Dr. Anate Brauer (REI, co-founder and IVF Director of Shady Grove Fertility’s New York Region) and Dr. Francisco (Paco) Arredondo (Chief Medical Officer and founder of Pozitivf and author of MedikalPreneur) hash out their agreements, and disagreements, on the upskilling of OBGYNs in the fertility space
Listen to the full episode to hear:.
Dr. Anate Brauer argue that years of training and experience as an REI do not equal OBGYN general practice upskilling, which compromises patient care and increases risk.
Dr. Francisco Arredondo state that it is taking place already, the need for providers far exceeds supply, and that OBGYNs are capable (and successful), if properly trained.
Dr. Brauer and Dr. Arredondo agree on where APPs can offload the burden of REIs.
Griffin question whether upskilling OBGYNs to handle IVF will create another chasm in the healthcare system.
Griffin push back that a solution needs to be identified, (after years of overpromising and underdelivering on the increase of graduating REIs), as they are handcuffed by fellowships and educational institutions.
Dr. Anate Brauer’s Information:
Website: https://www.shadygrovefertility.com/locations/new-york/manhattan-fertility-center/
Dr. Francisco Arredondo ’s Information:
LinkedIN: linkedin.com/in/fertilitysanantoniotexas
Website: www.medikalpreneur.com
[00:00:52] Griffin Jones: Can OBGYN do IVF retrievals? Are you good with that? Are you okay with that? You disagree. You the inside reproductive health audience disagree on if non REI fellowship trained OB GYN can do IVF egg retrievals or not. This is one of the things that we talk about today with my guests, Dr. Anate Brauer and Dr. Francisco Arredondo. We try to get down to the exact point that they disagree on and really zoom in on what they think OB-GYNs, that are not REI fellowship training, can do and can't do. There's a whole bunch of things that pile into this access to care argument, and I try to piece them out and I try to elucidate.
Okay. What's the exact point that you disagree? And I think we found that as well as we talk about the duopoly, the duopoly of the pharmaceutical manufacturers, we talk about the shortage of embryologists is that need even greater of a bottle of the bottle neck. Then the shortage of REI is we talk about expanding fellowship programs, which is never gonna friggin happen from my vantage point.
Maybe I'm being cynical, but Dr. Brauer promises to get me somebody that can walk us through that in a podcast episode. And I think these are two of the people to do it. This is a bit of a continuation from the debate that I have with Dr. John Storment and Tracy Keen, the CEO of Mater Fertility, both Dr. Brauer and Dr. Arredondo had listened to that episode as well as some others and felt that they had something to offer. And I think they both did have something to offer Dr. Brauer's of course, with Shady Grove Fertility in New York, she's fellowship trained from Cornell, which a various med fellowship program.
And Dr. Arredondo is the Medikalpreneur is going to be on a different episode to talk about that there are initiatives that he was involved in, including the foundation that he talks about in this episode that I didn't even know at the time of booking. I also didn't know that he sits on the board for Mate Fertility.
And so I feel that should be disclosed. It wasn't disclosed in the conversation. And so I'm disclosing that here, but I feel that both parties really spoke what they truly belief and and they both make strong cases for what they believe in. The shout out for today's episode is going to go to Dr. Matt Retzloff.
I'm sorry, friend. I probably butchered the study that you were recommending that would give us better data on making decisions about the quality of care. So, Dr. Retzloff, if you want to come on the show and spend the entire time talking about what you recommend. I promise to let you to do justice for you there.
So I can't make this debate. I'm not a clinician. We have two good clinicians on here who disagree, you analyze their motives. You do all the psychological analysis that you want, but you tell me, who do you agree with? Who do you think is right in this context and what are we missing? If anything, enjoy this discussion with Dr. Anate Brauer and Dr. Francisco Arredondo.
Dr. Arredondo Francisco welcome back to Inside Reproductive Health, Dr. Brauer Anate welcome to inside reproductive health.
[00:04:21] Dr. Anate Brauer: Thank you so much for having me.
[00:04:23] Griffin Jones: Dr. Arredondo has been on twice before. And part of the reason why you have Dr. Brauer is because I have had probably four or five people from Shady Grove on, at this point, and I'm going to be accused of playing favorites, but now I'm going to be accused of playing favorites with Paco too, because this is his third time on the show.
He's going to come back on for a fourth because he's got a new book, medical preneur that once I get finished reading that he and I are gonna go over that, but you're both on, because you each had some points of view on an earlier episode, a couple earlier episodes that I've done. One started off with mate fertility and that got people talking.
Then we had the CEO of made fertility on to talk with Dr. John Storment even before that episode aired. And that you shared with me that you had concerns about what the REI about taking things out of the REI preview and what that means Paco, you had points after that came out where you felt like that there needed to be a physician arguing for the side of upskilling or training OB-GYNs outside of fellowship, but let's start with your concerns not. And just, what was the concern that you had when you listened to that first episode, or just in general about the issue?
[00:05:43] Dr. Anate Brauer: Sure. So I think my background is I trained at Cornell, which I realize is in New York City, where there are 22 other IVF centers and there is a lot of access to care.
So I understand that we're coming at this from different perspectives, but my fellowship director always said to us when the time I was a first-year fellows. Our field of medicine, more than any other field of medicine has the potential to change society. As we know it right. For better or for worse. And I think that that comes with huge responsibility and liability.
And so it's a big undertaking. And one of the hardest things we'll talk about kind of bottlenecks to access because that's a big part of this discussion. But one of the hardest things I do is counsel patients not just do procedures, but also counsel patients on very complicated endocrine issues that have to do with competing, brokering failures and other things that we'll get into.
And I don't feel like I would be equipped. To treat the patient with the level that they should be treated. If I didn't have the training that I had. So it does concern me this idea of standardization of pair as a CEO of, of Mate stated that said that those words multiple times because each case is individual and all of the training that we've received and experience that we've had, I think helps us get that individual patient to their goal of competing safely.
And so that's my concern here in New York, by the way, what prompted my conversations about this and actually will prompted my interest in being on the start QA committee, which I'm now on, is seeing chart after chart of complications of IVF cycle overseen by general OB GYN who have not been properly trained, who are working for some of these companies that are looking now to scale very quickly.
And so that's what kind of prompted this concern in me. So there you have it.
[00:07:53] Griffin Jones: Okay. I'm going to come back that I took a couple notes on two different points. You made one about fellows and then another about the complications that you seen, but Paco, when you reached out to me and just said, there needs to be a doctor arguing.
There needs to be an REI arguing for the case of training OB-GYNs outside of fellowship. What did you mean by that? And if I'm paraphrasing correctly.
[00:08:14] Dr. Francisco Arredondo: Sure. No, no. Yes. I thank you once more for having us and thank you to, and not to be willing to do mental gymnastics here. So I would like to set three things straight before we enter into any debate in one of them is that debates in my view are not to be won or lost.
The baits are to be learned from that's the first thing I want to state. The second one is that if we agree in the context here, that we believe both sides, that human reproduction is a universal, right? That's the other thing that I want to set as a context, because everything else evolves from there.
And the third thing is that there is a difference between clinical medicine and health policy that we asked physicians at the clinical level. We use sometimes not always created at the same, and there are very different interests in individual care versus health policy. And when we have 90% of the needs of the fertility unmet in this country then is when I do argue that we have to think of different models of providing care and among them, we have to explore the possibility to utilize every one a was at the top of our licenses.
So that's basically what I meant. And I would start by saying that it is not my intention ever to replace REI's we don't be ever, but we have to learn from other places, even within our specialty, let's go to fetal maternal medicine, the fetal maternal medicine, which are high-risk deliveries and high-risk pregnancy.
Those guys do not do one single delivery. All of the deliveries are done by OB GYN. They basically handle themselves at the top of the license by managing different pregnancies, recommending guidelines, recommender, and course of actions, and are executed by OB GYNS. And it's the sociologist, the only way they run five or so at the same time is by having extensors like CRNAs radiologist.
They don't do every single x-ray. In fact, they just sit and read the x-rays that the technicians and other people run healthcare. Otherwise. If we have a potential market of 3 million IVF cycles in the United States, and we are currently doing 300 cycles. Even if you crank the production of REI, we will never have all the REI is doing every single egg retrieval that is out there.
So my argument is, and this is the argument of our nonprofit, which is called universities to train people, to do other tasks that physicians are doing, or nurses are doing that can be done by different people at the top of the license that is there.
[00:11:54] Griffin Jones: I want to let Dr. Brauer and analyze that in a moment.
I want you to start though Paco with what is the limit of what the REI can do? So if you already, I needs to practice at the top of their license. What is the limit to what can be done outside of fellowship training?
[00:12:12] Dr. Francisco Arredondo: Yeah, so I think I would approach it gradually. The other way it is, there is no question that an OB GYN and a nurse practitioner or a PA with good guidelines should be able to do every single diagnostic step of the fertility patients.
Number two. I think that doing an egg retrieval. For example, I would not give it to a nurse practitioner or physician assistant because they are not capable of resolving a complication bleeding, et cetera, but an OB GYN absolutely can do an accurate very well. There is no reason why an OB GYN can let's put it this way in the last week I spoke with probably 20 different fellows that our fellows out there that are coming out doing 10 egg retrievals in their whole fellowship that it's still to this day, they are reproductive endocrinologists that come out of fellowship without with zero embryo transfers, zero embryo transfers
[00:13:36] Dr. Anate Brauer: This is an issue write that down Griffin, because that's something that should definitely be touched upon regarding fellowship program.
[00:13:43] Griffin Jones: So I am writing that down. I want you to continue Paco with so every step of the diagnostic process OB-GYNs can do egg retrievals.
What else?
[00:13:52] Dr. Francisco Arredondo: Currently we're doing IUI is playing IUIs in the OB GYN office. And I think that there's no reason why they will not be able to do IUI and again, all under the supervision of a fertility specialist. Now you will have control of, or a guide, several OB GYN and there is a difference between what we call improvement in quality and innovation, because the requirements for improving quality are exactly the opposite to innovation quality requires consistency, repetition, precision standardization, because quality, the enemy of quality is variability. So that is what is required for improving quality. However, for innovation, you actually required the opposite. You require failure variation and serendipity. So we have to be able to dance this delicate dance between improving quality and innovating in healthcare.
And yes, how I see the market right now, or fertility taking certain steps imply that we will take some breaths. But not taking a risk right now, you will imply that will never satisfy the demand.
[00:15:37] Griffin Jones: So before we go improving the, before we go innovating, now, I want to see in this game of, of blackjack, let's call it and that where we're hitting you one after another, at first OB GYN is doing every step of the diagnostic process, then doing egg retrievals, then doing IUI.
Do you disagree with any of that?
[00:15:55] Dr. Anate Brauer: I think in general, all of these access conversations are glossing over one major issue, right? The issue with access does not just come down to how many RAs are graduating every year. There are other major roadblocks to access. So the three issues that I see with access are costs and affordability.
Even more than our eyes embryologists. Okay. And then REI is for us at SGS our biggest issue as we're expanding in various markets is not necessarily finding doctors to put into the clinic. It's even more so finding embryologists right. Takes about two to three years to train a good embryologist, to do biopsies and egg set cetera.
So all of these conversations are revolving around how do we get more providers? Did you retrievals to get more new patients in the door? But there's also roadblocks on the other end of that. I'll talk about some of the ways that we are trying to address from those, some of those robots within our organization and why I wish other people would be doing the same work.
I'm happy to talk about that. But one of my that, for example, when you were interviewing the Mate CEO that you were talking about access and costs, they don't take insurance. I have a huge, huge issue with that. And so I think we can not only talk about providers, if you don't talk about whats our solution for costs and embryologist, and a lot of the solutions for cost is well higher general OBGNYs, or would you want it?
And then you don't have to pay them as much as you do an REI by the way, some of my best friends in life are general OB GYN who are unbelievable, amazing what they do. And so none of this discussion in any way, a ding on being a general OBGYN. I also think we should look at our other fields in our space.
So I know some amazing generalists that are unbelievable surgeons. That doesn't mean that they can become GYN, oncologists. And so I think we should have a very clear discussion on what we need to do to expand more trained REI in this country and not only to roll over OBGYN, but also the role of APP.
For example, I do most of my own scans which I know sounds a little archaic, but that's how I was trained. And I'm in New York and my patients want to see me and I liked him the ultrasounds, and I think the more ultrasounds is even better, your retrievals. But I do think there's a role for APPs is, are advanced practice providers to do ultrasound, to do IUI, even to manage IUI cycles.
It doesn't even necessarily have to be a general overview. And I personally do not feel comfortable with the general do and doing retrievals unless they've done thousands and thousands of retrievals or unless it's an REIs physically on site. The CEO has made with saying, oh, we have five REI's on the board who are there by telemedicine.
She also didn't mention who these people are, but I don't know what REI that I know would feel comfortable with the liability of being on a video, walking in GYN, through a complicated egg retrieval, and some that has fibroids, maybe someone that needs an abdominal retrieval, it SDF. We have a policy that if someone requires an abdominal retrieval because of body habitus or anatomy or fibroids, there has to be two MDs on site to do that together in the, or so yes, 99% of retrievals are easy, but when they're hard, they're really hard.
You can be one millimeter away from the illiac I mean, I will not feel comfortable with an OB GYN handling case like that unless I was in the room with them.
[00:19:22] Griffin Jones: Okay.
[00:19:23] Dr. Francisco Arredondo: You will know those hard retrievals in advance. Obviously you will not have scheduled them.
[00:19:28] Dr. Anate Brauer: Not if I'm not scanning them.
[00:19:30] Dr. Francisco Arredondo: Huh?
[00:19:31] Dr. Anate Brauer: Not if I'm not doing the ultrasound.
Right.
[00:19:34] Dr. Francisco Arredondo: Do you think that an OB GYN will not affect the note by an ultrasound? A fibroid? I mean, I think that the OB GYN are capable of doing that and much more surgery, sometimes more complicated than, than I realized, but that is a debate that we can have, but regarding the issue of REI and the access of costs, I think it is very clear that the lack of production of REI is related to the lack of decrease of cost of idea.
We actually have very high IVF costs because we don't have enough supply. And if you think about any other industry, even in healthcare. Braces, I remember when I grew up only the rich people have raised raises a lot of other plastic surgery, every single one of those procedures has been going down in price.
The microwave was $600. Now you buy for 30. The only thing that has going up is the IVF cost. And it's not only because of the physicians. It is because there is a duopoly on the pharmaceutical industry. There is other reasons that there is no competition, but if there is in now with the consolidation of private equity, it actually will have even less competition that will not be quizzed the price of access.
So my point is that the correlation of access to cost is directly correlated with the lack of providers.
[00:21:13] Dr. Anate Brauer: Right. So how do we increase that? Right. So for example, we, so I'm part of Shady Grove Fertility, which is a part of a larger organization US fertility, we train, we graduate about six fellows a year. So we now run the NH fellowship program, the University of Colorado's program, and the University of South Florida.
[00:21:33] Griffin Jones: But how many of those are new fellowships? And not like the University of Colorado was acquired by us. Jeff Jones was acquired by us. Jeff, not how many of them are new?
[00:21:42] Dr. Francisco Arredondo: We need hundreds.
[00:21:44] Dr. Anate Brauer: Right. But hold on a second. Let me just finish what I'm saying. Right? So we support those fellowship programs. We train those fellows, we fund those fellows.
Which I don't see any other non-academic program doing or offering to do. We would love to open more fellowships. For example, I'm here at STF, New York with my partner Tomer singer, who was the director of the residency director at Lenox hill for almost 15 years. Right. So we would love to do that. The problem is there are many hoops and ACG requirements. You're required you to be affiliated with an academic center, which for us in New York, everyone's already taken up. Everyone already has their own fellowship program and they don't want the competition, which is a whole other conversation. It's impossible as an REI and New York city to even get hospital privileges because they don't want to give you privileges because they don't want you competing with them, which is a whole other problem that you really be on the cover of the New York time.
But that's the problem we want to train fellows. We do. I can't speak for other organizations like CCRM or Kindbody or anybody else. We want to train fellows. We are training fellows. We are training embryologist since we took over the Jones' program, we're expanding that training program. But these are the things that we need to be focusing on rather than taking shortcuts and hiring OB GYN and train them to do, what would we do.
[00:23:04] Griffin Jones: But everybody's been saying that for years now, and it still hasn't happened. We're still not adding more of them.
[00:23:10] Dr. Francisco Arredondo: I don't think that it's taking shortcuts. It's thinking out of the box to re think the model because the truth is being very realistic. If we are currently doing 300,000 IVF cycles with 1500 IVF doctors, and we have required 3 million cycles in the country, when are we going to produce another 10,000 REI?
We want. We want. Period. I mean, we have to be realistic.
[00:23:45] Dr. Anate Brauer: Right. I think the main issue is that the fellowship programs are siloed within academic programs who have no interest in expanding or working with private practices to expand fellowships because they're perfectly comfortable. In the situation that they're in.
Right. And so that's a major discussion that needs to happen. And I'm still asking the embryology question because my main limit to increasing my cycle number is how many embryologists do I have in my lab? And to me, it's much harder finding embryologists than it is to find an REI.
[00:24:19] Dr. Francisco Arredondo: And actually in that I would say Griffin to schedule a talk with Tony Anderson.
Who is our lab director and the main person. He has IVF Academy of IVF of USA and that he is going to be incorporated into our University. And basically he presented at the Pacific that after doing a two month training. The outcome is exactly the same as if somebody that has more than one year doing an exam.
He prove it. He has the data is not data that is just mentioned is data, solid data. So we are actually changing the way the training is happening. There is a hybrid training online, and then there is in-person with actual cases. And I think that the academy can produce very good embryologists in approximately four months with all the training.
Well, I'm not an embryologist and this is what my embryologists are saying.
[00:25:27] Dr. Anate Brauer: You should ask Michael Tucker and Jim Brown, and maybe they can debate each other.
[00:25:32] Griffin Jones: My job as moderators did keep this a little bit boring by preventing the 18 different topics from going, focusing on one. So I'm going to try and do that.
I do want to come back to Dr. Brauer's point about embryologists later because Dr. Storment afterwards texted me and said, I wish that I had brought that up to although now no, I'm going to save my tangential thought for when we come back to that, I want to, and the duopoly of pharmacies and the fellowship programs, I want to come back to still what you are comfortable with the OB GYN being trained to do not.
And it sounds like, okay, they can do retrievals if an REI is physically in the room and.
[00:26:13] Dr. Anate Brauer: Yeah. And then that defeats the purpose, right? Because I'm still physically in the room. I still have to physically be in there. They will do the retrieval.
[00:26:23] Dr. Francisco Arredondo: I personally disagree that you don't require a REI to be pressing down the hall? Not even, I mean, not even there because an OB GYN in a simple case, which is what we want to select to give to them. They have the capacity to open that patient. They have the capacity to the tech. When the patient is bleeding, they have the capacity to suture a cervical artery probably better than us.
So now they have not done it. And as I mentioned, there are currently a lot of our REI colleagues when they started practicing, they have done less than 10 equity retrievals. That's what it is in. we are naive and we don't think that that is happening, that we were learning on the train.
[00:27:09] Griffin Jones: Anate are you not satisfied that an OB GYN could address the complications?
[00:27:15] Dr. Anate Brauer: I fully again, like many of my friends who were generalists are probably better surgeons than I am I guess I don't understand what the, the kind of, it's almost a perseveration of OB GYN, OB GYN, up-scaling OBGYN and why is that?
[00:27:31] Dr. Francisco Arredondo: Because we have 90% of the market without cover. We have 90% of the market that is not covered.
[00:27:38] Dr. Anate Brauer: Okay, so let's talk.
Why are they not covered?
[00:27:41] Dr. Francisco Arredondo: Because A, lack of access financially, B lack of go live, go of competition because we don't produce and offer REIs and our boards have for 20 years spoke with both of them. Saying that they wouldn't increase access and they have not done it because we have not produced more REIs because there is access to care.
Like there are certain areas that are in rural areas that they want to solve right now. Their practice in private equity will not buy it because, oh, it doesn't provide a lot of revenue there. So those are in insurance coverage is another one and that it is not mandatory. So all those are reasons.
But the main reason, if you look at any healthcare issue is a supply driven market. The more suppliers you have, the bigger the market will be there and we are not supply-driven.
[00:28:43] Dr. Anate Brauer: So I just want to take those points one at a time. Right? So. And put the, my argument aside for a second, because one let's, let's talk about cost, for example, that's the first thing you mentioned.
So the main issue with costs is lack of insurance coverage. Right? If everyone had insurance coverage, everyone would have access. Is that accurate?
Right? So that's that we should be focusing on. If the,
[00:29:16] Dr. Francisco Arredondo: if the, if the, if the insurance is given to everybody, not only the ones that work, then it will be covered. So if they don't see universal health care coverage, yes.
[00:29:25] Dr. Anate Brauer: Your premises I'm from Israel. Originally, everyone has coverage and everyone has IVF pilots.
But
[00:29:30] Griffin Jones: how does that supply, how does that solve your supply and demand issue pocket? If, if, if, if we're, if, if we're only serving a quarter of the population are actually not a quarter, a fraction of the population and, and that's, that's covered and we still have eight and 10 week wait lists. How does, how does ensuring more people increase access?
[00:29:55] Dr. Francisco Arredondo: I don't think so because you have much more demand, but you don't have for supplies.
[00:30:01] Dr. Anate Brauer: Okay, so then let's talk about why are there waitlist? So we have, we have, I don't know, 40 something offices now in all different regions, we follow our waitlist very closely. We're not in any, , we're in Colorado, Colorado spring.
We're not, , we're not in the Midwest. So I have friends in Nebraska. I think she has a wait list of two or three months or something like that, which they can get their initial workup done with her OB GYN. And by the time they get to her, , I think COVID has changed a lot. We can do a lot of virtual consults to me.
When, when I talk about access, someone's not going to open you to financially support IVF labs, to be able to argue, to put an embryologist that two minimum, two embryologists there could you need witnessing and all the staff that you need to staff a, an ASC, et cetera. You may have an ASC in a major city and you may have kind of satellite monitoring.
Stations, if you will. And if I train some on whether it's an ultrasonographer or a PA, it doesn't have to be a general OB GYN is my point. If I train a PA to do all the monitoring there, I think I have more than enough time to review those cycles. So that's why I don't know what, why specifically we're talking about the way to solve the access to care issue is trained more overdue in because if I had someone doing monitoring and then coming for me to do retrievals and my partners to do retrievals and I can sit there and do virtual consults all day long, I don't see why, why this is an issue.
I don't
[00:31:27] Dr. Francisco Arredondo: think that we can, we can, we can not do 2.7 million ed retreat. We can't 1500 people cannot do 2.7 million egg retrievals it's on reasonable is up. It's not possible. I do agree with you a hundred percent. We open a satellite, a hundred percent run by a PA a hundred percent. She saw the patients she's monitored.
She sent them, we do the egg retrieval. We do the transfer could not agree with you more. And that I think that we can set it up here as the basis for agreement that we can develop satellites where everything else. And we can start as a point of view to start training those people, to do the satellites.
Now there's going to be a point that those satellites are going to saturate the egg retrieval bottleneck that will occur, and then we can discuss the next step. But I think that as a first step, we need to train people that. It's comfortable doing all the monitoring, all the counseling and tweaking the medication during the stimulation.
So we agreed that they can do the diagnosis. They can do some basic,
[00:32:49] Dr. Anate Brauer: oh, I said, I set
[00:32:50] Dr. Francisco Arredondo: a PA or nurse practitioner or a generalist. It's okay. It's cheaper. Or is less expensive if you use a RPA, but now for an country. I certainly will allow. In fact, there are plenty of OB GYN out there, general OB GYN that are doing that for,
[00:33:08] Dr. Anate Brauer: with as we speak.
Yes. And I have managed their complications.
[00:33:16] Dr. Francisco Arredondo: I
[00:33:16] Dr. Anate Brauer: have, I'm not saying there aren't out there and , we've all had complications.
[00:33:21] Griffin Jones: Did they appear to be disproportionate to you or not? Did they do, does it appear anecdotally, do you, does it seem that you're seeing more complications from
[00:33:31] Dr. Anate Brauer: hyperstimulation syndrome? Absolutely because they haven't been trained and.
Hundreds of thousands of simulation cycles. And by the way, I totally agree with you Paco. I was lucky enough to train at Cornell where by the time I graduated, I saw more simulation cycles and most attending feat in a year. Right. So I understand which is another issue. Like there's fellowship programs out there that do 200 cycles a year, that's it?
And they have two fellows. They should not have two fellows because those fellows aren't getting clinically trained. I mean, that's a whole other discussion even needs to be
[00:34:05] Dr. Francisco Arredondo: had. And that would be the second point of agreement, which is we agree that we can train all those people. The second to try to find common ground is that somehow we need to revisit how the people is being trained in fellowships, because we're putting a lot of emphasis of 18 months or 20 months in research when 99% of the people come out and do IVF, maybe we need to track.
So REI. The researchers
[00:34:36] Dr. Anate Brauer: and the IVF. So
[00:34:39] Dr. Francisco Arredondo: you'll have now two different tracks and you can produce in one year a good REI fellow in a, that is going to do IVF because by that year, they can do easily a hundred retrievals, easily 50 transfers and seeing their sheriff complications and they can go on. So that's another compromise that I have no problem doing.
But I think in, in, in basically that's one of the ideas or just university that we really need to create. And that's what we've made it a nonprofit, because we don't want to, anybody to mention that we're doing this for profit thing. We are doing this for the firm belief that we think that the United States.
Do not have the healthcare that they deserve at the level of fertility, we have 90% and we need to change that and how we do it, we can obviously have the debate and this, but we need.
[00:35:43] Dr. Anate Brauer: Griffin the fellowship question and the training. So at SGF, we require any one onboarding. I only have to do two weeks, but we require six weeks out of fellowship and spend it in Rockville.
You're doing hundreds of cycles. Minimum a hundred transfers before you can do anything in any of our labs. And so I, I, , unfortunately some fellows need a mini fellowship. We haven't made a business out of it, but maybe we should, but that's, ,
[00:36:11] Griffin Jones: and answer to your question of why this issue is I w I'm not qualified to argue that it's the most present maybe that maybe dogs are done to is, are arguing that this is the most important thing that we can do.
I'm simply observing that it is one thing that we can do out of many reasons. And the reason why we stalemate in politics very often, we're trying to improve education while the teachers need to, the teachers need to do this while we can't do that until the parents do well. And then you, when you. Go from one issue to another, just nothing ends up getting done.
So it's okay. We take the issues that we have in front of us and try to unpack each of them. I'm definitely not solving the duopoly of the, of the pharmaceutical companies here. And the embryologist, I do want to talk to more, but it's also another issue. Could it be more important than this one that's arguable, but this at least that the number of fellowship programs in the country is another issue, but I'm not a bog.
And and, and, and they still, nobody's still suggested in a bog person for me to talk, to, to do an entire episode soup, to nuts of what it would take to build find me, someone who, somebody listening, find me, that
[00:37:22] Dr. Anate Brauer: person find the same answer, but
[00:37:25] Griffin Jones: what's happening right now is that there are people training, OB GYN, generalist, OB GYN.
It sounds like. We have some agreement on what they can do. Some disagreement on the level of oversight needed and the, and the likelihood of complications that come from retrievers. What about the diagnostic piece? And what about OB-GYNs doing IUI?
[00:37:51] Dr. Anate Brauer: So I think so I would, I would, the first one talks about the diagnostic.
So is it Mitchell? And again, I am in New York city where I treat a very different kind of patient population. I very rarely see a bread and butter facilitation. By the time the patient is sitting in front of me, they've cycled the four other centers. And show up with their like binder of medical records.
And so I don't see kind of the bread and butter. I have a lot of friends who are generalists, who want to send patients to me and in the interim, they're kind of doing a workup. So I do feel like one thing that would definitely help is training is first of all, increasing REI education in general and OB GYN residency, right?
OB residency, four years, I spent a ton of time in antepartum learning all the MFM stuff. Do you want oncology that I, Cornell is a very, I also did my residency at Cornell, very surgical program. I, I went into ODU and to do, do an oncology and then swung the other lines of spectrum. But I spent so much time in OBGY/Onc.
I wanted to do REI and I spent three weeks in REI and this is someone who actually wants to do it. So you can imagine the resident that doesn't care. So the OB GYN is graduating programs right now. Residency programs really know very, very little about REI. So we have residents here rotate with us in New York all the time.
From various hospitals and, and the first step is to just teach them the basic workup. What does it take to make a baby? How do you talk to a patient about it almost from, as in flipping in normal uterus to implant normal ovaries with normal numbers of eggs and genetically competent eggs, right.
Just be at the conversations that the ingredients doing the workup, right. That automatically takes so much off of my plate. And so by the time they're coming to me, they're already kind of packaged up of, okay, here's the basic workup, also doing the preconceptual genetic testing so that they're all kind of set up.
So I'm totally comfortable with an OB GYN doing those sorts of things, then even comfortable with an OB GYN, managing IUI cycles. For example, as long as they're monitoring cycles, I'd actually rather have an OB-GYN working under. Stimulating patients and actually monitoring them than just randomly giving them.
Clomid like, it's candy. Like we see all the time. Right. And you don't even know how many follicles are growing and even an GYN or a PA or an MP doing an IUI at Cornell, which is very tightly managed. I mean, fellows can't even stand follicles that are over 13 millimeters, right? When I was a fellow, unless you were a senior fellow and very experienced and ultra down, but the NPS and the PAs would be the ones doing IUI.
So that's, that's very low risk. I have no problem with that. It's really, when it gets more into the, it's very important for me to counsel a patient on what IVFis, the pros and cons of it, the risks and benefits, the possible outcomes and complications, right? Because it's all about setting expectations.
And I feel like we know all the possible outcomes, genetic testing, which is becoming more and more complex. The pros and cons that are constantly changing every few months, we're learning more and more. And specifically when there's failures talking and counseling patients through that, we know with our eyes, what happens in the lab, most fellowship programs, you do spend time in the lab.
And so those things that take it does take a fellowship for them to learn all of those things, thin lining, but current implantation failure, we're current present the wealth, all of the things that we're still well versus taking it. So those are the cases that I want to manage. I feel comfortable with an OB-GYN managing a simulation cycle, but I also feel comfortable with a PA running through that dosing with me, which takes, , five seconds for me to do.
And I'm even profitable the PA doing the IUI. So that's why I don't, I don't think it even requires training general. I would do am. I think an REI can handle it. Doing more cases. If we, if we're set up in a more efficient way. I also think one thing that we haven't brought up here, which is huge for efficiency is AI, right?
The, we, we at us fertility are, have, are investing a lot of time and money and research dollars into exploring various ways that artificial intelligence can be used. I think one of the best ways it can be used is, and this is for everything from doing an ultrasound, like you can have an MNA, take an ultrasound probe, put it in the vagina and you get a read out of every follicle and what sizes objectives.
Cause there's always subjectivity when you're talking about measurement. So something is a little of that to extrapolating it, to. Dosing a patient's right. And algorithms of looking at hundreds of thousands of cycles and predicting even based on fire cycles that, that patient's done when you should trigger how you should trigger, et cetera, and also into the lab of grading embryos, et cetera.
So I think, I think where the investments should be is training more REI, which is complicated because that involves a bag and ACG made all of those things. We've got to find a way to do it. Training more embryology. And artificial intelligence to make our lives more efficient to solve our problem.
[00:43:09] Griffin Jones: Darn it. He will, he will buy the, it'll start a new one by the end of this podcast
[00:43:14] Dr. Francisco Arredondo: at 99% of the things. I agree because I agree that we only as a OB GYN rotate one month and the issue is when they pressure you to take vacations in our, in every I in just one month or two months in the whole 48 months of of training, I do agree that artificial intelligence is the future.
And obviously there are already companies out there, like we were just mentioning and all that. I think the key difference, and we agree that we need to train REI perhaps in a more expedite manner. Or in two different tracks, we agree that we can utilize nurse practitioners, physician assistants in order to increase efficiency in the system.
All that I think the only difference that we have is that I feel strongly that a OB GYN can handle equity tremble. And obviously she does not. But in order to dive into that particular question, let's think of other examples within our industry , that you have birthing centers and you have delivery centers and in the birthing center, you're not going to send a patient with a previous C-section preeclampsia and diabetes to be delivered there.
No, you want to send this straightforward case that will have. Very unlikely, a reason to have a complication. And if that thing arrives, you have a system in place to send it to the delivering hospital, which is rare. So it is the same thing in fertility where you can put the simpler cases, especially those that are in rural areas in markets B's.
And C's where a train OB can do the retrofit. And we don't know what is going to be in the future because now in the future, you might get. You send the act to a place where they do. They send this sperm, they do the, the embryo, and now you send the embryo back to the place and anybody can do a number of transfer.
I mean, that could be a potential business model for the future, right? Where you do it. Richard was in one place. You freeze the egg, you freeze the sperm, you send it to a very concentrated laboratory. And you'll create the Ember and you'll send it back. And then you transferred the embryo that is possible.
And now you increase access
[00:45:48] Griffin Jones: w one point that was given to me, and I want you to apply it on this Dr. Brown Dr. Matt Retzloffemailed me after one of the earlier episodes and says that the only way to really know is to the effectiveness and the safety is and if I'm paraphrasing your point, Dr. Retzloff, you can come on and do your own show.
But he, he was talking about, the only way to really know, is to do a randomized blinded trial of, of outcomes of safety. And because I'm not a clinician because I'm paraphrasing Dr. words, how would that work? How would we, would we really be able to compare the, the outcomes from a board certified.
An ecologist versus the training that's being
[00:46:31] Dr. Anate Brauer: done, IRB will ever prove that study. And I don't really see patients signing up for that study personally. I wouldn't do that. So, I mean, I think it's, I still am having a hard time wrapping my brain around this conversation, even being a conversation and the word upskilling, which I had never heard that word before a year, 18 months ago, ,
[00:46:55] Griffin Jones: I adopted the word to distinguish it from fellowship training.
[00:46:59] Dr. Anate Brauer: I understand.
[00:47:01] Dr. Francisco Arredondo: Well, what happened? What happens in any other country in the world, in Spain, which has been a leader of fertility for years, Spain and France in Eataly in any other place, there's no fellowship, they finished and they go through a certificate or they. And mentoring. I don't know if in Israel there is a fellowship, is there a fellowship in Israel,
[00:47:28] Dr. Anate Brauer: but they're yes, but they're, they're also required to continue practicing general OB GYN and to take call because it's a, it's a socialized system.
So they see their patients after hours. They do new patient consults, like at 11:00 PM.
[00:47:43] Dr. Francisco Arredondo: But in order to do an REI, do you have to go through a
[00:47:45] Dr. Anate Brauer: fellowship? The practice? Yeah. I don't know if it's an official fellowship. You're definitely certified in fertility, all these things that you're mentioning.
They're still training programs and they're not six week training programs. I mean it's years of training. So, but at the end of the day, it's not a new fellowship program. Right. Did you believe that a really good general OBGYN should be take to be cutting out cancer.
[00:48:10] Dr. Francisco Arredondo: But I would not compare, I would not compare an egg retrieval with the level of complexity of, of a surgery of cancer.
[00:48:18] Dr. Anate Brauer: The liability is similar. I mean, don't feel like our field has the highest liability pretty much at any field.
[00:48:27] Dr. Francisco Arredondo: I don't think so. I disagree with that. The the premiums of REI are very low compared
[00:48:33] Dr. Anate Brauer: to the
[00:48:35] Dr. Francisco Arredondo: liability. That's how it's based. The liability. The liability is based on how likely are you to be sued.
And, and the premiums are fertility. They are very low, very low. I mean, compared to high risk OB, those are high.
[00:48:49] Dr. Anate Brauer: I feel like what we do and the counseling we offer and the potential issues in the lab are extremely high liability. And so I personally would want to manage those liabilities myself rather than managing someone else's life.
[00:49:06] Griffin Jones: We can bring Dr. Katz on for a liability episode to examine that. But Paco, I want to put something on you because a lot of this conversation might be overlooking second and third order consequences with regard to access to care that come from training. OB GYN is like, I don't know what their overall workload and wait lists look like right now, but I don't think most OB-GYNs are sitting around waiting for new patients.
I think they have case loads and workloads that are pretty full, full. I could that it could be an assumption that needs to be tested, but either way I think it's one we were overlooking here. So if we solve for access to care with regard to fertility treatment, by bringing more OB GYN in to do some of the purview of the REI, then aren't we creating a shortage of care somewhere else in the OB GYN sphere?
[00:49:58] Dr. Francisco Arredondo: I, I don't know. The numbers on the OB GYN, how many are needed? I think that overall, if you look at the statistics by 2045, we are going to have like 70,000 a shortage of physicians in the United States. No matter what specialty you're talking about, because again, we're not producing enough. The, the medical schools are not producing enough physicians.
But I don't specifically to your Western. I, I don't know. We may. But the, the point here is that basically the big disagreement that we have is if an aria, if a OB GYN, after doing 50 or 100 supervised egg retrievals, if it is not capable of doing ed retrievals for an IVF clinic, my answer is yes, if that person and I don't know what the number is, 20 5100.
Which in certain clinics, that person can be trained two months after doing that, it can, that person do equity troubles for you. Absolutely. Absolutely can. In fact, they're are doing it right now.
[00:51:09] Dr. Anate Brauer: Yeah, I guess my, my question goes back to Griffin. The point he just made, which I still don't see how this specific concept of upskilling solves our issues, because who's going to who we're going to take these jobs.
And we already see that happening. Our residents who GRA, who wanted to do REI, who didn't match for whatever reason. And now this is what they do. And then they get to put on Google that they're a fertility specialist and market themselves in that way. And now you're going to run into a shortage of generalists, which there's already a shortage of generalist generalists, definitely in this area.
I can barely get a patient in to see an OB GYN. Larger problem personally, I would rather train ABPs to do ultrasounds and help me with monitoring and make mission so that I can say my lane and do what I need to do and not take away from any other specialties who, who have their own issues with, with access.
And the other big concern I have is creating a two tier system of care, which we already have in this country clearly. Right. And we see it with cancer, for example, right? The main cancer centers. If you have cancer, you want to go to the best place flown, , you want to go to Texas MD Anderson, there's several big centers in the country you want to go to, you're not going to find it in small town USA.
I mean, I grew up in Memphis, Tennessee, so it's not like I grew up with, , so, so much access around me. Right. And so I do worry about. Giving one part of the population, kind of a water down version of what we do. And one part of a population, an elevated version of what we do the argument against that is, well, you're giving one part of the population, no option and other populations, the best option, but there's something to me just wrong about just because someone lives in a certain place or doesn't have enough money to afford the bad that, that you're potentially giving them a less safe experience.
And
[00:53:17] Dr. Francisco Arredondo: we don't know if he's let's save. And I would say, we don't know if it let's save. And I would say that if we take a risk, we may fail, but if we don't take any risk, for sure, we will fail
[00:53:28] Dr. Anate Brauer: to cover everybody. I'm happy to take risks, but I'd rather do it not with upselling of doing.
Well, what I mentioned before, I'm happy to send that set up satellite monitoring clinics, and
[00:53:42] Dr. Francisco Arredondo: we have proven that that works and delivers the same
[00:53:47] Dr. Anate Brauer: actual care, so that can work, but I still don't want to solve our problems. They
[00:53:53] Dr. Francisco Arredondo: are randomized controlled trials where nurse practitioners do embryo transfers versus REI in England, randomized control trials.
Exactly the same pregnancy rate. Exactly the same pregnancy rate nurse practitioners in, in, in in England doing embryo transfers versus
[00:54:14] Dr. Anate Brauer: res so, okay. So do you feel like we should even have any fellowship programs at all? I mean, everyone could be trained then what's the point of fellowship programs with everything can be, everyone can be trained to do.
Exactly the same thing. If you have any degree or any letter behind your, behind your name? Well, when
[00:54:31] Dr. Francisco Arredondo: you go now, you're talking about medical education. That's a very important point. So the traditional medical education is based on pedagogy, which is training kids, the dietary pediatry, that's pregnant kids.
The new in, we don't learn like kids will learn by adults, which is unprovoked. And that is by doing things. And you can go and look at medical education. And the best way now is not to saturate people with theory and books and stuff, but it's to give a minimal basis and do things and do things and do things.
So that's why I would say that I will feel very comfortable if I give good basis to an OB GYN and I will train that OB GYN with supervision. To do 50 ed retrievals. It's an experienced surgeon already. I will feel as comfortable as a fellow that sometimes just finished 10 or 20 Avery Tribbles. He has a lot of information, but it does not have the experience or rather the ability to solve a problem.
I am talking specifically about this task. I'm not saying handling all the things I'm talking about. This. I feel very comfortable doing
[00:55:54] Griffin Jones: it. So I want to let each of you conclude how you want it to, before we do them, I'm going to give you each an open thought to conclude on, but let's hit the embryologist question for a second, which I'm, this is completely anecdotal, but we have strategies based on clinics, different needs and capacities.
And I'm talking about my firm is a creative and biz-dev firm and it seems to me like clinicians hit their capacity first and then embryologist hits their capacity. It seems to me, this is very anecdotal that across the board is generally speaking as possible. The embryologist really, we hit that lab capacity some time after the COVID reopening sometime in September of 20 in the fall of 2020.
And so, but it, it seems to me like they're pretty neck and neck. Maybe the REI bottleneck is tighter, but they're, they're probably equal now, but why not solve the. Problem first Pacoor is, is this, is the embryologist, how is it not more pressing than the REI issue?
[00:56:58] Dr. Francisco Arredondo: Well, I think that you have to also look at AI, , not that umbrella just will be replaced, but there is a lot, there is the pipeline three to four companies looking at doing the umbrella in a box.
So, and the other thing is not only producing embryologist, but producing umbrella in a way that is lean managed. For example, right now everybody's checking their embryos and they want, and they three, and then they find who you really need to do that.
[00:57:28] Dr. Anate Brauer: But when we
[00:57:29] Dr. Francisco Arredondo: used to write one, three and five, now there's people not even checking them until day five or do put them in the editor scope and they just look at it that is working efficiently without changing the effectiveness.
So , one of the things here on, on, on lean management is that you have those two levels. And you have a cost. So how can we produce the same outcome with less cost or how can we remain with the same cost and improve the outcome? And here on the embryology question, you may pray, but actually they might not need as much in five years because AI may catch up with us.
Now you have a lot of people sitting there.
[00:58:16] Dr. Anate Brauer: I don't think I will catch up that bad. I mean, I think it's moving fast, but I still think we'll also always need embryology. Not for us in New York. I'll tell you that we are bottleneck has always been the lab. And so we really had to hire me. Now we have seven embryologists here, but. You really had to staff up and it's, and it's tough.
And so that was always our bottleneck and that was the bottleneck it for now. And that was the bottom line at NYU. I mean, everywhere I've been, that's been the bottleneck because in REI I can always add another new patient slot. I don't mind working hard and I don't mind, , seeing the patients and adding onto my schedule.
I have no issue with that, but the lab I, , in the lab is safety. It's I want my lab to be happy obviously, and feel like everything's being done safely. So I do think a lab is almost a better book, bigger, if not the same bottleneck
[00:59:04] Griffin Jones: Anecdotally, I don't see REIs leaving REI. I'm seeing embryologist leave the lab, which is crazy to me because they're so in demand, we have embryologists applying for jobs at my firm.
I'm a biz dev and marketing firm because they just don't physically
[00:59:18] Dr. Anate Brauer: want to be. I said, you send, send me their CV.
[00:59:22] Griffin Jones: They don't want to be in the lab. They don't want to, they, these are 20 somethings that don't want to, they don't want to work long hours, one and two. They don't want to be in a physical location.
That's a 10 by 12 room for, for however long I'm going to let each, I'm going to let each of you conclude Dr. Arredondo, let's start with you. And then we'll go to Dr. Brower. How would you like to conclude your points?
[00:59:47] Dr. Francisco Arredondo: Yeah, we'll start with your PaCo. Okay. Now, I mean, just basically I, we believe in, in democratization of IVF, we believe that every single human has the right to be reproduce.
And that is. International and universal human, right. We believe that we are falling short in the United States and that we have to think out of the box to rethink and reshape the model of how we practice medicine without ever compromising quality and without ever compromising safety. And we believe that we've been practicing fertility the same way for 40 years, and it is time to rethink how we do it.
We believe that part of that is to consider training physician assistants and nurse practitioners to do some of the tasks. And if we want to meet that demand of 3 million IVF cycles, we all to train other people to do egg retrievals. And we believe that OB GYN are a good candidate to do that.
[01:00:54] Griffin Jones: Now, how would you like to conclude?
[01:00:56] Dr. Anate Brauer: So I agree with most of what Dr. Arrendondo has said today. I do think we have a major access problem. I also believe that repositioning is a human right, and everyone should have access to it. I don't think that the problem can be distilled and easily solved by one issue of training.
Would you answer, did you do retrievals? I think as I mentioned before, the issues of access involve cost. Providers and embryologist, and the only way we're going to solve those problems is by increasing training programs, which is the long game. And in the short term, becoming more efficient through advanced practice providers and artificial intelligence and technology.
[01:01:35] Griffin Jones: You're both very good sports for coming on. You're both also advancing this discussion in the field by being able to do so in good faith. And so I appreciate both of you doing that and that hopefully we can use this as leverage to get somebody we're bringing ABOG to come in and do an episode about what it would be to accredit a REI fellowship program from soup to nuts.
Thank you, Dr. Arredondo. Thank you, Dr. Brauer for coming on Inside Reproductive Health.