Video interview with Infertility & IVF specialist, James Grifo, M.D.

0:00 Hi, it's Doctor Robert Seicherd with a new episode of Doctor Podcasts. And now we're on the X platform, which was formally Twitter, which will eventually change of course. And today I'm very pleased to have a special guest, Doctor James Griffo, who's sitting here right next to me. Doctor Griffo is a professor of Obstetrics and Gynecology at the NYU Langone Medical Center and also at the NYU Grossman School of Medicine here in New York City. Dr. Griffo is one of the most renowned fertility specialists in the USA and the world and has developed many in vitro fertilization techniques, IVF techniques, and we're going to speak to him about that today.

0:50 That's very exciting. Now, Doctor Griffo has been the director of the NYU Fertility Center since 1995. That's about 28 years. That's a long time. So Jamie, tell me, over these 28 years, how many babies have you and the fertility center at NYU brought into the world that normally would not be here if Mother Nature had her way? Well, quite, quite a few. It's in excess of 30,000. I don't have an exact count back 30,000 that's that's a huge number that's. Very. You can go anywhere and you run into one of these.

1:31 One of these kids that are, you know, up to almost 30 years old now. Some of them, right. And that's a lot of college tuitions also, right? Yep. They don't come free with the college tuition. They don't come with the cops. We haven't figured out that gene yet, but we will, you're working in that, that's great. So we mentioned IVF or in vitro fertilization. Can you tell us what that is and and how it works? So in vitro means in glass, which is ironic because none of this is done in glass, but it implies test tube and essentially what happens is we.

2:07 Surgically isolate an egg from a woman and use sperm from a male. And we can either put the egg and sperm, the number of sperm together and let natural fertilization occur, or we can actually inject a single sperm directly into the egg. We have to do that in cases where the sperm counts are really low and the sperm are as modal. That's called Ixi, intracytoplasmic sperm injection. So we're injecting the sperm to get fertilization. It's quite effective. But those are the two methods. And then once an embryo is created, we grow the embryo in the lab.

2:42 And in the early days we used to just grow it for three days. And what we found is it was really hard to figure out which was the embryo that was going to work because most of them don't, most of them are not healthy. So we learned probably in the 90s that if you grow the embryos longer in culture, 5 days. The the stronger survive, so to speak, the ones that will make babies make it there. And the ones that don't kind of screen themselves out. And then you're able to choose fewer embryos because in the early days of IVF, we're making triplets at a 3040% clip and triplets at a 15 to 30% clip and twins 30 to 50% clip, depending on how many embryos you put back.

3:19 And we we learned pretty quickly how to manage that problem because that is a big problem. You want to make a single, healthy pregnancy? And so it's it involves couple of weeks of a woman taking a medication to stimulate her ovaries to make eggs. We then surgically recover them using transvaginal ultrasound. So it's not really a surgery, it's an ultrasound guided needle aspiration under very light sedation, 15 minutes. You know they go home an hour later. Usually they go to work the next day if they get a lot of eggs, some of them are in bed for a few days because they're sore and crampy.

3:52 But and then men just provide a sperm sample and you make the embryos and. Now we're doing all kinds of other technology we'll talk about in this podcast, right? That's fascinating. So just to bring the audience up to date, the eggs are made in the woman's ovary and you actually remove the eggs from the ovary, Correct. And then you mentioned that the sperm from the male you can actually inject and I assume that's done under a microscope. So everything is we have micro tools which are glass needles.

4:26 That are thinner than your hair and you can pick a sperm up with them using robotics and inject the single sperm into the egg. And the reason we have to do that, there's some men have very low sperm count and have very few that are moving. And so we go and find the few moving sperm that exists and then directly inject into the egg with a normal sperm count. You know, we'll take 2030 thousand sperm and mix it with the egg and let nature take over and the. You know most active sperm will fertilize the egg and the others won't, but about 40% of infertility is male factor related and often requires this.

5:04 That's fascinating. So you can tell if a sperm is healthy or not by the fact that it's moving and and swimming around. It yeah, that's not a perfect discriminator, but it's it definitely helps. It definitely helps a lot, yeah. And then you you actually put the sperm into the egg and then that's called an embryo. When that when you see evidence of fertilization, where you see what are called the pronuclei, usually the next morning you look under the microscope and you see two circles side by side inside the egg.

5:33 You know that half of that is from mom and half of that is from dad. That's the DNA that each provide. And then you say okay, this is an embryo. And then sometimes those embryos stop right there. They don't grow. Most of them will continue to grow. Only about 60% of eggs will fertilize. So you know, it takes a lot more eggs to make a baby than you think, which is going to be a big topic for tonight. Because I really have to help people understand the statistics involved and and the actual fertility system, which I think we we as a society need to learn a lot more about and understand so that people can make really good reproductive choices about when to have their baby.

6:14 Because what's happening now is we're having our babies older and that makes it harder so. Then when I say older, it's mostly the woman, because as women's eggs get older, you make fewer healthy embryos, you make more that make miscarriages or babies with problems like Down syndrome or Turner syndrome. When you're older, and if you're starting older, it's harder to get pregnant, harder to stay pregnant, and you run out of time before you have a family. So that's that's been what's happened over the last 30 years, this huge shift.

6:45 I saw on the news today, coincidentally, that there was some really important news. Can you tell us about that? Yeah, I was actually quoted in this article Baby Louise Brown turned 45 yesterday, which is now declared World Embryologist Day. I think the unsung heroes in our field are the people who spend their time in the lab, who manage the eggs, manage the sperm, never make a mistake, never mix up an egg in a sperm. Very critical mistake. Can't happen and are really. The heart of your success. If you don't have an optimal lab, you don't, you don't have success.

7:22 So in celebration of baby Louise Brown, the first IVF baby born in the world, who's very active in this field, she's taken on as a mission to help educate people about this really wonderful. She's obviously very grateful that she's here and she's an amazing woman.

7:40 Declared this World Embryologists Day. So we celebrated our embryologists and thank them because they're behind the scenes, they're doing a lot of hard work and they're what makes it happen Fascinating. And I hear she has two of her own children now. Right, yes. But I don't think she needed in vitro fertilization. Is that the story that just coincidentally it occurred to me.

8:06 Funny you should ask, I ran into. Have you done any second generation Ivf's? In other words, where did the parents and then the child has the same? A couple who had two daughters and the daughters were 28 and 31 and the mom recognized me and Doctor Griffin. Yeah. And there was her 28 year old daughter who we helped 28 years ago and her older sister actually needed fertility treatment and she was standing there pregnant at the time, holding her 1 1/2 year old baby. So. So it was like mom, daughter from IVF, other daughter.

8:39 Who has IVF? So this mom got her 28 year old daughter and two grandchildren out of this process. So it was it was a pretty nice reunion for me. It really was a privilege to help this lovely family have grow and thrive. It's really that's the best part of our job. We make such a impact on on these people, their lives, their families and and lifelong. So it's it's really a privilege right? I I think your specialty is is the most rewarding in medicine to to bring a a baby and a child and a person into the world.

9:12 I mean, I I don't know. It's it's hard, hard to describe when you run into a 28 year old who you know wouldn't be here if you didn't have the the skills, the privilege, the gifts from God and whatever to be able to help these people come into the world. And we really need it because. We're below 0 population growth and we're getting pregnant older, so fewer babies. We're gonna at some point, it's gonna become a social problem and already is starting to be right on that topic. You know, years and decades ago there wasn't that much talk about IVF and most people were having children just kind of naturally.

9:51 But in recent years I see more and more I VF being done. I have patients who who are here from IVF and and so on. Why is that? Can you explain that? So I started my OB GYN residency. So that was the beginning of my field, entering this field in 1984. And the average age at first birth in the United States for a woman was 19. So now if you're 19, having your first baby, and you make 12 eggs a year and you got 20 years of trying, not that you try the whole time. But you have plenty of opportunity to build your family.

10:26 But what's happening now, 2021 in the whole United States 19 has become thirty. So we've gone 11 years, which is incredibly remarkable given that 300,000 years ago when Homo sapiens first hit this earth as a species, the current fertility system designed by Mother Nature, which was which purpose was sole purpose, was to keep us on this earth and not be extinct so. And we weren't living very long then. We were dead by 25. And and a woman has all her eggs in her ovary before she's born. So your eggs are aging as you go along.

11:03 Meanwhile, men, we're making fresh sperm all the time. That's why, you know, a 79 year old can have a baby because there's always fresh sperm. It's not quite as good at quality, but it works quite well. Whereas women pretty much have a clock and probably age 42 is where it. It's pretty much over. Not many natural babies happen over the age of 42, and that's because of. Of old eggs. But 300,000 years ago, you were age 14. You ovulated maybe a hundred 120 eggs in your lifetime. You got to 25. You had to have three kids.

11:31 And the species survived. If you had too many, we would have starved to death, overpopulation. We'd be extinct. You had too few, We would have treated and we'd be gone. So this system in evolution, when it works and there's no reason to change it, there's no pressures, evolutionary pressures. So modern women today, imagine if you were. You know, trying to do Twitter on your 300,000 year old cell phone in today's world you would struggle. So the analogy is women are using a 300,000 year old technology to build their families.

12:02 I mean men are participating, but we don't have the same issue with sperm aging. Whereas women have a limited supply of eggs and they age pretty quickly, and you can measure decline starting at 25, you see some pretty incremental declines, late 30s, early 40s and pretty much. There's a blip at 41, there's a blip at 43 and it's you can pretty much down to 0. How many eggs does a woman have it at birth? So yeah, I mean, it's amazing you. And it makes sense because if you think about reproduction, it's a very, I don't know, wasteful is the right word.

12:37 But there's way more opportunities to make make a being in someone's body that actually happens. So a woman has seven million eggs. I mean, guys ejaculate millions of sperm every time they ejaculate. In a lifetime, they make billions of sperm. That's by design. That's by design for variation in the species, genetic variation in eggs. And sperm can then adapt to the environment. So the the healthiest survive and we can adapt to changes which now are pretty much obsolete. A lot of adaptation no longer happens because it doesn't need to.

13:09 We have such a controlled environment. But the one thing Mother Nature never planned for was like being in New York City and. 2023 and seeing that the average age of first birth is now like 36 to 37 and you know, you have maybe five years, maybe 60 eggs total of your worst quality eggs to try and find a few good ones to get a baby. And it's caused us to be incredibly busy. It's caused a lot of people to struggle and suffer and maybe never get a child. Or what's the alternative? You're 42, your eggs don't work.

13:41 We've tried a number of times. We couldn't get a good one. You say, all right, let's let's take your 25 year old anonymous egg donor. She's got a much better chance. Although what's remarkable, even an egg donor is not like a sure shot. I mean 55% baby rate from a batch of of eggs, frozen eggs from a from an egg donor. And you know, the idea is the more times you try something the more times you're the more likely you are to be successful. So it requires a lot of effort and cost and. It's But it's a numbers game.

14:12 It's totally a numbers game of getting one good egg that makes one good embryo. And the older your eggs are, the fewer do that, the younger the eggs are. They're even limited. I mean, it takes about 6 donor eggs on average to make a chromosomally healthy embryo. And just because an embryo has all the right chromosomes, it doesn't always make a baby. Only about 6065% of the time it does so. You have to go through a lot of eggs to find it. You can get it in one shot and that's what they teach us in the sex Ed cost cuz I want to scare us.

14:41 But most people don't get pregnant on the first try and but don't be trying if you're not ready for the consequences of it. So I think that message is good. So the egg number decreases with time and also the health of the egg decreases, so the DNA and the egg ages. And well, no, just because the ovary. First of all, you have 7 million eggs, and there's a process called Atria where you burn through your eggs. So a woman is born with a million having had 7 million. So 6 million eggs are gone. You you're not even born.

15:09 Then you get to puberty, haven't had your first period, and now you're down to 300,000. And you say, wow, that's terrible, that's awful. 99% of your eggs are gone before you have your first period. You don't need them. How many do you need? Do you need a few good ones? And every month your body recruits 500 to 1000 Eggs Wastes. You know 999 of them to ovulate the one and you got to hope that one is good. And if you're trying on your own, you never know if there was an egg. You never know if it fertilize, you never know if it made a good embryo.

15:40 And most of the time it doesn't. 25 year old woman has about 10% chance of natural conception resulting in a baby. You hear numbers like 20 and all that, but that doesn't account for the things that can happen. Not every embryo makes a baby can implant, make you pregnant on blood test, but you don't get a baby or you get a little bit further on, You miscarry or you get to 16 weeks and you find out your baby has a problem. You know, those things happen and people aren't so well, well versed in them.

16:09 So basically our culture and society is is creating some of the issue. Well and yes, so now a 40 year old woman has like 14,000 eggs and 14,000 much poorer quality. So if you look at a 25 year old natural pregnancy rate, 10% to a baby 40 year old 2%. Now you got a year is trying 2%. What? What's the chance you're going to be pregnant? And with a healthy baby, it's low. Those women can run out of time pretty quickly. The other thing is 40 year old woman will miscarry about 40% of the time because a larger percentage of the embryos that she make makes her chromosomally unhealthy and it's about a 15% rate in a 25 year old.

16:50 They they make a lot of abnormal embryos, but they don't make as many pregnancies as the 40 year old who has so many more. And then you get 16 weeks pregnant and one in 525 year old. Women get bad news when they have the amniocentesis test, where you take the fluid from around the baby and. Your doctor says, do you want to find out if your baby's healthy? Do you want to know if it's a boy or a girl that you can do that test? Well, one in 525 year old women are told, I'm so sorry your baby's got this serious illness.

17:14 What do you want to do 40 year old women, It's 2%. That's a big #40% miscarriage rate, 2% amniocentesis, bad results. So we had to pioneer technologies to account for that and that's that's one of the the major breakthroughs in the field, something I've been working on since. In the 80s actually you're you're one of the major innovators in in IDF over the years. We were the first in the United States to have a successful embryo biopsy pregnancy and that resulted in a baby. We were the second in the world.

17:49 The Brits did it first. We, our regulators, wouldn't let us do it until the Brits had success and which was fine. We we know as soon as they gave us permission we started and there's a 31 year old out there who. Was screened to not have hemophilia and she doesn't because we she had a 25% chance she was going to have a pretty serious illness. Mom's brother died of hemophilia from the treatment. She didn't want a baby from it. She knew she had a 25% risk. She volunteered to be the first patient. We were doing it for free because we all are new technology we we don't charge for to we're sure it works.

18:22 We had done tons of animal studies first make sure it was safe, and so in 1992 we had the first successful embryo biopsy, baby and. That that's really revolutionized what we can do with with IV F2 reasons. One, genetic diseases exist in nature. Having a baby born with a genetic disease is sad and and awful, and there's no way to prevent a genetic disease other than what we do, which is to actually find the embryo that has the disease and not use it. So we can prevent the formation of a genetic disease using IVF technology because there are couples out there who have a 25 to 50% chance.

18:58 When they get pregnant, they're going to have a baby with a serious lifelong illness and that's that's tragedy. So one of the motivators for us doing this was that and and that's how we end up with the first, the first baby. But the real motivation too was we knew that as eggs got older, they made embryos that were less healthy and we need to find the one healthy one. We need to stop making triplets and twins. We need to reduce the risk of miscarriage and so by screening an embryo. And taking some cells from the what would be the placenta?

19:29 You can tell if that embryo is destined to be a baby or destined to be a miscarriage or destined to not get you pregnant and only use the ones that give you the chance. And so that's revolutionized IVF because it's a streamlined way for an older patient. They make fewer of them. We just get more eggs, find the good one, put back one good one. Now they're the same pregnancy rate as a 30 year old if they can get that embryo and they all, they can't all get that embryo. So, so that was. One of the major breakthroughs in in IVF that has made it safer eliminated twins and triplets essentially and reduces miscarriage and and also babies with Down syndrome and Edwards syndrome and Turner syndrome.

20:10 So you're doing a great thing. You've probably heard that Elon Musk. One of the things he talks about the most is that we're headed for trouble because humans are just not producing enough babies. In fact, he wrote a tweet, which I have right here. I'll quoted. Population collapse is a major risk to the future of civilization, he tweeted. Do you agree with that? I mean, Elon Musk is an incredibly intelligent human being. He's got a lot of talents. He he recognized this. I guess that's why personally, his own life, he's decided he's going to have lots of children.

20:45 I think he has ten kids. Yeah, exactly. I won't get into any controversy around that. I, you know, my view too is I'm here to help people reproduce and I don't judge them. They they have to make their own choices and I support them. I don't let them make bad medical decisions. But I want love. Wanted child is the secret sauce to the survival. And so anybody who's willing to go through all the stuff we put them through, we're happy to help them and and you know, we help lots of different kinds of situations.

21:13 We have single women. We have. Women who are lesbian couples. We have single gay men who want to have a child, married gay men. So there's lots of different ways that you can make babies, but Elon really nailed it. We have a problem because as we are waiting longer and longer, we are having fewer and many of us are having fewer just by choice. And you know, we're not threatened with extinction now, but we've been below 0 population growth for many years. And if that trend continues eventually the.

21:43 Population will be threatened. So I think he's brilliant to actually have raised that issue and to that. That's one of the things that motivated us in 1999 to start freezing eggs. We started in mice. The reason for freezing eggs is knowing women were going to delay childbearing. They were going to have a much better chance with their younger frozen eggs than they were waiting till they're 40 and having a really hard time and maybe failing completely. And so we spent four years in the mouse lab, freezing and thawing mouse eggs, making baby mice.

22:11 And got so good at it that we were convinced we could do it. But, you know, we're fathers of daughters and we're we're, you know, ethical people. It's like, should we just start doing this? We can do it. We know we can. And the answer was no. We had to do something to prove that it could work. And and so we had a bunch of women who needed IVF. It's around 2002. They had no, no means to do it. They had no insurance to cover it. We felt bad. They felt bad. So we said to them. We have this new technology.

22:39 Our mouse data says it works like I VF. How about this? How about if we give you a free cycle, we'll pay for everything. We'll get data because we really need it. And we think it's a huge investment for our future patients. And also us as physicians knowing what we're offering to patients, a much better place to be as a physician makes our job so much better. So we were willing to spend the money and 23 women did a free cycle of egg freezing. And 57% of these women, they were age 27 to 37. Mean age was.

23:08 33 and we got a 57% baby rate, which when you looked at our data, we expected 50%. So we even got a little bit better. Well, it wasn't statistically better, but at least it was as good, right. And so then the idea that you could freeze eggs was born in our our oldest egg freeze baby just turned 18 this early July. So we've been doing this that long and we just published the world's largest study. Of women who froze their eggs waited up to 15 years because we we looked at our data 2021 we waited a long time because we want to have enough data that would be meaningful.

23:45 And so we were sitting on this watching this data accumulate knowing it would be helpful. But we wanted to just have enough so that it could be meaningful for patients and and the doctors out there so that we could help more people with with information and make make choices. So we 15 year up to 15 years of frozen eggs, some of them are five years now in the early days. Older patients showed up. It was an experiment. It wasn't covered by insurance. So like 3940414243 year old women were freezing their eggs.

24:12 That's not the age to freeze your eggs. But these women knew the technology was there. They knew they were going to be getting older faster and not be able to have a baby. And they said I'm going to do this. And and they did. And because they did, many of them have families they wouldn't have or babies they wouldn't have. And we showed that if you could get 20 eggs and a woman under the age of 38, but the mean age of that group was 36. 70% of those patients got a baby. And if if if it had somebody who got, you know, 19 eggs and one retrieval and did a second retrieval, about 90% of those patients got a baby.

24:45 So it's just a matter of getting enough eggs so they have the opportunity to find the few good ones that come out of it because that's the main concept is that most eggs don't make a baby, most eggs don't. I mean 40% don't fertilize. Most of them don't make a healthy embryo, and only a percentage of healthy embryos make a baby. So it's a numbers game of being lucky and getting that one good egg that makes that one good embryo that has the ability to make a baby just because it's chromosomally healthy.

25:10 Only 65% of those make a baby, 4535% don't, and you have to have enough eggs and enough embryos to be able to build the family size that you want. So what's happening now is a lot of young women, and now there's insurance coverage for this, are coming in and saying, look, I'm 31. I'm not having a baby anytime soon. I got this career. I haven't found the right partner yet. I'm going to put my eggs in the freezer and by doing that, what we've shown is that's the equivalent of doing five tries at 40.

25:39 So they have already started their family planning knowing that this clock is a problem and they're able to take an action, which is pretty empowering. It's like you don't just sit back and let life happen to you. Make choices and then you make a statement to yourself. And then you improve your chances of success and we're finding this. We have patients with whole families from frozen eggs. We see. How long can you freeze an egg? For as far as we're concerned, as long as you want. But what temperature?

26:07 Is it frozen? It's at the temperature of liquid nitrogen, which is -176 I think. I'm not sure if it's exact, but it's incredibly cool. That's colder than it's outside in New York City. Today it's not. It stops. It stops time. That's how cold it is. It stops time. So those eggs. They're frozen at 30. You wait 10 years and we've we've shown this scientifically when you saw them. Ten years later, they behave like they're 30. They don't age. We stop time on those eggs so that we can preserve a woman's fertility.

26:40 We first initially started doing this for cancer patients. A lot of women get chemotherapy. Their ovaries are shot, their eggs are no good. Before they did that, while they had their cancer, newly diagnosed, we put eggs in the freezer or embryos if they had a partner. And when they're cured of their disease, now they get their fertility back, so another piece of their life comes back. Can you freeze an embryo also? Oh, totally, yeah. For how long? Also indefinite. Same thing. Same thing. In fact, we're now seeing this and I have whole practice of patients like this as a couple.

27:10 They came to see me intentionally saying we want to have our babies when we're 40. We want to get our embryos now and we want to know how many good ones we have, which is the advantage to embryos. You can test them and know how many good ones there are so you can. Mathematically deduce how many you need there to really give you a high chance of the family size that you want, because we're now using our data to do that. And so they come and they bank embryos, and then they come back at 40 and one embryo at a time, 40, they have a baby, 42 they have a baby, 44 they have a baby.

27:39 They wouldn't maybe they wouldn't have any of those babies that they just waited for nature to take its course. But instead they took an action and did their family planning, and they were very young. And that's the concept. That really needs to be out there. It's like if you're a woman and a man, you need to think about these things because time passes pretty quickly and you know you may lose opportunity. So if you pay attention and you make intentional choices at a younger age, you can have a profound impact on the trajectory of your life and your family and where you're headed.

28:14 And because we're living longer and longer, this is going to this trend is we've seen it in 2016. The average age of first birth in the United States was 26. So we went from 19 to 26 from 1984 to 2016 and from 2016 to 2021 we went to 30. In New York City. It's like 3637 and and moving up, how do you ensure the safety and security of the frozen embryos? It's frozen eggs. It's a huge commitment and a huge responsibility. Because they're not replaceable, and so you can't just have a simple system. You have to have a very complex multifaceted system.

29:01 So you have to have storage tanks that you can figure out when they're failing before they fail so you can replace them, you know, before that happens. You have to have alarm systems that don't fail. You have to have backups to your alarm systems. You have to have more than one. You have to have them go by T1 cable. If the cable's up or by cellular if the cable's cut, you have to have a generator on the roof because you run out of power. Then your alarm system goes down that the eggs are safe because they don't need electricity.

29:33 We just need to monitor them and then if your generator goes down, you need backup to your backup. Now we have we can run our lab two days on batteries as a backup to our backup because you cannot afford one thing to go wrong and in life something always goes wrong and so we have multiple backups. So we we we we learned a lot at Hurricane Sandy where First Ave. was underwater. Our fuel tank for our generator, which was on the roof, was underwater and not functioning. We do have an auxiliary tank that got us 12 hours and we were.

30:06 I remember in the dark carrying few number #3 deal fuel up six flights of stairs to fill the tank to keep our generator going and then charging the batteries and use the battery backs we already frightening. For you, it was terrifying. It was terrifying. But you know what? In the heat of the moment with the team that we have there, most incredible people in the world, we all just like, said Okay. Yeah, do this. So it's a huge teamwork as well, right? It's not just you doing. All that. Are you kidding?

30:34 It's there are so many unsung heroes in this field. You know, it gets attached to the doctor. And look, we're good at what we do and we do an important piece of it. But we're only as good as our team. And I'm so fortunate to have one of the best teams in the world. It's really great. I've watched them grow up. The many of them have been with me for. 30-40 years. So it's it's really privilege. I'm very grateful that I have these opportunities and these lifelong attachments to people who understand what the mission is.

31:05 I mean, we get it and we know how serious this is and we know how impactful it is because. We get the letters, we get the pictures, we get the people bringing their babies to us. We get them seeing them when they're 25 and 30 now, right? That's amazing. So for the people out there in the audience of some of you young people who might want to become doctors or fertility specialists, this should be a role model. Doctor Griffo, how how long did it take you to become a fertility specialist like after college?

31:35 Because it just goes. Through four years of college. And then I did six years of medical school because I did an MD&APHD. So that's ten years. Then I did four years of residency. Now you're up to 14. And then I did two years of fellowship. Now you're up to 16 years before you have your first real job. You know, that's okay. I'm still working. I got a whole career out of it. I can work for a long time. This, this kind of job, these skills that they don't go away and you can, you can use them. And I'm fortunate too, to have.

32:07 One of the best fellowship training programs in in the country. And so the next generation of doctors like us are working with us as residents and fellows, and then now they're our partners and they will be our successors. So you've trained other fertility specialists. How many? How many of you trained over the years? Would just say probably about 45, 45 and they go all over the. All over the country, world. We keep the best of the best. We're very fortunate and they're incredible. My team of doctors are just there.

32:36 They're really awesome, amazing human beings. Not just not just great docs. They're just good people, right? Which is really critical. This is especially you got to be good people. You got to understand what the patient's going through. You got to be able to meet them at their emotions and manage that and and be empathetic and help them, you know, manage their heart breaks when they happen and losses when they happen, and keep them in treatment. Because the secret sauce to success is not quitting.

33:03 And it's not always easy. This is a big challenge when you find yourself infertile, you know, and and I tell this every patient who walks in the room, it's like, you know, the elephant in this room. And this is what why it's so anxiety provoking is. What if I never have a baby like who's who's planned that? Nobody. And you walk in that door and you sit down, you see the fertility specialist just meeting them, and you're talking about the most important, one of the most important things that ever happened in your life and, you know, get this flood of emotions of like, wow, what if this doesn't work?

33:34 Right. And we have to kind of help them through that. It's a challenge. What percentage of couples now are infertile and? So I mean that's been on the rise. When I started it was about one in eight couples. So you look in the room, you got eight couples, one of them's got it. Now it's one in six and part of that one in six. The reason it's gone up is because people are waiting longer and it's just age-related decline in efficiency. And it's a numbers game. So more eggs you get, more chances you get to get a good embryo, the better the chance you're going to get the one that changes your life, that that little miracle you mentioned earlier about genetic testing of of the embryos.

34:11 Can you explain that a little bit more and what discoveries and innovations you made that and why that's super important? So we can now test an individual. So when a couple sees me, first thing I do is. Send a blood test and test for 560 disease causing gene mutations that you could unknowingly carry. Because if you're a carrier, you have a good gene, you have a bad gene, you're healthy. But if two carriers with the same problem, like cystic fibrosis, husband has it, wife has it, 25% of their babies will have a serious lifelong illness that's eventually fatal, although they can live a long time with treatment.

34:52 But it's hard treatment and it's not fun. We can now. Test their embryo for those 25% of those embryos that will have the disease and not use them. They never get pregnant with them, so they don't have to terminate a pregnancy. We just don't use them and protect their family from a gene. Now BRCA, which is a breast cancer antigen, which causes breast and ovarian cancer and it if you have it as a woman, you're going to potentially get breast and ovary cancer and you're going to have all kinds of lifelong treatment.

35:23 You have your ovaries taken out when you're 40, you have mastectomy. At some point you may get breast cancer and be treated. You know, when you're a young woman and you know you carry that gene, the thought of having a child and getting that child that gene, you feel terrible. Right now what we can do is a lot of those women were freezing their eggs early because they find out early. So when we make their embryos, we can find the BRCA negative embryos and and take that gene. Out of that family tree, that gene that causes so much heartache in a family, and you now have technology that we can eliminate it, never use it.

35:58 Yeah, so that their grandchild won't have to worry about what their, you know, grandparents, parents and siblings are living with, right. You mentioned you have a PhD also, I think in biochemistry, right? Yes. Has that been helpful? And. Well, so creating these new. Molecular biology and and my project was really it was a virology project. We actually discovered how polio virus takes over the cell to make polio virus what the cell makes. So you know your height, your cell gets hijacked to become a virus factory and the cell dies, but makes enough viruses that the.

36:34 Poliovirus keeps surviving. Now good news is we've wiped it out with vaccines, so it's not a problem anymore. But understanding the mechanism has been very helpful and that foundation for science became the foundation for science. It's called translational science where we're in the lab trying to translate our scientific knowledge into the next breakthrough. So that's how we ended up with pre implantation, genetic testing, embryo biopsy, egg freezing technology where we can apply the same rules.

37:02 We can take your 30 year old eggs. Wait 10 years, make embryos and then test the embryos for genetic disease or chromosomal abnormality. Because even young eggs, half of them, are going to make a chromosomal abnormal embryos. It's not going to make you pregnant. Who wants to be 40, Have your eggs in the freezer for 10 years and you put back an embryo that gives them a miscarriage. Nobody so we can screen them when they meet their partner, find those embryos that are healthy, tell them how many they have.

37:26 They can do family planning. You're 37 now. You have three good embryos from your frozen eggs. Yeah. And you you got a family plan you want to have. You know two or three babies, well you're not going to start right Then you got to get more. So we were giving people tools to thoughtfully solve this problem that's created by evolution really or the lack of evolution and aging and having our babies older. So. So we're really empowering people with tools to intentionally. Family plan and not just be a victim of circumstance and luck, right.

38:00 So as we identify new genes that cause certain diseases, you can then test for them and basically eliminate that disease from propagating in future generations. Yeah, it's be a really good thing because the best way to treat a genetic disease is not have it because we can treat it. It's never going to be as good as if you don't have it. So that that was one of the main motivators that got me in this field, because I was. Seeing these patients come in holding a baby with a terrible illness or the picture of the baby that died and this this couple didn't know they had it because we didn't have a way to test them.

38:31 Now we can tell them before they start getting pregnant that hey, you have no risk, you're good. Don't worry. Which is nice, because not worrying is a really good thing in today's world. Or I'm so sorry we found this, but don't worry, we can do something about this. You don't have to have a baby with disease. We got work to do. We got to work a little harder. But it's better than the alternative if you choose it, cuz not everybody chooses it. You know, patients make their own decisions, right? Yeah.

38:54 I have a patient who's a carrier of a congenital glaucoma gene, which is a eye disease. And it turns out her husband was also a carrier of that, and they were able to avoid having a baby with that by the genetic testing that you mentioned. So that's very important and critical. And that's the beauty of being a translational scientist. You help provide this breakthrough, and then you can share the wealth. Everybody else can learn it, and so it becomes available to everybody. So that's the fun of the science part of it, right?

39:33 Making a difference. So it's gonna just help your patients, gonna help every patient, right? Recently, in the last few months or so, I've read some articles in the media and in some medical journals that some scientists around the world have actually created human embryos from stem cells from a person. In other words, they didn't take a sperm and egg, put them together in a test tube. They actually just took stem cells and then by putting them in the right biochemical condition solution. They were able to create an embryo, they didn't let it mature to develop stage, but in one of the studies they actually some of the cells went into became heart muscle cells when they were actually beating.

40:16 Is that science fiction at this point or where is that headed? The biggest problem in our field is trying to do good science and knowing the ethics of doing an experiment on an embryo and how some people view that and. So we never really did much embryo research because of that. It was both ethical and it was regulated that we couldn't, and it actually interfered with our success, our our trajectory of success. It really hurt patients in the early days because we learned so much more slowly than if we could do the right scientific experiments, but we weren't ready as a culture to do that.

40:52 But now here's a solution. Because we're not taking an embryo, we're taking a bunch of cells that you can. Use the molecular, you know drawboard drawing board to make them turn into cells just like an embryo and then that becomes an experimental model that we can use to further our knowledge and improve our technology and improve our success rate that that's the goal here. Now you know the thing about science is it moves much slow more slowly than the story in the in the media. So it sounds like you got the, you know, the.

41:25 The magic bullet. There's a lot of work that has to be done to actually translate it into something big, so but it's a great start, right? It's pretty fascinating. Potentially, if you extrapolate that into the future, you could make clones of humans. Yes you could potentially. And then if you use Elon Musk's neural link connection you could potentially download the original humans brain thoughts and ideas and memories into the cloned person. This this is probably 1020 years into the future, but theoretically that could potentially be done.

42:07 That's interesting. I don't know. I don't know that I'd really want that. I'd rather. I mean, I wouldn't want my on busy days. My fault. Yeah, but I wouldn't want my faults in foibles. I mean, our kids are so much more involved than we were, and they're not gonna make a lot of the same mistakes that we do. I wouldn't want my neural link to give it to somebody. Who? Who could be two generations down and be much more evolved because their parents were much more involved. That's great. Well, on certain busy days, I say, Gee, I wish I had a clone today, but.

42:36 I hear that's called a robot, right? That's also Elon working on his robot. What do you think is going to happen with IVF and this technology in the next 5 or 10 years? Where? Where do you think? I think we're going to get. Incrementally better like the low hanging fruit is we're past now. It's just getting a little bit better at each different step. That which translates into overall better success rates. Accessibility is a big piece this these technologies are expensive. Technology is happening to make them less expensive and and so we're going to make it more accessible so that more people can get help.

43:16 I think that's a really big focus and important one. I think automating a lot of the things in the lab will take some of the human error out of it. As much as you wanna control conditions in the lab, there's still the human factor and as much as you can eliminate that, you can improve safety and outcomes. So that's really another big thing, so. I think those are the major ones right right now. But it's not going to be, there's not going to be this dramatic change. It's like you don't have these breakthroughs in one day.

43:45 Also, something new happens, right? It's gradual. It's a lot of work. And my team, we've been toiling for 30 years and incrementally getting better and better and better. And you know, I remember practicing at Yale as a fellow with a 10% pregnancy rate. And that was, that was respectable. I mean, now you wouldn't have any patients come to you with that success rate. Now, I mean, you know, a patient, we get a euploid embryo on a chromosomally healthy embryo. It doesn't matter what their age. If we get that embryo, that's about a 65% baby rate.

44:14 Now it's just much harder to get it in a 40 year old woman. You know, we do an egg retrieval. A 40 year old woman will average one healthy embryo, but half the women won't even get one healthy embryo at all. You know some women will get 2. So we'll average about one per patient from about 12 eggs, which is average. That's that's what happens to a woman trying a year during 40. She'll make one chance and only 65% chance, and she'll make a lot of embryos that make miscarriages. That's why the 40% miscarriage rate and the 2% Down syndrome rate.

44:47 So we can, you know, like I have a lot of patients come to me, they're 40 and it's like how many babies you want. I want at least two. And it's like okay then we have to really change, shift the paradigm here. We got to get lots of embryos now before you even get pregnant. So do a bunch of egg retrievals, get enough eggs to make enough embryos that are healthy and then put them back one at a time so she can be 44 getting her second one back and not worry that we would never be able to get her pregnant at 44.

45:13 Very rare, it's like less than 2%. So, so that that's the kind of changes that are happening and and even better. Now it's the 30 year old who's coming to me at 40 and we're using her 30 year old eggs to get there with much more effective because they froze their eggs, you know, years ago. In recent years there's also been a lot of media attention to quote designer babies. I know we can't do it now, but potentially now since you can select genes or test for certain genes. And now we have this new CRISPR technology which allows us to edit genes.

45:49 And if we discover the gene, for example, for what makes somebody 7 feet tall? Is somebody going to come to you in a few years and say I'd like a 7 foot child so they can get a job in the NBA? You know, it all sounds so great. So in 1992, when we published that first successful human embryo biopsy done in the United States, where we prevented this woman from having hemophilia, the media took it took the story instead of the story being. We helped this family who had suffered really badly because of this genetic disorder, have a baby that wouldn't suffer.

46:26 Instead of that being the story. The story was the doctor with designing babies and it's like okay. That was 1992. Here we are 2023. We're still not doing designer babies. Yes, we can choose gender and some people view that as designer designer babies, but I don't, I think. Patient has a female and wants a male. That's their decision. Like, it doesn't hurt anybody else, that people make their own choices. But the idea that you could actually know the genes for the kind of traits that we would all select, we're so far away from that.

47:00 We were the 20 years ago. We're still far away from that. And then CRISPR, there's a long leap of scientific breakthroughs and studies to show that it's safe, that you can do it well that you don't. Headed at the wrong place and create a problem and make it safe. So there's so many barriers to success in that arena that we have so much more work to do. I don't think we're ever going to get to the stage where we do it because most of us are scientists. We're not trying to design babies. We're trying to help people have healthy families and and have lives and have a good life and have a life with free of disease.

47:32 We're not that interested in even pursuing, you know, the genes for hair color, eye color and, you know, intelligence and you know the. Arnold Schwarzenegger genes instead of the Danny DeVito genes like in the twins. You know, it's like we don't, we don't know those genes. We don't. It's there. And plus it's a bunch of different genes. We're we're so far away from that right it. Makes for good like, you know, AHA Media and and alarmist media, but it doesn't like I say 1992. That's what we were doing.

48:04 They thought it hadn't happened. We're, you know, and they were saying, oh, you guys got to be regulated. We are regulated highly the. Most highly regulated specialty in America. And believe me, not all regulation is helpful. Not all regulation does anything except increased costs make it harder and actually deny people care. You need effective regulation. You need people who understand what they're regulating because a lot of regulators don't understand what they're regulating, and so they make up rules that make no sense and we can't convince them because we're the regulatory and no one trusts us.

48:34 And you know, we're not, we're not trustworthy. Some of us, most of us are and we want regulation too, but we want it to be meaningful and impactful and cheap because the patients pay for it. So that, you know, maybe your future careers to become a regulator. I would never want to do that.

48:56 I would much rather use the skills that I haven't keep doing the things that I'm doing and with the team that I'm doing. We're just, it's just so amazing. We're just so. We're just so. We're so lucky to be able to do this. I mean, like, imagine a job where you go home and one day you've changed the whole family's life. Not just for today. Their whole, their whole life, yeah. That's why I said I think you have the most rewarding medical career. And it's a double edged sword though, because it doesn't work for everybody and that is so hard.

49:26 And you know, even though you know your limits as a human being and you know it's Mother Nature that limits us. You still always wonder what if I did this or I like just like the patient wonders, what if you did something different. You as the practitioner, your heart breaks a little when it didn't work and you feel frustrated that maybe you could have done something even though you know you couldn't have. It's it's emotionally draining and difficult and you know you can get burned out. It's hard because you watch all this suffering and you watch all this heartache now.

49:53 You see all, you see all these amazing stories. But the problem is those patients are gone. Once they have their baby, you don't see them. You're seeing the ones who are keep having the hard problems and. It's a challenge, but it is a great, I mean, there's no better field. I I was so lucky that I chose this field. I would never turn turn back on that great. Well, thank you very much for taking the time to come today and and do this Doctor Podcast with me. It's been fascinating, educational, entertaining.

50:24 I I think the audience is going to love this as well. And if you do, please follow us at-x.com or formerly Twitter.com and you can also like us and retweet us. We'd appreciate it. And if you have any comments, please send them along as well. We'd be happy to reply to them and answer. Thanks very much for coming today. I really appreciate it. It was awesome pleasure to be here. Thank you and thank you for listening.