preferring that MyEggBank would create embryos for their patients.

Send the embryos back to their clinics for them to just coordinate an embryo transfer cycle is Oftentimes just an easier lift for the lab versus doing the entire fertilization. 

[00:21:48] Griffin Jones: Is that something that has developed more in Recent years because I don't usually think of that when I think of egg banks Is that something that you've seen grow in?

Is it generally been steady since the time you've been there? 

[00:22:03] Betsy John: Yeah, I would say it has grown. So initially I think when we launched the egg bank and started the bank, it was generally egg sales that were going out, but as we launched this program, we were able to offer higher guarantees of embryo creation or embryo creation plus PGTA testing.

again, just. taking more off of their IVF labs were able to offer a higher guarantee because our lab is doing the work. And I feel like around COVID time was where we really saw a pickup in embryo creation. Again, it's probably a staffing concern or IVF labs just being overloaded with the cycles that they have.

And so having this external option, just. Really seem to benefit everyone. 

[00:22:46] Griffin Jones: Yeah, that would seem to me to be the motive that so many labs are, they're just, they're slammed. They don't have enough embryologists. They might have enough embryologists, but they don't have enough hours in the day. And so you have to, that's one way of, let's say you're 5 percent of your cycles or 10 percent of your cycles are donor egg IVF.

That would be one way to alleviate. Your capacity in the IVF lab by having that percentage, I could see some lab directors and then some clinical and medical directors. They're pretty picky folks and they're the best. So how could somebody else be as good? So you must have done something to assuage their concerns that you must have done something.

That says, okay, MyEggBank can rock with us. What is that? 

[00:23:35] Betsy John: So I have to say, I think it really goes back to a lot of our standardization. So in our training of the embryologist, as I mentioned, we do have these different donation sites that are giving us egg donors and those. 15 different locations are all thawing and vitrifying on the same protocols, where I do think that training is critical.

So we've really gotten to the point now that we're troubleshooting in real time often and able to really guarantee that level of success. And we stand behind our guarantees. So we're really confident in the work that we do. And if we're unable to meet that guarantee, we offer the patients a replacement cycle at no cost to them.

So we feel strongly enough in the products that we're offering. I think the practices that were willing to experience that got to see that and have built that trust over time. And more than that, our platform is also customizable. So for those labs that are rock stars and they want to do it all, they just want to do egg sales.

We can customize which guarantee options their patients can see. So when they're in our ordering portal, they All of the affiliate centers can have whichever guarantees they want to be in our program offering menu. That really helps out as well in those cases. 

[00:24:53] Griffin Jones: One of the other reasons that you mentioned is the scope of embryo banking and the scope of buying all eggs from a donor.

So does that mean that sometimes people are only able to buy certain batches of eggs from a donor and not all of that donor's eggs is, am I, what am I understanding correct? And then two, what's the significance of that? 

[00:25:14] Betsy John: Yeah, absolutely. So generally for our frozen egg purchases, the patients are purchasing them in a lot of six eggs.

So that's as a standard, what our process looks like for couples, a lot of same sex couples that want to do more embryo banking. They know they want a genetic. sibling match want to have more eggs to work with. So we started our fresh program that follows embryo creation. So it's still the same plan that the sperm is being sent to one of our labs.

We're doing the fertilization on the day of the donor's egg retrieval. And when we say all legs, we do define that as capping out at 18 eggs. So any and all embryos that are created out of those 18 eggs will be frozen for those patients for future use of embryo transfers at their clinics. 

[00:26:03] Griffin Jones: So it's for those folks that they know, Hey, we're going to likely want a genetic sibling in the future.

And, it sounds like that's a, an advantage that you all have to be able to offer that. What about on the fresh and. frozen side, like why is this, why is having both still important? And this is just my ignorance of embryology, because when I'm talking to two clinics, I say, Oh yeah, we're mostly using frozen.

And then others will say, yeah, but we have to have fresh donors too. And so why are both? still important? Why? Why are they both still important to clinics? 

[00:26:37] Betsy John: Yeah, it's an interesting question. And we talk about it often that in the IVF culture, we've just seen the pendulum swing both ways that when we first launched the egg bank, everyone was all about frozen eggs.

It helped make the process. wise, move much faster for the patients. So when they match the eggs are already frozen and ready to go. So it made the process quicker for those intended parents. They're purchasing the egg number that they want to use, or that's recommended by their practice. We ship the eggs out.

Generally, those orders are completed within two to three weeks. If. Genetics are all compatible, so it allows them to start their next cycle much sooner. And then on the fresh side, we just noticed that patients that might have had Not as good of quality sperm or as good of count of sperm that they tended to inseminate better We've noticed when it were they're doing a fresh insemination on the day of egg retrieval So we wanted to have options for patients in all capacities Wherever they're at in the journey, whatever their medical concerns may be and whatever their future goals are.

Are you just wanting one, maybe two children out of this? Are you trying to grow a larger family with potentially three to four? So just to be more all encompassing that we're meeting the patients where they're at, we're guiding them through this journey, and we just have all the options available to you.

[00:28:03] Griffin Jones: Frozen, asynchronous, patients can do it on their time, and clinics can do it on their time, and you can be a lot more adaptive with the schedule. Fresh seems a lot more logistically difficult, though there might be some reasons for it, like you mentioned, some malfactor reasons and perhaps others. How does FRESH work with you all being in different locations in all of your affiliate centers?

[00:28:26] Betsy John: Yeah, so it's interesting in that FRESH through donor agencies is very different in that the donors coming to you, to your local clinic, as I mentioned, our FRESH program follows our embryo creation models. So we're going to work with the intended parents to have the frozen sperm sent to our lab in time for the donor's egg retrieval.

We are going to thaw the sperm, inseminate. Fertilize culture, the embryos out to day five or day six, freeze them and ship them back to the practices to do a frozen embryo transfer at the time decided by their clinical team. 

[00:29:03] Griffin Jones: Good that everywhere flies direct to Atlanta, right? That's right. Couldn't do that in Buffalo.

I don't think it would be a little bit harder. And so then the first. Proactive reason you said when that clinics are talking to you about and the reason why they're having a conversation to perhaps become an affiliate center with you all is that they need more donors and They need a greater diversity of donors So is are those two issues separate or is there if for example?

If you only had one type of demographic of donor, would it still be important to have? A much greater quantity of those donors than not, I

[00:29:46] Betsy John: think so because it isn't necessarily going to be one item that the parents are looking for. I think when you look at our metrics and the analytics that we've compiled, it's generally not just one thing.

They may have started out. For the race, right? I want to find someone that's a similar race to me. But then I do feel the emotional piece, the personal piece, they want to feel relatable with the donor, that education may matter for some height, their interests, what their skills are. So things like that really do play a factor that I feel like people in general just want options, right?

They don't want to just be you. Here's choice A or B, they want to have the full gamut if possible. And we have had patients mentioned that some other banks don't have as much of a variety. And we just wanted to see what all do you have? How are you offering this and what, how, what makes you different? So to us, it really is important to be strategically placed around the country of where we're pulling donors from just to really cover all of those bases and try to hit those different demographics, those different metrics.

To really create the most diverse pool as possible. 

[00:30:57] Griffin Jones: A country of 330 million people, they're not always a perfect cross section in just one place. In one city you might have far more of this ethnicity, in another city you might have very different. Patient population and so you'd want to be pulling from multiple areas in order to be able to do that And so you've got production centers in different parts of the country and you also have donors coming from everywhere Talk to us about the scope like how many donors are we talking?

[00:31:30] Betsy John: Yeah, I think What I heard the other day was on average, we have about 175 to 200 donors on our website at any given time. 

[00:31:40] Griffin Jones: So that's probably several hundred over the course of the year that you're going through of different donors. Are there some, are there particular ethnicities or groups that you find that you tend to have more of that people are looking for?

[00:31:56] Betsy John: I do find lately, I think just, Again, with where we're strategically placed that something we've always struggled to have a healthy number of Asian donors, but it really has picked up in the last couple of years. And I don't know if that's efforts of marketing or education and just putting it out there.

It's probably become less of a taboo topic to do egg donation. I think it's more readily spoken about. Celebrities are talking about it. It's in the news. More often, people feel more comfortable and familiar with the idea. So we're, seeing an uptick there, which is nice. I think for a lot of those patients that have been struggling or looking for years are now really able to, meet those needs and find those patients.

So it's great.

[00:32:43] Griffin Jones: Is that as true for East Asian donors and Southeast Asian donors and South Asian donors? Or do you find that we have more of. These particular donors that are really hard to find or are all three of those subgroups Typically harder for people to find donors for 

[00:33:02] Betsy John: Yeah I would say all three of those subgroups are typically harder to find but I do think there's an increase So that being said, over the years, it's interesting how we notice that it's trending, that for whatever reason, it's just becoming more known, more acceptable.

I think maybe things that would have been a taboo topic to discuss in your families or with your friend groups, that maybe is now just becoming more acceptable. So we are seeing an increase in those populations. 

[00:33:32] Griffin Jones: And people are coming to you, practices are coming to you, because you've got 175, 200 of them at any given point of, different ethnicities, but you have, because of that, you're reaching, more of these.

Normally harder to find egg donors and sometimes they just need that. That's what brings you to them. So we went over these, what I would call like proactive reasons where the potential affiliate center is not unhappy with something, but they have got a need. We need more donors. We need greater diversity.

We need the opportunity to be able to do fresh and frozen. We need the opportunity to do embryo banking and to buy all the eggs from a donor. We need the opportunity to do embryo creation. And hopefully alleviate some capacity from our lab. But then there's also, there's the reactive side. So I mentioned like in marketing, people would say we weren't getting the reports that we needed to show the ROI or they couldn't show us the return on investment.

They were not responsive when we needed a campaign or content updates, or they weren't bringing us ideas. So when people aren't happy with an existing arrangement, what is it that they're typically not happy with? And people being. Fertility practices, several things. 

[00:34:45] Betsy John: So I, I do feel that we've heard from affiliate centers that other relationships they have had might have been more limiting that when they're signing contracts with other egg banks or gamete banks that they're only able to use that one bank, and that's something that we've never had an exclusivity.

We've always been, we just want to be one of the options. So I think that's very inviting to some of those practices that by signing to join our network, we're not saying you can only use us. We just want to be a choice. That was significant. And I think a lot of people really do appreciate that factor.

And also we noticed that a lot of practices within the last couple of years that may have had a robust internal donor. program around the time of COVID when they weren't having as many cycles. Oftentimes third party is the first program to pull back funds from, right? If you're investing a lot in marketing for donors, but if you're not able to manage that pull through of bringing them to the door, to the point of egg retrieval, some of the centers just don't want to invest as much in the donor population.

And their thought is if these egg banks are out there and they're doing it successfully, then maybe there's no need for us. to do that. I've noticed a trend of that as well. Just some of the centers not wanting to do that lift of finding the donors for their patients and just trusting us to be their donor resource.

[00:36:10] Griffin Jones: Are there any other common complaints that you think about? We don't like this about. A, and I'm not asking you to name a, but, or B or C there, imagine there might be some things where we, don't like this. What can you think a couple of things that they don't like about existing arrangements? 

[00:36:29] Betsy John: Yeah, there are several things.

I think some of the. Other options there will work with international programs. And, there's been a lot of buzz about that in the market that people don't feel as comfortable or confident using donors that are recruited in this fashion. And then also again, if, they're limited contractually with.

What they can do, how much they can do, or that they have a relationship where you have to bring us donors if you want to purchase donors from us, it's just an interesting dynamic of what that contract looks like, that it's putting more work on the practices, that maybe they just don't have the time or the staffing to invest in that, those are some of the points, I think cost is a factor, that if some of the programs are just highly important.

overpriced or for whatever their needs are, but if that's not what fits their patient population. And we offer a compassionate egg program where it's, donors that are proven with good success rates. They may not be as marketable with as many photos or not able to do any additional genetic testing, but we know the quality is there.

We're able to offer those at a discounted rate for patients who may be going through financial hardships. So in that capacity, I think, as I mentioned, we really do try to meet all of the patients in this, that they've complained about it on the flip side, that it's just more cost effective to be with us.

[00:37:57] Griffin Jones: Is that the case that some banks require that the clinic sends them donors in order to be able to buy donor eggs from them? 

[00:38:06] Betsy John: I've heard that such a relationship exists. Yes. 

[00:38:09] Griffin Jones: That's not the case for you all? That is not the case for us. Is there like a minimum that they, you know, we, that they sign up for, and we have to get, we have to use 20 donors from MyAgBank in the course of the year, is there anything like that?

[00:38:23] Betsy John: No, there's no requirement. We do probably have goals in place that we're trying to help some of these newer programs that don't have a donor program. Let's traject for 15 to 20 donors a year if possible, and we're going to help them along the way to really hone in on that criteria. What are we looking for?

What makes the donor marketable, saleable and to know that we're going to get quality eggs from that donation. So a lot of that is coaching in the beginning that we're helping them get to that number. None of it is a hard Pressed requirement, but again, a goal that we're trying to meet. 

[00:38:59] Griffin Jones: How does a new affiliate center start with you?

I'm guessing they're talking to you and it's starting with the conversations that you've been illustrating throughout this conversation. And then how does the process work? How do they go from, okay, we reached out to Betsy. We had a conversation with Betsy. Then what happens? 

[00:39:18] Betsy John: Yeah, so we do. It happens several ways.

So sometimes the clinics do reach out to us directly, but on occasion, It's the clinic's patient has found us and they go back to their doctor and say, Hey, I found a donor on MyEggBank’s website. I really want to move forward with them, but I noticed you're not in their network. Would you be willing to sign?

So that's a point that I would reach out to that. Physician, practice administrator, whoever it may be, I like to do an onboarding call to start just to walk through a screen share what our platform looks like, what is our relationship with you look like, expectations from the practice and also from our team.

and then once we send over those contracts, again, non exclusive, so it's still just establishing a business relationship between my ag bank and that practice. So once those are signed, we get a contact list of who our primary contact people will be. Then I set up an onboarding call with those people.

So we'll do a clinical onboarding call with whatever your third party team looks like. Same thing, we walk through the process, I answer any of their questions. questions. We talk about genetics a bit. What panel are you testing your patients on? This is what we use for our egg donor. And then we also scheduled to do that onboarding with the embryology team.

So that's also critical. We do that as early on in the process as we can, that our embryologists will reach out to their embryology team to do a virtual training. So it used to be in person, but now we do it virtually. It's about an hour to an hour and a half. where they just walk through our entire process.

We're going to reach out to you to coordinate egg shipment. These are our protocols for egg vitrification and thawing, medication protocols. This is how to enter outcome data into our portal. And they cover all of that during that training call. 

[00:41:10] Griffin Jones: I wouldn't be surprised if there's something in that training that is valuable, even Apart from the eggs that they get from you all.

I imagine that there's something in there that they walk away from that. And they're like, Oh, that's more efficient than what we're doing right now. I would hope you ever get that kind of feedback. 

[00:41:30] Betsy John: I do think in general, people feel we are a well oiled machine. We pride ourselves in being the first frozen donor egg bank in North America.

We've been at this for some time at this point, and I do feel like we've. things come up every once most part, we feel pretty process, understanding wh a larger university pract single practitioner in th country. So we know what for the most part ironed out those kinks and have figured out how to work with them 

successfully.

[00:42:04] Griffin Jones: What do you view as a couple of like different kinks that you see maybe that a smaller practice has that a larger practice doesn't have or vice versa? What are like a couple of the kinks that you're like, I would not have known that if I hadn't been working in this field for X number of years. But I do know that if I see a practice of this size or in this area or whatever, I've got to be on the lookout for X.

Can you think of any of those things off the top of your head? 

[00:42:29] Betsy John: Yeah. First thing that comes to mind was batching cycles. I had never really heard of this working with RBA previously. They hadn't done that. So in learning about that and how an embryologist comes in just for the times that there's cycles to complete.

That was something new to me that I hadn't heard of before. But even understanding that in educating our patients now, it's like we're shipping these eggs to you, but better check with your center to see when they're actually going to schedule to do your cycle. That piece was critical to learn and then also to understand from the bandwidth perspective that we spoke about earlier for those centers who were willing to offload the embryology piece to our team when they couldn't do the embryo creation cycle.

So That was interesting as well. And then probably the diversity in patients even just from what they're looking for, what their limitations may be in their personal cycles and journeys that we've really picked up along the way. 

[00:43:26] Griffin Jones: So you've been doing this, how many years? It's between RBA and between my bank.

[00:43:31] Betsy John: So June will be 12 years for me, 

[00:43:34] Griffin Jones: 12 years, which in millennial years is a thousand careers. You've been at this for a while and I got to believe that 2012 Betsy is not as good as 2024 Betsy. And there's a couple of things that you've implemented along the way that based on. working with so many different clinics, either process improvements or insights into the marketplace that you have taken some market feedback over those 12 years and you wouldn't have grown to the size that you have if, that wasn't the case.

You think of a couple of those things like over these 12 years, here's where, here was some of the lessons that we learned and here's what we did to respond to what the practices were asking us for. 

[00:44:19] Betsy John: We talk about our reach a lot, that we have these 250 practices in the network, but now being in the mindset of the post Roe v.

Wade era, that to be familiar with regulations as they apply state by state and staying on top of that, so that was something significant within our network in the last year to really push for that. State by state analysis, to be honest. So how is this impacting third party? How is this impacting egg donation specifically?

There's rules changing in Colorado and New York that we're trying to get ahead of that and really stay abreast of what's changing in that landscape and to be sure that Our consents are reflecting what's required that our patient education piece that we're counseling patients appropriately in the world of 23andMe, Ancestry.

com, just really educating patients that while we coined the term anonymous egg donation in the past, now we truly just say identity protected, that we in the best of our ability will protect you, your name, your identity, but what happens out there with all of these testing options. There's getting patients to under donation versus known.

It that landscape has some c So we're proactively talk groups about that. How ca but still compliant. So t That's really the significant things I think in the last couple of years that we've really tried to hone in on 

[00:45:55] Griffin Jones: You all have some resources for clinics to which I think is useful because there is a drop off point very often after a failed cycle or after maybe somebody's finding out that they need donor egg for the first time and they are thinking we're going to go in Using IVF with our own eggs.

And then somewhere between the first visit and the followup, they find that's not the case, or maybe they've done a cycle or two, there's a lot of drop off that happens there. And I think good resources are. are necessary to help people to help retain patients, keep them in the journey so that they can convert to third party IVF if it is something that they need.

And you all have some resources, like you have a kit. And I think we're going to be sharing that and the link to this episode. And I think we might share it some other places, but it's something that people can give to their patients that helps to educate patients. And I think it's probably a useful resource, no matter what egg bank that they're using.

Can you tell us a bit about that? 

[00:46:58] Betsy John: Yeah. So it, it's a starter kit that we implemented this year for affiliate centers that are joining us just with some materials in there. Talks about our different program options that I mentioned here. It gives them a sign up for our website that they can display on the nurse's desk, if that's where they're doing their console, just a quick scan of a QR code to get into our site.

and just more of these resources talking about genetics, some of those pieces that I mentioned from the education standpoint of educating the intended parents on various points of the journey are all included in the kit. 

[00:47:35] Griffin Jones: I've also. Got to believe that it's just useful to offer people that option to sign up for MyEggBank to get in for patients to get into your portal because then you have two different entities that can keep in touch with the patient.

We already talked about that. the clinic just very often times does they. don't have the manpower to follow up with patients in most cases, the ones that do, it really works for them. But so many people are treading water to begin with that they just can't provide that. And just by virtue of saying, okay, while you're thinking about everything, take a look at these guys, get involved, look at their donors.

And that way they're also in touch with you all. And, there's less likely for. The ball to be dropped because they're not, it's not just one party they're communicating with. They also have you as a resource too. That's right. Absolutely. Those little pieces for conversion. There's so much in conversion and dropout and retention that we can impact and some of it scalable and some of it less, but it all has to do with staying in touch with.

They, with the patient and continuing to educate them no matter where they are in their decision so that at least it doesn't drop off like it does in many cases. Do you yourself, do you hire people? 

[00:48:57] Betsy John: I do not myself. No, I'll help with the interview process, but I don't do the hiring. 

[00:49:02] Griffin Jones: Do you train some of the folks that, that work with practices now?

[00:49:06] Betsy John: Yes. So even for some of the onboarding, if it's something that I can't manage, then instructing team members on how to do that.

[00:49:13] Griffin Jones: So I got to believe that having been from having worked. For my going for 12 years that you're, you've built some relationships with centers and you're probably a little bit protective of those relationships and you want to make sure that whoever that's being passed on to is doing a good job.

I'm doing the same thing right now that we're really building out the team that works with our advertisers and we're building different structures of folks. Okay, I want. Account director that does this. I want account manager that does this and I want to traffic project manager over here that does this.

This person leads, they're responsible for A and B. This person's responsible for liaising. And this person's responsible for making sure all the deliverables are finalized. And we're building out all of our training and they require different types of training, but it's for years people have come to me and I want.

To make sure that they're getting the best attention from my team when you are working on this training What's really important for you to get across to new people on your team that when they're dealing with practices? They got to be good at this. They got to know this 

[00:50:27] Betsy John: Yeah, right away. The first thing that jumps out at me would be the compassion piece Because as we mentioned, most of these intended parents are coming to us closer to the end of their journey through IVF.

They're probably at the height of frustration and just feeling discouraged. So to us, In that concierge service is not just about, I'll be here all the time, but just really having the empathy to put ourselves in their shoes. Let me understand your journey, your financial burden up to this point, the emotional headache and whatever is going on with you, that we're going to take that minute.

extra minute to be relatable. Let me listen a little bit to your journey. Talk to you about my own journey for that matter and find that connection there. How can I help you? Let me make this be that it's a friend guiding you through, not just that I'm here to provide a service. So really getting patients to understand that.

And so personally, I feel having that, that compassionate. Mindset is critical in the roles of this of the egg 

[00:51:30] Griffin Jones: bank. You've got your finger on the pulse a little bit What trends do you see? Coming more of in the next couple of years, whether it's more or less of something or something new altogether, do you think we'll see more or less fresh donors?

Do you think we'll see, do you think we'll see more donors in general as Gen Z rises? And then as, and as Gen Z ages out, whatever generation is after them, do you think we'll see more or less and it will be harder to get donors? Do you think, is there some other trend that I can't even think of, like having AI case managers?

What trends do you think are coming? 

[00:52:06] Betsy John: I do think AI is going to be significant just from what we've seen Internationally people that have reached out to us and things that they're attempting to take off the ground. So I feel like that's going to be critical just even in maybe the matching piece of facial recognition things like that You truly want to find a donor that looks like you I feel like the technology is going to be there, if not already there of we can find exactly what you're looking for.

So that, additionally with the genetics piece, we know the panels have been growing year after year. They're probably going to end up doing a full genome sequence and having all the more scientific developments will be interesting. And then as far as fresh and frozen, I feel like it's, it's. probably still going to be both of them running closely side by side.

I feel like the need is still great for both options. So I don't see, I don't see one running ahead of the other necessarily. It'll be interesting to watch. But again, I think it's very positive that just as a culture, as a society, we're talking about IVF much more. We're talking about infertility. So for people to feel comfortable in that space to.

feel candid that they can discuss such things, proactively look into it. I always say that when I was in college, I never even heard about egg donation, but I really feel like that education piece is changing and we're heading in a positive direction of the needs are more. visibly out there and spoken about.

So I hope this is a program that's growing in that vein. 

[00:53:42] Griffin Jones: I think people should do two different things. I think that they should go to the MyEggBank link and that they should get the kit. And cause it's an easy way to start a conversation with you. It's also a free resource for their patients. I also think that people should go on LinkedIn, find Betsy John, connect with Betsy John.

And I think that most people don't watch the video for this, but we put it out there, but the most, the majority of people either listen or doctors are such voracious readers that they will read the transcript and, but I think they should go to LinkedIn so they could see who you look like so they can say hello to you and they can say.

30 years from now, 20 years from now, when you're one of the straight up OGs in this field that I knew her from way back when I think they should do that, but, and I'm not saying that just to, I'm not saying that for flattery one, I'm saying it because MyEggBank has grown as a company with you and in, and also in a part.

from that. It's what they've built. But to 12 years, one company, actually, it does mean something. And that was common in our grandparents era. It's not common today. And what it allows for is for someone to establish themselves as a seasoned expert, not what so many people in our generation have done, which is go do this for.

Two years, and that'll jump to a completely different vertical for three years. Not just a different sub vertical of this industry, completely different industry, doing a completely different job. And, I think so many people in our generation have been robbed from expertise by virtue of your tenure, by virtue of what MyEggBank has built.

I'm going to let you conclude though, Betsy, how would you, of all of the, topics that we've talked about of what clinics are looking for, what patients are looking for, where a egg donation is going, how do you want to wrap up? 

[00:55:36] Betsy John: Yeah, thanks, Griffin. Again, I sincerely appreciate the opportunity and just being able to speak on here about these topics and first and foremost, I do want to credit my team along with myself.

It's Deb Messarat is our director of clinical operations, one of the founders of the Egg Bank and truly with her guidance, I feel like we've made leaps and bounds progress, but I do feel that We're all in this together. So we're navigating these areas together as a team and also for the, for our network, for some of those legacy centers that have been with us from the beginning.

We respect you. We appreciate you. We're so grateful for you and for the new ones coming on. I know there are practices out there that maybe we haven't connected yet, would love an opportunity to do Feel free to click the link at the end of the podcast. If there's an opportunity for us to connect, I look forward to that.

[00:56:30] Griffin Jones: Betsy John from MyEggBank. Thank you very much for joining me on the Inside Reproductive Health podcast. 

[00:56:35] Betsy John: Thank you, Griffin. It was a pleasure. 

[00:56:37] Sponsor: This episode was made possible by our feature sponsor, MyEggBank, the premier network of donor egg banks. Discover the benefits of partnering with MyEggBank by visiting myeggbank.com/irh and receive our complimentary starter kit of resources. This exclusive offer provides a glimpse into how we can enhance your clinic's fertility services and streamline the partnership process. Join us in making a meaningful impact on the lives of aspiring parents. That's myeggbank.com/irh.

Announcer: Today's episode is paid content from our feature sponsor who helps Inside Reproductive Health to deliver information for free to you. Here the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of Inside Reproductive Health.

213 Projecting IVF Personnel Needs. Recruitment, Retention, and Training with Dr. Eric Widra

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.


The job market is red hot! There are more jobs open than people to fill them, true for the broader economy and just as true for the fertility field.

Dr. Eric Widra, Senior Partner at Shady Grove, talks through his experience with recruiting and training personnel, and how to project future needs.

Dr. Widra discusses:

  • The need for Human Resources (And the risks they mitigate or eliminate)

  • When to listen to what HR says you need (But also when to push back)

  • Redundancy and cross training personnel (The appropriate levels to have)

  • Adopting technology to automate and augment tasks (While eliminating others)

  • Individual job training (And when company culture training becomes important)

  • The “Godsend” technology solution that’s made the workload and workflow of his financial counselors a lot more efficient.


Dr. Eric Widra
Shady Grove Fertility
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US Fertility
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Transcript

[00:00:00] Dr. Eric Widra: We've often asked the question, should this be, should we outsource this or should we own it? And, outsourcing can be very effective, especially for medium and smaller practices because you just pay for what you need. And so you're not bringing on, long term overhead in terms of the staff and you're still getting, the, expertise that you need.

[00:00:24] Sponsor: This episode was brought to you by BUNDL Fertility. Fertility Clinics, ready to boost your online reviews? Our survey of over 2,500 online patient reviews showed that 30 percent of the negative experiences were focused on billing or finance frustrations. Improve patient satisfaction and billing experiences by using BUNDL with Medications™ services.

See the rest of our survey results by visiting bundlfertility.com/irh and downloading our exclusive report. 

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.

[00:01:19] Griffin Jones: Hot. The job market is still red hot. There are more jobs open than there are people to fill them. True for the broader economy, you know it at a cellular level if you operate a fertility center. My guest is Dr. Eric Widra. Eric is a senior partner at Shady Grove. I should have asked him for the latest headcount in both doctors and employees for both Shady Grove and US Fertility. Shoulda, coulda, woulda. Suffice it to say, they've hired a lot of people. We talk about how to train, recruit personnel, and project future personnel needs. That means adopting technology to eliminate certain tasks, automate others, and augment others. And it also means good old fashioned HR. I take us a little bit more down the second bucket in this conversation.

Partly because Dr. Widra said something to the effect of, I never knew how badly I needed HR until I had it. That resonated with my own experience. Eric talks about the gaps in recruitment that HR eliminates. He talks about the risks that they eliminate or at least mitigate. It gives general benchmarks for shady growth, staffing ratios, nurse to physician, average IVF cycles, numbers for each.

We talk about redundancy and cross training. What's the appropriate level to have? When do you listen to what HR tells you need? When might you have to push back? We talk about individual job training versus at what organization size do you need a company? culture training. Think of the Disney example.

We talk about the downward pressure for reimbursement in healthcare, what that means for projecting the needs of advanced practice providers. Dr. Widra believes they should be the first line of evaluation for fertility patients, and he explains why. And finally, he shares a technological solution that is almost a godsend that has made the workload and workflow of the financial counselors a lot more efficient.

Enjoy this conversation about training, recruiting, and projecting personnel needs with Dr. Eric Widra. Dr. Widra, Eric, welcome to the Inside Reproductive Health podcast. 

[00:03:10] Dr. Eric Widra: Thanks. It's a pleasure to be here, Griffin.

[00:03:12] Griffin Jones: I was interested in having you on as a speaker because I saw two of your talks at PCRS. One was about negotiating a contract, and I had originally thought about approaching you for that topic for this episode.

But you also did one about projecting staff levels, about meetings, staff, and filling positions. And I Want to go that route first because I think people are still struggling with it. It seemed like this came on as it's always been a challenge, right? But, then, but, then 2020, end of 2020, it really became a challenge.

2021 was really hard for people. 2022 was really hard for people. You sit at Shady Grove, which is a large organization across multiple. Dates was, which is a part of a larger organization in us. Fertility is in even more states and even more companies in your estimation is, the, challenge in retaining and filling seats as hard as it was in the peak of 2022, is it starting to calm down a bit or not?

[00:04:23] Dr. Eric Widra: It depends on what category you're talking about. and I, the fact that we are, large and diverse organization in my mind doesn't limit the challenges, to just those types of places. I think everywhere, everyone I talk to is still struggling quite a bit with attracting, retaining talent in the right seats.

One of the things that I think we've seen ease a bit. post pandemic, if we're allowed to call it post pandemic yet, is that a little less transition and turnover. And some of the clinical staff, specifically nurses and medical assistants, things like that is still a challenge. There's a huge fight to get nurses because of what hospitals are, paying them.

But people seem a little bit more willing to Come to work and sit in their chair and not be looking at the next thing as much as they were. On the, physician and embryology side. Yeah, this market is hot. And I think that there are, there are real challenges for us to not just address this on the staffing side, but address it on the technology side.

Like what can we do to be more efficient and. Utilize the staff that we have without killing them. 

[00:05:41] Griffin Jones: So I want to talk about the technology solutions because that's where I've found the conversations going. Each time we talk about the personnel issue, because it seems like it's the only way to solve the personnel issue that you have to reduce workload.

You have to make things more efficient, that different people can do more things because more. They have the assistance of technology or you're eliminating workflow because it can be automated. It is technology. The only solution is there an HR or management solution to this? And if so, how much is at play versus how much of this is, we just have to figure out a way to eliminate more things and give people more automated help.

[00:06:35] Dr. Eric Widra: Well, I think it's both. And, for anyone who's listening here, who isn't part of a gazillion doctor practice, I make the comment all the time. I didn't know I needed an HR department until I had one. And while, practices of varying sizes may not have that in house, there is a whole group.

Body of work and body of knowledge around HR. That's developed over the years that helps to identify and measure the needs you have and how you fill those needs. And, as an intro to the answer to your question, I think that, yeah, I think there are management. Tools that can be used to rationalize, the people you need and retain them and attract them.

But I think healthcare in general, and because so much of infertility is still in smaller practices, I think we underutilize technology more than many other areas of commerce. the, I've signed up for product services and healthcare online where I've interacted with a bot and my needs were met.

In terms of, scheduling something or onboarding a, a patient to the practice. And in some ways it was more organized. Like we didn't go down tangents. It's Hey, do you need this or do you need that? Are you this or are you that? I just use that as a, as an example. And

I think if you look at every level of the experience of a patient coming through a fertility center and our Struggling to meet their needs. There are opportunities for technology, but it's not the only answer. bringing a patient in, that's one example. Sharing medical records and filling out the forms and the paperwork.

I think that's still a disaster in healthcare in the U. S. and I think it's right for people to come up with solutions to that. And people are working on this. It's just, how does it filter in, how do you use technology for education? I think that's a huge piece of this because so much education falls on the nursing teams and they've got to do their workflow, right?

Which is make sure the doctor reviews the results, make sure you communicate those results to the patients and that it's done with high fidelity and that they follow and they get scheduled. there's all these workflow steps that the more we can automate, the better we are. And I think it's coming, but it comes in.

And first it's a very long answer to your question 

[00:09:12] Griffin Jones: i want to go into some of these technological births that might be useful you said something that i don't think is a throwaway statement i agreed with it wholeheartedly from my own experience that you didn't know how important it was to have an hr team until you had one tell us more about that what do you mean specifically by that.

[00:09:37] Dr. Eric Widra: presumably we're all growing a little bit, whether that's, very rapidly or slowly and that growth comes with real challenges in, your people and your human resources and the ability of a doctor or two doctors or five doctors and a office manager or supervisor to manage that over time leaves a lot of gaps.

It leaves gaps in. Evaluating the credentials of the people who are applying because you're just you're saying, Hey, this is what I think I need, and you might be right. You might be wrong. Doctors are notorious for having an opinion about everything, whether it's correct or not. And in many cases, it's I think I need this.

in health care, there are measurements that people take about What types of credentials perform in what environment the best and that an infertility medicine is not Immune to that we can figure this stuff out the other thing that HR does is it is it takes away risk and we live in an environment where In good ways and in bad ways, we're very sensitized to how we talk to each other and having an intermediary there when that conversation might not be perceived on either end is appropriate, is huge.

And so I think that there are layers. I think layer 1 is the HR professionals can help you identify. By having a broader view who you need for what role they can help you recruit that more effectively, and then they can minimize. Risk and conflict later by making sure the rules are clear, right? So I don't care how many staff you have, if they think they're supposed to be doing X, you think they're supposed to be doing Y.

Somebody's got to reconcile that and having a good set of rules up front and job descriptions and things like that sound. Very pedestrian, but they make a big difference. 

[00:11:43] Griffin Jones: Some of the people listening will work for organizations much larger than yours. Some will work for teams even smaller than mine, but many of the people listening are somewhere in between.

And so for. Many of them, they might be listening and say, that's easy for you to say, Woodrow. You work for the largest fertility clinic group in the country and now one of the, largest networks. and so there you have this HR infrastructure. I would have thought that way. I, a little more than a year ago until I realized, wait a minute, we live in a.

part time remote world and I can hire a part time remote HR person and then I can hire more part time HR people and it has, it's been dramatically life changing for me and someday I'm going to write a book about delegating to outcome and the importance that redundancy and the HR support. play in that.

But people might look at me and say, that's easy for you to say, Jones, you're not in a physical office. You're, you have a remote company. You don't have the regulatory burden of being a healthcare business. What would you say to someone that, that feels that they might not be able to build the type of HR infrastructure that you and I have?

[00:13:07] Dr. Eric Widra: I think you're exactly on the right track there. And I don't think it just applies to H. R. By the way, I think it applies to many aspects of what we do. And in fact, even as large in an organization as we are over the years, we've often asked the question. Should this be it? Should we? Should we outsource this or should we own it?

And, outsourcing can be very effective, especially for medium and smaller practices because you just pay for what you need. And so you're not bringing on, long term overhead in terms of the staff, and you're still getting, the, expertise that you need. And the reality is we live in such a competitive economy that while there's definitely going to be some, mediocre and even poor, Performers in that over time, you're going to find good people who want to do this and are motivated to do And that was redundant, but anyway, you're going to find good, And I think this is true for marketing. It's true for billing. It's true for credentialing for insurance. And as well, it is, however, a very difficult landscape to navigate because everybody's going to tell you. they're best at this and that's where I'm contradicting myself a little bit, but that's the rub, right?

All this stuff is out there, figuring out who's really good at it and who's going to help you. It can be a challenge, but it can be done. And we've done it through our growth in all those areas at different times. 

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[00:15:31] Griffin Jones: one way that I snipped through some of the people saying that they were the best is one of the things that I do now for every single seed is I really think about what that seed is to be responsible for, not just a job description, but what are the outcomes that I'm going to measure them against.

You can't quantify every last outcome, but to the extent that you can try to enumerate them, try to quantify them, try to make them as specific as possible for each outcome. I also identify here's what I think that I have for you to achieve the outcome. This software, this system, this process, this team member, et cetera, and here's what I don't have for you.

To achieve this outcome that you might need. I don't have this software. I don't have this process yet. I don't yet have these team members. And so I, for every single seat, I try to delineate what those are. And then if you do have the opportunity to do some outsourcing, there's, you can. Hire or contract people simultaneously and give them the same or similar assignments and you'll find out who's better at your outcome.

And so that's what I did. I just started with multiple HR folks and then ended up with one that was a good fit that took me to a certain level And then help me get to the next level that I needed for HR help. Is that realistic with fertility clinics when they need some when they have so many bodies in house and they have so many FTEs that are in a physical location?

Is it realistic for them to be able to try out part timers or independent contractors in that way? 

[00:17:15] Dr. Eric Widra: I think there's several things, insights in what you said that are worth touching on. And I feel like we're putting a little bit of a puzzle together here as we talk it through. I think one thing that we do poorly in healthcare is identify what the outcome from that person you want is.

Yeah, embryology is a little bit easier, but come on. The rest of healthcare doesn't have embryos, right? They have, nurses and MAs who need to Do certain tasks. And I think we fail sometimes by pigeonholing them into, skill sets rather than outcomes. And so when I think about onboarding nursing, one of the things I want to understand is, am I hiring somebody?

And I, for anybody who's listening as a patient on this, please forgive the operational nature of this. But, for any nurse that I hire, I want to know how many cycles she can handle, right? Effectively. So yes, she needs the soft skills and the nursing skills to engage with the patients and build those relationships, but she also needs the hard skills.

And if she's not at an appropriate level in terms of that throughput. you've got to make some hard choices. And so I think again, I'm answering the question a little bit differently, but I think both things are true that you should be getting HR that understands that. And I don't know whether it's reasonable to try more than one or not, but I, the, the, but I think that if we're careful about how we invest in this and ask good questions, we're going to make progress.

It doesn't mean you're not going to have errors or wrong fits or things like that. that's life in business. But I think if we're careful about it, just as you said, you're going to, you're going to kick some tires and you're going to figure out what the right fit is. Was that responsive to your question?

[00:19:08] Griffin Jones: Partly. It doesn't totally answer the question. if just by virtue, can you have remote? One of the reasons why I'm able to do this is because I'm an entirely remote company. Have been long before COVID. I've been remote. Since 2012, started building my company in 2015, finally zoom and the voiceover internet protocol videos infrastructure became viable in 2017.

And so we've always been remote. And so that. That I think allows me to play to this advantage where you can start people, you can start many of them as 1099s even when you move them to W2s. And is that, is, are you, is, that not realistic for brick and mortar fertility clinics that have to have bodies in house, even if some of their support staff might be able to be remote?

[00:19:59] Dr. Eric Widra: It depends on the seat, right? yeah, you're not going to draw blood remotely or do ultrasounds remotely, but we have a lot of remote nursing. We have mixed feelings about how effective it is and how to, manage it, but we have tons of remote nursing. I think that a lot of the back office stuff can be remote.

And again, for practices that don't have the size or infrastructure that we have, outsourcing that can be incredibly effective. Your billing, your insurance credentialing, your authorizations. one of the things that I think we're going to need to adapt to is, how do we do those functions?

Because those functions are going to become more important as there's more access to care and more insurance coverage. the rest of healthcare has mostly figured this stuff out and we feel like we have to reinvent it. But, there are software programs out there that automatically do benefits.

They're not perfect, but you don't need three people doing that. You need somebody who manages the software and, we're just starting to wake up to that because we've been in such a unique environment for so long. 

[00:21:05] Griffin Jones: Okay. So it is possible to have the HR support be remote. Oh yeah. That part. 

[00:21:10] Dr. Eric Widra: I, yeah, I think that those types of, I think HR is probably one of the easier ones to be honest because your measurements are easier.

It's I have this many open seats. Are you filling them? And I was, And to your point, are the outcomes from those filled seats what you need them to be? Billing is always nerve wracking because you don't know if you're optimizing it. 

[00:21:31] Griffin Jones: On the outcomes of those seats, you mentioned one example that you want your nurses to be able to do a certain volume of cycles.

Do you put that number in the job description? 

[00:21:46] Dr. Eric Widra: The way we describe it is we have benchmarks for, nursing output in terms of cycles, and we don't necessarily expect a new nurse, especially if she's not coming from fertility, it's almost always she in our specialty, to necessarily meet those benchmarks right away.

So no, we don't put them in the, contract, but it is part of their evaluation. Top of the pyramid nurse. And I actually Griffin don't know the number off the top of my head. So I'm embarrassed to say, but that's because I get to let somebody else do it. this is the benchmark for, a 90th percentile nurse.

This is the benchmark for a 50th percentile nurse. And if you're starting at the 30th percentile, we want to see moving in that direction. 

[00:22:33] Griffin Jones: So that's, I, don't put the numbers in the employment agreement typically, like it's not contingent on, like I'm not that sophisticated yet. Maybe someday there will be some sort of a performance for each of your, I'll do it for you.

Yeah, exactly. Yeah. But for the time being, I do have a separate document. It's not a legally binding document, but it is, useful for expectations that I have. Everyone. Look at and it's a, you're responsible for this many podcast editing, this many podcast episodes per month, you're responsible for this much billing under an account, et cetera.

and then when I can, I do try to put that in the job description and I'll, put. Up to in the, up to a certain amount so that I just want to set the table with anyone that I'm having an interview with that they know this is what I'm expecting of you. I want to set that expectation early and often not have them come in and be like, Oh, this is more than I thought.

And Even when there's a range I'll put the up to. And I find that really useful to start with in the job description while they're still applying. Do you see any reason why fertility centers shouldn't do that? Why they shouldn't put numbers in the job description? Absolutely 

[00:23:50] Dr. Eric Widra: not. And in fact, you just identified a hugely important function of HR, whether that's in house or outsource, which is evaluation and performance.

Reviews, we used to joke all the time that, if, nurse a wasn't performing, she'd go to Dr. X and complain and Dr. X would say, she's great, and you just got to get rid of that. And that's true. Whether you're two doctors or 200. 

[00:24:21] Griffin Jones: And so your talk was about also projecting for needs that I'm, hoping that because you were speaking at PCRS, yours is a little bit more sophisticated than mine is.

What I tend to do is I'll start at a part time level. Usually if it's a new, if it's something new that we're working on or a new area or a less mature part of the business, I'll start just part time and I'll usually Just get somebody at 5 to 15 hours. I'll make my outcomes more sophisticated as, that becomes developed and I'll start normally more junior on the accountability chart than senior and that's how I figure out what I, what, I need and, and.

how much it will cost me. And it's not the most scientific, but it does give me a bit of a measurement. how do you project staff levels? How do you know when it's time to hire a new person versus this doc just says he needs a new nurse when is it, this doc is doing more with less nurses.

[00:25:28] Dr. Eric Widra: And and I think the three areas that we're, we've focused on is, docs, when you need a doc, and I think there's some really interesting things to think about there as our system evolves, embryology nurses, some ways on the wind, you need somebody. Embryology is probably the easiest because what they, the, they, the measurements that they make are very.

it's not squishy. It's you do this many egg retrievals, you do this many PGT cases, you do this many ICSI cases. And over time you start to see, you develop a matrix, if you will, of how many people you need to do those things that does, however, need to be pressure tested with the rest of the world.

And I think that our professional societies actually do a good job on the embryology side of saying, Hey, we think this is a reasonable workload for an embryologist at this level or this level. And practices can take those data and then You know, massage them based on how, what their workflow is like and what their function is like and the capacity of their people.

and because it's the, risks are so high and the outcomes are so obvious, right? You get a baby or you don't. I think it really behooves us to, to be strict about those numbers. And, only adjust them or adapt them if we have really good reason to do And one of the things I see a lot in some of our smaller practices or newer practices are we sometimes make the mistake, it's a mistake.

We sometimes start with more people than we need. Based on those metrics, either because they were there already or we wanted to make sure it was as smooth as possible and then they struggle as with growth and managing that is really important, but I think if we're responsive to the data and the numbers embryology is probably the easiest way to easiest thing to do and nursing.

I think we've talked about a bit. It's Yeah, some docs do more with less and, at some point there's just going to be that human element that you can't measure perfectly because we're not going to turn the docs and, or the nurses for that matter, into robots. 

[00:27:52] Griffin Jones: Do you set a sort of standard as a company of this is how many, this is how many nurses one physician should have or is it, more by volume?

Oh yeah, and we have stuff that we, yeah. 

[00:28:05] Dr. Eric Widra: So it's, both actually. and a lot of our docs are coming out of fellowship. And so they're not bringing a patient base with them and we have, yeah, we have a standard approach to that, which will be okay. new doc is joining me and I'm just making this up, joining my office.

And so we'll hire another nurse and half of her old do Eric and half her new doc and his new dog grows. She can. do that or, cross cover other things, but yeah, we have a, again, it's not a formula I can recite for you and Griffin, but we, yeah, we have formula about that. and basically we start with the mean, and then we decide if somebody is, performing to the left or right of the mean.

So an average SGF doc, probably does, just, Plus or minus 200 egg retrievals a year. And they need two nurses to do that. But it's a pretty, it's not a very tight curve. it's pretty diffuse. 

[00:29:09] Griffin Jones: You mentioned embryology being one of the easier positions to look at the numbers to see where there's need.

Nursing might be in the middle of the road. What about support? What about support staff? What about medical assistants, phlebotomists, down to front desk? How do you, possibly project what you're going to need in those types of roles? 

[00:29:31] Dr. Eric Widra: I gotta tell you, that's HR's job. It's a struggle because there's high turnover in those positions, but, it's not that hard to measure.

You see this many people, between seven and 10 o'clock and, to get them through, you need this many people drawing their blood and doing their ultrasounds. it's not rocket science. 

[00:29:49] Griffin Jones: it might be HR's job to determine the levels that are needed, but there is a business call that's made on the appropriate level of redundancy.

I had David Burford, who's the CEO of Care Fertility on, and I talked about this bec And I thought it was fitting because he's in the UK, where they use the word redundancy to describe layoffs. If you were made redundant, that means you were laid off, and I think Ah, the English in their language,

[00:30:16] Dr. Eric Widra: I love it.

[00:30:17] Griffin Jones: yeah, there's, some poetry in there, and I, think it's a bit revealing because That is why you would do layoffs in a company as if you had multiple people doing similar things to become more efficient. You'd reduce your head count and you'd eliminate redundancy. I have found a necessary level of.

redundancy to, to, reduce burnouts, because if you have a, a certain number of people that are responsible for the total workload of the company, and then that number gets smaller, it becomes harder for the people that are there. And then you start to have more attrition because it's harder and you can't feel fast enough.

So that's one of the reasons why I think redundancy is important. Reason I think is that it's just it's easier to cover for people. It's easier for to plug people in when it's easier to cross train on. Then ultimately, if you have a big enough organization and especially if you have a wider layer at the bottom of the pyramid of junior people, you're, you have a feeder system for, senior people.

And if you, if your middle layer is a bit wider than you, then you've got another layer there. And but that's a business. 

[00:31:35] Dr. Eric Widra: People get sick and take vacation and have babies and all this stuff is just part of managing your business and you need that. Yeah. 

[00:31:42] Griffin Jones: And it's easy for me to make that decision because I'm a, I own 100 percent of the business.

I'm the only managing member. You're in a much larger organization where you have to consider different people's shares and you have fiduciary responsibility to the company and to each other. How do you make that decision at that level of what is the appropriate level of redundancy? 

[00:32:06] Dr. Eric Widra: To be honest, Griffin, I spend almost no time on that, as even in my leadership roles, we really do, we ask HR, what do we need to get this done?

Now, sometimes we'll see some 

[00:32:18] Griffin Jones: And you just do it, whatever HR says? 

[00:32:20] Dr. Eric Widra: Ah, within reason, yeah, but you don't I approach it like I do anything else. The hypothesis is HR is correct, and then we see the data, right? And if the data support the hypothesis, we're good to go. We have absolutely had times. That HR is seem to been just like on a hiring bench and you're like, guys, what are these people doing?

it looks like a lot of people standing around. yes, you need manage, you need input from the physicians and the managers and the office supervisors, but I, yeah, 

[00:32:48] Griffin Jones: I, I think you articulated it pretty well. 

[00:32:51] Dr. Eric Widra: Yeah, you. You are very well. Actually, you start out with what you think makes sense and if it's working and you add or subtract as needed.

I think that in health care, there's a real risk of being too lean in terms of the risk of errors per patient satisfaction. And so I think you're always going to see us error a little bit on the side of having some redundancy. But, we're very active managers at S. G. F. In fact, sometimes as physicians.

In fact, sometimes I think we're in too much in the weeds, but we push HR pretty hard to tell us why they're doing what they're doing and to prove to us that it needs to be done based on some metrics. 

[00:33:33] Griffin Jones: The default is that HR is correct and then you look at the data. What's an, and so most of the time you're going with the recommendations.

What's a specific example where you did push back against HR? 

[00:33:45] Dr. Eric Widra: Yeah. and it gets interesting and complicated, right? Because you and I might think that this job over here would be great for a part time person, but it may be really hard to fill that job with a part time person. In fact, the people who are applying for it as part time may be terrible.

And so you have to make compromises to say, maybe that person does something from 7 to 11, something different from, noon on. But sometimes you, need to really pressure test that we, what's interesting about the way our workflow in a day goes in the clinic is between seven and 11, we're seeing an enormous number of patients who are coming in for their IVF and IUI and other ultrasound and blood work.

And you need to be staffed for that. And these women want to come in and get out the door and get back to their jobs or their, lives. And. You need a lot of bodies to make that happen, but then one of those people do the rest of the day. And so that's been a great example. And one of the tensions we've had over and over again with HR through the years is, you I don't want to be paying somebody to be drinking coffee often, that's not.

That's not good business. And so I think that's one example. and, the reality is the solution to that ebbs and flows with the job market. 

[00:35:08] Griffin Jones: Have you developed a process for cross training to solve for that? Absolutely. Yeah. Tell us about that. 

[00:35:15] Dr. Eric Widra: Yeah, but not every, again, the, simply the volume demands are different.

So yeah, we will take, we'll take an MA who's in monitoring the call in the morning and cross train them to do the instrument prep for the OR the next day. but that presumes that the people who would normally do that are busy all day. So it's, a challenge. I don't have an easy answer for you on that one.

[00:35:40] Griffin Jones: as you're bringing on more folks and the companies get bigger, has there been a change, have you seen a change in, Shady Groves training of the Shady Grove way? So I'm not talking just about this is how you do this particular. role, but rather think of Disney. It doesn't matter if you're, a new VP of business development for a theme park, or if you're someone that washes the grounds of the magic kingdom, everyone goes through a certain level of.

Disney training. This is how we do it here. This is, we point with two fingers. Don't I, don't ever let me catch you pointing with one finger. That's so funny. I didn't know that one. Oh yeah. I still do it to this day, Eric. I point with two fingers whenever I'm pointing somebody in this direction. And so everyone learns a certain bit of Disney culture.

And I'm starting to do that with my company as well. Starting to, here's the inside reproductive health way. This is the fertility bridge way to, to have that cohesion. In addition to here's the training for your particular role. How much level of shady grove training is there? Has it increased? Is it remain the same?

[00:37:00] Dr. Eric Widra: It's big and it's a huge part of what we do. And for better or for worse, it still relies on kind of the ancient apprenticeship model, right? That, you're going to work with this nurse and she's going to teach you how to do this. You're going to work with this MA and this is, you're going to see how, the workflow happens and the way we talk to people and the way we escort them into the room and the things that we say.

And. Now we do, we have what we call it for nursing. We have what we call cohorts. So we've got a whole bunch of nurses that are starting between, month, between the 1st maybe that's 10 nurses. I'm just making that up, but they will all sit together in the same training and that training will be.

electronic and in person. And so we try to acculturate them that way. But then they're going to go and work with a more experienced nurse and, start to really see how to implement those concepts, as they grow their, practice, if you will, of, people that they take care of. we're really expanded our use of advanced practice providers.

And I think that's something worth talking about a little bit before we wrap today. And, we have a, whole protocol for onboarding. Advanced practice providers, and it still is very much here are the leaders of this and they've been here forever and they're going to show you how we do stuff. I can show you how to start an IV or doing all well, we'll teach ultrasound a little bit, but how do we approach problems?

How do we take care of patients? How do we triage? How do we fit in as that intermediary between the patient and the physician? So yeah, there's a lot of that. 

[00:38:36] Griffin Jones: But you're still getting away with doing it at the individual level where each individual mentor is doing that for their team as opposed to like having a cohesive Shady Grove University.

Here's the modules of here's how we do everything so that everyone and not just job training and not just handbook stuff, but like a cultural training. 

[00:38:58] Dr. Eric Widra: It's both. So yeah, like the nursing cohort and that stuff. And we do have, tons of manuals and online stuff that we used to actually call shitty good university, but I think we changed it because everybody called every, company at university after that.

We didn't invent it. Come on. it is, it's a combination, but, I think part of what we're trying to talk about today is, that's what works for us because of our size and complexity, but I think there's that it's critical in any corporation to have a culture that you can teach and transmit to your people.

[00:39:33] Griffin Jones: Yeah, I think I've found out how I thought we were such a small organization we had 20 people on team right now, and it's it's still really important and it would have been important when I had six, and, and I don't think I don't know, maybe two or three is too small, but for the vast majority of the people listening, I don't think it, they can be in too small of organizations in order to start building that cultural training and because they'll, find it very useful as something to point to later.

Yeah, I, agree with you that we should hit on APPs before we wrap. Is there an appropriate staffing ratio to? To, to APPs, how would one even figure that out in a formula because of the different variants of what they do? Is there, and especially as we move to utilizing more APPs, how, do you figure out when you need an APP versus when you need a nurse versus when you need a doc?

[00:40:32] Dr. Eric Widra: Yeah. And call me back in a year and I might have a better answer, but my, my, one of my projects for this year is to address the following pressures. We, have, to our credit, expanded access to care. It's got a long way to go, especially in vulnerable populations, but we're getting there. What that means is the reimbursement for the services is going to have downward pressure.

That's just the way the world works. It's not anything unique to us and the rest of healthcare has lived through this and probably much more. Disruptive ways than we're likely to, in addition, not just because of the price pressure, but just because of the volume pressure, you're going to need to, see more patients per unit time.

And because of the price pressure, you're going to need to do it more efficiently. And I think that the challenge for us is to find a way to get to that perfect or perfect is never going to happen to that correct ratio where you're still providing appropriate levels of service. But triaging that level of service based on what the patient is coming in for.

And so I think, and this is already being done in plenty of places. Bad thing about being this big is it takes time to institute change. But there's lots of places that are like, you use APPs, what do you do with them? I'm like, Whoa. Yeah. So I think. I think that the role of the APP in fertility medicine is definitely going to expand in some places.

They do all kinds of things now, but I think they're going to, they're going to triage new patients. They're going to see new patients and order testing before they get to see a doctor. I think they're going to continue to do more and more hands on stuff, ultrasounds, in office procedures. I've heard people talk about training APPs to do egg retrievals and embryo transfers.

That's a podcast unto itself. I think that's not going to be a very big piece of the puzzle, but the other pieces are going to be critical to maintaining the economics of what we do and the quality of the service we provide to our patients. 

[00:42:42] Griffin Jones: The APP topic is a topic in and of itself, but while we're still on it, you mentioned their role is going to expand.

What are some of the, what is maybe one thing that you feel many APPs are not doing now, or at least they're not doing in a great many places that they could and should be doing, and it's probably the first area in which their role will expand. 

[00:43:04] Dr. Eric Widra: I think that they should be the first line of evaluation for a lot of infertility patients, especially in underserved areas.

the fact that you live somewhere rural and have infertility shouldn't be such a massive burden because so much of what we do is not hands on. hopefully this joke will come across. Okay. I don't do physical exams on my patients. There's just no role for it. Yeah. They get an ultrasound eventually.

Sometimes the first visit, usually not. So I can, if I have an APPU seeing someone in, West Virginia, I'm in DC. And, they're in an underserved area, but the APP is happy to, they can order the stuff. The testing that we do is preliminary, is, straightforward. Anybody can do it. And then, and then I can have a virtual consult with that patient where I can be efficient and also provide a high level of care.

One of my associates, Edward Harton said something interesting to me the other day, we were talking about these challenges. He's the less I know about a patient, the more time I have to spend with it. And while our goal as physicians is not to minimize the time we spend with patients, that's not correct, we do want it to be efficient.

if you called a cancer doctor and said, I think I have cancer. Can I see you? They say, no. until you have a diagnosis and the pathology from the laboratory and all this test done and your imaging done, I'm not going to see you. Because it's not a good use of either of our time.

And so I think that as we move, as we expand access to care, I think you're going to see a little bit more of that. And I'm sure your colleague in the UK had some insights into this. in the UK, you don't see a doctor necessarily, especially in the private sector until you're pretty far down the pipeline.

[00:44:53] Griffin Jones: We're going to bring you back on in a year to talk about how you figured out those ratios, but you've at least given us a preview of what people need to project for as they start to expand their use of APPs. I'm jumping around a little bit, but we I had a thought pop out about training is have you learned any lessons about what absolutely needs to be in included in training?

So what we try to do is lay the process first. We use a project management system, and that's where most of our processes are documented. And then we'll use a software. We're called loom to do video documentation of it. And there's other softwares called train you all. And, other competitors to loom and train you all.

Have you found a bedrock of, about what absolutely needs to be included in every training or how it needs to be structured as, a framework, regardless of what specific role it is. 

[00:45:51] Dr. Eric Widra: It's a great question. And as you mentioned those things, I'm reminded how far we still have to go in terms of using these types of tools for that.

I think that's, that even though I'm proud of the way we train people, it sounds very primitive compared to what you're doing. And I think that's an opportunity for us to get better. But what I do think is the most important in healthcare, especially for what we do, is this acculturation.

That I don't think many of our skill sets are, so narrow that we need to like overtrain for those, the soft part of nursing is the same, whether you're, in a pediatric clinic or an IVF clinic, drawing blood and doing ultrasounds is the technique, the techniques, very little in the patient population, but their technical skills, but getting across the division and the mission and the culture.

Yeah. It's got, to be the most important thing in my mind because that influences not how you draw the blood, but how you interact with the patient and how you value that person's journey and the issues that they bring, that's the key. And I think that one of the things we've been successful at, despite the fact that we're, we were a business and we have to measure things and buy things and give services for revenue, is that we've been able to demonstrate.

That the patient comes first and I think if we can teach that and we can Live that because saying it and doing it are completely different things, right? you can be famous hospital X who says we're the best at this and you can get treated like dirt in the ER and it's all just talk. But if we can live that and show it and keep the people who are able to do that and redundant out the rest, that's the, that, to me is the secret sauce of staffing.

[00:47:46] Griffin Jones: We started the conversation talking about technology and HR as means of in, in being able to recruit more, being able to fill seats, being able to have longer retention. I took us down the HR route more deliberately. I still want to glean, a, second of a technological lesson if I can, is what's an example of in the, since.

Recruiting has gotten as crazy as it has in the last two years of a technology that you've implemented that has either made certain staff more efficient or just taken things off of their work entirely that has been a godsend to you. 

[00:48:29] Dr. Eric Widra: it's happening now. It's not quite at God's end level yet, but I can see it emerging.

So several years ago, we work with a vendor who does our consenting process and it's extremely thorough. It's video based. The patients have to answer questions along the way at the end to demonstrate they actually watched it. So both from a patient education standpoint, a consent standpoint, and a legal standpoint, it's awesome.

And, and, Mike Levy to his credit is like, why are we doing this for our financial counselors? Because we still have a lot of patients who are self pay and we have a whole menu of financial programs depending on the types of treatments they need and that can take a long time to explain.

Especially when you're talking to somebody with the anxiety they have about. Not just, am I going to get pregnant, but can I afford it? So we've made those modules, with our vendor for the financial counseling. And, it's, it was amazing, the resistance to it as there was when we did the consent thing, because people are like, are you taking away my job?

I'm like, no, we're making your job actually easier. 

[00:49:41] Griffin Jones: Because of what Dr. Harriton said, because the less you know, the longer it's going to take. That's also true for the patient. The less they know, the longer it's going to take. Yeah, and for the 

[00:49:51] Dr. Eric Widra: financial counselor. Yeah, a hundred percent. And so I see that as a great use of an adaptation of technology that, was staring us in the face.

[00:50:01] Griffin Jones: There you go, EngagedMD. That's your new slogan for your website. Almost at GodSend level, you can It's a free one from Eric Widra and I. you have the final thought, Eric, whether it's something from your talk at PCRS that I didn't ask you about. If it's just something else about how to train, recruit personnel, projecting personnel needs in the future.

How would you like to conclude? 

[00:50:26] Dr. Eric Widra: Thanks. I, it's great. I, the, horse that I've been riding lately is we have to adapt to the world is changing around. This is changing faster than we think. And we, need to be open to that. Physicians, especially hate change. What we need to do is get ahead of the things that are going to affect the way we deliver care.

And that means being open minded about the role of different providers. One of my, I stole this line from somebody, it's very businessy, but we want everybody working at the top of their license or their credential. I think that, but that makes a lot of sense, me explaining how the menstrual cycle works.

Probably not at the top of my license explaining how IVF and PGT works. Yeah, that's my job and being open to technologies that can streamline things for us. And that's a two edged sword because some technologies are better at it than others. But once again, your comments before left me like, Oh wow, there's still stuff out there we don't even look at.

So I hope that was a cogent closing comment. It

[00:51:30] Griffin Jones: was, and as much as there's more to look at, I'm still looking at more of it, too. I say that I'll write a New York Times bestseller once I'm a black belt at all of this. And I'm a yellow belt right now. I'm a yellow belt right now, orange belt at best. But someday you'll see it in the airport, and I'll send you a free copy, Eric, because I'm thankful to you for coming on the Inside Reproductive Health podcast.

Thanks for coming on. 

[00:51:56] Dr. Eric Widra: Thanks for having me, Griffin. Have a great weekend.

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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. Thank you for listening to Inside Reproductive Health.

212 Exponential Impact: For Young Fertility Doctors to Consider When Choosing Cities with Dr. Zachary Walker

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.


Could your impact as an REI be magnified by where you live and practice?

3rd-year REI Fellow Dr. Zachary Walker shares his strategies for creating an impactful career, outlining where and how he intends to contribute to the fertility community.

With Dr. Walker we discuss:

  • Promoting diversity among patients, providers, and outcomes (And research needed in those areas)

  • Income versus cost of living for REIs (Big cities vs. small)

  • Establishing REI Fellowships in states without existing programs

  • Talking about access to broader IVF care versus providing it


Dr. Zachary Walker
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Transcript

[00:00:00] Dr. Zachary Walker: I think the more we can start to push this agenda to current fellows that going to, I would say, these rural areas, not technically rural, but to service a population is definitely needed to improve access to care. And I think with my background of going from Indiana to Birmingham, Alabama to Boston, I've seen all different types of populations, cultures, and it's not very shocking to me to be able to practice in a place that may not be.

The most conducive or liberal to reproductive health, but feel comfortable being able to provide that care that's needed. 

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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.

[00:01:37] Griffin Jones: Exponential impact. As a graduating REI fellow, as a young fertility doc, as any fertility doc, you're going to have an impact. Could that impact be magnified if by no other factor than where you live in practice? I explore that concept in my conversation today with Dr. Zachary Walker. He's a third year REI fellow, and he's not moving from Indiana to Boston.

He's going the other way. Zach talks about what he wants to accomplish in practice to promote diversity among patients, providers, and outcomes, to do research in those areas, and to help to launch an REI fellowship in a state where one currently doesn't exist. Consider that for a second. It's one thing to say that we need more REI fellowship.

It's another thing to say, I'm going to move to this area and try to start one in this specific location with this specific institution. We talk about that. What's the difference between saying we want broader access to care versus actually providing broader access to care? We talk about the proportionality in income to cost of living for REIs in big cities and REIs in small cities.

And we talk about a relationship between the clinic and the lab, which might either be really complicated or might be a totally new and beneficial way. For Reis to diversify their business interests. This conversation was a lot of fun. If you're recruiting Reis or if you're an REI looking for the next chapter, I think you're really gonna enjoy this conversation with Dr. Zachary Walker. Dr. Walker. Zach, welcome to the Inside Reproductive Health Podcast. 

[00:03:00] Dr. Zachary Walker: Thank you. Thank you for having me, Griffin. This is amazing. I'm happy to be here. 

[00:03:04] Griffin Jones: Finally, I get to talk about a topic that I've probed at different times with graduating fellows, with younger docs, with some of the execs, where I'm really curious about how we expand access to care geographically.

I'm from a small city. I live in upstate New York. There's lots of Buffalo, New York, and lots of Akron, Ohio's and lots of Indianapolis, Indiana's and it seems to me like 80 percent of the graduating REIs go to 10 or 20 cities. And maybe it's not that uneven of a distribution, but it just seems like there's a lot of people going to the Bay.

There's a lot of people going to New York and Boston and L. A. and It seems like that the smaller markets are not getting their fair share. And so when we talk about access to care, we talk about a financial level. Can people pay for it at a technological level, the demographics that we're serving, all valid pillars of access to care.

The geographic one, I think is really important because until we all live in the metaverse, you got to see people in your area. And I was when I ran into you last and you told me that you were going to. Practice in the Indianapolis area after fellowship. I thought maybe this is the guy to talk about this topic with.

So let's just maybe you're a third year fellow right now. And so you're going to practice in the Indianapolis area next year that we're recording right now in January of 24.

[00:04:33] Dr. Zachary Walker: I started in August of this year. 

[00:04:36] Griffin Jones: So Tell us about how this came to be. 

[00:04:41] Dr. Zachary Walker: Yeah. So it was somewhat of a, I would say like a roundabout journey.

Initially, my thoughts were to, as you kind of alluded to, most people stay in kind of bigger cities during fellowship. So my plan was to stay academics and I was going to stay at Brigham and Women's Hospital in Boston, Massachusetts, where I am now in fellowship. And then things started to happen with my family, both me and my partner's family are both older, so they're getting thicker.

So we. And we also wanted to build our family, so it seemed that staying in the Boston area may not be the most conducive to our future as far as family building and being able to be there for our family because both of our families are very far away from Boston. I interviewed at different places, so I interviewed back and At my residency at University of Alabama in Birmingham.

I also interviewed at Indiana University, which is the academic institution in Indiana, and then also the private practices in Indiana as well. And then before I moved from Boston, I also interviewed at the private practice in Boston CCRM. Initially, my plans were to stay in the academic kind of realm, so I interviewed at Indiana University School of Medicine, and their school there does, they don't have a IVF lab, so they are partnered, at the time when I was interviewing it, with two different private practices to send their residents to get the experience with IVF.

And as a referral base, it's one of them being a Midwest Fertility Specialist, which I've signed with. And then another one being Indiana Fertility Institute, which is really close to the Midwest Fertility Specialist Practice. So I interviewed at both, and they both had their kind of pros and cons, but ultimately, I think we'll get to this in a little bit, but the Midwest Fertility Specialist Practice just felt more like home and really felt comfortable moving into that realm after fellowship.

So that's where I've decided to move forward after fellowship and continue learning and growing in that space. 

[00:06:39] Griffin Jones: There's a lot of people that live in Boston and places like Boston where places like Indianapolis are nowhere in their narrative. How readily did you accept this and just say, okay, my partner's from here and so I'm, I'm down.

Or how much of it was like like a pill you had to swallow? Tell us about that. 

[00:06:59] Dr. Zachary Walker: It was a very easy pill to swallow. I mean, I did medical school in Indiana, so I was familiar with the terrain. And if you ask any of my friends from medical school, they are very shocked that I'm coming back to Indiana because it was a very cold environment and I didn't see myself being there for a very long time, but then I met my now partner and I started to fall in love with the area more and most of my mentors from medical school are still there.

So when I interviewed, it was. It's like coming back home a little bit. So the foresight of me being back in Indiana has become more clear. And I feel like, as you alluded to before, the need is still there as far as REI in terms of how many providers are in the area. Basically the Midwest Fertility Practice and the Indiana Fertility Institute are the biggest two groups.

They are serving this IVF need. So patients are coming from all over the state to get their IVF in that area. Yeah. I think the more we can start to push this agenda to current fellows that going to, I would say, these rural areas, not technically rural, but to service a population is definitely needed to improve access to care.

And I think with my background of going from Indiana to Birmingham, Alabama to Boston, I've seen all different types of populations, cultures, and it's not very shocking to me to be able to practice in a place that may not be. The most conducive or liberal to reproductive health, but feel comfortable being able to provide that care that's needed.

[00:08:27] Griffin Jones: So when you say cold, do you mean culturally or you mean like it's chilly, like climate wise, it's a cold place to be. So you had this experience from medical school. Did you meet your partner in medical school in Indiana? 

[00:08:40] Dr. Zachary Walker: Yeah, so me and my husband, I met when I was a medical student in Indiana.

He works, he was working as a, in a restaurant as a bartender and we met and then things just kind of took off from there and he's been on this whole residency training journey with me since then, moving with me to Alabama, then to Boston. So yeah. 

[00:09:01] Griffin Jones: Had you met in Boston or somewhere else and you hadn't ever had that experience of living in Alabama, of living in Indiana, but particularly Indiana because that's where you're going back to, would you have considered it as 

readily?

[00:09:15] Dr. Zachary Walker: I think I would. I, The appeal of being in a big city, I mean, it's nice because of just the fact you have things to do and Kind of a accessible place, but definitely I grew up in a somewhat of a small town. I grew up in Hampton, Newport, East Virginia, which isn't like a big city. It's filled with military families and pretty much a lot of people know one another's close knit community.

So the attractiveness of moving to a big city, wasn't really top of my priority list. Mainly I just wanted to be at a place that would allow me to continue to grow and allow me to feel comfortable. to practice and to live and build a family, and that was the most important thing. So regardless of where we met, I think I would have still considered moving to smaller cities or outside of the, like the major network.

[00:10:03] Griffin Jones: Appreciate the distinction that you're drawing between smaller cities and rural because a place like Indianapolis is rural to someone from LA, but in the grand scheme of things, like I lived In the heart of South America in the country, two and a half hours from the city. And I had to hitchhike to the road to get to the main road, to hitchhike again, to get to the closest small town, right?

Like there's rural and then there's just small cities, which is. Which is like what an Indianapolis or a Buffalo is or a whole lot of places that are Tucson, Arizona that are really nice to live. And I think it's an important distinction to make because, unfortunately, the patient population that it does live in the rural areas is still driving to those small cities to, to the provider in many cases.

There are some people that are out in North Dakota and they're going to really, rural areas. But for the most part, when we talk about these small cities, we're talking about places that, sorry, you're going to have to take a connecting flight to ass around when it's in New Orleans.

I know that sucks. Like I want to take a direct flight too, but you know, you, you lose out on your direct flights. You lose out on. That your three star Michelin restaurants you, but for the most part in you, you talked about this in the beginning where your interest is in building a family and having a family, like you're a busy provider.

You're gonna be a busy husband and dad like. How many three star Michelin restaurants are you going to in a month anyway? Like, you'll go there when you go to New York, like, I will go to the nice restaurants when I'm in Toronto, in L. A. And then in the meantime, I'll just be a dad, work out, and work my tail off, and then not have time for anything else anyway.

So Correct. Do you think about this, though? Do you think about what amenities you're giving up, and what amenities you're 

[00:12:01] Dr. Zachary Walker: Yeah, I mean, we've been in Boston for the past three years, and me and my husband we go out, but it's not like a often thing, like every weekend, we're not going to like see a show or going to explore the city.

We are very much homebodies. And that's just me personally. So I can't speak with everybody that lives in a bigger city. But giving up those, I guess, amenities isn't a big deal. Because like you said, there's You're, there are always going to be times where you're going to go on vacation or you're going to go out and make time to do those things that you really want to do and they're not something that I do on a regular basis.

I mean, I think some of it might be a little bit overrated for me, but the small city to big city life is probably going to be very much the same in terms of what I access and did on a regular basis. 

[00:12:49] Griffin Jones: And, there are some people that I know, I've talked to some REIs that they practice in Midtown Manhattan, and they live in Midtown Manhattan, and that walk through Midtown is part of their day, it's like part of their essence, I get it, there are some people who having access to those amenities is really part of their life, I think for 80 percent of the folks Who often clinging to that.

It's like, how often do you really use it? And when you're a top one percenter, as most of the people listening are, or at least the top five, top 10% or earner, it's like, you can do that whenever you want, like especially have, did you look at like the delta in between, you know what? R. E.

I. s are making in some of these coastal cities and what they're making in some of the smaller cities. And then also the delta in cost of living, like they're not, how equal are they? 

[00:13:43] Dr. Zachary Walker: Like, yeah, it's, I, so I've looked at some of my other colleagues who have in my year who are have signed and moved to different cities.

Some of them are. Moving to like smaller cities, like, I think some people were considering moving to places in Tennessee and, or places like smaller cities in Texas. And definitely the cost of living is the part that is the kind of gets you as far as like the sign on bonus that they may offer you or how they do their bonus structure and living in Boston, like coming from Birmingham, Alabama, where me and my partner had a house, our mortgage was.

Like, like in the 500, they're moving to an apartment in Boston, spending, spending over like 3, 000 for an apartment. It's crazy, insane, but definitely you get that inflation in your salary that makes it seem like, Oh, I'm making a lot more money. The most that is coming out of your paycheck every month that you would have had to use to spend if you were in a lower cost kind of city.

So I think the contracts or the salaries that are being offered are pretty comparable. Throughout the states in terms of what it already makes coming out of fellowship, but as far as like the bonus structure, the sign on bonus may be a little bit higher for, like, bigger cities because they know. That if you're coming there and like moving stipends and signing on for an apartment or wherever you're going to live, needing like first, last, and for that lease.

So it's a little bit different from that standpoint, but I think overall the base salary is very similar throughout. 

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[00:16:51] Griffin Jones: My impression was that it wasn't proportional, though. Do you think it is proportional? Like, so that the cost of living is so much lower in this, in the smaller cities and the salary isn't that much lower relative to that gap. But you think your read is that it is more proportional?

[00:17:10] Dr. Zachary Walker: I think it's more proportional from what I've seen most recently among my year. I mean, maybe it has changed recently, but most of the salaries. are very similar, like from Texas, Indiana to Pennsylvania and some places in Boston. I think the salaries are, and this may also be with like private versus academic because academic has their kind of salary base here from everybody who's signing for an academic position versus if you were in private practice.

I think the gaps between what people are being offered is between 50, 000 to 100, 000 different. 

[00:17:45] Griffin Jones: And, which to me I guess it depends on, I would, maybe I'm assuming erroneously, but it seems like you could get a house in suburban Indianapolis for six or seven hundred, what would be two and a, two and a half million in suburban Boston.

Correct. So maybe some parts are proportional in some parts are less. So do you think about ways of being able to win the trade off in different areas? Like one of the reasons why I started remote work long before COVID was because I'm from upstate New York. I wanted to stay in a small city in upstate New York.

I wanted my money coming from the. to be more comparable to the larger markets. And I wanted to win the tradeoff. I wanted to have that lower cost of living, no traffic, nice quality of life, but also have that career opportunity that comes from being in a much larger area. And I think that may have been more difficult for docs to do even 10 years ago, but now with the opportunity to, as networks by practices, and then you could buy Equity into that network and you can sit on a seat for that network or you could be a medical advisor board for any of these new Fertility tech companies that are emerging like you can do that from anywhere You can do it from san francisco or you can do it from boise, idaho. Do you think about those opportunities? 

[00:19:05] Dr. Zachary Walker: Yeah, a little bit. I mean, I would say starting fellowship at Boston and having that network, I've been able to connect with a lot of interesting people and have a lot of interesting opportunities presented to me as far as like, being an author for up to date sitting on the ASRM committees and then doing some things outside of that realm as far as mentorship.

And then also I'm talking to researchers in the Boston area as far as collaborating research for new technologies that are coming out as far as like sperm research and analysis, which is my kind of niche and male factor infertility and being involved in that, either like remotely or actually doing hands on stuff.

So I do think that. wherever you are, you can get involved, especially when you're going to these conferences like ASRM and meeting all these different companies that are selling new products and helping them with research or innovation. And you don't have to be in a big city to do that. But I think the biggest issue is that what is your prerogative after fellowship in terms of, are you getting off as I say in terms of academic research and just Focusing on quality of life, private practice, taking care of your patients, and not really focus on research as much anymore and just wanting to be a normal working civilian in a sense.

Or if you're still ingrained in it and want to do research, then you might want to pick an academic job where you can focus on that and not have the constant drive or push to bring in patients for like IVF cycles and have that revenue coming through and you can focus on other things and expand that.

So I think the, as you mentioned, the opportunities are endless. If you're interested in them, they're out there. You have to seek them out and it may be a little bit tougher if you're in a smaller city or not in a collaborating with the big academic institution. But if you have that interest, it pretty much only takes an email or a talk at a conference to get involved.

[00:21:04] Griffin Jones: Now that you are moving towards this next part of your career, what is it that you want to accomplish when you're practicing?

[00:21:12] Dr. Zachary Walker: A couple things, I would say. The biggest one is mentorship. So my biggest thing is that I want to make sure that we continue to expand the amount of fellowship slots that we have available to, one, expand the supply for the demand that's needed in IVF or REI.

In America right now. And I think ASRM is currently tackling that by discussing, expanding the amount of slots at each institution and growing that so that we have that kind of Chain or flow coming through every year and then there are more institutions getting RAI practices. One of my goals while I'm at Indiana is to hopefully be able to foster or create a RAI fellowship with the Indiana University School of Medicine and partner with them to be able to create a fellowship because they have pretty much every other fellowship but the RAI one.

The second thing I want to do is make sure that. We continue to promote diversity within the field of RAI. I'm involved with the Health Disparities SIG in ASRM, and then I'm also on the Education Committee at ASRM. And one of the focuses are diversity in the field as far as patient care and also advocacy and who's taking care of these patients.

I think I was on a meeting with a couple of the diverse RAI physicians. And we're just thinking back to how many people are of color or underrepresented physicians are out there in RAI. And I think it's probably less than 20, and how many patients are underrepresented. Trying to find us or looking for us in the field and most of us are probably in bigger cities So we need to expand a little bit more to smaller cities or other places so that they can still find us or be Represented in a sense and feel comfortable coming to their provider, but you're actually willing to do it

[00:23:04] Griffin Jones: I want to stop on that point for a second Zack because we work in a field where that tends to you know Go one way just in terms of general I guess Dis ideological disposition or political disposition and people say the right things.

But then whenever ASRMs in Baltimore, people are like, Oh, Baltimore is like, it's like, really, what's wrong with Baltimore? 

[00:23:27] Dr. Zachary Walker: Yeah, I agree. 

[00:23:29] Griffin Jones: What's wrong with, what's wrong with Buffalo? What's wrong with Cleveland? What's wrong with Detroit? Oh, okay. So I get it. I get it. Like I grew up in these types of places and you got to have a certain, you got to be able to say like, I'm good with living with.

With less of amenities and or just different ones and having a trade off in amenities but it's like you can't say that we really want equity We really want equality and then do something that Yeah, that doesn't go with that. Yeah, that is part of moving away from the mean, but you're actually doing it though And so like do you does that play into your head?

Like do you think of like are you the type of person that's like f everybody else? I'm actually gonna do it or is it just like no This is where my husband's from and I think it's a good thing to do like do Does any of that chip on the shoulder play in your decision making? Even a little. 

[00:24:28] Dr. Zachary Walker: I I don't know if I, I would like turn myself as a trailblazer and like, say like, oh yeah, f everybody else, I'm just gonna do what I wanna do.

I mean, there are some days I do feel like that when I'm working and I just want to like, like be my own boss. But I think everybody, every fellow feels that way, . But no, I think we do need those leaders who say, Hey, we know that it's a need and I feel comfortable. Doing that or providing that and not feel like I'm going to be going out of my way, because everybody has different backgrounds, experiences, family concerns, family needs that don't allow them to be able to take those steps, and I'm not trying to say that we all need to move in this direction, but I do think we need to make it feel Less, what's the best word?

More comfortable for fellows to do that and not feel like they're being judged about not going to like a bigger practice or joining a bigger company because they're not getting a bigger salary or being able to be a partner at here or there. And I think it's, I mean, the future of REI may be moving in that direction where everybody's joining these big practices and they're expanding and that's the way that.

It's just going to be after fellowship that you just join one of these groups, but I think that we need to have fellows feel more comfortable that you don't have to follow this trend. You can pave your own path and do what you feel is best for you. And for me, going back to Indiana and being able to serve this population, create opportunities for other fellows, create opportunities for the residents that are there and for REI and train them.

That's perfect for me. That's always been a goal for me. So it just seems like a, probably like a perfect fit. 

[00:26:01] Griffin Jones: I also think that establishing a fellowship is a very meaningful, measurable to, to point to and say, I either did it or I didn't do it. And right now there are states, there's plenty of states that don't even have a fellowship.

There's no fellowship in the state of Arizona. University of Arizona doesn't have one, Arizona state doesn't have one. Does the state of Indiana have a fellowship right now? 

[00:26:25] Dr. Zachary Walker: Not an REI. So yeah, it's a, they have like definitely the private practices, but no fellowship. And Indiana university, it's a really great residency program.

So it's, they've had one in the past, but just over the years it got lost. And I think it needs a little bit, some time to come back. 

[00:26:45] Griffin Jones: That would be an exponential benefit, Zach, if you can pull that off, because you're not only bringing one REI to that state yourself, you would be, you'd be bringing at least three in a given year, right?

Plus the faculty, so maybe four, and then maybe every one, four years, one of those stays in the area. And so you could have an exponential impact. How do you think you might get that done? 

[00:27:11] Dr. Zachary Walker: So I think right now, my goal is to try to see what the tone is between my practice, Midwest Fertility Specialists and Indiana University in terms of like partnership or their ways to do that.

As you hear of other hybrid REI fellowships like RMA New Jersey or RMA New York that are with a big institution like Thomas Jefferson or Mount Sinai and they're able to have a fellowship through their kind of private practice but it's affiliated with an academic institution. I don't know exactly how that conversation starts or the kind of the build begins.

But I know Dr. Peipert, who is the chair of Indiana University's OBGYN program and had conversations with him when I was interviewing for to stay at IU. So I'm hoping that through my time there, being able to teach the residents and being able to Take care of patients that we can start to talk about how we can structure a fellowship program and I've reached out to some mentors who are doing it recently.

And I know there's a lot of paperwork that comes with it. A lot of logistics. So I don't think will be easy in terms of getting it started. But I believe when spoke with my current, my future partners at Midwest Fertility Specialists who are interested in doing that. And then also the residency program director at Indiana University, Dr.

Scott, would also be interested in trying to get a fellowship started. So I think the interest is there. We just need to hit the ground running and try to get it started.

[00:28:46] Griffin Jones: I want to go back to the topic of where, of how you sussed out these interests when you were looking at different programs and applying to different programs, but I did cut you off a bit when you were talking and I would just want to make sure there weren't any other core objectives that you mentioned that you want at hoping to add a fellowship, wanting to improve mentorship and also promote diversity and any other core objectives that you're thinking about for how you want to practice.

[00:29:14] Dr. Zachary Walker: Thank you. Oh, so I like the last thing for me is I still like to do research and I'm hoping to continue that even in kind of being in this private Demick center. So I'm currently mentoring one of the Indiana University residents. I'm hoping the best for her when she applies that she matches, but, trying to increase the research that they have available in terms of RAI at Indiana, and then also within my practice, whether it be like IVF techniques or kind of racial disparities care, whatever kind of niche I can grow into, and the fact that when I interviewed at this place and told them my interest, they were also willing to help me with research and were going to give me the space to do that, and I didn't feel that I was going to be the pigeonhole into just churning out IVF patients was a big thing for me to know that I wasn't going to have to give something up readily when I signed this contract and they were willing to work with me in whatever facet or space in the REI world to make sure I felt comfortable joining the practice.

And I think that's a big thing. And I didn't feel like I got that everywhere I interviewed. So when fellows are going out to speak with all these different businesses and companies, and they're telling them this is what your job is going to be, it doesn't, that doesn't need to be the end all be all, you should kind of seek out what jobs are going to work with you to make sure you're not uncomfortable signing this contract, you want to make sure you're getting into a job that's going to continue to expand your mind, expand your thoughts about the world of REI, and provide you satisfaction.

Yeah. 

[00:30:48] Griffin Jones: How much of the interview process was informed by having these objectives ahead of time and how much of the interview process formed your prioritization of the objectives? 

[00:31:02] Dr. Zachary Walker: I was looking back. That's a good question. I will say looking back. It was probably 50 50 So one of the things I do want to kind of Highlight or bring attention to is that as a R.

E. I. Fellow in our first year you go to A. S. R. M. You have once they know you're a new fellow or you're starting off, you'll get all these pulls or emails of what? Where do you want to go after you finish? What jobs are you looking for? Are you interested in this? We have these opportunities and it's overwhelming and you don't even know what you're doing as a first year.

Really? You're just trying to you. figure out what it is to be an RAI, but yet you have all these job opportunities coming to you left and right. And there's a some somewhat pressure to make sure you're not missing out on an opportunity because that's how we're trained as like residents or medical students.

We're very like type A personalities who don't want to miss out on something. So you. Get all these invites and you may jump into interviewing places early before you even know what you really want. And so I fell into that trap a little bit and interviewed probably at the beginning of my second year.

And I, they were asked questions of what do you really want to do when you come out of fellowship? How do you see your schedule? What do you think is the most interesting to you? And I really didn't know 100%. So it didn't start until late, my late second year, beginning of my third year, to where I really knew, okay, this is how I see myself in the future of REI.

And this is what I want to give back and had more meaningful conversations during my interviews about what I wanted and what they can offer and how we could find common ground to do that. We should feel comfortable working kind of signing contracts. It's at a place that, that is going to foster your ideas of what you want to do as an REI coming out of fellowship and also what they would need out of you.

So it takes some time to develop those, that knowledge. It did for me. I don't know for everybody else, but until my third year, I really didn't know a hundred percent what I wanted to do. So I think the more time people take to really Reflect about their thoughts of their future practice and see what is out there before jumping into interviewing would be my best piece of advice for any future fellows looking for jobs to not feel stressed about interviewing and missing out on certain opportunities and take time for yourself because the need is there.

There will be jobs available, but don't feel rushed to sign something so soon before you really know what you really want. 

[00:33:33] Griffin Jones: Sometimes general advice for determining who you want to be in this world involves outlining what you don't want to be. Was there any of that? Did you consider ahead of time what you wanted to stay away from?

[00:33:48] Dr. Zachary Walker: Yeah, and part of this did change a little bit because of all the stuff with my family that was going on, but initially I never thought of myself working in like a Private practice that didn't have research available because that was such a big part of why I was interested in RAI, why I wanted to be RAI fellow was because of the interest, the research was very interesting to me.

So I always thought of myself going into the academic Kind of space to continue that. And when I was interviewing and talking to different places, this private Demex model of this hybrid model was very enticing to be able to say like, Hey, I would still be able to make a meaningful salary. And also do IVF, but still have the ability to mentor, do research, and train the upcoming RAIs for the future was like a perfect fit for me.

And then this opportunity at Midwest Fertility Specialists and collaborating with IU seems like an even better deal. So having that space, kind of headspace of what I really wanted to hold on to. Was important and knowing that I didn't I wasn't going to sign a plate to a place that was going to make me give that up 

[00:34:58] Griffin Jones: How did you suss that out because in interviews people generally especially when they're trying to recruit you know, they're not the they being clinics and networks are not the Beneficiaries of the supply demand imbalance typically they are typically trying to everybody's trying to get their hands on an REI for the most part.

And so people very often be like, Oh yeah, you can do that Zach. Sure. And then it's like, when it actually comes time to do it, people find out they weren't specific enough in their negotiation and then they tend to fall back to maybe later, or no, that's not what we meant or not now or whatever it might be.

And so how did you suss that out of who could provide you with what you wanted the most?

[00:35:42] Dr. Zachary Walker: So I, Part of it was talking to other fellows ahead of me who've signed contracts with those companies or who knew someone who's working with them about what their day to day was like and if what I was being told was true or not.

And I think that went a very long way to have someone on the inside know. What is their day to day? Are they actually able to do research? Are they actually doing surgeries as much as they thought they were doing surgeries or how much of their day is literally? No, you need to sit down and see new patients and bring in as much IVF volume as possible.

So I'm very grateful for the people I know and like my network in the REI field from my co fellows to prior graduates and keeping those friendships close. Another part of it is My practice that I'm joining isn't part of one of the big conglomerates. Not yet, hopefully not anytime soon, but it's not part of the, like one of the big five or whatever.

And I think that is what allowed me to know that they were, I would have more wiggle room to do things because this practice has been in play for over 20 years and they have seen the shifts of all the different RAIs in the state and can. provide me with background on what's possible, what's not possible.

And they felt very comfortable in my goals and my dream for this, for the practice of what I wanted to do. And I believe them. So I think those two things really played in hand to make me feel more comfortable signing the contract and moving forward with them. 

[00:37:13] Griffin Jones: So if they're not part of one of the networks yet, as you say, but how many docs are there?

Four or five right now is five. Yeah, I'll be number five. You'll be number five. So that's a group that one of the networks wants to buy. And I've seen this before is that I have recommended I've helped connect some fellows with their future jobs. And then it's an independent practice.

And by the time they start, it isn't. And have you thought about what it will be like being in a city right now where there's like two, maybe three programs if you go further out versus, if you are in a larger city, if you're in the Bay Area, if it doesn't work out, it This place, you can go to one of 12 other places and in the meantime, you might have, if it doesn't work out at a particular place in a smaller city, you got your kids in school, you bought your house and say, gosh, do we have to like uproot and go somewhere?

Totally. I'll say, how do you think about those terms? Or do you just try to push it out of your head? 

[00:38:21] Dr. Zachary Walker: A little bit of the latter for sure. Just like, everything should work. But yeah, in residency, we had these kind of career talks about how often do people stay at their first job? And it's not that high.

Usually most people will leave within the First three years of their first job because of not liking it or things that were promised were not there. And, that definitely may happen to me, but definitely trying to be as optimistic as possible is my head space. But if it, yeah, if it doesn't work.

I will most likely have to move because of the contract of what's the term I'm looking for? Non compete. Yeah, non compete, yeah. So that may require me to move or not be able to practice for at least a year before I can sign again, which would be definitely very difficult. Like the biggest network of potential jobs would be in Chicago, which definitely has a plethora of REIs.

But. I'm kind of remaining optimistic, moving forward with that and hoping everything works out. I mean, I love the people that I have met for my future job and they all seem very great. They all are very supportive of me, so I'm just hoping it all works out very well. 

[00:39:27] Griffin Jones: It's also part of when you want to do something meaningful, there's a certain amount of risk involved.

I want to go provide access to care somewhere. It's a hard thing to do, which is what makes it meaningful. Hard things have risk attached to them. Hopefully that's it's win for everybody. And I, if you think about, do you want to like buy into the practice? Do you want to, do you want to own equity with whoever you're working for?

Or do you like not having to, have those business obligations? Where do you stand? 

[00:39:59] Dr. Zachary Walker: So I do have a goal of being a partner with the practice I'm with, so that is one of, one of the interesting things that drew me to the practice a little bit more, was that they do have a partnership tract, which I think some of the bigger companies may not offer that anymore for incoming providers, or it's not the same as what other people got in the past.

[00:40:20] Griffin Jones: Because there's not as many of them. Like, there's just, yeah, there's not as many of those types of, I mean, there's different types and they might be good too, but. That old, like, I buy in early, I get some equity, and then I'm part of, I put my sweat equity in so that I'm the beneficiary of a larger share of financial equity later, because I'm not buying it at a discount, I'm not discounting my future profits now, so that It is kind of, I wouldn't say unique, but definitely less common opportunity than it used to be.

But so sorry for my commentary. 

[00:40:51] Dr. Zachary Walker: No. Yeah. That, I mean, that's right. So the practice that I'm working with now just they are, the lab is separate from the clinic. So the clinic has just been bought out by a group called Axia. And even though the branding is different, the Axia women's group is partnered with Midwest fertility specialists.

They are recently kind of renewed contracts and that's when I kind of came in and I'm under this contract with the new group. 

[00:41:18] Griffin Jones: So they are, they are part of a bigger group, but you're just saying they're not part of one of the major fertility networks. They're not like 

[00:41:24] Dr. Zachary Walker: CC. Yeah. Like CCRM, RMA.

Yeah, but yeah, they are part of a group. Yeah, so the, and prior to me being there, they were part of another small group, I forget the name of it, so this turnover to Axia was happening in the past year. The lab, on the other hand, is a part of the Ovation Network of Embryology Labs and IVF Labs, so the ability to kind of buy into both of these practices is possible for me doing the partnership track.

And I mean, it would make sense for me to join right now from a financial standpoint if I can to work to be a part of that for future wealth. But that wasn't always the goal. The goal was mainly for the kind of academic research mentorship ability to create something new for the REI, like REI fellowship at Indiana, which is my primary goal.

So the whole kind of financial things that come with it are definitely a bonus, but they weren't going to make or break.

[00:42:30] Griffin Jones: can't wait to interview you in five years again and do a follow up of this conversation because I wonder if that is what kind of path that will be having the two different opportunities with the two different companies, one owning the lab, one owning the clinic, because often it, we've seen the ovation model before, and often the clinic will stay, you Independent then, and the Ovation owns the lab, then USF acquired Ovation.

And so many of those clinics that were independent, many of them still are those that then decided, Oh, I want to sell the clinic later on, I think would sell to us fertility. Same parent company still, I think of infertility institute originally had sold their lab to Vivera, which then was acquired by Prelude.

And then it became part of the inception and network. And then, but then later on, it was Prelude that, or either, one of their brands, Aspire, that bought, I don't know exactly that bought HFI. So still, again, still mapping up to the same parent company right now, Lab Clinic for you, two different parent companies.

I wonder if that will be complete chaos and you'll hate it or you. Or what I'm hoping, what I'm hoping for you, Zach, is that you are on the, that you have tapped into something like the record labels or the content producers who are on different streaming services, like South Park, is still on this streaming service, but then for these specials, they'll be over on Paramount plus and they can do it and they're benefiting from the different labels and some artists.

Can I'll make this content over here. But when I do my crossovers or I'm with as a solo artist, I'm over here when I'm with the band, I'm over on there. And when we do a crossover, there's a benefit and they're a little bit more diversified as well. So I'm hoping that's the case for you and that you, we'll see.

You definitely pioneered something. 

[00:44:21] Dr. Zachary Walker: We will see. Definitely. I'll check back with me in five years. Might have a little bit more gray hair. 

[00:44:28] Griffin Jones: How do you want to conclude, Zach, about either about expanding access to care either by geography or any other measure or any of the subtopics that we covered today?

How would you like to conclude? 

[00:44:38] Dr. Zachary Walker: Yeah, I think I just have kind of Three main points. One for any future fellows like listening to this podcast, you're in the midst of looking for jobs or thinking about starting the interview process. I would say take time to reflect and don't feel rushed to sign contracts or push to do that.

And definitely make sure you're having meaningful conversations when you're interviewing so that you feel comfortable signing the contract and can move forward with that process. The second thing is for future fellows as well. This is your time to see if you want to get off the kind of academic train and go private practice or continue on and finding like a hybrid model or moving towards just working like a private model and making patient care memorable and taking care of your family and moving in that aspect.

So this is a pivotal moment that we've never had before in terms of this isn't a match process. This isn't a put an algorithm. This is literally. your opportunity to pave the way for the rest of your future. So definitely take advantage of that. And then definitely the last thing is we do need to expand our access to care and making fellows feel comfortable moving to smaller cities or other areas to be able to provide that care.

So hopefully this interview will make other fellows who are interested in that endeavor feel more comfortable. And doing so and seeking out opportunities for themselves to be able to grow in their space. And yeah, thank you so much, Griffin, for having me on this show. This is amazing. 

[00:46:12] Griffin Jones: That's my pious hope.

Your wish at the end there, Zach. That's my pious hope. I haven't really been able to do it, so I'm hoping that giving you a tiny megaphone is able to do it more. Dr. Zachary Walker, thank you for repping small cities. It's been a pleasure to have you on the show. 

[00:46:26] Dr. Zachary Walker: Thank you so much. 

[00:46:27] Sponsor: This episode was brought to you by MyEggBank, the premier network of donor egg banks.

Discover the benefits of partnering with MyEggBank by visiting myeggbank.com/irh and receive our complimentary starter kit of resources. This exclusive offer provides a glimpse into clinics fertility services and streamline the partnership process. Join us in making a meaningful impact on the lives of aspiring parents. That's myeggbank.com/irh

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. Thank you for listening to Inside Reproductive Health.

211 AIVF's Tech-Driven Mission to Personalized Care, Efficacy, and Efficiency with Daniella Gilboa

DISCLAIMER: Today’s episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free, to you! Here, the Advertiser has editorial control. Feature sponsorship is not an endorsement, and does not necessarily reflect the views of Inside Reproductive Health.


In the realm of fertility, many claim to prioritize personalized care. But how often is this a reality versus following predefined profiles?

Daniella Gilboa, Co-Founder and CEO of AIVF, shares her thoughts and leverages her experience as a seasoned clinical embryologist to shine a light on where fertility can improve patient care and how AIVF is stepping up to the challenge.

With Ms. Gilboa we discuss:

  • Her definition of personalized care (Contrasting with what is being done today)

  • The micro & macro of what’s happening in the IVF field

  • New technologies improving efficacy & efficiency (And where the two come together)

  • AIVF’s innovations allowing embryologists to do more cycles more effectively (And its impact on the embryo) 

  • How this same technology can provide non-invasive genetic screening.


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Transcript

[00:00:00] Daniella Gilboa: So we've been hearing about personalized medicine for some time now. And it's it became like a, slogan, like we do personalized medicine, but what's the essence and where does it meet us? the, IVF ecosystem, do we really. give personalized medicine? So the answer is no, not yet.

then IVF clinics, that's as they work now, as we work now, there's no personalized medicine. There's we understand like profiles of patients and this is what we could treat like profiles of patients. 

[00:00:34] Sponsor: This episode was made possible by our feature sponsor, AIVF, the pioneering force behind the revolutionary EMA platform.

AIVF is at the vanguard of transforming reproductive medicine through cutting edge AI technology. The EMA platform sets new standards in precision IVF care. Learn how EMA can grow your fertility's efficiencies by going to aivf.co/precalc. That's aivf.co/precalc.

Announcer: Today's episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free to you.

Here, the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of Inside Reproductive Health.

[00:01:30] Griffin Jones: Personalized care. Nearly every fertility provider of a fertility practice says they want to provide personalized care to their patients. But are we delivering truly personalized, individualized care, or are we following profiles to deliver care? If we're being honest, I think we all know the answer to that.

Now imagine if one of your most talented embryologists noticed that. And after 15 years of experience in the IVF lab, got the backing and started a company to solve for exactly that. That actually happened. That's the story of my guest today, Daniella Gilboa. She's the CEO and co founder of AIVF. She was a clinical embryologist for 15 years.

She has a master's in biostatistics and epidemiology. And through this background, we look at the macro and the micro of what's happening in the IVF field in the soaring demand, but also from her experience as an embryologist, the insights for the limit of supply. Listen to Daniella's definition of personalized care and contrast that with what's being done today.

Then listen to how new technology is improving efficacy and efficiency and where the two come together. Are we really going to be the most effective in clinical success rates? Are we really going to be the safest in operating an IVF lab? If half of the workload that embryologists are doing can be offloaded today, what would you do if you had twice the number of embryologists?

Daniella explains how her technology allows embryologists to do more cycles more effectively. How does this technology provide non invasive genetic screening? What's the impact that will have on the embryo, on the field? And then toward the end, listen to Daniella double down on what so many embryologists have said recently, where she says time lapse incubation is a way of life.

As you listen to her explanation, I think, are we ever really going to be able to scale fertility care if we're manually collecting data points and manually entering them into various disconnected channels? If you're interested in AAIVF, they have an efficiency calculator on their website. It will be linked where this episode is distributed.

I recommend you go to the AAIVF website and use that calculator. But if you also just want to get in touch with Daniella, feel free to ping me for an intro. I hope you enjoy this conversation as much as I did. Ms. Gilboa, Daniella, welcome to the Inside Reproductive Health podcast. 

[00:03:33] Daniella Gilboa: Thank you for having me. 

[00:03:35] Griffin Jones: I have been interested in following the efficiency improvements in the lab, the efficacy improvements in the lab.

I'm also really interested in the AI revolution and you're at the seat of where all of those things come together, because I really do believe that AI is going to conquer every segment of our, world for in different purposes and every place in the marketplace and our field is no exception, but I guess even before we get to some of the technologies.

Your background, you're coming into this not first as a tech entrepreneur. To me, it sounds like tech entrepreneur came later, but you have what? Some 15 plus years in the IVF lab as an embryologist. Tell us about that. Tell us about the challenges that you were seeing that then brought you to the areas of interest that you're in now.

[00:04:35] Daniella Gilboa: Yeah. So first of all, I wanted to thank you for this amazing opportunity. My passion is really to talk about IVF and AIVF. So thank you for that. And yes, I'm a passionate clinical. I actually have two hats, clinical embryologist and a biostatistician. So I look at IVF, sorry, I look at IVF from the very, from let's say bottom up from the, from the clinical work and embryology and facing patients.

And also let's say from the top down as in looking at the data and trying to understand like different trends and correlations. so this gives me, I think, a holistic view of IVF from the inside and out and inside again. So I'm a passionate embryologist. I live and breathe embryos. I'm a big believer in time lapse.

I think time lapse, the introduction of time lapse into the IVF. Labs was something that empowered embryologists. It gave us real true knowledge of, embryo, sorry, embryo development and evaluating embryos. I think it became, it, brought us embryologists to do more of a data driven decision guesstimation.

So I'm a big believer in time lapse, and I've been working with time lapse for many years. It was introduced to the market, I think in 2012. So yeah, so it really, and time lapse for me was really the first step of AIVF because what time lapse did mostly is introduce data to clinics. Time lapse allows the clinics to actually generate data, and once you generate data, you're not only relying on embryologists copying, the patient's folders into Excel.

Once you generate data, you have the power and the knowledge and you have real value. So I think this is, this was the first step that the industry of IVF and the IVF professionals became to realize. That they have something here that could, I, think us as an interest, industry realized that we have something that could really take us forward and really move the needle.

And so this is where, IVF was, born due to the realization that A, we now have data we can work on. So we could transfer IVF from a very clinical biology into tech. Enabled ecosystem. so this was, the, understanding that labs have are able to generate data. And the other reason of course, is what I've been experiencing as an embryologist in terms of how, you work as an embryologist and the workflow and the success rates and the interactions with the physicians and interactions with, patients and with, my peers, with.

other embryologists and maybe can we really take this very complicated and sophisticated setup and do it maybe different to help more and more patients realize the dream of having a baby. So this was like a very vague kind of concept. back in around 1960, 1917. And I'll just add, this is where I started thinking about maybe doing something else than a clinical embryologist.

And I started my PhD thesis. It was in the field of biostatistics and IVF. And so the, company was born from, my years as a PhD student. 

[00:08:48] Griffin Jones: with a background in embryology and biostatistics, it seems to me like you'd have a pretty unique point of view on both the macro and the micro and how they come together.

So tell us about the, macro that you were seeing and the micro that you were seeing and Where they come together, how that's affecting personalized patient care or a lack thereof. 

[00:09:18] Daniella Gilboa: So, we've been hearing about personalized medicine for some time now and it's it became like a slogan, like we do personalized medicine, but what's the essence and where does it meet us?

the, IVF ecosystem. Do we really give. personalized medicine? So the answer is no, not yet. then IVF clinics as, they work now, as we work now, there's no personalized medicine. There's we understand like profiles of patients and this is what we could treat, like profiles of patients.

So we talk about different age groups, for example. So we talk about the 34, the 34 year old patient or the young patients or the, advanced age patients, but it's not, There's nothing personalized here. So it's, profiling. going down to the, if, I analyze the industry as an industry or, IVF from the bottom up and top down, so I think we realized two major trends and this is very interesting and so let's start with 40, 000 Viva.

48, 000 feet above ground and understand like the macro. So what happens macro and, this is interesting is a trend, I think a decade now of IVF becoming not just under medical indications, but rather something that we might choose to do. Like we want to plan our fertility journey. So like 40, 000 feet above ground, we see two major trends.

This one is IVF is now not only under medical indication, but rather something that we might choose to do. Like we want to plan our fertility journey, we want to understand more and maybe even control it. So this is a way for us, so IVF is a way for us to do it. First, I think it's, a decade now, I think 2013, we can freeze our eggs.

We want to delay childbirth. IVF is a way to do preventive medicine through PGT. New families, surrogacy, all this drive IVF to be social IVF, not under medical indications. So more and more people are seeing IVF or, are looking to do IVF, not because they have any medical indications, because they actually choose to do IVF.

So this is an important and interesting trend, and we see it more and more, and there's even a very interesting, paper that was published, I think, in Nature, trying to predict the effect of IVF by the end of the century. And, the numbers are about 3. 4, 3. 5 or 4 percent of global population would be IVF.

So this is big numbers. This is enormous. This is amazing, unbelievable. So this is the demand. Demand is IVF is growing enormously and it's not going to stop. And then there's the supply. The supply, the clinics are limited because we do mostly things, it's an art. We always say the art of ART, so it's, an art.

It's subjective human analysis, and it's really based on, on. the, group of embryologists and, everything in IVF is expertise. So it's not just OBGYNs, it's IVF experts and it's not nurses, it's IVF nurses and it's not biologists, it's embryologists. So it's another layer of expertise.

And so the fact that we have scarcity of IVF specialists and scarcity of embryologists, and, the way. we communicate and we do IVF by hand. So this makes the supply side to be limited, so unable to scale, not able to scale. And then the demand is huge. So demand versus supply, huge demand versus limited supply.

The only way for us to ever bridge that gap is by technology. And so this is where IVF comes in and we say, we come from the supply side, deep within the supply side. We understand the supply, we understand the state of mind, we come from within and we know what it means to do IVF and good IVF. And we know what, it means to have a group of embryologists that are, the end of the day doing the magic.

So we are here to create this technology, this magic that will help the clinics scale. the clinic's scale, more demand, or patients are able to realize the dream of having a baby. at the end of the day, this is the way to really move the needle and help more and more people. 

[00:14:30] Griffin Jones: On the macro, you have the giant global demand, the increasing global demand, not just from what's currently come from a medical diagnosis from infertility, but those that are doing their family planning in many different ways, whether they're same sex or single women or delaying childbearing, or perhaps more so in the future, those that are, that want to prevent genetic diseases.

And then there will perhaps be more implications in the future after that. And then on the micro side, you're seeing where, why the supply is falling short of the demand because you're working in the IVF lab, and the only way that the supply will be able to meet that demand is through a technological revolution through major technological advancement.

We're not there yet. And it sounds from talking to a lot of people, it sounds like we're, far and we're close. Like we're both far and close at the same time. You, which one do you think? Do you think we're further or closer? 

[00:15:30] Daniella Gilboa: No, I think we're there and I think that technology is there and I could only speak about the IVF, but I think that technology is there and I think that there's excitement now, and we see it, in the industry and people are willing to try and understand that this is part of, the evolution. It's not a revolution, it's an evolution. And so I think, it's there and it's, and I'm very optimistic.

I think we're now in a very exciting Time where we actually see the industry that we so much care for and you know the science IVF science Really changing and evolving into the next generation and you know We are there to lead it and it's very exciting and in fact I see the industry, of new technologies that is now forming.

And it's an industry and it's actually an industry. It's not just a bunch of companies. It's not just groups of, university groups in universities. It's an actual industry and we see it forming. And, we've, we even have a conference every two years of the, IVF. So, the, technology industry of IVF.

So I think, we're forming groups and working groups and think tanks and we work together as an industry and we sit in conferences, the, domination of the very dominant pharma. That is a bit, slowing down, and we see the rise of the, our industry, and it's very exciting.

It's exciting for all of us. It's us, exciting for the, for the physicians, and embryologists, and nurses, and patients, and, all the stakeholders in, in the IVF ecosystem, because at the end of the day, this is a real revolution, a revolution in evolution of, a new industry. 

[00:17:32] Griffin Jones: So by being so close, that the technology has finally seemed to arrive and now it's not, I'm starting to see people implement it at rates faster and higher than they were even just two years ago.

You mentioned that we're not there yet with regard, meaning, meaning what the average patient is experiencing right now is not personalized medicine yet. what exactly needs to happen in order. for that patient to receive true personalized medicine, not just profiles. 

[00:18:05] Daniella Gilboa: Yeah, so that's a good point.

So just to clarify, clinics who are not using any new technology, the very old fashioned clinics or the conventional way of doing IVF, this is not personalized medicine. This is profiling. I think with the arrival and the introduction of these new technologies, we, are going to be able to provide personalized medicine as in I'm Daniella Gilboa.

this is my medical history, my age, this is where I come from. How will this affect my chances of conceiving? When is it going to happen? How long? Will it take me how much? Will I have, to, how much time do I have to commit to doing that? Do I have to stop working? Can I change my job while I'm doing IVF?

Can I maybe pursue doing my PhD when I'm, while I'm doing IVF? All of these questions, how, how much it will cost me, all of these, this is personalized medicine. So what exactly like the, what medication? Will, is the best for me, what protocol will be the best for me to produce, six, eight, ten mature eggs.

It's like, all of these, this is personalized medicine, and if I'm diabetic, how will this affect my chances of conceiving? If I had, if I have, I don't know. Some, disease in the background. How will this affect? Can I conceive? Maybe I should do, surrogacy. All of these, this is personalized medicine, but we don't have any personalized medicine in IVF today as it is today.

So it's not just the efficiency of the clinic and the lab. But it's always, it's also providing real, real precise medicine and all of this can only be, can only happen if we introduce technology and, AI driven decisions and data driven decisions and, that we get used to working with.

data and really monitoring different KPIs and understanding what KPIs are and what KPIs we want to, monitor and who's going to monitor that. Maybe, I'm a simple embryologist, instead of just doing the wet embryology and the wet work and ICSI and IVF and thawing and freezing, part of my routine task would be, checking the different KPIs and, analyzing the data.

This is another layer. That IVF labs needs to be doing on a daily basis, not just when they want to publish something, but on a daily basis as in part of really understanding how good you are is looking at the data and looking at the data. You have to have data. When do you have data? When you work with data, you need an EMR that's connected to a time lapse, and that's gen, actual generation of data that you could, work and analyze, and it, needs to be part of your thinking, part of the method, part of who you are as an embryologist.

[00:21:12] Griffin Jones: It's messed up, isn't it? How this level of personalization is in areas of sales and marketing, but not in areas of healthcare yet. Like on Amazon, Amazon isn't targeting people that, watch golf and therefore might like bourbon. They're targeting people who bought a very specific type of bourbon and then can send them, ads for.

Particular types of whiskey glasses. And you bought this and oh, you bought this bourbon at this frequency for the last two years, and therefore you probably want this next bottle coming to your house on March 24th. we've got this in areas of sales and marketing, but we're, pretty behind on it in many areas of healthcare, including fertility.

It's a way of life for you as you're describing it, this bringing technology to. the fertility field to provide personalized care in this way. Tell me specifically, what is, what's AIVF doing? Wow. 

[00:22:12] Daniella Gilboa: Okay. So thank you for asking. So we are, a great company. And the reason I say it is it's not just a company that's developing AI or, or like a product, it's a company that lives and breathes.

Breathe is embryos and IVF and the patient journey, because we have here a bunch of people, from different domains, all of them looking at embryology and asking, how can we make it better? How can we really make an effect on the patient and on the physician? The embryologist. So what I love about IVF is that we have mathematicians and physicists and product people, and engineers and marketers and sales and legal and finance.

All of them are looking at I-V-I-V-F and the IVF journey from different aspects. So this is great because as an embryologist, my interaction was only with. Fellow embryologists and physicians, but now we all, we've, we, I think we opened up the IVF ecosystems to so many other domains that is just really exciting.

So this is, so IVF or AIVF is, deep in the sense of that we do technology and we do science and we even do basic science and, and we really create. The next generation of, IVF clinics. And so now I'll dive into IVFs, AIVF. So we're, I said before, we come from the deep within the supply side, the clinics, and we're developing the operating system of a clinic.

What we want, what we provide now to the market is a one single system that everyone. So we take, we're integrated in the IVF lab, and this is where the magic happens, the IVF lab. And we connect the IVF lab to the physician, one hand, and to the patient, on the other hand. So it create, it becomes like a transparent lab.

so any data that the physician needs In order for them to deliver the news to the patient or to, make decisions, clinical decisions, they have on the palm of their hand any, needs or information that the patient needs. They don't have to rely on the nurse, or the administrator, or the physician.

They have, they sit. Decision making will always be with, the, physician, and with The, embryologist or the lab, but it's like empowering all different stakeholders to access the data and to see, to understand and access the data. So it's like a transparent lab and again, the lab is really the essence because this is where the magic happens.

So it's the connector. And so we are the operating system and how we do that. We're connected to all different systems you normally have in a clinic. Like it could be a freezing system. It could be an EMR, of course, the incubator, whether it's time lapse or non time lapse, and we collect all the data and this is where we come in.

So for different decision points that you have throughout. The process. We have our own very deep AI algorithms to help you make better decisions. It'll never be an AI that makes decisions without the expert, but it's part of your methodology. It's another layer of information that helps you assess and understand and and evaluate whatever you need to evaluate.

Whether you're an embryologist or. a physician. And about the AI, I'll talk more in a moment because it's, very interesting. And apart from that, there's a very deep engineering and product that needs to be facing different stakeholders and needs to be interacting well and needs to be very easy and friendly and empowering.

So it's, it's, there's expertise there. But at the end of the day, the way we envision IVF is that you log in the morning, you open the lab, you open the clinic, you log in into IVF, and everything is there. Everything. We bring so much, value to clinics that we work with, it's in terms of the AI, in terms of more and more modules, that it's just become something that you cannot do, you cannot live without.

And this is something that we hear from many clinics we work with and, for me, this is what takes us, what makes us wake up in the morning and, A good IVF clinic and happy physicians and embryologists and a good IVF clinics means many more pregnancies. 

[00:27:35] Griffin Jones: You've got a lot more on the horizon it sounds like in terms of increasing the number of solutions that, that clinicians, the lab directors can't live without and right now using AIVF to make decisions that they aren't making on their own, that they're using technology to make much more.

informed decisions. What are the operational efficiencies that you're helping with? 

[00:28:01] Daniella Gilboa: So the two KPIs that we collect and we monitor, as AIVF are efficiency and efficacy. Efficacy is success rates. And I truly believe that AI, any AI solution could do a better job than myself as an embryologist without any other tool.

looking at embryos and evaluating embryos and predicting which embryo is bound to be a healthy baby, which embryo should I transfer, freeze, when to transfer, how many to transfer. This needs to be I need an aid here, and any, it's, by the way, humans can never predict, we can only identify. We're not good predictors, we don't know how to predict.

So this is where, this is really the next gen, and having such systems help us with understanding. What are the chances of each and every, embryo to become a baby? and the prediction of the genetic makeup of the chromosome. By the way, this is interesting. I'll talk about that in a minute.

It's our genetic tool. So efficacy is really success rates and increasing success rates. And yes, we can do it because once you work with AI and AI helps you make decisions, you will see it in the success rates. It's that simple. and, the other metrics is, efficiency and efficiency is how well we work in an IVF lab and how we can take the group of embryologists and get them do more cycles.

So this is having them focused on the wet clinical biology and all the, about 50 or 60 percent of the IVF workflow, workload is due to reporting and documenting and QA, QC risk analysis, safety analysis. There's much work here. All of this could be automated. I don't need as an embryologist to do, to, to do reports.

You could have AI do the report for you, and frankly, it will, do a better report than I can do. so all of this is efficiency. This means that we can really save time. We could really reduce the workload. We could really get the group of embryologists do more cycles. See more cycles because 50 or 60 percent of their load could be offloaded 

[00:30:51] Griffin Jones: 60 percent 

[00:30:52] Daniella Gilboa: but something like that 50 or 60 percent, you know as you know from clinic as a whole is We do a lot of reporting and documenting and, speaking to physicians and delivering news to the physicians and on the phone and making, trying to make decisions with the physicians and consulting and all of this could be aided and offloaded from us.

So you know. As an embryologist, and I consider myself a very good embryologist, I'm gonna do the one, the, the tasks that are not yet, could not yet be automated, like ICSI, or thawing, and then, the actual biology, which we all love. And part of the, training, and part of the day to day tasks that I love, like embryo evaluation, which takes a lot of time, and if you do it correctly, it takes a lot of time.

This needs to be aided by AI. And so the way we would do embryo evaluation from now on is a bit different. It's less, looking at the different biological features and trying to realize whether it's, exactly right or it's, working with the data and understanding the data. So it's a bit different, but I think it empowers us as embryologists and as physicians to work with data and understand the data and leverage the data.

[00:32:28] Griffin Jones: I'm glad you brought up physicians because one of the implications of technology that technology should have is it should allow physicians to practice more personalized care. I think some physicians are worried about some sort of vending machine type of future where it's only robots delivering care and I don't think that's the case.

I've always said that human beings should be Must be doing that which human beings should be doing, and human beings must not be doing that, which human beings should not be doing that. We should be using this technology to deliver more personalized care. So how does this allow doctors to practice more personalized care, to give more individual attention to their patients?

[00:33:13] Daniella Gilboa: imagine you have everything out there for you and not really, not, not needing to look for the data. So you, open the, computer, you open your iPhone and you have, meet, this is Daniella, you see the picture, you see all the different information, medical information, medical history, everything is out there for you.

You don't have to look for anything and this is not even talking about AI, it's just really, accessing. the data. And so this is one thing. And the other thing, of course, is this is personalized medicine. It's like not profiling, but understanding who sits in front of you and being able to provide the best IVF care that is specific for this patient.

And this is part of the macro and micro that we talked to before is like someone who's, I don't know, it's like diabetic. We don't know now if it really affect. the, the treatment and the, chances. We don't know, you don't know what type of medication you should consider if she has some kind of, medical background.

This is one specific example, but all of this We'll help, we'll guide you, or we'll help you, much better doctor, if you are able to provide personalized medicine, and really know your patient from the inside and out. Not just a profiling of, okay, you're 35, and you've been getting this and that. So let's see, the way we do now IVF is, okay, let's see how you react, and let's see how many eggs you'll have, and let's see, the fertilizations rate, and let's talk to more and see, what we get from the lab, and let's decide.

Just before the, transfer, how many embryos, whether it's one, maybe two, we don't know how many will, grow to be a blastocyst. So let's wait and see how many will be able to really freeze. And we'll, we'll be in touch. You're always, it's like a, it's an ongoing thing. So it could be better.

It could be different. 

[00:35:32] Griffin Jones: When you talk about being able to, offload half of the embryologist's workload, I want people to think about that another way, which is, what could you do if you had twice the embryologists? And people often think of it in those terms. We gotta get more embryologists, we gotta try to recruit more, we have to try and take the other embryologists from the Other labs in town, we have to figure out some way of training junior embryologists up and many of those solutions need to happen, but also what we have to do is take away some of the things that the embryologists are doing right now because it, we The recruitment problem is not going to solve itself.

It's going to be around for a little while. And even if you can figure out the recruitment challenge to a degree, as the demand continues to increase, you're always going to have that same problem. And then add to that, Daniella, when I'm talking to younger embryologists, like people and by younger, I just mean like under 40.

And many of them want to get out. of the lab because, not because they don't like the science. They just, they don't want to do these rote tasks. They don't want to do all this manual stuff. They don't want to sit in a little box where they're just like, punching in numbers into spreadsheets and.

So talk to us a little bit more on that. 

[00:36:58] Daniella Gilboa: Okay. So imagine a different world where you would have embryologist experts in different things. So you will, have like more of a data embryologist, someone who's working on the data and, getting trends from the data. You would have more of a basic science, so you could actually see if you have, if you have enough embryologists, you could do basic science.

This is really interesting. You could do what I call computational embryology, and, this is a new, field. that is now emerging through the, by, because of the fact that we have data and actual new technologies. So this is computational embryology. I'll give you an example. Again, another way of doing research in the lab and really understanding embryonic development.

So It's part of empowering the, the embryologist. It's not just routine tasks. And I'll give you an example because you have AI that identifies different features in the embryo and features that cannot be seen by the human eye. then now you have a sack of new features that you haven't, you, never realized and are, were identified by.

machine learning. How does this affect embryonic development? It's a new way of doing research, and it's part data, and it's part basic science, but it's very interesting. It's computational embryology. It's like you have biostatisticians, which are, the intersection of statistics and medicine. Now we have computational embryology, which is the intersection of, embryonic development or embryologist with embryology with computer science.

So it's a new field that is emerging, and it's not only going, it's not the new, it's not the, only one that's going to be emerging, it's, one of, out of many, I, think. So, you've got research, you've got data, you've got the ones that are, really clinical embryologists doing the day to day, the ICSI, you've got the ones.

Doing more maybe patient facing and more consultation. And so you could have different layers. If you have enough embryologists, you could, you could have different layers. And you have this IVF system or, a new system that really manages everything in the lab and collects all the, data and all the information into one single point where, one single dashboard.

This is huge. This is really unbelievable. And then you have different tools, like prioritizing. What task am I doing first? I come in the morning. Which of the embryos I have to look first? Which one is, emergency? What's, like, All of this is through, a new type of solution. It was never handled before in a, in a conventional lab.

what if there is an emergency? Something is happening in one of the incubators. I will have no idea. But now I can't. So it's part of safety, and it's part of efficacy, and it's part of efficiency, and empowering the patients. And I think all of us caregivers, through working with AI, our jobs or our positions are going to be slightly changed.

And we just need to accept it. And I think it's, very exciting for me. It's very exciting. So one more thing about efficiency and, why AIVF is really, affecting the IVF in terms of scalability is that imagine you have the best embryologist in the world In each and every clinic, you don't have to actually look for, these, for that embryologist.

It's there. This is seeing IVF is the best expert in the world. It could be the best physician, IVF expert. It could be the best embryologist, but it's there. And it does exactly this, it does, efficiency and efficacy. So I think it really, changes. The way we do IVF, this is clinic patient as patient wise and this we see, we've been collecting data for some time now and we see that it really affects time to pregnancy.

[00:41:31] Griffin Jones: you're sharing different aspects of efficiency, but I, and efficacy, but I'm seeing how they bridge together that you have to have the embryologist doing that which the embryologist should be doing, or otherwise there's too many distractions and too much wasted work. And that can lead to safety issues.

And we've seen safety issues of. A lot of different kinds happened in the IVF lab the past some years. They're all bad. They're all, really bad for that particular lab, that particular clinic. They're bad for that person's career. They're bad for the patient because dreams are shattered.

They're bad for our field because of the public relations that happens from it. There's things going on right now with lawsuits happening. And, and we have embryologists doing. manual work that could be automated. if we have them unaided where technology could be aiding them, then I think we would expect to see more incidents where there could be less.

[00:42:36] Daniella Gilboa: Definitely. Definitely. And I think the way it will affect our lives is. Something that we measure and we monitor as we speak, and it's seeing a chat GPT for the last, I don't know, a year or so, and seeing the responses and the interactions of people with this tool, and each one of, us work with it differently, so I think we're, this is something that we will see in IVF clinics as we go along, and some clinics would see it more as a, most of my embryologists are junior, now I have a very, senior best embryologist in the world here, I'm more relying on this.

so I don't care about the reporting and documenting. I just need that all of the, decision making would be made by AIVF, of course with the embryologists, but something that they would be more relying on. such systems. And some other clinics would say, great, this is a great tool for, for AI and for embryo evaluation.

But the other modules are something that are much more needed in this specific environment and in this specific lab. So I think it's just, it's different for, different settings. And it's very interesting to see the, different effect. For me, I think everything is important, but for me seeing embryologist interacting with the AI, it's really like iterations, like asking questions.

And as an embryologist, working with something like that and having such another layer of information that helps me make better decisions, real decisions, like which embryo has the most chances of becoming a baby and which embryo is. genetically normal or abnormal, even without subjecting it to biopsy.

I now have a tool that predicts ploidy status. This is huge. This is a game changer. And I just need to realize, and it is an embryologist, that all of this data empowers me and makes me I'm a much better embryologist, a much better caregiver, and, the system as a system would do much better IVF care.

I truly believe in it, and I see, now clinics are much more interested and excited, and I think they understand the value. 

[00:45:21] Griffin Jones: Is this what you're talking about, being able to see the aneuploidy of a, of an embryo? Is this moving towards non invasive genetic testing? 

[00:45:32] Daniella Gilboa: Yeah. And again, it's a screening tool.

It's not a diagnostic tool. It's not PGT. It will never be PGT because it's not a diagnostic tool, but as a screening tool, yes, it's, exactly this. And it gives us a prediction. And a very good indication of, okay, we have a bunch of embryos here. Should we subject to biopsy? Should we not? We can consult the patient, maybe the patient would say, this is And now for me, I have two, good looking embryos, they seem to be normal, let's transfer one, freeze the second, I don't need to do PGT, I don't want to do PGT, I'm afraid of the biopsy, or I only have one embryo.

And I'm 42 years old. I do not want it, never ever biopsied. So up until now, people really didn't have a choice because part of the game and part of the, state of mind is not only is it a good looking embryo, but is it normal, abnormal, is it healthy? And so I think now, so for, before AIVF, the only way to answer such a question is to do biopsy.

most. Really, most cycles are PGT, but now we have another layer. And this not, another layer, this layer is very interesting. It's another way for the physician and patient really consult and discuss and the end, of the day, everyone wants the best for the patient and they want her to succeed.

We want her to succeed. So it's just another tool for us to discuss how can we create this, how can we get this cycle to, to be the best for you. 

[00:47:21] Griffin Jones: Tell me more about the impact that's going to have on the field, because I recently recorded an interview and that one might actually air after yours, but I was asking the person, what do you see as the, this is the biggest need, that'll come down in the future and yeah, after, the interview, she said, Oh, it was, non invasive genetic testing.

That's what we need. So what is, what impact do you see this non invasive genetic screening having on the field? 

[00:47:49] Daniella Gilboa: I think it's a game changer. I think it's exactly like the NIPT. What NIPT did to, pregnant women, and, it's being able to access screening tests and understand, by the way, it's really understanding the, what you're going through.

And PGT is really sophisticated and complicated, and it's, it's massive. Like you you free, you, go home as a patient. First of all, you do, A fresh cycle and you go home, without a transfer, right? And then you ship it out to genetic test, genetic lab, sorry, you do the biopsy, you ship it out, you freeze the embryos.

As a patient, I really wait for the result to come in and understand whether this cycle is worth something because it's. Are my embryos are normal or not? I don't know, and the embryos are frozen and then I have to come back again and throw the embryos and throw the only one that is normal. So this is the patient side.

Science side, this PGT is controversial because of the, fact that it has, we see a high rate of false positive, which is, it's there, it's there. So I'm not talking about the fact that the biopsy is a biopsy needs to be done by the best embryologist in the world. And if you, a clinic do not have the best embryologist in the world to do a biopsy, it's really, it might harm the embryo, right?

And the biopsy is a biopsy harms the embryos. This was something that was proven and even, published here and there, but it harms the embryos. It alters. The, timing of the development, there is, an effect, okay? And then, and the, hustle of everything, so you, need to have embryologists doing the ICSI, you need to have embryologists doing the biopsy, and you have to have a double witness everywhere, it's like a hustle, the, we all work for this hustle, and, but it's a diagnostic test, right?

it's a diagnostic test, but, and that's okay, that's great. So we're going to have PGT, always. But then, it's another layer in between that might, some of the patients would say, I want the screening tool. And, yes, I want to verify or validate that the embryos that were screened as normal are in fact normal.

Let's also do a biopsy on these embryos. That's great. Some patients would say, this is enough for me. Some patients would say, I don't want the screening tool, I just want the PGT. That's great. But I think the more tools we have and the more options we have, it empowers us to really give best IVF care. And now we have it.

And it's a game changer. I'm excited to see it. I'm excited to see it in work. we've been testing it. A lot before launching it and we're still always, collecting data and always, running studies in the publishing results and it, doing very good science and doing very good study designs is part of this ecosystem because It is science, so we always have to speak this language, but we actually see it happening and it's, very exciting and it's, here.

[00:51:28] Griffin Jones: At the beginning of the conversation you were talking about being a big believer in time lapse and I keep hearing that from people and so I started asking every embryologist, every lab person that comes on the show, I ask them, is time lapse a nice to have or a must to have? And everyone has been saying, I think it's a must to have.

And I've never worked in. an IVF lab. I don't have an embryology degree, so I need you to educate me a little bit. But the first time I asked you that question, is time lapse a nice to have or a must have? You said time lapse isn't just a must have. it's a way of life. What did you, mean by that?

And what helped me as somebody who's never stepped, or of course I've stepped foot in a few IVF labs, who's never worked a day in an IVF lab to understand why it's a way of life. 

[00:52:16] Daniella Gilboa: Okay, before that, I want to tell you a story, I'll call it a story. So I think in the first days of, time lapse, so people, the, first response was, let's see if it's a better incubator than the conventional incubators.

So every, everyone like ran studies on the time lapse incubator, versus. It's the conventional incubator and it's like the same, like you don't see more or less, like you don't see more pregnancies in time lapse versus a conventional incubator. So like the, so, everyone were, was very frustrated with, okay, so why do we need to spend so much money on time lapse?

It's a gimmick. the, IVF center where I worked, huge IVF center in Israel. So they were saying like, it's a gimmick and we don't need time lapse. And it's not, and this is not the question. And I was like, really, I was angry, so much angry. And I said, it's not the right question. You're not studying.

The right question. it's not an incubator versus an incubator. Timelapse allows you to generate data. This is it. Okay. it's a, it's an incubator. It's closed system, which is of course better than any open system, but it's a closed system that has a camera built inside that captures images of the embryo.

Every 10 15 minutes, something like that, and so you end up after 5 6 days, you end up with hundreds of images that are translated, this is time lapse, okay, translated into a short video of the developing embryo. So do not tell me that you could do better evaluation based on one single image every day you have 3 4 points, rather than hundreds of points.

This is data driven decision making. And this was the early days of data driven decision making in IVF. This is one thing. The other thing, it generates data. Real data, okay? It's not me, copying to an Excel sheet, row after row. It's, automatic generation of data. Once you have data, and now, you, we can connect everything and we could connect the patient's history to the embryos and to the child that is born.

This is like longitudinal database, which is huge in terms of the value and the understanding of IVF and your IVF center. And all this could be done if you generate data. And data generation is not me copying things to an Excel sheet. this was like the early days. And now, it's a way of life.

Because, again, this is, this decision making could, should be made by looking at data and understanding what I do good and what I do wrong. And by the way, when we train algorithms to understand embryonic development and we see that an AI or, an algorithm that was trained on one single image cannot extract enough data rather than, the entire development from day zero to day five or six.

So I really don't understand, I don't understand clinics who are saying no to time lapse, I admit. 

[00:56:05] Griffin Jones: I think you may have summed up the crux of the technological revolution. IVF is that we'll never scale this if we're manually entering data into spreadsheets in order to scale, you have to have data and you have to have mechanisms for According and producing that data, then you've walked us through a lot in what's happening in the AI revolution in the IVF lab today, we talked about personalized care and what it actually means to deliver personalized care versus what's currently being done, talked about how that can be used to give doctors more time to practice personalized care and have a better experience for the patients you talked about specific operational efficiencies.

in the IVF lab and talked about the impact of non invasive genetic screening here, now, and perhaps more on the horizon. You talked to us about why time lapsing is a way of life, how it unleashes, and what you're doing unleashes the power of time lapse incubators. How would you like to conclude about the problems that AIVF is solving?

[00:57:13] Daniella Gilboa: That's a good question. let me finish by some optimistic, Looks or, or just the optimism of this industry. I think we're now in a time where things are happening and it's, a, it's an, we're going through an amazing process of technology coming into our lives and we have to find in within ourselves, as clinicians and as, embryologists, as.

As, IVF centers, we have to understand that this is the time for us now to really engage ourselves with these new technologies and to understand that's more and more to come. And we, if we choose not to engage ourselves with technological innovations, then we'll lose at the end.

We'll just stay behind. And the, the. these innovations are happening in a very fast pace. It's just going so fast. And what's now, beginning of 2024, it will be completely different. In six months and in a year time, it is what it is. It's not going to take forever. It's not going to take five years.

Like in five years, it's like my mentor in the PhD, she said to me, she said, you're going to have an amazing PhD, but in five years you'll end up with a very nice publication. And someone else. We'll actually create it and put it in IVF labs. So what I think you should do is you should found a start, you should go and do a startup.

This is what she told me and, yes, it's so right because it's just going so fast. So I think we're now in a point in time that we see these changes happening and it's just exciting and it's great and we have to do it. So join us. Everyone, join us in the science, in the technology, in the quest of what's next for IVF and how we can help more patients realize the dream of having a baby and help us really bring this evolution slash revolution to life.

[00:59:46] Griffin Jones: I hope they do and thank you for sharing this vision of the future of a more effective and more efficient form of delivering IVF and fertility care to patients that need it in a personalized way that aren't getting it in that way today. Thank you for sharing that vision with us. Thank you for taking the time to come on the Inside Reproductive Health podcast.

[01:00:10] Daniella Gilboa: Thank you so much, Griffin. It's just a pleasure. 

[01:00:14] Sponsor: This episode was made possible by our feature sponsor, AIVF, the pioneering force behind the revolutionary EMA platform. AIVF is at the vanguard of transforming reproductive medicine through cutting edge AI technology. The EMA platform sets new standards in precision IVF care.

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Thank you for listening to Inside Reproductive Health.

210 From a 2nd Year REI Fellow in the middle of the job interview process: Her thoughts on Fellowship, practice preferences and the future of the fertility field with Dr. Sarah Cromack

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.


Exploring all the different approaches to IVF.

That’s the objective of this week’s guest, 2nd year REI Fellow Dr. Sarah Cromack, who shares her thoughts on Fellowship, practice preferences and the future of the fertility field.

Tune in as Dr. Cromack shares:

  • Her 2 objectives for REI Fellowship (that every REI should have)

  • The criteria for choosing an REI practice (when navigating the interview process)

  • Why she prefers a bigger practice over a smaller one

  • Where she stands on the Fellowship length debate (3 years or 2)

  • What she’d like the fertility field to look like in 20 years


Dr. Sarah Cromack
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Northwestern Medicine
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Transcript

[00:00:00] Dr. Sarah Cromack: I think any group that has five or more docs you could consider as big because it means you're not going in every weekend or like you're not going in less than one week a month. So if you're, a four doc practice, you've definitely, if you're doing IVF on the weekends or you're probably on call one weekend a month. But bigger than that, so five or more, you may not have to go in at all during the month. 

[00:00:20] Sponsor: This episode was brought to you by Prelude Fertility, where top REI physicians find their calling. Practice anywhere with Prelude. The Prelude Network is the fastest growing network of fertility clinics in North America.

With more than 90 plus locations, we're ready to support you and your individual career aspirations wherever they lead. To learn more, please visit rei.preludefertility.com. That's rei.preludefertility.com

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.

[00:01:15] Griffin Jones: Every possible way to see how IVF is done. That's a noble objective for an REI fellowship, isn't it? In this episode, I interview an REI fellow that's halfway through her fellowship. Her name is Dr. Sarah Cromack. She's second year at Northwestern. She did her residency at UT Southwestern, medical school back home at Emory in Atlanta, and now she's thinking about what the future of the field looks like and what her future career looks like.

Dr. Cromack shares the two objectives that she had for her REI fellowship that maybe every REI should have. She talks about five of her criteria for choosing an REI practice. She's interviewing now what's important to her. Why does she prefer a bigger practice over a smaller practice? How do her interests align with the privademic model?

She didn't use those words, but it was something that I inferred. I'm curious if you infer the same. Where does she stand on the fellowship length debate? Three years versus two. And what does she want the field to look like in the next 20 years? If you're recruiting fertility doctors right now, I invite you to be a bug on the wall in this conversation and get to know what people in Dr.

Cromack's position are looking for as they interview for jobs. Enjoy this conversation with Dr. Sarah Cromack. Dr. Cromack, Sarah, welcome to the Inside Reproductive Health podcast. Thanks so much, Griffin. Happy to be here. I didn't even ask you in our prep, is Cromack how I pronounce your last name? 

[00:02:28] Dr. Sarah Cromack: It is.

Yes, I did just change my name from a much more complex Capelouto, which was my name before I got married. But Cromack was 

[00:02:35] Griffin Jones: How do you practice? Do you practice Dr. Cromack or as Dr. Capilouto? 

[00:02:39] Dr. Sarah Cromack: I changed my name and went for Dr. Cromack. It was a bold move to change in the middle of fellowship, but I went for it.

[00:02:45] Griffin Jones: Welcome onto the program. I look forward to talking to you about what you want to get out of your fellowship, your second year fellow at Northwestern. And so I want to start broadly, it's, it has surprised me how popular some of the fellows episodes have been, not just with fellows and aspiring fellows, but some of the Docs that are closer to retirement or maybe halfway through their career.

Sometimes it's because they want to grumble at what the fellows think is an ideal picture of what they're going to do with their career. And sometimes I think they're just curious to be bugs on the wall. I try not to let the fellows be too Bushy eyed without, sharing some of their own experience and what they want.

So every one of these interviews is an end of one, a focus group of one. But this I do think it's interesting just to see what people are paying attention to. And you were connected to me through our Mutual friend and your colleague, Dr. E. Feinberg, and she had a lot of good things to say about you.

So you're doing something right in in, in the very beginning of your career. And I'm interested in what you're paying attention to. So what are you trying to get out of your fellowship? 

[00:03:54] Dr. Sarah Cromack: Yeah, absolutely. I was, so I'm definitely providing the young millennial perspective of this. If anyone wants to listen, that's not a millennial, I guess that's a.

You know what you might get out of it, I would say right now in terms of what i'm getting out Of a fellowship i'm super lucky to be in a fellowship that has a lot of attendings We have 12 faculty right now, so one of the biggest things I'm doing is just trying to figure out like every different way you might possibly do IVS and go and see a patient.

So that's the nice thing about being in a fellowship where you have lots of different opinions is you can see so many different ways to do something. So that's one thing is I'm just trying to be like as absolutely well versed and know that when I exit fellowship, I will have seen everything out there and all the different ways to handle it.

I think another thing I'm trying to get out of fellowship is really trying to discover what my niche is. REI is a very, it's a small field. It's a small subset of what a general OBGYN does, but it has so many different aspects to it. It's actually almost crazy. You could focus on uncle fertility, you could focus on third party reproduction, you could focus on recurrent pregnancy loss.

And so I think that's one of the nice things about my fellowship is seeing what act really interests me and what can I say, Oh, I think that's going to be my niche in the future. And those patients that I actively seek out and try and make as part of my population. 

[00:05:13] Griffin Jones: So when you say you want to see every possible way of doing IVF, what does that mean with PGTA, without, with ICSI, without, tell me what does that mean every possible way to do IVF?

[00:05:25] Dr. Sarah Cromack: Absolutely. There are so many different protocols you can use, not just that, but how you actually follow someone throughout the stimulation cycle, how you increase their gonadotropins, whether you start with high dose, whether you start with low dose, what level do you trigger at? Do you trigger when they have two follicles over 18?

Are you someone that pushes further? You're looking for follicles 19, 20 millimeters. Are you always doing a mini STEM? Are you always doing antagonists? So we have so many different doctors and we all, they make decisions for each other. So because of how big the practice is, not everybody is making that decision every single time on their patient.

Although we all are, they're always following their own patients. But you'll see how different docs might do a different thing in IVF, and yeah, who's more likely to do ICSI all the time, who's almost always going to have their patients do genetic testing, or who's going to really convince people to not do genetic testing.

And so it's crazy to me that there's just so many different ways that you could do it. And really, it's just all about making sure you're on the same page with your patient. 

[00:06:25] Griffin Jones: So how do you know what you don't know in terms of the different ways that you can do it? To your point, there might be a certain number of protocols out there, but there's all different types of ways of doing patient intake.

There's different ways that, people might structure their, the lead up to IVF differently and what they do in the case of a failed cycle or what they do subsequently. So there's all these different ways. And how many docs are at Northwestern? We have 12. You have 12. Okay. So that's a ton. So you might be able to cover your bases with 12 docs, but they are in one place and there's, an infinite ways of doing things potentially.

How do you know what you don't know? How do you get experience if what you really want is to see every possible way of doing IBF beyond just what's available in your program? 

[00:07:12] Dr. Sarah Cromack: Absolutely. I think there's really two ways you can do it. There, there are so many REIs and IVF docs that are now on social media and a lot of them are using it as like an education platform.

So I know there's a doc at a Wash U that has these awesome whiteboard videos where he is. showing you the different protocols, what he typically does, walking you through someone's stimulation cycle. And so you can look out there and see what other people like on social media are professing as the thing they do for their patients.

And you can also, go to conferences, stay on top of research. I, I monthly, I make sure I get that FNS email that sends me like, what is the latest update? It's always nice. You can look and say, oh, this group from. Like California, this is what they have been studying and looking at for IVF or SVT protocols.

So staying on top of research it's nice. And I like getting those push notifications either through email or on Twitter too, following SNS, and you can really see what's out there and what people are doing. 

[00:08:07] Griffin Jones: This conversation will probably come out in spring or winter of 24. You and I are recording the conversation in December of 2023 which puts you about a year and a half into your fellowship, right?

You're about halfway through. Yep So you got it. What have you? Have you started to form like really strong opinions on certain things? Because I'm not a clinician at all. I I am not qualified to read the scientific literature. I just observe human beings and I see different docs who I presume are each very qualified to read the scientific literature, sometimes have very different opinions.

You have very different opinions on how prevalency should be used. You have differing opinions on the significance of aneuploidy and the use of PGTA. And I hear people debate this and say, okay, you're, you've both read a lot and you've both argued this for quite a bit for years. And it seems to me like it, at some point people I feel like they're convinced by a certain body of evidence, and then it's really hard to, then they would need a lot more evidence on the other side to make them think differently.

Have you started to find yourself in a couple of areas where it's now I feel strongly about X and I didn't coming into fellowship? 

[00:09:26] Dr. Sarah Cromack: I will say I feel like I'm still pretty open about most things. You're totally right. People will debate things until the end of time, especially in a lot of REI topics.

That's why they have that like fertile battle in the fertility and sterility journal, because it's just showing there are so many things that are good ground for discussion. I think so many people get really entrenched in ideas about, like you said, whether or not you're going to do ICSI all the time, whether or not you're going to always do genetic testing.

I think I'm super lucky to practice in a state like Illinois, where there's an insurance mandate. So we don't always have to include monetary considerations into treatment. Right now, thankfully, I'm very open. I really think just to doing what is best for the patient, giving them my opinion on the matter and letting them decide, thankfully without a monetary constraint for the most part here.

But I would say I've read enough literature to support both sides on most of these topics that I have not decided what my final opinion will be. And I'm okay with that. I think it's nice to be able to see both sides and offer patients either, as long as they're both reasonable. 

[00:10:29] Griffin Jones: How about protocols?

Are there certain protocols that you are starting to find yourself feeling very strongly about? 

[00:10:35] Dr. Sarah Cromack: Yeah, I think most of the people in the world of REI these days are probably going to be most strong about the antagonist protocol because it's easy for patients, and again I'm lucky in this, in the state of Illinois that Thankfully, things like Generelx and Cetratide are covered by insurance because they're not cheap.

But, there's interesting things out there. People starting to use things like Provera, which are really cheap to block ovulation. And so I think as we go along further in this road and we discover more and more medications, hopefully, We can drive down the costs. Right now I really think about most protocols from, what is the easiest for the patient standpoint, because what we're asking them to do in IVF is really hard.

And I get a lot of pager phone calls about difficulties drying up and injecting medicine, so I'm always super cognizant of that. 

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[00:13:38] Griffin Jones: I'm curious to see if Many REI fellows are malleable enough to work in a system like the one I'm about to describe.

So I don't know if it was like a year or so ago, I interviewed the CEO, Dr. Murdia of Indira IVF. It's one of the largest fertility clinic networks in India, and they have 250 at the time they had 250 fertility docs. Now that. The definition of that word is a little bit different there because they don't have three year R. E. I. fellows. It's someone that is a fertility specialist in India, simply someone that went through OBGYN training and then now focuses in fertility. So the difference in the word is important, but they've got 250 some docs in their network, and they all practice one set of protocols. So in this situation, if it's In this situation, you do this protocol in this situation.

You do this protocol. And I said, I've worked with fertility clinics that have two docs and they practiced different sets of protocol. How do you get 250 docs to do that? And he said, I only hire docs that are younger than I am. And that's how this is the way we're doing it. And we make changes, but only at the systemic level.

We'll make changes to the protocol once we see stronger evidence or All Or maybe new therapies being introduced, but only at the global level when you know, the Advisory board has voted on that but we don't let people do this protocol here and that protocol there. Do you think that I'm asking you to take a straw poll and just put your finger to the wind and guess But do you think that your colleagues your fellow colleagues that you know would go along with something like that?

[00:15:20] Dr. Sarah Cromack: I would guess that about 90 percent of them would not be cool with that if I, I had, I think this is the individualism of the doc here and making our own decisions is probably something very important to all of us that has been, training now for this extra three years and four years of residency and all of the time before that.

So I think we really do have a culture where we're probably. going to want to do different things for everybody. And I think too, we really are taking the patient's opinions into account. And a lot of times people will come to this and they said, I failed this protocol at XX at YZ clinic.

And now I want to try this protocol. And if it's not unreasonable, I think it's fine to do that. And so I think it is certainly their benefits to have a very system, like a systemized. Way of doing things and you can decrease medical errors like that, but it's nice to be able to play with things and give people different options for success, even though sometimes we know that doing the different protocols, you get the same result.

[00:16:16] Griffin Jones: Tell me about why that individualization is so important to you as a fertility specialist and before the audience thinks that answer is obvious from a business. Person's perspective. It's not entirely obvious because we have a massive pool of demand for fertility services. We have a limited supply.

We have a real big problem with the number of people that can get treatment that can't afford treatment. And one of the things that by definition scaling means is doing things the same or similar way. And so tell me why that individualization is so important to you as a specialist. 

[00:16:57] Dr. Sarah Cromack: Yeah, no, I totally understand there's like obviously a dire need for more REI doctors and people practicing in this country and if we can Protocolize it to make it easier So that people that are not necessarily REI docs, but are OBGYNs or other can apply these protocols to basic patients, then we can really improve access.

The problem with that then becomes that what is the importance of the REI specialty and why are we doing all this training for three years to learn these different nuances? And there are. So many different patient situations you're going to see and each one of them really can require something a little different.

And I think some people really want you to tell them what you think the best protocol is. Other people want it to be more of a shared decision making based on things they tried before. Other people might just want to change because they didn't get a great result with the last protocol and they want something new.

And so I think, especially also when you would consider sometimes the cost of somebody's treatments and how much people are paying out of pocket, it is really important to be able to take the patient's perspective. into what you're doing. And so I think being able to individualize and provide something that is more really for that patient and that you've discussed with them, makes people feel like they're not like, Oh, just another number in this giant factory of IVF that we're doing.

[00:18:14] Griffin Jones: Maybe that intersects with the concept of niche that you talked about earlier in the conversation. One of the things that you want to do in your fellowship is figure out what niche you're most interested in. What have you clung to so far? 

[00:18:27] Dr. Sarah Cromack: Absolutely. So I think right now what I'm really interested in is oncofertility being at a huge program like Northwestern.

We have a fertility preservation navigator nursing team who is amazing and gets referrals from our community. Absolutely. Children's Hospital, from our adult hospital, from other hospitals in the region of patients that are really quite sick. So we get, patients with sickle cell, patients with leukemia, patients with any number of cancers that really need to do IZS rapidly to be able to preserve a chance of having a child with their own eggs.

And a lot of times these people are so sick you have to take them to the operating room to do a retrieval. You have to sometimes admit them after if they have a complication related to their underlying disease. But we have been able to, thankfully, with all this coordination, bring these patients through safely and give them this like amazing opportunity to possibly have a child when they, finish their treatment or get a stem cell transplant in the case of things like sickle cell or anemias.

And so I think that's something that is really bolstering the importance of being able to really specialize and take your time to understand what, what happens with REI in a fellowship because this is not something that you could do just by learning it quickly. It's something you have to see over and over again and really feel like you've got, you're highly trained to get these patients through when they're otherwise quite sick.

[00:19:46] Griffin Jones: These two objectives that you laid out, finding your niche and then seeing every possible way of doing IVF. Do you feel like both of these objectives were laid out for you in well established tracks? Or did you have to do some veering off of an established track in order to be able to achieve those objectives?

[00:20:05] Dr. Sarah Cromack: Absolutely. So definitely the seeing every different way to do It was right in front of me with the ability of having so many different IVF docs and we're on every third week on call. And so we get to make decisions, run through different IVF protocols with all of our different docs because they rotate call.

So that one was, that one's easy. You can, we really are able to learn on the job, which is awesome. Finding a niche, I would say is something a little bit more. Went out and searched for it based on what a lot of my attendings were doing and following and shadowing in their clinics, see what I thought was the most interesting.

And so that when you certainly have to parcel out what you think is the most interesting and hopefully get a good mentorship from that, which I've definitely been able to do in my fellowship. 

[00:20:44] Griffin Jones: Is there any other type of track or any other type of objective that you feel you, you don't really see fellowships necessarily offering that the fellow has to take up upon themselves?

[00:20:55] Dr. Sarah Cromack: Absolutely. Good question. I think obviously the world of REI is changing with all of these larger corporations taking over sometimes smaller clinics. We're getting huge venture capital or private equity firms that are now involved. And so one thing I think I have to explore myself is just what the world looks like after fellowship in terms of the business of REI.

Certainly we learn a lot of the clinical aspects caring for patients, but we may not learn as much. Like how to run a practice, how to, work along with colleagues in these different business models, whether your private practice solo or going out and joining a bigger conglomerate.

And so I think, certainly it is something where you have to explore it yourself to see. What the different models are out there. Cause that's not something you might learn in these kind of academic programs that most of us are in. 

[00:21:44] Griffin Jones: What does the world look like for you after REI fellowship? Are you still on the dance floor or have you signed with someone yet?

[00:21:52] Dr. Sarah Cromack: No, yeah, I'm still looking for a job right now. So I'm in the midst of my job search, but certainly that job search has gotten earlier and earlier, which is something interesting. And actually, we're doing a research study on that right now to see the trend of. REI fellows in the last 10 years, what kind of groups are they joining?

Are they going more academic? Are we seeing more people go into these larger private practice, mega groups? And so I'm still searching out there. We'll hopefully, I'll find a place close to my family, but. It's interesting, the job market, and I think maybe people are getting into it really early without realizing all the different things that are out there.

[00:22:29] Griffin Jones: How are you prioritizing your job search? What's in your criteria? 

[00:22:33] Dr. Sarah Cromack: Great question. I think when you exit fellowship, it's the first time in your life where you say, Oh, this is maybe the place where I'm not going to move for a while. You jump from college to med school to residency.

And I'm from the South, I'm from Atlanta originally. I was there for med school, but I was in Nashville for college, I was in Dallas for residency, now I'm up in Chicago. So it's really the first time where the power is in your hands. And so that's strange. So I think there are lots of different priorities.

For me, one of them, I would love to be back closer to my family, which is in the South. Which is something that it's nice to be able to finally prioritize that. Sometimes you don't have that luxury and the match system with residency and fellowship. You can certainly hope and do your best, but now you can really put your own priorities there.

So I think that's important to me, but then of course, other things are going to be, the culture of the practice that I'm joining, I'd love to join a bigger group practice. I think you have to decide. Do you want to be in a place with a lot of MDs with fewer MDs? Do you want to be in a place that's, physician run that possibly has a venture capital or private equity backing?

Do you want to be in a place where you're interacting with residents and fellows? That's my hope. And so there's so many different things that are involved in this job search. And I think we're also seeing less and less people stay in that one job their whole life. Like my parents are both physicians and they've had the same career as physicians for the last 25 years.

So I think we are starting to see a little bit more of people bounce around from job to job. 

[00:24:01] Griffin Jones: Yeah, that's been true in the workforce at large for probably 30 or 40 years, but it was probably less so in the medical profession during that time period. It was still probably the case, and especially among providers that folks Stuck around for four at their hospital or their practice for a while, especially if it was their practice, but now we're seeing, we see partners leave, we see partners get bought out and then start up something new.

We see people go be associates someplace and then not get on a partnership track there and then go get on partnership track elsewhere, be employed elsewhere. So I hadn't thought about that trend before, but I think it's. Generally expected here. Now, at least, hopefully not like the rest of the job market where you see a lot of resumes.

It's eight months here, three months here. We can't have that for providers. But if you go a couple different places over the course of your career, I think we're all okay with that. You mentioned that you're well, let's you mentioned a couple different criteria. The first time the power is in your hands to choose the geo and I never really, before being married to a physician and going through this process and then becoming friends with so many of your colleagues, I never had really considered this part of the reason why I started my company 12 years ago is because I was like, I want to live wherever I want.

And that is just simply not the case if you're a physician in training. Yeah. And so now for the first time. You have this. And so do you mind if I ask where your family is from? What general area your family's from? 

[00:25:36] Dr. Sarah Cromack: Yeah. Yeah. I'm, my family's right now is in Atlanta and my husband's family's in San Antonio and Texas.

So mostly for the South, this is the most north I've ever lived, but you know what? I actually like it. It's quite cold, but I have a nice jacket. 

[00:25:48] Griffin Jones: Chicago is an amazing city. If it had the weather of a further South city, it would be a pop. It would have a population of 40 million people.

It would be the largest city in the world. The winter is the only thing keeping things under wraps there. But so the reason I ask is because Atlanta is a pretty large city and it's a very large city. It's probably top 10 metro and it has a good number of fertility docs. I don't know if they're if yeah.

Yeah, relative to population. But would you ever consider a small market or it's probably just going to be Atlanta or Texas? 

[00:26:19] Dr. Sarah Cromack: It's a great question. I think there's definitely benefits to being in a small market, for example, like you could go outside the city of Atlanta. You could go to Chattanooga.

Or you could go to Birmingham, much smaller markets, and that's nice because you do have a little bit more control and you have less competition in your surrounding area. So you may be that REI doc for, you or five other people might be the only REI docs in the area. So I think there, I definitely would consider like possibly smaller markets, but I do think, in, in medicine in general, so many people are closer to the big city just because that is, the urban space where a lot of us want to live.

But there is definitely a dearth of REI providers. For example, in Georgia, I can't imagine there's many outside of Atlanta or Augusta. There's a lot of other cities there. So we, I think it's nice that as we get big groups like, the U. S. Fertilities and Boston IVFs, we're able to expand and make satellites to reach those people in those more rural areas or, not even rural, just not the main city.

[00:27:17] Griffin Jones: So you're open to a smaller market. 

[00:27:19] Dr. Sarah Cromack: Definitely. I think so. I think it's real. I don't think I'd want to be the only REI doc somewhere. And I think it's hard. I think we are losing. I don't think there's a lot of solo REI practitioners anymore as we see kind of these changes in the market. But there is something nice about being, that person in that area.

[00:27:35] Griffin Jones: Be like a Delta flight back to Atlanta or whoever flies to whoever San Antonio's. Yeah. Just something like that, just close enough. Close enough. 

[00:27:43] Dr. Sarah Cromack: I'm always, I love getting in my car. I know it's not normal for people. People in Chicago don't really have cars. But I like to drive 

[00:27:50] Griffin Jones: small markets on the table that brings us to practice size because you said you'd prefer to go to a big group practice and as you mentioned that there are far less single dot groups than there used to be at least as a percentage of the total number of practices. What do you like about first? How do you define big group? How many docs is that? And what draws you to it? 

[00:28:13] Dr. Sarah Cromack: Yeah, I think there's certainly not like an actual definition, but I think any group that has five or more docs you could consider as big because it means you're not going in every weekend or like you're not going in less than one week a month.

So if you're, for doc practice, you definitely, if you're doing IVF on the weekends or you're probably on call one weekend a month, But bigger than that, so five or more, you may not have to go in at all during the month. And so certainly that's the, one of the nice things about that is.

As residents and fellows, we're used to working every weekend, every other weekend, maybe every third weekend in fellowship, but going to a place where it's like, Hey, I actually can have weekends off like my husband has for the last seven years. That sounds nice. And you do get to share a little bit more of those responsibilities.

So when you have a bigger group practice, if you're not able to do something, you're out of town, you do have that capability of having multiple. partners that can help you. And again you learn different ways to do things. You can offer different things to different people and people may have their niche.

So you may have your partner that's really great reproductive surgeon that you can send someone to, as opposed to in a smaller group, you may have to send them out to a minimally invasive surgeon or someone else. So I think those are some of the nice things about being in these larger practices.

[00:29:25] Griffin Jones: If you had to prioritize those two different advantages that bigger groups have, let's say five or more docs, it being that you have other people to help you cover your patient load, and there's some collaboration there, versus you could go much bigger than that and have, and then you start to get all types of different resources and different types of docs to collaborate with.

If you had to prioritize those two advantages, how would you prioritize them? 

[00:29:51] Dr. Sarah Cromack: I think it's a balance. As you start getting more and more docs eventually some people bite butt heads, the more people you have. So I think there's a happy medium. I think I would prioritize having, docs that you feel can cover for you when you're gone, that will, take care of patients like you would hopefully want them to versus being in such a big practice that some of your, some of the docs may not know exactly how you would want to, proceed with some IVF treatment or some FET protocol.

[00:30:17] Griffin Jones: I think that happens at five docs. I think that it happened somewhere, probably around four docs. And I still can't remember where we saw this, but I, it was at an SREI retreat. I wish I could remember the statistic and where it came from, but it was about patient engagement, patient satisfaction, I think measured by number of patient complaints.

And there was a J curve. So it was lower when you had a single one or two docs. I don't think it was by doc. Actually, I do think it was by volume, either patient volume or cycle volume. But the smaller end, the smallest end of the practice is you had fewer complaints and they got more as you got more docs until you got.

Until you got to a bigger practice, which I suspect has something to do with process, but I was more interested in your, in, just in your preference there of a big group practice. You also said that you wanna have some type of involvement with fellows and residents. What type of involvement does that look like?

[00:31:16] Dr. Sarah Cromack: Yeah, I think, not every academic practice or not every private practice won't be involved with, fellows or residents. So you've got lots of different universities that don't have a fellowship but still interact with residents. So I think being able, interacting with residents to me means having residents that rotate with me that sit in with me IVF because there are I A lot of basics I think that every doc needs to know, a lot of my friends that went into generalist practices are doing ovulation induction for their patients.

Sometimes they're doing follicle monitoring. Not a lot of them are doing IUIs, but it's not unheard of to have labs that are not REIs doing that. And so I think there's, at least right now, a lot of my colleagues say they're just learning it from their other partners, but not actually from REIs. So I think we really need to improve our resident education of the basics of REI, not only so people know when to send them to us, also so they know what tests they can order before they send someone to us to decrease that wait time, and so that they themselves can practice, if they want to practice, ovulation reduction in a safe manner.

So I think being involved with residents for sure is something I hope to do whether I'm in private practice or not. 

[00:32:27] Griffin Jones: So it doesn't necessarily have to be a faculty position if you want residents rotating in with you, like lecturing at the local OBGYN program. Tell me a little bit more about that.

[00:32:39] Dr. Sarah Cromack: Yeah, I mean, I think ideally that you'll find that job in a faculty environment, but I do think there are so many training programs out there that don't have access to REI. For example, in the Chicagoland area, we, Northwestern is the only fellowship, but there's residencies at Loyola, at UChicago, at Rush, at UIC, and, I don't know exactly how those residents are getting their REI exposure, but they're most likely going to some private practices or going to university based practices not associated with the fellowship.

There are lots of different avenues, and I think even if I was in a private practice, trying to make connections with residency groups in the area to have them come and shadow, and to have them get that exposure opportunity, would be something I hope to do. And I hope lots of people do, because there are a lot of residents out there that need exposure to this field.

[00:33:27] Griffin Jones: We're covering an article about the length of REI fellowship and either side of the debate there. And that article might come out before this podcast episode is there. So maybe some of the audience will have already read it. But it seems to me that there's a little bit of a divide. A lot of people calling for fellowship to be shortened to two years.

Some people, SREI and ASRM saying they're not recommending. the fellowship to be shortened. You are a year and a half in right now. Where do you stand? 

[00:34:01] Dr. Sarah Cromack: I definitely stand on the three year camp. I think having that full time for a full year to dedicate to research is very valuable to an REI fellow, even if you don't want to go into research.

So I'm doing. clinical research, not lab based. And I think more fellowships need to offer that to ensure that everyone can get something that they are interested in that year of research time. But, the ACGME has restructured fellowship. So now it's supposed to be 18 months, purely clinical, one year of research at six months elective.

So I think that was a Probably a good change, but I don't think that switch to two years will accomplish what everyone wants. What everyone I think wants from that is to improve the number of graduating REI fellows. The only way we're going to do that is by improving, increasing the number of spots.

So if we go down to two years, if you can add a second fellowship spot. That's great. Then you've maybe increased that number complement of REI fellows we have. Right now, I don't necessarily think that decreasing to two years will also give us that additional spot because a lot of this is, the ability to pay for and maintain that second fellow.

And not every group is busy enough to do that either. So I think we really have to expand the number of fellowship spots we have and also expand the number of fellowships if we can. And that's how we're going to really accomplish what we need to accomplish to get more REIs out there. 

[00:35:17] Griffin Jones: Yeah, I guess you would only increase the number of RAIs one year by doing that.

It's like your daylight savings here. Like you want exactly one year, you'd get 88 RAI fellows instead of 44 or whatever it is. But then you'd be back to 44 every year. 

[00:35:33] Dr. Sarah Cromack: It wouldn't change unless we add more fellowship spots. And so if you have three fellows. But you're only, it's a three year program versus let's say you have two fellows in a two year program, you would increase it up to four, but you've got, we've got to increase your fellow compliment if that is going to work.

[00:35:47] Griffin Jones: Why is it important to have a research year if you're not going to go into research? It's

[00:35:54] Dr. Sarah Cromack: a good question. I think number one, at least for me on this research year is like the first year after five years that you feel like you can breathe a little bit as opposed to, you've done residency.

A lot of times the first year for us is clinical and you're just busy. And it is so heavy in patient care and you've dedicated so much of your life to, yeah, answer the pagers, you're there for your patients. And it's nice to be able to put that aside for a second and say, let me focus on learning and reading and again, developing my niche and finding what I'm most interested in.

And you just don't have time to do that when you're heavily clinical. So allowing that research here, you're, you not only get more time to study and learn that you. probably didn't have on your clinical years, but you can also develop that niche and find that thing that interests you the most in REI and research it in a way where you can become a content expert in a time where you don't have to dedicate a lot of yourself to clinical duty.

So you get to work, I think, a lot on yourself and your own skill set, and you're just not going to get that if you're doing two full years of clinical. 

[00:36:54] Griffin Jones: You have been an interesting focus group of one to talk to today and just see where, to see where your head is at, to see what you're interested in, see what you think is important, and maybe that's somewhat of a bellwether for the rest of your cohort.

Let's conclude, I'll give you the concluding floor with. Either what you think the field is going to look like as specifically as you can within the next 20 years or what you want it to look like in the next 20 years. 

[00:37:23] Dr. Sarah Cromack: Yeah, I think I will go with what I want it to look like. So I would love for the field.

Obviously, I would love if we can have insurance mandates in every state. It is absolutely wild to me that we don't cover infertility as a medical diagnosis in a lot of states. And it's. It's just depressing for all of our patients that really can't sometimes access this care. So I would see a field in 20 years where we've got wide insurance coverage for this.

And with, through that, we actually increase access to care so that we are having people's all income levels being able to access infertility because it is present among everybody. So I think that in terms of the field, I REI docs out there. whether that's increasing complement of fellows in each fellowship or a number of fellowships, because there is a huge need for us out there.

And, I think we're going to see new technology. Obviously we are going to, things like gene editing. I think they just approved a gene editing therapy for sickle cell. Will we see gene editing in embryos? I don't know if we'll see that in 20 years, but I think we, I want in the next 20 years us to.

incorporate new technology in ways that is very ethically responsible. And so I hope, whether I'm part of ASRM or other future groups that we are making sure we have guidelines that allow us to move this field forward in exciting ways that are really helpful for patients, but that are, taking care to make sure we were doing it in an equitable and ethically sound way.

[00:38:50] Griffin Jones: Dr. Sarah Cromack, I've enjoyed getting to hear where you are in the earlier part of your career. I hope to have you back to, to check in on you from time to time as you continue to advance in your career. It's been a pleasure to have you on Inside Reproductive Health. 

[00:39:04] Dr. Sarah Cromack: Thanks so much, Griffin. It was great talking to you.

And yeah, I hope to come back maybe in five years. We'll see where I am at. 

[00:39:10] Sponsor: This episode was brought to you by Prelude Fertility, where top REI physicians find their calling. Practice anywhere with Prelude. The Prelude Network is the fastest growing network of fertility clinics in North America. With more than 90 plus locations, we're ready to support you and your individual career aspirations wherever they lead. To learn more, please visit rei.preludefertility.com. That's rei.preludefertility.com

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. Thank you for listening to Inside Reproductive Health.

209 Privademics and the Future of REI Research with Dr. Kate Devine

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.


Has research output in REI atrophied?

Dr. Kate Devine, Medical Director and Chief Research Officer at US Fertility, guides us through the current state of supply and demand for fertility services, and how Privademics could build the infrastructure to meet the growing demand for ART.

Dr. Devine shares her thoughts on:

  • Why, in her view, research in REI has atrophied

  • Her robust definition of a Privademic Practice (and their advantages)  

  • How Privademics can adopt new technologies faster (with a higher standard of quality control)

  • The specific research she believes is needed to improve innovation

  • Current technologies she’s paying attention to

  • Academic programs (will and should they be Privademic programs)


Dr. Kate Devine
US Fertility
US Fertility LinkedIn
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Transcript

[00:00:00] Dr. Kate Devine: I would argue that our field actually faces a little bit of risk as more and more graduating fellows go into private practice, that if we don't encourage them to continue to contribute academically or private emically, as the case may be our research output will atrophy. And I think that even Is happening a little bit.

[00:00:21] Sponsor: This episode was brought to you by AIVF, the innovators behind the EMA™ platform. The EMA™ platform is designed to empower fertility clinics with cutting edge AI technology, enhancing the precision and success of treatments. It's not just a tool, it's a game changer in reproductive medicine. Learn how EMA™ can grow your fertility's efficiencies by going to aivf.co/precalc. That's aivf.co/precalc

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.

[00:01:19] Griffin Jones: Research output in the field of REI has atrophied. That's according to today's guest and her colleagues. We examined some problems taking place in the fertility field. The demand for ART services greatly outweighs the supply. We need to adopt technology that makes the clinic and lab safer, faster, more efficient.

We need to do that yesterday in order to start making a dent in the supply and demand issue. But clinicians and scientists need to be able to prove that those solutions are in fact safe and effective. And this is where Privatemics might come into play. Dr. Kate Devine is medical director and chief research officer at U.S. Fertility. She's an OBGYN clinical professor at George Washington University. She's the associate program director for REI, for the fellowship program, that is. and age. She's the chair of the SREI research committee. She's the chair of the SART QA committee, and she's on the editorial board for fertility and sterility.

She practices for Shady Grove in the D. C. area. And so I get Dr. Devine's thoughts on why research output and REI has atrophied in her view, what specific research needs to be done. done to improve ingenuity and innovation. How PrivateMX addresses the supply and demand issue by training more REIs, APPs, and OBGYNs.

Dr. Devine shares her thoughts on if all academic programs will and should be PrivateMX programs. And she talks about some massive advantages that PrivateMX programs have. She talks about the powerful research database that U. S. Fertility has. doing approximately 20 percent of the IVF cycles in the country and the collaboration that they have between research and fellowship programs being affiliated with five of them across the network.

Dr. Devine talks about how private emics can evaluate and adopt new technology faster and to a higher standard of quality control, and she talks about some technology she's paying attention to. We start with her definition of private emic practice, which is more robust than mine. Enjoy this interview with Dr.

Kate Devine. Dr. Devine, Kate, welcome to the Inside Reproductive Health podcast. 

[00:03:15] Dr. Kate Devine: Thanks so much, Griffin. I'm thrilled to be here. 

[00:03:17] Griffin Jones: It's been a little while since I've talked about the privademic model. We've introduced it on the show, but I don't know if we've ever done a podcast. episode dedicated to going through the privedemic model, to going through the future of what it looks like.

As I was preparing for the interview, I started to think, is this what academic medicine is going to become universally? Will all academic medicine be privedemic? And so I'll, I guess I'll start with what I think my definition of Prividemic REI medicine is, and you'll correct me, and and maybe give us a more comprehensive definition, but I think of prividemic medicine as an academic or health system REI division that has partnered often in equity partnership, but maybe not always with a privately owned fertility center network that maybe private equity back that maybe venture back that maybe just regular independently owned network if there still are some of those left, but I think of the R. E. I. Division from a R. E. University health system that is partly owned and if not partly owned, partly operated and operated in conjunction with a privately owned network. How close am I to the correct definition? 

[00:04:56] Dr. Kate Devine: I think that's pretty accurate. I would be even more expansive than that in my definition.

I'd also quibble a little bit with the Equity portion being part of the definition. I would say that's pretty uncommon actually for the university based REI practice to be owners in The practice that is private practice that's participating and certainly vice versa It can happen, but I would say that's not really part of the definition.

Everything else is spot on. I'd say that essentially, we are in a position where a lot of the volume in terms of the practice of fertility medicine has shifted out of The university setting and fellows need experience and fellowships need funding. And so from the fellowship training portion of this and even residency training portion of this, universities have a need.

And private practices have the ability to fill that need. Particularly if they are practicing evidence-based medicine and have academically interested. REIs. The other piece of this, though, is I would expand private emics even beyond those practices that are necessarily affiliated with the fellowship or university.

I think of it as basically wanting to keep moving the ball forward. academically, intellectually, and in terms of the knowledge base of our field, whether or not you are at an academic institution. So wanting to practice evidence based medicine and do research. So contribute to academia, whether you're there or not.

[00:06:39] Griffin Jones: What does that contribution look like though? Because then can't anybody that just submits an abstract each year say I'm doing Privatemic medicine. I'm advancing research. What, how would you qualify those contributions? 

[00:06:54] Dr. Kate Devine: 100%. And I think that's fine. There's no limitation to the number of card carrying Privatemics there can be out there.

And I would argue that our field actually faces a little bit of risk as more and more graduating fellows go into private practice. That if we don't encourage them to continue to contribute academically or private emically as the case may be our research output will atrophy. And I think that even Is happening a little bit.

And certainly our ability to train enough high quality REs will will atrophy if we don't have private practicing REIs contributing to education. And if somebody hangs a shingle, which you know as well as I do is a little bit. Harder and harder to do all the time in this field. And decides that they wanna do research, God bless 'em.

And of course, there's a peer review process to make sure that the research is legitimate, a legitimate contribution. And then hopefully that doc decides over time that they do wanna affiliate with the university and train up and coming OBGYNs and Reis as well.

[00:08:01] Griffin Jones: You said that the research output might already be atrophying a bit.

What specifically makes you say that? 

[00:08:10] Dr. Kate Devine: They'll remain nameless but even speaking with some of my colleagues who work hard to You know make sure that our output as an, as a field in terms of our main fertility journals stays strong and again, contributes to advancing patient care and our technology and our abilities have told me that they think that the quantity and quality, more so quality of the submissions is 

[00:08:39] Griffin Jones: I'm a lay person, I have no clinical or scientific background, so when the quality is going down, does that mean the robustness of what they're attempting to study, or does it mean that some basic tenets of research are not being followed?

[00:08:58] Dr. Kate Devine: I think both things. I think just the ingenuity the innovation in terms of just being bravely going out there and trying to answer the unanswered questions. There's maybe a little bit less of that going on as fewer and fewer REs see research as part of their vocation. So I would say in terms of how novel the body of research that we're producing that is.

Seems to be less. You'll, I'm sure you heard or have heard at some national meetings, people saying, Oh, it's all the same stuff. I, not learning anything. And part of that is we're approaching an asymptote as a field that we've gotten very good at this, right? But I think part of it is that while we are increasing in being entrepreneurial as fellowship graduates, that comes to some extent at the expense of fellows.

Yeah. wanting to do research. And, it's not a coincidence. They also are having lower and lower requirements for research as part of their fellowship training. Why is that? I think it's multifactorial. Part of it is The demand of the fellows saying that if they're not going to do research for their whole lives Why would they need to do 18 out of 36 months of their fellowship doing research?

part of it is Diminution in the number of an hour is available from university based faculty to mentor fellows in research but you know most immediately it's A bog and acgme who make the rules in terms of what's required to cipher boards Have reduced the requirement. I think they feel that they are being pragmatic and answering a need that's Based largely on also increasing Number of things to learn over the course of a fellowship and cutting back, therefore, on the number of months spent on research.

[00:10:54] Griffin Jones: This is happening at the same time as people are debating should the REI fellowship be three years at all? Should it only be two years, and then if it is only two years, What gets cut? What? What is condensed into those two years? How much does this need for research play into that debate?

Where do you stand on that side of the question? 

[00:11:18] Dr. Kate Devine: I actually am of the mind that I think there should be a two year option. I do think More important than making sure that every single fellow comes out being an academic and a researcher is that we meet the demand of the population and we are not meeting it now and we sure as heck are not going to be meeting it as the demand continues to rise as has been predicted.

It's a very controversial topic, we just published this white paper in fertility and sterility just in advance of asrm We had about 27 reis or 27 authors including reis As well as app's Who really hotly debated this and there has been a expert panel that met that was convened by ASRM that came to the conclusion that it should be two years.

Our group by and large and. In garnering support from the various stakeholders, ABOG, ACGME and most importantly, SREI, ASRM, and SART ultimately decided that to recommend two years was too likely to just result in a diminution of the funding that's available that chairs of OBGYN programs would not allocate the saved monies from the program.

Going down by a year to additional spots That was what we heard from most rei program directors. And so basically it would just be less training but not necessarily more fellows I do think in programs where The feedback is they could get More fellows by offering a two year option That should be piloted.

That's my personal opinion. And I do think that if it enables us to train more fellows and I think it can be structured such that it could that should be an option. There are going to be those fellows that are extremely talented and driven towards research. And there could be three or programs for them, or they can apply for postgraduate K level funding with directed training.

So that We are focusing the resources on the most talented and ambitious people who want to conduct high quality research. 

[00:13:40] Griffin Jones: In your view, would that option be based on program? Would every program have a two year option, or would some programs be two years and some programs be three? 

[00:13:52] Dr. Kate Devine: I think it's, it would work best as the latter.

GYN oncology has done this for years now, where some programs are three years and some years our programs are four years. And so based on interest level fellows will opt in or out of a three year program, and the third year could be. focused on different things for different programs. Everyone has to meet a certain baseline level of knowledge base and curriculum, but then some programs would have an extra year that was focused on reproductive surgery.

Some programs would have an extra year that was focused on, obtaining an HCLD and learning more in the embryology laboratory. Some programs would have an extra year that was focused on research, whether that be clinical research or bench science. 

[00:14:37] Griffin Jones: Tell us more about this paper. I've seen it circulated on LinkedIn.

You said you, there's 27 authors on the paper, even before we get to some more of the findings. What did the paper set out to do? 

[00:14:50] Dr. Kate Devine: So the paper set out to define the scope of the problem in terms of the supply demand. Issue that we're facing as a field, both now and in the foreseeable future, and also to start to identify some potential solutions and then really largely to and live in this conversation because we're way late to trying to address this as a field as we both know industry is actively working on trying to solve this problem already in a way that will be as profitable as possible for them as REIs, we want to do it in a way that is as safe as possible for The population and so that's what we set out to do and it took us a year to publish what ultimately at the end frankly isn't An ironclad plan by any stretch of the imagination but essentially what it concludes is that we need to train more fellows.

We need to make appropriate use of other professionals in this field, especially nurse practitioners and physician assistants. And ASRM is hosting a meeting in a few weeks actually convening experts to try to figure out what's the best way to train and certify these professionals.

And then also we need to make responsible use of the available technology to make the process more efficient. 

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[00:17:40] Griffin Jones: So how would you say that you defined the scope of the property? You talked a little bit about it. Likely involves training and certifying APPs, there's technology involved, but in terms of the words that you ended up all coming to, and when you think back to the paper now, how do you define the scope of the problem of supply and demand as it is now?

[00:18:02] Dr. Kate Devine: So Right now, 40 years into the history of ART Even a little bit more than that we've got 10 million kids that have been born from ART And if you think about the world population and the number of births per year, which is somewhere around 150 million, and the fact that the incidence of infertility is around 9%, And then there's lots of other indications for ART other than infertility.

We really, in theory, and this is a pretty conservative estimate, should be able to help 20 million children be born per year. Of course, we're talking globally and not all of these, the infrastructure is in place to make that happen any time in the, future. But if we really wanted to help everyone that needs our help I think that is the magnitude by which we're underserving the demand.

[00:19:05] Griffin Jones: I suspect that there's a role that private emic plays. And getting us to a point where we can meet that demand globally and the reason I'm pulling at that thread is not just because I want to weave the two topics together, but I actually I perceive them to be related partly because of the tension that you described of you've got the industry side that wants to go full tilter is incentivized to go At full speed.

And then perhaps you have an academic system that it has atrophied on its research capability. And perhaps the bridge between those lies somewhere in private demics. Where do you see privademics in this greater struggle, if for lack of a better word, to expand the supply to meet the demand for infertility services.

[00:20:05] Dr. Kate Devine: Yeah. I think it's in 0. 3 training more fellows is the responsibility of every REI. It's actually, otherwise we're going to put ourselves out of a job if we don't. To also be part of the conversation as to how do we most responsibly use and work with our colleagues that are advanced practice, practitioners, providers and then also to be extremely open minded and curious about the technologies that are available while also being incredibly rigorous about validating those technologies prior to implementing them.

And to the first point about training more fellows, people in strictly academic settings think of this and they like, start to have palpitations because they say oh, every RE in New York City is gonna just Open up a fellowship and Start training a fellow that they that just plan to hire they're not going to give them really high quality training and the field that we love is going to lose a knowledge of endocrine and genetics and everything else that is and I agree intrinsic to The richness of our knowledge and our ability to manage complex cases That in fact cannot happen.

And so many changes in our system would have to happen. There are so many checks and balances to prevent that. So first of all, you have to be affiliated with an ob gyn department as a residency to be able to train a fellow so you can't just like You know say i'll train you'll be certified and then by the way You also have to work for me afterwards or something like that.

I would hope that our ethical standards would Discourage that anyway, but there are other things to discourage it, too and in fact despite the increasing demand You know there have been Fewer the number of fellowship slots has not increased in recent years The number of new slots has basically evened out with the number of closing and it's incredibly challenging to get approved To open a new fellowship slot.

One of the recommendations of the paper is actually for programs Who are experienced in expanding a fellowship or opening a fellowship to help mentor and be a resource to programs that want to add slots Because there have been a number of applications that have been denied in recent years probably just due to an experience in the process and knowing how to apply for lack of a more complicated explanation.

So yeah, so at the end of the day, I too want fellows to have a, an extremely rigorous training and to have a rich knowledge to be able to. And I don't, I actually don't think that some of the requirements, including to be affiliated with an REI or an REI fellowship and to be affiliated with a residency should change.

[00:23:18] Griffin Jones: What role does Privademic have in training? OBGYNs outside of an REI fellowship, if any. So this is another debate that's going on concurrently, is how much should generalist OBGYNs be trained to do without having to be fellowship trained in REI. And still seems like a pretty contentious topic. I think that it's shifting it seems to be.

In the last few years but I was at an event at ASRM where there was a British REI that was perplexed that generalist OBGYNs aren't trained to do things like retrievals and even transfers and and this individual said, where I come from, if you can deliver a baby, you can suck an egg and and there was a number of In attendance that agreed with that statement.

There were there are still some that do not agree with that statement. But I'm curious without getting so much into that debate because it's its own topic. What role does private Demick play in training? 

[00:24:24] Dr. Kate Devine: Yeah, my opinion is that the fellowships train OBGYN residents to know what they need to know about fertility medicine to be able to practice general OBGYN and hopefully to induce some of them to pursue a fellowship.

I am of the mind that. I think that generalist OBGYNs, should collaborate closely with REIs. I think that they are can safely do ovulation induction. I think that they can be a huge resource, especially our minimally invasive gynecologic surgeon. Colleagues and doing some of the cases that you know, REIs that are involved very deeply in endocrine or an ART maybe don't have the time or haven't maintained their skills to be able to perform.

I do think that it's a challenging question because We don't want to define being an rei as the ability to do an egg retrieval or an embryo transfer because that's not it That's a fair. Those are both fairly simple technical skills but they are not all created equal and Again, the management of complex cases is something that's well outside the scope of somebody who hasn't done a an rei Fellowship, which at this point is still three Full additional years of training.

[00:25:47] Griffin Jones: So that, that question ties into what is the future of the REI? What is the future role and responsibilities of the REI if more people are being trained to do retrievals and transfers don't comprise what a REI is or does, and ostensibly with a I. You'll have a much greater case load and R.

A. I. Is over more cases, and maybe it goes back to what you, you mentioned earlier in the interview of wanting more ingenuity and innovation from the research. So let's talk a little bit about that. What is ingenuity and innovation in the research look like and how does it develop the REI's role?

[00:26:37] Dr. Kate Devine: Yeah it's a great question. It's a great question. So there are lots of different fronts where I would where I think we hopefully will see innovation where I would like to see innovation I think towards that goal that we've also been talking about which is to Help the 20 million babies that would be wanted Be born, every year and so I agree with you in the setting of Ai and automation I think that in future decades the rei will likely be Overseeing apps who are appropriately trained and certified Managing a much larger caseload per rei And I think that and hope that more and more graduating fellows will take on a privedemic stance and see it as their responsibility to help train the next generation of REIs and also to do research.

There's plenty of scientists and entrepreneurs out there that are developing technology that hold great promise. For better or worse, given the regulatory environment in our country, the actual responsibility of validating those technologies falls on REIs, and that's not something that's likely to be done in a university based setting.

That is likely something that will be done in a privademic setting, if at all, and it's our responsibility not to just implement without validating. And so I think REIs and privademic settings. In coming years, in addition to managing more cases and overseeing, their team in managing more cases should also be actively involved in doing studies, appropriately designed studies, to validate technology before they're implemented 

[00:28:35] Griffin Jones: I want to explore more about what validation of technologies looks like, but staying on the research that you'd like to see.

If you had your druthers, what would privedemic REIs be researching more of if we were to say in two years, you know what, it's no longer the case that research is atrophying an REI. It's no longer the case that we're not seeing as much ingenuity and innovation in the research as we'd like. We're seeing plenty of it, and here's what's happened.

If you had your druthers, what would that research be specifically? 

[00:29:14] Dr. Kate Devine: I think there, there's a couple of different realms that it could that are my favorites, I guess I should say. Was talking about validation and, there are plenty of folks out there that are working on laboratory automation.

And I think that laboratory automation and the implementation of AI together have the potential to help us get to where we want to be in terms of serving the number of people, but it's super scary to, to, To let the machine, do IVF for us, right? And so one really important, and again, this is not ingenuity so much as being extremely conservative, right?

And cautious is to make sure that whatever it is that we are allowing to create embryos and manage our laboratories has been tested against the current standard of care as being just as safe. Effective in achieving success for our patients and also of great importance is, of course, safety.

So I hope that's something, and that's something that Privademics is ideally placed to be able to do. Other areas that I think are, hold massive promise but are extremely challenging to do research in academic settings in the United States because of the Dickey Wicker Amendment and because, no NIH funding can be used to do any research involving human embryos is, Again, the potential of genetics to cure and prevent disease.

And the applications of that are massive and varied but our field is ideally placed to be able to help to support and participate in that research, and again, even the smartest scientists in university based settings need foundation funding to be able to do it so I hope that's something that You know great scientists housed in universities and private practices will partner together to, to work on in the coming decade.

[00:31:17] Griffin Jones: Do you work on multiple research projects at once? Do you do like the paper that you just finished, do you do one of those and then do you take a breather and start the next or do you work on multiple projects concurrently? What is your privademic practice look like? 

[00:31:32] Dr. Kate Devine: Busy. We have currently five REI fellowships that we're affiliated with at U. S. Fertility. And all of those fellows, as we discussed, has research as a requirement as part of their fellowship. And yeah, no, I'm doing. A dozen projects at once all with lots of help we have two phds in epidemiology a number of physician scientists at u. s fertility that are Really committed to research and education I'm working currently on industry sponsored trials NIH funded trials, the NAPRO study is focused on maternal fetal health following frozen embryo transfer.

Given how many kids are going to be born from frozen embryo transfers in the coming decade, I think that's one way that we absolutely must contribute is to make sure we're doing it in the safest way possible. And then, we have, with the help of AI and improved data analytics, really, in my opinion, the most powerful research database out there because we have so much granular information, much more so than, some of the databases that are amazing that they've collected in Europe over the years, or even that SART has collected.

Very involved in SART and SART research, but there's just, you're limited by the quality of the data entry and the number of fields. And so we have a database that has enabled us to answer. Really almost any question that somebody has about what if you change this or if you do this in ART how will it affect the outcome and there are myriad outcomes that can be evaluated And so it's a huge resource for our trainees and thankfully and we hope to get better and better over time, but we hope that it is also benefiting our patients because we're able to figure out the best way to do stuff.

[00:33:31] Griffin Jones: And so you yourself are working with all five of these programs. You don't work with, let's say, just Jones over here for this Shady Grove Fellowship partnership. You're saying you at a network level are working with all five, five of the academic programs? 

[00:33:50] Dr. Kate Devine: I'm a associate program director for the NIH fellowship.

So I work most closely with that fellowship. And each fellowship program has its own academic infrastructure So it would be incredibly irresponsible for one person to be overseeing five different fellowships. That's not the case But my responsibility and really joy is to oversee the interaction between those fellowships And US Fertility so to help them with their u. s. Fertility based research projects as well as to help with their clinical rotations that occur at U. S. Fertility which are largely apprenticeships as is the tradition of training and academic medicine. And yeah, we actually started a new rotation, research rotation, which we've all been super excited about.

We've done it twice now, where all of the fellows from all of the various five fellowship programs come for one month and. They have the opportunity to come in person or attend virtually most do come in person to rockville And they have are paired one to one with a research mentor And they have a project defined in advance of coming to the rotation They have a data set a statistical analysis plan and over the course of that one month the four or five fellows that are there help troubleshoot each other's manuscripts with the help of their dedicated statistician and mentor.

It's been incredibly fun. They have structured didactics and they really learn soup to nuts, how to.

[00:35:30] Griffin Jones: So this is an interesting way of thinking about the future of private epidemic that I hadn't really thought about. I always thought about it one to one, Mount Sinai, RMA of New York NIH, Shady Grove, USC, HRC, always just thought about it one to one. But when you're talking about the network level.

You're introducing a couple more dynamics, one of which is the pure volume that you have to be able to study. You have a lot more data to be able to study because there's a lot more cycles happening over that many places, with that many labs, with that many docs. But the second is that a network can be affiliated with multiple university system, multiple fellowship programs in multiple areas, and and there's a way to bring those in the fellows and the researchers and the scientists from those institutions together.

[00:36:27] Dr. Kate Devine: Absolutely. Yeah. And honestly, it's a way for the fellows to network across a much broader swatch of the field with, as a national network, they meet, other trainees from all over the country were pretty dogged about making sure that they're paired with a research mentor that is outside their home institution.

So they get to know that person well and expand their professional network. Yeah. And yes, the big data is a massive asset that this provides, with somewhere around 20 percent of the cycles in the country, but with, every access nearly every data point that one might need for research it's extremely powerful.

[00:37:11] Griffin Jones: Do you think that for these reasons and the other ones that we discussed, that all academic medicine will have to be privademic in the coming years? That all of the hospital system and university system RAI divisions will be have to affiliate be affiliated with networks or at the very least large practices for these reasons.

[00:37:35] Dr. Kate Devine: I don't think And I sure hope not, honestly. I gave a talk recently at the fellow symposium in Park City. About private ems. And I said this and I really mean it, that if a fellow is graduating and just wants to be a basic scientist or do translational research please do it

We need those people who are really doing the basic work. That is the seed that inspires everything that downstream. And I think that's really hard to do in a private practice. Now, might there be a day where. Private practice is actually funding that research And that academic programs come to rely almost entirely on the big networks to train the upcoming reis maybe But I don't think so there is there are still things that can only be done in a university.

The converse is definitely also true, but I really think we need both things. 

[00:38:38] Griffin Jones: So let's talk about the evaluation of technology as part of the crux of private and academic and. What can be solved for uniquely with private demic because you mentioned that if just at the academic level, a lot of this technology isn't going to be implemented, but you also need the research to evaluate it.

So talk to us about a couple of technologies that you're paying it to. You mentioned I lab automation, but talk to us about a couple of technologies that you're paying attention to. And what is the appropriate level of adoption. Okay. It's being adopted somewhere at the clinic level. While it's still being researched.

[00:39:24] Dr. Kate Devine: Yeah. A hundred percent. I don't think that anything should be adopted at the clinic level commercially and sold to patients until it has been proven to be effective and safe full stop. Our patients are desperate and they are They will do anything we say if they think it's going to help them have a baby.

And, we all took an oath to first do no harm. It's my opinion that if we are charging patients and exposing them to anything invasive or even any lag in initiating what is standard proven treatment, we are doing harm if we don't have really compelling reason to believe that it works.

And so I think that we should absolutely be participating in studies to do those things. And, we just published earlier this year a trial on ERA, which we all had great hope for that Was in JAMA, I think just because of this phenomenon, not because it's like such a groundbreaking thing to publish a negative study but essentially because it is really important that we don't implement add ons before we know that they work.

And so we are working with a number of AI companies and participating in their studies to validate. We are also working on with a couple of different sperm selection. Companies to validate those technologies, which I think hold great promise if they were to be helpful but until those things come to bear and I sure hope they do of course Anything that we can do to help us raise that asymptote that we've approached in terms of success rates be massive It also goes to our overall goal of helping people have more babies and being more efficient, right?

So if we have to do fewer cycles and fewer transfers, that's efficiency and that's helping the population. So You know, I think that we have to bear in mind in the meantime that people get desperate after one unsuccessful transfer. That doesn't mean that you start throwing the kitchen sink at the problem.

We know that after three optimized transfers, based on Pertea's data, we get up to 95 percent chance of a baby. And so we really need to take the time to counsel patients that these things are not validated and to say, Keep calm and do another transfer until we know for sure that these things work.

[00:41:50] Griffin Jones: What about partial implementations or maybe partial utilization? I think of if many of these solutions, maybe they're still working towards FDA approval, or they're still working on they're still working on Their studies, but they have a workflow component that that they solve for, that they can streamline things and require fewer man hours.

And and so how do you think about that when the clinical benefit may maybe yet to be proven but in the meantime there's a clear workflow benefit. How do you think about those types of solutions? 

[00:42:29] Dr. Kate Devine: Yeah. The devil's in the details for sure. We could talk through specific examples, but at the end of the day, if it's no harm and it's improving workflow.

So one good example of this is quick warming, right? I don't know if you've heard anything about this, but used to take hours to warm an embryo for frozen embryo transfer. And now many labs and we're about to publish these data presented them at ASRM, yeah. We're doing it in minutes.

And there's enough data to show that there's minimal harm that I think that is completely reasonable to implement. And some things very much fall on the side of QA, right? And so if you are able to do appropriate QA in your lab, and every lab should Do this independently on these technologies, even if there's published data that show it to work in one center, you have to show it in yours to not everything needs a randomized controlled trial.

And yes, things that improve workflow and there's no biologically plausible reason why you think it would cause harm and you have enough data in your own center to show that it hasn't. I think that's totally appropriate. 

[00:43:38] Griffin Jones: How about networks and centers paying to be involved in certain trials, or if there's some of these companies might be ready for prime time, some of them might not be, but at a market level, I, me just standing back and not having a clinical, Dog in the fight.

I can't. I can't evaluate these products based on scientific or clinical quality, but I can see there is a market issue where they're not getting the adoption because they're, they are they're not advancing, with their findings because they're not getting the adoption necessary.

And the centers want to see maybe more Proof from studies. How do you view if they've got low cost? If they have a low cost barrier to entry, and it looks like they've got something promising that centers paying these places that are still doing studies. These companies that are still doing studies.

[00:44:39] Dr. Kate Devine: Yeah, I haven't seen that particular model. I guess you're saying there is commercial update before the study's done or before approval comes through or maybe they're using it off label or something like that. Yeah, I think you got to be pretty convinced by those data before you would ever have your patient buy it, or even if you're buying it and it's a a cost that's passed along to them really the way that, that it should happen, and I think it mostly is that at a minimum, these Companies that are bringing these add ons to market that again, I hope that they all work together and create the miracle.

Solution to help us administer patient care more successfully but they should Be offering it for free under a research protocol Until the data are robust if they are Great by all means they you know clinical adoption is appropriate but that really the And this is a whole other conversation, but they can't afford to pay the centers because they're startups But they really should be paying The centers to do the research, right?

That's the way it works with more established companies like pharma, et cetera. 

[00:45:51] Griffin Jones: I think it's a part of the challenge. And I think we'll see the rise of who's going to be the company's standing, but I think one of the challenges that they're facing is is that what their investors are looking for is, are people willing to pay for this?

But there's a huge upfront. Cost to be able to create something that clinicians are willing to pay for the reasons that you're talking about. And we've explored a lot with regard to privademic medicine. Will it will it make academic medicine obsolete? How is it involved in evaluating new technologies?

What is the specific research that you'd like to see to, that would? show more ingenuity and more innovation and stop the atrophy of research in REI. What is Private M. E. C. 's role in training APPs, OBGYNs, and REI fellows? We've covered a lot of ground. Kate, how would you like to conclude on the topic of private M. E. C. medicine? 

[00:46:52] Dr. Kate Devine: I'd say that we need to Better serve the population of americans and people globally who need fertility services We are not training enough reis the Industry side and the academic side are both going to be instrumental in solving this problem together and we need to collaborate We should do so in a way that maintains a high Quality of research output and we need to bear in mind always that as industry is involved and should be and must be we need to validate any newcomer to patient clinical care to make sure that we are first doing no harm.

[00:47:39] Griffin Jones: Dr. Kate Devine, thank you very much for coming on the Inside Reproductive Health podcast. 

[00:47:44] Dr. Kate Devine: Thanks very much, Griffin. 

[00:47:46] Sponsor: This episode was brought to you by AIVF. The innovators behind the EMA™ platform. The EMA™ platform is designed to empower fertility clinics with cutting edge AI technology, enhancing the precision and success of treatments.

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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. Thank you for listening to Inside Reproductive Health.

208 Dr. John Schnorr's Advice for Bootstrapping Your Fertility Company

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.


We bring back fertility entrepreneur Dr. John Schnorr to share his experience and advice for building companies in the fertility sector without investor money.

Tune in as Dr. Schnorr talks about:

  • Some great examples of how he’s proven concept (both functionality & market value)

  • The conditions for bootstrapping without a proven concept

  • How Cycle Clarity gave equity to early employees (and how you might be able to do the same)

The pros & cons of hiring top-down in the accountability chart (And bottom-up)


Dr. John Schnorr
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Cycle Clarity
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Facebook
www.cycleclarity.com
www.cycleclarityconnections.com

Transcript

[00:00:00] Dr. John Schnorr: I would say that importantly, I think you need to really be a master of that domain and know what the market is you're trying to hit and understand the details of that market. I had an advantage there. I think that you should set a financial limit on what you need to have happen before you put in your next hundred, $200,000. Like, you know, I need proof of concept and I need this to do X, Y, and Z. And if we don't get to that, I'm going to rethink whether or not I'm going to put in the next 200, 000 again, using examples. And so I think always stepping back, seeing where you are, figuring out what that financial commitment is, what our progress has been.

[00:00:38] Sponsor: This episode was brought to you by Mind360, a leading fertility mental health platform. How long does it take your clinic to get patients through their third party psycho psychological evaluation? Find out how your clinic compares with Mind360's free report at mind360.us/reducedwaittime. That's mind360.us/reducedwaittime.

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.

[00:01:23] Griffin Jones: He's back and we're talking about bootstraps. first conversation with Dr. John Schnorr was a popular one. We talked about the IntegraMed autopsy where Dr. Schnorr's group had been a part of the IntegraMed network and he talked about the collapse of that, what his entrepreneurial rebirth was like, and this is a sequel to that conversation.

And we talk about bootstrapping. Bootstrapping a company in the fertility sector. There's been a lot of companies in the fertility sector that have raised lots of money and some of them have done well, but others have really struggled to be able to prove what their business model even is, and some of them have gone bust.

We talk about what it's like to build companies in the fertility sector without investor money. What are the conditions for when you should bootstrap? When the total addressable market is smaller, when the concept isn't proven, when the money that you need to raise is less than what you could do by putting in a couple years of sweat equity or self funding.

Dr. Schnorr gives some really good examples. about how he's proven concept, not just the concept of functionality, but the concept that this is something that people in the marketplace are willing to part ways with their dollars for. It gives a really good example about why he had to shorten the length of his product's performance by six or eight X, even after it was a four or five X improvement of the status quo.

It wasn't good enough for 50 percent of the marketplace. He talks about why. He also gives a really good example of fertility clinic workflow. It seems like something small, but is embedded into the structure of how fertility clinics operate and makes it really difficult to adapt to change. It isn't just as simple as people don't want to change.

And I think that example that he gave illustrates it as best as any I've ever heard. John lays out how cycle clarity gave equity to their early employees and how you might be able to do that as a bootstrap company. He and I debate the pros and cons of hiring from the top of the accountability chart versus from the bottom of the accountability chart, having more smaller seats versus having more senior people doing more things.

And we each give our tips for how to solve the chicken and egg issue that comes with entrepreneurship and especially bootstrapping. I give my tips for constraints around pre selling. as a means of self funding and ask Dr. Schnorr for his thoughts on the topic too. You might have to bootstrap now in the fertility field.

The era of free money might be over. Oh well, partner. Might be a tough go for a couple years, but you'll end up owning a lot more of your company, which we hope is a really successful one. Enjoy this conversation with Dr. John Schnorr. Dr. Schnorr, John, welcome back to the Inside Reproductive Health podcast.

[00:03:56] Dr. John Schnorr: I'm so grateful to be here. Thank you for inviting me. 

[00:03:59] Griffin Jones: It's like a sequel to your first conversation because the first interview was an, it was an REI's entrepreneurial rebirth, and we're going to talk about more about what that venture has been like. And we're talking about bootstrapping. Will this be, will this sequel be as good as the original?

Will this be the Godfather 2 to the, to the Godfather part one? 

[00:04:18] Dr. John Schnorr: I guess all of the audience will know, and maybe they can tell us in a couple of weeks. 

[00:04:22] Griffin Jones: We'll try our best not to let them down. So it's specifically, I want to talk about bootstrapping companies. That's what you've done to this point. So your, your, your business as a clinic, coastal fertility in the Carolinas.

We talked a little bit about last time we talked about your relationship with IntegraMed. And that's not the business that I'm talking about this time, more your new venture cycle clarity. We're not talking necessarily about the features and benefits of cycle clarity today, but you up to this point, as far as I know, have bootstrapped it is, is that right?

Have you taken out any investor money up to this point? 

[00:04:56] Dr. John Schnorr: I have not. No, we did get a grant from the state, a very small amount of money just to encourage people to start businesses in the area. But it was a very small grant that helped us early on with kind of our kind of proof of concept, but a very, very small amount of money.

[00:05:11] Griffin Jones: Well, the reason why I think we should be talking about this now is because I think more people are going to have to bootstrap in the coming years for a decade or so. We saw a lot of VC money flying around because if you can borrow money, it's one or 2 percent rates and those limited partners want a much bigger rate than what they're getting in the stock market.

You're going to see. More money in venture capital. But if interest rates are 7 percent or, or whatever, and you have some of that money drying up, then you're likely going to see less venture capital money. And I've had some other, I had Dr. Santiago Mune on the show who runs a, uh, Basically a venture firm for fertility startups, and he said it's dry out there.

So I think people are going to have to do bootstrap down whether they like it or not. Why did you decide to do that though? Because you still probably could have gotten in on that era of free money. You chose not to. Why? 

[00:06:10] Dr. John Schnorr: Yeah, it's a great question. We started CycleClarity in 2019. At that time, it was a dream that had some patent protection that we were able to acquire or to develop.

And at that time, we needed a proof of concept and needed to move forward. I think there was an ability to get some seed round funding at that time. We did some preliminary talking with different seed round investors, and I think there was a lot of interest. But what was clear to me is, is that It was going to be a relatively limited amount of money that typically I think a seed rounds three, 400, 500, 000 for a seed round.

And it was going to be smaller than we probably really needed to do to get the job done. But number two, there was going to be a lot more time and effort into finding the right seed round investor, uh, doing the due diligence, doing all that work. And I honestly, A, had the ability to self fund and seed round myself, basically is what we're talking about.

And I could save time doing it, meaning I could spend time on the product and the team and the platform and the development, whether than the time to go out and court money and kind of get some investors to kind of go along with it. So I had enough belief in what we were doing. I had enough belief in my ability to know the market, which I think is really key.

I think if you don't know the market and the needs and the challenges and demands, you can end up with a product that misses the market. And I think that would be a big painful lesson to learn as a seed investor. And I think trying to bootstrap it myself, knowing what we had, knowing the team we had, developing, increasing confidence in the technology over time gave me the, the ability to move forward with confidence as our own investor.

[00:07:53] Griffin Jones: Do you think that if you had not owned a fertility practice for a couple of decades, been an REI for a couple of decades that you ever could have bootstrapped the company that you're starting now? 

[00:08:04] Dr. John Schnorr: I think financially, yes, but I think you just wouldn't really have true insight is to the demands on a reproductive endocrinologist day to day in his or her lives to know really what the limitations are, what the problems are.

What problems need to be solved and it's just not my viewpoint on the problems, but you get a connection of three, 400 other reproductive endocrinology, as you know, well, and get converse with them and share problems and understand how they're solving them. And I think it gave me the confidence that this was a good place to invest some of our resources.

[00:08:41] Griffin Jones: So there's a little bit of a lesson there of aligning with one's core competency in order to be able to bootstrap it is not necessary there because there's a million problems out there in the marketplace, and many of them will probably be lucrative. But there's something to be said. That allows you to bootstrap for going to, uh, to build something that you know.

Do you think that you could have even started PsychoClarity if you had not been an REI and not owned a practice? Even if, if it weren't bootstrapping, if you had somebody else's money, could you have done it? 

[00:09:17] Dr. John Schnorr: Wouldn't be real easy and it would be much more expensive because we used our own patients for the ultrasound images that got de identified that then got used for the training.

So we had our own data and images that we could work with, but actually very important. as the platform developed, I could use it in the office with the patients and understanding is it developing in a positive direction? Is this something that actually is going to be beneficial to, to clinicians and patients at the end of the day?

which gives you increasing conviction throughout the journey that this is a positive experience, this is going to become something. You could see its strengths and you could see its weaknesses and you could see it develop from month to month and year to year. And something that's been quite interesting is I like to journal what I've been doing just to remember what we were doing a year ago and two years ago and three years ago.

And to go back and look at where we were a year ago It shows how amazingly we've grown over the last year and over two years and over three years, literally three years ago, we didn't know if this was going to work at all. And if artificial intelligence was ever going to be able to see a follicle in the ovary.

Now we've gotten to the point that not only we can see the follicles, the ovary, we can do it with 94 percent accuracy and we can do it in less than 30 seconds. It used to take us five minutes to get a result process. Now we're doing it in about 30 seconds. And it's amazing to see that evolution with time.

What do you journal about? You know, everything. About meetings, like you have a big, important meeting, you know, that talks about an IT challenge and that kind of stuff. I put in kind of notes about who I met with, what the challenge was, how we're going to try to solve that, you know, what platform we're going to use to do that, what we think the cost is going to be to do that.

And it's, it's good to be able to go back to that. So when you get into that same conversation about, for example, how do we track follicles within the ovary, that's one of our challenges is. the same follicle will be in 10 different frames of an ovary. How do we track that same follicle through the ovary?

And it's a fairly complicated algorithm that looks to see how much overlapping there is from image to image and what the size is and what the degree of confidence is and, and all that little minutiae matters. And You know, at some level I'm functioning as the CEO and the CEO needs to be able to understand all aspects of your organization and help prioritize resources and troubleshoot problems.

And you need to have a real granular understanding as to how your organization works, what your strengths are, what your weaknesses are, what your problems are and how you're going to solve those. And journaling to me, is a tool for that where I can go back to that conversation, you know, six months ago and with really granular clarity, know what was said, who said it, how we're going to fix it and reflect back on that conversation.

So you're ready as you develop forward with tracking or whatever the issues are you're working on. 

[00:12:16] Griffin Jones: So you journal based on when there's an event that or an event or something that goes off in your head that merits journaling as opposed to like a calendar frequency, like on the first of the month or the first of the quarter calendars, 

[00:12:30] Dr. John Schnorr: I journal, I personally journal sentinel events like if something big's going on and we had a big meeting, I'm going I'll put notes about that meeting so I can reflect back on it.

And you know, it's, it's good for that minutia, but it's also good to look back at the progress of your company over time and to realize last Thanksgiving, for example, we were still solving these problems that you now look at and you say, God, that would, that seemed like that was a year or two, three years ago.

We're well past that. We're moving on to what the next star. And, you know, I think what we're learning over time is that the problems get smaller. You know, earlier on, there can be a lot of big problems that would derail you completely. And this will never work like the ultrasound machine, not being able to transmit the images efficiently, or maybe just one manufacturer being able to do it.

But the other manufacturer is not. And as you get. further down the road and eventually put more and more resources into it and understand in the clinic, this does work and this does work accurately. And it's a benefit to the patients and it's a benefit to the physicians and it's a benefit to the embryology lab.

You start to get increasingly conviction that this is meeting the market demands, that this is a product that fits the market well, and kind of gets you further down the road where you can actually then start. working with it in physician clinics, getting their feedback, making changes. And over time, we're finding that the feature changes that are requested from the clinics are smaller and smaller as we meet more and more of the demands.

And There's a lot of really great ideas out there that initially were revolutionary. And now the ideas that kind of come in to our platform are smaller little tweaks, which are very positive, but not as heavy of a list, don't require as much engineering and really actually enhance the output of the platform at the end.

[00:14:20] Griffin Jones: That's probably a way of thinking about proof of concept that makes it more tangible that I hadn't really thought about that. The part of proving concept is that the problems get smaller and smaller. That's probably a good sign. I want to come back to the topic of proving concept. But first, what, in your view, are the conditions for when someone should bootstrap?

If these things are true, that means that the company should probably more likely bootstrap. 

[00:14:49] Dr. John Schnorr: Well, I think a, I think you should have, of course, the financial resources that you can bootstrap comfortably. I wouldn't underestimate the resources needed that it's probably going to be twice as much money as you thought it was going to be at a bootstrap.

I know you're shaking your head. You've been there yourself. You understand that. So I think you need to prepare for the long run. I think along the way you need to understand, you know, is this product truly something that's going to meet the market? Meaning if I were developing something in gastroenterology and I'm a reproductive endocrinologist, I wouldn't have near the confidence to invest my own resources in it if I wasn't able to monitor the output and outcome and how it's developing over time.

So I think that would be good. And I would say, do you have the time to do it? Because, you know, I'm a full time reproductive endocrinologist. I don't mind working hard, which is why I'm kind of working cycle clarity after hours. And, and, you know, I would tell you, I probably put in six hours a week doing cycle clarity.

I think my wife would tell you it's really 12 hours. That's probably true. I mean, the time commitment's gigantic, but I think that eases off a little bit over time as you've solved more and more problems over time and you start gaining some clinical efficiencies, but also get a good team around you that can support you.

And I think that's really the key to success and bootstrapping is having a good team around you. 

[00:16:08] Griffin Jones: My brother and I used to backpack across the world when we were in our 20s and my brother always said, lay out all your clothes before you pack it, lay out everything you're going to bring on your bed, and then bring half the clothes and twice the money.

And, and so it's a, you know, Like half of the, it's probably half of the business plan and twice the money of, of what you're, of what you're going to need. Um, so there's a couple things that I, that I, I think you're pointing out that I, I've been writing down. Um, I think it's important to, uh, I think it's important to bootstrap.

If you really don't have the concept proven yet, um, I, we, we see so many. companies that have gotten a lot of money, tens of millions of dollars, sometimes even more. And they don't have a solid proof of concept of what it is that they're selling yet. And I know that there's a lot of technology companies that it would be really hard if not impossible to bootstrap because of the development costs that go into it.

So I understand not everybody can bootstrap, but I do think there is something to be said for that. I still would want to. Have more of a proof of concept of like knowing exactly what it is. I'm going to sell before I raise 25, 50, 75 million. So I, I think that's a piece of it. I also think if the total addressable market isn't that big, that you should probably bootstrap because you might not, you might not end up with the next Uber Airbnb, but you could still have a pretty decent.

Small size business. And I sent you, and do you remember the article I sent you like a month ago about it was, it was from this newsletter that I subscribed to called got acquired. And they told the story of some business that I wrote down the numbers that I could remember, but it was like a 2 million revenue business.

That had about 400 K in EBITDA and the person wanted to sell, but they had raised 2. 5 mil and, and so anything that they would have raised and anything that they would have sold it for would have gone to that, to the investors. And that's. When you think about it, that's a pretty lousy deal for both the investors and the entrepreneur, because the investors that day, that after the, the, the time value of money lost over that time period, even if they break, even they've lost money and the invest or the extreme of the entrepreneur has toiled for those years and has nothing to show for it.

But. If they didn't take that to begin with, if they could have made up for that 2. 5 million by sweat equity and slower and small pace and pre sale deliver, pre sale deliver, then that's a six and a half EBITDA and you're making 400k profit a year. Like that's a good small business for a lot of people.

So for you, when, when you think about cycle clarity, like. You don't have to give us exact figures, but how big of a venture do you want this? Or how, how small of a venture are you okay with it being? 

[00:19:09] Dr. John Schnorr: Yeah, I think it's a great question. And I think more than anything is, is I just want to see it through the journey.

So of course I want it to be a 5 billion company. I mean, everybody wants it to be a 5 million company, but. I, you know, I think it's going to be what it's going to be. We're, we're trying to make the best product we can for the market and then figure out, you know, how it enhances efficiency in the market and what it's worth is in the market.

So I think we'll know that as we get further down the road and your points, a good one is that a significant amount of equity is given up to seed round and a round and B round and. You know, we have had some of those discussions and realize what those numbers look like. And I'm doing my best to give that equity back to the employees themselves so that it encouraged them at a cycle clarity level to work a little bit harder.

And the further I can get us down the road with internal funding, the better we can be when we do want to get some, say a B round funding or even C round funding, depending on how we're going. But, you know, we've got a product now that I think has. product market fit. I think we have happy customers who were doing well.

We're learning from it. And the question becomes, you know, if we were to get a lot of funding, what would we do with that now? And would that really spin us out in a positive direction? And we're continuing to have those discussions to figure out what the next step is. 

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[00:21:55] Griffin Jones: Maybe this is in line with what you said. You had the ability to self fund, but I think even for those people that don't have the ability to self fund, maybe it's, maybe it's a couple of years of doing something else as opposed to having the money right off the bat to self fund.

But do you think that there's a, there's an amount that's too small to raise? Like, I think two and a half million dollars is probably. And anything below that is probably just not even worth raising. I know that's that's probably an arbitrary call. Probably depends on the type of business and and all that type of thing.

But it's like, man, I wouldn't want to give away any piece of my business like for two and a half million dollars, I guess. And, you know. I don't know do you think can you put better rules around it than I can 

[00:22:41] Dr. John Schnorr: yeah I mean I think I think it depends on how much money you're going to need to get a product to market you know I mean I think if you can get a product to market with three hundred thousand dollars you should probably do it on your own to your point if you're a big database company and you're going to compete with Oracle and you're going to need a lot of money to do it.

30 million to get to market. You better go ahead and get some, some venture capital and seed Monday to help get you through that. But you know what we had done along the way is just kind of figured out what our number was and ended up, it ended up being twice that, which I guess it always is. But you know, we kept seeing progress through it and it kept developing in a positive direction.

It kept being usable and you know, I didn't want to fool myself. So I wasn't trying to make these decisions about usability myself and We did beta testing with Michael Levy, who was incredibly helpful. I'm really impressed with Michael and his vision and his ability to see technology. And we worked with other doctors within the community who used it and loved it.

And so that just further emboldened me that this was headed in the right direction and we should continue to. Invest in it and move forward and invest in our team. I think you're never better than the team around you. We got an amazing group of engineers that have been great. Medical device specialists to go out and innovate, chief operating officer, who's amazing, a team around us that just gets better day by day by day.

And I love seeing that happen. 

[00:24:02] Griffin Jones: Tell me a bit about the rules that you've learned for proving concept. You talked about it first. It started off as a problem that you wanted to solve for yourself as a provider. Then you approached other providers that, you know, like Dr. Levy, tell us about how you prove the concept.

[00:24:18] Dr. John Schnorr: Yeah, so I started with just an idea. I think it was Philadelphia at the ASRM. I met with Michael Levy and I said, Hey, Michael, I got this idea that I think we can see follicles with AI. And, you know, I think it'll improve pregnancy rates. That's really what I said to Michael is we can better, more accurately do that.

And this was lunchtime. And Michael said, you know, John, I agree. You might be able to do that. He goes, but the value really is the clinical efficiency, right? to him, the value was not that we were necessarily going to improve pregnancy rates, but that we could do it quicker and more efficiently. And that's, of course, somebody who runs the largest fertility company in the United States and, and knew the value of clinical efficiencies.

And so we focused on that. That was the first thought we then needed to figure out who was going to help us. Kind of see this follicle with AI and even more importantly, who's going to track the follicle through all the images. And by serendipity and luck, we ended up with an AI company that specialized in tracking a football with AI go across the goal line so that they could predict when a score happened or not.

So they could track something over a video series. they looked at what we had and said, yeah, that should be able to work. And so with a relatively small amount of money, we were able to take about 300 images and which is a small number and train them. And they were able to show with some crude output that they could track this follicle across it.

That then started with COVID. COVID happened around then. And so we were all kind of locked in our homes, which is a great time for us to be. Annotating thousands and thousands of images and follicles and using kind of images that came from coastal fertility that we completely de identified and then we would show all the follicles and develop it.

That was probably a nine month journey of kind of annotating every follicle. I felt it needed to be done the right way so I as the physician viewed every follicle that was called a follicle and approved it and that resulted in what we called proof of concept is that we could with accuracy of greater than 90 percent figure out where the follicle was and how it was growing and so that showed that we could do it.

Now the next challenge was getting the data off of an ultrasound machine and securely transmitted to the fertility center and the data analysis center where we could see these images and provide them back. There was a whole separate team that helped us do that, and that was our third kind of piece to the platform we needed to make things work.

[00:26:51] Griffin Jones: How much familiarity did you have in the A. I. Space before you started working on the concept? Did you know those sports guys at all or so? Okay, so you had the fertility space pretty well covered in terms of knowledge and connections. Then you had to develop those knowledge and connections in the A. I. space. What was that like? 

[00:27:13] Dr. John Schnorr: That was a challenge because it's a whole different language with a whole different set of people. And so I think we got lucky with one of the first people we started working with that they had the competency to do what we needed to do. I had a conviction that if you can see a breast cancer with AI on a mammogram, that you can see a follicle on an ultrasound, to me they're much easier to see.

And so I had a conviction that this was something that would work out. And we had many, many meetings with people international who were eight hours apart time zone wise where, you know, I'd be trying to grab an empty conference room at the ASRM to do a video meeting with our group who's doing our AI training and understanding.

And it was interesting and fun. And then in the middle of COVID, literally I was on video calls with a group in China who were in the middle of COVID, you know, where COVID all started to the best of our knowledge. And. Talking with them in the middle of COVID about annotations and ultrasound machines.

And it's really interesting how the whole world becomes so small when you're able to telecommute and discuss all these things and collaborate together. So it really took a lot of people from all over the world to help get us to where we are. 

[00:28:22] Griffin Jones: So that's how you prove the concept in terms of functionally.

It could work. How did you prove, or maybe still are proving how it, it it is valued in the marketplace that people are willing to part way, part ways with money for it. 

[00:28:39] Dr. John Schnorr: And that's its own challenge, right? I mean, you're, you're smart to bring that up because you can create your own technology that works just great at coastal Fertility.

But not everybody's coastal fertility. That's probably good that not everybody's coastal fertility. Everybody does things a different way. And, you know, I think everybody wants to innovate. Like if you sat in a room with a hundred physicians, he said, who wants to innovate? I think all 100 would raise their hand.

But what we find is everybody wants to innovate, but nobody wants to change. Like if I said to you this is going to really make things better and you're going to have a better outcome because, you know, maybe MAs can do the scan and not the ultrasonography would be more accurate, but you're going to have to do the ultrasound first and draw the blood second on a patient.

That's just an example. You don't have to do that. But if I said, You're going to have to do the ultrasound first and draw the button second blood second, but they're used to drawing the blood first. That's a gigantic change for a clinic, particularly if you're a high volume clinic. And you might say, well, why is that a big deal?

Well, probably because the room for phlebotomy is right next to the reception area. And the ultrasound machines are on the other side of phlebotomy. So now you got to walk patients through phlebotomy to ultrasound, to ultrasound, and then bring them back. You know, all of a sudden this becomes a bigger problem than you would think it was.

And so we had to learn very quickly that every practice is different. Every practice sees and does things differently. And we need to be flexible on the cycle clarity end so that we can address all those things. And so one example is it used to take us three to four minutes to process an image. And while it sounded crazy, I went back to team.

I said, guys, we got to do this in less than a minute. We got to drive this number down and leave it to our great engineering team. We literally are processing images now in 30 seconds, meaning that you can be doing the ultrasound, push the first save button. And by the time you're done, the first image is already done.

And by the time you hang up the probe and help the patient up From laying down, the second image is done and you can show them all the results that revolutionized what we did, because no longer do you have to draw blood first or draw blood second, you can draw blood anytime you want. You're going to get results back instantly and be able to make instant decisions.

And so that was forced on us by the market who just did things in different ways, and we need to accommodate for that. And so that has been a change and that's something we've had to work on. 

[00:31:00] Griffin Jones: Why was that in, why was three to four minutes insufficient in the market size? Why, why, you know, because you would think, oh, if it normally takes 15, 20 plus minutes, three to four minutes, that's a four to five X improvement.

Great question. Uh, but why was, why was that not sufficient? 

[00:31:17] Dr. John Schnorr: Great question. At Coastal Fertility, we draw the patient's blood. We do their ultrasound, an ultrasonographer does their ultrasound, we then review the results about four hours later, we look at the ultrasound, we compare it to the blood work, we make a decision, and a nurse calls the patient back with the decision.

At least 50 percent of all clinics, the doctor is doing the ultrasound. They want to make a decision in front of the patient that might be a preliminary decision so that when the patient leaves they already know what they're doing so they don't need a call back. And so therefore if you're going to be efficient you need to do the scan, you need instant results so that you can show it to the patient and say we're going to do the same medicine and come back in two days.

But you couldn't do that if you had to wait three and a half minutes for the ultrasound. You already wanted to be in the next room and starting on the next patient and that really disrupted flow. 

[00:32:11] Griffin Jones: I love this. This is where companies are actually made in terms of proving their concept because everything is great.

Theoretically, right? We could come up with all sorts of businesses that sound great on paper. It's actually finding out when you're trying to get people to pay money, what the challenges are. And that isn't something that I would have expected either. And you weren't even expecting it as it didn't sound like, Oh, 50%.

And and they need to be able to do it because they that's what's important to them. What's important to them is being able to give the decision to their patient right there. And so that was an assumption that you had that that you had. Oh crap. Like we have to figure out a way to provide exactly right.

And I think your example of The the phlebotomy is like, Oh, why is it so important that they draw blood first or second? Well, because the, the, you know, the phlebotomy room is right next door. That's a really good example because there are so many good solutions that are having a hard time being adopted in our field and to say, Oh, Well, they, they can't just change.

It's like, well, it is kind of like they're there. You really have to understand it because there are reasons why they do things. And even if there are better ways of doing things, it's, it's hard to change. And it's not just because they're comfortable necessarily. It's because they, there are, there is an institutional momentum to do certain things in the structure and changing those structures is a lot different than just Changing one thing in a, in an order of operations on paper.

[00:33:45] Dr. John Schnorr: And to their credit, they've been doing it for 30 years. So to me, to ask them to do something different than they've been doing for 30 years to save them a couple of minutes on an ultrasound, but then hire a nurse to call people back in the afternoon that they're not used to, that's an instant fail, right?

I mean, that was going to go nowhere fast. So. our platform, our technology needed to accommodate for that. And, you know, never in my dreams would I think that I can really ask our team to get processing down from five minutes to 30 seconds, but they have been able to do that. And I think that's part through computing getting faster and platforms getting better.

And we've done more annotations and other things that have allowed this technology to get better. And to me, that's just one amazing example of going back to my journal, what's changed over the last year or two years, but also. A way to look forward at the future and think, well, if we can do that in one year, where are we going to be in the next two years with how the platform changes and how things improve?

[00:34:40] Griffin Jones: Do you feel like, because that you're bootstrapping, you are able to do this at a pace that allows you to actually figure it out? Like that's one of the, I would add that to the reasons where people might want to bootstrap is I like being able to go at. My pace that and I know there are certain things, certain like business fundamentals that I really want to master.

That wouldn't make sense to an investor. They would just figure it out, move on to the next thing where I'm trying to master it at a cellular level, like really trying to master how you delegate to outcome and manage senior leaders over other leaders. And I think that a lot of Venture capitalists would say too late.

You should have got an MBA for that. Hire an MBA to figure it out and just move on. Whereas like, I, it's like, I really, really want to, like, I really want to fix this, how, how much of bootstrapping. Has allowed you to go at this pace to figure out these challenges. 

[00:35:41] Dr. John Schnorr: I think a lot. I think a lot because we can make our own decisions.

We no longer need to go to our investor and say, Hey, we're thinking about doing this or investing in this or doing that. We can literally sit together as a team on a on Friday at 2 p. m. and identify a problem. prioritize that problem to the top and be starting on it Monday morning and done with it by Wednesday or Thursday of the same week.

We can just instantly pivot. Uh, and one way we're doing this. Another example of what we're doing is I'd had a doctor not too long ago who lives three and a half hours away from coastal fertility and she used to live in Charleston. She moved three and a half hours away. She said, John, I would love to refer patients to you.

Um, but you're three and a half hours away. I can't. figure that out. I can't make that work. And I said, I have the magic. Why don't we go ahead and install cycle clarity at your center? Your ultrasonographer can do the ultrasound. That image will instantly show up in our platform. I can see the image from top to bottom.

I can see every follicle and I can make decisions with every follicle while the patient is still three and a half hours away. And that formed what we call cycle clarity connections, the ability to connect patients at a distance to the fertility practice with technology that occurs instantly with the same accuracy as if the ultrasound was done in your own clinic.

And so we actually thought of that idea on a Friday and by three days later, the following Monday, We're halfway down the road in getting that developed. We already had the core technology. We just needed to add a couple of pieces to it. And so that is a new product line for us that was really thought about just over the weekend.

Does it commit capital to do that? Yes. We'll have some capital commitments to do that. Did I have to go to any investors to get approval and to meet on it and talk with the board? No, we just did it because it seemed like it fit the market. It was a need. We're probably now 3 to 4 months into that cycle clarity connections, and it's been a revolution for care of patients at coastal fertility.

There are a distance. And we're going to soon roll that out nationally and even internationally to help patients at a distance go to their center of choice, whether it's a lower cost center or a higher pregnancy rate center or a more compassionate center, then go wherever they want now. 

[00:37:58] Griffin Jones: Where have you had a board of investors?

They might've said, well, John, we think that's kind of a distraction. Forget about that for now. Whereas you're able to, you're able to make that decision as a, as a bootstrapper. 

[00:38:08] Dr. John Schnorr: Instead of them saying, Hey, we committed X number of dollars to you. You've used them up, you know, move on. We're not doing that or.

We don't have the time for that. You can see it as the end user, the physician, that this is really something that needs to happen. We had most of the technology here. Now let's just prioritize that above everything else we're doing and get that role in and then circle back on the other things we've been working on in a month or two, and I love the ability to do that.

And it really empowers the team that you're working with. to feel like they're a committed part of the process that's influential on the outcome to really make things better at the end. So not only do they have equity in the business, but they have significant say and sway in the business. And that's important to me.

[00:38:52] Griffin Jones: So this is the long drawn out battle to prove concept that I think is missing from a lot of companies that raise money really fast that they they get the money and then they're trying to prove the concept. And I think I think if you can, it is worth it. To spend that long, arduous battle, figuring out the concept and then you go get the money.

And I think the examples that you've given are are really good one. We both know Julius Varzoni, I think. And I think you've checked out his new venture, Mind360. I'm not just saying that because he's advertised on the program before. I'm saying it because I've, I've gotten to watch him on the entrepreneurial side.

And I think They're doing it the right way off of making sure that they've got something that's really valuable and we can take this off of your plate for the mental health professionals. We can integrate. We can do it a lot faster and we can ensure the quality. And I think That's a concept where, as you know, if he had investors at that time, I'm not saying it's wrong to ever get investors, but if he had them in that time, they may have said, no, move on from that, move on to the next thing without ever really mastering what, what they're doing.

[00:40:10] Dr. John Schnorr: We're one of Julius's customers. We love Mind360. They've done a great job. 

[00:40:14] Griffin Jones: I think there's another group, Cicero Diagnostics. I don't know them that well, and I don't, so I don't want to speak on them, but I, there is something that I could tell. is true for them that I don't think would be true if they were a VC back group, which is they, their testing is for a very, it's for a very particular niche where they, they think the scientific evidence really bears out that for this niche, this is truly valuable.

And I think that if they had more. Like investor money behind them, they would be pressured to try to expand what that niches and say, Oh, you should use the test for this. And you should use the test for that. Even if the scientific evidence doesn't bear it out. And so I think there's in addition to the proving the concept on me on the marketplace side that it allows you to find the niche that is actually Okay.

Going to benefit from from that solution, as opposed to having to expand it to be some kind of unicorn. Do you see that when you see other do you see like when you see some of the new solutions coming out? It's like, well, yeah, this would be useful for like this particular use case, but not for everything that they're trying to sell it for.

Do you ever see that? 

[00:41:26] Dr. John Schnorr: Yeah, I think my team hears that a lot. I think they hear my input on other products that are coming to market and what I feel might be hitting it solidly and what might be missing it by a mile and a half. And so, you know, and maybe that's just one person's viewpoint, you know, maybe I'm just one reproductive endocrinologist, but, you know, I've talked to enough doctors and seen enough clinics function that you kind of know when something solves a problem or when it's a.

Uh, near miss or far miss. And so you do see some of that. 

[00:41:54] Griffin Jones: Talk to me about your team struggles. So you mentioned, you mentioned your team a couple of times and, and how you've, how you've built that. Well, struggles, wins, lessons, the lessons you learned along the way. How did you structure your team? Would you have done anything differently in hindsight?

Would you have done more of things in, in, in hindsight? Talk to us about your team. 

[00:42:12] Dr. John Schnorr: Yeah, well, the team started with a close friend, a former next door neighbor who had a lot of expertise in software as a service and and kind of doing the engineering of that. And he quickly became our CTO to kind of pull all this together.

You know, with his help, we got a very senior engineer. Who's actually doing a lot of our engineering and we've been lucky to have him around. And so, you know, my thought is, is that I always wanted everybody to be fairly paid. Uh, so we wanted salary to be at market rates. I wasn't trying to low ball anybody on salary.

We tried to do salary adjustments along the way as the market demanded salary adjustments, but importantly wanted equity. I wanted people to be incentivized and the outcome of this. And so we use equity for this. And I think that's really helped us out a lot. I think we've been very fortunate with Paul.

Who's our CTO and Jack, a senior engineer. We have a data scientist named Seth who helps us with all of our data analysis. Who's been amazing. Caroline is our lead integration specialist who's been amazing. And then Chad, our chief operating officer. So I think we've gotten really lucky with who we've hired and they came from extensive interviews and making sure we were aligned over time.

And if things kind of got out of alignment, we're pretty candid and open about how we want things to change and why we want them to change and people got on board. Fortunately, we haven't really had any turnover and I think there are our greatest strengths by far. We meet monthly with big reviews. We meet weekly twice a week to go over minutia.

And I think everybody knows kind of what's going on at a macro level and what the problems are and how we're solving them. So I think keeping the team small, keeping it tight, keeping a team who's willing to. work outside their field. Like it's a common thing where we're going to want to do videos and, you know, who on the team knows how to do video editing?

None of us, right? None of us were really good at it. Okay. Well, who wants to learn it and master it moving forward? So we didn't go out and hire expensive video people. We did it ourselves internally. There's software that allows you to do that. And Cut and edit clip and probably all the things you know better than I will ever know, Griffin.

But, you know, we had team members who just volunteered to go out and pursue that and to learn that. And I think that really helped them out. We have engineers who, you know, have really learned how to do training with AI that they never knew how to do before, and it's broadened their horizon and helped them out a lot in their knowledge base, and they enjoy being a critical part of our successful platform.

[00:44:48] Griffin Jones: I think you got a little bit of lucky too. And I'm not, I'm not saying a lot of it. I think you did. And I'm not, and I'm not saying that you didn't do the right things with, with giving equity and the right things with, with how you figured out market rate and salary. But you know, I've gotten to know Chad and Caroline pretty well, you know, the last year or so.

And they're, they're There's not it's not so easy to find young people that can be put into roles like that that are it's like you're getting the people on their way up and you know, they're not always that easy to find. And when you can, they don't always necessarily want to work for a small company or or if they do want to work for a startup, they want to work.

They want to work for the one that's getting headlines for raising Yeah. 10 million in, in tech crunch and all that sort of thing. And so, so I think you, you've done well with that. And what I've noticed about each of them is that they're, I think they're both kind of old souls. And I think that might have to like, you have to be forward thinking to work in any kind of startup that by definition you have to, but I think for bootstrap, you have to have a little bit of an old soul.

Do you think that's the case? 

[00:45:53] Dr. John Schnorr: Sure. I agree. And that the people who are okay, not spending a billion dollars on little things here and there, and to be resourceful and to be proud that they've been resourceful, you know, to really take pride in the fact they did this for a thousand dollars instead of 10, 000, you know, those are things that I think really matter.

And so they. They've been great to do it and I think they enjoy it. A lot of them have worked in large corporations before and I think they run from that. I mean, I think all those endless meetings they had in these large corporations where no decisions were made after a four hour meeting. I mean, literally we'll have a 35 minute meeting and make pivotal decisions and then move forward and start implementing those the next day.

And that's just really rewarding and something I love about a small business in the startup. 

[00:46:36] Griffin Jones: Yeah, I think that that industriousness that you're talking about is necessary and bootstrap and, and I worry about that being kind of like pushed out of the culture a little bit that if we, if we lose too much of that, being proud that I did something for a thousand dollars that we could have spent 30 grand on willing to just kind of eat crow for, uh, for a longer period of time than you would like, not forever.

I don't want anybody to eat crow forever, but, yeah. But to be able to endure for a little while, if we don't do that, if we, if we only, if, if, if all of the fringe benefits become table stakes, like we, we, we all got to have the company car. We all have to have the ping pong table in the giant office. We all have to have, you know, Amy Schumer come to our, our annual retreat.

Then, well, then you're only going to have a small. handful of very financially embedded companies that can even afford that. And you look at who actually, who is doing a lot of bootstrapping in this country right now. It's the immigrants think about immigrants that come to this country that have no money to sell fund and they work 90 hours a week and they grind and they grind and they grind and they reinvest that in their business.

And all of a sudden this, this immigrant that came here with nothing 10 years later owns. 13 Baskin Robbins and 12, 12 Dunkin Donuts. I think, I think it's missing. And from a big part of the culture, I think you've found a couple of people and that's amazing. How did you decide to do, do you have a thought before I move on to my equity question?

[00:48:13] Dr. John Schnorr: Yeah. Let me give you a classic example. Caroline, our lead integration specialist said, I would love when I go to a center. I would love to have a phantom with me to train them. So I don't have to have a patient to train them. A phantom is, you know, a device that represents what a patient would look like with an ultrasound.

So you put your ultrasound probe in and do the scan. And I said, that is a great idea, Caroline. I said, you think that's important? She goes, I think it's critical. I said, OK, well, let's buy a phantom. Well, you can't find an ovarian phantom for less than 15, 000. Literally 15, 000. So Chad, who's got a degree in biomagical engineering, who's our chief operating officer, he goes.

You know what? I think I can help you make a phantom. So we bought ballistics gel, which you would use to shoot a gun into to stop a bullet, right? It's real dense gel, which phantoms are made from. He melts it down in his oven. He takes condoms and puts water in condoms and wraps it up. Melts it into the gel, puts it into a jar, and creates a phantom that looks identical to an ovary.

And that cost us 75 and it's perfect, and it's small enough to fly around with it gets through TSA without any problems whatsoever. And wherever we go, we got a phantom. So we have probably 7 or 8 different phantoms. Now they have all been named. They all have different architectural and feature characteristics of it.

Our favorite phantom is CC moon, a CC for cycle clarity. And so it's just fun and it's team building. It's inspiring. And it's just one of many things we've done to innovate, to become who we are. 

[00:49:48] Griffin Jones: That, that is amazing. And, and it's only like the fourth coolest Chad Clark story I've ever heard. Yeah. You guys.

Right. He's got a bunch. So I've, I've been interested in giving team members equity and thinking about that. I don't feel like I really understand the structure that I would use to do that. We, at one point tried to launch profit sharing and, and I still want to redo that, but. It was, it was more involved in, in terms of, of how you're able to do that.

And, and I realized that the team, it was not immediately obvious to them, like the incentives for doing so. And so I realized like, okay, I need some more training on this. How did you do that? How did you, how did you give equity to folks? 

[00:50:31] Dr. John Schnorr: Yeah, so, so by far this is probably my weakest area is corporate governance and all that kind of stuff.

But we do of course have a corporate attorney. We've done it mostly through stock warrants, which basically mean we promise to give you stock if you sign this when you want to do it. So they don't have ownership right this second, but they have Uh, you know, a guarantee that they'll get it once they sign it, which gives them tax benefits that they don't own it.

Now we don't, um, share profits with them cause we're not profitable. Hopefully one day we will be profitable and we actually do it in a way that I think people need to be part of the corporation to exercise that warrant. So, you know, if you got a stock warrant, you can exercise it whenever you want and we'll give you X number of shares.

for nominal dollar, like 10 or something, basically give you it, but you need to be working at the company at the time. Meaning, you know, if you choose to be an employee now and to work now and to work for stock warrants, but then you decide you're going to chase another dream in three years and not be part of us at the end of it.

then the stock needs to come back into the corporation so it can be redeployed to other employees who are now working with the company at the time. So we've chosen to use stock warrants. I'm sure there are many different ways of doing that, but it seemed like a tax advantage way for the employee to use it.

It seems like a non dilutional way that if we diluted shares over time, but you have a warrant. You wouldn't be diluted out. So that protects them in that way. And they get to exercise that at the end of the journey. If there were to be a transaction, if they wanted to, 

[00:52:03] Griffin Jones: That is a good lesson for those considering giving equity to their team members.

Was there, are there any hard lessons that you've learned about? With your team, giving them things that are outside their scope. Like, you know, you've got your COO helping with, it's not the mannequin. What is it avatar? What's it called? 

[00:52:22] Dr. John Schnorr: It's called a phantom phantom, or, you know, you've got people doing video editing.

[00:52:27] Griffin Jones: So I, a mistake that I made in an earlier generation of my business, John was that I gave too much to certain people at certain times. And I, I, I, it made it. Difficult for me to hold them accountable to an outcome because I had stacked other outcomes that were outside of their seat on their plate, and then I couldn't just walk away from that outcome because they weren't accountable for that one outcome because they were distracted with other things that I had assigned to them.

And so in this generation of the business. I've been hiring from the bottom of the accountability chart going up and I will get more independent contractors and part timers and I'll have them in smaller seats, but I've got different people in smaller seats and then I can walk away because I can divide it down to an outcome for which they can be responsible.

And so instead of like hiring a full timer that maybe I'm giving them like four or five, you know, main core outcomes, it's like you hire part timer two outcomes or something like that. Sometimes only one. And and then, you know, as is. Is the company grows? I've been adding more full time people to manage those folks once they have a team of those folks.

I seem to like it better that way because of the mistake that I made. Have you ever? Have you? Have you run into that challenge at all where it's like when you have a small core team that you're loading too much up on them? 

[00:53:42] Dr. John Schnorr: Yeah, I do think that, you know, we need to be understanding people's demands and their bandwidth and those types of things.

I think we've been lucky to get consultants who will train us and teach us so that they can learn from the expert that allows, for example, Caroline and Chad to become expert themselves because they're learning from the experts and to practice that discipline internally. So they become our guides and kind of mentors these consultants.

And I think that's worked out very well for us. 

[00:54:09] Griffin Jones: It's a good idea. What other tips would you have for people that are that are trying to solve this chicken and the egg when it comes to bootstrapping. So I have come to understand entrepreneurship is the art of solving the chicken and egg problem. I said in passing to David Sable one time in a conversation where I said, Well, yeah, but how do you do that?

That's chicken and the egg. And he just looked at me and said, Griffin, the entrepreneur's job is to solve The chicken and the egg. And then I thought, Oh yeah, that's all it is. That is exactly what the entrepreneur's job, what comes for it? Well, we can't, we can't make the product if we don't have the money.

We can't make the money. We don't have the product. We can't hire the people if we have et cetera, et cetera. It's, it's about trying to, to, to balance that. And I. The ideal of having capital investment come in is that we can circumvent some of that chicken and the egg because they just give us a chicken.

I don't think it actually works out for that for the conversation that we've talked about that many times, but what tips would you give to people trying to bootstrap to overcome this chicken and the egg paradox? 

[00:55:11] Dr. John Schnorr: Yeah, I would say that importantly, I think you need to really be a master of that domain and know what the market is you're trying to hit and understand the details of that market.

I had an advantage there. I think that you should set a financial limit on what you need to have happen before you put in your next a hundred, $200,000. Like, you know, I need proof of concept and I need this to do X, Y, and z. And if we don't get to that, I'm going to rethink whether or not I'm going to put in the next 200, 000 again using examples.

And so, I think always stepping back, seeing where you are, figuring out what that financial commitment is, what our progress has been. Again, I'm big on journaling. I think being able to look back and see where you've been. Forget where you've been and how big of problems you had three or four years ago compared to the problems you have now.

I get tremendous reassurance out of seeing that and then really listening to the team around you. And then, you know, I'm a physician who has my own opinion, but do other physicians have the same opinion? I do meeting with people like Michael Levy and other experts in the field and making sure I'm not too far off base, incredibly reassuring.

So I would say. Really get to know your market, get a product out to market in a beta form, look to see what's hitting, what's missing. Don't be afraid to go back to the drawing board, make quick decisions along the way to readdress the market as we have with, for example, ultrasound processing timing so people can make decisions in front of the patient.

[00:56:46] Griffin Jones: Yeah, I might go a little bit beyond that of you saying getting to know the market, which is what you did, which is work in the market. And I think that it's part of, you know, I, uh, it took me a while to build fertility bridge to, The goal that I had for it probably took like seven years in something I wanted to do three, the version of inside reproductive health that I'm building is going faster because I had that experience with fertility bridge.

I would, I would recommend that people work in the field that they go work for someone. I think that there's a lot of contemporary advice that says, You're not a true entrepreneur if you ever work for somebody else. I think B. S. Like maybe if you're Mark, if you're Mark Zuckerberg, sure. Like go and go and go and do the thing.

But for most people, especially if you're going to end up being a small business owner, a 10, 15, 20 million business, which by the way, is being a one percenter, you know, it's being. It's still a really, really good life, then you can learn a lot by going to work for somebody and maybe go work in one vertical and then another.

So if you wanted to work in the R. E. I. Space and the tech space, go work for R. E. I. Company for three years, then go work for a tech company for three years and In meanwhile, network with everybody you possibly can because you're going to need those early customers fast and you're going to need to hire people that can deliver really fast and not have to figure, figure that stuff out later.

Is there anything about that you've learned about pre selling or, or selling, you know, On one hand, you don't want to sell so early that you can't deliver something. Um, on the other hand, if you waited for the perfect solution, like the absolute theoretical perfect solution, you would never actually get it because you need to sell in order to figure out what it is.

So have you learned some lessons around rules for pre selling? 

[00:58:44] Dr. John Schnorr: We've learned a lot of lessons and I think the sales cycle is longer than I would think and again my own Personality is I'll look at something I'll decide if I want or not and move on and implement it move on and act quickly But now all organizations can do that.

So you might be bringing a software solution that improves clinical efficiency And in some organizations, there's going to be one or two people who are going to make that decision. You're going to move on to the next week and everything's going to be fine. There are other organizations. You need to get through three or four committees to make sure it gets approved along the way to make sure that it is okay.

And security is okay. And then some centers want to measure every follicle for three months to make sure it's accurate. And others are going to say, well, you know, if the FDA approved it, then I'm good with it too. Let's move on. And so I think everybody's different and you need to understand. A, what the center's challenge is.

Why are we here? What are you trying to address? B, talk about what our technology can do and figure out how we can implement it the best. And I think you need a physician champion. And I think for us, you need an administrative champion too, who's going to try to encourage people to invest time into it.

Technologies like ours, you start by losing you time. You, you lose time to learn this technology and implement it. By two months in, you might break even, you really don't start seeing the benefits until four to five months down the road and you got to prepare the client for that journey. 

[01:00:08] Griffin Jones: John, this has been a blast.

I've had a great time going through this with you because I think your company is doing it right. I think you're doing it right as a bootstrapper. I'd like to see a few more companies do it. Other companies like the ones we talked about, I think are. doing it well. And of course, there's more, but I, I think it's a solution that is not for everyone or a pathway that isn't for everyone, but should probably be considered by more than it is now.

And so how would you like to conclude, you know, maybe you will raise money someday if the time is right, but you haven't up to this point. So how would you like to conclude with how you think about bootstrapping in this space? 

[01:00:46] Dr. John Schnorr: I would just like to conclude and say that I think entrepreneurship is for the brave.

That it, you know, you got to have bold ideas. You got to have convictions. You got to be willing to put resources behind it. Sometimes less, sometimes more depending on how you end up funding yourself. But I think that entrepreneurship creates great ideas that make the world a better place. And I'd like to encourage people to pursue their dreams, to think about.

what problems are that they can help solve and help solve those. And the more of that you could do with your own funds, the more equity you'll have at the end for having a big investor kind of help get you to that, you know, international, you know, deployment or wherever you're headed next. 

[01:01:26] Griffin Jones: Dr. John Schnorr, it has been a pleasure.

I look forward to having you back on for a third time. Thanks so much for coming back on the Inside Reproductive Health podcast. 

[01:01:36] Dr. John Schnorr: Thank you so much, Griffin. 

[01:01:38] Sponsor: This episode was brought to you by Mind360, a leading fertility mental health platform. How long does it take your clinic to get patients through their third party cycle psychological evaluation?

Find out how your clinic compares with Mind360's free report at mind360.us/reducedwaittime. That's mind360.us/reducedwaittime

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. Thank you for listening to Inside Reproductive Health.

207 Your Legacy as a Fertility Doctor. From the Egg Freezing Revolution to the Latest, Featuring Dr. James Grifo

DISCLAIMER: Today’s episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free, to you! Here, the Advertiser has editorial control. Feature sponsorship is not an endorsement, and does not necessarily reflect the views of Inside Reproductive Health.


Scalable and solvable questions.

According to Dr. James Grifo, Chief Executive Physician for [Inception Fertility (TM)], that’s what REI’s need to bring to the table to advance fertility medicine over the next 30 years.

In this week’s episode we look back at Dr. Grifo’s fertility legacy and look forward to the new opportunities REIs have to create their own.

Tune in as Dr. Grifo talks about:

  • Your biggest opportunities in the years to come (From egg retrievals to streamlining ovulation induction)

  • How to bring patient education into the culture

  • Non-Selection Studies and how you may be leading them

  • The unique opportunities the Prelude Network offers (Like pioneering research at the Prelude Research Institute)

  • How one legacy career leads to another: Yours.


Dr. James Grifo
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Prelude Fertility
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Transcript

[00:00:00] Dr. James Grifo: There's going to be more and more need for assisted reproduction. If the trends of age at first birth in these last 30 years, we went from 19 to 37 in New York city and, and, you know, 2021, it was 30 for the whole United States. It's a matter of time where we're having our whole families in late 30s, early 40s.

And we're going to be using assisted reproduction as the safest way to get there. 

[00:00:23] Sponsor: This episode was made possible by our feature sponsor, the Prelude Network, where top REI physicians find their calling. Join us and leverage state of the art technology. Collaborate with the best physicians in fertility.

And be part of a network that's redefining fertility care across North America. At Prelude, your expertise helps turn dreams into reality. Discover more at rei.preludefertility.com. That's rei.preludefertility.com

Announcer: Today's episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free to you.

Here the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of Inside Reproductive Health.

[00:01:18] Griffin Jones: Scalable, solvable questions. That's what critical thinking REIs need to bring to the table to advance this field of medicine over the next 30 years, according to today's guest. If you're at the beginning of your career as an REI, How do you contribute and leave a legacy like my guest has? How do you collaborate with your colleagues?

How do you make things dramatically better for your suffering patients and maybe, just maybe, also be lucky enough to get an angry phone call from the FDA? My guest is Dr. Jamie Grifo. You might know him from NYU Langone. You might know him as the chief executive physician for [Inception Fertility (TM)]. He's a combined MD PhD.

We weave through time in this episode. I'm interested in Dr. Grifo's history. Because he's one of the pioneers of fertility preservation. NYU's First Egg Free's baby was born in July, 2005. So we go back 19 82, 19 92, 2005, 2016, and look at this tremendous progress that Dr. Grifo and his team made, and we use that as a look and glass into your career.

What do you accomplish in 2030? In 2040? In 2050? How do you as an REI embarking upon your legacy? Bring patient education into the culture. We talk about the unique opportunities that the Prelude Network has, like their Physician Advisory Board, like their Physician Summit. How are all these REIs that are on the inside collaborating with each other?

And the opportunities for pioneering research through the Prelude Research Institute, and what Dr. Grifo sees might be your biggest opportunities. Research in non invasive egg retrievals, in streamlining ovulation induction. in advancing egg freezing and the mission that might be close to you, avoiding miscarriage.

Dr. Grifo talks about how you might be involved in these non selection studies, how you might lead them, and how scalable, solvable questions are necessary from critical thinking REIs. I hope you enjoy this conversation about how one legacy career leads to another, yours. Dr. Grifo, Jamie, welcome to the Inside Reproductive Health podcast.

[00:03:15] Dr. James Grifo: Thanks, Griffin. It's great to speak with you today. 

[00:03:18] Griffin Jones: I've had a lot of shows and a lot of content for young REIs and talking about career paths, but it's mostly been about the initial career trajectory. It's been about how you think about partnerships and if you go work for an academic. practice or, you know, what you should consider having in contracts and that sort of thing.

It hasn't really been, I'm trying to think if, if I've done an episode or two where we really go through a career and when you and I spoke recently and you were talking about what you've done with fertility preservation, egg freezing, I was like, this would be cool to do, to, to think about how you actually.

You know, go through a career and present young doctors with not just here's the job that you can get now, but what do you want the next two or three decades to look like? And so I look forward to going into the past with you a little bit, into the present, into the future, weaving through the three of those.

Let's start with. with your own history with fertility preservation, because I think, I think you and I have only met in person once and we had a 10 minute conversation and it, and it was about this, this practice passion of yours. And, and so how did that develop? 

[00:04:44] Dr. James Grifo: So, I mean, it started before medical school.

You know, I didn't know a lot of the things I knew. Going into it, but I, I was very interested in science. I didn't know if I wanted to do just science. I was very interested in medicine and, you know, because of that, I ended up doing both. And same with college. I didn't, you know, I, I majored in biology and chemistry 'cause I couldn't make a decision.

So I, I did both and then, you know, I realized that college I want, I wanted to go. It's a medical school, but I still wanted to keep the science doors open. So I applied to MD PhD programs, uh, knowing that if I got the extra chaining with the PhD, no matter what I did, that would benefit me. And if I was going strictly science, I was prepared.

And if I was going medicine, that would only make me better. And, and so I, I went and did a combined degree at a time when they were just starting those programs and I was very fortunate to go to Case Western Reserve and then during medical school, you know, it even started the first day. It was like, all right, what am I going to do?

Like what, what, what field is gonna be the field I want to go into? And, you know, the first two years of medical school was all didactic. And during that time I was doing my, my PhD. Coursework at the same time as medical school and it was pretty streamlined and I was able to do that and I started my research, you know, during the summers and then once I finished the first two years of medical school, I went to the lab and did some pretty fun, interesting molecular biology research that actually led to about 10 publications and one of them actually was foundational for one of the drugs that is now being used.

And in a very indirect way, so it was kind of cool to make that impact, but when I went back to medical school and I started doing the clinical rotations, every rotation I did I loved. It was like, all right, I'm going to be a surgeon. All right, I'm going to be a pediatrician. All right, I'm going to be an internist.

And in fact, what I did was I deferred OBGYN until my fourth year because there was a chief resident who said, look, you can be my sub I, sub intern, your last month of third year, even though you're not supposed to do it until fourth year, because I'll be gone. And I got permission to delay my OBGYN until my fourth year, which no one.

It was really allowed to do at that point, but they accommodated me. And after a month on those wards with the MD PhD training, the kind of thought was I would go into cancer biology and cancer treatment and go to the NIH and that's how, and after a month on the medicine wards, I thought, you know, this really isn't exactly what I want to do.

Seeing these patients with chronic illnesses, it seemed like we were just. You know, not really curing them. And, and then I did the OB rotation. That was so positive. There was a lot of surgery that there was happy moments. And, you know, then there was this fertility thing that came out of nowhere, you know, back in 1984, it was when I graduated, it was 19.

82 that I was doing my clinical rotations and the average age of first birth for a woman was 19. It's pretty remarkable because you think about where we are now, just to give you kind of the sideline of that, in 2016, average age of first birth of 19 in the whole United States became 26. And in two thousand twenty one it became thirty new york city last year it was thirty seven and say wow that's eighteen years in the last thirty five years which is even more remarkable because three hundred thousand years ago when we first hit this planet as a species we we were.

Having our babies at 14, we were dead by 25. And if you think about the system, I'm always, I'm a little bit nerdy that way. I like to think about like, how did this evolve and what was the purpose? Purpose of reproduction in the early days was keep us on this earth evolution. We had to adapt to our environment.

So we had to make a lot of embryos that didn't quite make sense unless there was something they adapted to and kept us. As a species on this earth and then what about how efficient, you know, we always think of, you know, that sex ed class way back when in fourth grade where they said have sex one time you'll be pregnant and get five sexually transmitted diseases all in the same night, which is, you know, a little bit remarkable.

They wanted to scare us. They don't want us to make any bad decisions, but reproduction is nowhere near that efficient. A 14 year old 300, 000 years ago in our lifetime released 100 to 120 or 7 million eggs. Yeah. And had three babies and that was the goal, not too many, not too few, if we had too few, we'd be trit and be extinct.

If we had too many, we would overpopulate, get disease and famine and be gone. So, it was never designed to be that efficient and then, you know, 300, 000 years later, it's 1984, we're 19 having, having babies and a woman has 12 eggs a year and 240 eggs in a lifetime to build a family of three or four or whatever.

You know, fertility issues were less of a problem than they are now, because our biggest problem is just the age at which we're having babies. This system was never designed for that. 

[00:09:41] Griffin Jones: So I want to make sure I understand. So you're saying in 1982, the average age of first birth per American woman was 19?

That's in 1982? 

[00:09:51] Dr. James Grifo: Yeah, 82 84. 

[00:09:52] Griffin Jones: And then when did it rise? You said at some point it rose to 26. What, what year was that? 

[00:09:58] Dr. James Grifo: 2016. But we, we saw that happening even before. We saw that in the 90s when I first started practicing in, you know, in IVF, that our patients were getting older and older. And just as a remark to that, I remember on my rotations going through, you know, the OB wards and this young female, high risk OB, head of department, high risk OB said, all right, now we're going to see something that you, you probably are going to be seeing more of in your career. And well, what's that? Well, we're going to go in and see this geriatric pregnancy. And I'm like, first of all, that's an awful term.

Why would you use that term? Like I have six sisters. I don't think they would like that. Um, and I didn't say that cause you know, you weren't like that back then in medical school and you just said, yes, yes, yes. And so we go in this room and there's a 32 year old woman having her first baby. And like that was considered a geriatric pregnancy.

That was 1983. You know, so just to give you a perspective last year, I mean, in New York City, 37 was the average age of first birth, not not second, not third. And we're having families. And really, if you look at the clock for women, it's never really been described to them well, you know, pretty much age 42, it ends.

So if you're starting at 37, you got five years and about 60 eggs to have a family. And you say, well, that's plenty of eggs. Not when they're 37 year old eggs. It's not so it's not such a straight shot. But back in 1984, you know, you were 19 and you had a lot of opportunity. And I guess the analogy I always like to use is like you ever see a farmer go out in the One seed in the ground and go home and eat dinner saying the crop's coming.

No, they throw a hundred seeds down knowing they're getting, getting 10 plants and embryos are just like that. And no one thinks of it like that, but I always did from the beginning. Bottom line is during that OB rotation, it was pretty clear to me with my molecular biology training and IVF just starting to happen.

That we had a whole future ahead of us because during my medical school training, I spent time with a friend of mine on the cystic fibrosis ward with all these young people born with this awful disease that couldn't be diagnosed before they were born and their lives were really hampered. They died young, they were infertile, they had miserable lives, they were in the hospital a lot, they had chronic pneumonias and it was like, we couldn't do anything about it.

We couldn't cure them, we got better. But, you know. With, with my molecular biology training, thinking about IVF and what we could do, we could prevent those diseases. And that, that was really my initial focus of IVF is like. We could use this technology to eliminate genetic disease by only putting back embryos that don't have genetic disease.

And essentially, you could wipe out all genetic diseases. Now, fast forward. Here we are today. Our patients come in. We check them for 566 recessive genes and see if they carry any one of those recessive genes, which is not a problem if they do, but if their partner carries the same one, like cystic fibrosis, The 25 percent of their embryos will have cystic fibrosis, and the baby will have a disease that we now can prevent, and in our clinic, because we screen everybody who is willing, and most are, we don't make babies with genetic disease anymore.

We've eliminated that, which is, like, that's happened in a 30 year span. It's remarkable. So, I mean, I didn't see that, that happening that fast or even in my career, but that was kind of the focus when IVF started. It was like, all right, during my fellowship, I started biopsying mouse embryos so I could learn how to do this technology to diagnose embryos and prevent genetic disease.

And that led to them. The one, the first one that I did was in 1992 when I was at Cornell, and we literally waited four years for permission to do it. The Brits did it first. They had permission. We didn't. Once the Brits had success, it was Alan Handyside and Mark Hughes, who's from the U. S., but he helped.

He did a lot of the genetics. We were waiting in line. I had a patient lined up. She needed IVF. We had done the mouse studies. I'd gotten permission. It worked. And she said, look, I want to be your first patient. My brother died of hemophilia. I'm 25, 25 percent of my babies will have it. I'm willing to be your experiment.

And she was, and her child is 32 years old now and doesn't have hemophilia. So that, that, that technology was born. I started my IVF career at Cornell in 1990. I trained at Yale and during my Yale fellowship, I was where I pioneered a lot of these technologies. We were, you know, there were several investigators.

I was one of them working on these methods of embryo biopsy and that led to the first United States successful embryo biopsy. In 1992, we were the second in the world to do that. And you know, that led to the next thing, you know, older women miscarry 40 year old woman miscarries 40 percent of the time, she'll have a down syndrome pregnancy one to 2 percent of the time, you know, we were seeing our patients get older, we were seeing them failing to get pregnant, we were seeing them miscarry more, you know, 25, percent of the time, you have a down syndrome risk of one in 500.

Well, as our patients were getting older, because You know, even in 1990, our average age patient in IVF was like 33, 34. And we were not having very good success with the older patients. And what was clear was so obvious. Embryos being chromosomally abnormal was the cause of age related decline in fertility.

Now, we knew that thesis in the 90s. We didn't publish the paper until 2010 because it took us that long to get the data. But it was also, not only could we prevent genetic disease, we could find the embryo that makes the baby. We could eliminate Down syndrome if patients don't want to have a baby with Down syndrome or Turner syndrome or Edwards syndrome, those chromosomal abnormalities.

But mainly what we could do is eliminate. Not completely, but to a great extent, miscarriage risk, because there's nothing worse than doing IVF and getting a miscarriage. Except getting the 16 weeks pregnant and having a down syndrome pregnancy, which we were making routinely in the years before we were using PGT a routinely, which is only recently, relatively recently.

[00:16:11] Griffin Jones: Let's go back to 1992 for a second, because I'm seeing the, this trajectory from 1982 to 1992, where you're, you're learning about molecular biology, you're going through medical school, you're seeing the demographic changes in terms of first pregnancy, which leads you to the implant. Implications of of what used to be called geriatric pregnancy and but then how do you get to the point in to take that first step to where you were among the first people to biopsy an embryo in 1992.

I see how you got the interest, but what was the actual step that you took to become a part of that team and and be able to actually bring that into your career? 

[00:16:56] Dr. James Grifo: So, you know, during my fellowship, I, I said this was going to be my career. I'm going to biopsy embryos is going to be the future. It's going to help us with so many things that the initial focus was genetic disease.

When I went to Cornell in 1990, uh, Rosenwax was in charge of that program. And the goal was for me to. Developed an embryo testing program and we started initially with genetic disease, but Santiago Mune joined us and he was going to study reactive to oxygen species and sperm. And I sat him down. I said, Santi, like the future is not studying sperm.

The future is genetics. And he, he agreed. And he did a pivot, complete pivot and said, all right, I'm going to work on methods that we can diagnose the embryo. And so And we had research protocols at the time, embryos that weren't being transferred that patients donated for research embryos that were tested for genetic disease and had genetic disease patients donated for research.

And we started asking, can we count chromosomes and that's where fluorescent in situ hybridization, a way to like, look at the cells of the embryo and see if they have the right number of chromosomes we showed in 1994. Think about this. That 20 percent of embryos were mosaic and no one knew what to do with it.

It took us three times submitting it to journals to publish it. No one thought it was real. They thought it was an artifact. And here we are 2016, how many years later now you have next generation sequencing as a technology to diagnose embryos, and now we're finding that there's mosaic embryos that we were transferring for all those years unknowingly.

And, and not believing our original research in 1992. And what have we learned? Mosaic embryos make babies. They make healthy babies, depending on the extent of mosaicism. It's either they are very low chance of making a baby or they have a high chance of making a baby. They don't perform as well as euploid embryos that have the right number of chromosomes.

So we started the foundational research in the early 90s. And at first, we started with five chromosomes because accounting for most miscarriages. And you know, it took us how many years to get to a stage where we can now screen for all chromosomal abnormalities. And now we have the most sophisticated technology in the world doing that.

You know, the, the labs like Cooper and. And you know, there's, there's tons of them. There's really good labs out there. I worked mostly with Santi who sold his lab to Cooper. And so I've done most of my research with them. I have no financial interest in them. I benefit not at all by using them, except I know it's a product that I've, I've helped develop.

And so I could, I trust it. I think now the whole field is going in the direction of routinely screening all embryos. It's still controversial. It's still, there's still issues with it. There's a lot that has to happen, but you know, when you've spent 30 years doing it, And your embryologists have the quality of your product is going to be better than someone who starts, you know, last year or five years ago.

So, you know, part of the reasons it doesn't work as well in some labs, they just haven't put in the time and the training to get there.

[00:19:56] Griffin Jones: So you persuaded Dr. Mouneh to get on board with this and say, listen, the future is in genetics. It's not, it's not here and just analyzing the sperm. And so you had a small team in the beginning, but 30 years ago, there wasn't.

A prelude network. There wasn't the networks that we have today. And if you were a 33-year-old REI or a 30 5-year-old REI, that was doing the equivalent of whatever the pioneering, uh, the next, uh, phase of segment of this field of medicine is, what would you do differently having the network that you have now?

[00:20:35] Dr. James Grifo: Don't know that I would have done it much differently because, you know, it would have take someone with a vision to do a high risk investment in something that, you know, sounded like a crazy idea that actually 30 years later turned into a really good idea, you know, mainly through not just my work, but there were hundreds of other people at different centers, you know, we all saw the same vision and we collaborated even though we were competing and, and really this field pulled itself up by its bootstraps.

Most of us did it with. With clinical money, like I, I never had research grants, you couldn't get embryo, embryo research grants, it was politically charged. I had a patient who was incredible to me, she has five kids from our efforts, and she's very wealthy and she supported us. You know, with annual grants that we use that money, we use clinical dollars.

We did a lot of stuff for free. My first, you know, five years of embryo vibes who've never charged for it. We just, because we, we, we didn't charge for anything until we had a, had a product. And so, you know, we saw that. PGTA was going to be the future. And we started focusing on that in the nineties. When I came to NYU, that became our, our prime focus.

But as in the nineties, we were watching our patients get older and it was very clear and we were seeing more and more patients needing egg donor, and that was. a problem because not everybody could get there. So a lot of women in their forties who wanted their first or second or whatever child, they were past that age and they needed egg donor.

Many of them didn't have that baby because they just couldn't get there with egg donor. And so that's where, you know, I spent With John Zhang, as my first fellow, we spent years trying to fix old eggs by taking the nucleus out of them, putting them in young eggs, and we got to a whole lot of trouble. I almost got, I almost got in trouble, you know, with this technology.

And, you know, 16 years later, it actually turned out to work and it actually turned out to be safe. But at the time that there wasn't a lot of appetite for that. I got shut down. I mean, I can tell you stories. I got a personal letter from the assistant surgeon general of, of. I got a phone call and she called me up and she said, what the hell do you think you're doing up there?

As we published something at SRM, it was a prize paper. We took old eggs, took the nucleus out of the old eggs, put them in young eggs and made embryos. And by the way, we did all this stuff in mice first and showed that it worked. So the babies were born were healthy and we got IRB approval to do this.

But once this happened and people thought it was cloning because we were doing nuclear transfer, it wasn't cloning, but they didn't understand the science even, she called me up and said, what the hell do you think you're doing up there? This is a, I said, excuse me, is this a personal call? Or is this like, no, no, you know who I am and you know why I'm calling.

And then the next week I got a letter from the FDA which said, We regulate you, you have to stop your work, you need to file an investigational new drug application if you're going to keep doing that work. I don't want to get too bogged down in this story, it was five years and a lot of clinical capital and money that we spent on a project that never took off, and you know, again, high risk capital, that turned out to actually be a good idea and could work and does work.

It will never take off. But you know what? There's always for every crisis. There's always opportunity. It kind of forced us to say, you know what? This is never gonna fly. No one's gonna have an appetite for it. Let's let's start freezing eggs. And so in 1999 2000, we started freezing mouse eggs, thinking that that would be the cure for egg donor.

We could let patients be their own egg donor by freezing their eggs. And we spent four years, a lot of money, again, personal money and, and donated money. Because again, it was hard to get, you couldn't get grants and, you know, would, would these big networks invest money now in such high risk stuff? I don't know.

Probably now there's, you know, there's, it's a whole different science world. I don't know. Certainly the opportunity is there. The bottom line is we, we got really good at making baby mice to the point where like, okay, it's 2002. We can do this, but you know, we haven't done it in human. We've done some frozen egg donors, but you know, we always do everything in our lab.

We do it in the animal first. We show that we can do it. We then move to the clinic. We do it for free. So now we had to design an experiment, which we paid for, and it was a lot of money. We did 23 free cycles of. egg freezing in patients who needed IVF, and back in, you know, 2000, most patients didn't have insurance for IVF.

A lot of them didn't do it because they couldn't afford it. So we had a natural group of patients that we wanted to help, and we had a need. Our need was to see how good we were at freezing eggs, because our mouse data said we would be as good as IVF. But we needed the data. So we did 23 free cycles of egg freezing in patients who needed IVF, waited a few months, thawed their eggs, made embryos, put back the best looking embryo, just like they had an IVF cycle.

And we said to them, you know, we think this is going to be as good as IVF. We don't know. Because we don't know, and because it's new, we'll pay for it. And we paid for their drug, their anesthesia, their whole process. And 23 women went through 13 of them had a baby from it. We had a 57 percent baby rate. We expected this group of women who they were 27 to 37 mean age was 33.

We expected to get 50%. We got 57 percent our first baby from that study. I got my annual picture from mom every year. I just got the first year at college picture this year. Uh, she's 18 and just started college. It's pretty incredible how much even just an experiment changed the trajectory of that family's life.

They never would have had a baby had they not been part of that experiment. I would call that life changing. 

[00:26:20] Griffin Jones: So now you have now NYU has a, an REI fellowship program. Is that right? Yeah. You have a fellowship. And you also have a lot of young docs throughout the prelude network. How do you involve them in what you're working on now?

[00:26:35] Dr. James Grifo: I don't have to, they're, they're like in there figuring it out and they're doing their own stuff and they're You know, using the basis and foundation of things we've done, they're an incredible group. They know, they see the future and they're, they're working on it. Really now we're at the stage of just refining egg freezing and getting better at IVF and get better at the testing and, and, you know, trying to make the patient experience better.

And that, that is one thing where, you know, Prelude Network has been really big on is just trying to make the patient experience better. Cause there's so many opportunities there for streamlining and, and also making things efficient. And, you know, that's where our, our, you know, medical advisory board meetings, physician advisory board meetings, we, we all get together and we talk about possibilities of how to be better and try and as much as you can standardize things to make consistency and that makes less errors and that makes for, you know, better process for patients.

And, you know, we at NYU, one of the things our fellows do, which is, I think, with our best experience, is we every, you know, a couple times a year, we ask specific clinical questions. Hey, we do this this way. Find out what the rest of the world is doing. Get all the papers. Let's talk about it. Let's come to a consensus between the doctors.

How are we going to do frozen embryo transfer now? What's the best protocol? And so we sit down and we review the literature and we come up with a consistent strategy we all use for many things, like all these new tests that come about and, and so it's made us better doctors, but then that gets trans translated to the network.

So then it's made a whole team of people better, and it's all about cooperation and being on the same team. And in the old days, we were all competing programs, although I got to say in our field, we have amazing people. And despite fierce competitiveness. We cooperated. I mean, Richard Scott, my fiercest competitor, we, we collaborated in so many, he made me so much better and I helped him get better.

Same with Schoolcraft. I mean, we, we, we were cooperative, but now in these networks, you could be a lot more cooperative and, and, and translate that into, you know, scalable stuff that benefits patients and benefits process and streamlines and makes things more efficient. So yeah, a lot of that stuff's happened, but our fellows, yeah.

See a heavy dose of all that. And then they're, they're out in their career. I mean, we've hired the best of our best fellows is our, our practice. And, you know, our, our practice are filled with. You know, five incredible young women who are, you know, have bright futures and they're doing the next generation of studies.

We had like 30 some odd abstracts at ASRM last year. One of them was we were part of the prize paper at ASRM for mosaic embryo transfer. I mean, we did one of the earliest mosaic embryo transfers in 2016. So you know, we're, we're always trying to move the needle and get better, not just. Not just in the science, but in it actually, how you conduct yourself and, you know, present to your patient and how you can make their lives better.

Many of us have been patients. I personally have gone through multiple failed IVF cycles. So I kind of know what it's like a little too well. And so that's influenced us as well. And we have a group of people here who are, who are, you know, many you have as well. So that's made us better, but you know, so the egg freezing thing.

Now it's 2005. We've had our first baby from it. And now it's like, all right. And PGT is starting to take off. And now it's like, my view is any principle that works well in IVF, we should apply to embryos that we get from frozen eggs. So we started doing some of the first studies with frozen eggs when we started thawing them of, Hey, our patients who showed up initially for egg freezing, who do you think they were?

They weren't 25 year old saying, Hey, I'm going to protect my future. That no one had a knowledge of any of this stuff. Egg freezing was an experiment. No insurance covered it. The 43 year old, the 42 year old, the 41 year old, the 40 year old showed up and said, you know, I'm like one year away from needing egg donor.

Like, why don't I at least put something in the freezer and see, and take a flyer on this. 88 women did from 2005 to 2009. The first five years of it, I mean more, more frozen than that, but 88 of 'em came back and used their eggs, and these were women who had a mean age of 39 40, knowing that the majority of their embryos are gonna be chromosomally abnormal.

We said to them, look, we're doing this in IVF. There's no reason why we shouldn't do this with frozen eggs. Let's thaw your eggs, make embryos not transfer them. Let's biopsy them and find the euploid embryos. You know, you're going to have a 30 percent miscarriage risk or 40 percent miscarriage risk and a 2 percent down syndrome risk if we just put back the best looking embryos.

And so we had some of the first frozen thawed eggs that were biopsied as embryos, frozen again and then transferred as single embryos. And I'll give you my last tweak, what I ran into. Patient of mine, I met her at 34, she's 46 now, she showed up at 42 having had two batches of frozen eggs from 36, she was 41 and a half.

With the guy, we made embryos, she had three euclid embryos, we put one back, she had a baby at 43, she now just came back at 40, you know, 45 and a half, and we put back her second embryo, and she's going to have her whole family from a batch of frozen eggs. We have over 30 patients who that's been their way of family building.

This is happening so fast. And, you know, it's happened sooner in the coast because that's kind of the, what's happened, you know, women are older in the cities having babies. They are having careers. They are delaying. And, and now this technology is coming to help us. This, this egg freezing is starting to take off.

You know, our average age of freezing eggs till about two years ago was like 38 and older. Now we're freezing eggs in 30 year olds who are like, yeah, I get this. This is important. Or we're banking embryos in couples who are 32 and they're on their career path of partners in a law firm and they don't want to have a baby now and they know they're going to be 40 before they get around to it and they're making their embryos now to have their family later, knowing that they'll put back a single embryo.

Whereas if you're 40 years old, the chance you get a single euploid embryo from one retrieval. Half the patients don't get one, and average is one, and one only gives you a 65 percent chance of a baby. You're not going to have a very good chance doing 40, you know, starting at 40 to build a family. You know, you do your retrieval at 30, you're going to have a chance to have enough embryos that you can build your whole family, and you can even Make sure you have enough by doing enough cycles to do that.

That's something that's happening. I mean, this is kind of like under the radar. People don't know this, but this is every day here now in our, our center, because that's just where we're at and our patients are at in our little microcosm. 

[00:33:28] Griffin Jones: Now it's become established and you've worked on this with other docs and now younger docs are working on their own initiatives.

And you talked about the Physician Advisory Board. I'm curious as to what that is and how somebody gets on that. Is that just any doc in the network? 

[00:33:47] Dr. James Grifo: No, so there are two year terms. You know, because I'm the Chief Executive Physician, I'm always there. And, you know, we go out to, to Napa Valley, TJ has a bunch of friends out there.

They let us use their space and, you know, we, we do fun things in interspersed with lots of lectures and discussions and planning and task management of what we're going to do next year. So people get nominated to be on, on the board. We try and get a good geographic exposure of our programs and, you know, people rotate in and off of that.

It's only been happening about four years now, I think, or maybe five, four, I think. And so it's a relatively new thing. We're still learning. We're still, but it's also just the chance to talk to other people from different places who are doing things a little different from you. And, you know, you find out what you thought was optimal, maybe they're doing it better.

So I better adopt it. We're making each other better. And then we're looking at. Globally more what, what kind of network kind of projects can we do? What kind of network research projects can we do where streamlining data? We're trying to get big data and pool all our data and doing a lot of things to improve, you know, the medical record and the data that we get from it.

And also streamline that some of it is even business oriented in terms of, you know, making us more efficient so we can, you know, lower the costs and not have to raise our prices. Things like that. So there's so many positive, good things about it and, you know, the docs want to be part of it. 

[00:35:16] Griffin Jones: And, and they are, how many docs are on the advisory board?

[00:35:20] Dr. James Grifo: Don't, yeah, I should know this number. It's about 10. We do have a physician summit, which is a bigger group. And a lot of the similar things are done. So we have annually a physician summit and annually a physician advisory board. But the Visition Summit is, you know, up to 20 docs and we all meet in one location and have meetings and, and fun too.

There's some social aspects to it just to kind of learn about each other and all the stuff that we're doing. And those are heavy science oriented and clinically, you know, clinical practice oriented. You know, a lot of sharing it, and it's the thing that's unique about it is when you're under the same umbrella, it's not like you're at srm with all your competitors, you know, you don't work, you don't try and keep, you know, some people are very secretive about things.

We have no reason to be, we're all partners, so, so the level of dialogue is more productive, it's a better feel for, you know, talking to your colleagues. You know, you're not threatened. And, you know, we share things that, you know, look, we had this really terrible thing happen. Here's how we handle it. What do you think?

And, and, and they learn from our mistakes, so they won't make the same mistake. You know, it was incredible. So we're, we're sharing things that you wouldn't normally talk about. And that's making us better. Programs and better, you know, managers and doctors and, you know, patient care people. 

[00:36:43] Griffin Jones: It's so how is that different in your view from just rounding with your colleagues inside the clinic?

[00:36:50] Dr. James Grifo: Well, because we're very focused and very narrow. I mean, we, we, you know, every, every place has its own way and thinks their way is the best way. And you know what? It's humbling because you go and you hear, man, maybe that idea that we're doing this way, maybe it's not the best way to do it. Maybe we should try it that way.

We do that with our clinical consensus meetings, but we do that at those two meetings as well. And, you know, we share. And so now the network gets more uniform in quality and that's good for patients. It's good for us. And it also allows us to get more data to see if we can refine further. But, you know, these kind of efforts take years and years of effort.

They don't bear fruit in one meeting. But you can see over four years how much we've improved. And, you know, we go to work every day wanting to get better because we know our patients depend on that. Our futures depend on that. And it's kind of the passion of behind everything we do. We want to get better.

You know, we see the failures, we see the patients who don't succeed. We want everybody to succeed. And we want to try and get as many people on that success train as possible. And so it motivates us. It keeps us. honest, it keeps us, you know, going forward, moving the ball, moving the needle, getting better, doing things better, thinking about the patient, thinking about their experience.

How do you put all those things into a better outcome and a better product? And then that will help because there's going to be more and more need for assisted reproduction. If the trends Of age at first birth in these last 30 years, we went from 19 to 37 in New York City and, and, you know, 2021, it was 30 for the whole United States.

It's a matter of time where we're having our whole families in late thirties, early forties, and we're going to be using assisted reproduction as the safest way to get there. And also the most preventative, because now we can eliminate genetic disease. We can eliminate. Babies being born with down syndrome, Turner syndrome, Edward syndrome, the things that you terminate pregnancies at 16 weeks for.

And you only find that out because you didn't test the embryo. And I remember the days when we were putting back just good looking blastocyst and getting the call of the patient saying, doc, I just got my results from my amnio, that picture that's sitting on my freezer that you told me was a beautiful embryo.

As down syndrome, like it's the worst phone call you get. And as you know, multiply that by a million, cause that's how the patient feels and I know how bad it feels to get that call. So I can only imagine what it's like to be the patient, although I've had too much experience that way too. So, you know, it's human suffering that we can prevent it's human, it's futures, it's health, it's so many things that we're going to influence with this technology.

And at some point, if the trend continues of being this old, we're already below zero population growth. At some point, we reach a point where we start declining in population and then it becomes a threat to survival. And I don't, this is not going to be in my lifetime, although I don't know, I didn't think we'd be here at this point in time.

And here we are, we're going to be at a point where this is going to keep us from being extinct. Because biology and evolution will not fix it. We are stuck with a 300, 000 year old biologic system designed for a different species of Homo sapiens. And it hasn't changed and it's not going to change because until we're threatened with extinction, there's no even selective gene pressure for that to happen.

So we're going to be the fix. We're going to be the adaptation. The system reproduction is going to save the species at some point. 

[00:40:30] Griffin Jones: This isn't a question that I was planning to ask. And so if it's too personal, feel free to decline. But you mentioned the struggle that you went through personally with IVF and you have a number of colleagues at your own practice at NYU, you have 10 or so other physicians on on the Physician Advisory Board, you have 20, 30 physicians that you're, that you're seeing at the Physician Summit throughout, across this whole network.

Does that ever come up with them? You know, like, just that perspective as a patient, do you ever say, no, I know that this isn't the right way, or I know that this is more important than we're weighting it presently because, um, Because I've been on the other side. Do you ever bring that into? 

[00:41:17] Dr. James Grifo: Oh, we talk about that all the time, all the time.

And in fact, TJ, that's his whole demo about, you know, why he got into this company. You know, he was in radiation oncology and, you know, he then, you know, went through assisted reproduction. He's very public about it and, and he didn't have a great experience. And so his main focus is to give a better patient experience.

And the way you do that is you make sure your workers have a good experience because they're the ones who are on the, on the, You know, front lines and we have to show them and respect them. And this is a big topic of discussion at these meetings. It's not just the science it's like we have to treat our, the people working for us in the best possible way, because they're the ones representing us.

And we're only as good as the, as the people that are part of us. And so we have 160 people in our program. We have to make sure they're doing their best, make sure they understand what it feels like to be a patient and how to be empathetic to them and meet their needs and help them have a good experience because that's just as good, just as important as getting them pregnant.

And, you know, every clinic has patients who feel like we did a bad job in that arena, but we have patients who failed multiple cycles and had really terrible, awful outcomes who still to this day are so grateful how we treated them. Like they say, they sent me a note, even though I didn't have a baby.

Thank you so much. You know, you guys did such a great job helping me through all this stuff. It's a really important piece of it. And it's a really hard thing to do and do well. So yeah, that comes up a lot. And yes, because most of us, look, we're all delaying childbearing. That's how I ended up needing assisted reproduction.

It was a second marriage, but we were much older and it wasn't going to work. And it didn't. So we, I, you know, I learned firsthand what it's like to fail IVF cycles, what it's like to have your transfer fail. And you know, it just is what it is. It was my best teacher. 

[00:43:11] Griffin Jones: So can other, can younger docs contribute in the same way?

Like can, can a doc that's only been practicing for a year or so even join the physician advisory board or do they have to be practicing? 

[00:43:23] Dr. James Grifo: They come to the summits. Anybody is a, uh, a, a prelude physician. Is eligible to get on the board and you know so the process i'm not really clear completely of the details they get nominated and then you know pretty much headquarters decides you know who to take because they want they want to make sure that network is represented they want to have.

You know adequate voices they want to have you know no gender bias they want to know. They want us to be a really good, cohesive and diverse group of people with different experiences and different clinical experiences. So it's a work in progress, and we're trying to learn how to do it better. And, you know, we get feedback every year from the docs who are part of it, and then we try and address that in the next year.

So that that in itself is a whole other project to learn how to do that better, because that's going to benefit. I mean, face it, consolidation is happening in our industry. There's going to be three or four players that, you know, control most of the IVF. Um, it, I've been watching that train, you can see it in 2015, you know, it was probably under 10 percent and now it's, I don't know the number, but it's, it's getting close to over, over 50 percent where, you know, 50 percent of the IVF cycles are being done by, you know, networks.

And it's going to go there because just the. The capital costs and all that make, make it that you can do it better as, as a network. So that's one of the benefits of all these networks is to streamline process to, you know, cut costs by having, you know, more centralized management part of, of. You know, back office type stuff that you can make it less expensive and more efficient and have it streamlined with technology and, you know, medical records.

So those are other aspects of focus of trying to make us better and also streamline the process to eliminate errors and, and. you know, make, make tracking of things more easy so that we can do studies with data that will show us what's better and then make changes. So, yeah, I mean, it's a really exciting time.

It's a really exhausting time because our patient load has just like boomed. I mean, just here at NYU, we've gone from doing about 16 to 1800 retrievals a year this year, we're going to do 4, 200 retrievals. We moved into a new space and, and egg freezing has really blossomed because now it's being covered by insurance.

Now it's got traction. We just published the world's largest study of 15 years of patients with eggs in the freezer. The first 15 years of our, you know, from 2005 to 2019, what happens to those eggs? How many babies do we get? What, what can we learn from it? And you know, we showed several things, very obvious conclusions, but we have data to prove it.

Now, the more eggs you get, the better the chance. The younger you freeze your eggs, the better the chance if you do more than one cycle, you have better chance. And we showed that if you are under 38, when you froze your eggs, and in this study, they would mean each was 36 of the under 38. Most of the patients were older and you have, you have 18 eggs in the freezer.

70 percent of those patients got a baby, which, you know, the New York times, when they wrote their article said sobering statistics from freezing eggs, because Our study was an honest study. We took all the patients in those 15 years, 40 percent of whom were over the age of 39, not the age you should be freezing eggs at.

And we included it in the data. And it's incredibly remarkable that even though 40 percent of the patients who froze eggs were over the age of 39, we still had a 40 percent baby rate. That was not expected at all. It was stunning. Under age 38. Anybody who did at least one retrieval had over 50 percent baby rate.

If they had 20 eggs or more, it's 70 percent baby rate. And if patients did two cycles, they dramatically improved their chances. And now that data is, is real. Some of it is published. We're still trying to get more specifics of it published. Peer review process is brutal. It's been rejected two times. We have data that really needs to get out there.

I just give it to my patients because I can't wait for peer review. We have a grid of if you're this age, you froze this many eggs. You did one cycle, here's your baby rate. You did two cycles, here's your baby rate. Because we have the data now. We've been doing it that long. We have big data, and it's significant.

Although, you know, the peer review says, Oh, it's not a big enough data set. It's only 612 patients who thawed eggs. It's only 300 babies that were born. It's the biggest data set in the world. Publish it, because people can use it. It's helpful data. But we haven't gotten it published yet. But I use it on every consult.

And, and say to patients, and so now our patients are doing two cycles of egg freezing because they see that there's a benefit. And you know, now we have patients building their families from frozen eggs only. I mean, that's become a big part of our practice. So It's, it's transformative. 

[00:48:23] Griffin Jones: What still needs to be done to advance fertility preservation?

When you think of, okay, we started thinking about this and in the eighties and we started working on it in the nineties and I'll maybe make an assumption that you're not going to be practicing for another 30 years. 

[00:48:38] Dr. James Grifo: Hopefully. I could be. I could be. I'm not that old. 

[00:48:41] Griffin Jones: Well, that, that, well, I mean, I 

[00:48:43] Dr. James Grifo: guess I went to Howard Jones's hundredth birthday party.

[00:48:47] Griffin Jones: Fair enough. So maybe you will, and let's pretend for a moment that you're not and you, that you have to turn over the reins. 

[00:48:56] Dr. James Grifo: Oh, I will. 

[00:48:58] Griffin Jones: The people that are listening now might still be in fellowship. They might be, they might be out of fellowship, but they're only like a year or two in and they're thinking about where they want to work next.

And let's pretend it's not someone that already works for you and not somebody that already works in your network, but someone that is at the very beginning of their career, what would you want them to take over? Or not even what would you want them to take over, but what is their For them to to take over that they're going to be doing over the next 30 years 

[00:49:30] Dr. James Grifo: So making this more accessible is, is, would be great.

And the only way to do that is to make it more efficient and scalable. And so there's a whole focus on automating the lab. And there was lots of research going on and a lot of venture capital doing that. That's going to happen. I don't know when or how long it's going to take, but that's going to be a big, a big element.

You know, being more efficient at egg freezing education is a big piece. Like I I'll tell you a story. It's, it's pretty scary. I was president of SART somewhere around 2000. I don't remember the exact year because I don't keep these things in my head, but. Phil McNamee was, and David Adamson were, you know, either president, president elect and, you know, moving through the, you go through three years to become the president.

And during that term, when I was on that three year track, we as a group, the SART group, using our own money, put forth a, an educational public service, hey, patients are getting older, you need to know what it does to your fertility. And so we did it in a very, you know, thought out way. We thought we were being smart.

And just to say, Hey, do you know what your age does to your fertility? And, you know, the longer you wait, the harder it's going to be. And you need to have, be thinking about this and planning your, your family and your future. And so we spent a lot of money on this thing the first week that it went out.

The National Organization for Women was publicly accusing us of scaring women and trying to tell them to come to our office and be treated. And we were just trying to educate them. We weren't, we weren't looking for patients. We were busy enough, but we were seeing our patients get older and we wanted to get the message out.

And, you know, it's so mad, uh, maddening how, um, uh, uh, a message. Shoot the messenger always can take over and it gets, goes viral, you know, the way media handles things now and we don't have common sense anymore. And it gets so political and it was awful. It was awful. Here we did this well meaning thing that we paid for out of our own pockets to try and educate.

Education is the most important thing. Kids need to learn this in college and high school. Women need especially to know what happens to them fertility wise. They need to see the lecture I give to every egg freeze patient to understand what the clock truly is and what it isn't. You know, most women think it's just bad luck that you have infertility.

Most women think it's something they did in college or high school, that they harmed their eggs, or they did something, they were doing something wrong now, or they're stressed and they should quit their job, or all these magical thinking things that have nothing to do with this biology being 300, 000 years old and not designed for us to be having babies in our 30s.

And so that's why we're so busy and we're just getting busier. Why? Because more and more people are delaying for good reasons. It's a social thing that's happened. There's so many good reasons to be older, starting your family. There's so many reasons to be, you know, financially stable and have a career as a woman before you start your family.

And yet this biologic system is not designed for that. And so we're the fix. And so education is a big piece of it. You know, making, streamlining the process, finding more non invasive ways to do the things that we currently do, finding ways to safely get more eggs without, you know, hyper stimulation.

There's so many opportunities, streamlining technology of the tools that we use in our day to day. I've watched ultrasound get so much better. It's helped us with embryo transfer and having better, more effective embryo transfers. I mean, there's so many opportunities. What I would say to someone just starting out, find your passion.

Find the thing you want to fix. Find the problem that you think we could do better and then find a way to make it happen because you can 

[00:53:15] Griffin Jones: so it sounds like two different spheres one is the education piece, which I would say is more than just education. It's like bringing it into the culture. That's something that the up and coming generation of docs is doing somewhat, but, but neat, that that is part of the ethos of what they need to do. It's not just educating the patient that's in front of you. It's bringing the awareness into the culture. And the second piece is some of the things that might be, have to do with the network research projects, the maybe, maybe that's what you're talking about with more noninvasive ways to do retrievals or to, to safely get more eggs.

Tell me about what. What research projects are either underway that you'd love to see people be a part of, or what research projects that you think are not underway yet that you would love to see this up and coming generation take up? 

[00:54:07] Dr. James Grifo: So, I mean, one of the focuses here is streamlining ovulation induction and making that more efficient and more effective and safer, getting more eggs and less hyperstimulation.

That's a focus. You know, getting better at egg freezing, that's more in the lab, using PGT in a more effective way and making better, I mean, one, one project that was done, one of our residents now fellow happens to be the daughter of Dr. Lecharty, one of our partners. She helped use artificial intelligence with the Cooper platform to select embryos better for transfer that were PG, PGTA tested to be euploid.

And we, we could improve the, the pregnancy rate. Using artificial intelligence, using our data and training their assay, knowing our outcomes, I mean, that, that was a little, a little win, but every little win adds up to a lot of wins over, over time, you know, there's now improvement in the technology of accuracy of PGT testing, you know, we've done a lot of studying of mosaic embryos and we'll continue to do that and finding the ones that Are worthwhile transferring to get good outcomes and maybe there are some that the risk is too high, for instance, you know, if you have a high level whole chromosome mosaic where you know more than 60 percent of the cells are.

have an extra or missing whole chromosome, you know, those embryos do poorly. They make babies, but you know, only about 15 percent of them do and they miscarry about 60 percent of the time. Having that data empowers patients to say, you know what, I'm willing to take that risk. It's my only embryo. I'm going to do it.

Or you know what, I'm just going to do another retrieval. That's just not worth it. That 60 percent miscarriage risk for a 16 percent chance of a baby. I don't want to be, I don't want to be that miscarriage. You know, we have that data now because we're doing PGT on these patients. Most other clinics, they're just transferring that embryo, not knowing because they didn't test it.

And so the patient takes an unknown risk is never counseled for it. The doctor is not responsible because they don't know. And so that's inferior technology. That's inferior treatment. You know, and it's a big debate whether we should be doing PGT on everybody. It's such a useful tool if you have the data and we spent 30 years at NYU getting it, and now it's our network has it.

It's avoiding miscarriage is our biggest goal now. And PGT is the way to get there. Avoiding we still have a 15 percent triplet rate. We have to 30 percent twin rate. I haven't seen triplets in, in, I don't know, 14 years. Um, we put one embryo back and 98 percent of our transfers and we still have a good pregnancy rate.

Why? Because when you're putting back, you put embryos, you don't need to put back more embryos. We sometimes put back two because patients want to, and we still let them make some of those decisions, but they're counseled. We still don't have very many twins because those are the patients whose embryos aren't that good of quality.

They're euploid and they don't have a good, as good a chance. And we say, all right, you can put two, mostly we put one at a time because you get there anyway. You know, and I haven't had to counsel somebody at 16 weeks with a bad amnio since 2012 when we were only doing about 60 percent PGT, you know, where patients would get pregnant and get to 16 weeks with untested embryos.

I haven't had that call. 

[00:57:27] Griffin Jones: Because of the advancements and we've weaved through the past, present and future, the advancements to come. I'd like to conclude with what skills or not, not even skills, what qualities would you want to see docs that are sitting on your physician advisory board three or four years from now?

Let's pretend that they're not. People that you already work with. These are not prelude docs. There, there may be, there may be just finishing up fellowship. Maybe they're working for somebody else right now, but they, so it's, it's not somebody that you've met yet. What qualities do you want them to bring?

[00:58:07] Dr. James Grifo: Well, they have to be critical thinkers. They have to be well versed in science. And they have to know how to ask good clinical questions that we can get a scientific answer for. Design a study that will get us the answer, you know, and what's the question you want to ask. You know, for instance, like frozen embryo transfer protocols, there's two different ones.

You can use a program cycle where we give Natural estrogen, natural progesterone. It has a lot of advantages. It's three visits. It's easy. And you don't have a lot of canceled cycles because patients don't ovulate because they're not ovulating through it. You do natural cycle, more visits, they ovulate naturally.

They're transferred. We get the same baby rate, but you know, can we make, can we do better? Is there a better protocol than either of those two that, that, you know, design a study? Let's figure this out. Let's, let's get better. We're getting there. So the, the, you know, being able to ask a scalable, solvable question and not, not just a, a, a theoretic ideologic question, you really just need to look at the problems in front of us and say, how do I solve that problem?

And then let me use good science to figure it out and let me design a study to figure it out. And it's really hard to do that. The best thing now are non selection studies where you test your test. So, for instance, Richard Scott did one of the best ones. He did PGTA on all the embryos that were collected.

They were all frozen. He did the first transfer just by morphology, looking at the embryo, not knowing the results of PGTA. And then after the babies were born, and he got the patients to do it. He said, look, we'll do the PGTA for free. You'll get it on your second cycle. The first cycle you get your best embryos.

Pretty good pregnancy rate. What do you got to lose? And patient said, yes, sign me up. And what he showed was that 0 percent of the aneuploid embryos made a baby, meaning that's a pretty good test. If we know 100 percent of those embryos aren't making a baby and they make a lot of miscarriages, there's no reason a patient should get those transferred.

There's no benefit to them. He showed that 65 percent of the euploid embryos made a baby, and he only put back one embryo, so we're making singletons. And the miscarriage risk at a 40 year old went from 40 percent down to 10%. So he showed that his test, and the same test we're using, could improve the quality of outcome and, and life for the patients.

Avoiding miscarriage is a really big thing. Seeing, I used to see so many miscarriages, we used to do so many more DNCs. I don't miss them. I don't miss them. And we still see them because we can't eliminate them completely. You know, those patients often give up, they quit treatment. So I mean, that's a non selection study that proved that his technology works and our technology works.

You can't argue it. And yet people still do. I don't know why. Well, that's a whole other topic. That's a whole other discussion. But those are the kind of studies we need to be doing. We shouldn't just do, like, for instance, the ERA test has caused so much heartache because, you know, the initial studies suggested that it was very helpful and now recent studies show that it doesn't really offer that much.

And so it was never tested properly. You got to do a non selection study. Um, you know, all the things that we do, we did a non selection study looking at endometritis. We learned that endometritis Is not as big of a threat as we thought, although there's a small sub subset of patients where it is and we treat them only and not everybody that was a non selection study that changed the way we treat.

We need to do more of those studies and patients need to help us so that we can help their care get better and everybody else's in the future's care get better. 

[01:01:49] Griffin Jones: I know that Prelude has a form that docs can fill out to get in touch, and we'll link to that. But if people wanted to continue this conversation directly with you, if they were interested in maybe collaborating with you in the future, would you be against them reaching out to you individually on No, not at all.

We can include your LinkedIn in the show notes, or if people want to email me for me to make an introduction, I'd be happy to do that if you're also open to that. 

[01:02:19] Dr. James Grifo: Yeah, I'm open. I'm open to anything. 

[01:02:21] Griffin Jones: Dr. Jamie Grifo, it's been a pleasure. I look forward to having you back on the show. It's probably been too long for this to be the first time we've had you.

So I look forward to it being not as long when we have you on again. And thank you so much for coming on the Inside Reproductive Health podcast. 

[01:02:37] Dr. James Grifo: Thank you so much. Thank you for doing this because educating our, our, our own is really great and we appreciate this. 

[01:02:45] Sponsor: This episode was made possible by our feature sponsor, the Prelude Network, where top REI physicians find their calling.

Join us and leverage state of the art technology, collaborate with the best physicians in fertility and be part of a network that's redefining fertility care across North America. At Prelude, your expertise helps turn dreams into reality. Discover. For more at rei.preludefertility.com, that's rei.preludefertility.com

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Thank you for listening to Inside Reproductive Health.

206 Launching and Growing a 3rd Party IVF Program with Dr. Daniel Shapiro and Dr. Monica Best

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.


What does it take to grow a third party IVF Program?

Dr. Daniel Shapiro and Dr. Monica Best from RBA Atlanta provide exclusive insights into the intricacies involved in establishing and developing a third-party IVF Program.

Tune in to learn:

  • The essentials to staying compliant with the FDA

  • How to properly counsel patients on 3rd party options: Dr. Best’s tips

  • What to tell donors during the application process (And what to tell them if they’re not selected)

  • Processes currently impeding more 3rd party IVF cases (But how new technologies are changing that)

  • Dr. Shapiro’s hard-won lessons from running an egg bank


Dr. Daniel Shapiro
LinkedIn

Dr. Monica Best
Reproductive Endocrinologist

Reproductive Biology Associates
Website
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Facebook
Instagram

Transcript

[00:00:00] Dr. David Shapiro: The barrier to egg donation is the supply of egg donors. If, if you build it, they will come, you know, there's between 18 and 25, 000 egg donation cycles a year in the U S and the demand is far greater than that. And so with the limiting factor right now is the availability of donors. And so anything we could do sociologically, technically, medically, financially, to make donation appealing to young women and safe, um, at the same time. Yeah, that would, that would grease the wheel on the egg donor side. 

[00:00:36] Sponsor: This episode was brought to you by Mind360. A leading fertility mental health platform. How long does it take your clinic to get patients through their third party psycho psychological evaluation?

Find out how your clinic compares with Mind360's free report at mind360.us/reducedwaittime. That's mind360.us/reducedwaittime

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[00:01:27] Griffin Jones: What does it take to grow your third party IVF program? What do you have to do to be compliant with the FDA? What qualities does your staff have to have? What do you need to say to the patient as they're being counseled on third party IVF options? What do you need to say to donors upon application? And what do you tell them if they're not selected?

And how? What are the process and technological impediments preventing more third party IVF cases from being done. And how is technology being used to remove those impediments? Technology that's on its way and brand new technology that's already being vetted and implemented by my guests. My guests are Drs.

Monica Best and Danny Shapiro. They're both practicing RAIs at Reproductive Biology Associates. who you know is RBA Atlanta. Dr. Shapiro is their medical director, and he's the clinical manager and co founder of an egg bank that you know pretty well. And we talk about the hard lessons learned from that and the mechanics behind building an egg bank of that size.

Dr. Best finished her fellowship in 2013, stayed in Atlanta, joined RBA. And for me, it was fun to interview Two physicians who worked together but started their careers roughly two decades apart. I found it insightful because it made it easier for me to figure out milestones, and I'd be interested to hear where you track on that timeline as well.

I hope you enjoy this topic on growing a third party IVF program with Dr. Monica Best and Dr. Daniel Shapiro, Dr. Best Monica, Dr. Shapiro Danny, welcome to both of you to the Inside Reproductive Health Podcast. 

[00:02:52] Dr. David Shapiro: Thanks for having us, Griffin. 

[00:02:53] Dr. Monica Best: Thank you, Griffin. It's wonderful to be here. 

[00:02:55] Griffin Jones: It's my pleasure. It's been a while since I've covered a topic on third party IVF.

I feel like I should be covering it more. Maybe it's just because I'm on a David Sable kick and Dr. Sable is just recognized in New York and he's constantly talking about the, Potential population for art services being much greater than what we're currently serving. And so I feel like, well, third party is a big piece of that.

Maybe that's part of the reason why I feel that we need to be digging into this a little bit deeper. And each of you are recognized for your expertise in third party IVF. But I'm not that familiar with with either of it. And so I would love for, uh, each of you just to share what your third party IVF practice interest in areas are and how you develop them, Monica.

[00:03:49] Dr. Monica Best: Well, I mean, I'm, I'm really interested in almost all facets of third party, you know, to include, you know, egg donation, surrogacy, you know, helping couples through their journey with, You know, really any facet of this process. You know, I enjoy in many ways like opening, you know, the eyes of my patients because oftentimes, you know, really most often they're not, you know, this isn't on their radar as something that they're going to need to build their families.

So, you know, I really enjoy all facets of, you know, this field of medicine, you know, and, and ushering couples through their journey to reach their goal of building their family, no matter how that looks. 

[00:04:35] Dr. David Shapiro: My interest in third party reproduction is not quite as ancient as I am, but it's, it's old. We've been doing egg donation at RBA since 1992.

I joined the practice in 95. Our lab director, Peter Nagy, brought vitrification here when it was

And I'm the physician founder of MyEggBank North America and its medical director and also the medical director currently of RBA and with Peter and our then office manager and our nurse manager, we put together the egg bank and Helped to change the way third party's done because we brought in frozen egg donation as a routine technology The other part of it that really fascinates me.

I love egg donation, by the way Very few of us love it to be honest with you. It's not something that most reis say. Oh god I can't wait to do egg donation But it really, it really grabbed me because it's the solution to a very common problem, which is diminished ovarian reserve. Now, some patients with diminished ovarian reserve are going to get pregnant on their own.

Some are going to get pregnant with IVF using their own eggs. Some actually need another form of third party, they actually need surrogacy, even though they might have diminished reserve, they also have a uterine problem. But egg donation solves the diminished ovarian reserve problem by bypassing it. For some people, that's appropriate.

For others, it's not. But for a great many, it is. And aside from that, egg donation is the only technology available for gay male couples that wish to have children. And, you know, with gay people in the family and they're thinking about family building, you know, there's, there's a personal angle to this too, where, you know, everyone should have the right to child.

rear if they are so motivated and third party reproduction makes that possible. And so I'm real enthusiastic about that because it expands the definition of parenthood. It expands the definition of childbearing and it gives us something really fascinating and rewarding to do. I want 

[00:06:35] Griffin Jones: to hear more about what led you to forming an egg bank now almost 20 years ago, but I'm curious, Monica, if you agree with Danny's assessment that very few REIs love egg donation.

[00:06:51] Dr. Monica Best: Yeah, I mean, I, I think, you know, it's, it's oftentimes a very difficult discussion you have to have with, with patients because of course everyone comes in, you know, at least, you know, aside from, you know, the, you know, the same sex male couple who understands very clearly that they need an egg donor and they need a surrogate.

I think most of our, you know, patients do come in anticipating. being able to get pregnant, you know, if, you know, especially even if they're using donor sperm, they're still expecting to be able to use their own eggs and carry the pregnancy. And so it's oftentimes a really difficult discussion to have.

But I think once you get beyond that and, you know, patients. understand the efficiency oftentimes of the process. You know, I think it can be very, very rewarding, you know, to help someone build their family in this way, because in many cases, they may not have otherwise been able to achieve their goal of becoming a parent, you know, just with the barriers that we may have had either with, like Danny said, diminished ovarian reserve or uterine factors that really, you know, you know, present a blockade for patients to be able to carry.

[00:08:07] Griffin Jones: Was that the reason you were thinking of Danny, the heaviness of the conversation, or was there other reasons that you think of the Ari Aiza? 

[00:08:14] Dr. David Shapiro: That's a big one. And Monica's absolutely spot on with that. It's a very uncomfortable conversation when you're talking to a woman in her thirties with severe diminished ovarian reserve.

And they really expect it to just be able to get pregnant and carry and have the baby shower and the whole thing. And it's, it's a dream blowing up. And and interdigitating oneself into that and not not implying that I'm deficited because I carry a white chromosome but it's it's a little harder actually I think for Especially us old guys to talk to younger women about this loss because we don't, we don't have that experience personally ourselves where, I mean, again, I'm not meaning to berate my kind, but younger women who are in childbearing age, I think have a better understanding personally what that's like.

But the reason I think REIs don't like it is because it's labor intensive. to recruit egg donors, to get egg donors through an ovarian cycle, to be compliant with the FDA, to make sure that every single box is checked and that there is not a thing missed, requires an awful lot of attention. and a staff with OCD.

Because you really just can't miss anything. And though the FDA regulations are really not that difficult to follow, you do have to know them. And special situations occur all the time, where we have to make an eligibility determination about whether an egg can be used or not. And that's, that's all part of the day to day management of an egg donor program, and especially with a frozen donor egg program, which is what we founded, um, not only do you have to be compliant, but you have to consider different state regulations about quarantine.

Like New York, you have a, there's a six month quarantine on gametes. Now, it hasn't really been applied to eggs the way it has been to sperm, but technically, they're supposed to be quarantined in six months if they're collected in New York. I don't think anybody's doing that. But, but if you follow the truest letter of New York regulation, yeah.

So we also have to have tissue licenses in some states where others we don't, because we're selling eggs literally. across state lines. So the, the management and the ability to follow and problem solve and take yourself away from the regular day to day of REI, which is busy enough to administer an egg banking operation.

That's a lot. And even if it's a small donor program, it's a lot. The, the nuts and bolts of it aren't that much different than regular IVF, but the regulation and the management is three to five times more labor intensive than regular IVF. And I think that's why a lot of REIs would rather not have anything to do with it just takes too much time. 

[00:11:08] Griffin Jones: I want to go through those boxes that need to be checked when we come back to talk about management and I'll, and I'll go to Monica when we do, but I don't want to lose the, the thought of you starting my, I guess that was in 2005, was it, is that when you said Yeah. 

[00:11:24] Dr. David Shapiro: Well, sort of, not exactly.

So one of the pharma companies brought a study to us in end of 2005, beginning of 2006, involving the new freezing technique. So vitrification is rapid freezing. You literally by hand plunge whatever you're freezing into a vat of liquid nitrogen and it It doesn't technically freeze for those who like P Chem.

If there's no phase shift, it's still in liquid phase, but it's so cold it can't flow. Vitrification literally means turn to glass. For people who know the physical chemistry, glass is a liquid. If you've ever looked at the windows of a 1750s Revolutionary Era house on the Concord Trail, you'll see that the windows have ripples in them.

And that's because the glass is flowing. It's a liquid and it's following the direction of gravity. It just takes 250 years for it to go an inch, but it's a liquid. The vitrification process, there's no crystal formation. So ice, as you may know, forms a crystal when it When it forms from water and it expands, which is unusual among freezing things and little knives is what those crystals are.

And they kill the egg or the embryo from the inside out. If you don't get the water out, vitrification allows ultra dehydration. And then rapid cooling to the temperature of liquid nitrogen. And the beauty of that is that when you take it out of the freezer and you rehydrate properly, you get back what you put in, where the older technique, the slow freeze technique was automated.

That's its one advantage, but you didn't get all the water out. And the water was replaced with antifreeze rather than just completely evacuated. And so that led to lower survival rates, worse pregnancy rates, very inefficient, relatively speaking. So when the pharma company brought the study to us as the then medical director of the practice, the nurse manager and I sat down and we over selected our best donors and great recipient candidates to see what this would look like.

And we took 10 donors, we split their eggs, we froze them first, and then we distributed those eggs to 20 recipients. And 15 of the 20 were pregnant on the first embryo transfer. And there were 5 who had frozen embryos from those frozen eggs, and this had never been done before. where frozen eggs were turned into frozen embryos and then made babies.

And we had two of those five. And we were sitting at a meeting after the first nine cases had been completed and there were seven pregnancies. And I looked at our lab director, who is still our lab director, Dr. Naj, Peter Naj, and I said, I think we just became an egg bank. Now, there was some resistance in that moment.

That was at the very end of 2006, beginning of 2007. There was some resistance because it was a newer technology and we didn't want to stick our necks out too far and then have our heads cut off because we made a mistake. But we had enough proof of concept that we were able to organize a bank relatively quickly.

And so I sat down with a handful of selected nurses. Some of the best nurses in the practice at the time. And we established criteria for donor selection. We established criteria for donor management. We established criteria for posting of eggs. We started our rudimentary website to make the eggs available to recipients who wanted to review the frozen donors.

And by the end of 2007, we'd done about 30, 40 cases. And then in 2008. We just went hog wild and we did a hundred and something, and then in 2009 we did like 180, and then in 2010 we did over 200, and then we went national in 2011 and we invited other practices to join us and we shared the technology. So that they could make eggs at the same time we were and then we developed a network of egg banks basically that share eggs Share the technology and we like embryos can be made in Seattle and shipped to Atlanta to for an Atlanta recipient eggs can be shipped from Las Vegas to Boston where they can make the embryos in Boston.

We can do PGT in some of these cases. And so we created a commerce really over, over biologicals that previously had not existed. And the end result.

[00:15:45] Griffin Jones: So you're among the first, you're, you're establishing this and I, and I want to hear more about that. And result. But as you, as you're training, Monica, as you're training in fellowship, as you're coming into the field, how much of this is established versus how, uh, versus how much of it was all already established or still needed to be established?

[00:16:05] Dr. Monica Best: Yeah. So I, I started at RBA my career in 2013. And so I am walking in to this very. Rich history and, you know, just the richness of something that, you know, I previously, you know, did not have a lot of access to in training, you know, at Emory, um, where I did my fellowship. So, you know, there was a very steep learning curve here.

for me, but I think, you know, I just was tickled by the fact that we had the availability of this resource so that I could help my patients. You know, I did not have very much exposure to this. Before I started at RBA and so, you know, as Danny was saying, you know, it was just starting to explode At the time when I started practicing and so, you know, I you know as they say, you know You stand on the heels of Giants and you don't even realize you are and it seems like you know, oh well Of course, we have, you know, egg donation.

Of course, we have this network. But, you know, it, it just, you know, I tell patients all the time, like, what a great day in age to be practicing because I have every resource at my disposal and I know that I can help you get there. It's just a matter of, are you open to all of the options? 

[00:17:34] Griffin Jones: And so was this, was your first job at RBA?

Was that your first job out of fellowship? Yes. So you're in fellowship, presumably like 2010 to 2013, somewhere around there. Yes. And during that time, are you learning about egg banks forming and how they work and, and gestational care agencies and how they work or are you just learning about the medicine but not necessarily how it all, how you actually get those gametes, how you get those gestational carriers?

[00:18:02] Dr. Monica Best: Right. I think I had very limited understanding of egg donation in an egg bank. When I started in 2013, of course, you know, I understood surrogacy and, and I understood, you know, things like sperm donation, you know, anonymous sperm donation in patients that I treated, but really knew very little about, you know, egg donation and just, you know, what a, what a game changer it could be for my patients.

in terms of the availability of it. So, definitely was eye opening when I started. 

[00:18:36] Griffin Jones: How is it, how important is it for doctors to know the mechanics of how an egg bank works, how a GC agency works, how, like, is, it, it, it, like, is it really important? Is it somewhat important or not very? 

[00:18:49] Dr. David Shapiro: Hard to answer my bias is that it's medium important.

Okay, the nuts and bolts. Nah, no one's got time for that and they don't need to but to just say, oh, it's an egg bank. I'm just going to send my patient there. It's better to understand. I think sort of the. the gestalt of, of how a donor winds up being a frozen egg donor. Some of the egg banks, they take donors and dedicate them just to egg freezing, which is mostly what we do in the frozen side.

Others will use eggs not claimed in a fresh cycle. As the leftovers so to speak as their egg bank eggs, they'll freeze the leftovers The one's not inseminated for the benefit of the original recipient when you do it that way when it's when the bias is toward freezing the leftovers for People to come and take what's on the you know, filings basement shelf, the pregnancy rates are lower.

When you dedicate donors specifically to a frozen program, you get pregnancy rates pretty darn close if not the same as the fresh transfers, even without the genetic testing of the embryos. So. Knowing what model the bank uses, I think the physician should know that because if they're sending their patient to egg bank X, they want to know that the frozen eggs available to that, to their recipient are going to be eggs that were dedicated to that.

Purpose, because that's going to give the highest yield, where they could send to egg bank Y and be getting the eggs that were the last state of the 27 that were collected, and the lab, through insensible means, assigned the first 19 to the fresh cycle or whatever. And the eggs that they didn't like quite as much, but wouldn't say that, actually are the ones that wind up frozen.

You know the negative selection bias when you split the eggs fresh and frozen on purpose Winds up deficiting the frozen I think in fact, I think there's some evidence to that And so we do that too here. We the leftover situation, but the the primary Goal is to find a donor who should be all froze, frozen, so that you get the best eggs from the cohort in the freezer.

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[00:22:42] Griffin Jones: Monica, you're coming in. This infrastructure is established and you said you're standing on the shoulders of giants, but giants don't, fig, aren't, don't, aren't able to figure everything out and none of us are over. Even giants. Just saying.

And, and, yeah, and, and, and you're never tall enough to have everything figured out. And so what did you have to still figure out when, as you started getting into practicing third party IVF? Monica. 

[00:23:10] Dr. Monica Best: Yeah. I mean, I think, you know, just the logistics, like Danny alluded to earlier, you know, just the attention to detail and, you know, helping patients to sort of understand why we do what we do, that things have to be done a certain way, and we have to be compliant with the FDA.

I think one of the things I do is kind of walk patients through, you know, this is, you know, the process by which we select our egg donors, I think is important for every physician to understand so that they can relay that information to the patient just because that is important for them to know. But, you know, you know, they're, they're even, even if, you know, again, we're the most well oiled machine around, still as a clinician, I was, you know, having to You know, interface with the nurses who were expert in the FDA and understanding almost always there's an exception.

Almost always there's a special situation that comes up or tends to come up at RBA just because the complexity of our patients. And so, you know, having to go back, even though there are well defined guidelines of what the FDA requires, okay, well now we have this exception or now we have this complexity, you know, how do we either.

You know, you know, do something to make it compliant, or is this a case or, you know, a scenario that we can't accept moving forward? And there unfortunately have been those cases. 

[00:24:42] Dr. David Shapiro: Third party is as much getting all of the pieces of the puzzle organized properly as it is the science, the reproductive science.

[00:24:52] Griffin Jones: Let's talk about a couple of those. Those puzzle pieces for each of you to walk us through it. You said, you know, everything has to be all the boxes have to be checked. What are those boxes going going as chronologically as you can? 

[00:25:09] Dr. David Shapiro: Well, all right. So if you're, if your goal is safety for the donor, respect for the donor recognition for the donor's autonomy, and at the same time getting good eggs so that you get the pregnancies at the expected rate, you should limit it.

The age 21 to 31 should not take donors over 31 years of age. They should be able to fill out the questionnaire that we developed without triggering any of the hard stop questions that get them excluded. And they don't know which ones those are. They need to, we used to require that people be free of genetic carrier states.

But with 550 plus diseases on the panel, everybody carries something. So now we, we make sure there's no infortuitous match, but we do allow donors to carry pretty much everything except for X linked and obviously dominant diseases. The, the exclusions are numerous and you have to know what they are. I mean, they're, you can't even have a relative.

One relative who had heart disease before 50. One first degree relative, you're excluded. You can't have two relatives with diabetes. You're excluded, right? You can't be on psychotropic medication at the time of your donation. You're excluded. And the donors don't know this. And when they're filling out these questionnaires and we're vetting them, this is what we're looking for.

What are the exclusions? What are the exclusions? If they get through the questionnaire, then we assess their genetics by blood testing and genetic counseling. Then they go for basal antral follicle count and anti mullerian hormone level to make sure they're going to make enough eggs. Because if they're not going to make enough eggs, it isn't worth their time and it isn't worth it to us, quite honestly.

And so we, we bias heavily in terms of excessive ovarian response, which we can do safely now, which is one of the other big innovations in reproductive medicine in the last 10 years is the ability to get tons of eggs without hyperstimulating the patient. That's really what makes egg banking possible.

Something called agonist trigger, which replaced the old technique, which was called HCG trigger, which caused hyperstimulation and hospitalized donors all the time. It was a fraught technology, but with agonist trigger and a little bit of moderation, you can do this safely. The average egg yields within the egg banking.

practices that we're contracted with is 26 per retrieval, which is a very high number, right? But if each egg lot is six eggs, you get four egg lots out of every retrieval, which is the goal, right? And so we can do that safely. So we screen for very high ovarian response. We then have them come in for infectious disease testing because the FDA requires it.

They also, the timing of the testing is critical too. You have to get the egg donor, has to have her FDA infectious panel done within 30 days of the egg collection, otherwise the eggs are invalid, can't use them, right? So we typically draw the blood when they start their cycles, because that way we'll have it within 30 days.

But they also have to go through psych testing before they even begin a cycle. And they either do something called a personality assessment inventory or an MMPI 2, Minnesota Multiphase of Personality Inventory. We require that our egg banking network requires that PhDs administer the test because they're the only ones with enough training to actually score the tests themselves.

So that's the, the MyEggBank standard, which is the name of our egg banking operation. We use the PhD standard because. We think it should be the standard of care. The idea that you can test somebody to make sure they're psychologically stable and then send out the test to someone who has not interacted with the donor and have the test scored and be valid?

Too much risk. We won't do it. So we, we, it has to be a PhD level to screen our donors. Otherwise, no. We won't accept the screening. If they've been screened elsewhere and it was not by a PhD, we make them redo it. Once that's all done, the infectious disease testing, the full exam, the full interview, the psych, the ovarian reserve screening, the genetic screening, and of course the questionnaire, then they can go through ovarian stimulation.

And then there's a, a kind of a rote thing that I've noticed this just because I'm an old guy. The younger generation that's training now, they've learned ovarian stimulation kind of on, you know, like Betty Crocker, like Betty Crocker recipes. My generation was the first generation to benefit from the founder generation.

Working all of this out, but part of my training was I had to learn the basic physiology of each one of these drugs and why you pick one over the other. What we've, what we've learned in the last, well now 15 years of regular egg banking is that not every donor should be stimulated the same way. That there are combinations of drugs that are more favorable in some situations and less favorable in others.

And you have to be flexible in how you write the stimulations. There's a concept in reproductive medicine right now that everyone has to be on something called a combination protocol. It actually goes against the science. And the people in my generation were trained on that difference. My generation knows there's a difference between what's called an FSH only protocol and the combination protocol.

Now certainly there's a role for combination protocols, there's a big role for them, but it's not 85 percent of the protocol. It shouldn't be. The, the more basic protocol, the FSH only version actually is preferable in most cases. But that's not what people are taught now, even though the science says that that's true.

So part of the management of all of this is understanding what pieces you can manipulate to get the optimal outcome. So somebody with a lot of experience in ovarian stimulation or somebody who can teach others about ovarian stimulation, that's a critical component to this too. 

[00:31:05] Griffin Jones: So you're talking about change and innovation, which is a theme that I want to dig into a little bit more, because I Have this feeling that if you were to just sum up just if someone from outside of the field that knew nothing about art had to just kind of listen to people's feedback and then summarize in a sentence or two the level of change that's happened in the field that From all of the voices, they would surmise that nothing has changed and everything has changed.

And I suspect that there might be some of that flavor in third party as well. So before we go all the way back to 2013. What has changed in third party IVF since you've been practicing, Monica? 

[00:31:50] Dr. Monica Best: Oh gosh, you know, I mean, I just, I think the just sheer availability of eggs from multiple egg banks and just having to sort of manage that with patient expectation, you know, just coming from, you know, the perspective of RBA and our egg bank.

And, you know, having some level of control of the information about donors and understanding kind of the efficiency of our program and then having to sort of manage patient care with respect to them, you know, acquiring eggs from other egg banks, you know, just, you know, having to kind of, you know, deal with those differences I think is, has been something that's changed for me because.

You know, when I first started, I mean, it was, it was our egg bank. I mean, that's, you know, we were the largest egg bank in the country, the first egg bank in the country. Again, there's a lot of control and there's a lot of management of efficiency there. So I think that's one thing that's, that's, that's sort of changed.

And I also think, you know, patients. understand more about egg donation than they did when I first started. So I think that's helpful in counseling patients. 

[00:33:06] Griffin Jones: What makes you say that Monica, what kinds of questions are they asking you now that maybe they weren't 10 years ago? 

[00:33:12] Dr. Monica Best: You know, I mean, I, I think, you know, they're, they're asking about the availability of you know, of the resource.

You know, I don't necessarily have to, you know, counsel each patient that, you know, that egg donation is their most efficient path. Many of them come in understanding that or understanding that they need surrogacy. And so that, that does make the conversation easier. That does kind of help with efficiency of getting them.

from point A to point B. So those things have changed, I think, in the sense that, you know, we, we do have more resources, but in some ways it does make it more difficult because it's just, I mean, it's hard to find the same efficiency with other egg banks and other kind of, you know, third party entities that we have.

[00:34:01] Dr. David Shapiro: I, I think, I think there's also been a cultural shift among physicians on this. When I started here, without naming any names, there were physicians in our group who were flatly opposed to taking care of same sex couples, men or women, wouldn't. And that's going to be the bulk of third party in years to come.

And now it's every day. Everyday. And what, you know, might have raised the eyebrows of a baby boomer 25 years ago makes a Gen Y, Gen X, or millennia, or millennial, whatever you call them, go, yeah, and, I understand, right? This is what you do. Why are you even hesitating? Right? So there's that shift. Patients have come to expect also that this is something that they can access easily because they see famous people using egg donors and surrogates.

So it's out in the common, it's out in common parlance. People talk about this like it's nothing. Janet Jackson having a baby at 50. You don't have to be a rocket scientist to figure out how that happened. Right. Or Gina Davis at 48 to figure out how that happened. 

[00:35:17] Griffin Jones: But do you have a lot of not rocket scientists coming in because they, they have not figured it out?

Because I hear that from doctors as well, that people have an inflated expectation of what they can do with, you know, just their own eggs. 

[00:35:31] Dr. David Shapiro: Because when the desperate housewife, I forget her name, the redhead, she went. She had twins with egg donation. She was very public about it when it happened. She said, this is egg donor.

Don't be ridiculous. I was 44. That's what she said. And that I remember when that happened, because I remember the patients and the reaction in the months that followed that revelation after her twins were born, people were like, it's all egg donor, isn't it? Like, so, I mean, all of these. Trade mags and the globe and, and national inquire with babies at 52.

I mean, it's not like donor, right? Like, like, yeah, we, we watched the interview with what's your name? And yeah. Yeah, we get it now. Now that hadn't happened in a while, but yeah. But they hear it. They know. More and more. 

[00:36:24] Dr. Monica Best: Patient expectations, I think, is helpful, right? Um, you know, those difficult conversations we were talking about before sometimes aren't as difficult when patients You know, when their expectations are, hey, I'm 44.

I know what I need. Or, you know, just like Danny was saying, you know, I think the ability to be able to treat same sex couples is extremely rewarding. You know, they, they come in, they understand what they need. And again, we have the resources to get them there. So, I mean, that's, that has shifted and grown and morphed really since I started practicing in 2013.

[00:37:04] Griffin Jones: Are there instances where expectations go the other way? So there's, there's a higher education on the part of patients, but does that ever put them in a place where they know enough to be dangerous now? 

[00:37:19] Dr. David Shapiro: You want to take that one? 

[00:37:22] Dr. Monica Best: Absolutely. You know, I think I, you know, I spend an inordinate amount of time you know, trying to manage expectations.

I think even under the best circumstances, there's still a failure rate of 30 to 40 percent. You know, embryos don't implant 30 to 40 percent of the time. Miscarriages still occur, even if we know we're dealing with genetically normal embryos, this gold standard. So I think, you know, yes. Yes, there are sometimes unrealistic expectations.

And some of these are emotional, right? You know, you're, you're spending all of this time and, you know, your, your resources in terms of, you know, your finances, your physical resources, everything. And you expect that after you You know, invest all of that, that you're going to be pregnant and, and I think sometimes those are, those are the difficult places to be.

[00:38:15] Griffin Jones: So , you started talking about the, the different requirements for donors from, it has to be done by a PhD, the, the hard stop questions, the exclusions, what were some of the hard lessons that you learned in the last, whatever it is, 16, 17 years regarding those? 

[00:38:39] Dr. David Shapiro: Some, some of the donor candidates with good reason.

I mean, I understand this. They take it personally when they're, when they're excluded. Right. It's yeah, they came because they were going to be compensated. There's no question that money makes the difference when there's no compensation for donors. There is no donation. That's very well established. And though they may come for the money.

They're personally invested in it because they realize they're doing something altruistic. And when they're informed that for any number of reasons they can't, some of them take it personally. And so we've had to modify how we handle notification of the exclusions. We used to do it, it was automated when they were filling out the questionnaire, if they tripped one of the booby traps.

They'd get an email saying we can't screen any further and that was it. And that was, that was chaotic because it created a lot of phone calls of angry donor candidates saying, why would you do that to me? I want to give my eggs. There's nothing wrong with me. And there may not be anything wrong with them technically, but there's something on the FDA thing that's excluding them or there's something on the questionnaire that's excluding them.

And there's no way around it. We used to, when they were excluded on psych, we used to be the ones to inform them, now the psychologists inform them, when they're excluded based on psych. Because it's not that they're crazy, it's that somewhere on one of the scales where they got assessed, the risk is to them, not actually to the baby.

That going through the process and knowing that you have donor derived offspring out there without being able to know who they are, for some people, that's a little bit psychologically taxing. They should not be donating. And it comes out in the screening. And so the, the way the psychologists now will say to them is, look, there's nothing wrong with you, but here's what got tripped on the testing and this is the reason for the exclusion.

So it's not personal. It's just based on nuts and bolts, what, what can we can allow according to the care standards from our professional organization. It ain't about you personally. And that's been, that's turned out to be way better than having us make the. Notifications that they're excluded. So we learned that.

Um, we also learned that if you tell the truth really starkly about what to expect in terms of pregnancy rate per embryo transfer, people hear it, they hear it right. Yeah, this works great. And the cumulative pregnancy rates, meaning with multiple transfers, there's 85 to 95 percent live birth rates in most donor programs, right over time, but not per transfer.

And so in the course of the conversation, you have to talk to patients about, we learned this along the way. You have to talk to them about the cumulative rates. You have to talk to them about what multiple transfers look like before they reach their goal. You have to. Set expectations, as Monica was saying, and Monica is very good at interacting with her patients.

She's being a little modest by describing the emotional piece, but her patients love her and they get a lot from her over the emotional piece in third party. And that's a very important thing to tend to. If you make it too science, science, science, people kind of glaze over a little bit because in the end, they're talking about their baby.

Right. And they're, you're trying to, you can't science size their babies. And so, you know, the emotional connection, the ability to show somebody that even if you're not feeling what they're feeling, you understand it. 

[00:42:03] Griffin Jones: So I've made a note because I want to ask Monica about that, that counseling. But what you're describing, I would never equate a gamete donor with a job applicant.

Donating gametes isn't applying for a job, but there are parallels. And one of the th One of the things that I would love to be able to do with people that apply for jobs at my company is tell them the reason why I'm not moving them forward. But every HR professional will say, No, you don't do that. You just tell them you just you just give them the thank you and stay, please stay involved and keep us consider us in the future.

And so what to what degree are you informing them of why they weren't selected? 

[00:42:45] Dr. David Shapiro: The donors, when they're not selected, they all get told why. 

[00:42:50] Griffin Jones: They'll get told why. They're told the very specific reason why, or is it kind of, is it a general 

[00:42:55] Dr. David Shapiro: It's going to be a lab test. It's even, so this is the other thing people don't realize.

If you run the FDA panel, and even though the patient, the donor, does not have HIV or hepatitis, a false positive test, even if you can later prove they really don't have the disease, They're excluded. You can't go back and say, Oh, no, that was wrong. And then use the donor. And so you have to tell the donor why she was excluded based on a false positive, because what's she going to do?

She's going to go to the next program down the road and they'll retest her and pretend like she wasn't tested before when she was already excluded. And so, you know, you have to have the paper trail. There is no donor registry. There should be because people who do that should not be approved in another program after they've been properly excluded in the first.

But because there's no registry, we can't keep track of that. So if you say to a donor, Hey, the psych came back with an invalid score, but you're not crazy. There's nothing wrong with you. You're highly functional. Don't worry about it. But this is why The booby trap got tripped then either they're going to take the appropriate amount of time which on the psych is two years And you know wait until they can be retested because they've been told you know, you shouldn't be applying again for two years So we've done our due diligence by telling them the reason We're, we've taken responsibility for saying to a donor, look, you got excluded and by rights, you should always be excluded on some of the testing, or you should be excluded on the site for two years, but it's not permanent.

And then that gives them a framework. And then we can document why we excluded. And if anyone ever comes back and asks for our records, they can see exactly what we did and that we properly counseled the donor so that we're still compliant with FDA. We're still compliant with best practices and.

American Society for Reproductive Medicine guidelines. And we're doing the right thing for future recipients because some of these exclusions actually do protect the recipient, though most protect the donor. So, we have to tell them. They have to know why. 

[00:45:04] Griffin Jones: Wish we could do that for jobs. Monica, I want to ask you about the counseling prior to treatment when you're counseling a patient on third party options because I noticed some years back that The physician's approach is probably one of the is probably the single biggest variable on determining if they move forward with treatment, provided that, you know, cost isn't a barrier and that sort of thing.

And we really researched it for a while. And I could tell that there is one end of the spectrum. This is just kind of this isn't third party. This is talking about more generally IVF. But there's one end of the spectrum where you can be too prescriptive and the patient feels like they're being pushed into IVF and they or they and they feel like they're not being listened to.

But there is also another end of the spectrum, which I think is easier to err on, actually, where the patient feels like they're getting too many options and they. It's like I'm coming to you the expert and I don't know what I'm supposed to do after this. And I found that the, the, the docs that are, are more prescriptive, as long as they're, they don't go too far, tend to, to, to resonate more with the patients.

Although there's, there's a number of different personality variables, but what is your approach to counseling on third party? What do you find to be? 

[00:46:26] Dr. Monica Best: Um, Yeah, I mean, I think I think of this really from, you know, an efficiency standpoint, and I try to get the patient to see it from that perspective. You know, I have.

A large volume of patients in my practice who are, you know, advanced age and, you know, again, never thought that they would be able to, or never thought that they would get pregnant any other way besides utilizing their own eggs. And, you know, I have to get them to understand that not just RBA, not just Dr.

Best, not just the clinic down the street, but nationally in the world. You know, the limitations to being able to utilize your eggs are going to yield a likely zero percent chance of success. And, and so, you know, we give our patients lots of autonomy at RBA. You know, we, you know, we of course just recently established an age cutoff.

And so we give patients. a lot of autonomy to proceed with IVF with their own eggs. But I think what I do is I really spend a lot of time talking about how, yes, we could do four or five cycles and still not get there. Or we can shift our resources to doing something that's actually going to get them a baby.

And, and potentially multiple siblings from that one cycle. And so, it's oftentimes not just one discussion, it's oftentimes not just one consultation, but it may be, you know, two or three. Again, just. You know, kind of going back to what Danny and I were talking about earlier in that, you know, yes, there are a lot of physicians that don't like doing this and that's why, you know, again, you know, you plant the seed and it's something they never conceived of and then they come, they marinate on it, they come back and you're like, listen, If these are the resources we have to work with, if we really want a baby, then this is the direction that we need to really be, be moving in.

And, and so it's, it's, a lot goes into those discussions and just meeting the patient where they are. You know, some people need data, some people need for you to, you know, just speak to them woman to woman. And, you know, I oftentimes will say, look, I've had my own struggles with infertility and I've been in your shoes before and I understand, you know, kind of what the emotional piece of this is.

And, and oftentimes you'll, you know, you know, some patients may still cycle a couple times and then you just still keep bringing it back home. Okay, so this is what we had, you know, I have a 45 year old recently who, you know, Had like six blast biopsy at each cycle and everything's abnormal. And of course, you know, I said we, we would have to do an inordinate number of cycles and you just don't even have the time left to be able to do that and still be efficient.

[00:49:45] Dr. David Shapiro: If, if I may, there's, there's another part of the counseling that I lucked into by accident. It just sort of flew out of my mouth one day and it turned out to be one of my stock statements because it worked and it's true. Which is that DN That's half 

[00:49:58] Griffin Jones: of my sales pieces, by the way, Danny, half of, half of my sales scripts are from just, Oh, that worked that one time, somebody that's, the light bulb went off.

I should use that one again. But yours are DNA 

[00:50:11] Dr. David Shapiro: might be destiny, but it isn't parenthood. Right. And so what we're getting to with egg donation, and same with third party surrogacy with people carrying, um, a baby's a human being that's going to have its own soul that it's naturally wired for, but that is influenced by the people who raised it.

And, yeah, the DNA may Direct the behavior in one way or the other, and intelligence may vary a little bit. But in the end, the parental influence is the bottom line. And the experience of carrying a baby, even if it isn't your DNA, it's your baby, right? By everyone's definition, except the genetic one. You deliver the baby, you experience pregnancy, you experience the, the aches and the pains and the terror with, uh, contraction at 22 weeks, all of that makes you a mom.

And so when women start, and again, this is an old man having this conversation, but when I introduced that concept, I see younger women's eyes kind of go, Oh yeah, right. And it opens the door. It doesn't always get them through. But it opens the door, they may 

[00:51:28] Dr. Monica Best: need another consult to hear it again, you know, or more or more and I think to, you know, as couples go through this process and I'm just speaking of like kind of just, you know, your routine, you know, couple where the woman has diminished of Aaron reserve and, you know, you're going to use the partner sperm.

I mean, that's. That's, that's a huge advantage because patients are like, okay, well, what about adoption? What about this? Or what about that? And just kind of going back to what Dani was saying, you know, just being able to tell patients, you know, you have the opportunity to experience pregnancy. Your partner has a genetic link.

Even though you don't have that same genetic link, your, your genes and your body are influencing the expression of those genes. And it's a, it's powerful. It's really, really powerful to patients. And, you know, again, they see that, that advantage. And I think just from an efficiency standpoint financially, it's just as efficient, if not more efficient than adoption in many ways.

And you get this added benefit of being able to carry and potentially your partner having a genetic link, if that's It's the scenario, you know, and so it's just, it is, it is extremely rewarding. And I tell patients, I've never had a patient who pursued egg donation who regretted it when they saw 

[00:52:55] Dr. David Shapiro: absolutely 100 percent agree with that.

[00:52:58] Griffin Jones: There's no way to, yeah, there's absolutely no way to. 

[00:53:01] Dr. David Shapiro: That's right. I, and I won't, and I've never seen it either and I've been doing it longer and I'm going to retire in the next 10 years and I won't see it before then either. Yeah. So I 

[00:53:10] Griffin Jones: think I want to conclude with what you see as the roadblocks that can and should be removed, converting and, and, and, and for the providing third party IVF treatment for those that need it outside of the payer stuff.

So don't not, not coverage and let's, let's pretend that that's solved for or will be solved for. Let's pretend that for this conversation and as specifically as you can think, what are the technological or process impediments if, if, but for those, uh, we would be seeing a lot more third party IVF patients.

[00:53:48] Dr. David Shapiro: Depends if you're talking about surrogacy or egg donation. Either. Your pick. The barrier to egg donation is the supply of egg donors. If, if you build it, they will come. You know, there's between 18 and 25, 000 egg donation cycles a year in the U. S. And the demand is far greater than that. And so the limiting factor right now is the availability of donors.

And so anything we could do sociologically, technically, medically, financially, to make donation appealing to young women and safe, um, at the same time. Yeah, that would, that would grease the wheel on the egg donor side. Surrogacy is a little different though. That's, I think that's a social, a socialization process is going to take a while.

Because, you know, right now most surrogates are paid. And surrogacy is the kind of thing a sister can do, a best friend can do for you. The more sociologically this becomes. De rigueur, actually, the more I think people will be showing up with friends and siblings and not paying the agents and not paying surrogates for hire.

That's going to take a long time, but that's, in my opinion, a sociologic barrier that will eventually fall, but it's going to be a while. 

[00:55:04] Griffin Jones: I've got to ask the AI question because it seems like every, no matter what subtopic of the fertility field we're talking about, there's some application for AI and often we're talking about it on the lab side.

Where do you see applications for AI in the next two or three years with regard to whether it's, whether it's donor selection or whether it's gamete grading or embryo grading or what are the applications you see for third party? 

[00:55:33] Dr. David Shapiro: All of it. How close are we? We're there. It's the ultrasound that we demoed the other day has an AI function to make sure the follicular diameters are exact and reliable and reproducible.

And it's the first system we've seen that has an AI function in it to guarantee that what you're getting is a true representation of what's in the ovary. It's a quick, much quicker scan. It just right through the ovary, every follicle gets. Uh, counted almost instantaneously the exact shape, the location, an accurate number of follicles, right?

Ultrasonographers are human beings and they're real good, but sometimes they're under counts, sometimes they're over counts and that gets the patient expectation and what it's like in the retrieval suite if they think they're getting 30 eggs and only five come out, right? So AI and ultrasound is already there.

It'll be there in embryo grading. If it isn't already in some practices, I think there's a program that's been released already, but I haven't seen it. I think it's going to help us determine who's going to be a good responder and a not good responder, because AMH, though a very good tool, is not a perfect tool, right?

We're going to be, all the predictive modeling that goes into AI, is going to help reproductive endocrinologists know who should be a donor and who shouldn't, who should be a recipient and who shouldn't, who's likely to get pregnant and who's not. Right? And you can, you can show all of this to the patient and say, here's what the math is saying.

Here's what we can do to either bypass or trick the math, but here's what it says. 

[00:57:14] Dr. Monica Best: Everything. Everything. It's going to be everything. Like I want to know, I want to know down to, I want AI to tell me down to which eggs we should be fertilizing and which sperm we should be picking up to do ICSI with. You know, or, you know, because I mean, I think, I mean, again, there's just so many applications to that, you know, women that are coming in and freezing their eggs, like, okay, well, we can't genetically test eggs, but is there some function?

I mean, again, that I would. You know, that would be right. 

[00:57:44] Dr. David Shapiro: Is there something in the microscopy that I could recognize? Is there something in the stimulation in that you plug into an AI function and it tells you which set of eggs are going to work better within a cohort, right? Which egg is the one you should use first, right?

Yeah, all of that's coming. 

[00:58:03] Griffin Jones: Dr. Monica Best, Dr. Danny Shapiro, thank you both for coming on, sharing your thoughts of what is happening now in third party IVF, what needs to come so that more third party IVF patients are able to be served. Thank you both for coming on the program. 

[00:58:21] Dr. Monica Best: Thank you so much for having us.

[00:58:24] Sponsor: Guide your patients to Mind360 for immediate access to high quality psychological evaluations and fertility mental health tools. Don't delay your patient's cycle. Find out how quickly this process can be completed by downloading their free report at mind360.us/reducedwaittime

Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you.

But the themes expressed by the guest do not necessarily reflect the fuse 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. Thank you for listening to Inside Reproductive Health.

205 Vertical Integration of the Fertility Field: What Lies Ahead with Louis Villalba

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.


Is vertical integration inevitable?

That’s the question we explore this week with Louis Villalba, CEO of TMRW Life Sciences, as he dives into the consolidation and current business climate within the fertility space.

Tune in to learn about:

  • The 5 ancillary services of the fertility space (And how they make the distinction between vertical and horizontal integration)

  • The argument against concentrating these services (Like risking new buckets of liability)

  • The argument for concentrating these services (The sweet spot to acquiring a related service)

  • Backward integration vs Forward integration (Move closer to raw materials or toward end patient consumers?)

  • A breakdown of the recent major lawsuits in fertility (And what those would look like in a vertically integrated fertility space)

  • Speculation on when we could expect to see antitrust regulation in the field


Louis Villalba
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TMRW Life Sciences
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Twitter: @TMRWLifeSci

Transcript

[00:00:00] Louis Villalba: What this does is it shows you, as we have obviously a lot of natural, you know, you know, kind of consolidation in our space that's occurring with private equity, as the buyers become more sophisticated, what you see is actually a lot of focus on how do we continue to control more of the patient, you know, experience, if you will, and then how do we monetize, you know, those, you know, those efforts in terms of providing other services that we outsource.

[00:00:24] Sponsor: This episode was brought to you by Surrogacy Roadmap, a self led educational course created by Family Inceptions. How many social media surrogacy matches have you come across? Get your free lesson from surrogacyroadmap.com/for-professionals. That's surrogacyroadmap.com/for-professionals.

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.

[00:01:14] Griffin Jones: Can you just be a fertility clinic anymore? And I don't even mean, can you just be an independently owned fertility clinic anymore? I mean, like, even if you're a large group, a network of fertility clinics, multi state, multi lab even. Will you be able to get away with providing lab and clinical services only, or will you have to integrate into other verticals?

Vertical integration is happening in the fertility field. It's not just kind body. It's not just recharged capital in Southeast Asia. I suspect with these massive capital firms like KKR and Blackrock entering the fertility field that we are going to see a lot more vertical integration. And so that's why I brought in my guest, Luis Villalba.

Lou has recently been promoted to CEO of Tomorrow. He was the CEO of Geneo Biomedics, and he's led commercial divisions for a number of different companies in the space. To make the distinction between vertical [00:02:00] integration and horizontal integration, Lou lays out. The five main ancillary services in the fertility space.

This is from the point of view of the fertility clinic, safety and technology, storage, lab, egg banks, which I'm guessing you would just say gamete banks and surrogacy services. He talks about the buyers like KKR bringing a new level of sophistication to their approach to controlling the value chain. Lou makes the argument against concentrating ancillary services.

And he makes the argument for it. In the argument against, he talks about the risk of a headcount and new buckets of liability. I push him a little bit about what the strength of a balance sheet means. How relative is it in the time that we're in now where capital is starting to tighten up versus five years ago when seemingly anyone could get a loan for a low amount of money, for a low amount of interest.

We talk a little bit about major lawsuits that have been recent like The chart ink lawsuit from the Pacific Fertility Center failure five years ago. What that would look like in a vertically integrated fertility field. With regard to the healthiness of the balance sheet, Lou talks about the healthiness of gross margins for fertility networks.

What's the good end of the range? What's a poor end of the range? In the argument for Lou talks about the sweet spot for where it makes sense for a fertility company to acquire a related service. I asked him about backward integration moving closer toward the raw material versus forward integration moving closer towards the end.

patient consumer. I ask him about what tomorrow is up to. Lou gives his opinion on if it's a five horse race among the largest fertility clinic networks, what will happen next in that dynamic, like consolidation between horses two through five. I named some companies and I asked Lou to tell me who he thinks are the front runners right now.

And then finally, I asked Lou to speculate on when we might start to see some antitrust regulation happening. in the field. We've seen a little bit. There's more integration happening. Politically, there might be an appetite for trust busting on the populist waves of both the left and the right, according to my amateur political analysis.

And Lou gives his thoughts. Enjoy this episode about the inevitability of vertical integration in the fertility space with Lou Villalba. Mr. Villalba, Lou, welcome to the Inside Reproductive Health podcast. 

[00:04:02] Louis Villalba: Thank you, Griffin. Happy to be here with you. 

[00:04:04] Griffin Jones: I'm happy to have you on because you and I have gotten to know each other over the past few months.

But recently we were at a meeting and when you and I were just having a side conversation about vertical integration, I was like, stop, this needs to be, I need to be recording this. It needs, I got to get this into a podcast episode. And I want to ask you all sorts of things about vertical integration, about specifically what's happening in the field of how necessary it is, when it backfires, how, how people go forward and backward.

But let's maybe start with just how you would describe vertical integration and ancillary services and introduce the theme for us. 

[00:04:43] Louis Villalba: Sure. Sounds great. And I appreciate it and appreciate the, uh, the discussion. So if we look today in terms of ancillary services, and let's say, for example, we focus on some of the larger IVF networks in the U S a lot of these groups have taken a look at, you know, kind of You know, bringing on into their operations, what I'll [00:05:00] call five different components.

One is safety and technology. So anything they can do to automate their existing platform on a day to day basis. Second would be storage. Obviously as storage, you know, is some people outsource. Some people have actually started to manage directly on their own. Then obviously you have genetic labs, which is a very big, you know, important part of the day to day business.

As we see networks starting to own their own labs and integrate and actually acquire some of the labs and services they were using, then you obviously you have egg banks and you have surrogacy services. So these are generally the five major components of ancillary services that most networks are concentrated on.

And not only networks, but if the single providers are large enough in terms of scale, they would also benefit from, you know, concentrating on these types of components. 

[00:05:45] Griffin Jones: So, are some of these, would some of these be examples of horizontal integration? Like, I guess it depends on where you are in the journey, right?

Like, because if you're a, if you, if, if it's third party IVF, then I suppose [00:06:00] that having the egg bank and the surrogacy services as a part of the chain would be vertical. But how do you distinguish horizontal versus vertical in this case? 

[00:06:12] Louis Villalba: Yeah, it's an important question, and we'll just take a quick step back.

So if you look, for example, at like innovation fertility, it's prior to their, you know, merging with U. S. fertility, and you look, you look at the services they were offering, I think they were, you know, a lab focused, you know, network, right? That, you know, basically took on, you know, a lot of different aspects.

They had storage, they hired actually a sales team. led by some, you know, highly qualified, you know, talent to go out and sell their genetic lab services, their storage services and amongst and amongst other things. And they were looking to expand that as they went into their merger. So time will tell with us fertility, what they choose to do.

So if you compare that to vertical or horizontal. you know, integration, you can make the case that if it's their own existing, you know, kind of physicians [00:07:00] that they support, that would be more of a horizontal. If they take it out to other, you know, entities, we could, you know, we can talk about virtual integration in terms of, you know, those types of services.

But I think first and foremost, what this does is it shows you As we have, obviously a lot of natural, you know, you know, kind of consolidation in our space that's occurring with private equity. As the buyers become more sophisticated, what you see is actually a lot of focus on how do we continue to control more of the patient, you know, experience if you will.

And then how do we monetize, you know, those, you know, those efforts in terms of providing other services that we outsource. Now, there's obviously like all good things in life. There's a lot of execution as you continue to offer more services that's required from a network perspective. And if you think of day to day care versus bringing on additional services, it brings on a different set of circumstances that you have to execute to provide that patient experience.

[00:07:56] Griffin Jones: So when you say buyers are becoming more sophisticated, you're not talking about the fertility patient and consumer, you're talking about the business to business buyer, the buyers purchasing clinics, clinic networks, and fertility companies? 

[00:08:11] Louis Villalba: So I would say we have, we have sophistication increasing on both sides, okay?

And I would say that obviously the buyers are becoming more sophisticated. You look at KKR's acquisition paying two and a half billion dollars for, you know, for Evie RMA, that is, you know, that's a major player. There's no larger private equity group in the world. That's probably going to get into private equity or excuse me, into IVF outside of a BlackRock, let's say something of that nature.

So what does, you know, a purchaser. of that, you know, kind of bandwidth bring. It brings a level of sophistication that is different than, you know, in terms of how the business has actually grown. I always love to point out we're 44 years old in the world in terms of the oldest IVF baby, right? And so this business was, you know, this industry was built on the backs of a lot of great healthcare providers that, you know, established IVF to where it is today.

And that attention continues to multiple or multiply. in terms of the buyers that are coming in to the space now. So we see progenies of the world going directly to the patients, right? They go to employers, they offer benefits that creates a, you know, a level of sophistication that, you know, takes them, you know, a middleman out of the equation.

And now you see these types of, you know, providers starting to influence patient treatment patterns, right. In terms of where they go, what types of services are offered, what things are covered. You know, we see obviously a lot of. You know, you know, if you look in my opinion, if you look at a Massachusetts or an Illinois and you look at the mandates that have been approved in those states for some time, that's the future of IVF in the United States to a certain extent, okay?

We're going to see that type of coverage continuing to expand as it should and provide more coverage to, you know, to patients because we know that, you know, currently right now there's nowhere near enough treatment for the amount of demand that's in the market today. 

[00:09:56] Griffin Jones: So do you think a lot of the drive towards vertical integration is coming from the investor side?

Is this part of the investor thesis now? Is this, how much is it coming from operators that feel like, well, I just simply need to do this in order to complete the rest of our business plan versus investors coming in with is part of their thesis. And it is, is it, is it part of almost every investor's thesis now?

[00:10:22] Louis Villalba: Think that, you know, every investor is going to look to obviously maximize their investment, right? And how do you do that? Do you do that by controlling more ancillary services, you know, and increased profit? through providing, you know, or controlling that type of the business. And there's, you know, there's a great debate that goes on.

There are some networks CEOs that, you know, would, would, you know, argue that concentrated on ancillary services is not the right way to increase profitability. And, you know, in an IVF network, actually seeing more patients as a way to actually increase profitability is, is what some would say. Others would argue and say, look, this is the best way for me to control quality.

This is the best way for me to control safety. And yes, for controlling those things, I probably will realize a better profit. Okay. And I, you know, in terms of, you know, where they will call the sweet spot from a risk and profitability equation. I think it's a lot of that depends on scale. So once you reach a certain size and you're obviously, you know, your volumes obviously support these types of investment.

These make it natural sense for some businesses to, you know, to take on this type of service, but it doesn't come without risk. Right. And anytime you actually perform an additional service for, you know, for patients that comes with an execution, you know, responsibility that's on the back end. And let's look at, for example, at genetic labs.

All right. So genetic labs obviously have grown tremendously in the last, let's say seven to 10 years. Okay. You look at where things started with PGS and you just follow the natural equation, you know, to where we are today with PGTA, et cetera. And what you'll see is a lot of, you know, networks now, once they reach a certain size, taking on their own genetic labs.

Okay. So in terms of, you know, the responsibility that comes with providing, [00:12:00] let's say, a genetic test, the results. There is an enormous professional liability that you don't have as a care provider, but you do as a genetic lab operator. And so these are the types of considerations that I think people go through and they have to look at, you know, what type of, you know, professional liability insurance do I need to carry outside of my malpractice insurance to perform these types of services.

[00:12:22] Griffin Jones: Okay, so there's a couple different ways, I want to, I want to, I'm making some notes because I want to dive back into risk. I want to talk about controlling the value chain to best ensure the patient experience. I want to, to first start on asking you to steel man the argument that concentrating And on ancillary services, not the best way to increase profit, but that to just focus on patient volume is, whether that's your position or not, I'm just asking you to steel man it.

What's the argument there? 

[00:12:54] Louis Villalba: So one of the most expensive parts of, you know, of any services business is headcount. And the amount of headcount required to provide additional services actually increases your expense level, right? So on the, on one end of the equation, you're going to argue that my top line revenue is going to increase, right?

Because I'm now going to bill out and enjoy the profit that I was outsourcing to a genetic lab, you know, previously. If I manage that responsibility on my own. So the other part is going to be, you know, when you look at any IVF clinic in terms of a network or a well run business, the, you know, the general P and L statements of an IVF clinic are going to range.

And if, you know, unfortunately the low 20 percent when things aren't going well to probably low 40 percent when they're run close to perfectly. Okay. So if that is your range, 20 to 40 percent in terms of your profit, and you're going to reinvest that back into. offering additional services to your patients, you don't have a lot of runway for margin of error.

So if you take on a responsibility, for example, like storage, and you actually go out, you acquire a facility, you make the investment, you actually are bringing on additional risk now because you have an outsourced facility where you're storing some of your most you know, precious, you know, kind of resources of any IVF, you know, network.

And then you are going to manage that on a day to day basis with additional headcount. Okay. On, you know, in terms of managing that responsibility. So those types of risks you manage, obviously in your clinic, one way, when you outsource to a different facility that you're running, okay, that you're eliminating risk, you're actually bringing on additional risk to yourself, but more importantly, you're actually increasing your expense level.

And so that relationship between risk and reward is an important equation. When ancillary services comes up for clinics to consider, because if we said, for example, you know, your revenue per patient's going to increase. If you concentrate, you know, just on the patient experience within your own clinic versus, you know, managing outside services.

I think that's an important distinction any CEO would want to think through as they make a decision on, you know, managing things directly versus outsourcing. 

[00:15:00] Griffin Jones: If the trend of vertical integration really continues and the number of fertility clinic groups that remain unintegrated gets smaller, do they have to have a really strong consumer brand in order to...

Maintain that niche and not be in all of the other verticals. 

[00:15:26] Louis Villalba: Yeah, it's important to think about this. All right. So your, your patient experience is obviously, you know, in the journey is created by so many different interactions, right? It's the interaction from when you walk into when you sit down with, let's say, you know, nurse before you get to the MD.

Or in some cases where embryologists do speak with patients that, you know, they have those types of interactions. You bring in ancillary services and let's say, God forbid, you have a bad experience with a genetic lab. Okay. Where does that brand reputation get hit? Does it get hit on the, on the clinic or does it get hit?

for the genetic lab. If it's an outside service, it's going to go on to the clinic, you know, generally, because that's where the direct patient experiences. And so I think that, you know, the, you know, the, the ability to build a, you know, a strong brand in this space is, you know, encompasses all of those points of interaction.

And so the more that you're obviously, you know, focused on the things that you can do to increase your brand awareness and create a good experience, the better off, you know, your interactions with. Patients are going to be, and that's going to be the strength of your brand. The quality of the people that you partner with is going to be the strength of your brand.

Okay. And I think that's, you know, what will eventually, you know, rise to the surface in this, in this equation, as people, you know, look like in all types of, you know, of businesses. You know, the more points of execution you have in any equation, the higher risk you have, right? And so if you want to bring on, you know, additional, you know, points of execution into your care model, you have to realize that you're going to need the management involved and the expertise involved to execute against, you know, those responsibilities. 

And I think that the attraction of the profit is one part of the equation. The execution of the quality is, is extremely important because that involves safety, which at the end of the day, we're all most focused on. 

[00:17:14] Griffin Jones: Well, let's go to a different industry for a second where safety is less of the concern and it isn't as serious as what.

People do in this field, but we were just in California recently, and I don't eat fast food normally, but every time I'm in California, Lou, I just want In N Out Burger. And, uh, so last time we were at PCRS, and I'm getting In N Out Burger, and I start, I'm really curious about the company, and it's a three billion dollar company, Lou, no franchises.

Owned almost entirely by one woman. Now, granted, she's an heiress, it was her grand grandfather, I think, and then her father and her uncle, and her uncle didn't have heirs, if I remember the story correctly. But, this is a three billion dollar company. No franchises. Highly profitable. I haven't really dug in, but I don't, I don't think a ton of vertical integration.

I think, I think they mostly occupy their spot. Contrast that with McDonald's, let's say. And you know, I think McDonald's might, their parent company owns a bunch of shares of Coke and, you know, and, and, you know, they probably own the distributors or at least some. Parts of the distributors that for their suppliers and they own the potato farms in some cases and, or at least independent contract them like they do.

And, and so who would you, would you rather, would you rather be, would you rather own In N Out burger in that situation, or would you rather be the equivalent level shareholder in terms of capital at McDonald's and why? 

[00:18:44] Louis Villalba: Yeah. Yeah. It's great. It's a great scenario. And I love the in and out story. You know, a long time, California, it's a, it's, it's just a fantastic, I think, you know, example of, but one family that controlled the entire, you know, evolution of that brand starting out, you know, obviously it was a Southern California based business.

They knew they had a high quality product. They have been enticed along the way. You know, you can imagine every year with their growth of someone to come in from a private equity side, acquire this, scale it, you know, nationalize it. And, you know, from that, create it into a worldwide brand. But what they, you know, what they figured out early on was, you know, obviously there's, you know, there's always more than one route to success, right.

And their route to success was going to be about staying as a high quality brand. And so not to say that other brands aren't. High quality, but they definitely have stayed a higher quality brand, which is why they have such a cold following. And whenever they, you know, their distribution centers in terms of where their products go out to the different stores, those have been very geographically selected.

Right? So there're only a certain number of hours on a truck, you know, from the distribution point to actually the point of, you know, service and I. I believe that model in healthcare has some, some similarities, right? So we, first and foremost, we have, you know, we want safety and we want success, right? And success in my mind is quality in this.

And so what we want to continue to do is we want to build obviously points of care that deliver the highest success and the highest safety and the best patient experience possible, right? Everything encompasses into that patient experience. That's why. The patient referral in our business is still by far the most effective referral, no matter how much money, technology, artificial intelligence we spend in trying to control, you know, patient pathway, you know, patient referrals still drive, you know, a majority of a lot of our business.

And we know in terms of the number of diagnosis, you know, versus the number of treatable patients, we've got a lot of room, you know, for continued growth in this, in this business. Quality is, I still, in my opinion, going to be one of the most important things for us to build IVF worldwide in terms of its reputation.

We need to continue to support high quality providers and high quality standards. 

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[00:22:22] Griffin Jones: You give very tangible examples of what In N Out does, but also what other people do.

So I think if people do want to maintain that route, that thinking of what those, what those indicators of quality are and truly investing them as necessary, as opposed to just saying, Oh, you know, we've got a good reputation. I don't think, I don't think that's going to come. I think quality has to be a measurable strategy and in that situation, at least I suspect it does.

I want to have you. Dealman, the, the, the case for controlling the, the value chain, but before we do that, is there also a strategy that can be applied if you don't control the value chain that you can pit vendors against each other? Like, I'm thinking of what happened in, what seems to me to have happened in genetics.

Like, you, you have the fertility networks and they're driving down the price, having all the genetics companies compete with each other. And so that seems to me like a cost saving strategy that might, that might not be duplicable If you also own that vertical, or am I missing something? 

[00:23:32] Louis Villalba: No, you're not missing anything.

So, look, there are only, you know, when a patient walks through the, you know, the entrance of a clinic and actually, and arrives for care, you know, call it whatever. There are 30 unique events for you, for example, to drive, you know, revenue on a patient, right? There's a, you know, so there's screening on the front end.

There's, you know, there's diagnosis, there's obviously pharmaceutical treatment, and then you actually get into, you know, obviously, you know, trying to, you know, produce eggs, right? Those sites or, or do a sperm analysis. So then you get into your laboratory process, right? And within your, what we'll call your case rate, all of the, all of the fees that are associated at case rate are, are to cover.

everything to let's say a blastocyst production, and then a transfer, right? A retrieval and a transfer. And so when you take, you know, in terms of the number of steps that are in a case rate, and you say the value that's been assigned, you know, to that, you know, to that case rate, then the only thing you can do on the back end of that is sell additional screening, additional storage, you know, additional services, you know, you know, to patients.

And that in terms of what, you know, the ability for them to kind of increase the revenue per patient, that's where people are, are, are evaluating, evaluating, obviously, where are the options there and under our current, you know, care paradigm today, it's a pretty strict protocol in terms of how you can actually increase revenue in a, within an IVF clinic.

Other people are trying to expand that, you know, let's say that, you know, kind of. care, you know, option, meaning that they're not just going to do reproductive health. They're going to do gynecological services, right? So that gets into well, woman visits that gets into more of a general maintenance of, you know, of, you know, of a female health life.

And that is where they're trying to say, look, we built this infrastructure. We want to drive more, you know, patient volume through this infrastructure. You know, women's health services actually can encompass not just reproductive care. They can also, you know, encompass, you know, gynecologic care. And so that's where I think.

You'll see, you know, in terms of the, the focus continue to evolve. We'll see this now. It hasn't succeeded. People have tried it in the past. Was it too early? Was it not the right design? Was it, you know, and let's say for example, you know, geographically, you know, not, you know, not, you know, kind of aligned in terms of, you know, with patient mindsets.

There's a lot of factors that go into expanding, obviously, you know, patient care. But I think with the level of sophistication that is now coming into IVF, we're going to see some successful models that expand the, you know, the care continuum. 

[00:26:01] Griffin Jones: Is there something to be said about the timing right now that impacts the risk that you started to talk about?

You talked about both legal liability, which we want to talk some more about, but you talked a bit about financial risk. Is there a risk, especially now, of being over leveraged if you're acquiring other companies and other verticals and maybe three years ago it would have been fine because if you started to stretch out your runway you'd just borrow some extra capital at a very low interest rate and now that Interest rates are higher.

It appears that lenders are getting a bit tighter. A couple of the big lenders like Silicon Valley Bank and Signature have gone under. And I suspect that we're going, there's rumors of, of, of a couple, you know, of a bankruptcy or two or a mass layoff or two in the pipeline. When it, when it happens, we'll report on it.

Right now, they're just rumors, but I, I think that some of them will happen because of the climate that we're in. What is, What is the timing that we're in right now due to vertical integration that might otherwise happen in the fertility field? 

[00:27:07] Louis Villalba: Right. So the businesses that, you know, have weaker balance sheets obviously are not in a position to go out and acquire ancillary services or invest in ancillary services because they're obviously, you know, They're financing their current levels, you know, of debt if they, if they have them.

And so that puts them obviously in a more conservative position in terms of looking at, you know, building these types of, you know, of care, this type of service, you know, for their, for their patients. What that does though, is it means the independent providers that obviously specialize in these types of ancillary services, the strength of their business, obviously.

starts to rise to the surface. And then what you'll see in competition, as we've seen, obviously in the genetic screening world, and you'll see in the storage world, you'll see in, you know, and obviously the surrogacy services, not to the same extent, but definitely at some level and egg banks, you'll see, you know, obviously the force of competition, people will negotiate.

You know, the strength and the size of some of these organizations will mean that they're going to pay, you know, they're going to actually save money in terms of, you know, providing these types of services through a third party. And they'll leverage that, you know, to increase their profitability on a per patient basis by not carrying all the expense of actually hiring headcount, investing in technology, all the things that are required to, you know, to deliver these types of ancillary services.

They'll approach it, you know, in the, what I'll say, the good old fashioned way, which is their core competencies is what they'll focus on. They'll outsource the things that aren't, you know, important to their, you know, are central to their core competencies and rely on high quality partners to deliver that level of care.

[00:28:39] Griffin Jones: Our business is trying to improve their cash position right now so that they could, they can still continue a vertical integration strategy, even if capital tightens up. 

[00:28:50] Louis Villalba: Yeah, I would say, you know, you have obviously a lot of private equity buyers that are coming to space and everyone in the private equity world has a, you know, a longer, you can say a shorter or a longer term, you know, strategy, and that's to monetize the assets that they've required.

Right? So the way that you monetize, obviously, is you have the balance sheet. You know, be as strong as possible. And then you're either going to go to the public equity markets or you're going to roll them up and sell them and a bigger, you know, to a bigger consortium that has a longer term vision. I think some of the big players in this space that have come in have a longer term view.

Okay. I think a lot of the initial private equity that we attracted and that the reproductive health actually is experienced in the last, you know, we'll call it three years is a shorter term view. It's something in that three to five year time horizon. I think the bigger players actually look at things in a 10 year time horizon.

They're not as, you know, reactive to market conditions like we see today, where some of the, you know, the, we'll say the smaller players, you know, they have to return on the funds that they've committed and they actually have to show, you know, obviously returns to the shareholders that they're providing for.

So this will benefit us, I think over time as we mature and we get in longer term, you know, relationships with bigger providers that have long, you know, longer term views. 

[00:30:03] Griffin Jones: Whether the strategy and the outlook is long term or short term, the strength of a balance sheet is still somewhat relative, isn't it?

Relative to if, if, if there's money that can be easily borrowed or, or. Received some other way versus it looks like things are tight. Not only are capital markets tight, but also our AR is starting to age out more. It was at 45 and now it's at 60 or now it's closer to 90. And so, so what is like, what is the strength of a balance sheet have to look like nowadays?

[00:30:38] Louis Villalba: Yeah. So I think, you know, in a, in a services model where you see, again, these, you know, these kind of general, you know, returns, you know, in a high quality, you know, IVF clinic, you'll see, you know, you know, close to kind of a, a low forties in terms of gross margin. Okay. And then let's say in an underperformer, you can see something as low as, you know, as 20%.

So if you think in terms of that's your gross margin and what you have to invest in and what type of investment you're going to attract into a business like that. People are going to want to see, obviously, they're going to want to see that your balance sheet is improving over time, that you have growth in terms of, you know, the services that you're providing.

So we, you know, we have a lot of what I'll call the central, you know, checkpoints that can, you know, acquire and attract investors into the space. What a lot of it kind of comes down to is now what is the management skill set to execute and show improvement in terms of the profitability of these businesses over time.

And so that strength actually has to come through and, and, you know, what we'll call higher quality, you know, performance and that performance now is, is, is starting to be looked at, you know, under a different lens because you have seasoned investors that actually. you know, hold these, you know, groups, obviously accountable to the, you know, to delivering the results that they expect.

Now, that's not always an attractive, you know, comment within healthcare. And I completely understand the reality is, you know, medicine is a business. Okay. Our, of course, our job is to provide the highest quality of care. And one would argue if we provide high quality care, the business will sort itself out.

And I think that's very accurate because if we're doing the, you know, the right thing in terms for the patient, we're going to this market. And there's plenty of growth. Plenty of greenfield in front of this space for everyone to appreciate, you know, in the years, in the years to come.

[00:32:20] Griffin Jones: So you talked a bit about the risk liability and one example that you gave was, well, if you're in just in the clinical vertical, for example, you have your malpractice liability, but then if you go into a lab vertical, a storage vertical, there's other liability that you have.

What other examples are there in terms of legal? risks that people need to consider when they're moving into other verticals. 

[00:32:48] Louis Villalba: Yeah. So, so kind of the two categories fall between professional liability. Okay. And personal liability. Right. And so professional liability, you're an MD or an embryologist, you have a, you know, you have your normal set of standards that you perform, you know, on a, or steps you perform on a day to day basis.

So those are covered generally your malpractice policies. And because, you know, that that's what's designed to cover. that part of your day to day job. When you start to, you know, expand the types of services that you offer, for example, something in genetics, you start to actually take on, you know, providing a result, right?

And a result that people are going to continue to, you know, make clinical evaluations against and make more importantly care decisions against, right? And so when you look, for example, at the accuracy of the test results that you provide, obviously, you know, if they're the lower the, you know, the accuracy, the more risk there is in terms of the type of guidance you provide.

You obviously include all types of fair balance statements saying something's 97, 98 percent successful or predictable, but guess what? That still leaves you a little bit of a window, you know, of risk there. All right. And so that isn't risk that if you are outsourcing, you carry, you carry it from a malpractice standpoint.

Okay. But you don't carry it, you know, directly as a professional liability perspective. And those are the types of, you know, important, you know, considerations that. Any network or any clinic needs to think through if they want to expand, you know, into ancillary services, you know, for example, in storage, you know, if you actually have, you know, let's say, for example, you know, 10, 000 patients on one site that you're storing from a legacy inventory, and you have some type of tank failure, which unfortunately happens from time to time, where does that risk fall?

If it's in, you know, if you're providing. That service on your own versus outsource. The answer is it falls everywhere, but it's going to fall to one side more. Okay. If you're actually, you know, so to speak, holding the bag on that, you know, directly, and that is, you know, that's an important consideration, I think, as people get into this and some of the sophisticated buyers now are obviously forcing, you know, some of these networks to actually look outside, you know, to use third party services, you know, for these, you know, these ancillary steps that are involved in the business.

[00:34:59] Griffin Jones: You're making me think of the recent Chart, Inc. settlements. So, Chart, Inc. was, I believe, the manufacturer of the tanks at Pacific Fertility Center. I don't know if they also were for the Cleveland Clinic as well, but, you know, so, I think patients sued Pacific Fertility Center, Pacific Fertility Center sued Chart, I think patients sued Chart directly, then Chart.

Went and I believe one of their suppliers was Extron and so they're, they're suing Extron. So either that doesn't get to happen if you're vertically integrated because you're just being sued at all of those points. Or, or is it like the McDonald's example where it's like that one little vendor that, because they're not, no one's vertically integrated and absolutely.

Everything, right? Like even Amazon still buys some things from other people. And so does that, if you're in that type of situation, does that put someone in a position where it's like, okay, this is how the, you know, it was 90 percent through our different verticals and maybe 10 percent through this supplier that we have, but we're going to squash this supplier in a legal battle and make it seem like it was 50 percent their liability.

Is that something we might expect to see? 

[00:36:10] Louis Villalba: I think, you know, the trial lawyers are always, you know, you know, very focused on going towards the deepest pockets wherever they're, they're positioned. So if there is a path to, you know, get into that party in the equation, they will find it and they'll, they'll naturally end up there.

You know, you bring up a good example in terms of the equation that's involved, like for any finished product, there are, you know, generally a consortium of, you know, of, you know, just different providers that, you know, all, you know, have their contributions to a finished product. The quality piece that comes out in the back end of that in terms of who is responsible for checking that, managing that, those are always a central point of where most of the liability is probably going to, you know, fall on the shoulders of, but that's, you know, that in terms of a physician's office or an IVF clinic is, you know, is why it's, there's so much risk for them in this type of ancillary service.

And so I think what, you know, for example, what we learned in the Pacific fertility case is that, you know, not only did we, you know, we have, you know, a long list of people that are, are going to be, you know, kind of subpoenaed in this, we also learned another important thing that the technology that's involved today.

They're that was involved in at that point was completely inadequate in terms of identifying the problem, right? The alarm systems that set up now are set up to be reactive. They're not set up to be predictive and where we need to shift in these types of ancillary services where I think most of the providers are currently doing this.

is they actually have things that predict, they monitor things like LN2 consumption, they monitor oxygen, they monitor temperature, they remote access into these systems because they watch them 24 7. And that's the type of focus that we need to improve the quality within reproductive health because that's the trust that patients are putting in us in terms of building, you know, this, you know, uh, obviously service into something that's extremely, you know, high quality.

[00:37:59] Griffin Jones: Well then let's shift to that quality argument about controlling the value chain. So we've gone through the cons of integration and the potential risks and the pros to perhaps just focusing on patient volume or focusing on one piece of the vertical as opposed to integrating. Now let's talk about the pros and steelman that argument.

If controlling the value chain ends up appearing to be totally necessary in the next five to ten years, why might that be? 

[00:38:26] Louis Villalba: So I think, you know, there's every business has what we'll call a sweet spot, just in terms of the, you know, the amount of, let's say, kind of strategy, technology, headcount investment that you have into a business, that investment's actually going to help you, let's say, for example, maximize your quality, maximize your return on investment.

Figuring out where that intersection is in every business is, you know, is a critical part. And I think that, you know, if you look in terms of the healthcare services model that we're involved in, you think of the number of headcount that's involved within an IVF clinic, you can think about, you know, the administration side, think about the lab, you know, in terms of embryologists, technicians, et cetera, think on the MD side.

And then as you add different ancillary services, They're going to have to add headcount to manage those responsibilities. So, you know, there's a volume that at a certain point, it's going to make sense. Right. And then there's an argument that says until you reach that volume, or if you have to increase your headcount to a point because the volume is so large, then, you know, you have to ask yourself.

I have buying power. Am I better off doing this and managing this internally under my own roof? Or am I better off negotiating a very competitive deal with a high quality provider? And that's the trend that's in front of us. And that's what I think we'll see, you know, in the next two to five years, we'll see this.

And we see the negotiations right now. There's, you know, discussions underway at this point for all the networks to actually band together. to have, you know, competitive purchasing agreements with some of the major providers of this space. So it's naturally occurring. I think it's just part of the maturity of reproductive health.

And we'll continue to see this evolve. I believe strongly over the next few years. 

[00:40:00] Griffin Jones: What about those vertical integrators that seem to have no sweet spot? You said there's a sweet spot that makes sense because it has got, but then you look at like Tesla and it's like, man, he's buying. Everything. You look at Amazon, it's okay.

Now they got the cloud services. Oh, and they have Whole Foods. They've got that distri distribution. Now they're in content creation so that their products are everywhere. So that you're not leaving Amazon, you're, or you're not going to Netflix, you're not leaving Amazon. You're staying, you're watching your videos in Prime, buying your products in Prime.

Oh. by the Washington Post, too, just because, you know, it can't hurt to, it can't hurt to be in D. C. when you're playing at this level. And so it seems so I know those are like the top of the top examples. But do you how likely is it that we'll see someone in the fertility field that doesn't seem to have that sweet spot?

They're like, we're going to be in absolutely everything that touches the patient. 

[00:40:58] Louis Villalba: So, you know, I, you know, there's so much execution, right. And the examples that you just provided. So for example, on Amazon, we look at where Amazon started and, you know, the argument was, it's never going to be a profitable company.

You can remember that, you know, for many, many years. Right. But what, what did they do? They continued to grow their top line and they can. Tended to consolidate, you know, against their original foundation in a step-by-step fashion, right? They didn't grow into the company. They are today, just overnight to several years and several years of high quality acquisitions, several years of high quality management of a business.

And it built a brand, a brand that people trust. And so, you know, how do they control the American, you know, the worldwide consumers buying behavior. Now they're seen as a high quality provider and they have a trusted brand, right? So I think same thing applies to Tesla in a big way, right? They were, you know.

You know, pioneers in the EV market, but they also had a premium brand to begin with, right? Who didn't aspire to have a Tesla, you know, let's say back in like the 2007 to 2010 range, when they were more scarce right now, that's a common brand. People see it around, they see it everywhere and it, you know, and they've created different price points to bring different levels of the market in.

And what are we continuing to see in terms of reproductive healthcare? Some will argue that obviously like, for example, in the U S we have, you know, we, in terms of cost of treatment, we've created a market that only, you know, treats a certain segment of the market. And so we have other entities that have come in, for example, like a kind body that say, our mission is to create, you know, is to improve access to care.

We want to do things at a lower price point. We have these efforts now to go directly to the employers, to the progenies of the world, right. to manage the cost associated, you know, with treatment. So we can encourage, you know, companies to invest more in reproductive, you know, reproductive healthcare and treatment.

And so all of these things I think are, are growing, you know, our industry right in front of our eyes in terms of who's going to consolidate them and who's going to maximize. I think you look to some of, you know, the recent acquisitions that have, you know, have taken place when you attract the names of like a KKR, their longterm view.

Obviously has a long term strategy. And if you look at the brands that they're buying, I would, you know, I think one could argue there are some higher, high quality brands. So I would look, you know, at those types of buyers to see who's going to kind of set the, you know, the strategy for what pieces are going to be rolled up and at what time, because.

there's, there's a lot of consolidation still in front of us, but you know, the foundation in terms of the number of clinics that we have that are available today to treat patients, I believe that number is going to continue to increase over the next few years. 

[00:43:28] Griffin Jones: So we might see it from the behemoths that are coming in like KKR and maybe BlackRock will too and some others are who, who, who do you suspect is in the lead right now?

So, you know, you mentioned us fertility, we'll see what, what. They, they end up doing, it's, I might guess kind body, you know, from just what I can see in terms of they got clinics. I don't know if they still do the mobile testing, but they had that. They've got the employer benefit carve out. They've since gone into a third party.

I believe they acquired a gestational carrier agency. The one is escaping me right now, but so, and, and I think they expanded EOS when they bought VIO. So they're, they're more in a third party. So I might guess them who's, who's. Charging ahead. And who are the front runners right now? 

[00:44:14] Louis Villalba: Well, if you look in terms of volume size cycles and who has control right now, it's, you know, us fertility control is obviously a majority of the market from that perspective.

You start to go down the list from there. And I think there's some arguments that if it's a five horse race and you have one that's in the lead right now. Horses between number two and number five, if they consolidate together, you're going to have more of an equal parity in terms of volume and size.

And I expect that those are the next moves that we'll see in front of us. Okay. I mean, you look at groups like Pentacle that, you know, have been high growth in terms of the number of acquisitions that they've made over the last few years now with valuations actually coming down to a more respectable level and a more competitive level.

I think that the ones with the strong balance sheets, we're going to see them continue to accelerate their acquisition strategies. Over the next 12 to 18 months, because prices are more competitive than they were, you know, just 12 months ago. And in terms of, you know, what shifts in the business strategies for some of these networks, I think that there's a tremendous amount of evaluation going on right now about what is the next natural extension for their care paradigm.

to add, you know, to offer to this patient group. And I think that, you know, we have success rates, obviously, that are, you know, continuing to improve year over year. Some might argue that our live birth rates aren't, you know, accelerating. This is a complicated field to succeed in. I think everyone knows that, but I think in terms of like the number of blastocyst embryos that we're producing on a day to day basis, I, you know, those percentages, you cannot argue it.

They've improved dramatically. Okay. There's a lot that goes into that, but you know, starting with the blastocyst embryo is obviously a great place to start in terms of long term success for reproductive healthcare. So I think we'll, we'll continue to see, you know, that the trust and the quality of the market improves year over year, which will be a natural, you know, extension to bring in more people in for treatment.

[00:46:05] Griffin Jones: Is this integration necessary in order to actually be able to implement a lot of the innovations that are happening because I see all these solutions coming in and some of them are probably they're not going to win their duds and they maybe just be features but some of them seem it's like oh I can really tell I can see the value in that but they're still having a hard time gaining adoption for whatever reason, and often it just has to do with the variance of workflow.

So even if you have an MSO, you've often pasted those different clinics together. They've got different workflows and often it's, it's just not the same as like I, I had the CEO of Indira IVF from India and he said, I hired 250 Uh, OBGYN physicians, I train them on fertility, meaning my company does, and I make sure they're all younger than me.

So they all do the same thing. And so it's a lot easier to implement a lot of some of these scale innovations and the workflow, the variance and workflow is one of the things that, that seems to hamper is, is this vertical integration necessary in order to be able to, to get things in? Because there's a lot of.

things. It's like, man, you really do automate. You really do reduce that level of work that people have. But in order to implement it, it's an add on for, for where people don't have capacity. So is, is this necessary in order to be able to implement the rest of the innovations? 

[00:47:31] Louis Villalba: Yeah. So, you know, I think that if we think in terms of the, you know, the meeting that we attended out in Napa together, the, one of the great debates is around, you know, I practice evidence based medicine.

Okay. And so everyone's looking for evidence in terms of how they make decisions. And then I think what's equally there for a lot of people are people who are looking at the cost of, you know, the different decisions that they make. Okay. And so in terms of looking at AI technologies and where they are today, if you went to someone and said, I'm going to give you higher quality information.

Do you think you're going to be able to have a better chance of success? Okay. I did. Short answer is going to be yes. Right. Because people are qualified and you know, part of the decisions that they make are based on the information they have. So you know, this whole, you know, great debate on what, how much data you need to obviously, you know, kind of make, let's say a clinical decision.

I think kids is a very important part of this equation and the value of that data that you provide is what people are obviously thirsty for and they're thirsty, you know, for an advantage. Right. Right. So you'll see. you know, some people obviously get on the front end of the equation in terms of, you know, of, of acquiring, let's say a technology before the middle of the market will adopt something.

Right. And so the early adopters, like if you look at an AI, you look at time lapse imaging, you look at single step media. I mean, you know, there are a lot of markers that you can look at, but the, you know, I think one of the more interesting things that, you know, from a behavior standpoint. is, you know, you are not going to get what's called a standard of care where you're treating 51 percent of the addressable market with anything in a short period of time.

It's just, there are so many, you know, and factors involved with changing people's behavior around different things. And they can be business related. They can be behavior related. They can be control related in terms of you're on a network and your protocols get set and you're going to follow those.

Which, you know, in the Indira equation, you know, they're doing a great job of setting a standard that they want their, you know, their groups to follow. I think the hardest thing to do in medicine is change behavior in terms of if you want to try and do it fast, because the faster, you know, you push. the harder that they resist.

And that's just the natural, you know, kind of ebb and flow of our market. I do think, you know, um, from a society standpoint, we're continuing to set practice guidelines around very, you know, very important things with innovation and how you present and offer those early innovations to patients. If people see things as an advantage, you know, certain groups are always going to, you know, obviously maximize that they'll take advantage of it.

Then certain patients are going to be attracted to it. Okay. And if it's gone through [00:50:00] a regulatory process, which in most, you know, aspects it has, because if people are making clinical decisions, they've had to take it through an FDA clearance, they've had to take it through, you know, some type of, you know, it has to adhere to CLIA lab regulations, something of that nature where things get.

you know, unfortunately inconsistent is if they don't have to follow those types of controls, then one could have an argument about, Hey, how did you, you know, get to offer this to patients? Right. Because if we look, you know, in terms of today's, so let's say for example, you know, of the 450 plus clinics we have in the U S Most of them, you know, probably are doing things, you know, that don't have a lot of FDA clearance because they weren't required to do that.

Right. They have CLIA lab regulations, but, you know, on a day to day basis, they've created their own SOPs, their fine running labs, and they adhere to those types of controls. 

[00:50:48] Griffin Jones: If this happens and someone is kind of driving it at the vertical level, I'm just picking on KineBody, I'm not saying it's them, but Gino has of course said that vertical integration is part of their thesis and touching all the parts of the value chain is part of their thesis, and so let's just say it's them and they, you know, And.

own EMR, own pharmacy, own everything for those that don't, does that force them to, even though they're not integrating as businesses, they have to have more in integrative features that so that does it force the pharmacies that are left, the EMRs that are left, the scheduling softwares, et cetera, that are left to have to communicate with each other in order to, and have more interoperative functionality because otherwise it would, it seems to me like it would be a cheetah against a.

[00:51:43] Louis Villalba: Yeah. Right. So there was definitely a, um, a level of efficiency with automation, right. And offering a complete, let's say, you know, offering in terms of, you know, from pharmaceutical through, you know, let's say delivery of a, you know, of a healthy, happy baby. And so if that is in terms of your longer term, you know, care strategy, the pressure on the business is to.

Did you know, is to demonstrate that they can manage that at a, in a cost effective way, right? So there's a rush to control all these different steps. What we haven't seen yet is the importance, you know, kind of, you know, output on the back end, is it more cost effective or your outcomes better, you know, all of the things that are generally going to drive, you know, longer term investment, longer term strategy.

I think it's a natural maturity cycle that we're going through, you know, as an industry, and I think it's the right normal thing to do. I think the question will become, all right, so what are the most important, you know, steps in my business? What steps do I need to control to provide the best experience for my patients, meaning, you know, and hopefully delivering healthy, happy babies and what's really rolled up into that.

Okay. And, you know, and that's, you know, that is, I think left to be determined just in, you know, in terms of where we are, you know, as an industry, but I think that it will be highly competitive for the next several years as the great race, you know, kind of continues for that, that type of control. 

[00:53:03] Griffin Jones: Do you think that we'll start to see more backward integration, so forward integration, meaning I'm, I'm a fertility clinic and then maybe I acquire, you know, an OBGYN or, or some sort of referral source, I'm getting closer to the end patient and backward being go, go back to the raw material, you could go all the way as far back to the raw materials, but just in that direction, whether you go that far back or not.

Will we see more backward integration? 

[00:53:35] Louis Villalba: I definitely think we will. There will be some groups that will look, you know, in terms of the, of the backward review lens mirror, and they'll, they'll go, they'll probably be ones that I think. As we naturally go through this process and we see where success is on the front end, they'll look at, you know, what can the back end of the equation be?

And does that give me any, you know, strategic advantage over those that are offering, you know, things on the front end? If you can contract with the patient up front, Then you control the pathway in terms that they follow, right? And that's what some of the benefit providers have done a masterful job of, okay?

They, they have, you know, in terms of the patient, their points of care, if they're going to be established to their network, then from a competitive standpoint, you're then, you know, you've plugged them into your equation, right? You have to naturally manage them through the process, but you have control at that point.

[00:54:25] Griffin Jones: Will we see tomorrow buying a fertility clinic network, will we see tomorrow buying a Hamilton Thorne or... 

[00:54:31] Louis Villalba: No. So at this stage, you know, I think, and I, you know, if anything, I've learned in 30 years of business, you know, try to do, you know, do one thing, do it well. Okay. And be the best at it. Right. And that sounds, you know, cavalier, but it's the honest to God truth.

It's, you know, we obviously built a technology platform or the only company that wrote It's own, you know, operating program. I'd be F. O. S. It's proprietary to tomorrow. The first step was to automate, obviously the storage component of the business and bring as much digital, you know, kind of chain of custody, you know, protection to that side of the business as possible.

We're obviously in the midst of. You know, of launching this in the U. S. Now, and what's quite interesting is normally when you launch new technology networks aren't generally the first adopters, they have bigger operations and they're generally you succeed with them later in an equation. But for tomorrow, it's been the it's it's inverse.

It's the opposite. And so the obvious question is why? And I think that there's more of a strategy to manage the risk side of this business from a higher level. And they see obviously also from their buyer standpoint that they need better digital chains of custody and better you. You know, trace traceability more importantly in this side of the equation and who's got the best platform to do that.

Obviously, tomorrow's got, you know, very established FDA cleared system. And so that's been the natural pathway that we'll follow. And I think that automation in the, you know, in the lab, it's definitely a path that will continue to go upstream with. We think that there's a lot of ways to, you know, to obviously improve, you know, the day to day lives of, of laboratories.

And we're. Concentrated on going upstream to deliver that we have our partner and conceivable. Obviously our founders from tomorrow, they're creating another lab automated company that will probably, you know, be a nice, you know, development house for tomorrow, you know, based services and products in the future as they continue to innovate on that side.

[00:56:17] Griffin Jones: Do you think it's inevitable for those behemoths that we were talking about before, like if you're KKR and you're picking up your EVRMA for three and a half billion or whatever, I don't remember how much it was at that time, but, and you see it working, it seems like if you really believe in assisted reproductive technology as part of your thesis and that company is profitable in your portfolio to me, then it seems like, yeah, let's go out and get a storage company.

Let's go out and get, let's get progeny. Well, it would be hard to take progeny off of the market, but let's, let's buy a, if not Hamilton Thorne, at least try to get them to sell us one of their brands. Is it, is it inevitable to see backward integration with the behemoths coming in? 

[00:57:01] Louis Villalba: Yeah. So consolidation is, you know, is obviously part of the world.

I think, you know, to run a medical device company versus to run a healthcare services company are very different, you know, kind of management skills. And it's obviously they fit under the same therapeutic area, but they have very different business models and there's usually very different skill sets that succeed in managing those types of businesses.

I think that, you know, what we see in a lot of other industries and within medicine is you see people, you know, consolidate where it naturally fits. And then you see them obviously partner where it doesn't naturally fit. And I think the naturally fit part is where our space is still going through the evaluation of what really fits under, let's say, a healthcare services model and what really fits under a medical device or a pharmaceutical model.

And that's where, you know, that's just, you know, kind of the natural growth that we see in terms of reproductive health. I think it's the right focus. And more importantly, I think what it will do is it'll help deliver high quality care. And we'll continue to attract, you know, obviously the trust of more people based on the higher quality of care that we'll provide.

I think that, you know, for example, the, you know, the Hamilton Thorns of the world, they, you know, there's continued demand for them to innovate, bring more technology to the market. I think the partnerships between industry and healthcare services. You'll see, for example, innovation funds of a lot of the large networks now, like U.

S. Fertility, Pentacle, for example, they're all going to have their own types of innovation funds, and they're going to make investments into the technologies in the early stages that they see will benefit their day to day care, you know, management. And so that, that's, I think, what's been lacking in the past, and we'll see that as a very, you know, important component of the future, you know, of care and IVF.

[00:58:41] Griffin Jones: You're not a lawyer, but I want you to speculate a bit because all of this begs the question of when we might start to see antitrust regulators come in. Do you know of, can you speak to any red flags of when, when they would come in and how likely it might be? 

[00:58:56] Louis Villalba: Yeah. So look, I think that we saw our first signal of antitrust in this space when Cooper, you know, was focused on acquiring the assets of Cook for the women's health business.

And antitrust, you know, obviously, as they mentioned in their, in their public disclosures, they had some reviews that they had to, you know, they had to go through. They just made an announcement in their last quarterly hearings that they're no longer pursuing that, you know, that acquisition. So I think that that is the first signal in terms of we have the attention of the regulators in this space.

All right. And ones would argue that now, you know, over 50 percent of IVF cycles are now controlled by IVF networks. Okay. So we reached, let's say a milestone that, you know, people are going to start to pay attention in terms of the consolidation of clinics. You know, there, it does seem that there's general momentum in those directions.

So you know, I'm not going to, you know, speculate that I know anything more than that. I could point to Australia as an example. So Australia actually. As a competition authority got involved, I think close to seven years ago when they reached a 50 percent kind of milestone in their market comparably. And they basically, you know, have not allowed, let's say the big three to consolidate any more of the market to protect, you know, some independent, you know, offerings.

So I think it's, you know, we are starting as again, as young industry, we're starting to lobby a lot more. And I think we're starting to help, you know, a lot of edgy, you know, kind of. You know, different government officials understand the importance of reproductive health care. We obviously have declining fertility rates in this country and every major G7 country for that matter.

So the, you know, the importance of actually supporting reproductive health care can probably never be more important. All right. So what do we do with that as an industry and as a specialty in terms of how we, you know, utilize that momentum within Washington to support, you know, the continued expansion of this service.

[01:00:37] Griffin Jones: Lou, I didn't, I deliberately didn't even go too deeply into the, the five core pillars of the ancillary services, the safety and technology stores, own labs, the egg banks, the surrogacy services, because I want to have you back on. I wanted to use this episode as painting the picture of, of what's going on in vertical integration.

I would love to have you back on in the fall to go more deeply into these. And unlike the director of the hangover movies, my sequels are always better. Lou, Lou Villalba, current CEO of Tomorrow, and congratulations on that new post, by the way. Thank you so much for coming on the Inside Reproductive Health podcast.

[01:01:16] Louis Villalba: Thank you, Griffin. It's a joy to be with you and appreciate the kind remarks. Thanks very much. 

[01:01:22] Sponsor: This episode was brought to you by Surrogacy Roadmap, a self led educational course created by Family Inceptions. Guide your patients to Surrogacy Roadmap for all independent journeys. Get your free lesson from surrogacyroadmap.com/for-professionals. That's surrogacyroadmap.com/for-professionals. 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 fuse of inside reproductive health, nor of the advertiser.

Announcer: The advertiser does not have editorial control over the content of this episode, and the guest appearance is not an endorsement of the advertiser. Thank you for listening to Inside Reproductive Health.

204 Opening, Relocating, and Expanding Your Fertility Clinic and IVF Lab with Lindsey McBain

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.


Your fertility center is growing.Do you expand your current office or build a new one?

Lindsey McBain, Executive Director of IVI America, has overseen numerous IVIRMA office setups, relocations, and expansions, playing a key role when they relocated their headquarters to a new city.

Tune in as Lindsey reveals:

  • The differences between starting, expanding, and moving your office [And the unique considerations of each]

  • The difference between building a new office and moving into an existing building [With and without a lab]

  • When to Buy vs. when to Lease

  • The non-negotiables that should go into a letter of intent for a new lease

  • Building a Standard Operating Procedure for launching new locations [So organizations can do it at scale]

  • How she selects vendors for each new site

  • Some Pro tips for what small offices can do to save money [And simplify logistics]


Lindsey McBain
LinkedIn

IVI America
RMA Network
LinkedIn
Facebook
Instagram
Twitter: @thermanetwork

Transcript

[00:00:00] Lindsey McBain:
Typically, when your lease comes up for renewal. We look at economic factors. We look at location factors, you know, we make an analysis of what's best. We look in the market to see if, you know, it makes sense to move. Moving is an investment, but sometimes it's the right investment.

[00:00:18] Sponsor:
This episode was brought to you by LEVY Health.

Seeing more patients for a first consultation may actually decrease IVF revenue by 30 to 40 percent. To see why, download the numbers for free at levy.health/conversion. That's levy.health/conversion. 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.

[00:01:03] Griffin Jones:
Opening a new fertility clinic, easy. Moving a fertility clinic location, easier. Expanding a fertility location. That's the easiest of all said nobody ever. And I brought in someone who has done it a lot. Is Lindsey McBain a household name in the fertility field yet? She ought to be, she better be after this episode.

She's the executive director of IVIRMA America. She's moved, set up, expanded. A number of RMA offices. She was a linchpin when they moved their big headquarters from Morristown, New Jersey to Basking Ridge, where they are today. We talk about the differences between moving an office, starting a new one, expanding one, which is the hardest.

And what are the unique considerations of each the difference between building a new office versus moving into an existing building with a lab without she talks about. What goes into scouting a location for site needs evaluation, including variances in site plan approvals. Talk about when to buy versus when to lease.

Talk about building a standard operating procedure for launching new locations like this so that organizations can do it at scale. We talk about the non negotiables that should go into a letter of intent for a new lease. Talk about considerations for square footage. For those of you not looking to expand all over the globe, Lindsey gives a couple pro tips for what small offices can do to save money and hopefully not be logistically impossible.

She gives pro tips for looking at blueprints ahead of time and as the site is being built. She talks about who's on her team, what their roles are each responsible for, and her outsource team when she goes into a brand new state. That's to hire new architects, new project managers, how she does that, and how she selects vendors for each new site.

I enjoyed this episode. If you enjoy it, let Lindsey know, because she gave us a lot of value for starting new locations, moving locations, and expanding locations. On to the conversation with Lindsey McBain. Ms. McBain, Lindsey, welcome to the Inside Reproductive Health podcast. Hi, how are you? I'm doing great after some technical difficulties and switching to an old software.

We're recording this episode on Zoom, so I want you, the listener, to tell us, does it sound better, worse, or the same than the last several dozen episodes you've heard? Better, worse, or the same? I want your feedback, the listener, to let us know. Because what I really want to focus on is the conversation.

I've known Lindsey McBain for seven, eight years. Probably I'm thinking we both have said and said on the board for the association for reproductive managers of which Lindsey. was chair. She went through that whole officer cycle and Lindsey, you're not usually the loudest person in the room, but when you talk to people, listen, and I'm one of those people, and one of the topics that I have clung to that you've spoken on over the years is about.

Building new offices, building new labs, launching new offices, whether it's Terranova or not. And so I want to go through that concept with you today and maybe we'll end up breaking them into categories of like brand new office buildings, brand new labs versus when you might put an office in an existing hospital facility or something like that.

And I've done it across a number of states. So I want to ask about some of those nuances. But I'm interested in. The first time that you ever launched a new office, tell us about what that was like, because if my LinkedIn serves me correctly, you started your career in fertility with with RMA at that time, RMA of New Jersey at that time, at pretty much the very beginning of the Great Recession.

So pretty much the worst time to start a new job is September of 08. If my records are correct. So tell us about what was the first mission that you were put on? Because it's probably a very different landscape than, than what it looks like today. 

[00:04:56] Lindsey McBain:
Yeah. So when I first started my first year at RMA, I did not do what I do now.

After about a year, year and a half there, I got involved into operations. And at that time, RMA was growing and we were in the best, we were in Morristown. That was our headquarters. That's where it all started for RMA. But we were outgrowing it. It was getting way too small. So they were looking, even before I got there, they were looking for a building.

They were looking to move their New Jersey headquarters somewhat in the same geographical area, but to move a new lab, new OR, and be on our own. In Morristown, we leased space from the hospital, Atlantic Health. We were across the street from them. But this was going to be our own building, everything. So I Um, Once I got in the field, I was started helping them go look at locations with Dr. Scott, Dr. Drews, and Dr. Berg. At the time, they were the three partners that were overseeing that. So we would go look at sites, we'd evaluate needs, we'd evaluate location, making sure that it was big enough that it allowed for some growth, and that it would be convenient. To our patients and fit within our footprint in New Jersey, my first construction, I will say, was not that it was a small satellite office for New Jersey was West Orange and Eatontown.

I did. And those were not labs. They were just office space locations for New Jersey, where those are the first two I did. I got involved in both of those. Probably I took them over from my predecessor. So those were my first two and then we started working on the Basking Ridge project, which like I said, I was involved from the search to negotiating the purchase to the construction with the partners.

[00:06:31] Griffin Jones:
So Basking Ridge is moving the headquarters from Morristown to Basking Ridge and that's about a year and a half into your tenure at RMA. So this is when it 

[00:06:43] Lindsey McBain:
started, but it was. I mean, it took a couple of years to find a location to negotiate everything to start construction. I mean, nothing goes fast when you're doing real estate construction permits. There's a lot of red tape anyone who's done this, 

[00:06:56] Griffin Jones:
I want to, I want to talk about that. I want to get to that of how it's, if you're thinking of a certain deadline, you should be tripling that in your mind. I want to talk about, Those expectations. So that's moving from Morristown to Basking Ridge. And that's process starts in ideation in 2010.

[00:07:14] Lindsey McBain:
I mean, like I said, they were looking before I even got involved. But yeah, I think 2010 is when it really took off. I'm trying to think. I got married in 2011, and I know we were in the thick of things, and I'm on my honeymoon because I was panicking being away. 

[00:07:27] Griffin Jones:
Delightful. So. It's a nice, it's a nice little honeymoon gift, worrying about what is happening with the contractors and everything else.

But the West Orange and Eatontown, that happened before you chose the Basking Ridge location? So you were cutting your teeth a little bit. Yeah. 

[00:07:44] Lindsey McBain:
Yeah, those, and those are satellite locations, which, with not having, you know. Oh, ours are labs or anything like that. And you're not buying a piece of the property.

It's a little bit different. It's a little bit easier when you buy property, you typically have to do well for us, at least we've had to go for variances or site plan approvals. It's a little more involved if you get town approvals, it's different than just normally when you go into a location for a satellite, sometimes you need a zoning permit, but the local town.

But typically that's something you can just handle with paperwork and fees at the local administration without having to appear before a board or getting a use attorney and putting a case forward. 

[00:08:22] Griffin Jones:
It's like minor league versus major league, but I think it does merit some discussion that some of the lessons from those smaller offices.

How much of a process did you have at that point? Like a standard operating procedure. This is how we. open new offices when it, when you were working on West Orange and Eatontown, how mature or not was that at the time? 

[00:08:44] Lindsey McBain:
So for me, it was brand new. We luckily had a GC that had done prior RMA builds with predecessors of mine.

So he had some basic guidance. The partners at that point were very involved as well. So they were still looking at plans and giving feedback as well. So it was very helpful to have their input and their expertise. So I worked with them closely. I worked with the GC and I just was learning everything.

Anyone that had been involved in prior. Offices at RMA. I was picking their brain. I was just learning anything I could to try to figure out what I was doing, how to do it the best way, how to do it better. And I was, I mean, I think I was just hands on with everything. I mean, I was doing anything and everything I could so I could learn every piece of it.

[00:09:29] Griffin Jones:
What do you recall a surprise or a harder lesson being from one of those first to the Eatontown? West Orange Satellite offices, 

[00:09:37] Lindsey McBain:
I think just the coordination of the people and expectations. So you do work on this whole project and The people that are moving in usually aren't that involved the staff everyday staff and then to get them on board and showing up and All those pieces to fall in is harder than you think.

You're so focused on the construction that you kind of forget how to embrace the people into the move and make them feel invested and that they should be happy for. And that it's the right layout for them 

[00:10:09] Griffin Jones:
With how do you make that decision to especially when you have a number of different options that People could go. It's not like you're in one city and then you're just opening one satellite office three hours away. It's like they're fairly close to each other.

There's at least, there's probably people that live in suburbs in between. How do you make the decision of who goes where? 

[00:10:32] Lindsey McBain:
For staff, I mean, we look at the geographical area. If we're moving an existing office, we're typically staying within the same area so that staff will move. If we're opening a new office, we look for typically you have your doctor first.

So Eaton town was a new location for New Jersey at the time. West Orange was a move of one of our existing offices. So they were both a little bit different with Eaton town. We were really building with Dr. Molinaro was the doctor there. She was. Very, very involved, but it was building a team there and building an office rather where West Orange we were relocating a team to a new location.

So it's a little bit different given the staffs. They are moving them and reorienting them versus seeking out new staff or sometimes their staff that wants to relocate that's commuting and it makes sense to relocate them. And then you have experienced people. And they're moving with it. So there's different variables, but definitely for any of the builds, even the ones we have now, when you're going into a new area, the doc is key and they're always very involved and very crucial.

I mean, to anything, obviously. 

[00:11:32] Griffin Jones:
How often do you find that you're hiring new staff for offices that are not so far away, let's say within 20 miles or so, are you hiring new staff specific to that area? Most of the time, or most of the time, are you bringing folks over?

[00:11:47] Lindsey McBain:
Sometimes. The nurses and docs will have them in the system already, or at least the lead nurse will try to have in the system.

But you're hiring new front desk, typically you're hiring, not always, but typically you're hiring new front desk, new clinical assistants, new phlebotomist, andrologist that are in that area. Again, sometimes you find someone who will move, but typically when you're opening a brand new location, like we recently opened in Jersey City, we did have to go to the local market and supplement the staff.

[00:12:15] Griffin Jones:
How much variance is there when you're, when you're. Opening, whether it's opening a new office like Eatontown or you're moving an office like West Orange. Do you find that, okay, this is typically the flow of this doctor is going to be here this many days. If he's going to do this many NPVs a week, then it's this many nurses, this many techs, this many, this many people for the front desk team.

Is that Do you typically have a formula that goes with each of those? Or is it so variant depending on the doctor? 

[00:12:47] Lindsey McBain:
Well, it definitely is on the, it's more variant on the volume. I mean, our offices are typically five days a week. So we staff for patients to be there five days a week. Whether we're staffing for, we, we do morning monitoring a little bit different in New Jersey than a lot of even our other locations, because it's a block of time where you just come in where it's not scheduled.

So, five days a week that is open and then there's new patient visits and stuff after that. Each department has its own staffing model and based on the volume that we're telling them, they kind of go from there to assert the staffing. We definitely try in a new location. To allow ramp up time. I mean, you don't want people sitting around doing nothing, but you also don't want patients not getting the care they need.

So it's a balance of making sure, but it's all volume based and every department kind of has their own metric for how to stop it and how many visits or how many rooms or numbers that they can fit for the staff 

[00:13:38] Griffin Jones:
Does that that tentative have. thing five days a week for who you're open. Is that like a minimum criteria for you all?

Is that one of your criteria for opening a new place that you just won't open a new place if, if you don't have a doc and a team to be there all five days of the week? 

[00:13:55] Lindsey McBain:
Right now in New Jersey, all of our offices are five days a week. And then we have some that are seven days a week because of the geography of New Jersey, you know, you need to be able to offer a weekend hours.

In certain key locations, we don't have in every office, but because we go from Marlton all the way up to Englewood, we do offer multiple locations with weekend hours to serve our patient population and help decrease their weight on a weekend and their drive time. Uh, but generally all our offices are Monday through Friday, uh, minimum.

And then we have the seven days a week because we're three inches, five days a year. We're always going. 

[00:14:31] Griffin Jones:
A lot of people that are listening to this are in markets much smaller than the greater New York Metro. And they're in markets that are a lot more sparsely populated. And so they do have satellite offices that might be open.

One day a week or two or three. And, but given that New Jersey is the most densely populated state in the union, it sounds like the juice wouldn't be worth the squeeze real all if you had to have open a couple of days of the week. 

[00:15:04] Lindsey McBain:
No. And even when we open our EBRMA offices, the original offices are always about seven days as needed.

And then when they open satellites, we generally aim for five days, but you try to make sure you have the volume. But I can understand if a smaller market, a smaller one doc office, it's much harder to staff and make it worth it. I do know there are offices where they also share space with other providers to grow their footprint, which makes sense.

At one point, we had a post and overlook that we were only there. Three days a week, I believe it was. It was years ago. We're, we're no longer in that area. But to get in that footprint, we had a doc go three days a week with a medical assistant who also was able to do front desk and it had limited hours, but they were scheduled and it was there for that patient population.

So it can definitely make sense. I mean, the idea to be at the right location for your patients, I think. 

[00:15:56] Griffin Jones:
Outgrow that location and overlook or was it this is a pain in the neck having a doc out here for three days and if we lose that medical assistant who can also double as the front desk, then we're in tough position because that person is going to be hard to replace with one.

And so what was it? Was it? 

[00:16:15] Lindsey McBain:
Yeah, we grew our foot part in New Jersey, so it didn't make sense when we added offices. We were kind of covering that area with existing offices. When we grew our IVF, with IVF New Jersey came part of Army New Jersey, we kind of grew our footprint and we were in different locations, so it didn't make sense for us.

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[00:17:58] Griffin Jones:
I wonder if there's any kind of rule for, for folks that, that if you're not planning to grow to a certain volume that maybe you don't.

Try to open a satellite office there for part time unless it's one of these locations where that's the only way they're gonna They're gonna get fertility treatment And there are many rural parts of the country where those are the only places Where that that doc coming out there a couple days a week is the only way they can get treatment.

There are docs that Have their own planes that fly to some of these rural locations that they go out to yeah, and 

[00:18:36] Lindsey McBain:
so if you can share a space, like I said, another MD like use it or a hospital space. I mean, that kind of lessens some of the burden on the cost and overhead. If you're able to do that and expand your footprint.

[00:18:48] Griffin Jones:
Did you ever share with? Another REI, because I have heard of groups doing that. 

[00:18:53] Lindsey McBain:
We, we have not, I don't have experience in that area. I mean, overlooked. There were other providers there, but not other reis. 

[00:19:01] Griffin Jones:
Were they all women's health? Like does it make sense to Yeah, it was all 

[00:19:05] Lindsey McBain:
there. Or it was women's health and it wasn't just a reproductive health either.

It was. But it was all gear. It was a woman's health unit, but it wasn't just all reproductive health. 

[00:19:15] Griffin Jones:
We got a lot bigger fish to fry than this place that used to be in an overlook. But I do think you've laid out a couple of good rules that can make life a little easier for people. One is the sharing space.

People might have thought about that. But I also think the having a medical assistant that can also double as the front desk person is very important in a situation like that, that can make life easier for people. Are there any other lessons that stuck out to you of when you had a place that was only open a couple of days of how you made it?

Not too logistically burdensome. 

[00:19:50] Lindsey McBain:
I mean, I think RIT infrastructure really helps us. We were able to remote into our network and remote into our EMR. So I don't think patients felt it. We also made sure that the ultrasound that our, we're most familiar with and worked her best imaging was there. So we didn't want our patients that were there to not receive the same quality that they would anywhere else.

You know, so we made sure that the basis of. The foundation of what we needed to provide the excellent care was still there. 

[00:20:18] Griffin Jones:
Oh, I think that's a pro tip. So you didn't buy the ultrasound machine there, did you? You chose the, the providers that were there had the ultrasound machine? 

[00:20:26] Lindsey McBain:
No, we, we, we brought one.

We brought our own ultrasound, but it was, it was ours. We was, we leased our ultrasound. So it was a lease that we put there. And when we left, we took it with us. But like the exam table was there for us, the exam light, the stools, the waiting room chair, the desks, all that stuff was there. 

[00:20:43] Griffin Jones:
Okay. Well then that pro tip is mine.

Then people are listening and they select a place that has an ultrasound machine that is like yours. So that that's one less thing. If you're going out to one of these places, we're only going maybe a couple of times a month or once a week. All right. Yeah. 

[00:21:01] Lindsey McBain:
You've been fine. That, that's great. 

[00:21:02] Griffin Jones:
But Lindsey's pro tip of leasing is probably more realistic in most cases.

All right. Bigger fish moving on to back to West Orange and Eaton Town, which were two offices. What are the, what are the considerations of, is it categorically easier to open a new office or to move a new office? 

[00:21:23] Lindsey McBain:
I think it's, well, from construction wise, I think opening a new office is easier. Usually moving.

Is you're running two offices in tandem. You have to worry about the coordination of the move. You have to make sure that patients know where to go. There's always that time to get them acclimated to the new location. You don't want anyone to miss an appointment. So make sure that you're communicating well and getting the word out that you're moving.

And also it's a change for people. So change is always a little harder than. something new. I think the hardest is expanding a location, quite honestly. I think that's the trickiest because you're have a practice going that you don't want to compromise, but you need to grow it. So coordinating that construction around people working, patients coming in, I think that's the trickiest, to be honest.

[00:22:11] Griffin Jones:
Okay. So we have, we got three categories when it comes to location, you're moving, you're setting a new one up and you're expanding on the moving side. Pain in the neck that we always had to deal with was the changing of the local listings, which is just not as easy as it should be. Still, I, I started this, I started doing this stuff like 13 years ago and, and it's not any easier really.

[00:22:35] Lindsey McBain:
Now, even to update your Google location as much harder than I ever thought it would be my poor marketing team. 

[00:22:40] Griffin Jones:
And it's, and it's critically important. It's one of the most important things. And, and you can send people to the wrong place. I've actually, we had a client where they. For whatever reason they Google was putting the pin in the wrong place of the new spot.

And so God bless her. 

[00:22:56] Lindsey McBain:
Yeah Our marketing team is very good and very proactive But I know it's hard for them because it's very hard to make sure that You're communicating the right way, that patients are hearing it, that everything's updated. And then there's always someone that misses something or referring data as an old had in their office or old brochure that they give someone.

[00:23:18] Griffin Jones:
So when do you make the decision of if you're going to expand or if you're going to move? So let's, let's stick with the example of West Orange because that's where you had moved, so where?

The previous location was no longer sufficient and now it's time to go to a new place. What, what goes behind that decision making process? 

[00:23:42] Lindsey McBain:
So typically when your lease comes up for renewal, we look at economic factors. We look at location factors. We make an analysis of what's best. We look in the market to see if it makes sense to move.

Moving is an investment. But sometimes it's the right investment. You have to look at your relationship with the landlord. You moved in 5, 10 years ago. Are they, is the building still in good condition? Is, if they're ahead of the bargain being upheld? Did the landscape outside the office, did roads change?

Is it not ideal? There's a lot of Pieces that happen when you're in a lease for five to 10 years that are outside of your realm of control. And there's other locations where that 10 year lease comes in and you're just like, Oh my God, I want to stay. This is the best location, like, let's renew, let's expand.

But it's definitely a conversation you have to have with the local staff and you have to be involved. And part of my role is also visiting these locations, going out, checking in, seeing how stuff's going, making sure. I have a team that runs day to day operations and is involved in all the day to day at these locations.

We're very aware of what's happening. Not just when we walk in to evaluate that we're involved the whole period so we have relationships with the buildings Maintenance the landscape we're out there. So it's important 

[00:24:55] Griffin Jones:
And how do you decide when to expand because that's got to be a hard decision maybe perhaps even a harder decision because it seems to me like all of the Considerations you just listed are still at play when you're thinking about expanding and you're ultimately deciding are we?

Do we want to do those things here? Or, or, or start anew? So when does it make sense to expand an office location? 

[00:25:19] Lindsey McBain:
So funny enough, we just, we, so 10 years ago when we moved West Orange, when I got involved in that project, remember it was started, I came in, we just expanded West Orange after being there 10 years in the newer location.

We're very happy where we are. We think it's a really great location. But we had thankfully grown with the doctors there have a very heavy referral base and they needed more space to adequately treat patients to make morning monitoring more efficient to add better space for our staff. And there was, the other thing with expanding is there has to be availability in building.

So we knew that there was adjacent space, which is vast, available, and we knew we liked the location. So we reached out and we started negotiating that deal. How long did that take? That one was a little, that was the trickier deal. It probably took me six months to get terms that we were happy with. I worked with Dr.

Drews, was very involved in that deal. And we worked together and negotiated with the building manager and got that deal secured. And then after that, construction started. What? I want, I want to talk. Some deals where you expand can be in two weeks. That was a trickier deal where they were going back and forth.

They had other people interested in the space. 

[00:26:34] Griffin Jones:
Sure. And then was there a lab at that location in West Orange? 

[00:26:38] Lindsey McBain:
There's an andrology lab, but not an embryology lab. 

[00:26:40] Griffin Jones:
Okay. So then, it's not like, it's, it's not the hardest thing in the world to move a location like that. Like you said, it's hard, but you also said it's harder to expand.

So why expand there instead of going to a new place? 

[00:26:55] Lindsey McBain:
Well, I mean, we like the location. We like the building. There is space available. It's significantly less, like, more economic sound to expand sometimes than it is to do a whole new location. You have to look at all the factors. If you're in a good location, and you're in a good building, and you think everything else makes sense, and there's that prospect to just add a little bit more.

Sometimes that's the better economic decision. 

[00:27:19] Griffin Jones:
Tell us about what goes into the negotiation process. What do you have to make sure that you're on top of? 

[00:27:26] Lindsey McBain:
I think one of the most important things for us is that we have very specific hours. So I want to make sure that there's no issues with the doors being open for my patients when we're open.

We like our doors to open either between 6 a. m. Most buildings do not, even medical, do not open that early, to be honest with you. So that's one of our key tenets. We also need to HVAC during that time period. We don't want people coming into a freezing cold building or a stifling hot building. We also need to be secure when they're coming in.

We don't want them going into a pitch black parking garage somewhere. So those are all kind of the basics. Basic stuff that, like, I think don't even, we can't even talk if we're not going to meet those basic pillars of access for our patients and safety for our staff. And then we need 24 7 access for MDs, but typically in our, like myself, that's really never an issue with any building.

If you're a tenant there, usually getting 24 7, that's not an issue for something critical. And then from there, we go into what makes sense economically, what they're, if we're going to do a tenant allowance, if it's a fit out, what they're contributing. To the cost versus and that's, I mean, that's economic decisions here, because it's really a T. You are paying that in your rent in some ways. So you have to weigh out all those factors and the timing and all that information for the lease allowing typically we negotiate some rent delay. Went to the lease to allow for construction, so. 

[00:28:48] Griffin Jones:
Do you have all of this, like, in an SOP checklist now? Like, like, here's our standards for HVAC, here's our standards for what the parking needs to be, here's our situation for how the badge access needs to be, and what time patients need to be able to get in.

Like, do you, is this all in, like, kind of a checklist that you're just, voom, that you can send to any landlord? 

[00:29:09] Lindsey McBain:
Yeah, now it is. Now, after many years and each year, I think we get a little more sophisticated and I've gotten better about documenting stuff. I'm really, and I try not to be one of those people that a lot of stuff stored in my head, which is not great for other team members.

So I've tried to get much better at documenting stuff for my team and Then everyone has to ask me a question, they can look it up and they'll have access to it. And it's much clearer also with working, not just the landlord. We're trying to very clearly our expectations with working with an architect or a general contractor, like this is what we expect.

We're laying it out. So we've gotten much better at documenting that stuff. I got it. And some of it, I'm just documenting. I'm getting from other genius people. Like I don't know everything, but. Gathered knowledge from people and I have a document so I know that this is what we need. So a lot of it is just taking all the information you learn and all the data of what the different departments and you know what we need to really function great and having it in one place.

That's not all knowledge that I developed or I know. I mean, that's key. I'm taking the wisdom from everyone else. I think that's important to realize. And I think that's one of the key things is that I spend a lot of time learning the different departments in different areas and learning from all the brilliant people I get to work with because that's really like where you learn.

[00:30:25] Griffin Jones:
You do deserve credit though for not letting it just go in your head though, because that does happen very often where someone does come, they benefit from the institutional knowledge that's kind of there in the ether, anecdotally talking to people, maybe they compile it for themselves, but they don't get it into an SOP for the organization.

And so that is, you deserve some credit for that because you want to be able to repeat and not have it. Be all you so that the next person doesn't have to think about it on their honeymoon. And so when you go on your, your anniversary, your 15th anniversary, you don't have to, you don't have to be thinking about all of this stuff.

People can access it from other places. And I've written, I've made a couple notes about your team because I want to ask about the team. I could jump all over the place. You've got so much. Gold in here. So let's stick with negotiation for just a second. Those are all really good places. Are there, is there any kind of phrasing that you learned to be aware of where there was some kind of phrasing that you, you, you were certain meant one sort of thing.

And then after you go through something like, Oh, that's not what we wanted or, or you, Oh, You promised us X and they gave you Y and is there any type of phrasing that that sticks out? 

[00:31:41] Lindsey McBain:
Not so much. I mean, I, an LOI, I don't need an attorney for like, we know our terms. We know our letter of, LOI, letter of intent.

We know the terms we want to go in there. I mean, when then we get to a lease, we, we are smart enough to bring an attorney in to look at like the legal jargon that could step us up. And like, I tell the attorney, these are the things like I need to make sure are in my lease. Is there any hidden? I mean some of these leases are 200 pages long.

Is there something hidden in here that I didn't catch that I need to be aware of that's going to make it so my HVAC isn't on or they're going to close every third Thursday or something crazy like or their holiday schedule is X and my holiday schedule is Y. Can I pay to be open or are they shut, shuttering the doors?

So I think it goes back to knowing you're operating non negotiables and putting that in your letter of intent, which is the. Framework for your lease, and then relying on your legal experts to make sure that there's no legal barriers set up. 

[00:32:34] Griffin Jones:
Is it always a lease? Do you ever buy? 

[00:32:36] Lindsey McBain:
No, we own a couple locations.

We do. So, I mean, then it's different. It's a little bit easier. But typically most people, especially new people into the industry, usually are leasing their first locations, I would say. It makes more sense. But yeah, we do own some locations. 

[00:32:51] Griffin Jones:
And, and I, I wonder what the breakout is. I wonder if it's like, I wonder if it's, if it's much less than a quarter that do that would be my guess is that it's a quarter of people that, that maybe it's less than that.

Maybe it's. Yeah. Well, we can add that to our arm team's surveys

too. Tell April, we've got one more survey for you. So when you all decide to buy, is it. What's the criteria behind that? Do you have to be the anchor tenant there? Is it like something that you did with your Basking Ridge location because you got a lot more people and then you can be the anchor tenant?

Talk to us about when it's time to buy versus when it's time to lease. 

[00:33:36] Lindsey McBain:
So definitely for us being the size we were in New Jersey, we were well established. It was, it made sense to have the entire building. We were going to need the entire square foot building and they wanted to make it a purchase. That was always the intent.

We really weren't looking to lease anymore because of the growth they wanted and the flexibility to really design it themselves. So that's what we did there. I mean, we did the original construction and then I think it was. Five years later, we added 30, 000 square feet to our Boston Ridge location. I don't know if you've ever been there, but it's our original 60, 000, 65, 000, then we added about 30, 000 to it five years later.

[00:34:17] Griffin Jones:
So you're talking almost a hundred thousand square foot building. 

[00:34:21] Lindsey McBain:
Almost. And that sounds a lot more because you have, you have to remember, you've got building areas, you've got elevator rooms, you've got loading docks. Like you, that's the one thing with buildings and you'll, even in leases, they have cam.

So there's different areas that you have to pay for, for like use, like your entryway. So there's a lot of lost space, even when you own a building that you have to be aware of when you lease, you pay for common areas. But when you buy, like, even though it sounds more, there's a lot of wasted, not wasted, but there's like lost space.

Like you need HVAC rooms, you need Duckworth, you need electrical rooms. Like it's not all clinic space ever.

[00:34:56] Griffin Jones:
The CAM, what is that? Common Amenities, Common Access something? 

[00:35:00] Lindsey McBain:
Yeah, it's Common Areas Maintenance. I believe that's what it stands for, but it's. You know, typically you have those fees in your lease because you're paying to have elevators, entryway, core bathrooms, all that stuff.

So you still need all those amenities when you own a building as well. And that takes away from the footage that you have in there. 

[00:35:17] Griffin Jones:
So it's, it's a big operation in, in Basking Ridge, but you are the only tenant there? Adding... 

[00:35:23] Lindsey McBain:
Even with adding these other genetics is out of there. But yeah, all okay. 

[00:35:28] Griffin Jones:
And so all right, then this is a good segue to go back to the when you were starting to move from Morristown to Basking Ridge, you had already done Eatontown and West Orange at that point, one was a new location.

One was a move. Now you're back at a another move. But at this time, it includes the clinic offices, but it also includes the corporate offices and a lab. And so did you leave a lab in a space there in Morristown? Or was it completely, we're completely getting out of here and moving into? Basking Ridge. 

[00:36:07] Lindsey McBain:
We kept a satellite there.

We did not keep an embryology lab, but we kept a small andrology lab and we kept a, like a satellite office there. So we downsized our footprint in Morristown. in the same building? We've now moved, we've just actually moved Morristown in August, but we were there for another, we were there for many, many years afterwards.

We kept in the same location. We literally just downsized our current space. Our waiting room was the same. The main entrance was the same into our office in Morristown. We had space on the first floor and the third floor. So we gave up the entire third floor. We gave up part of the first floor. But we kept a location there and we also phased our move.

It wasn't, we all moved on a Friday and opened on a Monday. Departments moved in different waves to help control and allow time for setup and. Make it more efficient. 

[00:36:52] Griffin Jones:
So at this time you're you're scouting the locations you're they had been looking around Prior to you even starting you start in 2008 you start getting more into it in 2010 of of starting the okay.

We're starting the moving process. What is What did the, the, the location scouting process look like? 

[00:37:17] Lindsey McBain:
I mean, you're going to look at location, like, how easy is it to get to, I mean, any time you go to look at whether it's a satellite, a new build, how easy is it to get to a location, like, and I'm horrible with directions, if you ask my husband, so I think I'm a really good person because I can get lost, like, going down the street, so if I can get there, I always feel, like, better that other people can get there.

So you want it to like be pretty easy to get to off of main thoroughways. If there's multiple thoroughways there, there are like highways, it's more ideal because people from different areas can get there easier and then you like want to have plenty of parking. You want to feel safe. Like I said, you. We like it to look like a place you want to go.

You don't want to be like an industrial shipping warehouse going to your doctor's office. I think that the building says something about, and then there's code requirements. Again, parking. We want to have enough, but there's also parking code requirements. There's sometimes having a covered walkway as a requirement.

The loading dock where you can put a generator if you need it. Like there's all those.

That's one of the key questions. 

[00:38:23] Griffin Jones:
We should put you as the person that goes to SRM conference cities before we have to go and you go through the airport and you point out all the frickin places where the rideshare signs don't connect to the other part of the rideshare sign. Oh my god. Cause I can't stand that anymore.

So you, you're doing a little bit of that recently. Yeah. It's going to happen. All of us, when we go to SRM this year and they'll happen again and again. And so you're doing this for the offices themselves, physically, how much. 

[00:38:57] Lindsey McBain:
Do the first, like, sometimes someone will see a spot and be like, I was driving past this.

Can you look into it? Or I think this building is really great lens. Can you see if we can get in there? And I'll typically do like the first run through, like, and then I'll shortlist it and typically bring someone else for another opinion or present my findings back to like the board or the doc involved, depending on who.

The right framework is all typically, but I'll typically shortlist it. We'll have, I'll get 15 locations with a realtor that we'll find and we'll get it down to like three or four, and then we'll get other people involved and them to see it and or review that on a map, even if there's different variables, depending on the undertaking and where it is, but we'll definitely get other people's input.

[00:39:39] Griffin Jones:
Well, that's what I want to ask about. How much of it has changed with new technologies coming into play? Like in 2008, we were still printing out MapQuest in 2008. We didn't have to really consider, Oh, can a ride share? Oh yeah. I guess you would consider, can a taxi pull up here, but there are different considerations for ride share sometimes.

And so now that's into play. We didn't have. The virtual tours that we have of all kinds of real estate. 

[00:40:07] Lindsey McBain:
Yeah, the virtual tours and even what when you're working with architects, they can map out and remove walls and you can walk through it is amazing. I mean, learning how to read a blueprint and really be comfortable and be able to guide yourself through that is very different now.

[00:40:23] Griffin Jones:
When did you do that? When did you learn how to read a blueprint?

[00:40:25] Lindsey McBain:
When I started doing clans, I had to. When I started, when I started this role back in 2009, I guess, then 10, that's when I just had to figure it out. I had never really looked at anything other than like a fire escape so much. 

[00:40:39] Griffin Jones:
I bet there's a lot of people opening offices that still don't know how to read a blueprint.

How, how critical is it and why?

[00:40:48] Lindsey McBain:
I mean, I think to really like visualize the process, you really have to think about the path and you know, how everything lays out and how patients are going to walk around and how staff's going to access. So I think it's really important. I know it's hard. I work with colleagues that this is not what they do.

And I try to show them a blueprint of like, oh, it's so great because the nurses are here and the docs right here and the labs over. And they're like, wait, where is so I get it doesn't come. But if you're going to be in charge of it, I think it's really important that you can look at it and really see the different pathways and be able to follow it as a patient be able to follow as an employee on really Grass that it's going to work because it's much more expensive to figure that out when walls are up than it is when it's on paper.

I mean, even when you're building, they spray paint, they'll spray paint the floors. So that's I found to be a key time to go walk your site is when the floor plan is spray painted on the floor. So then. And walk around and feel it and help. 

[00:41:43] Griffin Jones:
Well, that's useful to be able to do. So you could theoretically do it with the architect virtually beforehand, but then you can physically go there when they've got things spray painted and, and, oh, that's, that's, that's a good, a really good pro tip.

And so you, you mentioned that you're doing this with your team. Tell us about who's on that team. 

[00:42:05] Lindsey McBain:
So we definitely, now that we're across the country, I definitely utilize project managers, which will be contract based because I. We don't have team members everywhere. And sometimes it doesn't make sense to have a long term team member.

Like I said, the docs are usually very involved. And then I have my core team of operations folks that are based out of New Jersey, but that do travel. I'm also finding the right architects and engineers to work with. They're important. Um, typically they'll be local and do site visits. But it's definitely setting the expectations up front for everyone and knowing what you expect and knowing the right times to check in and see stuff.

I still think that it's important that I make certain visits or someone on my team that knows make certain visits. I don't need to be there every day. If it's, if I'm building something in New Jersey and I can drive to Phoenix to be there a lot more often, then I can go to like Houston. But there were still key times when I had to get on the plane and I had to see it in person, even having wonderful team project managers and people involved.

Me and the physician were both in New Jersey at the time. So we had to go there sometimes and really walk in and see stuff in person. Like when it was on the floor, we need to see that layout and really feel it and make sure that stuff was right. And we made changes. So, but it's, it's specialized and it takes people a long time.

To really learn and get understanding of what goes into it. It's a lot and some people find it very dull and some people love it. I mean, there's a lot of different facets that I've talked about. There's negotiations, there's the ongoing maintenance, there's the construction. So I likely have team members who kind of thrive in different areas and we all work together.

And I also think that's really important. Oh, sorry, I don't mean to cut you off. I think it's really important, like I said, to work with all the other departments. and understand their needs and constantly check in with them and make sure that what I'm doing is still what represents what they need in the field.

I can't just go on what worked in 2010. It's really what's meeting the needs of the team and 2023 2024 that we're planning for. I have to constantly be in contact with them and checking them and they're the experts. I'm building something for them to be able to use and really do the magic. So I have to make sure that I'm checking in with them and seeing what they need and what they want and how They want to portray it.

[00:44:09] Griffin Jones:
So it's working with the docs and the lab team and the nurses and getting input from everybody and you're bringing in people from new areas as you move to those areas beyond your local team. Do you ever hire? Consultants, or are you beyond that, right? You're hiring project managers. 

[00:44:24] Lindsey McBain:
No, for the project managers, they're consultants.

They're usually a contract, and they come in and help just for the projects. 

[00:44:29] Griffin Jones:
Do you use, like, is there, like, a vendor of project managers? Like, a company that, that they have different project managers in different areas? Or do you just go hire a firm that's local to that area? 

[00:44:41] Lindsey McBain:
So both, I mean, there are national firms that have offices locally.

I've worked with them. I've worked with people that are only based out of local areas, because even if a company is great, their L. A. person could be amazing, and their Washington, D. C. person could have never done healthcare, and not the right match for me. So we typically try to interview multiple vendors for anything we do, and get multiple quotes, and do interviews with people, virtual interviews.

I'm not flying out there to meet people just to do an interview. Thank God there's... These platforms where you can talk to people and see people virtually now, but it is important. You are. 

[00:45:15] Griffin Jones:
And so that brings me to my next question, which is probably more of my ignorance about what it actually takes to build.

A new edification rather than smart question, but I'm thinking like we had clients all over the place and we would do, we hire cinematographers or photographers in their area. And then eventually got to a point where I say, I don't want to hire a cinematographer in Houston and San Diego and Seattle and Toronto and all of these other places.

We got this person and maybe a backup that had been killer. I would rather just pay for that person to fly across the country and do that job. And it works for that person because they're, you're lining up their work for them for a year pretty much, or at least getting them way busier. And it works for us because we have one throat to choke.

It's like they're, that's a very familiar person and we can be a lot more predictive of the quality for the client. Building a building is a lot harder than that. So why not? Send an architect that has worked really well for you in a couple places in New Jersey out to California. 

[00:46:28] Lindsey McBain:
Are they licensed? They need to be licensed in the local jurisdiction.

They need to know all the local laws and regulations. And sometimes we have done that where we've had someone work with, that has a partner office in another location. Sometimes it's not possible. Sometimes there's not someone that we've worked with licensed in that area. And there's also a different cost sometimes if you have to have, if it's not the same office and you have to hire two offices and two architects.

That just financially doesn't make sense because you do need to be licensed in the area to be able to file. You need to know the local codes. And sometimes cities have codes and it's not just state just because you're in California. San Diego and LA may have different city codes that we have to adhere to.

So there's different things that go on and then general contractors aren't always national and they also have to be licensed and have staff and buying power and negotiating power in the area. So I would love to have one team. I just, hasn't always been possible or always makes sense. If in New Jersey, it's a little bit easier.

We can reuse professionals. But when we go national, it hasn't always been so easy. 

[00:47:29] Griffin Jones:
Speaking of those regulations now that you've worked in a number of different states, what do you find, who's been the hardest state thus far? 

[00:47:38] Lindsey McBain:
I think you learn your stuff with each time. I think... That more on more rural areas and it was a little bit easier than a city just because the unions and the different regulations and there's more building going on sometimes it's harder, but not always you get a town that's really difficult in the middle of nowhere where the inspectors and the takes forever or they have a lot of regulations.

So it really depends on the job and everything going on and also the quality of the documents you put forth and the team that did your work ahead of time is really important. And can we can be in the same city and I've done 2 projects and I'm 2 different realities because you had a really great GC or you had a really great architect who didn't need to make a lot of changes or another 1 who's missing the town and the town needed 30 changes.

[00:48:24] Griffin Jones:
Are there any regulations that stick out at you? It's like, well, I've done this 10 or 12 times. I've never seen that one before, like a municipal regulation or, or anything that sticks out of note. 

[00:48:37] Lindsey McBain:
No, I think it's just interesting. Some cities, the architect files the permit. Sometimes you need a GC to file the permit.

I think that varies, which is interesting that each town, each city has its own little special quirks. I would say they all really give you a run for your money in some way. It's just working with them and knowing expectations and you're kind of at their mercy to some extent because they can stop you from construction and inspections and stuff.

[00:49:05] Griffin Jones:
So you want to make it nice and you want to follow the rules. So now that you're expanding to now, RMA is now RMA New Jersey, you've got EVRMA, you've got EVRMA America, EVRMA Global, what's on the docket for you? What's the next big lesson that Lindsey McBain is going to have to learn? 

[00:49:24] Lindsey McBain:
To delegate. I think the more, the more we grow, the more I do have to trust other people to do stuff where I said, I've always been the mindset that I need to see stuff.

I need to make sure that it's okay. I need to trust these wonderful people that I work with that. And I know they can do it, but just trust them and really some of the control. 

[00:49:42] Griffin Jones:
So what, what did each of them do? You talked about the project managers and the architects and what they do, and then what your in house team, the one that's with you physically in New Jersey, whether they travel or not, what?

What do we, each of their roles do? 

[00:49:55] Lindsey McBain:
So I have another person that really just works on construction and projects with me across EV America. I have someone who works in New Jersey who really, she does some, she's amazing at moves. She's mostly just deals with New Jersey. She helps make sure all the day to day operations run.

Then we have, we also overseeing purchasing. So we buy all the equipment and furniture and everything for these new locations. So we added a purchasing specialist to our team this year because we were All doing it ourselves. There's a regulatory person who comes in and make sure it is the ASCs are meeting code and looks into the regulations for like you want to HST, she'll call the state and make sure that we are following all that as we set up and then we have an administrative team members that more work on credentialing and the paperwork behind the move.

I mean, my role isn't just this, I get involved in a lot of different facets, so my team's a little diversified, which is wonderful because they're all experts in their areas and they help me in the different areas that I need to be over instead of them all having to be experts in every area, they kind of help manage their.

Spheres of influence and they're all amazing and very, very lucky. And like I said, they all value you working with the other teams. I mean, I think that's very, like I keep saying, being constant contact with the lab. Is this the right equipment? Is this the right layout? Like we're constantly, we kind of put it out there.

Then we walk with them and we're like, okay, this is what we think. What did we screw up? Don't you like, what do we need to tweak? Okay, we just built this office. What did you hate about it? What would you have made different? And then there's certain things that we know we love and we keep trying to recreate that and put in different locations even if it might not be the ideal first thing.

[00:51:36] Griffin Jones:
What's fast and we added in and each time are you are you normally working with the same? Vendors now like we're gonna lease our ultrasound from the same folks. We're gonna buy our microscopes from the same people We're gonna buy PB from the same folks. Are you normally? Going to your current existing vendors, or do you find yourself going to new vendors when you go to new locations?

[00:52:02] Lindsey McBain:
Well, we try to use the same vendors across the network for economy of scale and purchasing sense that makes sense. You're, you have better buying power, but we're constantly looking at new vendors just because you were the best last year doesn't mean you're giving me the best this year. So we do constantly check and we quote stuff out.

Like I said, I'm big on getting multiple quotes for stuff just to make sure that we're still competitive. You, I think if you just rely on something, you're going to find that you are missing out. Even if you want to go back to your current vendor and be like, you are not competitive anymore because you have a great relationship.

That's a discussion you can have. And sometimes it doesn't make sense. I also won't hand over price lists to competitors. I don't, that's just not me. I'll tell you you're not competitive, but I'm not going to tell you what Mike down the street selling an ultrasound for. I'm going to tell you to sharpen your pencil.

So that's kind of the discussions that I'll have. But I do think you need to be out there and you have to be looking. You can't just say, you know what? McKesson looked good to me last year. So I'm just going to buy everything from him. Maybe Henry Schein or Fisher Lee. You have to shop around. You have to make sure it makes sense.

You have to. Make sure you're getting in the right GPOs. You have to make sure you're looking at economy of scales. 

[00:53:05] Griffin Jones:
I think that bidding out process could be its own topic. I think there were 10 topics we talked about today. It could be their own topic, but this will be sufficient for the day. And I will be very happy, happy to have you back on Lindsey.

How would you like to conclude to our audience about what. Wisdom they should impart when considering expanding, starting anew, or moving a location. 

[00:53:28] Lindsey McBain:
I think just to really look at what your team needs and talk to your team and make sure it makes sense for everyone. You look at the economic benefits, look at what your team needs, look what will be right for the patients.

And getting the big picture. And again, I've said I think multiple times about this podcast is that I always I've gotten to work with brilliant people. I've gotten to learn from brilliant people. And I take all that in and really value everyone's input. And I'm just making their ideas happen. 

[00:53:53] Griffin Jones:
Lindsey McBain, thank you so much for coming on the Inside Reproductive Health podcast.

[00:53:57] Lindsey McBain:
Thank you for having me. 

[00:53:59] Sponsor:
This episode was brought to you by LEVY Health. Seeing more patients for a first consultation may actually decrease IVF revenue by 30 to 40 percent. To see why, download the numbers for free at levy.health/conversion. That's levy.health/conversion.

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. Thank you for listening to Inside Reproductive Health.

203 7 Categories of AI Investment in Fertility, and the Barriers to Their Adoption with Abigail Sirus and Dr. David Sable

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.

Quality Disclaimer:
Despite our best efforts, technical issues can occasionally arise.  Please excuse the audio in the following episode as it doesn’t reflect our usual quality standard.


The innovative potential of AI is an increasingly common topic in IVF and beyond. But on this week’s episode of Inside Reproductive Health we bring back Dr. David Sable and Abigail Sirus to ask a different question.

What’s preventing AI from completely taking over the fertility space?

Dr. Sable and Ms. Sirus discuss the seven big areas of AI investment in IVF and the obstacles standing in the way of full fledge adoption.

Tune in to hear:

  • The 7 categories of AI Investment (And their criteria)

  • Their visual for how they categorize AI in the fertility field (Corresponding to their seven categories)

  • Current developments in AI across the IVF space (Including the sticking points)

  • What’s preventing the inflection point of AI completely sweeping fertility treatment (And making their four principles the standard)


Abigail Sirus
LinkedIn
Twitter

David Sable
LinkedIn
Twitter

Transcript

[00:00:00] Dr. David Sable:
But the big part of that is doing the work is merging the software with the hardware so that you're getting reliable data so that the information they give you is based on the hardware and software shaking hands. in a, um, in a valid way and not giving you, it's not like, it's not like with chat GPT when you ask it a question and it makes mistakes and it makes things up.

The data we're getting now is not made up. It's really truly reflective of what the hardware is finding. Taking the next steps of plugging that into real decision making is going to be difficult. 

[00:00:38] Sponsor:
This episode was brought to you by LEVY Health. Seeing more patients for a first consultation may actually decrease IVF revenue by 30 to 40 percent.

To see why, download the numbers for free at levy.health/conversion. That's levy.health/conversion. 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.

Despite our best efforts, technical issues can occasionally arise. Please excuse the audio in the following episode as it doesn't reflect our usual quality standard.

[00:01:34] Griffin Jones:
Why? Why? Why? If any of you are gracious enough to think that I'm good at my job as an interviewer, it's simply because I'm a child that wants to know more specifics.

I want to know why, and I'm not satisfied with the answer of fertility clinic workflows are just too complicated. Why is this tipping point that almost all of us can see we're so close to having a I move over this inflection point and totally dominate how fertility treatment is delivered? Why are we still not at that inflection point?

When we're so close, what's holding us back? So I bring back two very popular guests. They're Dr. David Sable, who you know very well, a former practicing REI turned investor, and his colleague Abigail Sirus, a venture capitalist who worked with IBM for a number of years. Last time Abigail and David were both on the show, they went into their four guiding principles for democratizing IVF.

That's have a la carte options for IVF services, go around incumbents if you can to incentivize them. Set the standard of today's highest pregnancy rates as the absolute basement for outcomes for the future and pay for outcomes, not cycles. In today's conversation, I asked David and Abigail, what's preventing the inflection point from AI completely sweeping fertility treatment and making these four principles the standard of the day.

David and Abigail have . visual of how they categorize artificial intelligence in the fertility space, corresponds into seven general categories, and we go into each of those categories. David and Abigail share some developments of what's happening in each of them, and they detail the sticking points for each.

That's oocyte assessment, embryo assessment, sperm selection, hormonal stimulation, non invasive PGT. clinic decision support and workflow. And in their other category, which may overlap with obstetrics and other areas of healthcare, you're talking about follicles, preterm birth, reproductive immunology, and ovulation.

If you're having trouble picturing this visual, we'll link to it in the show notes and follow along as I try to get the specifics of why we're so close to AI domination, each of these areas and what specifically is standing in the way of each. Enjoy this conversation with two of your favorite recurring cast members here on the Inside Reproductive Health Show, Dr. David Sable and Abigail Sirus. Ms., Sirus, Abigail, Dr. Sable, David, welcome back to both of you on to the Inside Reproductive Health podcast. 

Always a pleasure, Griffin. 

You're both troopers. You're both gonna have to go to the chiropractor after this episode because like our last episode, your backs are gonna break from carrying that episode.

Last time, it was after Thanksgiving and I... It was the first thing on the Monday morning after Thanksgiving. And I know business owners are supposed to say, I love Mondays. I love mornings. I don't, I don't love Mondays or mornings. And I really, really love Thanksgiving. I remember being in a funk and you both carried that interview.

Now you're going to carry it more today because not only did I ask to talk about a visual concept on a show where the audience is 90, 95 percent audio only, I also. Send one image where I sent you one image and said let's talk about this and then was thinking of going in a different direction so you have so many different visuals for investment areas of the IVF space so I will have you back on for yet another episode to talk about the.

Other map that you've used to, to wireframe the, the, the whole IVF process. But today let's zoom into AI and the visual that we're talking about today, Abigail and David, is this going to be something that we can either share or that we'll be able to direct people to, to your website or previous article that they can reference themselves?

[00:05:28] Abigail Sirus:
Yeah, so I think that we we've published it on David's blog, David's medium site, so it's what you're not seeing to everyone who's on on audio only is it's basically just a chart of the different areas of innovation and AI in the IVF industry, so we're Talking about things like an oocyte assessment, embryo assessment, sperm selection as well.

So just the different versions, uh, different flavors of companies we're seeing innovate in AI and IVF.

[00:05:58] Griffin Jones:
In this realm of AI, you break it into oocyte assessment, embryo assessment, sperm selection, hormonal stimulation management, non invasive PGT, clinical decision support and workflow. And then you've got an other box.

And then in that other box, you've got follicle preterm birth. REI and ovulation. So, or excuse me, that's not, that isn't REI, that's reproductive immunology. That's, that's in your other box. Why did some things make it, uh, it, why did the things that are in your map make it to the central part that it is?

And others, Not appear here. 

[00:06:37] Abigail Sirus:
Yeah. So the way we think about it, Griffin, we're venture capital investors and fertility is, is really looking at the market as a whole. So we map out a universe of all the companies. Find IVF and right now that number is around 280 and what you're looking at is our map of AI Subsection of that larger one, which is specifically the 20 plus companies It seems that the number is is growing more and more with every week that passes That are specifically focused on AI or are using AI as part of their processes and the way we map it out We're just looking at two buckets The first is companies that are looking to optimize IVF, the procedure itself, using AI.

And so that might be via oocyte selection tools, embryo grading tools, or things like, um, hormonal stimulation tools. And then the second bucket are the companies that are kind of adjacent to IVF itself, that are looking at the processes and procedures around delivering. IVF care and using AI to optimize those.

So we're talking there about, for example, an AI enabled chatbot that can help answer patient questions perhaps more quickly. Or, um, there are a number of companies that are focused on kind of the iOS for fertility or the operating system across a clinic or clinic network and using AI, AI to optimize things from billing to staffing, etc.

[00:08:03] Griffin Jones:
As the players become more fluid on either side, as there's more vertical integration, do you see the map changing? And that one bucket is the company's optimizing IVF itself, and there's others working on processing procedures. But as these players Start to overlap with each other and with what they provide.

Will we see this change over time? Or do you see these two buckets as a long term way of looking at this? 

[00:08:30] Abigail Sirus:
I think it will change over time as we're early stage investors. So startups can, can. Pivot from time to time. But really, we're seeing a mixture of startups that are going after either point solution.

So we're really focused on making the best AI enabled salute or embryo assessment or those that are taking a more comprehensive approach. So might be doing The solution I just mentioned, while also looking across the clinic at ways to opt. So it really varies across the ecosystem in terms of whether people are focused on point or comprehensive solutions, but I think it's only going to continue to evolve.

It feels like there's been this kind of tidal wave of interest in AI ever since. Chat, GPT came to the fore and had, I think it was a hundred million users in the first few months, which far passes any product launch. But in reality, a lot of these companies that that we're mentioning in IVF have been working on it for a number of years, but it still feels early days.

[00:09:27] Griffin Jones:
The visual that you have is broken into these categories, and then as the offshoot, there's a, a blurred out section. Are you mapping companies that are in each of these different areas are working on each of these different areas? Right now? I know because you all are in venture capital, there's regulation about you not being able to talk about specific.

Companies. And so is that what's blurred out? Are you tracking who's doing who's involved in each of these sections? 

[00:09:57] Abigail Sirus:
Exactly. So you can imagine that even behind this, I'm a data and spreadsheet person. So we have kind of our database that, that in those blurred section takes all of the 20 plus companies, which are what's represented as kind of the options that you were mentioning.

And we analyze them each across a number of dimensions. So one of them is. What I mentioned before, whether it's a point solution or whether it's comprehensive, another would be with something like A. I. Data is so critical to how we evaluate these. So it's understanding what are the data sources that each of these startups are using?

Are they proprietary? Is that data source going to grow? And we've been talking a lot, at least in the ecosystem about quantity of data. But from our perspective, it's really about quality. So it's about the signal that the data is releasing because IVF is is still growing. And in many ways, when you compare it to healthcare in general, it's a niche industry, even though we believe it's going to grow exponentially over the next coming years.

And so a lot of the companies that we talked to are using similar data sets. So what we try to understand is how are they differentiated because when you're building an AI algorithm and you're using all the same inputs, we're, we're curious to see how it shakes out in the coming years among these companies of how the outputs are really different and how that makes an impact on patient care.

[00:11:15] Griffin Jones:
How is it shaking out right now? Are you seeing meaningful differences? Are they all coming to the same conclusions and starting to build very similar solutions? Or are they coming up with radically different solutions using very similar data sets? 

[00:11:33] Abigail Sirus:
I'd say it's still too early to tell in terms of which, which are going to be the winners of the pack and so on.

What we are seeing is kind of a convalescence or convergence around the same use cases, which are kind of laid out on that diagram that you mentioned before, embryo grading and selection. Hormone stimulation using AI, but what we are noticing as well is what's what's potentially differentiate companies or what clinics are they partnering with and going beyond that software or an AI powered algorithm is only as powerful as it can be actually applied in the clinic.

So what we're also looking for are companies that are focused on integrating their solution with Hardware and kind of bridging the gap between the digital and the physical worlds, because what we've seen is that companies who come into the space and might be really excited about this small part of the universe that they're innovating on, if you don't think more broadly about how it would actually be Impacting an REI's daily workflow or an embryologists and how you can make that part of their experience in a seamless way, solutions can have a hard, hard time taking off and being adopted when we're not thinking not only about the product itself, which is driven by AI or powered by AI, but also how it will be distributed and be made part of the IDF ecosystem as it is today, or the IDF ecosystem as it will be defined over the coming years.


[00:12:52] Griffin Jones:
Because hardware integration is so important, are you seeing multiple, in this blurred out section, are there multiple players that are appearing in different, in the different core categories, these eight boxes, as you have them laid out, or do you try to, do you try to identify which of the eight boxes they are most Best describes them and keep them in that singular category.

[00:13:19] Abigail Sirus:
It's a great question. And it's one that, that David and I talk about a lot because we like to be precise, although with things changing as quickly as they are, it's hard to do. So it really depends on the company and what we've learned and kind of. How far along they are. So yes, there are some companies that are tackling several of these areas that might be going after both oocyte selection and sperm selection.

And so they would be listed in that blurred out area that you mentioned before in both sections. But for others who might be in the early days of exploring one use case, but farther along, much farther along a different one, it would only list them in one section.

[00:13:55] Griffin Jones:
You mentioned that they use similar data sets very often.

Is that equally true if they're in very different categories? Meaning you might expect the folks that are working on O site assessment that they are using similar data sources, but are. Does it matter, are the people that are working on PGT, non invasive PGT, or the people that are working on clinic workflow, and the people that are working on sperm selection, is there still great overlap in data sources for them?

How much did data sources vary depending on if they're in entirely different categories? 

[00:14:35] Abigail Sirus:
I think it's, Definitely different. If you're focused on oocyte selection, you're not going to be looking at the sperm data, unless maybe that's going to be part of an algorithm and your future roadmap. So in that case, what I would be talking about is, so in oocyte selection specifically, I'm looking at the map on my computer now, but that's not blurred out.

We have five plus companies just focused on oocyte selection. So they would be like using the same or similar data sources. 

[00:15:03] Dr. David Sable:
One of the problems, Griffin, that we do see is that you see a difference in data sets, not so much the data being collected to make the decisions, but in some of the categorizations.

Something as simple as a diagnosis. One clinic's unexplained infertility will be another's ovulatory dysfunction. Depending on what the algorithms pull out, the connections they make, you hear that one of the great The beauty of AI is that these are unbiased mechanism agnostic algorithms. So if we use these things kind of differently from one clinic to the next, or maybe one operator within a clinic to the next operator, that's going to sort of infect the data.

And we're going to see these kind of artifactual differences. And since an IVF, we're limited by the fact that the data sets are pretty small, relatively. These are not big. When you talk about big data, when we're only doing a few million cycles worldwide every year and capturing only a tiny percentage of those into these data sets, we're handicapped from the start.

You start throwing some, I don't want to call it sloppy data, data collection, but let's just say inconsistent data collection. On top of it, and that makes our job that much more difficult, and it makes the algorithms have to work harder to avoid presenting things to us that are not really real. 

[00:16:37] Griffin Jones:
Is this part of your advisory role for your portfolio companies?

Do you advise on the data sources that people are using? Oh, we, we've seen this before. We know that the data that you're showing us here is inconsistent and you might consider this other source.

[00:16:56] Dr. David Sable:
I think the, I think the data people, the data scientists know that going in, and they're, unfortunately, they're limited by who's going to, who's going to work with them, who's going to send their data to them.

Let's say, as you can imagine, and rationally, rightfully so, clinics are very protective of their data. So it's a, it's a bit of a trench warfare, trying to accrue enough things to feed into the systems to start building the training sets and building the algorithms themselves. 

[00:17:27] Griffin Jones:
What would allow for more data sources to become available?

So if there's, if, if there's. So a lot of redundancy and overlap in different companies using similar data sets, what would allow for more data sets and more data sources to become available? 

[00:17:48] Abigail Sirus: I think even before tackling that question, there's a level of kind of data uniformity or unification. So in a previous life, I was, uh, focused very much on data, uh, while I was working at IBM.

And we would build out a, you know, garbage, garbage out. And what we've heard in the industry is sometimes even using a popular EMR system for one clinic, they might use a specific data field or mapping that's, that's different than another clinic. And so there's this high level of customization across the industry today.

In terms of how they're just thinking about how they talk about data, and that's going to create challenges of bringing the disparate sources together in a way that makes sense and unifying them so that you could even be run an AI algorithm on top of them. 

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[00:20:05] Griffin Jones:
I wanna ask, uh, you, you can't talk about particular players, but I do wanna go through each of these categories and give the audience an update on, on what's going on in development.

And I understand that in some things you're gonna be limited and I'll try to press. for specifics where I can, but tell us what's happening in the development in an O site assessment right now. What's going on with that grading and with regard to AI. 

[00:20:32] Dr. David Sable:
In a large sense, the big challenge is demonstrating the value proposition.

The, uh, we, we know that the use of. Uh, advanced imaging systems and vast data handling can give us legitimate, uh, insights into which oocytes are more likely to turn into good blastocysts and good pregnancies. Uh, they can rationally rank the embryos as to which should go back First. Problem is how, when, you know, you and I and and Abigail have talked before about our criteria of dollars to baby time to baby and life disruption to baby.

And if we can do it little bit better by offering a point solution to put back an embryo in February instead of, instead of in March, so the pregnancy occurs quicker, how much is that worth in the grand scheme of things? By itself and how much better are we doing some of the business plans that we've got early in the AI journey were beautifully engineered solutions to answer a question and absolutely terrible business plans with the expectation that the price points that you could achieve.

Sometimes per cycle, sometimes hundreds of dollars per embryo assessed. We're just completely unrealistic in terms of getting the patient to where she wants to be. And we kind of, you know, then you may ask about advising the companies. Well, you sort of start advising them and say, Listen, you got to go back and put this into the grand scheme of What the patients themselves in the clinics are trying to solve for.

So we haven't really seen data telling us how much better we can do on specific, specific items. Embryo assessment, the same embryos are going to be sitting in the lab anyway. So it's a matter of when an embryo goes back versus other embryos that might not turn into a pregnant. Oocyte assessment is a wonderful, uh, science project.

I think it's, it's fabulous knowing which oocytes to use. But frankly, what we do now is we let nature tell us which oocytes to use because Some of them will fertilize, some of them won't. Some of the ones that fertilize will develop well, some of them won't. And then we've got other means of assessing the subsequent embryos.

So, up front, Determining which oocytes to use really is valuable, I guess, only if you have very, very limited numbers of sperm to use and you're triaging those sperm. Our work in AI for sperm selection is brilliant work being done right now. But it may be work that's being done looking at the wrong things.

For ever since we put sperm under a microscope. Hundreds of years ago, we've used this, the number of sperm, the way the sperm look, and the way they swim, as surrogate reasons for choosing one sperm versus another to, to fertilize the eggs. When we do, certainly when we're doing ICSI, in old fashioned IVF, we just kind of squirt the sperm into the dish.

Nature does that choice. Now, we don't know yet Whether the computers have been smart enough to find new things to look at versus what we look at. Because the important things are really the quality of the DNA and whether the DNA is normal within the sperm and the sperm's ability to kind of direct early regulation of first early cell division.

We have no way of measuring that. So while we have trained the algorithms and in some cases the algorithm and hardware combined to do things in a more systematic fashion. And some of the things that we as human beings just don't have the capacity to do, like we can look into a dish under a microscope of sperm and how many sperm can we track versus a brilliantly designed surveillance system with computers that can track all the sperm and then choose them based on certain criteria.

The algorithms haven't been trained back on the pregnancies yet that result from those tests because there just haven't been enough experiments done. Again, getting back to the limited amount of data that we have. So it's a very incremental process by which we can put in the, put the playbook into the various steps and try to extricate better chance of having a baby.

Now the stuff that we can judge earlier are some of the efficiency steps. We do something quicker. Can we do it? More error free. Can we free up people so to let machines do work that people do that takes longer or it's subject to fatigue? Or frankly, we just can't do as well as a well trained machine.

And those are things we're getting data back on. Now, I don't think we're in a position yet where we can judge company A does it better than company B, because these are all iterative processes and AI and IVF is such a new thing that it's exciting to watch things get better with the expectation that we're going to get some real, real decision making quality data. We're just not there yet. 

[00:26:20] Griffin Jones:
The answer to the question of what's going on in these two categories, is the answer not enough? 

[00:26:24] Dr. David Sable:
Well, they're, they're, they're in spring training. 

[00:26:27] Griffin Jones:
Is that gonna be the, is that gonna be the answer for each of the categories? So before I go through each of the categories and, and just find out that everybody's in, in spring training, maybe instead of going through each category one by one, where would you say of, of these eight categories, oside assessment, embryo assessment, sperm selection, or hormonal stimulation, non-invasive, PGT.

clinical support and workflow, and then other, where would you see, where would you say we are, who's beyond spring training, or which of these categories is seeing players that are beyond spring training? 

[00:27:03] Dr. David Sable:
Well, certainly clinical support and workflow. That's pretty straightforward. In embryo assessment, there is data showing there's validity to the ranking systems.

Again, we're challenged in proving that we have a viable value proposition, but certainly the rankings, some very good publications on the ability to rank embryos in ways that improve the efficiency of selection there. OSI selection, sperm selection, we have, a big part of that is, Doing the work is merging the software with the hardware so that you're getting reliable data so that the information they give you is based on the hardware and the software are shaking hands.

in a, uh, in a valid way and not giving you, it's not like, it's not like with chat GPT when you ask it a question and it makes mistakes and it makes things up. You know, the data we're getting now is not made up. It's really truly reflective of what the hardware is finding. Taking the next steps of plugging that into real decision making is going to be difficult.

The clinical data support, having the algorithms choose. What stimulation should be done having them make the decisions along the way for how the stimulation should be should be run That needs a lot more cycles to chew on and to have those cycles and have them collect connected to the outcomes So and there we're going to stratify the value in two ways The first will be that when it shows that we can relieve doctors from having to look at dozens or hundreds of data points per day for each cycle they're monitoring, and the computer can do it for 98 percent of them, just kicking the outliers out, we'll know that before we learn that the computers make better decisions than the doctors did.

So this can be a two step process there. So it's, yeah, I think that given that AI infertility was pretty much non existent, just a few years ago. We've made some terrific progress, but it's kind of like, like in biotech, what we say, we're still preclinical. We've got, we've identified molecules that can make a difference in the body.

Now we've got to stick them in the body and see what happens. 

[00:29:20] Griffin Jones:
You mentioned that some of that is down the road. What's happening? What are these players that are in the support, the clinical support and workflow category right now doing that's being implemented right now that maybe wasn't even happening a year or so ago?

[00:29:36] Dr. David Sable:
There's, there's two areas. One is they've got to plug them into, into existing clinics and have them adopt them into their workflow. The other end of it, some of these companies are actually starting their own clinics. And they're running clinic prototype clinics with the AI systems in from the start as foundational elements.

And it's going to be really interesting to see in those two settings, what kind of difference we make in just the efficiency in which we can run an IVF program and those efficiencies will flow to both the clinic operators themselves later. do what they do cheaper, and hopefully to the patients themselves at a lower cost point, and in down the road, a faster time to getting pregnant.

[00:30:28] Griffin Jones:
Those that aren't starting their own prototype clinics and those that are still selling into clinics and being implemented by clinics, are you seeing a different rate in, uh, adoption than was happening a year or two ago? Have we passed a threshold where. They are starting to be implemented, or is that still the beginning of a mountain yet to be climbed where most clinics are not implementing these solutions?

[00:30:58] Abigail Sirus:
Yeah, and so when I used to do software development, we would describe it in three phases. There's proof of concept, when you're just getting started, testing things out. The next is pilot, when you're maybe working with a couple clinics or a few clinics or a handful at a time. Having them initially adopt the software, testing it out with them with maybe some real data, some simulated.

And then the third stage is production, when you're fully live, maybe across a handful, a number of clinics or clinic chain. And so I think for clinical decision support and workflow, we're seeing a mixture between still in proof of concepts phase, but also some that are doing pilots with clinics, with some live and simulated data.

I wouldn't say that any. Solutions that I've come across are quite production scale yet. It's still early days there, but I will say that what has been interesting for me to see is the difference. It's the difference in how incumbents, so existing clinics are integrating AI solutions and the new startups that are coming to the fore with kind of AI as part of their, their backbone or, um, their core foundation.

It's, it's kind of like with other platform shifts we've seen with. The Internet coming to the fore, for example, there was this general assumption that a lot of the advertising companies that already existed would just simply port everything that they already did onto the Internet or the World Wide Web and would continue to maintain their market leadership.

And then there were these new upstarts like Google's and others of the world at that time who were originally written off who came to the fore with the being on the Internet, and ended up being able to kind of come after the advertising industry and really flip it on its head. So, we're still in the early days of understanding how the adoption is going to be spread.

And these, these clinics are powerhouses for a reason. They are innovative and thinking towards the future. And they also control... pretty much all of the data that upstarts would need in order to have meaningful algorithms that actually make a difference in patient care. So it's going to be something that we're monitoring closely.

[00:33:08] Griffin Jones:
So a lot of the programs in the, the players in the clinic decision support and workflow category are still in pilot. Mode. What are they working on specifically? Is this that is using smart technology so that when supplies are low, they're automatically reordered. Is it that when a certain prognosis is given that, or a certain diagnosis or prognosis, it automatically schedules tasks, tell us about what specifically is happening.

[00:33:37] Dr. David Sable:
Yeah, it really depends on clinic to clinic. And one of the things we can't ignore too, is there's still the incredible amount of consolidation going on with larger and larger networks being formed and there they've got to homogenize their processes before they can, they can, before they can even think about adding something new in terms of the technology and what they're doing on the ground.

A lot of it depends on. what specific problem they're solving. Some of this, like doing order procurement or deciding which test to order relative to a single diagnosis, these are not exactly sophisticated decision, decision treats. Some of the things that we've been presented with are, yeah, I used to say it's kind of like making the Instructions, instructions to the babysitter.

It's like the baby wakes up and cries. If it's this time, you do one thing. It's not a heck of a lot of choices, not a lot of decision points. And applying, quote unquote, AI to it is, you know, kind of glorifying a little. And really, the benefits that we're going to see are in the much more complex decision making, where you just have a tremendous amount of data that's all being aggregated that needs to be looked at.

We've been making connections that we haven't been able to make yet. We've got 40 years of great human artificial intelligence based on the work that the embryologists and scientists have been doing in the lab before. They're just iterating and iterating and iterating slowly because that's what humans do.

If we're adding this extra layer on top of it, the greatest amount of benefit we're going to get are the toughest things to instill. And realistically, the more complex Problem you go after the more constituents you have to. Get behind it. When you run the lab, you've got to get the doctors behind, you've got to get the embryologists.

The scientific director needs to get each embryologist to sign off on it because, you know, you get one person in your workflow who wants to slow walk the implementation of a new system. And as, and where are we going to get the best information? We're going to get them from the largest clinics that do the same things, but they're also the ones that are consolidating most.

So it's a, you asked a perfectly good question. And here I am doing my best to dodge the answer because the reality of the IVF industry right now makes it a lot, it makes it kind of tough to get to that so what kind of thing where we say, oh yeah, we absolutely need this and we can define precisely what the benefit is.

So we know how much we should be paying for it. Once we get to there, we're going to see really rapid adoption. Now, you see the, a lot of the entrepreneurs, the founders will come to us and say they'll approach a clinic. The clinic will say, all right, well, you got to make it effortless to do it. We don't want to pay for it.

And we're going to give you nothing for what you're going to do. The, the founders themselves want to go to the clinics and say, all right, we're going to do this for you. Here's what we want to charge you for, and we want access to all of your data, so we can advance what we're going to do moving down the line.

Those are not easy negotiations to have. So in some cases, they're really left at the, all right, so let's make a little micro step along the way. But that microstep is not particularly clinically meaningful because they're being asked to optimize something that's easy to optimize. Frankly, this could have been done by systems that don't have the AI name on them, but are really just some combination of arithmetic or math or basic computing.

So it's a kind of a multi tiered answer, uh, a long winded non answer to your very good question. 

[00:37:40] Griffin Jones:
Well, let's maybe get answers in a different category because even a general answer would be more than I've covered on the show before. I never have really delved into the category of hormonal stimulation management and the solutions that are coming in that category.

This is the fourth category that you have in your visual and so is Am I understanding it correctly by thinking of it, this is how AI is going to impact pharma and dosage and, and, and med protocols that talk to us about this category. 

[00:38:17] Dr. David Sable:
Let's, let's go to the do it yourself IVF cycle and let's, let's fast forward to when every, every one of these systems works perfectly.

So there the patient. Does her own diagnostics because there's a list online of all the things you can order from Amazon You need a lot of testing done very easily If you need some type of invasive test it can be done the way a colonoscopy is done You just make an appointment in a place that does it you never get to know the doctor gets it's done So you line up all your basic testing?

You have, you've disaggregated stimulation from the big box, big tent IVF program, and there are OBGYNs that do it, or maybe freestanding IVF stimulators that do it, run by whatever combination of medical professionals. They take the information that you've put together from your checklist of pre IVF testing.

It gets fed into the computer. The computer says, all right, here's the optimal. stimulation regimen. Frankly, there's not that many regimens. We, again, we have a version of that written out on a yellow legal pad as instructions to the babysitter now. So that stimulation starts, the patient gets her medication from lots of different ways of sending medication to someone.

And she's monitored the monitoring. We hope to move to the home. Urine testing instead of blood testing, ultrasound only when it's needed. We do over, over scan people now and maybe we'll invent a really good cost effective home ultrasound, kind of like putting a pro, you know, patient. Places the probe herself saves hours of going to the clinic each time data that's collected the hormonal levels Whether it's from urine or saliva or whatever and the images from the probe go to the cloud the cloud sends them to a Processing system that in a big data AI way Uses those inputs to make the decision as to what the medication should be changed to or kept the same and when the next monitoring should be.

Now, on the ground, having done thousands and thousands of IVF cycles over the years, personally, and as a field, we've done millions of them, we know that most of these decisions are pretty routine, so that the computer will do maybe 98 percent of them, and kick out the 1 or 2 percent that are outliers, and that will go to the reproductive endocrinologist, who may be in a consulting role.

We've talked to you, I don't... Griffin, we talked earlier about moving the reproductive endocrinologists from doing a couple hundred cycles a year to overseeing thousands of cycles a year. This will be part of that. So that the AI system has chosen the stimulation, the AI system does the monitoring, and in conjunction with the overseeing RE, decides when the trigger for retrieval should be.

At that point, the AI system can take a break for a couple days. We go to retrieval. The oocytes are retrieved. The AI system is part of the microscopy. It talks to the microscope, sees the eggs as they come out. If there's a need to rank the eggs to be fertilized, because there's very, very few sperm, Or, if we get smarter about oocyte culture, and maybe different eggs need to be treated differently depending on things that the AI system may be able to see that we can't, the AI system will kick in there, and now the AI system is working in concert with the embryologists.

So it helps us choose the eggs to fertilize if there's minimal sperm, or stratifies the type of handling of the oocytes themselves. And then the fertilization will occur. This is where, hopefully, we'll be in a system where the AI system is really good at choosing the sperm that should be, maybe based on some type of marker that it sees that we as humans can't, that correlates really, really well with the genetics of the sperm.

Something we can't tell now, like we look at a sperm, the way it swims, the way it looks now, many sperm. It's like trying to figure out what's in the trunk of the car by looking at the license plate. So here we've got the AI system can look inside the trunk of the sperm and know what's inside. So it tells us which sperm to use and, and for which eggs then mechanically.

Let's say we're doing ICSI, there is an optimal angle that the needle should be at. There's an optimal speed that the needle should go through the zone of pellucida. There's an interplay between the elasticity of the shell of the egg. And the speed button, the speed and the sharpness of the angle needle itself.

This is a Toyota assembly line type optimization. May make a big difference or may not make any difference at all, but as AI gets smarter and smarter and smarter and smarter, it's going to turn ICSI from a procedure that maybe hurts a certain percentage of the eggs, maybe doesn't hurt to one that doesn't hurt any of them.

Then we go to the development of the embryos and the culturing. Right now, it's sort of a one size fits all type thing, where the embryos are treated all alike. They may be all in their own little wells with a probe inside, monitors the vital signs of the embryo. How much fuel is this embryo eating?

What's the pace by which the cells divide? Maybe we should hit the gas a little bit or hit the brake a little bit on the specific embryos themselves. And then ultimately we'll reach a time when we need to do the choosing. So there's tons of things that a really great hardware software hybrid that measures everything in ways that we as humans can't.

And over time, if we implement systems that are efficient enough and, very important, it's cheap enough to gather these data, then it's going to start telling us things that we had no idea we were doing wrong. All of which, hopefully, will result in being able to do the procedure cheaper and better, getting better yields at every step, higher fertilization percentages, higher number of blasts, higher numbers of percentage that develop well because we change what we do during culturing, and better decisions.

So that'll result in higher pregnancy rates and cheaper implementation of the cycle itself. A real virtuous process. Problem is, there's so many things that we could work to optimize, that it's just to figure out which ones make a difference first. So what we've been doing is we've been choosing the stuff that's easiest to do.

Like, okay, we got 12 embryos in the dish. Let's train the system on the embryos and start matching up which ones get pregnant based on what they look. And so the solutions that are being find now may not be the ones that important, but there's the ones that in this early stage, I hesitate to say this embryonic stage of AI infertility.

It's sort of that really, really early auto assembly line in the 1920s. Let's say, okay, there are some things that we can just do easily. It may not make our outcome that much better, but let's just start checking them off. So, uh, that's, that's sort of where, where we are in terms of the, you know, what's being looked at now and where it can go.

[00:46:24] Griffin Jones:
How do these changes, particularly those in hormonal stimulation management, impact the pharmaceutical, the, the pharmaceutical manufacturers, the, the Drug volumes other than just ordering more of them because it ostensibly if you have a I doing the monitoring and they are doing 98 percent of what the area I used to and they can scale that volume that there be an increase in the use of pharmaceuticals, but are there other input?

Other implications that these changes will have on the pharmaceutical side? 

[00:47:02] Dr. David Sable:
Well, AI and drug development is a huge thing now. And we're trying to figure out what these same huge data crunchers, these mechanistic huge data crunchers, can tell drug developers about how molecules should be different. There may be a modification to the drug itself, or the drug's delivery itself.

Or, something that it picks up in the dynamics of when a dose changes, that can take that information, take it back to the drug developers, and they could do something different to their drugs to make them more effective. Or it may turn out that a combination of hormones that's been used rarely makes a big difference and We can package the drugs in a way that takes advantage of that.

So it's certainly, you're right, the most likely is great, cheaper, easier IVF, more drugs. Terrific for the pharmaceutical industry. But in so far as they're always looking for better versions of what they do or novel versions. All these data that we collect may make connections that just never occurred to us or never dawned on us.

We'll go back not to the way the cycle is managed, but to the way the drugs themselves are designed or manufactured, which would be enormous for the pharmaceutical companies. 

[00:48:26] Griffin Jones:
Are there specific features that we might expect to see because it like other than press release around Esri time that we're not that close to oral FSH, is there features that we should expect to see?

We have a An article that will probably come out before well before this episode airs just about some things happening in the pipeline, but what's of note Abigail? 

[00:48:52] Abigail Sirus:
Yeah, but maybe before we get to that topic, I just wanted to mention that there are there's a couple companies that are focused on the hormone stimulation and one.

Release paper last year that showed that they could potentially decrease the amount of drugs that were needed for a cycle. So you could maybe decrease the cost. And we know the average IVF cycle is expensive and out of reach for, for most patients today. So being able to decrease that cost could be a part of it.

And then it would be that kind of cost decrease, which would be obviously less sales or fewer sales for the Pharmaco, would hopefully be offset by more cycles being able to be done over time as the industry expands. 

[00:49:30] Griffin Jones:
Are we starting to see any features that might be, that we might see in drug development in the next year or so, or are any of them close enough to call?

[00:49:41] Abigail Sirus:
No. No. I think there are some exciting developments happening in drug development and IVF in general, but I haven't come across data to suggest that they were driven by any kind of age. 


[00:49:56] Griffin Jones:

Yeah. Okay. So let's, well, let's get into PGT because I have been in this field as a non clinician for nine years. And as a non clinician, it seems to me like the debate is still the same, Dr.

Gleicher's camp talking about PGT being overused and then other. Other folks saying that we might not be using PGT enough. Are we, is AI being used to break this stalemate yet? And if not, will and how it'd be. 

[00:50:33] Dr. David Sable:
Two areas. One is. You're right. AI at PGT has done too much and it's done not enough because we really haven't figured out who we should be doing it for.

That is a great AI challenge and we need a ton of data for the AI to tell us, to answer that question for us. So that's going to be, that is an ongoing issue. The other is making PGT better and the obvious thing there is using a mass data Processing AI system to help us figure out just to what extent we can do non invasive genetic assessment and other means of embryo assessment.

There are other things we can do without biopsy. It's, it's, it's got some encouraging data sets, but they're way too small to be anywhere near conclusive. AI should be able to answer both of those questions once the once enough data has been fed in. And once the AI here, really, particularly in non-invasive assessment, it's gotta be able to look at things that we don't.

So here we're doing a lot of mixing and matching of the data handling capabilities with things like new visualization tech. All these systems were based on light microscopy. And some rudimentary staining. And now they're based on more sequencing technology. So which also has its limitations. So we've got sequencing and we've got visual visualization of embryo characteristics.

So we let the AI systems digest all of that and tell them to tell us the stuff that we've missed. We've been probably been pretty good. about optimizing within the context of the limitations of the systems we have now. Then the AI systems are And you didn't notice the connection between this and that.

And if we start throwing all that stuff in, that's where the AI system is smarter than we are. And it's going to turn around and say, Okay, you can get all the information you want, the problems that you want to solve in terms of detecting implantability, ability to turn into a good, a good term pregnancy and genetics and disease prevention in ways that we're just not smart enough to do yet.

So the AI can do all that, but again, you're going to hate me for saying this, but we're way too early. 

[00:53:01] Griffin Jones:
For it to be clinically meaningful. I'm trying to salvage this with some, somebody that's, that's kicking butt. If I can, if I can think of an area where it might be happening in, in your other categories of your seven categories in other, you've got follicle, preterm birth, reproductive immunology, ovulation.

And is, is part of the reason that this is an other category is because that's where you have a lot of overlap. So in this category, you've got overlap with obstetrics and, and genetics and, and, and broader areas of women's health. And, and so are there things that are happening in this other category developments that are happening fast that we might expect to.

Be adopted in the fertility field fast because they are mature. They're in other areas and now they're starting to to take. on like wildfire in the fertility field. Is that happening at all in this other category? If not, tell me the damn reason why. And if, and if it is who, what's happening?

[00:54:02] Abigail Sirus:
Let me give you, first of all, it's, it's unfortunate about that.

Not that exciting. This other category in terms of why. And broken out separately. It's just that in this area, there are, um, typically just one or two companies working on each of these segments. So that's why I just kind of grouped them together just because they're not necessarily haven't reached the point where they need to be broken out on their own, like embryo assessment, which has the most.

On that topic. So that's not an exciting answer. However, what I will say is that there is a company working on, they're adding AI to a, that they're using a software system to look at follicle development, which is already being deployed in clinics. So I would actually put them at kind of a mature pilot stage.

So that is exciting. And they are, they are maybe farther along than I am. Uh, majority of other names on this, on this image specifically. So hopefully that's, that satiates you, Griffin, and we salvage it a little bit there. 

[00:54:58] Griffin Jones:

What are they doing? 

[00:55:01] Abigail Sirus:
They have a software solution that you could use while you're looking at follicles, obviously.

And they are using AI on top of it to help identify development and to make the process faster and more efficient along the way. 

[00:55:16] Dr. David Sable:
Griffin, for the part two of your question, the why has been so few things that reached the kind of clinical so what stage and in the other areas, women's health is really difficult that way, both fertility and women's health in general.

It goes back to the information we use medically. It used to be all pattern recognition, analog, it's like it's syndromes and yeah, diseases were defined globally or by organ. Now we're at a molecular and cellular level. The more molecular and cellular you are, the more usable data you can, you can plug into systems that will look at them digitally because the data is much more homogeneous.

Women's health is back with psychiatry and neurology in areas that are really difficult. to get reproducible quantitative data. You can't just stick a probe into the uterus during early pregnancy. And figure out what's going on and measure lots of stuff. And that filters all through women's health. Even the diagnoses we have.

A lot of them have the word syndrome attached to them. Syndrome is almost like the Latin word for we have no idea what's really going on. Just a bunch of observations and we make logical things that we try to do. But we really don't know. So, that shows up in a lot of the stuff that we try to develop.

Like, and we've talked earlier about in IVF, there's only so many things we know how to measure. There's a few hormone levels, there's a number of eggs, number of sperm, percent fertilization, percent to blast, genetics of the embryo, and whether you get pregnant or not. Now, when you try to engineer the system, and you try to intervene at different points along the way, whether it's selecting an embryo, whether it's...

The angle by which your ixy needle enters the egg, which eggs that you choose to fertilize and when, the change that you make on the sixth day of stimulation, you try to figure out what difference does that make in getting pregnant down the line, each of these things gets drowned by what we call confounders.

All these other things that are happening in an uncontrolled way along the cycle and it makes observing, making meaningful observations very, very difficult. And the data scientists tell me, it's like, yeah, you just need a data set big enough. to plot all that noise. Problem is in IVF, the data set is maximally, if we had every cycle in the world being analyzed maximally, still only 3 million, which isn't a lot.

If it's something in pregnancy, and you're trying to figure out, well, what should we be doing in that 11th week of pregnancy to avoid the chances you're going to have hypertensive disease in pregnancy in the third trimester, you're going to deliver early or something of that sort. Well, you've got... 130 million pregnancies worldwide, but you've got nine months of observations to lose the validity of that one intervention.

And women's health is just, it's one of the reasons, in addition to women being kind of discriminated against and women not being put into clinical trials, it's one of the reasons that the amount of investment into women's health. has been relatively low because it's damn hard to do. So when you asked before, say, well, why, why haven't we gotten there?

It's, I have no doubt we will get there and we need. Technology to take us that next, next mile on the backs of all the really great human artificial intelligence that we put together. But that's why in 2023, when I first saw my first AI company in IVF in 2018, we're still in that kind of early, it's like, it's like when the genome was elucidated around the turn of the century and three or four years later.

Who cares? Like what's come out of it? Well, now it's incredible what's come out of it, but we're in that kind of foundation building stage, like spring training, if you will, where we haven't gotten to the so what test and maybe two years from now, five years from now, seven years from now, it's going to be dizzying, all the benefits we're getting from all this, it's kind of frustrating and I can see from your point of view, you want some headline stuff for us, we want to be able to give it to you, but it's kind of all, it's all inside baseball.

[00:59:45] Griffin Jones:
But it still is a fitting sequel, even though I prepared for the wrong sequel to our previous conversation. It still is a successful sequel because the last time when we were discussing the four guiding principles for democratizing IVF, I wanted to know why, what, what's blocking us from this inflection point that we're Almost at you mentioned you started investing in AI in this space in 2018 2023 and the next two to seven years are going to be dizzying, similar to how no one had heard of chat GPT.

And then that became dizzying all overnight is barely hyperbole in terms of its. Release and recognition to the public. And I, I, I can see that we are so close to that point. I needed to go in specifically into each of these categories and find out what's preventing us from being that at that inflection point that we're almost certainly going to be at very soon.

And we did that today in detail. And I want to give each of you the opportunity to conclude of what we might expect to see as we march toward this inflection point in the next year or so.

[01:00:54] Abigail Sirus:
I think that it feels public sentiment talking about AI is at a fever pitch. It's almost a subsection of every news site you look at now, but we are still only in the early days.

And I know that that's frustrating, but for me personally, thinking about the future of IVF enabled by AI, We have one in six people are struggling with infertility. Only 2 percent of that population is actually getting the care they need. We have a massive... Massive match between supply and demand. And it's only going to be technology like AI and bringing those into the clinic, optimizing existing processes, making it more efficient that we can close to serving the number of patients who are struggling with this.

And so I'm really excited to see more of these, these proof of concepts emerge as pilots and these pilots start to gain traction. And we start to see results that are actually making an impact, whether it's on the time to baby, the cost to baby. or on cycle outcomes as well. So still early days, but definitely lots to be excited.

[01:02:00] Dr. David Sable:
Griffin, what I'm most excited about is AI is going to catalyze the trying of new delivery methods, cutting up the cycle and disaggregating the cycle away from the big box, enormous lab, trying to find ways to pull in that 90 percent of people that aren't even in the arena yet that want to be, whether it's by Cost efficiencies or just setting up prototype programs that treat people for much less expensively and discover things that result in operational efficiencies.

I think it's going to be a little ways until we start seeing specific techniques that result in. higher pregnancy rates, only because pregnancy rate, by the time you get to the pregnancy rate, again, the data of teasing out the influence of one thing. But I think that it's going to show up first in the ability to deliver IVF cycles of one type or another to a lot more people than we do now.

And I think that's in a way that just as exciting as getting higher pregnancy rates, which will virtuously happen faster. The more people we get into these systems. So, I think let's look for operational efficiencies, let's look for people opening clinics, whether it's people outside the field or whether it's the big networks saying, look, there's other ways to do this and there's lots more people we can help.

Let's start going after that as well. I think it's a great facilitator for lots of areas of one degree of separation, uh, from the pure tech part innovation. 

[01:03:39] Griffin Jones:
Abigail Sirus and David Sable, you're like the Star Wars or the Marvel franchises to my sequels in that we'll just keep making them forever and people will keep eating it up.

I look forward to having you both back on. 

[01:03:51] Dr. David Sable:
Looking forward to coming back. Thank you. 

[01:03:54] Sponsor:
This episode was brought to you by LEVY Health. Seeing more patients for a first consultation may actually decrease IVF revenue by 30 to 40%. To see why download the numbers for free at levy.health/conversion. That's levy.health/conversion

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.

Thank you for listening to Inside Reproductive Health.

202 Bootstrapping a fertility company. How Inside Reproductive Health has avoided taking outside money. Kim Abernethy interviews Griffin Jones


Tables are turned in this week’s podcast as guest Kim Abernethy, CCO of PC Alliance, interviews Griffin Jones about the origins of Inside Reproductive Health and his journey as a fertility entrepreneur.

Throughout the interview Griffin talks about:

  • How he built IRH without any outside funding (And if you should do the same)

  • The “Rising Stars” in the fertility field (And who he believes will be the big winners)

  • The complications of nailing product-market fit (And how doctor’s expect us to provide value)

  • What advice he would give to fertility entrepreneurs looking to make a name for themselves.


Kim Abernethy LinkedIn
PCA LLC
LinkedIn
Griffin Jones
LinkedIn

Transcript

[00:00:00] Griffin Jones:
Stop taking outside money. The learning curve is longer than is accommodating of having to return investment money, you can pile on tens of millions of dollars and they still don't have the product market fit to where it's scalable, reproducible, huge customer satisfaction and profitable by the end of that investment

Should fertility companies stop taking outside money. That's the theme we eventually get to in this conversation where I am not the interviewer But the interviewee. You might know Kim Abernethy. She's been the chief commercial officer for the PC Alliance for the last two years So she's still on the pharmaceutical slash pharmacy side of things, but she was with EMD Serrano for a very long time in a field where people sometimes jump around a lot and she's gotten to know many of you during that time.

Kim asked me why I chose the fertility field, how did I build my company with no investor money, no money from family and friends, and not even a commercial bank loan. She asked me about the direction of Inside Reproductive Health. How we're building a trade media company for everyone director level and above in the fertility field worldwide.

She asks me, which was more fun building an earlier version of my company or the version I'm building now. And I tell her. Oh, she asked me to name two interviews where I was totally caught by surprise. And even though I was totally caught by surprise by that question, two interviews that I've done did come to my mind.

And I tell you who both of those doctors were. She asked me to pick some rising stars of some of these companies that are growing and emerging in the fertility field and who I think are going to be the big winners. I am no fortune teller by any stretch of the imagination. But I name names. And as I promised, right after the interview, I thought of a couple more that I probably should have said, and I'm not going to say them now in the intro because I'll still think of more after this.

I'm sorry that I left you out. Keep kicking ass and I will be less likely to forget you next time. Finally, Kim asks me what advice I would give to fertility entrepreneurs. really trying to take their place in the field. And I wonder if the answer is to stop taking outside funding. I don't know, maybe I'm wrong and I'm not arguing it categorically, but I put forth a counter argument against taking outside funding.

Just bootstrap your damn business the old fashioned way. I tie it in to broader advice about how hard it is to provide value to fertility clinics and providers. How long and complicated it can be to nail product market fit in the fertility field. And how seriously doctors and others... Expect us to be able to provide value.

And of course, there's some fun, cute questions along the way. Thank you to Kim. She's a wonderful interviewer. As far as I know, this is the first time she's ever interviewed on a podcast. So if Kim, send her a LinkedIn message, send her an email, send her a text, tell her she did a great job as an interviewer and enjoy this episode where Kim Abernethy interviews me.

[00:03:04] Kimberly Abernethy:
I'm Kim Abernethy and today I will be interviewing our special guest Griffin Jones. It wouldn't be Fertility if we didn't mix things up, wouldn't you agree Griffin? 

[00:03:13] Griffin Jones:
I think so. This is the second time that I've been interviewed on my own show that it was four years ago that my friend Stephanie Linder did this and I was interested when you proposed the idea, hopefully I can make it interesting enough.

[00:03:29] Kimberly Abernethy:
Tell us, how does it feel to be in the seat of the interviewee after conducting so many interviews? 

[00:03:34] Griffin Jones:
I am hoping that it will be useful enough because I try to make the interviews useful to the audience who's fertility docs, execs, and I've gotten much better as I've gone along about making each interview more specific and I don't know if we'll go like an Oprah route today and we'll do like a Griffin human interest story.

You and I talked a little bit before we did this interview Or if we are able to tackle enough business to make it Transferable to the people listening. That's my pious. Hope that I can still do that even as a business owner in my type of business.  

[00:04:17] Kimberly Abernethy:
I think that it's always important when you are in your type of business to make sure that you never lose touch with the personal aspect of things.

So if we do go a little Oprah, I think your listeners will want to hear it. I've been talking to a lot of people since you and I originally spoke about doing this interview. And it's amazing to me how little most people know about you. 

[00:04:38] Griffin Jones:
What made you decide to want to do this? Because you proposed the idea to me, and I thought this is a cool person.

And that's sweet of her to think of me. What made you interested in doing this? In interviewing the host. 

[00:04:56] Kimberly Abernethy:
All right. So you're not supposed to be interviewing me, but I will answer this question for you because I do think it's interesting. I've been in the fertility space for 24 years and I remember when you started your business 10 years ago.

And it's actually leading into one of my questions for you. What on earth were you thinking when you had no fertility experience? You ran a media company, a social media company for three years. You'd worked in the media industry for nine years doing different sales executive roles. So what made you wake up one morning and decide I'm entering the fertility space and I'm going to be a subject matter expert in not only marketing, but the industry as a totality?

[00:05:38] Griffin Jones:
Do you ever see the movie Lone Survivor with Mark Wahlberg? I think it's, I think it's called Lone Survivor. It's about four army rangers, I believe, in Afghanistan and they are surrounded by Taliban and they're under fire and at some point they, they just have to jump off the cliff. It's not a good idea to jump off the cliff.

They just don't have any other option. I'm certainly not comparing myself to an army ranger. But from a career standpoint, I was at a point where it was like, I have to choose something. I was a D student growing up. I worked in radio ad sales, maybe as a result of that, I didn't learn anything in college.

I went to a state college that I would blow my nose with the degree that I got in. Communications and that found me in a 100 percent commission only sales job, which I got good enough at paid off my student loan real fast. I learned a little bit about the real world and talking to business owners and learning how to sell things, not just for myself, but for other people, for my clients.

So I got a bit of that experience over five years, but it was radio is 26. It was not. Something that was growing, like how the tech space is, and I could see the corporate ladder vanishing before me, and this is prior to the advent of remote work as we know it now, and there were very few advertising agencies in Buffalo.

There are zero fortune 500 companies headquartered in the city of Buffalo, where I'm from, and I knew that if I wanted to stay in my area that I had to. Sub specialized, or at least specialized, and so it was more about I, I knew that I had to find a niche and I had to go deep into the niche rather than I had some really bright idea.

The niche happened to be fertility because I started working with a fertility clinic in my area and and got some good results from them doing some really rudimentary organic social media and and got to know them a little bit and got to know a little bit about the field. But I was working with a number of different categories and because of the nature of when you're successful helping fertility clinics, they're successful helping patients.

That's pretty meaningful. And I talked to a number of patients that were very grateful that I was even trying to learn about what they're going through. And so I just said, okay, this one. It felt good and it made the business criteria of, it was high growth, it was recession resistant, and I knew that I needed to sub specialize.

[00:08:23] Kimberly Abernethy:
Alright, so you're working with a fertility clinic in Buffalo. You see some success, I'm guessing new patient visits are up, you're doing some social media, and you think... Recession proof, I get it feel good. People are getting through the door. There's a lot of surrounding areas in the Buffalo market that don't have a fertility clinic.

They have to drive to Buffalo to see a fertility specialist and you decide you're going to jump off the cliff. And you do, what do you do from that point, though? Because that's one customer in Buffalo. There's maybe four clinics in Rochester, maybe one or two at that time in Syracuse, maybe not. Like, how do you take that?

I'm jumping off the cliff. And being able to support yourself, specializing in marketing for fertility specialists who really weren't thinking about it 10 years 

[00:09:12] Griffin Jones:
I think I had already jumped off the cliff. I think jumping off the cliff came in 2012 when I quit my job in radio ad sales and then I went and started traveling here and there, went to Ireland for five weeks and later that year went to Japan for three weeks.

The things that I think a lot of people should do in their mid twenties. And I. Then moved into a studio apartment, the cheapest apartment I ever lived in, and lived like a pauper, and made the least money that I had made since I graduated college, and I moved to South America for a year and a half, and it was it.

It was while I was in South America that I started working with that fertility clinic in Buffalo, and that's what taught me Oh, I don't have to physically be in this person's area And so I knew that I could do that with anyone then and so before I started Before I even moved back. I started working with another clinic, which I think I can say is was Dr. John Fratarelli's practice in Hawaii. And so with two fertility clinic clients, I could say we served fertility clinics from New York to Hawaii. And that was in 2014, moved back to the U S in 2015 and just started cold calling. And so you asked, how did I support myself? I didn't, I made hardly any money in 2014 because I was living in South America.

I made, I don't know how much I made, like probably made 15 grand that year. And then probably something similar to the half a year that I moved back and then started. After that started really cranking and building the business. 

[00:10:48] Kimberly Abernethy:
So when you look back, so you're talking, 20, 2012, 2015, that era, like when did you decide, Oh my gosh, I'm going to make this work.

It's actually starting to pay the bills. And I think that this is going to be. successful. Do you remember when that moment 

[00:11:04] Griffin Jones:
There are two different questions because the question of I'm going to commit to this and make it stick versus this is paying the bill didn't happen at the same time. The sticking came first.

And it was like, I'm going to pick something and I'm just going to keep showing up and I'm just going to keep trying to learn more. And every time somebody says no, I'll try to ask somebody else. And and that's, that was in 2015. That was before I even moved back to the U. S. And when I came back to the U.

S., I moved back at midnight on a Saturday morning, and I started cold calling at 7 a. m. on a Monday, and I didn't stop. And so I didn't start making money until, by 2017, I could afford to Move out back out of my parents. How I moved back. I moved back into my parents house for a year when I was 30, Kim.

And that was in 2015. And then by 2016, it's okay, I'm making enough to where I can go out, get my own place in 2017. Okay, I'm making maybe what. What somebody would make in Buffalo, my age, just very middle of the road. And then 2018, 2019 is when I started. It's okay, this is, this feels pretty cool.

And at least I'm on the right track. And but I would say it was gradual. I don't think. The first was just a commitment I have to commit to this and trust that there will be a competence and the benefits that come from competence later. But the fruitfulness was a lot more of a long process.

[00:12:31] Kimberly Abernethy:
Okay. When you look back over the years. And you Monday morning quarterback yourself, what would you have done differently? 

[00:12:39] Griffin Jones:
Everything. So it's it's how far back would you go? Would I go so far back to, do I get to go back to senior year of high school?

It's if I could go back to senior year of high school, then I would never have gone to college. And I would have just gone, I would have found any really good business owner. and just shadowed them. I would have done anything for them, just learned from them. I would have gotten their coffee. It would have mowed their lawn.

I would have worked for minimum wage or less and just learn from that. It's like can you go far that far back? And so if I can't go far that far back, then I just don't feel like it's every mistake that I made as bad as it was necessary to Achieve a higher level of proficiency in business.

This is a really hard game because there's so much involved. It's hard to provide value in the marketplace. And if you want to do it, you got to get good at a lot of really hard things and getting good at a lot of really hard things. The price to do so is often looking and feeling stupid. 

[00:13:45] Kimberly Abernethy:
Interesting.

We're talking a lot about jumping off the cliff. We're talking about fertility bridge, like how you got there, but let's take a step back and share the vision of fertility bridge. You decide you're going to focus on the fertility space. You have success with a couple clinics and doing some social media, maybe some marketing.

When do you take a step back and say, okay, this is going to be my company and here's a vision? I. I'm assuming that you didn't just keep jumping off the cliff and there must have been a business plan that you finally said, this is what I'm going to do to make this company. Successful or maybe not, and that would be great to hear too.

[00:14:25] Griffin Jones:
That's very kind of you to give me that much credit. I, it all came in phases, but the, I really believe in the quote, I don't know if Zig Ziglar said it first or one of those. guys that one of the Ra guys that said it, or if he was just quoting someone else, but he said, go as far as you can see, and then you'll be able to see further.

And there are lots of people in this country, in this world that can't see that far. And I'm probably somewhere in the middle of the road. We have a lot of people in the audience that could probably see pretty far because they're really talented. They had really talented parents. They came from A highly competitive affluent background and they could see far and they're kicking butt now and and they're gonna get even further.

And then there's lots of people in this country that don't even know how to become a manager. at McDonald's, and I was probably somewhere in the middle of that really long spectrum, but I could see at least, okay, I can see at least how to make a client services firm. I can at least see how to make a profitable client services firm, even if I don't know how to do all of it.

I could see how we can return enough value for our clients and get people on board. And so that really just, that's, that started as a foggy vision, perhaps in 2015, 2016, and then by, by the end of 2017, it's okay, we're starting to make process, we're really starting to scope now the 2018, 2019, really refining the sales process, 2020, really refining operations and delivery processes.

And it wasn't until the end of last year where. I wouldn't say the end, but maybe the middle of 2022, where the opportunity to build a media company. So instead of Inside Reproductive Health being just a little marketing channel for Fertility Bridge, my client services firm, Inside Reproductive Health being the bigger of the two brands, being the one that scales and being the part of the company that I'm really growing.

And that wasn't until. Mid 2022 where all of the stars sort of line, it's this is exactly how it happens and the time is now. 

[00:16:46] Kimberly Abernethy:
So that's interesting. So you start as a client services firm inside for reproductive health, right? Inside fertility is a smaller portion of it. It's always co existed, would you say with your larger client services?

And now what you're saying is it's morphing and flipping and inside reproductive health is becoming. the larger of the two entities within FertilityBridge, fair? 

[00:17:14] Griffin Jones:
Yeah, it's, yeah, exactly. Now it is becoming the bigger of the two and in a couple years it will be much larger and it, they didn't always coexist.

I, so it was 2014 when I first started working with my first FertilityClinic client and then 2015 when I moved back to the U. S. and started building a firm. It wasn't until Early 2019, January of 2019, that Inside Reproductive Health launched. First is a weekly podcast, and then it wasn't until the very end of 22 where the Weekly News Digest launched one news article, originally sourced, written by a journalist about the business dealings of the fertility field that also comes out weekly.

And that was, so they didn't always co exist, but when it started, it was just let me get some more exposure for myself, sell some more client services, and then the audience grew way more than than just people that were ever going to buy. marketing services for me. And that ended up being the business that more people were asking for anyway.

[00:18:21] Kimberly Abernethy:
So what do you think caused this morphosis to happen? What do you think was a trigger that grew inside? Reproductive health and inside fertility at a greater pace, like what is it about that portion of the business that's attracting people? 

[00:18:37] Griffin Jones:
There's this, there's the part of where it was attracting people and then why it did.

The part of why it's attracting people is because there are a lot of business developments happening in the fertility field right now and generally no one reports on it. And so if you're an executive, you just want to be you want to be keeping up with what's happening. If you're a doctor, you want some kind of business education.

So too for nursing managers and practice managers. And so there was that void both on business education for those folks there. clinical or have scientific backgrounds. And then for those folks that have sales and business backgrounds, they want to be kept abreast of what's going on. The fertility field worldwide is estimated at a 23 billion industry, I think somewhere around there.

And there's no trade media outlet for it right now. If we were in another 23 billion industry, it's. It's very likely that there would be an established trade media outlet. And and so I could see the business model and I was at a point in my company, in my life where I thought this is, Definitely the more scalable of the routes that I could take.

Which business do you enjoy more? I enjoy building inside reproductive health more. And the reason is because I love being at the tippy top in the visionary seat. And I can't say that's the only seat in the accountability chart that I occupy. I still do occupy multiple seats. But I see myself getting out of them.

More easily and I am getting out of them more quickly. Part of the reason why I really decided to double down on this route was because in building a client services from there was no way that I was ever going to be able to take myself totally out of it. It was profitable. I never had a problem with money in those later years.

It was that it could never be something that totally functioned without me. It's too small of a niche to have both a consultancy and an implementation agency to serve, 400 fertility clinics in the U. S. Maybe 500 if you're counting all the U. S. And Canada. And whereas Inside Reproductive Health as a media company is...

Scalable. The more content I create about India, the bigger my Indian audience grows, and then the more valuable we are to genetics testing companies and pharma companies and other fertility solutions that sell in those parts of the world. And... And I can make more replicable systems more easily, and I can bring on people faster because they don't need so specialized of a background as when you're building consultancy.

If you're building a consultancy for fertility clinics, It's a really steep learning curve that is very hard to educate people on in the consultancy. They have to come with a lot of that institutional knowledge. And that's a very small pool to draw from. Whereas on the media side, on the marketing side, there's just a lot more people.

I can bring them, I can train them, I can put them in smaller seats, and we can do so a lot more rapidly. So I say Inside Reproductive Health that I enjoy more because I really feel like the business owner, Kim, like I'm working on the business, of course, I still am doing some working in the business, but I'm doing more working on than I was before, and I'm seeing the working in, I'm getting out of that faster.

With all of that said, I still do consulting for fertility clinics, and I love it because it keeps the saw sharp. I love talking with practice owners. I can give them so much value in a little hour, and I don't need to stick them on a recurring monthly engagement. They don't need to pay me thousands of dollars every single month where I've got to struggle so hard to keep up with the value that is required of that.

Instead, I can make it worth it my time because my hourly rate is high. I can give them a lot in that little bit of time. I can help them that other partners and help them put things into place without getting so sucked in implementation and without them having to be. They engaged in a big long term commitment and and they get a ton of value from it.

And I really enjoy it. 

[00:23:11] Kimberly Abernethy:
Where do you see Fertility Bridge going in the next five years? 

[00:23:15] Griffin Jones:
It's funny that you'd say Fertility Bridge and not Inside Reproductive Health because Fertility Bridge really is now the strategy consultancy and the content studio for the advertisers on Inside Reproductive Health.

So I'll start with Inside Reproductive Health because where I see that going is we have an audience of a couple thousand unique listeners and readers over the course of the year, and I think that can probably get up to 30, 40, 000. I'm just looking at. How many people are director level and above in the fertility field, whether it's industry side, clinic, lab, scientific, worldwide, I suspect it's around between 30 and so I think that we can get a majority of those people as members of our audience, even if they're not the people that read every week and day and listen every week and day that over the course of the year that.

They are part of the audience and right now, if you ask people, have you heard of Inside Reproductive Health? Some people will say, yeah, everybody has but that's not true because you'll then talk to the next group and they'll say, no, I've never heard of it. And my goal is for If you're talking to someone that's director level and above in the fertility field, almost anywhere in the world, and you ask them that question in five years, if they were to say, no, I've never heard of Inside Reproductive Health, you would look at them like, you've never heard of the Wall Street Journal?

You've never heard of the New York Times? It would be that ridiculous. Our goal is to grow Inside Reproductive Health. to that level of audience to build out the daily news to build out the news site, the level of frequency will be determined by how valuable it is being consumed. And then Fertility Bridge is now the strategy consultancy for the businesses that advertise through Inside Reproductive Health.

So when an advertiser is, wants to Sell to our audience when they want to get their message out there. We help them. We help them with the landing page We help them with the copy. We help them with linking those two things and linking that marketing effort to their sales team because We one we have the audience, but two we Have a lot of their behavioral data.

This is first party data. We can see what they're doing. We know what they're clicking on. We know what they're sharing. When a news article goes out, I can see what's really popular, what executives are sharing with their teams. And while we'll never share like, people's data, what we can say is we can strategize people on tailoring their message and putting their message into a place where it's gonna be something that.

Their decision makers who are really hard to reach are reached and want to consume the message very 


[00:26:07] Kimberly Abernethy:
nice So a lot of times when people are like you Very driven you're out there. You're Jumping off the cliff, I'm just going to use that analogy again. Do you ever take time to realize that you're everywhere?

And by that I mean you're interviewing CEOs, you're providing marketing support for centers across the country I've seen you emceeing at every conference or event that I'm going to. I feel like you're somewhere on stage. Do you ever take time to sit back and look at the impact that you're making on fertility Where you are today in this journey, 

[00:26:49] Griffin Jones: not really.

I'm just not wired to do that. So much. I think the nature of hungry people very often is to just think about what's next. And and sometimes I can do that to a fault. Sometimes you'll have team members that they want to celebrate something big. And all you can think about is This we always have to keep moving forward, and so I think sometimes to a fault. And then also I just also want to be humble is that I'm so grateful when people do say that. I also know that any one individual's impact will it's just a drop in the bucket in the grand scheme of things. And and I'm happy to be a part of it, but and hopefully I've, I make some really big connections happen and meaningful impacts over the course of my career, but yeah, and hopefully I'll live a long life, but at the end of it, people will probably mourn me for a couple of days, and then if that, and then they'll get back to their lives, like we all do, like when I, and so there's that part of it and and then it's yeah.

Being everywhere, I still just don't feel like we're everywhere yet. I feel like I'm, this is just a straw poll, but I'm thinking that maybe 20 to 30 percent of the field knows what inside reproductive health is and, I want it to be over 90. Okay. 

[00:28:14] Kimberly Abernethy:
Fair enough. So some fun questions.

You've worked with clinics across the country, out of curiosity, which clinic do you feel your services had the greatest impact on and 

[00:28:23] Griffin Jones:
why? Thank I don't want to put anyone on the, any one of the clinics on the spot. You don't need to name the clinic. I think, for among one of our first clinics one of our very first was, is still in some ways the most fun.

And that was when I was only doing organic social media, because it was like, I'm not doing anything. From a clinical perspective, but I get to benefit from the elation that's coming from their patient base because I'm just helping them get stuff on social media and then they're talking about how much they love the doctors and they're talking about, they're connecting with each other and then you see people a year after that say it.

And That are posting their baby picture. And they're like, we came in because we saw something on Instagram or Facebook. And so that's a, that was a ton of fun. There's also been a couple of times where you have clinics that are, they're just really good people. And they're in a position where they've started to lose some patients and you're like, I can help with this.

I know how to do this. And and. And those are, those have been really fun and then there's been some really big clinics that we've worked with and it's maybe they're so big that our impact is less memorable over the course of what their whole trajectory will be because we're just a small piece of it, but you do some like really awesome videos.

client that we had. I won't say who it was, but everyone knows them. And they already had a great brand. They had a really good patient acquisition system and they're just missing like some really important creative pieces that we did for them. And I remember when we watched their videos for the first time, we all screened it together on zoom and they watched from the, from their houses and.

It was like at nighttime. It was after work hours. It was like 9 p. m. My wife came and sat down with me and their kids were watching with them and they're crying. And I know it wasn't one answer, but there's been some really cool things over the years.  

[00:30:38] Kimberly Abernethy:
Now think about some of the interviews you've had and hopefully you can say this one, but which one surprised you the most when you were interviewing someone and what caused you to be so surprised?

[00:30:49] Griffin Jones:
Oh, gosh, this is putting me on the spot. I can think of two examples. One was with Dr. Amy Avazadeh and I was interviewing her about why does she have this gigantic patient acquisition funnel, like her social media presence, her brand. And she's just one practitioner in a small practice in the Bay Area that, and I kept asking her like do you want to grow?

Is it, do you want to, are you trying to get a bunch more docs under you? And she's no, really just want it to be me and have my own small operation. I'm like then why the heck do you have this whole big funnel? I couldn't figure it out. And it wasn't until afterwards that I realized, I don't remember if she told me or someone else told me, or I.

A lightbulb went off like in the detective movie, and they're just walking through the supermarket and they finally figure out who the murderer is that I was like, Oh, it's because she just does self pay patients. And yeah, so she's drawing from a much larger group. And that's something that I've always talked about in branding is that the bigger brand that you have, the more leverage you have, the more choices you have.

At different points of channel conflict, you can opt not to if you're getting a short end of the stick from insurance companies or cash pay. Pay, or excuse me. Yeah, employer carve out companies. You can choose to serve a segment of the marketplace if you have a big enough brand and a big enough presence.

And so that was something I didn't realize until afterwards. And so I felt like a dummy listening to that first interview. So I brought her back on to talk about that specific topic. Same thing with Dr. Rui Jelani had her on, we were talking about her patient acquisition funnel, and I knew that it was a really good presence that she has, and she's very good at getting new patients and moving them through the funnel.

But I never stopped to ask her like, how many is that bringing? And then find out afterwards, she did 1300 retrievals last year. I was like, okay. And then I brought it, it was like three weeks later, I brought her back on. So those were two interviews where I was like I, you want to be prepared as a host and sometimes you end up discovering a topic that you hadn't originally even set out to cover.

[00:33:05] Kimberly Abernethy:
Do you still get nervous when you interview people? 

[00:33:07] Griffin Jones:
Not really. 

[00:33:08] Kimberly Abernethy:
Thought I'd ask. 2022, you got engaged, you're married. What's going on with the Jones family today?

[00:33:16] Griffin Jones:
Maybe by the time this episode airs, baby Jones will be here. We don't know the sex of baby Jones yet, but we're excited either way and we're loving life in upstate New York and we're family oriented people.

We try to work a lot. We both work a lot and, we both exercise and then the rest of our time is spent maybe on a couple of the community interest things we have and with family, and we really try to kill anything in the middle. There's not too much Netflix or maybe a little bit here and there, I'm not I've never watched.

Breaking Bad or whatever's popular now. I don't know what it is. I haven't seen an episode. I don't care. And I don't play video games. And I don't go out to happy hour during the week. And I don't do any summer kickball leagues. We're pretty myopic in that sense. 

[00:34:18] Kimberly Abernethy:
Don't worry, that baby will change all of that.

Trust me. Yeah. Do you consider yourself a Bills part of the Bills Mafia? 

[00:34:25] Griffin Jones:
It's too cheesy for me to say that. Also I think that I'm too much of a skeptic to be in the Bills Mafia. I'm a Buffalo Bills fan. I can't not be. It's not something that I really want to even be. I just am. And there was a number of years where it really made me so negative that I had stopped watching altogether and that's not something that someone in Bill's Mafia would do. In fact, I think you get whacked by Bill's Mafia if you do something like that. But I just don't like the blind faith and I was... Also, at a point in my life where, yeah, in my early 20s, it's fun to go to a tailgate and and get silly, but, by the time I was going in my late 20s, I would bring my little brother from the Big Brothers Big Sisters program because they would give us tickets and it'd be like December and raining and team would be getting pounded by Tom Brady and the Patriots and no chance of going to the playoffs and drunk dudes are like touching my little brother's hair.

It's Dude like almost like getting in fights to just like with drunk people and I'm like, I don't want any part of this. So the table stuff is funny. Like I do think it's funny. I do think that the mayor of Buffalo should do it only if they ever win the Superbowl, smash through a table like Bill's mafia does.

But I'm, yeah I'm a Bill's fan, but I'm not as, as. True blue as those guys 

[00:35:57] Kimberly Abernethy:
completely understand. So when you started your company, there were not a lot of disruptors in the industry. Progeny wasn't even around maybe 2016 they were just starting. So you were on the forefront with some of these new ventures thinking about all of the PE firms, the new disruptors in the market.

What advice would you give to those embarking on a new adventure today? New venture, not a venture, maybe both. 

[00:36:24] Griffin Jones:
I wonder if the advice that I would get, that I would give, is stop taking outside money. I don't know if that's good advice, but it seems to me like the learning curve is longer than... Is accommodating of having to return investment money.

And that sounds counterintuitive, even as I'm saying it, because that's the whole point of outside money is to extend your runway, to even have a runway. If you're bootstrapping, you might have zero runway, but I, it. It seems to me like no matter how much outside money people have, at least in some cases, this probably isn't universally true, but at least in some cases, you can pile on tens of millions of dollars and they still don't have the product market fit to where it's scalable, reproducible, huge customer satisfaction, and profitable by the end of that investment.

And I wonder if people won't have to take that advice because the... era of free money will be coming to an end. It seems like it's coming to an end. I, we'll see if it actually does or not, but that probably dovetails into broader advice where I think it takes a long time. to figure out how to provide value to fertility providers.

Part of the reason why that is, is that their workflow is so complicated and so variant from one another that it's difficult to come up with scalable solutions. And many of the solutions entering The marketplace now say that's exactly what we intend to solve. We know how busy fertility doctors are.

We know how variant their workflow is, and we seek to make it less complicated. My good friend, Dr. Eduardo Harriton gave me a book called the innovators dilemma, and it talks about. Why incumbents have such a hard time either innovating or adapting to new technology. And it's because they're already in a position, they have delivery and fulfillment commitments, and then anything else, even if it ultimately will streamline operations in the future, is still in the moment.

An extremely cumbersome task to undertake, and so I think it takes a long time to figure it out and and I'm grateful that I could do that at a pace where the only person that was really suffering was me, and if a client was suffering in engagement, It's client services. I can make it up to them. I can, I, we phased our engagements that if this phase wasn't as good as the last one, then I would just stop chart.

I would just make it easy for them to leave us and then provide value, continue to provide some value to them until they felt good about the whole thing again. And and I could do that because I, Okay. Didn't have this huge outside financial obligation to fulfill. I've never taken a penny from investors, never from family or friends.

The only loan I ever took was three P during COVID. And that ended up being a grant that wasn't alone. So I've never borrowed. And so I, I don't necessarily recommend that everybody do it. That way, to a tee, but I think that one, if people take less money, outsider money, they may be in a position to where they can go longer, which is the real advice of spend that long time iterating, reiterating of finding how how to provide value to fertility clinics because a friend of mine an REI who I won't name, but after this, I'll ask him if I can say his name in the future.

He said, it feels like we've got our pie and everybody's coming in and they're just taking a piece of our pie and our pie is getting smaller. And what that means is that. People, at least at a perception level, are taking more than they're contributing in value. And perception, to some degree, is reality.

And I want to provide value I've done it, and I've not done it, and I taste the difference, and I hate when I don't do it, and I love when I do it, and I can't sleep when I don't do it, and I feel like a thousand bucks when I do it. And, so my advice is, maybe try to be independent, but certainly...

Go the long haul of figuring out this value game.

[00:41:07] Kimberly Abernethy:
I think you said something really interesting in all of that When I used to work for a manufacturer we'd have new people come in all the time and they would say no fertility is exactly like dermatology or oncology or Cardiology and we would say no, it's not wait to get involved in it.

You will learn that it's not the same and When you talked about that patient journey in a clinic, like every patient's journey is different, and the way that every clinic responds to that patient's journey is different. So there's no two patients whose journey is identical, even if they're going to the same clinic, or to the same doctor, or they repeat a cycle at the same clinic with the same physician.

It's just never the same because there's so many variables that occur every single Cycle. It's, it was, it's really interesting that it's, there's a lot of things that people are trying to fix, but the challenge is that there's no one plug that's going to fix what's broken at any one time. It's, it was just interesting. 

[00:42:09] Griffin Jones:
It could be the case that. These companies finally do, especially these artificial intelligence companies, that they are able to account for all of these variables at such a scale because of AI, that they are able to streamline a lot more. And it's just so much ease that those human variables will still exist, but the AI will be able to account for them so rapidly and you will really be able to fulfill what.

Dr. Sable talks about of instead of doing 200, 000 cycles, we're doing 2 million and then 3 and then 4. It very well can be the case. I think we also would have thought that would have happened by now. So I think in 2002 we would have, Oh, 2003 they'll have this figured out. So it is, it's hard for me to picture not having it out, figured it out by 2045.

But. Here we are now. 

[00:43:00] Kimberly Abernethy:
Yeah. I'm with you. Okay. One last question. A lot of new companies in the market today, a lot of product services entering in. What are your top three? 

[00:43:09] Griffin Jones:
Oh, some people are going to be grumpy that I didn't put them on this list. And you did tell me you were going to ask me this question.

So I probably should have thought a little bit harder, but I'll just go with what I've been, what I've. I've thought about it at a cursory level. One is PsychoClarity, and I'm not just saying that because they were one of our earliest advertisers on Inside Reproductive Health, but I just like the way a company like that is set up right now.

I just I like how Dr. Schnoor is a true end user. I like that so far. He's doing this on his own. He's got a really small team. I've met two of them and they're sharp and they're committed and they're young. It's man, if you can keep that, I'm not a, I'm not a soothsayer. So I don't know if he'll keep that made by the time this happens.

I don't look into the future, but right now it's like I, I, it seems to me like that set up well because of not having that investor obligations yet, maybe, maybe that's what they're out for and trying to raise, I can't speculate on their behalf, but at least what they've done at the bootstrap level so far.

And really trying to figure this out of like, how do we help, how do we get this implemented? Like we have the value, we can sell it, but how do we get it implemented to where it's easy for clinics to do? And then it just becomes part of what they're doing. I think they're working on that in earnest without saying anything proprietary.

And then I think who else? Could be a big player. I still feel like my friends that engaged MD have a lot more up their sleeves and You're just plugging it's every but I can develop advertisers there. That's it's also who I know but I tend to bet on jockeys, even if I only know the horse somewhat, and the horse, most people I know really like Engaged MD most of my clients that have overlapped with Engaged MD really like it, and so I feel comfortable enough speaking on the horse, but just knowing Jeff and Taylor, I feel like these guys are there for me.

Or the true blue, then who would be three, and so many people are going to be pissed off that I didn't give them a compliment, I think. that I'm not totally sure who would be third, but I think if some people came together, like if Dr. Rui Jelani and Dr. Eduardo Harriton did a venture together, that it would probably be unstoppable.

And so there might be a couple of people like that. My friend, Dr. Dan, has a company called a future Fertility, not to be confused with future family and I don't know enough about the lab side to speak about future fertility, but that's another guy that I really believe in. And this is the Oscar speech that I never won and was never...

Prepared to deliver in terms of all the people that you forget. And of course, I'm gonna even though you told me you were gonna ask me this question, it's I'm gonna, when we hang up, I'm gonna be like, oh crap, should have said that person or that company. But that's who's, that's who's at the top of my head right now.

[00:46:27] Kimberly Abernethy:
Very nice. Anything you'd like to add before we conclude? 

[00:46:31] Griffin Jones:
I would like to say that I'm very grateful. I just listened to an episode that I did with my friend Stephanie Linder where she interviewed me four years ago, and that was how I concluded that episode, and I am really grateful. I've gotten to know a lot of people and when you have clients that invite you to their home and have dinner with their family and you have people that write You Handwritten thank you cards and and when you're in a session with somebody, a strategy consulting session and they're just lit up after that because they felt like they got a ton of value.

It lights me up and yeah, I didn't, I really felt like an outsider when I came in and I don't anymore and I'm grateful for it. 

[00:47:20] Kimberly Abernethy:
Very nice. Now what's the due date so we can all put it on our calendars? 

[00:47:24] Griffin Jones:
It's in August. And it's mid August. And so we'll see if this episode might even come out after that.

I don't do project management. That's part of working in the business that I don't do. And so I have no idea when this episode will air, but maybe baby Jones will already be here. 

[00:47:40] Kimberly Abernethy:
Very nice. Thank you, Griffin, for joining today. And it was my pleasure to interview you.


[00:47:44] Griffin Jones:
No, Kim, it was my pleasure to be interviewed by you.

You have a knack for it and I could tell when when I first met you that, that curiosity was, it's a humbling feeling. Something I can learn from because sometimes I have it and sometimes I want to hear myself be the smartest guy in the room. And I think you have less of the latter, more of the former that genuine curiosity.

And I appreciate you wanting to apply some of it to me.

[00:48:13]Announcer:
Thank you for listening to Inside Reproductive Health.

201 Deconstructing the role of Chief Medical Officer with Dr. Neel Shah MD

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.


Dr. Neel Shah, Chief Medical Officer of Maven Clinic, deconstructs what it means to be a CMO and gives an inside look into his roles and responsibilities regarding reproducibility with clinical outcomes.

Listen in as Dr. Shah discusses:

  • The indoor vs outdoor cat methodologies of CMO (90% are outdoor cats)

  • Why resolving Medicaid constraints means putting your fees at risk for clinical outcomes

  • His system for qualifying providers (And how he gets product and protocol feedback from them)

  • Some examples of what he believes to be disinformation within the fertility space

  • The overlap between business and clinical operations (and where the CMO role converges and diverges with the CEO and Medical Director)


Maven Clinic:
Website
LinkedIn
Twitter
Instagram

Dr. Neel Shah
LinkedIn
Twitter
Instagram

Transcript

Dr. Neel Shah  00:00
The way that I look at the Chief Medical Officer job is that there's basically two kinds of chief medical officers. There's outdoor cats and indoor cats. The outdoor cats like sales for thought leadership, and the indoor cats are like product and operations.


Sponsor  00:14
This episode was brought to you by Embie. To see where your time is going, visit embieclinic.com/report. That's embieclinic.com/report. 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 guests appearance is not an endorsement of the advertiser.

Griffin Jones  00:54
Are you an indoor cat or an outdoor cat? That's not a phrase I was expecting to talk about in this interview. But it was a fun metaphor that I took from my guest, Dr. Neel Shah, Dr. Shah is the Chief Medical Officer of Maven clinic. According to this CrunchBase profile that I'm looking at right now that may or may not be accurate, they've raised over $290 million in funding. They're a digital health platform that works with health plans and employers to offer virtual services for women's and family health. So they're also in that employer coverage game, but I spend my time talking today with Dr. Shah about how the role is constructed. Dr. Shah says there are two kinds of Chief Medical Officer outdoor cats who are more figureheads of sales and thought leadership in indoor cats who form products and operations, etc. He thinks 90% of CMOs are outdoor cats, where he was charged with reproducibility of medical outcomes. Dr. Shah talks about the economic constraints of Medicaid and how resolving those constraints means putting your fees at risk for clinical outcomes. So I asked him, what was his original mandate? What were some of the first things that he worked on to create reproducibility for those clinical outcomes. He talks about what he did to reduce the need for C sections. Dr. Shah shares which positions are his direct reports, he talks about where the chief medical officer and the Medical Director roles converge and diverge, where the CEO and ce o roles converge and diverge with that. And the chief medical officer, if you listen to this show, you know that I'm not convinced that there's a complete separation between clinical and business operations. I simply don't believe that there is I don't want to speak for him. But Dr. Shah seems to agree with me that there's a great overlapping area of the Venn diagram. And he talks about what that is specifically, he talks about his system for qualifying providers in getting product and protocol feedback back from them. And he gives a couple of examples of what he views as disinformation in the fertility space that I hadn't heard about yet, so I'm gonna go look them up. While I do that you enjoy this conversation with Dr. Neel Shah, Dr. Shah. Neel, welcome to the Inside reproductive health podcast.

Dr. Neel Shah  02:50
Thank you, Griffin. Thanks for having me.

Griffin Jones  02:51
I want to have you on because you're the chief medical officer of a very large organization. We have chief medical officers of varying size organizations listening, but I imagine we also have some folks that see that in their career path. And I've never spent an episode breaking down structurally what that looks like. I want to go through that with you today, what the duties look like what the corresponding roles look like. But perhaps we'll just start with Maven clinic as a large organization. I've read headlines where you've all raised a lot of money and you're growing fast. And how did you become the Chief Medical Officer for Maven clinic.

Dr. Neel Shah  03:35
It was a combination of the midlife crisis and Pandemic onwy. I think I spent the last decade most of it as a professor of obstetrics gynecology and reproductive biology at Harvard Medical School. And so actually, fertility was relatively far flung from my primary interest other than the fact that I did women's health, but I was one of the people who helped uncover the maternal mortality crisis in the United States and some of the underlying racial inequities and had been following Maven for pretty much the whole time since Kate Ryder founded the company back in 2014. And we Kate Knight, who's the founder and CEO had corresponded, you know, as a professor, you get to have hot, hot takes and just sort of pontificate. So she emailed me, I'd email her back. And then, honestly, I remember being pretty skeptical, not of Kate, or Maven, but just as digital health as a whole. I mean, there's a lot of hype in digital health, you also can't deliver a baby through a screen or do an egg retrieval through screen. So it's just kind of confused, you know, obstetricians are pretty tactile. But then in 2018, Mavin, started to increasingly convert from being a direct to consumer business to being a b2b employer benefit. In fact, there's a really good Harvard Business School case study. We're almost a canonical example now of how to do that conversion. And I remember when Maven signed up Bank of America as an enterprise client, and I was like Bank of America knows what they're doing. They've actuaries so it's probably valuable to them. Sorry to pay much more attention. Ultimately, I joined the Scientific Advisory Board of Maven. It was actually the first for profit board I joined. Because as an academic, you try to be pure, you know, and neutral and objective not have any, you know, profit driven interests. But this was a company that was doing really innovative things. So that's where I started. And then when Kate was looking for Chief Medical Officer, my plan was to help her go find one. And I was like, Hey, what is the Chief Medical Officer kind of like you're asking me now. And it turns out, there's many kinds Griffin, if you've met one chief medical officer, you've only met one chief medical officer, they're all different. So we converged on what the roll would mean for Maven. And then the more we talked about it, the more I felt like that's something that I wanted to do. So I was like, Hey, how about me? And here we are,

Griffin Jones  05:44
I want to talk about how that role converge. I do want to dig in a little bit more to your skepticism of digital health, because this is one means of you vetting, not just the company that you ended up going to work for. But the whole space that you ended up going into what were you skeptical about? Specifically? What are you no longer skeptical about? Either because you your skepticisms? were unfounded in that regard or something changed? And what skepticisms Do you still hold on to?

Dr. Neel Shah  06:14
That's a great set of questions. I'm skeptical that there's such thing as a pop up fertility clinic, that's any good, I'm still skeptical of that. I don't think that you can create a fertility clinic overnight. I think that there's a lot that needs to go into ensuring quality for people who are building their families. But I guess that relates to how I thought about the transition. My mentor is Atul Gawande, who is a New Yorker staff writer and a surgeon and innovator. And he had famously left his academic role just like I did to join Haven, which was the JP Morgan Chase, Berkshire Hathaway, Amazon, health care startup that lived for a couple of years, and then didn't, but he gave me a lot of really, really good advice about that. His own skepticism and what led him to do it. And what he told me to do was to be intentional about, you know, the hardest thing for me and joining a startup, honestly, was not the leap of faith on the company, at the end of the day, it was myself of identity, because it's an academic, your job is to be an honest broker of information. And you know, now when the CDC wants comment on, you know, new numbers that come out, I'm not the person they go to, because, you know, I'm at a startup, I'm no longer an academic. But what he told me was to be intentional about what I leave behind in the academic world, what I bring with me, and what I newly adopt and kind of make room for, and what I left behind was my objectivity when it comes to, you know, profit. But what I brought with me was my commitment to scientific evidence, I think that digital health has as much potential to improve people's well being as drugs and devices, but it's not regulated by the FDA. So there isn't the same standard of rigor to proving that things actually work. But when I came to me, but actually brought my whole Harvard research team with me, and that was a big part of how we formulated the role to

Griffin Jones  08:06
Let's talk about formulating the role. Did it start off as Kate asking you to help find the person in the same way that when people are like, do you know anybody that would babysit my kids this weekend? Like, well, you, they're just politely asking if they'll do the babysitting was? How much of that was at play?

Dr. Neel Shah  08:26
Yeah, that's a good question. I don't I think it was genuine, can you help me find someone because I mean, I've been pretty fixed in place, like, you know, like a decade into being a professor. It's pretty cushy, you know. And I think that was actually part of my own personal motivation, as I was a little bit too comfortable at a time where Honestly, I'd been kind of radicalized against the status quo. I mean, the pandemic for me, in 2020, there was a moment it's rare in life, that you have a cinematic moment that totally changes your worldview, but I was afford deployed physician, and there are pregnant people that were calling me. And there were no beds in the hospital. And if you weren't sick enough, I couldn't make room for you. And I've profoundly remember there was a woman who called me who had shortness of breath, she was pregnant, she was frightened. And I told her, she wasn't sick enough to come into the hospital yet, and she should stay at home and self isolate. And she was like, I can't because I live with my young children and with my parents. And it was very clear to me in that moment, that health is not produced in the four walls of my hospital. It's produced in people's homes and their communities and the workplaces. So, you know, I was already kind of thinking in that direction. But I think when Kate asked me, you know, she honestly just wanted to know who is out there that would be credible. And we really did have a conversation about what the role was that evolved. But, you know, the way that I look at the Chief Medical Officer job is that there's basically two kinds of chief medical officers. There's outdoor cats and indoor cats. The outdoor cats like sales for a thought leadership, and the indoor cats are like, product and operations and I came to the company with a public profile. And so I expected to be involved in our growth. But I didn't want to be the spirit animal Maven clinic, I wanted to make sure that I had a role in building the things that we were going to do, so that I could represent them and really believe in them.

Griffin Jones  10:14
So the indoor cats our product, and operations in the outdoor cats are What did you say sales and business development?

Dr. Neel Shah  10:20
Yeah, the some BD, but usually just like thought leadership, you know, that kind of thing. Which, like, that's, that's important, too. But I would say like 90% of CMOs are more outdoor cats, and about 10% of them are focused internally on building the things that they're trying to sell. And, you know, it's not necessarily a criticism, I think that, you know, it's very clear with a CEO as some of the CFOs, I think, chief medical officers have space to design roles that makes sense for their company and their phase of business. But we were in a phase of our growth, where it made sense for me to have the remit that I have today, which is, you know, I'm responsible for designing our care model for delivering it and for proving that it works, which, for me, was sort of the ideal job. And I think that combined with the opportunity, you know, the the momentum of the company, but also just a window of opportunity in what I see as a movement, to try and improve the well being of people who are trying to build their families in America at this time. Like, I couldn't say no to that.

Griffin Jones  11:23
How much did Kate have in mind really specifically detailed before you started contributing to what the role would become? What did she come to you with it with what she viewed she needed at that time? Specifically,

Dr. Neel Shah  11:39
I think this is almost emblematic of our working relationship to the present, I think, you know, she can't always has a point of view, and a high level vision. And then, you know, and brings the perspective of both the business leader and a woman who's had multiple pregnancies while building Maven out. And I bring, you know, I'm the nerdy Doctor alongside that. So like, I was like, Okay, well, you know, we're a technology company, and a healthcare company. And those two things are sometimes intention, you know, and I had a point of view on that. And we sort of worked through like, for example, you know, the canonical product leader, their source of truth is always the end user. And if healthcare had more of that, it would be a lot better. Also, very few folks in the technology business have ever heard of the evidence base that we're discussing at the future IVF clinic, you know, like they're at BDM, epidemiology and product management are like worlds apart. And so oftentimes the job of the chief medical officers together the two together,

Griffin Jones  12:42
So talk to me about how you started to actually delineate the role and what it would become what did that process look like? Was it you starting to think of certain areas that you might be responsible for? Was it specific duties? How did you start to map it out?

Dr. Neel Shah  13:00
Well, honestly, the commercial impetus was that Mavin was increasingly successful as an employer benefit. At that time, we had just started to contract and develop formal relationships with a lot of the national health plans. And we were seeing a growth opportunity into Medicaid and fully insured. So I wrote a whole textbook on value based care, actually, and didn't understand until I came to Maven, how a health plan has multiple product lines, they have a product line that is kind of like their cash cow, where they're just doing administrative services for self insured employers. And this may be obvious to a lot of your listeners, but I didn't realize that, you know, they think about that business really differently than their fully insured business and their Medicaid business where they're taking a lot of risk. And so, you know, the willingness to pay of a Medicaid plan is lower than a fortune 50 company. And the only way to make the unit economics work is to put your fees at risk for clinical outcomes. And, you know, you're not really putting your fees at risk if your outcomes are reproducible, but the only way to do that is to have scientific rigor, the purpose of science is reproducibility. So I didn't come in as a business operator, but I understood science really well. And that was the focus of my role. It's like how do we do that? You know, how do we build the almost like Toyota precision reliability into our care model so that we can actually go and put our fees at risk substantially for both fertility and maternity

Griffin Jones  14:36
You brought your team with you to do that. Did you start working on this process and bring your team over little by little was this was you bringing your team contingent upon you taking the role? How did that work?

Dr. Neel Shah  14:49
No, I mean, yeah, it was more little by little, I mean, I made the jump first and with a lot of humility about how to build inside of a hypergrowth FISI Baxter Now, you know, the way I think about it in the public sector, there's sort of this classic project management triangle where you have time, scope and budget. And if somebody gives you two of those things that sort of fixes the third, you know, and in the public sector, I just squeezed resources out of stones, but you have a minute to solve a generational problem. You know, in this world, you have access to liquidity, you have, you know, revenue streams, but you've got to turn it into shareholder value in like two seconds, you know, and so there are different constraints. And so I came in with a lot of humility about how one does that well, and the team in place was masterful at moving fast. In fact, it's a company value. But yeah, there were opportunities to bring in more clinical expertise around me. And so yeah, it was bit by bit. And also, you know, when you're moving from, I think we three or 4x in size, so you just got to hire quickly. So you hire people that you know, are great, you know,

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Griffin Jones  17:08
In order to be able to have a model that works you have to be put your fees at risk for clinical outcomes. In order to do that you have to have reproducibility. What was your mandate? In the beginning? What was the first thing or set of things that you were to work on that needed to become reproducible?

Dr. Neel Shah  17:28
That's a great question. So my initial attention was on people who are already pregnant. And it's it's since shifted, not shifted, but it's been balanced out with people who are not yet pregnant, where you know, honestly, Griffin, fertility is like the total Wild West. So we should get into, you know how we're starting to think about being honest brokers, they're in a sea of disinformation. But on the maternity side, that was where I had my real depth of expertise. And it was trying to consistently help populations, decrease the section rates, decrease the number of babies going to the NICU, improve mental health outcomes, and avoid emergency department use. And we built a whole ROI model around that. And then we built a number of programs to address specific conditions that people have. So you know, Maven isn't a condition based company were really a phase of life based company. And the chassis of the product that was already in place was we're very good at engaging people digitally, who, you know, they're not in a waiting room that can put their phone down at any moment. So you've got to be you earn the opportunity to make people healthy, if you can engage them all that already existed. And we were really good at sort of learning about the context of people's lives. So my job was just like, Okay, once you can engage them digitally, and you can connect them to a provider within 30 minutes anytime a day. How do you wrap that around a person to demonstrably make them healthier? That was the job?

Griffin Jones  18:54
What did you do to either reduce NICU time or to reduce C sections? What were some of the measures that came from that?

Dr. Neel Shah  19:02
Yeah, I mean, this was like, What made this a greatest job ever, right? It was like, Okay, I've got this awesome capability. And what do you do? So for example, how does an app decreased NICU utilization? answer is, it can't like an app isn't what's going to fix health care, what we did is we turned the device in people's hands into a portal that connected them with a human service on demand. So for example, if you're a Medicaid recipient in the Delta region of Arkansas, and you have gestational diabetes, you probably don't have a nutritionist anywhere close by. And you certainly don't have one on demand. But the difference between good glycemic control and bad glycemic control is having someone who can look through your phone at your refrigerator and help you plan a meal in real time. Because changing your diet is very hard. But, you know, if you're not able to do it, you might be induced in labor at 34 weeks, and that's months in the NICU, if you do it, well, you can get all the way to term. So it's like one example. It also turns out, you know, only 5% of Americans who are priding come to see a mental health provider, you know, it's very supply constrained. And there's all kinds, there's all kinds of reasons to slip stigma. Whereas depending on the population, 30 to 40%, of our total membership, say that we help them manage depression or anxiety. And that's just about like, showing up for people at the right time in the right way, and then connecting them in a timely way to the right service.

Griffin Jones  20:31
And then how do you make these into protocols? So is that the role of a chief medical officer as well? So your job is to discover the reproducibility to see what interventions are working, then how do you build that into protocols that the rest of the organization executes?

Dr. Neel Shah  20:49
Yeah, that's a really good question, too. I mean, so the way that my org works, I have an innovation team, that's sort of like a clinical product team, we work alongside product to design these care models, we have a provider group, and that team's job is to scale the care and deliver it and then to qualify the providers to write the protocols to QA it to make sure that people are providing the care that we expect them to. And then there's a team that measures the outcomes. But I mean, yeah, I mean, honestly, when I first joined, Mavin was growing so quickly, there were 1000s of providers across 30 different specialties. So a big part of my job was to make sure we're qualifying people credentialing them in the right way. And then because our care model was also rapidly evolving, making sure that we were training and engaging them in the right way to

Griffin Jones  21:39
What roles are your direct reports.

Dr. Neel Shah  21:43
So we're startup, which is sort of like being in a garage band, sometimes you learn how to play all the different instruments. So right now, it's I've got a Vice President of Clinical innovation who oversees a clinical product team, I have a senior medical director who has the whole provider group. And we have a large as I mentioned, provider group, including people who are fully employed for mental health, obstetrics, pediatrics, and other highly, highly utilize specialties. So it's a big team. And then we have our clinical outcomes team, which is both the academic research team that I brought over from Harvard, and an economics team, it does all the actuarial calculations for a health plan.

Griffin Jones  22:18
So that's probably going to be a lot larger than many, or at least in different areas. I don't expect a lot of chief medical officers having an economics team, but maybe some will. And maybe that's the future of of that more will, that you said earlier, you may have talked about something that many of my audience already know, I don't know if they'll know that or not, they might know the next question that I'm going to ask you. But I want to ask it anyway. Because I don't know, where does the role of Medical Director and Chief Medical Officer converge and diverge as a suspect, it'll be something like you said before, if you've met one chief medical officer, you've met one chief medical officer, and I suspect that that relationship is unique to every to every role as well. But in your view, where where do those two roles converge and diverge?

Dr. Neel Shah  23:05
That's a really good question. Because, you know, I've hired a couple of medical directors along the way. And I think that there's actually more of a clear delineation, and even consistency in these roles, what I've observed, I'll tell you what I've observed, and then I'll tell you what we're doing at Maven, because you know, I did a lot of benchmarking. And it's, it's hard to hire medical directors, you want to find somebody who is grounded in scientific evidence, but also not totally dogmatic, such that they can think progressively about the difference between the alternative which is a brick and mortar healthcare system, such that it is and what the future might look like. But I would say what I observed in out there is a lot of medical directors are not full time. And there's advantages and disadvantages to that. I think, actually, there's advantages to practicing in the brick and mortar world. And, you know, I still see patients not very often for two half days a month in my clinic in Boston, and it keeps me grounded and honest. You know, like, if what we're building at Maven can't work for the people in front of me that I'm eyeball to eyeball with. That's sort of my litmus test for developing a good product. So I actually encourage medical directors to spend some amount of time I think a lot of them are pure outdoor cats. And we have a mix of both at Maven, we have people to help on our commercial team. And we have people who are just embedded with our product team, particularly on the fertility side where there's a lot of building to do. I think one of the differences though, in my opinion, is that the CMO should really be, you know, an executive, somebody who can help run the company and drive it forward. And typically, I think for a startup, it would make sense to have a CMO at the point where you're, like in that hyper growth phase of the business.

Griffin Jones  24:57
Want to Talk about what driving it forward looks like. But in this case of a medical directors, is there a distinction between medical directors that maybe work for a company, whether it's a new tech platform versus working for like a group of clinics? Because if it's a group of clinics, I don't think the medical directors are typically part time. And I think they usually are also seeing patients. So is there a distinction in what type of company it is?

Dr. Neel Shah  25:24
I think that there might be Yeah, I mean, typically, management of physicians or clinicians is a little bit different from managing, like other kinds of business operators. You know, I mean, clinicians should have KPIs, but they generally have not heard of them. You know, and, really, in any setting, clinicians, generally speaking, are a little bit more self sufficient. They need performance management, they need accountability. But it's, it's just different, because part of the value of having a physician in particular is that they are able to use their discretion within certain boundaries. So I think there are differences, I mean, in let's say, a big IVF clinic network, probably the medical director would be responsible for like a region, right, and then their primary role is to ensure quality. Because there's not necessarily a product to be developed, right or there, there, there may not be there's a very clear revenue model, so not doing a lot of BD, or they're not doing a lot of commercial work.

Griffin Jones  26:29
Should the KPIs be coming from the medical director? Or should they be coming from the chief medical officer? If it's both, then where does the distinction lie between which KPIs should be coming from where?

Dr. Neel Shah  26:43
I mean, I think it depends on the company, the organization, the face of business, but I would imagine that it's the executive team that setting the objectives for the business. Right, and usually KPIs for a forward deployed clinician should be a combination of clinical quality related KPIs and, you know, efficiency KPIs, for example, or even just service level KPIs. Right, like we expect our clinicians to be responsive, show up on time finish, you know, things like that, like, you've got to monitor all that you can't assume it. But typically speaking, it'd be the job of the medical director to execute on those to enforce them to make sure they're actually happening.

Griffin Jones  27:24
Whereas it's the job of the chief medical officer to be an executive and drive the organization forward. So where does the CMOS role converge in diverge with that of the CEO or the CEO? Oh, if if the CMO was supposed to drive the organization forward, but that's really the that as a globally, that's the CEOs job, and then CEO is executing in a lot of different levels. So how does this the Chief Marketing Officers role in driving the organization forward look, and then how does that converge and diverge with other executive roles?

Dr. Neel Shah  28:02
Well, you said chief marketing officer,

Griffin Jones  28:05

Which is I'm sorry, I know, I misspoke.

Dr. Neel Shah  28:06
It's funny, because I can't even tell you how many times I've met chief marketing officers were like, I'm the CMO. I'm like, Cool. I'm the CMO, too. And then you have a conversation for 45 minutes. And like, nobody knows who the person is talking about. And they're like, Ah, okay, got it. That's a good question. You know, I mean, I think CEOs also have very different REMAX right, and really different roles, depending on the organization and how they partner with the CEO. But I would say, what's unique to the CMO is often they're like the scientific or even the moral voice of the company, particularly in spaces like reproductive health, where there's a lot of underlying injustice and challenge and things like that. So they have, you know, they're aspects of the role where they're your job is to sometimes be the keel sometimes be the kind of grounded scientific voice. But I would say it depends at our company, the way that I see the identity of my org, which is not just about the person, right. And so the org that they run, is that we're the glue between product growth and operations, all of which you hope are tightly tethered together, but may not otherwise always be the case, right? You want to make sure that product is building, what growth is selling, and that the ops team is operationalizing within the company. So the clinical team and even the way that I've organized my team is that there's a arm of my team that's directly partnering with product, a team that's directly partnering with ops and a team that's directly partnering with growth.

Griffin Jones  29:35
Talk more about how your team's interface so in some cases, you're you're developing protocols, you're developing reproducibility and other people are executing on what's currently in place. How do how do your teams interface with each other while you're working on something new. We're improving something that exists and is already being deployed at a big scale.

Dr. Neel Shah  29:59
That's it Question? Well, I think, and these are, these are all really good questions, and they're so deep in the weeds that you're not getting a canned response on anything, right? They're just like, you know, I don't have like a schematic diagram, because it's so dependent on the use case. But I'd say generally speaking, there's a team that's like delivering the services, right, like day to day, like, literally like 1000s and 1000s of visits per week appointment. And then underneath that, there's a team that's QA it, which means like, they look at every single interaction with a member or patient that's less than a four out of five out of 10. They go through all of the comments that we get back as free responses, and then they audit the medical records themselves. They do random sample audits. So that's happening in the background all the time. Right. And there's a there's a dimension of improvement, that's just QA, which is like, isn't the right service quality? Is it clinically appropriate? You know, are there product related things that are getting in the way, then there's okay, we're going to stand up a new program around conception, because we've decided that among a fertility population, we think that we can help a lot of people conceive naturally. And we think anybody who should should be able to conceive naturally, we should support them to do that. So we actually have to build a more robust program. So that, you know, for example, if what they actually need is a $5, thyroid medication, we can identify that need and get it to them. So that team will spin up that program. They'll pilot it with a limited set of clinicians, they'll demonstrate that it works, they'll learn a ton about it, we'll model out, like how to scale it up. And then we'll deploy it at scale. And then the sort of QA team will sort of take over from there.

Griffin Jones  31:52
You have mentioned a couple of times how important it was for you to be an indoor cat meaning to have influence over the product itself, the operations, as opposed to an outdoor cat, one that might just be there for the figurehead of sales and thought leaders. Yeah,

Dr. Neel Shah  32:08
I mean, I like being outside. I just didn't want to only be an outdoor cat, you know, you're outside today.

Griffin Jones  32:12
There's this there's a little bit of,

Dr. Neel Shah  32:14
Yeah, exactly. Yeah, towards the tribe. Meeting, that was great. That was a lot of fun. But, you know,

Griffin Jones  32:20
So but you want to have a role in development for you what were specific, can you think of what the deal breakers were specifically, in other words, if I don't have control over x, then I'm not an indoor cat, if I don't have ability to work on these areas, or hire these people, or whatever it might be as specifically as you can, what were deal breakers for you, that would have meant I'm not an indoor cat.

Dr. Neel Shah  32:45
Maybe rather than deal breakers, I would like kind of frame it as what are the pillars of my role? And I think it's really important to think about that with a lot of intention. Because at a startup, everything about the company is continuously evolving, including like org structures, right? So, for example, actually, and until relatively recently, I oversaw a big part of our operational teams like the shift scheduling, workforce planning, you know, and then we brought out a great operational leader, and I gladly handed that off, I didn't feel like that was a pillar of being the CMO. Right? I think when I'm in the market, I want my counterpoints our clients, the chief medical officers of health plans, the benefits teams, you know, among the employers that we work with, I want them to be able to know that they can hold me accountable for the quality of services that we're delivering. So I need to control that. That's really important. How we qualify our providers, like is, I think the job of any cmo in any organization. The other thing is, you know, Kate and I are very aligned in one wanting to differentiate Maven. And hopefully this will be honestly less of a differentiator as digital health enters the Pruvit era, and more people are developing an evidence base, but, you know, I wanted to make sure that it was when I, when I, again, like look at a client, and tell them the evidence for how something works. I wanted to make sure that it met my standard, you know, because it's, it's very rare that things are totally black and white and either work or don't. Right. And so like, as a scientist, you're always hedging. But in the market, it was important to me to say, Okay, this is why we think this is a good product and why we think it will be capable of making your population healthier. Here's how we did the study. Here's how I think it translates to your population. So that was really important to me.

Griffin Jones  34:44
I want to ask you about the qualifying of providers and how you interact with them and feedback loop. But while we're on this topic of developing things with the CEO and the CEO, I've argued for some time that I don't see I don't see A clear cut separation from what people might call business operations versus clinical operations. And that I think that there are things when people say, Oh, we we don't make clinical decisions, we leave that to the doctors. It's what you do. Because you might, you might choose what software they're using, or you might choose what vendors they're able to access or a couple other things. And there's some overlap. And I think even when people say that in good faith, in my view, they don't fully understand that these things are not perfectly surgically removable from one another. And so in your view, what what is where is the separation between clinical apps and business apps? Where it's like, okay, okay, you get to say this. But when it comes to this, this is, this is my area.

Dr. Neel Shah  35:51
Okay. Kate is the CEO. So she's, she's, you know, there's very, very few things where I wouldn't defer to her. But I think the way that I would answer that, first of all, it's a really good question. And it's one that we've thought about a lot internally, too, because there's not there's definitely gray between the two. What made sense for us, for example, is we've got this big, wonky, complicated provider network, one of the one of the wackiest math problems in the world is how do you connect a person anywhere in the world anytime a day, to the right provider within 30 minutes, wonky math problem. Network ops can have that we and we have we have input into it, especially when it comes to the booking flow and the logic for how the matching works. And that's where that gray is where the collaboration is so important. But yeah, I mean, ensuring that our providers are paid on time, doing the projections around what we think our capacity needs are going to be in a seasonal business, it's really tied to benefits, like all that stuff, very happy for that to live with the expertise that it should with a great operational leader. And then the the clinical piece of it, a lot of companies actually have a kind of dyadic relationship between the two parts, right, such that, and you need to separate KPIs so that there's clear lines of accountability, I really believe in single points of accountability. But yeah, when it comes to the standard for clinical quality, how we determine clinical appropriateness, how we credential a provider, how we write the protocols for which medications we can prescribe, and how, like that very clearly lives on the clinical side. So I think it's a Venn diagram, I actually think it's fairly easy to figure out what's on the two sides of the Venn diagram. The hard part is like that middle part, right? I think so too. And it's not even defining what goes in the middle. Because that can be pretty clear to it's like, to your point, like how you actually operationalize that. So for us, you know, it's how we actually define a clinical need and put into the booking flow is right at the center, and our product, if that Venn diagram, it's a very, very close working relationship and with product as well.

Griffin Jones  38:04
So how do you met that's in that in that specific example? How do you manage it? You know, it's close? It's right in the middle of the Venn diagram, how do you manage it?

Dr. Neel Shah  38:12
Yeah. So like, basically, to do it really well, you need a couple of different inputs, you need user research, which comes from product products, job to make sure their KPIs or like make sure we're engaging people in the right way at the right time. You also need to retrospectively like, look at, you know, your notes. So we looked at like 1000s, and 1000s, of clinical notes, and we continue to do that ongoing basis. And we're like, what are people coming to us for? How do we put it into categories? That makes sense clinically, right? And then, you know, the ops team is like, Okay, well, based on our network constraints, you know, and the requirements were being given like, this is how we think we can set that up. This is how many clinicians in this service line we have to recruit, it's their job to model that out. So when you get down into the details, it kind of actually pulls up pretty cleanly,

Griffin Jones  39:01
To talk to me about qualifying providers, or perhaps even more the feedback loop that exists between you and provider. So you you're working on protocols, you're working on scalable processes for the company, how do you get feedback from them? And how does it? How does it get down to them? How does it get back to you?

Dr. Neel Shah  39:24
Good question. So we are in the fortunate position of getting to be selective about the providers we bring on, first of all, so we've got a pretty rigorous recruiting process that I think is the first step of qualifying. Then before they can practice on our platform. They have to be credentialed. So we have to verify their identity, we have to make sure they've got the licenses that they say that they have. We look at all their dealt malpractice history and review it with the committee in detail. And then once they're qualified to be on the platform, they get scorecards every month that are quantitative that show whether they've met the service level or not. are minutes like setting their availability 30 days in advance showing up on time, things like that, that they're meeting the right member experience metrics. So we look at a star rating after every appointment. And then we do a review of their records. And we check for clinical appropriateness. So they get that every month as feedback. And if they're below benchmark, they get a conversation, depending on where they land or more. In addition to that, we make sure that we have a service line structure with clinical leads over each one. So the communication is bilateral, we're getting product feedback from them all the time, we're taking care of an increasingly diverse population. So it's not just product feedback, sometimes it's about the populations we're serving, we're learning about what their needs are, for example, we relatively recently stood up a menopause service, and came out of the gates with a strategy to make sure we're getting people HRT that needed it. And we very quickly learned that there's six other ways we can help people resolve their menopausal symptoms that don't involve HRT. And so we had to adapt our clinical protocols to be able to prescribe gabapentin, or to bring on board physical therapists for people who have incontinence related issues that, you know, we didn't realize we're going to come in that way. So anyway, I think on a principles standpoint, it is very important to make sure that it's truly bilateral. And that, you know, there's sort of two ways of designing a complex care model. One is to draw a schematic diagram and hand it to people to deliver it. The other way is to put your best people in front of it and actually learn what they're doing, and then scale it up. And Maven is honestly doing much more of a ladder than the former.

Griffin Jones  41:40
Do you have people that try to go outside of that communication framework, like someone that's got your phone number, or they're hitting you up on LinkedIn, or, you know, you have the clear systems for them to give you product feedback, but they're like, I'm gonna text, Neel. Anyway, I want to text. Yeah,

Dr. Neel Shah  41:56
Totally. I do want it to do that, honestly, yes. But my point of view is, if they're motivated enough to just reach out directly, I probably want to hear from them. So, you know, I'm used to having, you know, kind of most of my career, I was a public figure with a email address that everyone could see my Harvard page just came down a few months ago, you know, and so the entire world could email me whenever they wanted. And that was something I just sort of got used to. And there were things that were pretty wild, that would come into my inbox, and there were things that were really compelling. The same is true now. but to a lesser degree, I'd say the ratio is even more skewed towards things that are compelling. Like if a provider really wants to reach out to me, it's because they've really got something to say, I should probably hear it. So you know, my policy last two years is to try to be as successful as possible.

Griffin Jones  42:40
That's an interesting thought, how much of a pre work requisite Do you think it is for someone to have been a public figure before they decide to be a chief medical officer? And even if they haven't been one before? Are they basically agreeing to be one,

Dr. Neel Shah  43:00
I don't think it needs to be a prerequisite to be a quote, public figure. I mean, what, what that meant in my case, was that I was an academic, and I saw my job as being a teacher broadly, so to my students, but also to like industry and to, you know, other people out there and ended up really enriching my academic career. Because it turns out, there's a very diverse group of stakeholders that care about the well being of people building their families, you know, elected officials, people creating documentaries, and it was really compelling to me to be a part of that whole ecosystem. I think that aside, I do think it's the job of a CMO to be accessible. I think that's a hard requirement, in fact, so you know, my team knows that they can reach me 24/7 All the time. Part of that mentality, honestly, came from being an obstetrician. And, you know, that being kind of my disposition towards my patients anyway, but always on. Yeah, and I think part of a safety culture is that people have to not feel like their barriers to telling you something uncomfortable, you know, so I really encourage it, and it's, it's benefited us, right. You know, I think things happen when you're taking care of people at scale, recover 15 million lives. And so, you know, there are all kinds of things, cases of domestic violence things, cases of mental health acuity where there are people that are really in trouble, and we have to go the extra mile to figure out how to make it work for them. You know, we've taken care of Ukrainian refugees, where again, we had to we had to go like an extra couple of miles to make sure that person was getting what they needed. So I don't I don't mind being accessible.

Griffin Jones  44:37
That brings me back to your honest brokers comment that you made earlier in the conversation and you talked about a sea of disinformation around fertility. Tell me more about that.

Dr. Neel Shah  44:49
Well, people are anxious out there, Griffin. And I think, you know, in high school, a lot of people are told how easy it is to get pregnant. And then as soon as they get to be a certain age, maybe just post college, they're told their fertility is rapidly declining, and they're anxious. You know, and I think that we need to be thoughtful to make sure that we're not stoking that anxiety in order to sell things. And I see a lot of examples of that. This there's a difference between misinformation and disinformation. So misinformation is well intended, but it's not necessarily factually accurate. You know, and that's a lot of like, for example, what's on tick tock, where, actually the plurality of people today are getting their fertility information as a primary source, then there's disinformation, which is intentional, and it's for power, politics or profit. And in our space, that is, there's a Washington Post article yesterday about a prominent Rei in New York City who's Hocking, a supplement, a hormone supplement that's considered dangerous by the medical establishment but has a stake in the company. There was an article in New York Magazine this month about a company that is selling sperm freezing services, which could have a lot of value for some people, but it's doing it in a way that may make many men think that they have to do it in order to preserve their fertility. And so I just think that we've got to be careful about things like that.

Griffin Jones  46:31
How would you like to conclude with an audience of many people who might like to become chief medical officers someday, whether it's something that maybe I didn't ask you or something you'd like that, that you want to expand on further about the role of being a chief medical officer, the floor is yours.

Dr. Neel Shah  46:49
That's quite an opportunity, Griffin, I would say, you know, a title is this a title. But healthcare is messy. And there is no shortage of opportunity to jump in and try and make it better. I think that a lot of I assume a lot of chief medical officers or people who maybe today are working in roles as forward deployed clinicians. I'll tell you, Griffin, I have never seen the clinical workforce more demoralized than today. It's it's really profound. And I think it's sort of partially related to the pandemic, but partially related to a whole bunch of convert converging forces, and it's very clear that healthcare is in need of more leadership, and that we're better off when clinicians stepping on roles where they can work alongside business operators, technologists, and others to make things better.

Griffin Jones  47:41
Dr. Neel Shah of moving clinic Thank you very much for coming on the inside reproductive health podcast.

Dr. Neel Shah  47:48
You bet Griffin My pleasure.

Sponsor  47:50
This episode was brought to you by Embie. To discover where your time is going and how Embie can transform your clinics efficiency, visit us at embieclinic.com/report. That's embieclinic.com/report. 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 guests appearance is not an endorsement of the advertiser

200 The New Standard of Care for PGT-A and Preventing Catastrophic Gamete Swaps Featuring Dr. Peter Klatsky and Chelsea Leonard

DISCLAIMER: Today’s episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free, to you! Here, the Advertiser has editorial control. Feature sponsorship is not an endorsement, and does not necessarily reflect the views of Inside Reproductive Health.

Dr. Klatsky’s opinions are his own. He receives an honorarium from CooperSurgical for his time and expertise.


I always recommend parental DNA checking. Parental QC provides important protection for everyone, both patients and clinicians” – Dr. Peter Klatsky

Dr. Peter Klatsky, Co-Founder of Spring Fertility, provides harrowing examples of catastrophic close calls with gamete swaps, prevented only with the help of the latest advanced technology in PGT-A. Dr. Klatsky is joined by Chelsea Leonard, Clinical Science Specialist at CooperSurgical®, as she walks us through the current and future developments of PGT and its place in helping to maximize patient success while minimizing risk of irreversible harm.

Ms. Leonard and Dr. Klatsky dive into:

  • Developments in PGT-A testing that are critical to help avoid gamete swap

  • Real life examples of where and how PGT discovered DNA mismatches (Helping reduce legal and ethical liabilities)

  • The technology behind a new test called PGT-Complete (And its impact on the origin of aneuploidy)

  • AI’s place in PGT Testing (The new possibilities in scaling and learning)

Why tests like CooperSurgical’s PGT-Complete℠ Tests are necessary to help avoid gamete swapping catastrophes (And how they might protect those providing fertility treatment)


CooperSurgical
Dr. Peter Klatsky’s
LinkedIn
Chelsea Leonard’s
LinkedIn

Transcript

Dr. Peter Klatsky: [00:00:00]
100 percent of your patients, 100 percent of, I'll speak in the first person, 100 percent of my patients, whether they articulate it or not, have in the back of their head the day of their egg retrieval, don't mix up my eggs. I'm giving you my eggs, I'm giving you my sperm. How do I know that those are going to meet?

And it's a massive degree of trust that your patients send you and place in you. 

Sponsor:
This episode was made possible by our feature sponsor, CooperSurgical®. Download CooperSurgical’s brand new PGT-A Clinician's Reference Tool, an indispensable guide for clinicians like you to unlock the full potential of genomic treatment, by clicking the button below.

Announcer:
Today's episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free to you. Here, the advertiser has editorial control. Feature sponsorship is not an endorsement and does not necessarily reflect the views of Inside Reproductive Health. 

Dr. Klatsky 's opinions are his own. He receives an honorarium from CooperSurgical® for his time and expertise.

Griffin Jones:
You've got to hear this story because I think people are going to be talking about this at ASRM and other conferences. The whole time he's mentioning this example, I'm thinking it's a hypothetical. Come to find out, this was an incident that actually happened at gamete swap. But they caught it and that's at the root of my conversation today with Dr. Peter Klatsky, who, you know, as the co-founder of Spring Fertility, fast growing bi coastal group in New York and the Bay Area growing beyond. And Chelsea Leonard, she's a Clinical Science Specialist, a genetic counselor at CooperSurgical®, and she has some really keen insights. On the development of PGT-A developments that have implications that are critical for preventing some of the potential catastrophes like the one Dr. Klatsky talks about. We talk about because I was curious, why is PGT one of those things that you all really seem to care who you partner with for that other categories? You'll pick any random vendor, but it seems to be very important to you who you choose for PGT. So I want to know why that's the case.

Dr. Klatsky shares his view. We didn't cover an inflection point that happened around 2018 with PGT, particularly at Cooper. I asked Chelsea to reveal some of that. You can't get enough AI content, it seems, but we've never talked about how AI can be used for PGT, specifically PGT-A tests. Chelsea talks about the scale and the learning that the AI technology has that simply wasn't possible before.

And I asked her to let us under the hood a little bit about what's happening at Cooper. She talks about that technology and specifically the technology behind a test called PGT-Complete℠. That test, PGT-Complete℠, ends up becoming central in the conversation because we talk about how it impacts the origin of aneuploidy, how it changes the philosophy about discarding or keeping abnormally fertilized oocytes. [00:03:00] 

And we talk about how this test raises the standard of care and has almost an incalculable benefit to the clinic and to the business because of its critical use for parental quality control. That has to do with the story that Dr. Klatsky tells. Have you ever heard of someone deliberately bringing someone else's sperm to the fertility clinic?

I hadn't I thought Peter was talking about something hypothetical. But keep on listening in the conversation and you'll find this was something that actually happened at Spring Fertility that would have been awful for them and awful for everybody involved, but they caught it. And they talk about how tests like PGT-Complete℠ are necessary for having that level of quality assurance, ensuring parental quality control, preventing gamete swap catastrophes.

And yes, they are catastrophes and how they critically raise the standard of care and protect you as someone who provides fertility treatments or who pays for those who provide fertility treatment. You can look for Dr. Klatsky and Chelsea and certainly the rest of the Cooper team at their booth at ASRM. [00:04:00] 

Tell them they did a great job putting up with this host and they can tell you more about it and you can get more information by visiting Coopersurgical.com, by clicking on the page that's associated with this podcast episode that will take you right there. Enjoy this conversation with Dr. Peter Klatsky and Chelsea Leonard.

Ms. Leonard, Chelsea, welcome to the Inside Reproductive Health podcast. Dr. Klatsky, Peter, welcome back to the Inside Reproductive Health podcast. 


Chelsea Leonard:
Hi there. 

Dr. Peter Klatsky:
Thanks Griffin. It's a pleasure to be here. 

Griffin Jones:
I'm in a fun spot where I get to talk to a scientist and geneticist and an REI physician about PGT and I want to talk about what Cooper's got going on. I have a premise to start with Peter, which is as I talk to docs, I'm just always curious about why do they buy things? Why do they choose certain things? Why do they hire people? Why do they partner with certain people? And there are certain categories of goods and services that they really care about who they partner with and then other categories that they don't.

Sometimes it's like, that's just a commodity. We can use any vendor for that and then there are things that they really care about who they partner with and PGT-A is almost always one of those things that they really care about who they partner with for PGT-A. 

So the first question is, Is that correct? Is PGT-A in that camp of who they really care they partner with?

And if it is correct, why is that the case? 

Dr. Peter Klatsky:
Absolutely. It is one of the most important decisions we make in a lab, that also where we get media and what reagents we use. We, patients trust in us and we take that trust and that confidence very seriously. If we are going to send four cells, a sample of four cells, five cells out for analysis, that's on us later on.

If we are trying, if we get inaccurate results, if we get a high no call rate or if we are potentially throwing and discarding good embryos, potentially viable embryos, all of that will hit our patients, lower their success rates, and in turn, lower their confidence in us. So similarly, the ability to accurately call diagnosed embryos will make us appear better to our patients and ultimately deliver better results. So once we send that sample out, we are really relying on our partners to deliver accurate and complete results. 

Griffin Jones:
What makes a good partner then? Like, why does it matter who you choose? I get the gravity of PGT-A, but what's the difference in the type of people that could provide what makes someone really good at that. You feel trusting them with that. 

Dr. Peter Klatsky:
Well, I, first of all, I love that you said partner, right? Because whoever you're working with, with PGT, they have to be a trusted partner. It's not a vendor relationship because it's not a commodity. So a good partner is somebody who's going to, with regard to PGT, is get us the most accurate results first. [00:07:00]

And that means the lowest false positive rate. A low no call rate, but who's going to have a really high level of professional confidence and professional professionalism and accuracy and who's going to be your partner if something happens and I don't know any PGT companies that haven't experienced a case or cases where there's a high no call rate.

Or something happens in the amplification and we expect our partners to continue to be our partners and not try to throw the clinic under the bus. Oh, something happened in the lab versus something happened in the center. We want to investigate it. We want to explore it together and when you have a high priority situation like that, you really want their attention.

And occasionally there's cases where you need a result quicker or there's some specific peculiarities about it and you want a partner who's going to listen to your clinic's needs. And who's going to be responsive to those, both on individual case and as you grow together, I would also say that the field is so rapidly advancing. 

The technology that we're using today for PGT-A is not the same technology. It's not the same platform that we were using four years ago. And frankly, I would bet that within 12 to 18 months, the entire field is using a different platform, a whole different template procedure to analyze embryos. So, also in choosing that partner, you want to choose a long term partner who's going to have the resources to be at the bleeding edge of the field, but not advance that technology, not advance that science until it's been adequately tested, validated, so that your patients are getting accurate results. 

Griffin Jones:

I want to talk about that progress that's happened in the last four years. So it's not even the same platform that was used four or five years ago. Chelsea, our audience probably has a general idea of the history of PGT, you know, at a high level, but to what Peter's talking about.

The dramatic changes that have happened in the last four or five years. What are those and what's been happening at Cooper during that time? 

Chelsea Leonard:
Yeah, so I think it's always really incredible when we reflect on that history. Like you said, Griffin, even in the last couple of years, Cooper came out with what we call  PGTai®. 

AI standing for, of course, artificial intelligence and its first iteration in 2018, where we moved away from what we would consider totally subjective interpretation, where you have a human technician looking at a next generation sequencing profile, all of the blips along every chromosome, making decisions.

 [00:10:00] Is this noise? Is this aneuploidy? Somewhere in between mosaicism, what am I looking at? So removing that potential for error with that subjective component and really making calls based on big data with all of the embryos, thousands at this point where we have made a classification, seen an outcome and fed that back into the algorithm.

And as Dr. Klatsky said, really important that we have confidence in our calls and we're doing that based on big data. 

Griffin Jones: Tell us more about how the AI works. There's been a lot of hot topics on our show in the field recently. The episode that I did with Dr. Gada and Manish Chadwa about chat GPT was like a really popular episode.

And we talked about the different applications that AI might have a virtual Dr. Klatsky in a couple of years that people are seeing on there, but we didn't really talk about how AI specifically applied to PGT. So tell us about how AI is specifically being applied to PGT. [00:11:00] 

Chelsea Leonard:
Yeah, so I know that AI is a really hot topic and not all forms of AI, even in the context of PGT, are equal, right?

But I like to think about it when I'm explaining PGTai on an individual basis with clinicians is that human technician that would be making a call on an NGS profile, may have years of experience, be highly qualified and trained, but that person doesn't ever get to know the outcome of an embryo they classified, right?

They don't know what happened. Did that embryo implant then miscarry? Did it result in a healthy live birth? The difference with AI is we have a classification, an outcome, and all of that data can then be fed back into how we decide on and classify embryos with with future patients. It's not continuous learning, so we don't let it run wild, but it's important that that data is being fed back into how we make those future decisions and how the platform continues to improve.[00:12:00] 

Griffin Jones:
This might be elementary for a lot of the audience, but then how are human clinicians getting, how are they advancing their knowledge of what worked? Are they basically having to look at retrospective data in cohorts afterwards? And how does this compare to what the AI is doing? 

Chelsea Leonard:
Yeah. Are you talking about the subjective interpretation approach?

Griffin Jones:
So if the human clinician doesn't actually get to know, like, the, what happened afterwards, then how are they learning about what's working? Are they just looking at retrospective data in cohorts after where the machine is learning about specific cases and what happened in specific cases? 

Chelsea Leonard:
Yeah. So I, of course, Cooper doesn't use that approach at this point, but I would imagine to your, to your point, you know, there, I'm sure there are training sets and comparison between technicians to make sure they would make the same call on the same sample, but that's not big data, right. And we can't learn from nearly as many embryos nearly as quickly when we compare against AI. [00:13:00]

Griffin Jones:
So you've got big data happening for, at a scale that isn't been the case for when we were calling it PGD and PGS years ago. How did this start to unfold in 2018, 2019? What did that timeline look like at your company?

Chelsea Leonard:
Yeah, so I think one of the things that many of the listeners may recall if, if they were in the field in the last five, six years is Cooper Genomics formed from several legacy genomics companies and at that time, when all of those laboratories were coming together and standardizing protocols amongst themselves, it was realized that technicians at each laboratory, whether within a single location or across, were sometimes making different calls on, on the same or similar samples, right, using different approaches and so it was realized at that stage, as the labs were coming together, that this subjective interpretation component was really a problem because again, we want to have confidence in the call we're making for embryos. [00:14:00] 

So at that point, Cooper decided to invest in this AI approach that we've continued to iterate on and lots more to share about that in the coming discussion. 

Griffin Jones:
And Peter, can you tell us about like what's happening with case studies during this time that you talked about the emphasis of you have to be able to innovate but only after there's a substantial amount of evidence to support it.

Can you tell us about the case studies of what's gone on in the last few years? 

Dr. Peter Klatsky:
Yeah, or not case studies, but clinical trials really, where they compare the outcomes and the calls and how often are they different and how would they be different? And you know, so anytime you're applying AI, I think best practice is to do so with clinical oversight, human oversight, for a long time, and I believe Cooper did that for several thousand cases prior to writing it. [00:15:00] 

So what if, you know, I, I'm a quote, believer slash somebody who fears the implications of AI long term. So there are benefits, there are social challenges with it that are going to be dramatic, but I think whenever you're introducing new technology, you need to validate it, and you need to validate it.

Not, you know, in a small case series with a hundred people, but rather, you know, series of thousands and thousands of hundreds. 

Chelsea Leonard:
And Dr. Klatsky, I think that's such an important point because the validation as, as we've talked about so far, this is based on actual. embryos, embryos that have resulted in an outcome that's been tracked rather than cell lines, for example, which might not be the best representation of, of what we're doing with PGT.[00:16:00]

So real embryos, real outcomes. 

Griffin Jones:
Peter, can you give me an idea of like what the significance of the scale is introducing this new technology, because it seemed to me like PGT has always been a powerful tool. I'm a complete lay person, not a clinician. I'm not a scientist. And it seems like whenever you have a powerful tool, it's going to be more important in certain cases than in others.

And the more data you have, the more scale you have, the better you're going to have for fine tuning exactly which implications and which uses maximize them. So, can you give me an idea of, of how much of scale is a game changer with having the technology of AI behind it? 

Dr. Peter Klatsky:
I'm not the best person to speak to that.

I think somebody at Cooper or one of the other genetics companies are, cause they know how much time it takes for somebody to look at the data point, the key point for the audience to recognize is when you're currently testing an embryo, you're getting read lengths of one of those chromosomes that you're testing that are only about 70 base pairs long and, you know, 75 to 150 base pairs.[00:17:00]

That's the current generation of, if you're, if you're doing it through sequencing, if you are, you know, and then you get a area that may be five to 10, 000 base pairs with no reads. And, and now you've got a chromosome that's a hundred million bases long, right? So you can get enough, and I always talk about it as Shazam for embryos, like you get enough, you know, snips of that song, you know, okay, that song is present, and here's the number of times that's present.

And so when people are looking at it, they're looking at how many hits are in chromosome seven, how many hits are in chromosome eight, how many hits are in chromosome nine. And they're using that to judge how many copies of that DNA, and if there's twice as many hits on chromosome seven as there are on chromosome eight.

And then chromosome seven and chromosome eight have the same length. Then someone's going to interpret, well, chromosome seven, there must be twice as many copies of that chromosome than there are of chromosome eight. And that's how this is done. And sometimes when you look at the reports and you know, in those heat maps, it's super clear and a monkey could do this.[00:18:00] 

And then sometimes, it’s ambiguous, so the AI probably gives that human interpreter more confidence, um, potentially, you know, does it help in the workflow? Um, as increasing numbers of people are using AI should, and you know, and where I think it probably helps is on those edge cases where, where they're developing confidence intervals and where they are constantly learning.

But as far as like, does it improve flow? Does it improve ability to scale? That's a question I'd leave to the Cooper, Natera, genomics, you know, all the other, you know, to the companies that are delivering this service. 

Griffin Jones:
Chelsea, can you expand on that a little bit? 

Chelsea Leonard:
Yeah, I think a little just to say it, it does, right, but I think At least in my clinical conversations with providers, we really focus on not so much how it improves the workflow in a practical sense on our side, but what it means in terms of confidence for those cases that Dr.

Klatsky mentioned, right? If, if we have a noisy sample that we're not over calling that as aneuploidy, if we're seeing blips across multiple chromosomes, but that sample may in fact be noisy and is either euploider or no result as an example. So in those cases, it's critical for us. [00:19:00]

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Griffin Jones:
Tell us about how this impacts parental quality controls from the business development seat that I sit in the public relations seat that I sit in whenever I see a case of someone got the wrong embryo or or something happened, not having necessarily to do with genetics testing, but just any case like that, I, you know, anything happening with down the road in chain of custody, I think, wow, that's, that's a big area for concern. [00:22:00]

So are there implications here for improving parental QC? 

Chelsea Leonard:
Yeah, so from our end, one of the things that we've been excited about what we've sort of built on in the last year or so is our newer test PGT-Complete℠ that is built off of PGTai. So our, our standard PGT-A test, but with the addition of parental buccal swabs. And in those buccal or cheek swabs, we're looking at SNPs, single nucleotide polymorphisms and comparing those genetic markers from the egg and sperm provider to what we're seeing in the embryo and with that, we're able to do a couple things. One of those is parental QC. Helps us confirm that we have a match between the egg and sperm provider and the embryo sample that was submitted to us.[00:23:00] 

The other components that I'll share very briefly that I'm sure we'll get into later are what we call genetic PN check where we can confirm at a genetic level that normal fertilization has happened. That we have not only two copies of every chromosome, a euploid sample, but that one copy came from each side, the egg and sperm, and also origin of aneuploidy.

We know that that information is important to patients and to providers as they make future treatment decisions. 

Griffin Jones:
Peter, how important is that as a clinician to and how different is that from what previous technology it offered? 

Dr. Peter Klatsky:
Anytime you can make a technology safer, I think we should. Anytime you can provide reassurance to a patient, I think we should. And, you know, in parental QC or parental DNA matching and confirmation PGT a hundred percent of your patients, a hundred percent, I'll speak in the first person, a hundred percent of my patients, whether they articulated or not, have in the back of their head the day of their egg retrieval, don't mix up my eggs. I'm giving you my eggs, I'm giving you my sperm, how do I know that those are going to meet?[00:24:00]

And it's a massive degree of trust. That your patient sends you and, and placing you and, and as the provider, I am not present when the sperm and egg are being fertilized and we are not present at every step in this, in this equation. We make sure at Spring, we 100 percent of the time, we have two people signing off on every transition of every gamete.

[00:25:00] That's what I tell everybody. And, and we never sacrifice on that and no matter what somebody is doing, you have to stop, get a second eyeball. Right? And without that, you can't be sure. Your patient has to trust you on that, and they do, and, you know, having that other layer of backup of saying, hey, by the way, we took a cheek swab before this, we, we have a copy of your DNA, and, and just when we ran that, that, that embryo result, oh, we have a little check mark, yep, it was your DNA.

That reassurance to your patient. It is well worth the extra time in this whole process where we're making people go through multiple blood tests, right, to see how your estradiol is changing, how, you know, is your progesterone fluctuating, go through multiple ultrasound things to get that, you know, reassurance on egg quality.

Why wouldn't we just make sure that that embryo corresponds to the embryo that was tested? 

Griffin Jones:
I had heard of a gamete swap case recently. I wasn't familiar with that case study. Are you familiar with that, Peter? [00:26:00] 

Dr. Peter Klatsky: 
No, I'm not. Well, no, I, so one, you know, there are these crazy stories that you hear about on the Today Show, Good Morning America, that are devastating for families and then, you know, you hear about cases in the back, you know, round of people who, at age three, their child, they're devastated by the fact that their child develops leukemia. And they're trying to see if they can give a bone marrow transplant to their kids. In this one case, you know, high profile lawsuit where the parents then found out while their child's going through chemotherapy that not only was the, the father not an HLA match, but, but it wasn't his sperm.

I can't even fathom what that must be like for that family and for that clinic. And, you know, fortunately, every case I've ever heard of that happening, there were not two people witnessing every transfer of every gamete. So I want to, so I always want to reassure patients that to date, at least to my knowledge, there's never been a gamete mix up with double identification at each step.[00:27:00] 

Every single one of those cases that I'm aware of, one embryologist working that day. You know, and, and, and didn't have double sign offs. So, to my colleagues and peers out there, like just let's make sure we all take that really seriously to sign offs, two names, two eyeballs every time and not signing it, but really looking at it.

Our lab director enforces that in our lab takes that very seriously. The other part about this is one that one has trouble contemplating when you have high profile cases like that. That are going on Good Morning America, Today Show, and there's lawsuits that one can't even begin to contemplate what the settlement amount is.

[00:28:00] One could also contemplate that somebody, a bad actor or somebody for other reasons, might decide to misrepresent fraudulently a relationship and have somebody else provide sperm in place of their, their partner. So, so the way this could work out is that if I were a three parties, right. And, and there's my intimate partner who I want to have a child with, but maybe for other reasons, I married somebody else, whether they have to do with whatever reason, right. And so you have a legal arrangement with a marriage with one person. And, and maybe the, the intimacy has changed. And there's a third party who's really the, the, the long term life partner for, for that patient. Um, now that person could go into a fertility clinic, um, take Shady Grove, right?

They're a very big clinic with deep pockets and, and, and they could. present themselves as two people, man and a woman, who want to have a baby together and they end up doing IVF and they want to do PGT and they go through the process and the day of the egg retrieval, the husband brings in the other intimate, the true intimate partner's sperm source, right? [00:29:00] 

And, you know, sperm production remains a private act without two people identifying the actual sperm production. And it's not that hard to, you know, bring in a cup with somebody else's sperm. And then that sperm is handed off to the embryologist who confirms the identity of the person who came out of the sperm production room, but it may not be his sperm.

And if you do at home sperm production, then it's just, you're trusting the husband is handing off his sperm. And you would never know about that, right? The only way you can know about that before transferring embryos, so let's play this out, if you didn't do parental source DNA, you'd then transfer an embryo, lose somebody else's DNA, and then that family, six months later, says we have a baby and we did a 23andMe cheek swab, and it says my husband is not the genetic parent of this baby, but we went to your fertility clinic. [00:30:00] 

Jaw drop, right? You're in a really a world of hurt. And if you don't genetically type everybody and make sure that that embryo's coming from the sperm and, and egg. And in that case, that fertility clinic might have done everything right.

And…You know, yet, what would be your, your next steps, right? I, I would want to QA everything, make sure that everybody signed off, that we, and you'd look at chain of custody with a sperm and you'd see there were no errors on your side. And yet you're looking at a baby and his ostensible two parents and there's not a genetic ID.

So, so just, there's like a pause thing. Okay, now what's your next step? Right? And, and, and your next step is, well, how, if this baby's not using this husband's sperm, who gave us the sperm, where could an error have gone off? And so, in that moment [00:31:00]

Griffin Jones:
Okay, Peter, now that you've scared the crap out of everybody, I actually, I actually do think this is worth digging into, because these are, these incidents do happen from time to time and they can be career ending. They can be reputation tarnishing. They can be, they're beyond traumatic for the families that are involved. So I do think that this is a point that is worth digging into more. And I also think that things that start off as new features or new tools, sometimes quickly become the standard they're established.

I feel like it could be something like five or 10 years from now, we're saying like, oh, remember back when Cooper started doing this? Remember back when they were calling it PGT-Complete and now it's like, and, and so it's like, it, it's something thar you know, is, is starting now. That might become the standard of care in short order. [00:32:00]

Chelsea, can you talk a bit more about how it works at, at a technical level to prevent the types of situations that Peter's talking about? 

Chelsea Leonard:
Yeah, absolutely. I think. Really, really what we're talking about here is with those parental buccal or cheek swabs that are collected before or at the time of the egg retrieval, you know, when we can and get patient and partner to provide an easy sample, we are using the SNP or single nucleotide polymorphism data from.

And it becomes very apparent when you're looking at all of those genetic markers for those three parties, if there is a match or a non match. I think it's also important for listeners to understand that a non match could occur for a variety of reasons. For example, contamination, maternal cell contamination is another thing that we think about in these examples where we're seeing only SNP representation from the maternal side.[00:33:00]

In the sample, and that's another situation where we could end up with a false result for an embryo, even if we've done everything right in the laboratory, because we'd be picking up euploid or normal female just from the maternal cells and underneath the surface, that embryo could be male, could be abnormal.

We could have any number of scenarios. And if we didn't have those parental swabs, then we may not know that until after a transfer. So lots of different things that we can detect in addition to gamete switches.

Griffin Jones:
I want to talk a bit about aneuploidy as well. It's something that I have very little understanding of. It's something that I hear you all talking about all the time. And it's. And so I hear about it being associated with maternal factors, but I also hear that that's not always the case. It sounds like this test is able to determine where aneuploidies come from. Can you each talk more about that? [00:34:00] 

Chelsea Leonard:
Yeah, I think I can jump in and just start that conversation by saying, you know, we, we often think of aneuploidy primarily in that maternal context.

Right. We know that aneuploidy rates increased with maternal age and that most of the aneuploidy and most cycles is maternally derived. Right. So for an example, if there's an extra copy of a chromosome in an embryo, most of the time that may have come from the maternal side, but not 100 percent of the time.

[00:35:00] We know that about 90 percent of whole chromosome aneuploidy is maternally derived. On average, but about 70 percent of segmental aneuploidy, where just a part of a chromosome is impacted is paternally derived based on recent studies. So we've all had those cases where we get a PGT report back for a patient and there's aneuploidy across embryos and it's unexpected based on maternal age. Something's not really making sense. I think we're realizing more and more that at least in some of those cases, it's the sperm that's creating that result. 

Dr. Peter Klatsky:
And if it's the sperm, is it accurate? 

Griffin Jones:
Tell me about that, Peter. 

Dr. Peter Klatsky:
Chelsea made a really good point. When you look at the studies on just mono, uh, monochromosome aneuploidy, so single whole chromosome aneuploidy, you will see most studies looking at that. We'll find rates that I think Chelsea now correct me if I'm wrong, but around seven to 8 percent paternal whole chromosome derived aneuploidies, uh, and maybe depending on the platform, it may be higher, but, but, but I've seen data as much as 6 percent whole chromosome.[00:36:00] 

So then just talk about your, your, the test PGT. It's not perfect. It may, it has false positives. Does not matter whose platform you're using. Every patient should recognize that there is, there are mitotic errors and mitotic errors are going to happen and that's going to lead to the ability to sample an embryo and and have discordant trophectoderm and inner cell mass.

So, so if you recognize that this is a good test but a good test means there's a four to five percent false positive ratio. Every single one of my patients getting this test knows that. Every single one of my patients says no matter what platform I'm using we are going to throw away We are going to discard some potentially good embryos.

[00:37:00] And that's a cost of the test. It's a cost of the improved accuracy, the lower number of embryos to transfer. And that's a limitation. It's not a platform limitation. It's a biologic limitation. Unless you believe there's no mitotic errors, which I don't think anybody believes. And so a mitotic error, Griffin, is as the embryo is growing, cells divide and have errors.

Right. And so you can be sampling up so that, so then the embryo is a true mosaic and the area outside is going to become the placenta may have errors. You biopsy that, that embryo is called abnormal. And then the inner cell mass, if you were to re biopsy, destroy the embryo, you'd find more normal. And in the studies looking at that range from about 3.5 to 5%, and that's what I, what I tell patients. Now, there's a really nice non selection study where they transferred 104 abnormal embryos and not one live birth. So that's reassuring. But if they'd transferred a thousand embryos, I would bet you'd find about 20 live births. So about 2%. That's my guess based on my understanding of the false positive rate.

So now say you're 44 and you've been at IVF for six attempts and you've been fortunate enough since you were 43 and 44 and been able to make a lot of embryos. And in one of those embryos, you find out that the only chromosomal abnormality was parental, paternal DNA. Is it possible that that's your false positive? [00:38:00]

Well, if you look at sperm DNA studies... Right. Looking at individual sperm from sperm donors, what they find is about 98, 99 percent of individual sperm are, are you not, you put it, but haploid and have one copy of each chromosome present. So they have 23 chromosomes, each one copy of each chromosome in 98 to 99 percent of sperm.

And there's a nice study out of China looking over 20, I think it was like over 20,000 sperm samples and so that's a pretty low error rate, one to 2%. And now if you're looking at clinical studies saying, Hey, we're seeing 6% whole chromosome abnormalities that only come from the sperm, but we know that most sperm, maybe it's 2%. [00:39:00] 

And if you were to find that difference, what, 4% is the difference? Isn't that the false positive rate in the test itself? So, so could we take a patient well counseled, maybe under a research protocol to say, if you have a whole chromosome abnormality, nobody's doing this yet, by the way, this is like, like just forward looking for that rare patient who, who's so hard and only has one, and it's one of like 20 chromosomes.

And if you don't think this exists, like it's personal to me because like I know a patient's name who's like this and we got tons of embryos and we couldn't get a euploid embryo. There's one aneuploid embryo that only had parental, paternal only error and I'm looking at the studies showing that, well, paternal only aneuploidy of embryos about 6% sperm DNA about one to 2%. And then most of those other studies are showing that four to 5% false positive rate. 

[00:40:00] So does that mean that for that embryo, there's a two-thirds chance that, that that was actually one of the false positives. And if it was a two-thirds chance, we're looking, you know, so there's a 66% chance that this is actually a euploid embryo and that's a mitotic error.

And if you were to sample the inner cell mass, and, and if you knew that, then you could transfer that embryo. You wouldn't give her a 65% live birth rate, but you might give her a 35% live birth rate. with their own DNA. So I'm getting a little bit into the weeds here, but like these are ways in the future with further studies.

I've always wanted to do that study looking at well counseled patients with a paternal only whole chromosome aneuploidy. Obviously not chromosome 13, not chromosome 18, 21, but something that's not compatible with life and transfer them. And, and you might find similar to the segmental aneuploid studies.

[00:41:00] Julia Kim did a great study during her fellowship looking at segmental aneuploidies and not finding a difference in, in outcome when you transfer those. So, you know, as we refine our thinking about how to use this technology, you know, we talk a lot about the platform, but I'd almost argue that as important as choosing a platform is understanding the underlying science and the limitations across all platforms.

Griffin Jones:
Are these the same as AFOs, Peter, because I hear, I hear abnormally fertilized oocytes, but is this the same thing that you're talking about? 

Dr. Peter Klatsky:
It is a bit different. So this is more of, as an embryo is dividing, say it's going from four to eight cells, does one of those four cells have an error in that mitotic error?

And then is there, you know, and so now you've got two out of six cells that are abnormal, but they keep dividing and and some people would argue that well those abnormal cells won't divide as well And so it's lower chances But we know that there is not a hundred percent concordance between the trophectoderm which we biopsy and the inner cell mass Anybody who says differently has not read a scientific paper on this, right?And so it doesn't mean you throw the baby out with the bathwater, right? [00:42:00] 

Like, it doesn't mean you say, you say, okay, the test is no good, right? There, you know, the folks who are anti PGT, it's inaccurate, it's got false positives. I say, yeah, you're right. And I still do it over 95 percent of my cases. I counsel the patient, here's the limitation, but the ultimate benefits of the test, lower miscarriage rate, higher single embryo transfer, you know, we do a hundred percent single embryo transfers when you have a euploid embryo, but I don't kid myself that there's not an error rate.

So, so I talk too much. Sorry, Griffin. Back to your question of like, how does identifying the parental source of the aneuploidy make a difference. One, it provides a reassurance to the patient that their DNA were used, in fact. Two, it addresses the issue that Chelsea mentioned that maybe it didn't fertilize and maybe you've got two copies of maternal only DNA that you wouldn't otherwise know and then, or maternal cell contamination. [00:43:00]

And then three, if there's a really smart fellow with a great REI division director and program that wants to do this study and, and, and we'll collaborate with you at Spring Fertility because, because, you know, we all want to participate in those studies too.

I would love to understand when you have paternal only errors. If there's viability to those embryos, if that's a marker of a possible false positive and mitotic error. And if that were true, then you, that could be a way to pick up about half of those mitotic errors. 

Griffin Jones:
So AFO is being something different than it's a, it's a different category.

Chelsea, can you talk a bit about, have you seen changes in philosophy in terms of whether you discard those evos, whether you keep them, what's, what's happening in that landscape? 

Chelsea Leonard:
Yeah, I would love to, before I just have one additional thought to, to tack on to what Dr. Klotsky was describing with origin of aneuploidy.[00:44:00] 

Which is when I go into clinics and talk with providers about that feature of the testing, you know, oftentimes the provider will share. There's that case that they recall where a patient had persistently high aneuploidy in their embryos across cycles, and that patient was transitioned over to egg donor.

And in that cycle, after utilizing an egg donor, there was still unfortunately a high rate of aneuploidy. And at that point, the provider considered maybe it was. the sperm that was contributing in that particular case. And typically providers can think of a case, maybe a handful of cases where that was the situation where we realized after shifting to egg donor that it may have been the sperm that was contributing.

[00:45:00] And so I think for that reason also origin of aneuploidy information, especially before we consider transitioning a patient over to a gamete donor, making sure that we're going in the right direction. And sometimes it could be the sperm. But the area of, of AFOs or abnormally fertilized oocytes, I think is really exciting and love chatting with colleagues in the laboratory about this because there's that step that occurs after the egg and sperm meet.

I love that phrase that Dr. Klatsky used where we want to make sure that fertilization has occurred, right? So the embryologist is looking under the microscope for, uh, the pronuclei in the Petri dish to make sure that we are seeing what would represent a copy of chromosomes from both sides, the egg and the sperm fertilization has taken place and we have an embryo starting to develop.

[00:46:00] We know though that that's not a perfect science and there are laboratories that may look under the microscope at a single time point to try to visualize those pronuclei. Maybe they're faint, they're stacked, it's hard to see quite what we're looking at. And that call that the embryology just makes, for example, this embryo has one pronucleus or has two pronuclei.

Oftentimes that's then a decision made on whether to discard that sample or attempt to keep growing it out to the blasts stage. What we have found is that there are laboratories that are shifting their protocols on that slightly, where they will hold on to what we would call those abnormally fertilized oocytes, try to continue to grow them out to that blastocyst stage and biopsy them for testing.

And from the studies that have come out to date, there are what I would consider a meaningful, significant amount of those AFOs that continue to develop. And when we biopsy them, They turn out to be euploid and not just euploid, meaning two copies of every chromosome, but with proper representation from both sides, egg and sperm.

[00:47:00] The implication of that is that this is an embryo that may have been discarded based on that visual check that can now be considered for transfer. And that's so important for patients, especially those that have few options in the process. 

Griffin Jones:
Peter, in your view, is this going to become part of the standard of care?

Because I just go back to the what used to be nice to haves become must haves, what used to be a feature or tool or, or then becomes part of, you couldn't imagine practicing medicine without it. And I think I'm paraphrasing one of David Sable's quotes, but he says that today's ceiling has to be tomorrow's floor.

In other words, if, as we expand access to care, we can't lower the quality as the quality raises, that needs to become the, the minimum in order to provide the scale, we have to be able to, to have more control over outcomes. And so these technologies are part of it. So is, is, is this task something that you see going to become a part of the standard of care? [00:48:00] 

Dr. Peter Klatsky:
Yeah, I mean, first of all, I love everything David Sable says. So, today's ceiling, tomorrow's floor, like... I like that. Yeah, you know, for me, you know, in our lab, we don't tend to discard, you know, if there's a 1PN for exactly the reason that Chelsea mentioned.

So, so that part may add value and it may add value again to the fact that, you know, to avoid, um, you know, uniparental and so to me that, yeah, I don't know whether the PN check is the way really solves for that, but it, but it certainly would solve for the rare cases of uniparental disomy. And again, once you get it into your clinical flow, it doesn't slow things down much, and it just adds more reassurance.

[00:49:00] And so finding ways to do this in a way that is not necessarily increasing cost to the patient, but providing that reassurance and safety, like I said before, I think it should become the standard of care. I think it protects. Patience is, it protects, it protects the clinic, and it just, you know, the safer we can make our technology, the better it is for everybody involved. Physicians, embryologists, and above all patients. 

Griffin Jones:
Let's talk a little bit about that in terms of the benefit to the clinic as a business. That is, after all, why the heck people listen to this show or pay any attention to whatever content I put out.

They're not coming to me for the latest scientific developments. The reason why this platform reaches a few thousand of you. 

Dr. Peter Klatsky:
You have some good stuff, man. You have some good stuff.

Griffin Jones:
Peter, I'm not saying this to be modest every time I say it on the show I was a D student in high school. I barely got through high school biology.

 [00:50:00] What I understand is what's, what's important to end users. What I understand is how markets function and how things that that maybe were once novel become part of the standard of care. That's part of how innovation happens. I also understand how competitive forces come together. And I try to bring all these perspectives together so that people can listen to them.

And they listen because there's so many people that are either, maybe they're young docs and they are starting a trajectory of where they're going to be a senior partner at a big group. Maybe they're going to come join you. Maybe they're going to go start their own group. We have more embryologists and lab directors, lab directors starting to take business interest.

[00:51:00] We've got a lot of CEOs that listen to this show and CFOs and COOs who are parts of these big MSOs and it used to be just us people that are listening and now it's people from India, it's people from China, people from Australia, it's, it all of these business folks that are listening. And so I, I look at a test like this and I, and I see like, okay, I can, I can see that this clinical benefit and I can see at a public relations marketing level, how necessary these controls are to have in terms of the scale and opportunity. I see how important the AI implications are. I'd like to hear from you. What are the business benefits that you see from a test like this? 

Dr. Peter Klatsky:
Anything that makes, first of all, you've got a great audience of amazing people listening and biologists, clinicians, any of them who want to have the most rewarding career possible, who are interested in going to the Bay Area or New York please reach out to Spring Fertility. 

[00:52:00] So I, I, sorry, Griffin, I can't help, but for our, our actual practice, anything that makes this process safer, anything that makes this process one where I can have more confidence that when I transfer an embryo, I am going to, you know, have the highest success rates possible and avoid a catastrophic event.

In our field, we've seen catastrophic events. We've seen, you know, child fertility in Los Angeles does not exist anymore. We've seen cryo tank failures. Those are catastrophic events that I cannot fathom. And my heart goes out to the patients. My heart also goes out to the doctors who are in that situation, who probably didn't have anything to do with it.

But we'll be held to account. So what, what I know is that this, you know, this is a tool that can make a double check and everybody who's been in an IVF lab who knows the, the, the behind the scenes knows that there's redundancy and there's not redundancy twofold there's usually in triplicate. 

[00:53:00] So our nitrogen gas, right? We have three tanks and two rows. So when this tank ends, we go to the second row and in fact, in most of our gas tanks, we have three rows of multiple tanks so that we will never run out of gas. We will never run out of CO2 and duplicate isn't enough. Almost every IVF center in the world has three levels of redundancy.

So this is just another level of redundancy to reassure your patient and so if you want to be totally business, attempt about it. We've never had an embryo mix up at Spring, but we did once have somebody take somebody else's sperm, and we only caught that because we were checking parental source and to this day, I don't think that they were bad actors.

[00:54:00] I think there may have been other cultural factors, other, other issues going on, but I couldn't figure out, you know, at first it sounds funny, right? When somebody, when you hear about, like, essentially a married couple that separated, yeah and they're no longer living together. And the husband brings in the new partner's sperm.

And for the first four minutes, when you discover that people are like wow, relationships are complicated and interesting. Right. But then when you say, well, why? And you think, hearken back to that Good Morning America episode with it, with the, with the gamete mix up and you think about the liability there that shook me and everybody who had visibility into that because you couldn't help but wonder, are we being set up?

So yes, if you're, if you're managing a practice that in you are the CEO and you are the Director of Operations. I can't fathom why you wouldn't want to have that double check. Because that is so easy to do. 

Griffin Jones:
I think of, of, if you're the CFO of a group or the CEO or whatever, and that catastrophic event does happen. It's one thing if the technology doesn't exist. You can say, well, these are the measures that were currently in place. But if you didn't have it and like two or three other networks do and use it and, and people can point it, courts can point to that. Patients can point to that. The media can point to that. 

To me, that seems like doomsday. I want, I want to focus more on the positive of the, the, of the test, but part of what the positive is, is avoiding that potential absolute negative cat. [00:55:00] 

Dr. Peter Klatsky:
That's right. And I want to be fair, you know, Cooper is not the only company that offers that and and so but but I would make sure whatever whoever your PGT partner is that they are providing that. 

Griffin Jones:
I want to talk to you about your selection process for a partner because I know how, oh, what's the polite word of saying idiosyncratic you and Nam Tran are with you QA at, at Spring and like, it's so embedded into how you, you've built your, your practice group. You have QA measures that I hadn't even heard about before. We talked about that in the first episode that you came on and I know everyone listening is, is really important. QA is really important to them. I just feel like you take it to another level.[00:56:00] 

And so it's like one of those scenarios where it's like, what if they're good enough for him. That means, that means there's something there. What was it about, and I, and I also presume that you have worked with other partners in the past. What was it about Cooper that made you say this is the partner for me?

Dr. Peter Klatsky:
I want to be cautious because there are a lot of great colleagues in this space and there are a lot of great PGT labs. And so I want to speak more in general, generalities because you know, one, you want to have like we started off at the beginning, you want to have a, I want to have that one, a high degree of confidence in the accuracy of the calls.[00:57:00] 

Two, I want to have a low, no call rate. My current no call rate is under 1% in New York with Cooper. I have worked with other companies. I know I had a positive experience with Natera as well and so I want to know the professionalism of the people. I want to believe in their accuracy. And then I want to know my limitations in Griffin.

I am not the smartest person at Spring Fertility. I want so I, when I need that scientific, we're going to go to Nam Tran. Who is our Chief Medical and Scientific Officer working with our, our head of all of our IVF labs, Sergio, and, and get insight from them. But it's also important that your physicians who work in your practice have autonomy and, and physicians may have preferences as well. [00:58:00]

So when physicians are working at Spring, we, we put it up to our whole group. We look at the data. We have every group come in and, and give a presentation. After that presentation, we talk about it. We, we try to limit. The number of PGT partners to two per each lab, just because it makes it easier for your lab.

It's hard if you're going to have 10 different providers using 10 different labs. That's hard. So, so you want positions to have autonomy and to be respected and have their reasons, but you want to have an open dialogue. And I'm lucky enough to have, you know, people smarter than myself guiding me and then we constantly review the literature.

We constantly review the outcomes. And so when we choose a partner, we want to make sure that there's a quick turnaround time that they are responsive to the clinic, that if we need something in a hurry for a particular case or particular reason that they're able to do that, if we need, uh, an exceptional case that we need to do that, but as a general rule, I don't want to work also with a PGT provider who can't source the DNA, can't provide parental source DNA.[00:59:00] 

And, and, um, my experience with Cooper working in New York has been wonderful. I don't want to be, you know, a commercial and I have a lot of wonderful colleagues who work for other organizations, you know, outside of Cooper. And so I don't, but, but I think you want to have an honest conversation. You want to know that you're in this together.

And if something happens, you know, that you're going to get a phone call and you're going to be able to work through it quickly and come to a resolution about things. Because there will always be cases, no matter who your provider is, where you'll have like suddenly a high no call rate. For one case, right?

And, and you want to be able to delve into that and in a non confrontational, but, but information finding way solution. 

Griffin Jones:
I want to conclude with a couple of different ways. First, what are the takeaways that, that people should walk away with about this test specifically thinking of PGT-Complete℠, knowing that we have the scientists listening. [01:00:00] 

We get the lab and embryology folks. We've got the docs listening. We have the business folks. that are like me that don't have clinical backgrounds. Chelsea, maybe you start. What should they walk away with?

Chelsea Leonard:
Yeah, I think from my perspective, a buccal cheek swab takes 20-30 seconds. It can be done from home or from the office at the center itself and really enables us to produce the most informed and confident results, right?

[01:01:00] When we get that PGT report back for the embryo reassurance protection and the potential to, in some cases, rescue embryos that may have been discarded or make the correct treatment decision going forward. For example, choosing, choosing the appropriate gamete toner. So, it's an easy thing, a cheek swab, and it leads to our ability to offer improved outcomes to patients, and, and we all know that there are cases where this could have been useful if, if it had been around at the time, and now it is, and it's available.

Griffin Jones:
Peter? 

Dr. Peter Klatsky:
Yeah, I think that's, I think you said it well. I've given a variety of reasons. I think that one case in particular probably is going to stand out for a lot of people in this audience. And, you know, again, there, you also want to track your outcomes, right? So you also want to track what is my, uh, single euploid embryo by birth rate.

[01:02:00]And, you know, if there's deviations in that, if you feel like you're not getting the outcome that you should be, that's, that's what I do. But, but, but, Griffin, I think the ceiling should be the floor and when you have something that makes a technology safer and provides reassurance for patients, again, 100 percent of your patients are afraid of this, whether they tell you or not 100 percent of your patients.  

Griffin Jones:
So let's use the things that give them less to worry about. I want to as you about where people can learn more about PGT-Complete℠. We're going to link to information about PGT-Complete℠. It will go out in the email that delivers this podcast. For those that subscribe, it will also be on the podcast page. We'll also include it in the show notes. Tell us, where can people learn more about PGT-Complete℠? 

Chelsea Leonard:
Yeah, of course, there's lots of great information about PGT-Complete℠ on our website, so CooperSurgical’s website, including white paper, you know, further description of the features, some case examples. We'll be chatting about it extensively, I'm sure, at ASRM, as well as hopefully some upcoming discussions about real case studies with what we've observed with Complete in the last year or so, since it came out.

Griffin Jones:
So that’s the timing. Some people are going to listen to this episode, maybe three or six months after it comes out, but a lot of people are going to be listening to this episode right as it comes out, which is right about ASRM time. Some of you are probably on the plane right now, headed to New Orleans, listening to this episode.[01:03:00] 

And if that's the case, Cooper's I imagine is going to have a big booth and big presence as always. And you're going to have a lot of your scientific people there. A lot of your sales people there. I invite you to go to their booth, talk to them about it. Tell them about this conversation. Peter, will you be at ASRM?

Dr. Peter Klatsky:
I will be, and anybody who's interested in having an amazing career in New York or Bay Area, we're hiring there. We're interviewing people. We're a great group of folks. We deliver the best science and look forward to meeting my peers there too. 

Griffin Jones:
When you bump into Dr. Klatsky or Chelsea, tell them that you heard them on the show and tell them thanks for putting up with the host. [01:04:00]

Dr. Peter Klatsky:
Are you going to be there Griffin? Are you going this year? 

Griffin Jones:
I wouldn't miss it. Yeah, I will be there. 

Dr. Peter Klatsky:
Will you bring your baby? 

Griffin Jones:
I will go sans baby. But, uh, I've thought about future appearances with the baby in some matching suit that I wear that fits my Conor McGregor suit MO. So not 2023, but, uh, we might see it in 2024 that all right, Cooper Marketing team, there's, there's something that we could do for our 2024 initiatives, but brand, brand new baby.

Two, two months old. Yeah, it'll be two months old by the time this episode airs. 

Dr. Peter Klatsky:
Awesome. Congratulations. 

Griffin Jones:
Well, thank, thank, thank you. And thank you both so much for coming on and advancing the conversation. 

Chelsea Leonard:
Thanks so much. 

Dr. Peter Klatsky:
Thank you.

Sponsor:
This episode was made possible by our feature sponsor, CooperSurgical®. Download CooperSurgical’s brand new PGT-A Clinician's Reference Tool, an indispensable guide for clinicians like you to unlock the full potential of genomic treatment, by clicking the button below.

Announcer:
Today’s episode is paid content from our feature sponsor, who helps Inside Reproductive Health to deliver information for free, to you! Here, the Advertiser has editorial control. Feature sponsorship is not an endorsement, and does not necessarily reflect the views of Inside Reproductive Health. 

Dr. Klatsky 's opinions are his own. He receives an honorarium from CooperSurgical® for his time and expertise.

Thank you for listening to Inside Reproductive Health.

 
 

199 The Chief Medical Officer Behind Kindbody's Growth from 1 to 32+ REIs Featuring Dr. Lynn Westphal

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.


In this week’s episode of Inside Reproductive Health we dissect the successful rapid expansion of Kindbody with their Chief Medical Officer, and 25 year Stanford Professor, Dr. Lynn Westphal.

Dr. Westphal discusses:

  • How her role of CMO was constructed (As well as her part in designing it)

  • Her process of establishing protocols (And her process for amending them)

  • Where she believes, as CMO, it’s important to have input (Why staffing ratios are high on the list)

  • Her take on the difference between clinical and business operations (And if/where they overlap)

  • The major differences between REI business plans (academic institution vs venture backed enterprise)

  • One crucial thing she’s used to support her medical team (And why its effectiveness surprised her)


Dr. Lynn Westphal
Kindbody.com
LinkedIn
Instagram

Transcript

Dr. Lynn Westphal  00:00

I think it's really important if you're looking at next steps or thinking about other opportunities to, to talk to people who have lived on that. And it's really important to find good mentors to find someone who can help guide them in that process.


Sponsor  00:21

This episode was brought to you by The World Egg and Sperm Bank. 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 appearance is not an endorsement of the advertiser.

Griffin Jones  00:52

One REI, you blink you open your eyes again, four and a half years later, you have 32 RBIs. Who knows maybe they'll have even more than that by the time this episode comes out, I'm talking about Kindbody and more specifically, I'm talking about their chief medical officer, Dr. Lynn Westphal. You may know Dr. Westphal from her time at Stanford she was there for 25 years and there's no way that an established academic REI center runs the same as a very fast moving venture backed enterprise that might IPO in the next couple of years. Rest assured I asked her about the differences of going from one to the other and I asked her about this chief medical officer role was constructed and how she constructed it chief medical officer is a role that some of you who are listening now do not currently play and you will play and even if you choose not to go that route a great many of you will be asked to so I interviewed Dr. Neil Shah of Maven clinic in a separate episode, I interviewed Dr. Lynn Westphal, of Kindbody here and now because I want you to have some insights for what these roles can look like. Dr. Westphal talks about her earlier responsibilities, helping to design clinics training and recruiting establishing medical protocols. I asked her how she got out of each of those seeds. As the organization expanded, she talks about how she organizes protocols and her process for mending them over time. Dr. Westphal talks about how the Chief Medical Officer interfaces with Cambodia's Medical Advisory Council she talks about decisions that are implemented broadly but sometimes require exception like telehealth for new patient visits, you know that I don't believe in a perfect distinction between clinical operations and business operations. And I load that question that Dr. Westphal with that presupposition in place asking her to point the parts of the Venn diagram where clinical ops and business ops really overlap. And where it's really important that she is chief medical officer has an opinion and an input her answer there is about staffing ratios. And she talks about why I asked her if the speed at which decisions come at her to make have sped up or slowed down is Kindbody gets larger. And finally I asked Dr. Westphal to think of something on the spot that she's used to support her medical team that's effectiveness surprised her so she talks about the different ways that she connects different team members and different leadership roles. The rest is for you to enjoy on my conversation with Dr. Lynn Westphal. Dr. Westphal, Lynn, welcome to the Inside Reproductive Health podcast.

Dr. Lynn Westphal  03:09

Thank you so much for inviting me, I'm happy to be here,

Griffin Jones  03:12

You are a well known figure and you're a popular figure you were known before you went to work for Kindbody, you have since joined Kindbody as their Chief Medical Officer. And that's the role that I'd like to deconstruct a little bit today both your particular role, but also how that works. As a chief medical officer, I've had the privilege recently of also interviewing Dr. Neil Shah of Maven Clinic, and I'm not sure which episode will air first but this gives the audience a bit of a career path tutorial of how they might construct a similar role or how they might follow in a similar role, how they might take some pieces from it, and be useful to them. But let's maybe just start with your own career path. How did you come into this role of chief medical officer for such a very large company?

Dr. Lynn Westphal  04:06

When I started, it was not a very large company at all. And my transition to Kindbody was kind of an interesting move. I loved my academic career, but wanted to work on improving access to care. And also, you know, wanted to learn more on the business side and to help build like a new a new company. I had always been a big institutions. And so being in the Bay Area, where there are all these startups, you know, I always thought it would be interesting to see something developed from the ground up. When I started at Kindbody in early 2019. We had half a clinic at the time, and I was the first reproductive endocrinologist currently we Have 32 reflective endocrinologists and are adding a few more. So it's grown very, very rapidly. As the first chief medical officer, at our brand new company, there wasn't, you know, like a specific role to follow. And so, you know, I had to kind of create what I was doing. And that has changed a lot over the time. So early on, I was involved in many, and almost all aspects of the company from, you know, helping design the clinics and going and getting the clinic setup and doing all the training in the clinics and recruiting and developing all the initial medical protocols. You know, getting all of the labs up and running worked very, very closely with the embryology teams. And, and then over time, as we grew, my work has had to shift right, because now I think we have close to 1000 people, and, you know, can't do everything that I wasn't in the very beginning. But it was really fun, being able to create a different model for health care. And I love that both of my daughters go to Kindbody for their, for their general GYN care and all their friends. So that's been really rewarding to see, you know, even my family wanting to come to Kindbody. And then and then seeing that increase in access to care has been, has been incredible, especially with the Walmart, being the health benefit for them and, and really having health care benefits for people who never ever thought that they would be able to do fertility treatments. That's been really incredible. A lot has happened in these four and a half years. Did I did I hear you correctly that you were the first REI? Did you say you're the first or the third. You were the first?  I was the first REI at Kindbody? Yes.

Griffin Jones  07:12

And now there's 32. 

Dr. Lynn Westphal  07:14

Correct.

Griffin Jones  07:15

Okay, so you're you're laying the groundwork for a lot of people that come after you, presumably that are now your colleagues when you started in 2019? Were you the chief? Was your title originally, chief medical officer? Or was it something else that grew into that see, title?

Dr. Lynn Westphal  07:37

I was the chief medical officer from the very beginning.

Griffin Jones  07:41

What did you think that your role was going to be in terms of being mapping out of okay, in a couple of years time, I'm going to have dozens of colleagues, and I'm responsible for laying this framework for them. What did you see your task was at a time when when you were the chief medical officer with one Doc, you being that one, Doc?

Dr. Lynn Westphal  08:04

Well, the first things I needed to do was hire other doctors. Right? Because those are the people that we need, you know, to have our clinics. So that was, yeah, one of the critical tests early on was was recruiting other people to join con con body and finding people who believed in the mission, and we're as passionate about creating this new way of delivering care. And we're as passionate as I was.

Griffin Jones  08:39

How did you make that case to them? So if I'm the if I'm Gina, if I'm an executive or a big investor came about and thinking, Okay, well, let's get Lynn because she's got some credentials, and we'll we'll get have her to help us with the recruiting of the docks and building this Rei base. But you've got to paint some sort of vision for people to come over and and show them okay, this these aren't just investors in business people they are soliciting My advice for how we're going to approach are our medical framework, and I'm the one that's in the leadership position for that right now. So even if you could paint a corporate vision of access to care and, and having a better aesthetic and expanding demographics in generations, there's that corporate vision, but then it still has to be brought down to something more tangible that Rei is could say, Okay, I'm gonna go work for this person. What was that vision that you painted?

Dr. Lynn Westphal  09:42

So early on, I think people did have to take a big leap of faith. I mean, obviously, I had to get started. But, you know, the healthcare space tends to not change very rapidly. And people have done things the way that they always have done and, and it takes a long time to change anything. So being in a new company where we were creating everything from the ground up, it gave everyone a chance to be involved in that, which is, you know, it's really exciting to be able to look at a clinic and say, you know, I'm going to be building this, and we're going to have this culture where we're, you know, going to make it easy, and very comfortable for patients to come in. And, and then there was the opportunity to really promote leadership in the people who are coming into the company, that was a big passion of mine. I loved being a fellowship director. And then after fellowship, I found that a lot of my fellows, you know, they still would call and text me. And I think there just are not people who are promoting or supporting people when they first wanted to practice, right, so there are different models and practices that people join. But, you know, I think a lot of people just, you know, jump into a practice and don't always have the support that they would like, or they need, and maybe don't see that they have the opportunities to grow, and be in a leadership position. Because we had so many places where we needed help, you know, so, you know, someone could be over the third party program, and someone could be over, you know, the PGT. And write that in there, just like so many places where, where we just needed people who could lead. And I really wanted people to think about what they were passionate about. And if there was a program that they wanted to develop 100% would want them to do that. So I saw my position as being able to maybe open doors and promote people in leadership positions.

Griffin Jones  12:24

You have these people coming in that you're helping to get to leadership positions, you're aligning them with their interests and their fields of study. What thesis did you have them entering into? Was it? Did you have a general thesis for them of this is how we're going to build this structure. And here's how someone that is interested in third party can contribute, or here's how someone that's interested in PGT can contribute? Did you have some guiding principles or systems in place when they joined? And if so, what were they?

Dr. Lynn Westphal  13:03

Well, so early on, right, the focus had to be to build up the actual clinics, and, you know, would promote them. So, you know, early on, we would focus on a lot of the marketing, you know, building the clinics, because you need to have the patients before you can build some of these other other programs. And so it was, you know, talking to them about things that we would need to do in the future as we get larger, you know, so for the very first clinic in New York, you know, we had our, you know, we were the people there were helping decide, like, you know, what PGT company we were going to use, and then, you know, eventually now we have our LM time labs. So there's just been this big transition early on with a small number of clinics, there wasn't quite the scale to have some of these bigger positions. But now that we have clinics all around the country, with that scale, there are so many leadership positions, because we have so many different areas that that need someone you know, to be the advocate for that program. 

Griffin Jones  14:24

Do you then see yourself as an arbiter at times? Yeah, if you have so many people that you can draw from with different areas of expertise, maybe this person's got really strong expertise and PGD. And this person's really got a really strong expertise in recurring pregnancy loss, et cetera. And and even if you break them into different roles, where they have influence over those domains there, those domains overlap. You have you have protocols that maybe you want to access as a company. Are you an arbiter in some way? Are you a referee and if so, how does that process to work,

Dr. Lynn Westphal  15:01

I'm really fortunate we have, you know, just an incredibly talented team. And when people come on, right, many of them will have an interest in a certain thing. And so, you know, if there's someone to, let's say, uncle fertility, and there are a number of people in the company who, you know, have experienced in that, but you know, had one person who was very passionate about that. So, you know, she's kind of leading that developed slide decks that we can use, you know, for the new patients. So she is the head of that, but then we have other people on that team, who are very experienced and have, you know, probably been doing it much longer than she has, but, you know, because she was so passionate and kind of took that on. So in these different areas, that there's usually been one person who has raised their hand and said, You know, I really want to do this, and then we find other people to kind of join a team. So it hasn't really been been an issue. And I think just the way that the culture has developed, you know, everyone just really tries to support other things that people are doing, and that people who are involved in, right, different different programs. So some people have multiple interests, and so maybe helping with this program and another program, but then you have kind of the the point person for a specific program.

Griffin Jones  16:34

Is there a source of truth for all of the programs? Like is there some kind of anthology? How do you organize it all of it? Here's, here's the different data sources that we pull from, in these different areas. Here's the our own rounding that we've done before, here's the points of view that we've written on before. Here's some of the abstracts that are different folks have worked on how do you organize all of that?

Dr. Lynn Westphal  17:03

So you mean, how do I organize these different programs are just organize? Just overall the medical piece,

Griffin Jones  17:11

like organizing all of the the literature and study that's been done in in different areas? Do you? Do you leave that to each person? Is there any kind of like central repository of where everybody is kind of contributing? And here's, here's all the abstracts that we've covered on this, here's all of the rounds that we've debated on these particular topics, is there any kind of like, I guess, I'm envisioning some kind of, you know, Kindbody library where all of this lives, I'll be at virtually, but that that makes it more easily accessible, so that you're not constantly having the same debates or that you're able to move things along. Because you're you're, you're revisiting previous conversations, and previous studies and previous decisions. So that, you know, it's not it's like, when you're in a meeting, and you're like, why didn't we already vote on that, who's got the meeting, who's got the minutes from the last meeting? Like, I'm just wondering if there's any kind of repository where all that kind of information lives.

Dr. Lynn Westphal  18:20

Early on, I developed just for the medical piece, like all the standard protocols, and you know, what to order in different situations. And then, you know, as we acquired other practices, and, you know, really expanded that in the last year and a half or so, we actually have what we call our kind ways. So there's a whole section, a drive where you can, you know, there's a protocol about, you know, x and, and then it has, you know, in that protocol documents that were used to develop that protocol. And, and we have someone who is frequently reviewing all the protocols to make sure that, that they're up to date, you know, in terms of the guidelines, you know, even things like, right, antibiotics for different infections, right, the the guidelines may change, so, so we'll have in the protocol, you know, where the guidelines came from, and we update them, you know, as as we need to. So we do, we're constantly revising our protocols, and we do have a place where, you know, if someone isn't sure, oh, how do I treat this? Or how do I do that? We have a document and it and it has, you know, all of the studies that were used to come up with that, and we're, you know, and then sometimes there are things that are a little bit less straightforward or something So we'll have these protocols and then, you know, there'll be some new study, and we'll have to revisit. And then if we're having a lot of debate, we actually have a medical advisory council. And so often those issues will come to that group. And we'll discuss it there and then hopefully come to some agreement and then present that to the whole group.

Sponsor  20:26

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Griffin Jones  21:35

So, you wrote the protocols in the beginning you set all those standard protocols and and then that was an before you hired all the other Doc's.

Dr. Lynn Westphal  21:46

So I had a basic protocol book, that, you know, went through the basics of what you do, and you know, these different situations. So you know, I focused on all the fertility, there is a separate one, because we do some gynecology, too. But I wrote, like a basic just so you know, people knew what to order in different situations, and, you know, went through different IVF protocols, just so that across the different clinics also, like for the nursing, they knew that if someone was going to do this type of protocol, this is, you know, how that was done, and how to order the medications. So all of these things do do relate. And then now we have much more extensive protocols that, you know, go into more detail with, you know, the references for, you know, for why we've made these decisions. And, you know, so for things like, you know, endometrial biopsies era is right, the data on that has changed over time. So we've in our protocols kind of changed. And we put in there, the studies that that we think are most relevant and kind of our recommendations.

Griffin Jones  23:05

Tell me more about how you included other doctors in there or chose certain protocols. As that process evolved. The beyond just it got bigger. That's one thing that happened, more references were added. But in a different podcast episode, I had Dr. Murdia, the CEO of Indira IVF, which is a network in India that they've got 250, fertility Doc's, he says, I've got one set of protocols, I've got one protocol for every situation. And the way I get them into implement is that I hire Doc's that are younger than me, and I teach them this is the way we do it. And of course, he talks about his mechanisms for feedback and how he adapts it. But I know that that that's not Kindbody's trajectory, didn't just start a big network and then hire a bunch of Doc's that were younger than you and then and then have them come in to that. And this, these are the first protocols that they're practicing. That wasn't how it happened with Kindbody. So as you're growing from one Rei to 32, you start off with, you know what, template might not be the right word, but you have a starter with your protocol book, and it gets bigger, but how else did that process work, as you start to bring on Doc's that have a lot of experience and, and might be doing things fairly differently in different parts of the country.

Dr. Lynn Westphal  24:29

We did put together a group to review all the protocols. And, you know, obviously, there are many modifications that that people will do. So we have, you know, kind of the basics if you're going to do this type of protocol. You know, this is how you do that. If you're going to do this type of protocol, you know, the sleeves, you know, this is how you do that. But then there are always tweaks. So we do I realized, it'd be nice if everyone did everything exactly the same. But you know, the person who's in the room talking to the patient, and you know, in the US, there are people who go around to different clinics, and they've tried this, and they've tried that. And, you know, they sometimes come in with a very specific idea of, you know, what they want to try, or they say, Well, I've done, I did this protocol, at this other center. And this worked better than that protocol. So they're always going to be these individual variations. But I think in general, for, you know, there isn't an average patient, but for, you know, kind of a patient who hasn't done a lot of treatment in the past, you know, I think most people will do one or two protocols routinely. So I think the standard is, you know, pretty consistent. And then they're, you know, some of these outliers, people have done many treatments, other places. And so, you know, we're trying to work with them and tweak things. And I think, you know, the patients do appreciate that we really do try to work with them, Listen, you know, to what has worked and what hasn't worked in the past. And it really is a collaboration with the patient.

Griffin Jones  26:20

And with regard to collaborating with the doctors, how does your role interface with the Medical Advisory Council that you were talking about?

Dr. Lynn Westphal  26:30

So I made that meeting? And, you know, we all add things to agenda to the agenda. And, you know, I tried to listen to all the views, and hopefully, at the end, we can come to an agreement on what makes the most sense, you know, for all of our doctors around the country, because we're also right, we're practicing in different states, there are a lot of different considerations. Some clinics are, you know, much smaller than others. So, every clinic functions a little bit differently. So I have that perspective, since I, you know, tried to visit most the clinics. And, you know, hopefully that that perspective, can come to an agreement that works for clinics, and whether they're small or large.

Griffin Jones  27:23

Do you find yourself giving assignments to the Medical Advisory Council, like we want to you that some new literature has come out in this area, and we want to update this protocol? I want to put someone on the Advisory Council for it, do you find yourself doing any of that? Are people coming to you and saying, I think that we should revisit this or we should maybe consider a different protocol in this situation? How much of it is is? Is you doing some tasking versus things being brought to you?

Dr. Lynn Westphal  28:01

It really depends. I mean, there are, you know, issues that will come up and they'll either ask, you know, can we have someone kind of be discussed at the Advisory Council, if there's something that I know someone has a special expertise and, and that is just come up, then I'll ask them, you know, to give us advice. So we also have, which is really nice, a Slack channel just for the Irie eyes. So like if things are coming up, you know, in real time, or someone has a patient with something unusual, you know, then they can put in the Slack channel, and they can get a lot of ideas from people. And then sometimes if we see that there's certain issues that are coming up a lot, then you know, that may be something that we discuss it our advisory council.

Griffin Jones  28:54

You were at Stanford for 25 years. That's a, that's a better part of your career. And it's a very different environment, being in a known established academic center, versus what at the time was a startup, a venture backed startup, looking for national and global scale? And maybe someday IPO and all of the things that come with that two very different environments, what aspects and look, trying to get you to be as specific as possible beyond collegiality and evidence based medicine, but but try to think of the specifics of what are those specifics that you came with that you transferred to your new role in this very different space? And what did you have to dispense with?

Dr. Lynn Westphal  29:46

Well, the biggest change was having to move quickly. At an academic center, you know, any change needed to be discussed and would take a long time to implement. Here, there was a lot of right having to make decisions, and, you know, sometimes make a change, right, within a day or so. So the, the timing of making decisions, like vastly, vastly different. But, you know, practicing evidence based medicine, you know, I think is obviously something that was very important in my academic career, and has translated and, you know, there are a number of people at Kindbody who, you know, have been in academics for a number of years, and I think we practice, everyone really wants to practice evidence based medicine. And so we do try to make sure and we and related to that, like, we will have journal clubs, where we will review articles and discuss them. And sometimes that will be something that we may bring to the advisory council to see is it something that maybe we should change our practice, you know, our field, things are changing so rapidly. And, you know, being at a smaller company, we're able to make those changes more rapidly. Also, you know, able to kind of think about things outside the box a little bit more. And obviously, with the pandemic and COVID and telemedicine, everyone had to switch a lot and how they practice medicine. And, you know, the switch to telehealth has been a big change for for us, too. And so a lot of the changes that I'm seeing also, were just kind of related to allow the changes have just happened in the last few years, too, right. So, you know, when I was in academic medicine, we never did telehealth. And now that's primarily what we what we do. So, to allow these changes, I think we're have happened just as the world has changed too. 

Griffin Jones  32:16

Are almost all new patient consults still telehealth?

Dr. Lynn Westphal  32:20

The majority there, there are a few locations where there are patients who are not as comfortable with telehealth. And so they tend to have more patients come in. And you know, and I do see this, you know, I see patients in all 50 states, and there are definitely pockets where people are not as comfortable using telehealth. So, I think depending on the patient population, what I mean overall, most people find it much more convenient. And now people who are in these remote areas where they don't have much of an option, other than, you know, driving along distance, but overall, you know, the majority of our patients, I think, prefer telehealth, at least initially, I think people it's become kind of the norm and I think patients now, almost expect it, right? It's much more convenient, they can do it at home, lying in their bed. You know, it definitely has made access better for a lot of people.

Griffin Jones  33:35

The use of telehealth, is that something that you let each clinic decide or do you decide at at a governance level, generally new patient visits are going to be telehealth. And then you make a couple exceptions for those areas where it's been less receptive.

Dr. Lynn Westphal  33:53

We've tried in general to move to primarily telehealth for for most visits.

Griffin Jones  34:02

Is that Is that like a decision that you make as chief medical officer that that finally said, This is good or this is even better for access to care?

Dr. Lynn Westphal  34:11

It was done as kind of a group operations decision. So wasn't just just my decision.


Griffin Jones  34:21

I want to ask you about where Clinical Operations and Business Operations overlap in your view, because I'm not convinced that these two are totally separable. And I think even in good faith, he could say we let the doctors make decisions, but there's just some decisions that impact other areas of the business and a different interview. I talked with Lisa Duran and we analyzed the New York Times podcast about the incident that happened at Yale there's a very popular podcast that The New York Times has released about an incident with Yale and fentanyl and patients that didn't have didn't have fentanyl, they were getting saline instead, and why We talked about retention and recruitment as a risk mitigation factor. And so there's an example right there where you could say, well, our hiring policy or hiring software is purely a business decision. But if it ultimately resulted in them having fewer nurses than that B, that impacted a clinical outcome. And so that's just one example of where business operations and clinical operations don't perfect. They don't, they're not perfectly separable from each other, there is an overlap in this Venn diagram. And so what is that overlap in your view? And how do you manage it?

Dr. Lynn Westphal  35:39

So clinical decisions, clinical care? I mean, we always make the decision on what is best for the patient. Now, in terms of, you know, workflow, and hiring and who's, you know, in the clinic, and staffing obviously need to work with business development about, you know, kind of what makes the most sense, and, you know, also, you know, discussing, you know, with the staff, like, what hours, you know, do we need to be open, right, so they're all the like, logistics that, you know, in terms of, you know, retention of the clinical staff, right, you don't want to burn them out. And actually, you know, that's one of the things that keeps me up at night a lot is just, you know, worrying about burnout of the staff. And right, it's not just in our field, I mean, burnout is a is a huge problem. And, you know, many reasons for that. So, you know, working with the operations team, we need to make sure that you know, that their expectations of ours and how people are working, aligns with us being able to provide the best clinical care, and a lot of it is, is education. Now, we have some wonderful business people who, you know, understand, you know, how, how complicated the IVF clinics are, but it is something it's very different than almost any other type of care, right? Because you have embryos in the lab. So even if you do your last retrieval today, you're gonna have embryos in the lab for another week. So, you need to think about that type of staff. And so the staffing is is very complicated and, you know, trying to have kind of the right model so that you're efficient, but you're staffed enough so that your your staff are not burning out.

Griffin Jones  37:56

The staffing ratios might be an area of overlap. How do you view staffing ratios right now? Is it is it still as hard as it had been in that in like, 2120 22, for getting doctors in embryologists are in A League of Their Own with regard to recruiting them, but I'm talking nurses, med techs, phlebotomist, front desk people, is it as hard as it was in the peak of the great resignation time that started in 2021? And went through 2022? Is it? Is it harder, just as hard? Is it starting to lighten up? How do you see that?

Dr. Lynn Westphal  38:36

I think it's just as hard I don't see that it has gotten easier to staff, the clinics. You know, partly because, you know, every clinic is looking for talented and trained staff, you know, so if someone isn't happy one place, right? It's often easy to find a position somewhere else. And just, there aren't a lot of nurses who you know, who are trained is because it's a very different field. It takes a long time to train someone so that they're comfortable in the clinic. And also depending on the state, right. And some places do have noncompetes you know, California and they're no noncompetes and so people can move around easily. And I have not seen that, that it's been easier to recruit people.

Griffin Jones  39:36

I want to ask you about how you got out of some of the seats that you started in the beginning. So you mentioned that in 2019, you got to have a clinic, you're the only Rei you're helping with training and recruiting. You are working with the embryology teams, you're involved in designing the clinic and various aspects of the company. Now the organization is around 1000 People are getting there. What seats did you start to pull out of? Or roles, tasks responsibilities? Did you find that you had to pull out of earliest? And how did you get out of them.

Dr. Lynn Westphal  40:12

So, as we, you know, built up different teams. So probably one of the earlier ones that I got out of was involved with the whole enterprise and, you know, talking to employers about benefits. So it was really fun, I didn't enjoy, you know, kind of doing these pitches about benefits. But, you know, we built up a big team. And, you know, one of the physicians is very talented in that. So she's kind of stayed on that, but so I haven't had much involvement in that piece for for a while. And, you know, it just got very complex, that whole side. And then, and then as we had more labs, right, the compliance side, we had to build that up and have much, you know, have more people involved in that piece. So I'm involved, some in the compliance, but we have, right like a whole team, and they come in and set up the procedure rooms. And you know, make sure that the embryology labs and all of that are, are set up. So those are probably two pieces just because we have such robust teams. And then I guess, also, on the HR side, you know, we have actually a team that just handles all the recruiting and interviewing and all of that. So I'm not involved in usually any of the initial, so early on, I, you know, often did some of the initial calls and much of the discussion, and now with a larger HR team, and not so involved in that.

Griffin Jones  42:10

The whether it's employer benefits and talking to employers or the compliance side or HR, what resources did you have to put in place before you could exit those seats, I'm thinking of this now, in my own businesses, I want to exit a few seats, there are things that I need to have in place, because right now, it's been my judgment call. And I need to expand my I need to codify my judgment calls in some way so that other people can make decisions. They don't have to text me for approval for every little thing. Otherwise, I'm not in that seat at you for editing the News Digest. Right now, I'm still the one that's doing most of the editing, I would like to be out of that completely. Within some months time, one of the things that I really have to work on is okay, here's an editorial guide. This is exactly how we sound and how we don't sound I go through our own examples of this is why we chose this story. This is why we chose this editing of this story. I'll go through examples of news outlets that I don't like, I'll show you, here's what we don't do and which one of our attributes that goes against take examples out of the Wall Street Journal and said, Here's examples that do enforce our attributes. And, and then I'll do loom videos to show here. If I'm editing an article, this is why I'm taking this out. This is why I'm striking that this is an adverb, it doesn't follow our editorial voice. And so I make these resources and attempt to to get out of those seats. I do this for all kinds of seats. But this is one where it's just it's very close to me. And right now, my judgment is the one that is the body of governance right now, when you stepped out of talking to employers about about structuring employer benefits, for example, or whether compliance or HR, you had competent people, but you still had something that you needed them to be able to work off of, as opposed to your judgment, otherwise, you're not really out of them. What resources did you put in place?

Dr. Lynn Westphal  44:15

Well, the resources were right, from multiple places and the company, right. So, you know, the CEO, was great at finding great leaders for these different areas. And as those people came in, right, they just kind of took over. So it was and I guess, you know, there are only so many things that can be a focus. And so, you know, just as someone became the senior person in a division, I just, you know, kind of backed, backed out so I was, I think, a little bit different than than what you're doing. I mean, obviously, you need to find the right person. But, you know, I, and those people in those positions, often, you know, we're being mentored or trained by by someone else standing and the company

Griffin Jones  45:21

in some of those cases, because this isn't like the it's not like they're taking over the medical officer seat in which you do have your, your established protocols, you have your medical advisory council, in the other seats, it sounds like you are filling in, in many cases, do you feel that way? Like you you are filling in for other seats? Or did it feel like it was a part of your seat at the time?

Dr. Lynn Westphal  45:46

Well, early on, right, there were very few people at the company. So everyone was doing kind of everything. And, and, you know, it was interesting, I learned a lot being involved in all those different aspects. But, you know, then, as we grew, and there were people to take over those different divisions, then, you know, kind of back away from some of those roles and focus more on the specific medical aspects

Griffin Jones  46:21

you talked about as you came from Stanford, one of the things that you got used to was the speed of decision making very different in an academic setting, versus being in a in a venture capital backed enterprise. Now, that kind body is bigger, you're not quite a startup anymore, there's there's been at least a couple years of maturity and development. And it's at a much bigger scale, is that speed of decision making the decisions thrown at you that you have to make quickly? Has that sped up or slowed down?

Dr. Lynn Westphal  46:55

As we've gotten bigger, I think the speed has slowed down some, because, but there are more people who are involved in the decisions early on. Right, it was me and sometimes maybe one other person making some of these decisions, but now, you know, we, we need to get input and, you know, a decision in one area, we have to look at the impact on some of the other areas. So, you know, it's, it has slowed some of the decisions down

Griffin Jones  47:35

the manageable pace, perhaps finally, maybe you can breathe for for half a second, how does the Chief Medical Officer role interface with medical directors, in other words, when does the Chief Medical Officer role and in the medical director role begin.

Dr. Lynn Westphal  47:54

So the medical directors at each site are the ones you know, who deal with their specific workflows, you know, any issues that come up day to day, you know, kind of managing the staff there, if there's something that that they need help with, or, you know, something that is a bigger issue than that, then that will come up to me, but the medical directors, you know, do all the day to day management. And, you know, if there's something happening, they'll they'll reach out to me that they, you know, if they think there's something that I need to be involved with, or if there's something that I can do to help, and then I'll get involved, but I, you know, the medical directors are, you know, a very talented group, and, you know, and I want them also to, to be able to grow as leaders, right? So, you know, if I'm micromanaging everything in every clinic, right, they're not really going to grow as leaders. And that's really important to me, I want these people to feel like they're, they're developing these skills. And related to that we actually have a director of, of leadership or of learning and development and she has leadership courses. So we want all of our areas to do a leadership course, shall so we'll do like some individual coaching to help people build skills that they need for their particular setting.

Griffin Jones  49:42

What's the biggest thing to the extent that you can talk about it that you're working on that you really need feel want to get done in the next six months?

Dr. Lynn Westphal  49:54

There are so many things that that I would I'd love to see. I mean, I mean, in the next six months, we're opening more clinics, right? So that I mean, that's always a big, a big lift to get new clinics open, we get the staff trained, get everyone comfortable, you know, know all the protocols, the I don't know, if there's one specific thing, I think just trying to get all the clinics so that they feel that they have the support that they're as efficient as they can be. And then hopefully, the medical directors feel like they're able to do what they need to do in their clinics.

Griffin Jones  50:47

Does anything stick out in your head when you say, I want the clinics to have the support that they need? Does anything stick out to you in the last four and a half years that you thought, you know, I didn't realize that people would need this for support, I maybe didn't need it as as a clinician I, but but people seem to need this, or maybe I didn't need it before, but I need it. Now, what's something that sort of surprised you if you can, I'm putting you on the spot. But if you can think of something off the top of your head, that might not be obvious that people need for support, but has been very useful for you in supporting your medical team.

Dr. Lynn Westphal  51:25

So one thing that seems to really help people is to feel like they're making these connections. So I really try to find ways for people to connect different ways. And, and I love it when I hear right there little groups that will have like a little text chain, where they're discussing this or they're discussing that. And, and I don't want anyone to ever feel like they're like they're alone. So everyone knows that they can text me anytime I'm like, always available, I don't want anyone to ever feel like they're in a situation, and they're not sure what to do. And they just don't know who to talk to, I think making sure that everyone feels that they have someone to reach out to or, or know that there's always some available and having these these connections and feeling like they're really part of a team. You know, I think that's been, I think, really important for everyone mentally to feel like they they have someone that they can reach out to right, no one, I think feels comfortable, if they think that they're just isolated and in some location or don't have someone to talk to. So I think making it very clear that there's always someone that they can reach out to and, and helps them.

Griffin Jones  53:06

The floor is yours to conclude with your thoughts. And maybe we think of some of your colleagues that might be a few years behind you but are considering the next step and Chief Medical Officer, whether it's for a network of clinics, or whether it's for a tech company, or somewhere in between, but they're looking at this opportunity to be a chief medical officer, and whatever that might mean for the opportunity. They're assessing it. What maybe we just keep them in mind and and what how would you like to conclude?

Dr. Lynn Westphal  53:43

I think it's really important if you're looking at next steps or thinking about other opportunities to to talk to people who have lived on that. And it's really important to find good mentors. There are a lot of people who I think struggled because they just never found someone who could support them or haven't found the right support system. And and, you know, I have seen the difference it can make in someone's career to have right to have that person who is there to mentor them. And so I think for anyone who in any situation is either trying to move their career forward or think about doing something else to find someone who can help guide them in that process.

Griffin Jones  54:40

Dr. Lynn Westphal Thank you very much for coming on the Inside Reproductive Health podcast.

Dr. Lynn Westphal  54:45

Thank you so much for inviting me. 

Sponsor  54:47

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