Dr. Norbert Gleicher breaks down why he believes PGT- A is overused, over-funded, and over-aggrandized on the latest episode of Inside Reproductive Health with Griffin Jones. Is the genetics testing industry the new “big pharma”? Could PGT-A be harming pregnancy chances instead of improving them? And if so, why isn’t anyone talking about it? Tune in to see where you land on this week’s topic.
Listen to hear:
Grif and Dr. Gleicher talk about IVF “add-ons”.
Discussion on the huge differences in practice patterns.
The failures at the early attempts of rolling up IVF centers in the 1990s.
Talking points on the efficacy, or lack thereof, of PGT.
Gleicher’s stance on scientific literature’s inability to support the use of PGT to the level it is being used.
Gleicher explain why he believes Big Pharma has been replaced by the genetic testing companies, who also happen to be the biggest benefactors of PGT.
Dr. Gleicher’s info:
LinkedIn: https://www.linkedin.com/in/norbert-gleicher-88101916/
Transcript
Griffin Jones 00:57
Its the same old song, since I've been in the field, or at least working in the periphery of it from my perspective, but I admit that I can't judge the quality of the debates. I can't even assess the arguments properly because I'm not a clinician. What interests me about this topic is because of my vantage point, as a lay person, it seems like there hasn't been a shift. There hasn't been a consensus. Dr. Gleicher is from the very first generation of fertility specialists. He did his residency at Mount Sinai in New York. He went to rush Medical College in Chicago to work on immunology and microbiology, and then he founded his practice the Center for Human Reproduction in 1981. With Dr. Gleicher to talk about IVF add ons, we talked about the huge differences in practice patterns. We talked about the failures of the early attempts at rolling up IVF centers in the 1990s. And we zoom in on the issue of this efficacy or lack thereof of PGT. I need to be careful of how I summarize Dr. Gleicher’s arguments because I'm at risk of getting it wrong, but I think it's safe to say that he feels that the scientific literature does not support the use of PGT anywhere near the utilization that it is being used at in fact that it could be harmful, and that many of the reasons for PG T's wide implementation are from economic and social pressures. Dr. Glasser says the Big Pharma has been replaced by the genetics testing companies and the MSOs the fertility networks that are the biggest benefactors that PGT as the biggest exhibition spaces at annual meetings, there's a limit to how much I can press Dr. gletscher. In this interview business people with no scientific and no medical training should not be doing that. That's your job. What I am interested in is why isn't there a consensus? And is it the case? And how is this impacting the business of reproductive medicine? There may be people that want to argue the counter argument, they're welcome on the show, it's very likely that you're going to hear genetics companies sponsoring this show that I would even let a genetics company sponsor this episode. But I'm not going to be the guy to moderate that debate. Not on this show. I could have someone moderate the debate if I felt like it was going to be meaningfully different from what we've heard at the conferences. I'd be open to that if some of you want to be guests on either side of the argument. But first, you should hear Dr. Gleicher’s argument and I hope you enjoyed this conversation with him on inside reproductive health. Dr. Gleicher. Norbert, welcome to Inside reproductive health.
Dr. Norbert Gleicher 03:25
Thanks for having me. It's a pleasure being here.
Griffin Jones 03:29
The pleasure is mine. You and I have known each other for a while but we finally made each other's acquaintance. Someone mentioned to me that you had mentioned our newsletter in your newsletter, I became aware of your newsletter, and read one of your articles. And such is the compounding effect, the compounding network effect of content creation. And one of the things that caught my eye had to do with the perceived overuse of PGT. And you can correct me if I'm not characterizing it correctly, we'll set that up. But I noticed a concern for empiricism and transparency in medicine. And I want to go through that argument with you today. But first, am I characterizing it correctly?
Dr. Norbert Gleicher 04:17
You are characterizing it perfectly. And I would say that the concern about transmission of information has increasingly become a central issue at our center in our internal discussions in our research, in our evaluation of the literature, and has not the least been a big impetus for the creation or I should say the expansion of our newsletter because if you may have noticed, a very important section of our monthly newsletter is A review of the literature that relates to reproductive medicine. In general, it can be general medical articles, but there must be relationship to reproductive medicine and research in our field. And that section of our newsletter has really grown the most, because the response to it has been really phenomenal. And so we are really addressing this issue very aggressively.
Griffin Jones 05:32
What would you say the issue is specifically?
Dr. Norbert Gleicher 05:35
The principal issue is that I think that, especially since 2010, the the impact on our field from external, often financial sources, has been increasing. And that has been to the detriment of outcomes in IVF. Best characterized by the fact that like birth rates in IVF, which until 2010 have progressively improved since 2010 have been plateaued, and then in more recent years have actually been declining. And this is not only seen in the US, but around the world. And seems to correlate with the addition of add so called add ons. This is a term created by British colleagues several years ago, describing new things introduced into IVF practice without proper prior validation studies, and probably the most significant or one of the most significant is indeed PGT. Specifically PGA I'm not concerned that other PGA formats,
Griffin Jones 07:14
why 2010? In your view, is there a catalyst event, as far as you can tell it? Did it just happen to be around that time?
Dr. Norbert Gleicher 07:23
Well, it's it's really the acceleration of what I and some of our publications have called the industrialization of IVF practice. I don't know if you know that. But I was probably the first to try to roll up IVF clinics in the late 1990s, during the physician management practice, bubble as it is now known. And very quickly, learn how difficult it was and what the arising problems. Become when when when you develop chains of Fertility Centers and try to integrate them and try to establish best practice. All of those things that, really since 2010, have, again, become Vogue and have accelerated. I mean, I don't have to tell you, because I've gotten a lot of my recent information from your newsletter, about what has been happening over the last 12 years, 13 years worldwide in terms of roll ups, and creation of large fertility clinic networks. I think that has played a significant role.
Griffin Jones 08:57
I don't want to take us too far off, but I do think is germane to the conversation as far as discussing IVF centers, workflows and different providers workflows. What were the greatest difficulties at that time, you said you were among the first in the 1990s to attempt a roll up of IVF centers, you very quickly found out the difficulties, what were the greatest difficulties,
Dr. Norbert Gleicher 09:22
huge differences in practice patterns between individual centers for a variety of reasons, and certain conservatism amongst doctors. Meaning, resistance to change. And then, of course, economic considerations. The facts The more you intervene in a physician's established practice pattern, the more of a decline in productivity you will encounter. And so, it, it becomes kind of a vicious circle. It is very, very difficult at least that was our experience to to change a physician's practice pattern. And so if you acquire an infertility practice that had a very distinct or different practice pattern, you will be successful in changing that practice pattern, at least in our experience, then only at the cost of losing significant revenue.
Griffin Jones 10:52
And specifically, as you can please give us examples of these types of practice patterns.
Dr. Norbert Gleicher 10:59
They're almost unlimited if we go into into presentation genetic testing, for example, which in those days already existed, was called pre Implantation Genetic screening. You know, some people then already believed in it, others strongly opposed it. I think this discrepancy if anything has increased over the years, but also the utilization of PG TA has greatly increase. You just have IVF clinics out there, that till today swear that it's it's the best thing that ever happened to IVF. And then there are others like us, who feel that not only is PGT a, useless for most patients, in terms of outcomes, but for many patients, it actually does the opposite of what is claimed it does and actually reduces their pregnancy chances. So this is probably one of the most dominant subjects where this kind of discourse exists today in our field, but there are many other major subjects, routine culture of embryos to blastocyst stage, for example, that the even ESRM considers that today, the routine embryology practice in IVF. But when you look at what is really behind it, the you have to question the routine, embryo culture to blastocyst stage for everybody because the people who initially promoted this did their studies in a very highly selected good prognosis patient population. And subsequent studies who tried to show the same improvements in general populations have universally failed. Yet, we as a as a field, have accepted the claim that routine embryo culture to blastocyst stage improves, improves pregnancy outcomes in IVF. That is categorically false. Yet still, like with pgpa. This is the main treatment that is being pursued in this country for most IVF cycles.
Griffin Jones 13:55
Are you familiar with these very large consulting firms that they're retained by companies in lots of different sectors, health care, energy commodities, and they have rolodexes of experts in different verticals, and then they call you and they pay you for an hour at a time to talk to someone identified. group on the other end, they ask all these questions. Are you familiar with those groups at all?
Dr. Norbert Gleicher 14:20
I'm familiar with them because I get a lot of calls asking, asking me to set up meetings. I rarely do it. But yes, I'm familiar with that.
Griffin Jones 14:32
So I get these calls, too. And I take some of them sometimes, and I often get the question about PGT about its implementation and about its use and if if the doctors view it as an add on or if they view it as necessary, and I tell them I'm not qualified to answer the question. I say the only thing that I'm qualified to remark on is that I've been showing up since 2014 to 2015 And it doesn't look like there's any more consensus than there was eight years ago, it seems to me like it's the same debate. And from my vantage point, it doesn't look like there's any kind of consensus. So that's what I tell them. I can't speak. I'm not I'm not clinicians, I can't speak on the issue of PG. Tea itself. But you said that some people even back when it was still called PGS. They thought that it was it was the great they swore by it. And and some people say today, that is the best thing to happen to IVF and where others, like yourself believe that there's no evidence for that. Why Why isn't there consensus if it's the same darn debate at SRM and PCRs? Well, first off, maybe I'm making an assumption, is it the same debate that's been going on for years? And two, if it is, how has consensus not been able to emerge?
Dr. Norbert Gleicher 15:55
It is the same debate. I would argue that there has been a shift, I think there's increasing recognition that that the hypothesis of PEGDA, which is that by removing supposedly chromosomally abnormal embryos, from the embryo, embryo cohort, before embryos are being transferred into the uterus, will improve pregnancy chances for patients. I think that this increasing doubt about this hypothesis, so that from my vantage point, is a positive development. At the other end, as you correctly stated, they are those who are holding on and if anything else, they even have become more aggressive in in defending PGT A, and I cannot speak to their motives. Um, but several months ago, I spoke to one of those economists who called me and he made the startling comments to me in our discussion of the field, and his comment was, if PG ta were to disappear tomorrow, a third of IVF centers would have to close or at least to restructure. And I found that that interesting, because what what he meant to say was that the profitability of IVF in the US is obviously marginal. I mean, this is not a huge, not in an industry with huge profit margins. And he suggested that, in in many IVF centers, that profit margin comes from PG TA. But without PG TA, there would be no profit and maybe even loss. And, and this, this makes sense, when you think that PGA is not covered by insurance, and so as as a cash payment on top of what IVF centers are getting from insured patient coverage, this is a significant addition to the average cycle revenue. And if that were to disappear, because let's say for example, the FDA comes out with a statement that it considers egta inappropriate in certain circumstances, that would have an enormous economic impact on the field, so you cannot ignore that. But yet at the other side, there are people who, who see PGD as a religion, you know, there are people who are just believers, and they are not convinced by studies. They are not convinced by the opinions of people who are much smarter than I am. And they just stick to their opinions. So the motivations are open for a discussion.
Griffin Jones 19:49
You can't speak to their motivations, but at this point, you should be able to speak to their arguments because you've been on the other side of it for many years. What are their arguments in the best way that you can run? Present them.
Dr. Norbert Gleicher 20:01
Their arguments have been shifting over the 20 plus years that this procedure has been promoted. The the, the original argument of embryo testing was that it would improve pregnancy and life birth rates and would reduce miscarriage rates that has been dismissed over the years by various studies and has been acknowledged by ASRM in policies they statements by Essure, the European counterpart of ASRM are both in repeated statements have concluded that there has been no evidence to show that it really improves outcomes. And so as it became harder and harder to make the argument for improvements in outcomes, the rationale shifted shifted to Okay. It, it makes. It improves outcome, maybe in some subgroups. And first, it was in younger people, and now it is in older people. And again, I don't want to go into technical details. But those in my opinion, at least, those arguments are incorrect and are contradicted by by many studies, then the argument became ei increases, it still reduces miscarriage rates, that was also contradicted by studies. Then the argument became, yeah, but But it helps with single embryo transfer, which is, again another subject that deserves separate discussion, because this is also an add on. That, in our opinion, is is not logical to do single embryo transfer on every patient, in our opinion doesn't make any sense. But that is again, an opinion that has evolved. And so the pro PGD, a crowd argued that by testing the embryos and selecting a normal embryo, it helps with single embryo transfer, pregnancy and life birth rates. Again, studies have shown that that is not true in my opinion. But what is even more important than this proving their argument for potential benefits with which have shifted so much over the years, is that in parallel, there has been increasing evidence that PGT a harms patients and harms many patients in their pregnancy chance. And let me give you only one example for that, which is probably the strongest evidence for harm by PGT. pgpa allegedly classifies embryos as transferable or not transferable meaning, yes, you can put them back in the uterus or you should not use them and even throw them out. And that's that's the whole concept of pgti. Now, we started to doubt this concept in 2014. And we in 2014, started transferring so called abnormal inputs selectively, initially only so called mono soulmates because they are known not to implant and we transferred them under the theory. Okay, if they are really mono Assamese as pgpa claims, then they will nothing implant no big harm there. And lo and behold, we started seeing normal pregnancies. Now, we just published a paper in human reproduction a few months ago, about 50 consecutive such cycles from patients who shipped the embryos into our center because their own centers refused the transfer because they were by PGT. A declared this abnormal So, if they could not have shipped them to us for transfer, those embryos would have been thrown out to not use these patients had even though they were very unfavorable with a median age of 42, which is quite old. These patients had a pregnancy rate in the mid 20s. At that baby take home arrayed in the iteams. Now, what does that tell you? That tells you that there are 1000s and 1000s and 1000s of patients out there who went through PGT, who ended up with embryos that were declared as not transferable and who therefore don't have those embryos transferred. Yet, those embryos have a decent pregnancy and life and life birthrate. And these 50 Women who I just described, they didn't even use all of their embryos, yet they still have over half of the embryos frozen here, and therefore have even higher pregnancy chances sitting up there, they are not used. Is that a better evidence for the potential harm of egta than that? I don't think so.
Griffin Jones 26:21
Is that also not an argument, though, against the financial incentive argument of PGT, that if it is the result that we're not transferring embryos, Fertility Centers aren't in the business of forgoing IVF cycles for nil is, is there not a counter business argument to be made that there might be incentive to not use PGT, because it may result in people not transferring some embryos.
Dr. Norbert Gleicher 26:54
The issue of egta and not transferring embryos leads to another problem. And that other problem is that a lot of women who go to through two or three IVF cycles and are told in every one of their IVF cycles, that all of their embryos are chromosomal abnormal. The next message they're getting is okay, yeah, the only remaining choice is to do donor x. Now, donor eggs are a wonderful option, because they have the highest the pregnancy chances of any IVF cycle that the woman can have, because nothing can compete with 20 or 25 year old eggs. But I always tell patients, and I think this is another thing that differentiates ourselves from from many others, that I have seen very few if any women who came to us and said, Hey, I want to get pregnant with donor eggs, patients usually come to us because they want to get pregnant with their own eggs. And therefore we see egg donation as a wonderful treatment, but only as a last resort. And that is not the opinion of many of our colleagues. They are very, very quick, in in moving into egg donation with their patients. And when you look at national IVF data in the US use the FSC very few patients after age 42 Certainly for the three who still are going through IVF cycles with their own X. At our center, the median age of our patient population, well, the last four or five years has been 43 plus. So I think that's a reflection of of the different philosophy that is prevailing in the field. In most centers and and how we look at what is happening in in the fertility practice today.
Griffin Jones 29:12
If I dig any deeper there, I will leave my scope of competence and and won't be able to contribute. So I'll instead ask each of us to leave our scope of incompetence. Let's each step out of our pay grade for a moment and speculate that if it is the case, that there is a financial incentive to increase PGT add ons because of the increase of insurance or simply because PGT is usually cash pay. And then even if someone is covered via insurance, it allows for a cash pay option that's more profitable. If that is the case. Should we expect to see that bear out one way or the other as we start to see payer provider models so the He's groups that are doing are the payer and contracting with employers, as well as buying existing clinics starting clinics de novo? Shouldn't we see on one end of their model, a correction? Or am I missing something? In other words, if it is to gain more, if it is to just to add more money, would they be? Would they be losing something? Because they're not getting that on the employer benefit side? Or is it in fact better for them to add it on the employer benefit side? Because then they would be that they would be getting better outcomes on their provider side?
Dr. Norbert Gleicher 30:45
So that is a very complex question. With an equally complex as the complexity comes from the question, what is benefits. And I think that is the core issue of the whole discussion. Because in the old days, of IVF, and as you can see, from my hair or lack of hair, I am still a member of the first generation of, of IVF people. In those days in Chicago, when when I started an IVF center, we were the first IVF center in the Midwest, and one of the first in the country. In the early days of IVF. We all competed based on our outcomes. And that was healthy. Today, outcomes almost no longer matter. Yes, they are being listed national reporting sites, but very few patients, take them as a guide. And today, the competition is at a very different level. The competition today is much more than economical competition, it is a competition of academia versus private. It is a competition between networks versus individual practices. It's an economic competition, it is no longer a clinical competition. You know, the issue now is to grow. The issue is no longer to to get better pregnancy rates and better live birth rates. And I think that is at the core of our current problems.
Griffin Jones 33:00
Why do you suppose that is the case, though, because there's still an incentive on the patients and to pursue better outcomes at a lower cost.
Dr. Norbert Gleicher 33:09
There is a an incentive, the patient's on this on a portion of the patient side because insurance coverage has increased. And therefore patients who are insured, the only incentive is to go to somebody who is in their insurance. That financial incentive exists only among the non insurance, a paradoxically, the very poor. And the very wealthy. And, and the very poor, unfortunately, simply can't afford it. And therefore they are not visible. They don't have a voice. And the very wealthy frankly, most of them don't have to care. You know, they go by where they feel they will get the best care and what they perceive to be the best care not only in our field, I think that is true every throughout medicine, most information patients still get from their physicians. Yes, the Internet has become very powerful and and has much more influence than in the past. We had a good example. Because if it wasn't for the Internet, we wouldn't have patients and their so called normal embryos. from Europe and from Asia. God knows from where to us for transfer. But but the truth is still most infamous addition, patients do get from their physicians.
Griffin Jones 35:04
Let's talk a little bit about the information that physicians are getting in your newsletter. You reference a scientist named Carl Bergstrom, who I believe is an evolutionary biologist. But Brookstone wrote a piece where he gives aid rules for combating medical misinformation and for reviewing literature and other sources of info I suppose. And I'd like to go through each of those eight rules with you and see where might apply in this case. And so the first rule that Dr. Bergstrom offers is be aware of the environment into which we release information, how would you describe the environment in which information about PGT is being released,
Dr. Norbert Gleicher 35:50
I'd be happy to discuss his very interesting article, which was based on an even more interesting book. He wrote a while back, but I want to preempt that by making the point that the reason why he wrote that article recently, was his concern for misinformation, that the permits, medicine, medical publishing medical information, etc, etc. And partially driven, obviously, by our environment, and therefore, we have se se correctly, I think makes the point we have to be aware of the environment in into which we are releasing information. If we're sending out a news release, it's a different story than when we are talking to a patient or when we are giving a talk to colleagues. I think that is very important. And and we need to recognize that information needs to be delivered differently to different audiences.
Griffin Jones 37:03
The second rule is avoiding hype and tenuous claims of significance with regard to PGT. You talked about a few of those and summarize that what is you talked about that they have changed that the claims have changed? What are they now?
Dr. Norbert Gleicher 37:21
Oh, that's a very good question. And I think it is a question that that nobody, nobody can answer. Let me give you an example that I think demonstrates that the best. And then just taking PGT as an example again, but it applies to other issues, other subjects and other things. Equally. As I noted earlier SRM released 10 years apart to policy statements or opinions, which clearly declared that PGD has not demonstrated any outcome benefits to those points. The first one was in 2008. The second one was in 2000, at ASHRAE, kind of similar yet, yet. SRM just announced that they will update a release on the interpretation of PGT a results. Now, explain to me how a professional organization logically can provide a document explaining how the results of a test should be interpreted. That same organization claim has no benefit. Where is the logic? And I think that's, again, a good example of that, we need to be careful in what we are saying to the public. You know, we cannot say to the public on the one hand, test X is useless, it doesn't give you any outcome benefits, and then go out and say, okay, but if you do test X, interpret it in this in this way.
Griffin Jones 39:38
The next rule is to recognize the importance of visualization in making figures stand on their own. Is there a way that's being used by the opposition argument, in your view to represent the information that they're trying to get across?
Dr. Norbert Gleicher 39:59
Yeah, I Think this is a this is a more or less technical issue, I'm not sure if it has the same importance as, as the first two, it's more a technical issue in the how you present that, again, you can you can manipulate everything. And and that includes how you how you present that, and how you present that graphically. You know, you can you can present a graph in different ways, trying to, to, to support you with direct message without without really being objective in presenting the data. And I think that's what the author said in this, again, technical aspects. I'm not sure it's a major issue.
Griffin Jones 40:57
Here Berg strim talks about the vantage point of the writer of the literature with trying to envision and head off in advance abuse of one's findings. But let's put ourselves instead in the position of the reader as opposed to the writer, what what abuses Do you anticipate potentially coming? If the arguments have changed multiple times? What will they change to next?
Dr. Norbert Gleicher 41:26
That's a good question. moving the goalposts does not only happen in medicine, as we know, they happen in many other areas of our existence as well. What comes next is, is it's hard to predict. And again, I do not want to concentrate our conversation just on PG TA, because there are so many other issues in involved, as well. But what I think he wants to say with that point is that what you write and what you read, needs to be both done with caution. As a writer, you have responsibilities towards your readers, in how you present your data, and how you present the interpretation of your data. It is not uncommon in our in our medical literature, and again, I'm not referring only to reproductive medicine or only pgpa. I think it's an issue all over medicine and all specialties. It is not uncommon that authors performance study, produce reasonably reliable, good results. But then, in their own interpretation of their own results. lose it. And I think that's what he's referring to. And on this other side to answer your question about the reader. I think readers need to be cautious, I would say maybe even suspicious, not only in reviewing the study design, whether the design is appropriate, or whether you selected patients or you did anything else otherwise inappropriate. But the reader also needs to, to think through the conclusions of the author, it is not appropriate, though I don't think it is smart to automatically assume that the author is right in his interpret, or her interpretation of their own data. Okay, we need to be more critical. And that brings me back to what I said before that's a big part of our newsletter in reviewing literature and providing our subjective acknowledged subjective opinion about papers we think are of interest, both in the good and the bad.
Griffin Jones 44:19
When I see this happening when I see someone give a very different interpretation of the data that they just that they themselves compiled. It's very often not for economic reasons alone. It's very often for social reasons. And those two things overlap. They can compound each other of course, because you can have socially and economically aligned incentives. And if you're really trying to achieve an aim, you do want those two things too, to intertwine. But even though they overlap, it seems to me that the social is a lot more powerful. And even if it's driven by economics, it's Social, not wanting to be a pariah, that often leads someone to giving a very different interpretation from what they know to be fact. Do you see social pressure happening in the field? And what is it?
Dr. Norbert Gleicher 45:15
Absolutely, absolutely. There's social pressure. At every level, there, I can tell you that, in the early days of our criticism of what Ben was still called PGS, I hate to come back always to the same subject. But as an example, again, in the early days, and I'm talking about 2008, we reanalyzed, some early studies on PGS, from Belgium investigators. And we concluded from those studies, that PGS probably doesn't work. And not only doesn't work, but that it actually in older patients may be harmful. And we wrote a paper and send it to every journal, in our field and in the general medical literature and couldn't get it published. Until Swedish colleagues published in the prestigious New England Journal of Medicine, a study that showed exactly that point, much better than we would have shown in our paper, at which point I was called by one of by the editor in chief of one of the journals that had rejected our paper, and had us to resubmit. And they then published our paper subsequently, the point I'm making is that our review process in medicine and again, this is not only in our field, this is universal. Our review process is based on what is called peer review. And peer review is the review of your submission by your peers in that particular field in which you have submitted the paper, the editor of a journal, takes your paper and sends it out to peer reviewers who are quote unquote, experts in that field. But what does that mean that they are experts in that field, it means that they have an opinion in that field. And they usually have the predominant opinion in that field, because that's why they became experts in that field. And if you then come into this with, with a paper that contradicts the predominant opinion, you have a hard time and and it shouldn't surprise, and this is not only a problem in medicine there, this is a problem in physics, this is a problem. In in every field of science, experts are biased. And philosophers have known this for centuries. And our editors, unfortunately, very often still don't understand. But let me kind of make one additional point. In next month's newsletter, we are indeed discussing a paper that that was recently published about the big scandal that has kind of shaking up the medical publishing industry recently. Because I'm sure you're aware that one hot topic in science in general now are fake, fake papers, fake photographs, manipulations. It's it's a it's a major problem allowed this coming out of China, unfortunately, but it's also coming out of local from local sources. So a very prominent journal, not in our field, was notified by some scientists about alleged fake figures, fake photographs, in a whole series of papers by a particular group of investigators, resulting in an investigation. But what that investigation revealed, which is at this point unresolved, it's still open and ongoing. But what they discovered is that the people who complain about those papers which related to the introduction of a new Alzheimer's drug, had shortened the company which produce that Alzheimers truck. So the people who claim that the papers were fake, really had an interest in bringing down the stock price of the drug that was supported by those people. I am mentioning this here. Again, it did not happen in our specialty. I'm mentioning this here, just to demonstrate how closely intertwined today, medical opinion, medical messaging, medical publishing, is with economic interest. And that is a major issue that we are not openly and transparently addressing here.
Griffin Jones 51:05
That impacts what type of information the patients receive, what type of information lay people receive both extremes. fifth rule is if submitting in unreviewed preprint, consider its reception by the public. Let me paraphrase this rule for for the question of the example, which is, when you're seeing patients come with information, where are they? Where are the sources of incorrect information? Most common, as far as you can tell,
Dr. Norbert Gleicher 51:37
today, unquestionably the internet?
Griffin Jones 51:41
Sure, let's try to be a little bit let's try to be a little bit more specific than that. Is that anecdotes from friends? Is it? Are they reading papers that they that have summaries that they just they can't read the scientific literature themselves? And they're reading a couple lines from the summaries? Are they deliberately getting information marketed to them by companies? What do you see as the most common?
Dr. Norbert Gleicher 52:05
I think? To answer your question, we have two separate information to whom, if we're talking about the public, I don't have to tell you that the longstanding controversy in the US has been advertising to the public's about drugs, for example, we are one of the few countries in the world that permits direct advertising of medications to to to the public. And they are you have a direct influence of the public by drug manufacturers and whatever they want to present. That is not our primary concern. Our primary concern is, I think, maybe even more important, because our concern is the influence on those who prescribe those drugs, and physicians. And, and, and I think we underestimate here, what is really going on, I find it ridiculous that the laws were passed that prohibit pharmaceutical companies, from bringing pens to doctors offices, when reps, or coffee cups to doctors offices, when when the reps come by to push a drug. While at the same time we ignoring all the other influences that strap companies have on us, you know, just look at what happened during COVID. And look at what happened to the influence of drug companies on health policy during COVID. I mean, we we we are because of of the trees not seeing the whole forest. Yeah.
Griffin Jones 54:16
Is that because of the necessity of that influence that financial influence in order for the institutions to conduct their business. So the pens, the coffee cups, that's two individual providers, but I tried to picture in SRM where there was no pharmacy support to look at Gold Ruby diamond sponsors or or any conference that we had, I suspect they would look very, very different. And where would that money come from? Where would the money come for? For many of these? And I don't ask that cynically, I asked that truthfully, I appreciate that everything is a trade off, and that there could be benefit to those companies paying for events and studies. And but it seems to me though, that The reason why that may not have been regulated out in the same way that the coffee cups the gifts the individual correspondence was, is because could you even have an ASRM without that level of corporates spot and I'm not picking on SRM. It's true for any society, any conference.
Dr. Norbert Gleicher 55:19
Absolutely. But your observations, very astute. But can I ask you who you saw having the big exhibits at the SRM recently?
Griffin Jones 55:28
It's still still the pharma company. They're not gone. But it's the pharma companies and its genetic testing companies
Dr. Norbert Gleicher 55:34
and genetic testing companies that need
Griffin Jones 55:38
more storage and more AI. And
Dr. Norbert Gleicher 55:41
that's exactly it. That's exactly it. So this is exactly what has been driving our field in recent years ASRM. And, and God bless them. And I can't blame them because they need the money. ASRM does not have the support anymore from the drug company that drug companies because of all the stupid laws that were passed in the in in the last two decades. And what happened, new blood came into the same business and that blood a genetic testing companies and again, not only in the infertility field, go to the oncology conferences, go to other conferences. The genetic industry is now the new drug industry in their influence on what is happening and coming back to your earlier question about social pressures, they determine who the speakers are, who are invited. They determine to some degree what medical journals are publishing, just like the drug industry was very, very influential, you know, 2030 years ago. Now, over the last decade, it has been increasingly become the position of the genetic testing industry. And that is why there is so much genetic testing going on.
Griffin Jones 57:25
I want to conclude with one summary question. When we conclude I will let you conclude with your thoughts. I want to conclude our summary of Bertrams rules by summarizing the last three because they all have to do with media, traditional media press releases social media. And one of them says if you're submitting an unreviewed preprint considered reception by the public, this is the point where you start to see the social pressure come to bear, isn't it when you first release something, it's when people get jumped on that they very often either reverse their opinion or they say, Oh, well, maybe I didn't. And they issue some sort of caveat. They don't express their findings as strongly. Or if they don't do anything to revise their findings, they simply just stop talking about it. They don't submit the posters and and so this is the point where it where you start to see social pressures when you release that into the environment. And you can see people recoil. So what advice do you have I suppose for someone who's going to produce something that that may make them socially undesirable for some time.
Dr. Norbert Gleicher 58:41
It is the political correctness question. Political Correctness exists in medicine, as much as it exists in the political realm and the media environment. If you contradict political correctness, you have to be ready for the social consequences. You know, there are Nobel Prize winners who couldn't get the papers published and had to publish them and some third class journal. You have to be ready for the consequences. You know, it is always easier to be part of the echo chamber. There is no question. That's what what will make you popular that will give you all the invitations to speak. If you are not part of that, you have to live with it.
Griffin Jones 59:47
Dr. Gleicher, I'd like you to conclude with our audience who's largely your peers, but it's going to be some of the folks that are executives of the genetics companies as well. And so we have many practice owners and physicians but We also have a lot of folks that work on the, quote industry side, how would you like to conclude our discussion today?
Dr. Norbert Gleicher 1:00:07
We are in our respective medical fields all together. Like in in politics, I have a very hard time accepting the notion that, that we are enemies that that just because we do not share in opinions, we we have to be antagonistic to each other. I'm a capitalist, I strongly support the profit motive. But I also like to believe that I have a such a social conscience that mandates that I as a physician set the interests of my patients at the very top of all of my considerations. And that just because it's the nature of the bees will at times contradict other people's opinion. But that doesn't mean that we need to be enemies. That doesn't mean that we cannot together fine, find solutions that will benefit all of us and most of us our patients. Dr. Norbert
Griffin Jones 1:01:37
Gleicher, thank you very much for coming on inside reproductive health
Dr. Norbert Gleicher 1:01:41
was my pleasure.
1:01:44
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