Transcript
Speaker: The one thing that we as doctors should get really good at is simply like being a place where they can talk. Feeling like you are like heard and feeling like you are noticed is medicine.
Speaker: If IVF didn't work, what comes next? For many people, that's one of the hardest questions they'll ever have to ask. Because after failed IVF, miscarriage or difficult diagnosis, it's easy to feel like you've run out of options.
Speaker: And it's easy to feel like your diagnosis has become your whole story. It's very, very rare that there are no options left. They are definitely feeling like I'm going to tell them this is the end of their rope. This is the end of their journey. Today, I'm joined by reproductive endocrinologist, Dr. Leah Kay from the Fertility Center of Las Vegas to talk about what happens after failed IVF, miscarriage, or a difficult diagnosis and why the next step starts with treating the whole person.
Speaker: not just the diagnosis. Dr. K, I was watching one of your videos where you shared that you originally pursued reproductive endocrinology because as an OB-GYN, you saw just how emotionally difficult infertility could be for your patients. How has that shaped the way that you care for your patients today?
Speaker: Oh, great question. and Yeah, to kind of summarize that video, you know, it was when I think about not just like what got me into this field, but also thinking about like why still show up every day. You know, all of us have to kind of do a a daily check. Like what what are we getting up for today?
Speaker: It honestly hasn't changed since I was in that residency program. You know, that you do a lot in residency and and in medical training in general, it's very easy to turn into sort of this rote machine. You see the same things every day. You get really good at what you're doing, but you also have to detach a little bit to protect yourself. But OB-GYN is a field where you see so much. The highs are so high. The lows are so low. And in in my training, the the stories that stood out to me the most happened to be those
Speaker: stories that were in many ways heart-wrenching. in many ways, it's like a lot of repeat miscarriages, repeat pregnancy loss in particular. Those are the stories that as I went through my training, I said, you know, this is real medicine. This is not just making a diagnosis,
Speaker: giving a medicine, treating you with a surgery, but like going a little bit deeper and figuring out like what's going on in the hearts and minds of those parents. and And I may not be able to like prescribe something for that, but the one thing that we as doctors should get really good at is simply like being a place where they can talk, being somebody that will listen.
Speaker: Feeling like you are like heard and feeling like you are noticed is medicine. And so those kinds interactions starting as early as, you know, that those training days are kind of what got me into this field.
Speaker: There's just more space to allow for that kind of connection than the rest of medicine. Even in this space, there's not enough. Like I wish I had so much more time that I could devote to just like being there with a a parent or an intended parent or a soon to be parent. That's the best part of what we do.
Speaker: Yeah, for sure. i mean, i you're you're so right because I do feel like fertility medicine, you know, really is often centered around, you know, the diagnosis and statistics. But, you know, every patient brings, like you said, just so much more. They are so much more than a medical chart.
Speaker: How do you go about just treating that whole person and not just the diagnosis?
Speaker: booms it i If I had like a magical formula, then we would all get it. And not just in infertility, but all doctors. i think it's... it's I think we feel pressured every day as doctors to get through a schedule. You're seeing a person at this time, everybody who's waiting is going to be angry with you if you're not on time.
Speaker: and sure And especially like post-COVID times and so much of what we do is telehealth, it's hard to remember that you're still a patient in a waiting room waiting for your doctor. And that doctor might be going through some with somebody else at this moment.
Speaker: So I think the way that I've tried to get very good at is to talk less and listen more and be comfortable with uncomfortable silences.
Speaker: um Because even though I might not know the right things to say, and in the infertility world, nobody knows the right things to say. Everybody does a really good job of saying all the wrong things. When you're going through it, it's like everybody knows exactly the last thing that you want to hear, right? Yeah. So it's more about, and it doesn't require a medical degree to do this. It's more about just like sitting in silence with somebody and then they'll tell you what they need to tell you. them the space to feel what they're going to feel, acknowledge it, go through it verbally, work through some stuff with you.
Speaker: that's That's part of the strategy that I like to take with my patients when a lot of times they don't feel like they have anyone else that they could go to with that. Yeah, no, I really love and appreciate that because I think, you know I know for me personally, whether it was you know as a surrogate, whenever I was talking to the reproductive endocrinologist or even just as a woman in general, and I'm going to my OB-GYN or my general practitioner, it almost feels like... um
Speaker: you as the patient, like you don't want to take their time. Um, and it was like, I had to retrain myself to, you know, almost be like, no, like I'm, they're here for my questions, but they can't answer them if they don't know what they are. and yeah, like you said, giving room for silence and not, you know, having someone feel rushed. But like you said, it's kind of giving room for that, that whole person. um Yeah. this week This week I've had to tell three or four different patients that had questions.
Speaker: you're not a bother. Like they'll start their question with, I'm so sorry to bother you. i i know you're busy. And, and i always have to reply to say like, this is what, this is what our relationship is. Like, you mean, you're paying me to be your consultant in some ways. You're paying me to be your therapist in some ways. Like it's, it's, I wish there was somebody else that could be playing that role with me. Like we all need a good, ah like everybody could use a good therapist. Yeah.
Speaker: Absolutely. There's this thing in us, especially as women, where we are a bother and we should not be made to feel that way, especially in this field where so much of this is a mystery. Like science can do a lot, but so much of it is out of our hands and sometimes crap's going to happen and sometimes it's not going to work the way that you want it to. And so people will, like as humans, we'll bottle it up, we'll put it away, we'll say, okay, this is going to disappear. It's going to dissipate on its own. Hmm. I don't want to bother anybody about it.
Speaker: But sometimes you've got a burning question and it's spinning around in your head and you're not going to go to sleep at two or three in the morning with it spinning until you write it down you ask somebody who get answers. And to be honest, the reason I tell patients that it bothers, I'd rather them ask me than start to go down the Reddit rabbit holes and get misinformation that I'm going to have to correct for them later.
Speaker: ah No, for sure. Absolutely. when When a patient does come to you you know after either maybe they've they've been told they have very few or even no options left, where do you like to start?
Speaker: Well... almost, it's very, very rare that there are no options left. I like that. It feels like there are limits to what our bodies can do because it's true, there are. But it takes a lot to get to the absolute end of options, I will say. And and for a lot of patients, that's not the first thing I'll say to them when we're starting a hard conversation.
Speaker: But one of the things, so like a very, very common scenario I'll have is I'll have ah a couple that's been trying... They've gone through one or even more cycles of IVF, which we kind of feel like it's okay. That's the best thing that we have to offer the best.
Speaker: And maybe those IVF cycles didn't work. And they are definitely feeling like I'm going to tell them this is the end of their rope. This is the end of their journey. I have nothing left to offer them. They're prepared for that.
Speaker: But one of the first things that I'll say to them is like, you're at a point in time where you need to decide what it is that you truly want, because, Many patients will get to this point and say, all right, we've tried everything that's kind of within our means to try. It didn't work, but we can rest easy knowing that we've tried.
Speaker: And we're otherwise like happy normal people outside of this weird infertility world. We're going to go back to being happy normal people who love each other, who are not scheduling sex moving forward. sure and And we'll come out of this okay. That's one road that people will take. The other road though is there are so many other options that have very excellent success rates. Egg donors, sperm donors, surrogacy.
Speaker: And so... You have to decide, are we are we was our goal to say we tried and we're going to be happy with ourselves knowing we did? Or is our goal to go home with a baby? Because the take-home baby goal is one that is still very attainable.
Speaker: It may not look the way you thought it was going to look when we first met, but that option is not off the table if you're willing to kind of Open your minds and your hearts a little bit more to the other alternatives that are available because they work for everybody that wants to pursue them. Such high success rates. But you i have to have like a heart to heart with patients to say, you you tell me where you're at and you tell me what you want and what has your goal been all along. And then we'll start to reframe how we're going to get to that goal.
Speaker: I love that. How, when you're having those conversations, how do you help patients maybe feel hopeful but while also kind of setting realistic expectations, if you will.
Speaker: Yeah. Well –
Speaker: A lot of it is anecdotes. Like a lot of it is, let me tell you about this other patient that I just discharged with her pregnancy last week. um Because a lot of, I think a lot of parents don't realize that there's somebody else that's been going through the same thing they've been going through, even in the same waiting room with them at the same time. yeah sure But we don't talk about each other's stories openly nearly enough. And so a lot of it is is that. It's saying, you know, and I just had a consult with somebody who six months ago, we had the same conversation. Let me tell you where they're at now. And I'll always preface it by saying not every path is right for everybody. I would never tell you you have to do this or you have to do that.
Speaker: But if you think about what your life looks like three or four or five years from now, let me give you this option. And and it may mean that, yes, we are theoretically closing one door and we're ending one chapter, but it doesn't have to be the end of the book.
Speaker: um There's also great resources out there, like books that are available for patients that are like particularly struggling with the idea of you know working with an egg donor or needing to work with a surrogate.
Speaker: Where other people, other families have put their anecdotes together all in like one concise place. And I think the mental health professionals do a great job of like pointing parents to those resources. And so I do rely on them a lot for that.
Speaker: But occasionally also will like keep a few books in my office to say, hey, put this in your Amazon cart. Like check it out. I know you might read it and your gut reaction might be, no, this is not for me. But then at least, hey, you know it now.
Speaker: Until you start to explore it, you kind of don't know how you're going to feel about it. And so i will... it's very easy to continue the hope on my end because I see these success stories every day. Like I see miracles every day. um and And I think parents may not be ready to see immediately how we get to those miracles, but when they start to learn more about it, read more about it, ah it becomes much more a reality. And then so many parents will come back to me and say, I can't believe we waited as long as we did to get to that point.
Speaker: yeah Oh, I love that. and Again, I feel like, I mean, what a what a beautiful illustration of in your role of the and, you know, a guide in some ways. Because, yes, these conversations, like, they aren't just medical. um You know, they're they're emotional. As you're having those conversations, how do you kind of help them maybe transition from, like you I mean, you said it so beautifully. We, you know, ended this chapter, but the book's not over. How do you kind of help them process through that?
Speaker: i mean, part of it is...
Speaker: I work in a ah village of amazing people. It isn't just me running this show. So i kind of plant these seeds. I introduce these ideas. And in a lot of cases, there will be patients on the other side of this conversation who are not yet ready to hear it. But if they're at least ready to continue showing up, then the next thing I do is let me set you up with my case manager, who's going to give you a lot more of the logistics and kind of point you towards the resources. Like, here's what our egg donor database looks like. Let's get access to it. Let's start to like explore that. Here are the agencies that we work with a lot who have sort gets that can kind of introduce you to their process and their role in this project with you. And it may not, and always tell parents, it doesn't nail you down to any particular decision or any route. But I at least want you to have the information that you need to decide together what is right for you and maybe what's not right for you.
Speaker: And so it is a continued conversation where i set up, okay, here's who you're going to meet with next. I'm knowing that I'm only like... one early piece of it. And then you give them space, you back off. If you make them feel like, okay, you need to do this now, your clock is ticking. That's the thing that they've been feeling the last, you know, months or years. And that there's, this is also for me, this is their first chance to like,
Speaker: take a breath, like take a break. These egg donors are not getting any older, even though you feel like you might be, they're going to stay the same age. um And I feel like there's like ah a bad joke, like a hashtag me too kind of joke in there somewhere. But this is the first time where patients actually get permission to like, say, I know your biological clock is ticking.
Speaker: it it will continue to tick, but your uterus is much more forgiving than your egg supply. i will in our clinic, we'll get patients pregnant up to about age 50 as long as they're healthy and medically cleared to do so. And so take three months, take six months, explore this as long as you need to before you feel like we're ready for it.
Speaker: And it's that time too and that space to kind of rest and reflect that that allows people to come to their their own decisions themselves as well. Mm, that's really beautiful because, again, i i feel like that – well, one, i think whenever you are so in this world, it – I mean, it takes over your life. I've talked to so many intended parents where, I mean, – they were They describe it as basically living a double life. And what a beautiful picture of looking at that whole person and giving them permission to, like you said, rest and reflect.
Speaker: Especially in you know in in situations where, again, maybe... um Maybe someone is coming to you with a diagnosis that is kind of deemed like, hey, this just we're not we're not coming back from this. this is just a This is just maybe too complicated. How do you handle maybe those situations where maybe other doctors have said, i don't necessarily have the the full understanding of how to approach this? How do you maybe choose to approach those, what is considered a complicated situation?
Speaker: I think for me, because, um you know, it makes me think a lot about when we get second opinions. It's it's funny that this comes up now. Like I, have another clinic in town and I communicate with the doctor there and he messaged me yesterday and he said, you know, can I send a patient your way for a second opinion? Not because, you know, their relationship is ended, but he's sort of just like, I'm at a loss for what to do next. And so we do that kind of exchange a lot. And, know,
Speaker: I think most of the time I don't, I'm not going to pretend to be like a better, smarter, more well-read doctor than any of the other peers because all of the REIs that I know and love and I, you know i have my text chain of like, here the doctors that I go to for my phone of friends. Sure. They're all geniuses. Like they're up here and I'm not worthy.
Speaker: so I would never pretend to be like, I'm going to find something that somebody else couldn't find. But I do think that patients get a lot of value from us taking the time to read through read through everything that they've got, like read through where they've been, read through their records. And in many cases, that situation is truly complicated.
Speaker: Complicated to the point where it is going to require some of these alternatives, working with a surrogate, working with an egg donor. And, you know, sometimes you need a fresh voice that's preventing presenting another perspective. And it may not be any different than the other perspective that that other first doctor might've given them.
Speaker: yeah But to hear it from somebody else who's coming at it with fresh eyes, it makes it a little bit more believable to say, okay, here's this person that hasn't been with us up to this point, but she's just looking at everything ah as objectively as one could. And she still says,
Speaker: The same thing that we just heard now, it makes it makes it more real. It makes it feel like, okay, this isn't just one person, you know, trying to get money from us, trying to push us towards the most expensive treatment. Like that's always one of, it's it's so crappy in this field of medicine that this is one of the risks, but there's one of the fears that patients have is some of this is a financial investment. And so do you trust that your team is is advising you not based on financial, but on medicine specifically?
Speaker: I take a complicated case and I may not tell them anything different than what they've been told, but sometimes telling it to them in a different way. And again, being that sounding board for them to be able to say, well, here's been our frustrations up to this point.
Speaker: Sometimes those frustrations are not about another team, and another provider. It's just about the unknown. It's about how much we can't know. And we just need another person to kind of acknowledge like, yeah, it's really crappy that I don't have an answer for you, but it doesn't mean I don't have a solution for you. And that sometimes will help patients get past a certain complicated situation that can maybe be made more simple with the options they hadn't really considered in the past.
Speaker: Sometimes though, there is like... Some of the counseling that we do is exit counseling. It's hard to see you know somebody that you've spent a lot of time with and they get to what truly might be the end of not just this chapter, but for them, a fertility book.
Speaker: And a lot of what we sometimes have to do is say, you know, you deserve to continue living your lives. You should look back on this chapter knowing you did everything that it was within your means to do. and sometimes that's how life works. And it doesn't mean that you are failures and it doesn't mean that you did anything wrong. In fact, you did above and beyond what other people might have to do and But sometimes too, there's such thing as like too complicated and helping patients understand that Sometimes there's relief in that for patients. And sometimes it's simplified to just say, it's okay for you to to be done if you think that actually in your heart of hearts, you might be. And they need permission for that too sometimes.
Speaker: Yeah. Yeah. Well, I mean, you said it earlier, right? Like you get to a certain point and just giving, giving patients the, the knowledge. And like you said, permission in like, if you're like, you're, you're okay. Like you have, you've exhausted this option. And and and if this feels good, that's fine. We'll get right back to the show, but real quick, if you're dreaming of growing your family through egg donation or surrogacy, we'd love to help.
Speaker: At egg donor and surrogate solutions, we've spent 18 years guiding hopeful parents with compassion, expertise, and personal experience. Our team includes people who have been intended parents, surrogates, egg donors, and even nurses.
Speaker: So when we say we understand, we truly do. You can schedule a free 15 minute call with our team at create a happy family.com to get your questions answered and explore your next steps.
Speaker: You don't have to navigate this journey alone. We're here to walk it with you. All right. Let's get back to the show. I love what you said about, you know, I may not have the the answer, but I do still have a solution. um i think that's so beautifully said because I think it can be so hard to be in this situation constantly having to readjust how you even thought you were going to build your family and then within this world continuing to readjust.
Speaker: Yeah. Yeah. um And it comes up all the time with our patients with miscarriages too. and all All of these pearls are things that I think I've gained simply by learning how to like counsel patients through a miscarriage.
Speaker: and Because it's when when you get this diagnosis of a miscarriage, Like we know on our end, that was already a baby with a name, with their car picked out, with their college application. Like you your brain goes so far in advance just by seeing a positive pregnancy test.
Speaker: And so to get this complete pregnancy, opposite piece of information. it is a real blow. When I, when I'm counseling patients, like I remind them of like several very important things. One is this was not something that you did. This wasn't something that you should have been doing that you weren't.
Speaker: And because a lot of us women in particular will find, they want to find a ah a place to lay blame. And most the times it's going to be on themselves. And they need to hear everybody around them remind them like, this isn't you being a failure. This isn't you failing everybody. This is crappy luck. This is nature. This is human reproduction being wildly inefficient because it is.
Speaker: And so I always make sure patients have permission to be angry, to be sad, to be frustrated, but they don't have permission to be guilty is what I tell them.
Speaker: and The other part of it is, you know, when we have a miscarriage, we have to, we watch their HDGs until they go all the way to negative, which can take four to six weeks. And I will tell parents like your body needs this time to recover. And so I don't want you to schedule your next treatment. I don't want you to plan away your grief.
Speaker: We love to not feel And we do that by distracting ourselves. Let me make my list. Let me make my schedule. Let me know what's coming next. And I don't want my patients to do that. I don't let them do that. I say, if you've got questions, you write them down.
Speaker: And when your HCG is negative, we're going to go through those questions. That's when we make our plans and our schedules when we talk about what's next. But these next four to six weeks, it's not just time for your uterus to heal. It's time for your heart to heal. It's time for your your relationship to heal. This is a time where you're taking care of each other. You're treating yourself to the things that you didn't get to do when you were going through IVF and when you were pregnant. like This is your break time.
Speaker: Because if you don't like process those feelings and that grief, when it's time to get back on the saddle again, you're going to be terrified. You might be paralyzed.
Speaker: It's going be hard no matter what. But if you don't process the anger, the frustration, the sadness, all of those things, like you you won't be ready for what is next. And so that carries on not just for miscarriages, but for everybody going through their fertility journey. Yeah.
Speaker: I think it's so, there's that extra complicated layer with surrogates where they also feel like, well, it's not my grief to have, it's their grief. So I can't feel that. No, like i whenever, whenever we go through a loss with a surrogate, I always make sure they have the opportunity to have a consult with me one-on-one to, to give them permission to feel those same things that they maybe feel like is not theirs. They don't get to own it, but they got to get through it too. Or they're going to be terrified. They're going to be paralyzed. They're going to wonder what did I do? and they need to hear from me. That wasn't something that you did.
Speaker: um And so, but, but you're absolutely right. From the surrogate standpoint, it's, these are, these are women that have not usually had to really suffer much in the way of their fertility journey. They're coming to us as surrogates because they've been incredibly lucky. This is something they've been really good at. This is something they've loved, they've enjoyed. And so just to start to experience a loss or a failure in that way, it can blindside them because almost didn't think it was possible. um And so that it's, and if you don't handle it correctly, there can be disconnects between the intended parents and the surrogates too. And that's the last thing that we want is, you know, a change in that relationship. So it's, it's hard. It's hard, but it's, it's an art. It's, in some of this is science. A lot of this is art and it's working with humans. Yeah.
Speaker: Yeah. Can you speak more into that um in terms of balancing that relationship, particularly with intended parents and their surrogate and navigating just that piece of it?
Speaker: it's It's always tricky because there's so many moving parts, right? Like there's the medical side where I'm communicating with the parents, I'm communicating with the surrogate, and usually it's the questions about why didn't this work? Is there something wrong with the embryo? Is there something wrong with with the surrogate or uterus? Like what are the things that we're going to do differently? But I think a lot of it is being very transparent with the parents of what I'm telling the surrogate and being very being very transparent with the surrogate, what I'm telling the parents.
Speaker: I usually am not having this conversation with all of us together because I want both parties to be able to ask me their candid questions. um But it's, again, it's being able to like set aside that time, not necessarily with an agenda for what am I going to get through on this call? What am I going to say? But more like, well, what are the questions that they're going to bring to me?
Speaker: not Not assuming that I know the questions they're going to ask, but rather just making sure that they have a chance to feel ready for the next step, especially, you know, the way we kind of practice is we'll we'll allow one or two, even three transfers with a surrogate before we say, maybe there's something else going on here that we just can't detect.
Speaker: And so after that first either failed transfer or a miscarriage, most of the time the parents at least need reassurance that I wouldn't cut ties here, that I still expect that she's going to be able to get pregnant with you, and that she was compliant with her medications and that there's not something that I'm not telling you, that everything on on everything and on our our end looked as good as it could so that it reinforces their trust in that surrogate.
Speaker: um And I always will tell the surrogates, like, this is what I've gone through with the parents. They know that this is human nature. This is not you. I make sure that that when I talk to them, they're not going to blame you at all. Like I want, I tell both of them what i would want them to hear together, but I do it separately so that, again, they have a chance to talk candidly with me.
Speaker: Mm-hmm. Mm-hmm. No, i I really, really appreciate that because as a coordinator, it felt like that if there was a failed transfer that surrogates were always asking, well, what about the quality of the embryo? And then intended parents were always asking, well, what was in the control of the of the surrogate? And and again, and none of it being blamed, but just purely that that desire to have to have knowledge, to have understanding. Everybody wants to find that why. And it's so hard. Like you said, science can take us so far. And you know this is somebody so beautifully said, you know i feel like this industry, this is one of the only times where doctors do something and then they say, good luck, um because science can only take us so far. Yes. Yes.
Speaker: um Well, it's on that same note there have been changes in very recently from ASRM, like in May of this year, ASRM published a new like ah guideline on miscarriage and miscarriage diagnostic workup.
Speaker: In part, I think, because there's this huge... want and desire need for answers where we can get them. So in the old days of like treating and diagnosing recurrent pregnancy losses, they used to call it three losses. And then over time that changed to be like two losses in a row, but they needed to be diagnosed like on an ultrasound, like far enough along. So not chemical losses. The more recent guidelines say two losses, they can be urine or blood confirmed. They don't need to be ultrasound confirmed. So the bar is getting lower and lower to say this is a person where this is a miscarriage worth exploring to figure out if it's, if there's something, an answer that we could provide. And the huge shift has been, you know, there's this test that's available on, on the tissue, on the products of conception where you can look at the genetics of that tissue
Speaker: And it used to be the case we really didn't do that test very often. We might offer it after like two or three miscarriages. The recommendation now is on your second loss, you're collecting that tissue and you're sending it for a karyotype.
Speaker: And in the reason is most women, we all feel like it's probably pretty cruel that we should have to do this three times before we can get some kind of answer. Because the reality is all the other stuff that we check for for miscarriages so often comes up with nothing. It's maybe only half the time that we actually find a problem.
Speaker: And the rest of the time we're just told, Good luck with the next one. We don't know. These genetic tests that are available on the tissue are becoming more and more affordable.
Speaker: And so the recommendation is switched to doing them a lot earlier to give people answers earlier. And it's actually looking to be cost effective, not checking all of these other zebras on this side. If we can find, oh, hey, there was just something genetic about this embryo. It wasn't you. It wasn't ah the uterus or your surrogate. It even an embryo that's PGTA euploid, like been tested, there's some evidence that if you test the tissue, you're going to find a problem that couldn't have been picked up with PGTA. And so I think we'll start to see a shift in being able to where we can find answers for people earlier in their journey so that ideally we're not sitting with so much unknown for quite so long. It won't be perfect, but there's this shift more towards like, let's use science to help
Speaker: treat the mental a little bit yeah and not not just make a diagnosis, but also be able to give people answers. Yeah. Well, I love that. I mean, i i love that, like you said, it it is giving people answers, which does help so much in you know just the mental health aspects as anyone is navigating through this. But I also really love that in terms of you know just specifically for a surrogate when you are looking at that whole person. I mean, right now,
Speaker: the the standard is that if the surrogate has had, you know, a failed transfer or miscarriage, you know, it's really hard for her to match or rematch because, hey, you're not, you know, there's been a problem. You're not, you're not proven. Do you feel like a test like this would be able to, you know, again, just give more information? So if this, like the surrogate could potentially be rematched because we now have you know, the information to say, Hey, this was, this was a genetic component, nothing that she could control.
Speaker: Yeah. I mean, I think there's definitely that potential there. Um, because so much of the time, all we can do is like, look back at how did the embryo look before we put it in? And if it didn't look good, then we probably shouldn't have put it in, in the first place. It's always, it's like, Oh, the embryo was probably fine. but There's definitely, I think, potential to get more answers to say this was an embryo issue, nothing more. But there's also like there's some risk in that, too. If that genetic test on that embryo also comes back normal, then you have a little bit
Speaker: Less of a place to stand and say, I don't think it was me. Like, I think that I could do this again for somebody else. And so there's there's a little bit of risk, too, that you could shoot yourself in the foot by doing that kind of exam.
Speaker: Sure. it's I think for everybody involved, not necessarily just a surrogate, for the clinic that's trying to get better and better success rates, for parents that are wondering, like, should be we try to make new embryos and do it in a different way? Like, it's I always think it's better to have more information than to have less And so it may not tell us what we're expecting it to tell us. And sometimes that's good, but sometimes that also can be a little bit more damning, depending on, you know, your goals with that test.
Speaker: But it's readily available. And I think we all should be talking about it more often as we go through these hard things, because it's genetic tests in general becoming far more affordable than they ever were. This isn't science fiction. Like there are answers to be had. And so much of what we do is genetic. And we've just it's all been in this black box up till now. And so we should use these tools as we develop them.
Speaker: When you're looking at, you know again, like you said, with knowledge knowledge is power and you know it can be so helpful. Particularly with a surrogate, how do you maybe approach situations where a surrogate may have something in her history that another physician maybe sees as an automatic you know disqualification, um but maybe you see as an opportunity to just look at ah the bigger picture? Mm-hmm.
Speaker: But it happens all the time because yeah there are different clinics with different standards. And to be honest, some of it is not completely objective. Some of it is again, those anecdotes. If we had a particularly difficult journey because of some particular medical problem that we never really thought to be that important before, and then all of a sudden it is,
Speaker: you get burnt once and then you change your policies. And so it's, it's definitely, you know, it's going to be unique clinic to clinic and, and team to team in terms of what's acceptable to us because of our previous experiences.
Speaker: But I always try to one, get as much information as we can about whatever it was that was going on. And then two, do a really thorough and updated like kind of literature review on that particular diagnosis or issue. Like what is the most recent literature say? Because could be the case that something that a doctor that hasn't like looked at the updated data said, ah, it's probably fine. And then now there's this big study that's come out in the last year that says, actually, this is something we need to take more seriously. or in the opposite direction. Maybe this is something that we thought was going to be a very big deal in the past. And then more and more studies have come out to suggest actually maybe it's not as important as we thought it was. So yeah making sure you are understanding by looking through the records in the past thoroughly, like what really was going on, as well as continually educating ourselves on the most recent recent literature.
Speaker: More often than not, I'll say our clinic is more um picky than other clinics. I feel like we are the ones that are saying, um thank you. It's sweet of you to to try, but there's this thing that is going to be dangerous for you or the baby or both. And thank you, but no thank you. And then, and and sometimes I will close that that decline with, there may be another clinic out there that's comfortable with this, but I apologize. It's just not us. So I'm usually on the other side of that where we kind of have higher maybe than average standards for surrogates, not because we're, you know, mean or stingray, want to reject people, but it's truly like all of this, is out of the goodness of your heart as a surrogate, there should be as minimal risk as possible that you take on. you know a really A recent example we've had is like a a surrogate who had melanoma in the past.
Speaker: And for us, almost every kind of cancer is pretty much a hard no. um and And melanoma in particular is a really interesting one because it's one of the very few cancers that can spread and and recur and metastasize to placenta tissue, interestingly. Yeah.
Speaker: And so like pregnancy presents this risk of melanoma coming back, particularly within like the first three to five years of that diagnosis. And so we've had a few candidates come through in the past with this history. And the first thing would say, okay, well, when was it? Have they had more pregnancies since then? Or was this the last thing that has happened to them? And everything is case by case. And so that's that's the other big piece. part of it is, yes, we've got our policies, but we will review every case. And if it is a decline, a disqualification is not without like a thorough case by case review with, from my part, an explanation about why so that patients don't just feel like rejected, but that they understand, oh there's actually this real health risk here.
Speaker: Yeah. Well, again, I really appreciate the fact that yes, while there is, you know, while there are parameters and of course, you know, ASRM guidelines, again, I love the fact that you are looking at the whole person, the whole history, asking those questions and giving an explanation as to why, um, and not just being like, Oh, saw it on the list. Okay. Bye.
Speaker: Yeah. Yeah. Yeah. and And it can feel like that, especially like as an agency might have like a a, they might be trying to make a match and they've been getting unlucky. And like, we've had, you know, a couple in a row sort of gets that just didn't make it through. It can feel like, why is this doctor so picky? Why is this clinic so slimy? And I always feel very bad. Like as a human, like I hate rejection. i hate being the one to reject. I hate getting rejected. It's human nature. Yeah. And so I at least try to say, here's the medical reason why it is not personal. It's not against you. There's this real safety issue. And then and then usually it's a lot easier to say, okay, I get it.
Speaker: Yeah. Yeah. Well, and like you said, like, yes, of course you are looking at, you know, everybody wants a a healthy and positive outcome in terms of, you know, bringing home a baby. But, you know, you are looking at more than just can this person get pregnant. You're looking at their risk and, you know, what it could do for ah them and their health. And that matters. Yeah. Yeah.
Speaker: are you know Are there patients maybe who have changed the way that you practice medicine? Like maybe someone whose outcome challenged what you thought was possible or maybe just simply reminded you just why this work matters.
Speaker: Mm-hmm. Yeah, you know, we as doctors, we've given a lot of tools to help use big data and statistics to like guide patients. So like, let's say, for example, you're at the very beginning of your journey, you've been trying for a year, you do your diagnostic testing with me.
Speaker: we come back together. I've got this like handy dandy calculator that I trust is very good and it's very accurate, but you plug in these things and it'll tell you, okay, if you did one cycle of inseminations, here's your chance of a live birth. One cycle of IVF, here's your chance of live birth.
Speaker: And we like to have those numbers so that we can kind of present it to patients. And then my, my, practice style is you take these numbers and you tell me what you want from it. Like this is going to be joint decision-making. I advise you tell me what you like, we make it happen.
Speaker: There have definitely been patients that have challenged those statistics for me in, in a great way. Like I already said, like I see miracles every day. And so, you know, I,
Speaker: And without having a lot of experience in my earlier parts of my career, kind of like, well, here's what the data says. Like, this is kind of risky. Are you sure you want to do this? Like, I've got this other option. We're talking about 15% versus like 90%. Are you sure you want to do this? And I'd be very kind like hesitant because I know that at the other end, it's likely I'm going to be having a very hard conversation when things fail.
Speaker: But I've got one patient that's one of my like miracle stories. And I share it every time that I can where, you know, she she came to us with, a she's already had like her own normal fertility in the past. And she has two sons that are a little bit older now and they just want their daughter. um And it's actually a patient that lives outside of the country.
Speaker: and I reviewed all of the tests that she had done with her gynecologist near home and her egg supply Like it does not get much worse. She still gets fairly regular periods, but like incredibly low AMH. Like when we do ultrasounds, we'd see like three follicles.
Speaker: And so, and because she didn't live in the United States, there's also this component of the logistics, the travel. Like we may be able to get something done in, you know, three to six retrievals, but that means you're going to have to travel to Las Vegas every time.
Speaker: And, you know, she's a very, a very lucky family where this was within their means. This was something they could try. And as opposed to the egg donor option, they said, like, just let us try. And so I said, okay, this is like, you're going into it with your eyes wide open. I know that I've counseled you up, down and sideways about the ways that this can go.
Speaker: And then she followed up with, not only do we want to have our girl embryo, but if I had any extra embryos, I want to donate them to my sister. She's 45. She went through her own journey with her partner. They didn't have any luck. And so if, by the way, Dr. K, you could put aside some extras.
Speaker: And I was like, ah okay, okay, okay. like Slow your roll. We're working on one miracle here. like We're good, but like let's let's focus on, let's try to get you one.
Speaker: Sure. this This amazing woman who is otherwise like brilliant, powerful businesswoman. She's like a CrossFitter. Like she blows my mind. She came for three stimulations.
Speaker: She had three retrievals. One of those retrievals, we didn't even get any eggs. So we literally are starting with like three eggs total. She made two embryos that were testable, two euploid embryos, one girl, one boy.
Speaker: She has a baby girl. Her sister has a baby boy. Oh, my
Speaker: her story has changed quite a bit in terms of how I counsel patients about the risk that they're willing to accept and what we're willing to try. Because statistically, that should never or have happened.
Speaker: And it did. Yeah. It's crazy. Well, again, there's always those outliers and there's always... there's There's always room for hope.
Speaker: And like you said, it's whatever the patient at the end of the day is willing to, you know, what which adventure they choose. Yeah, yeah.
Speaker: yeah i Again, they they choose. like I give them the tools and they give them the data because there's comfort in that. But some people are going to defy data. And we have to keep that in mind when we talk about doors that are open and doors that are closing.
Speaker: so yeah it's yeah it's as long as you can verbalize back to me that you understand, then let's go for it. Let's see what happens. And I'll be there for it with you, good or bad. Hopefully it's good.
Speaker: yeah But I also can deal with it when it's bad. We'll deal with it together. That's beautiful. When you look at fertility care today compared to when you first entered the field, what developments are you most excited about just as you kind of maybe look ahead maybe over the next five, 10 years? Yeah.
Speaker: hey a That's a great question. um You know, even just like the the eight or so years that I've been here and in the job that I'm in now and come out of fellowship, I feel like a lot has changed in the level of like the partly the laboratory and like the technique and the science and the research that's coming out of the labs. Like embryologists have the coolest job in the world.
Speaker: And so if I could inspire any young listeners out there, like be an embryologist, like there's so much that's rapidly changing there that I'm really excited about that the technology in the lab gets better and better. um Will it ever be perfect? No. And do I ever want it to get to the point where we're like cranking out babies in like a factory with like artificial wombs? No, I don't. I don't think that we're going to get to that point. Yeah. It gets better and better and better. ah We're pushing the limits of what we thought we could do. So that's really exciting.
Speaker: And the other part of it is there's a lot more being explored and published in terms of like the uterus. And, you know, there there have been tests on the market that have come and that have gone and that have not really proven to be perfect. But we we tend to not really pay nearly as much attention to the uterus because we've also been a little bit stuck. And what can we do to make it better? What are the things that we check? Because do we have solutions for those things? Yeah.
Speaker: And so I think we as a field in science is looking at that in a lot more detail, exploring things like the effect of endometriosis and adenomyosis, chronic endometritis, uterine anomalies that are subtle, but that might not be completely benign, taking that a lot more seriously. Because as we push our limits in the lab of how good an embryo we can make, we're still never reaching 100% because there's also these limitations that have been a lot harder to...
Speaker: to get a grasp on. And so it's not to say that I want the idea of having a surrogate to be like obsolete by any means, there will always be room for surrogates.
Speaker: But I do think there's a lot more data and a lot more treatments that are going to be available in the next five to 10 years to help our uterus be better at this as well. I feel like just the the shift healthcare and making room for particularly women's health and health giving women the ability to have conversations and not say, oh, I'm so sorry to bother you. And particularly like with endometriosis, hey, that pain that you're having, like, no, you don't just grin and bear it. Let's find out why.
Speaker: And being able to get to, you know, just the source. And like you said, not only are you going to find out why, but let's explore a solution. The advocacy part of it is huge. People as advocates for themselves, people as advocates for everybody else who's silently going through this. like that I also think the conversation, for better or for worse, around infertility, around reproductive health in general has become much more public than it was when I went into this field.
Speaker: And so as much as it does expose us, I think, to some extent, it also empowers us to say this is a real problem. And, you know, in in general, infertility care has been kind of treated as other when it comes to like health problems, even if we just look at like insurance and coverage.
Speaker: There are a lot of insurance companies that are perfectly happy to not consider this healthcare. And as a result, to electively not cover the the treatments that we know are medically necessary with a medical diagnosis.
Speaker: So I think the more that we advocate for ourselves as a field, as patients, to say like fertility care is healthcare, care the harder it will be for people to not recognize this healthcare.
Speaker: healthcare care and to stop, you know, to to continue to like refuse to sort of provide coverage for it. um That I think has changed in the eight years that I've been in this job. And I i hope and pray that it continues to change for the better as well.
Speaker: Yeah. No, I completely agree. I think you know the idea that fertility care is viewed as you know a quote unquote luxury item um is just is just not – it's just not it.
Speaker: It's just not it. And you know like if you need an egg donor, if you need a surrogate, like that is not a luxury. There's a need behind it. Yes. 100%. It's ah weird A weird world that we live in, but I i am very hopeful that like the right people are speaking up and that we're making movement in the right direction to to get better at this from a scientific standpoint, from a mental health standpoint, from ah an access to care standpoint.
Speaker: Yeah. Yeah, for sure. for For someone maybe listening today, if they, maybe after they've received, you know, some disappointing news or they're feeling like they're running running out of options or, you know, they're just, they're at this crossroads.
Speaker: What would you want them to know?
Speaker: that I know I've heard you ask this of other people on your podcast. And so I was trying to think of how would I answer that question myself? Because there's there's different answers for different people at different points in their journey. The easy automatic answer is like, never give up.
Speaker: You know, there's there are a lot of things. And I already said this at the beginning of our of our conversation is like almost never you actually truly at the end of a road. Like there are often opportunities, alternatives that will get you to the end goal.
Speaker: But I also have seen, unfortunately, sometimes like the the other thing to say is it's okay to be done with this.
Speaker: You know, it's yeah sometimes people feel like they get on the train. They can't get off of it. they've They've told too many people that they're in this. And if they don't go home with that baby, like that's a failure. And that is devastating. But sometimes secretly underneath, they're also relieved to have permission. Yeah.
Speaker: to be done. And it doesn't mean that you're done with your life. It doesn't mean that you're done pursuing other goals, but it may mean transitioning back to like, who was I before we started this project has changed me so much. Let me get back to who that person was. And sometimes the medical conversation is you've done a lot. You've done enough. You are enough.
Speaker: If you're, if you're ready to be done, like that's okay too. Um, when people are ready to hear that, they'll hear that if that's what they need to hear. But if everybody around them is also only giving you the like, don't give up, don't give up, don't give up.
Speaker: Sometimes it feels like it's wrong to give up. And and so I would remind patients too, like there's there sometimes there's a right time for that to be okay. um And we never want that at the beginning of our journey, but for some people, that is how their journey will end. And that's okay too.
Speaker: Again, just what a beautiful... Beautiful illustration of you specifically looking at the whole person and not just focused on a outcome.
Speaker: the The whole person needs to be the outcome, you know? Yeah. Like it's, I will usually tell patients like you you had this idea in your head of what things were going to look like, of what your family was going to look like.
Speaker: When you've gone through everything that you can go through with us, like you're already parents in some way. they It may not be that you are delivering a baby in a hospital the way that you envision, but you're already parents in one way. There's somebody else in your life that would benefit greatly from that thing that you have to give. Maybe it's adoption. Maybe it's nieces and nephews. Maybe it's your fur babies. um And you never say that to anybody too soon. Like if they're not ready to hear that, but you don't say those things.
Speaker: But I will always remind people like you can envision yourself as a parent and it may not look exactly the way that you thought, but that doesn't mean that you are any less of a parent in one way you will find a way to parent.
Speaker: That's beautiful. That's absolutely beautiful. Well, Dr. K, thank you so much, again, just for your your expertise, all of that beautiful wisdom and all of the ways that you have counseled you know just all of your patients beyond just a medical diagnosis. um You know this question is coming since you you know have listened to a couple of the episodes, but...
Speaker: coffee and i were just two peas in a pod. And so I always love to ask what has filled your cup lately, literally or figuratively, what has been the thing that has been filling your cup lately? There like, um, a number of things that I was thinking, okay, what would I prioritize? But I'll just give you all of them. i I, my, well, one, the next season of Ted Lasso was coming out in August I don't know if you're Ted Lasso person, but oh I am a huge Ted Lasso person. Yes. yes I was kind of like, it's never going to happen. Like, you know, there's these rumors, of but it's just rumors. and never going to do it. And then when we heard earlier, they were going to do it. And now I saw something come through that said, okay, your countdown starts now. If you're going to watch one episode a day until the new season comes out, you got to start now. And so I'm like, okay, it's coming. So that's one thing that I'm like, Probably abnormally excited about. um Another is, so you know, i've got I've got two little boys at home. They're four and they're three. They're best friends and worst enemies. I'm covered in bite wounds because they're constantly breaking up fights. um
Speaker: But for other people, they are sweet as can be. And so, know, have a coworker here who's got sons that are a little bit older and she always hands down their clothes and their shoes. Yes. Oh, that's the best. So for the last week, I've been watching my three-year-old, who's very petite three-year-old, running around in clothes and shoes that are far too big for him. But he's so excited to have this new, like, Spider-Man hand-me-downs and they're fighting over this new clothes. And so that fills my cup, too, is to kind of remember, like,
Speaker: All those people that want to be parents that are coming to us, like, this is the dream. Yeah. Yeah. Yeah. No, for sure. Oh, there's such a gift in that chaos, especially, you know, yeah, yeah when when they're all being feral and you're just like, I don't even, like, what is it? It was like, i I can't wait for them to go to bed and then I can't wait for them to wake up in the morning. like Exactly. yeah Exactly. Yep.
Speaker: No, for sure. For sure. And I'm 100% with you on Ted Lasso. I don't think there's a show out there that I am just like, this is just good. This is just every human needs this in their life. yeah Like 100%. Absolutely. Absolutely. my My second baby's middle name is Roy after Roy Kent.
Speaker: He's here. he's there. Yes!
Speaker: Yes. Oh my gosh. little bit obsessed. um That fills my cup. So I'm loving that so much. Well, really, again, thank you so much just for your your time, your expertise, all the ways that you counsel and help. um And I am just, I'm so grateful um for you. so thank you so much.
Speaker: Thank you. This has been a pleasure.
