It's part of growing up in this deal and knowing who are your true competitors.
It's a little harder in some respects, than just through the name, because you
do have other competitive factors now that you have to go up against ... the
bigger medical groups. Pacific Fertility, in the California area, is an example
of that. You may not have any big name players in some of those corporate
groups, but you have fiercely competitive marketing and financing schemes that
you also have to fight against in terms of losing patients to those groups. So
there's a lot of different little wars you fight, to stay in business doing
this type of medical care.|
... What do you think of the way infertility is advertised?
I think it's on par with what we see in other fields. I don't think we're any
worse than dentistry or some of the other fields. Law, for instance. But it's
becoming increasingly apparent [that] in infertility, there's sort of a fine
line between what's a tasteful ad and what maybe goes a little bit to other
sensitivities, especially if you're in the field and you're dealing with these
issues every day.
[The] registry numbers of promoting one's rates have been frowned upon recently
by the American Society of Reproductive Medicine, but people are still doing it
out there ... I worry about the commercialization of ... initially, at least,
academic exercises, and how they may be exploited. I worry about truth in
advertising. Even with these numbers that everybody looks for in success rates,
they're at least two years old before they're ever reported.
I came to New York and I'm fighting that battle right now. The numbers on which
people judge my program for are literally the numbers of the old program, but
that's not explained. So my own competitors will say, "Well, look at their
numbers and they'll speak for themselves." They don't ask us for what we've
done since we've been here. It's a trick everybody knows; yet, it's not below
people to do that, even people that are in the know.
So again, it gets back to the same issues. A very competitive environment.
Everybody knows how to steer patients. Everybody knows how to inflate numbers,
and that's unfortunate. That's not what any of us intended when we started
putting together registries, and looked at national reporting and the value of
that. I don't think that was ever the intent.
How have success rates affected the competitive environment ...
Success rates are difficult, because everyone looks at a success rate as the
baby for which they are trying so hard to achieve. They don't usually question
the number. They don't ask what that really means to a program.
For instance, if you lie two programs side by side and you see discrepancy
between the programs' success rates, the automatic assumption is that one
program is better than the other, and that's really not true in most cases.
Programs are always different. They may treat different types of patients. If a
program wants to maintain a very high success rate, they can and do literally
select the best patients to treat.
On the same hand, the competitors who may not get those best patients, a new
program, for instance, in a marketplace, may be sort of stuck treating patients
that other groups won't treat, which will automatically lower their success
rates. So it's Catch-22. You can't really get out from under that unless you
start selecting out only the best patients.
So it does have an impact on the way you treat patients. I have patients here,
for instance, that have been turned from other programs, that have had children
... or that are pregnant. It's not that it's futile care. It's just it's high
risk care, in terms of pregnancy success. So each program director is faced
with a very daunting task of trying to make a decision as to who they are going
to treat, with the full knowledge, it's no secret, that the harder the cases,
the lower the chance of success, and the more it may overall hurt the image of
the program ...
We see, in many clinics, people that are white and look like they have
money. Do you think that infertility treatment has been skewed in a particular
Oh, I think definitely it has. The cost of infertility care is pretty
outrageous. If you look at our own patients, I'd say the average patient we see
here ... are going to spend anywhere from as little as $5,000 to as much as
$50,000 within a year or two of trying to have a baby. That's not uncommon.
There are patients I've seen that have had seven, eight failures of IVF [in
vitro fertilization] and come here for egg donation, and they're going to drop
another $20,000 to $30,000 on egg donation tries. So there's a lot of money
being spent. No one, no middle American or below, is going to be able to afford
We also [see] this in the public clinics that have been a part of every program
I've been a part of. It's kind of an interesting juxtaposition. Come to Madison
Avenue and you treat very well-off patients, and they're exactly what you
described ... You go uptown to our indigent patient population clinic, and
you're going to see a whole different demographic. They're just as deserving.
They should have the same ability to access care, but they don't because they
plain can't afford it, the state won't pay for it and insurance doesn't pay for
it. So it's skewed, certainly.
What does that mean? You actually were fairly passionate about this issue
when we talked to you in December.
What it means is there's a large population of Americans that are not able to
access state of the art fertility care. They just can't afford it; they deserve
to. Many are going to be operated on because it's covered by insurance, and I
would argue many of those operations are unnecessary, with very low rates of
success ... We know that the surgery is not very effective, but it is covered.
You'll see a lot of Americans go that route for no good reason. I would say
there's, therefore, a lot of women being sort of mutilated for nothing more
than insurance reimbursement purposes ... I know that's going to get me into
some trouble saying that, but it's the truth. You're not getting IVF coverage,
because it's not considered an insured benefit, which is highly unfortunate.
It's probably the most cost effective thing that we can offer any couple; yet,
it's withheld to those that can afford it.
Egg donation has gotten more expensive. So you take a therapy like egg
donation, that has about a 50% success rate. No matter what your diagnosis, no
matter how old you are, [it is a] highly efficient way of getting a woman
pregnant. But if you don't have about $20,000 up front to pay for that, you
will not get care.
It didn't used to be that way. Ten years ago, when I was doing egg donation, it
was about half or even less than half that cost. Nothing much has changed,
except it's more competitive than it used to be. So you have to pay a lot more
for the donors, and you have to charge a lot more to the patients. We're
pricing ourselves, unfortunately, out of some of the market. And the market is
our patients trying to have children. Which is, you know, in the name of
medicine, something you shouldn't be doing. You should be trying to find a way
to treat these women, and unfortunately, economics speak against that.
There was a little bit of a war over egg donor prices last year. What
happened in that?
Well, there's still a war going on for donors, all over America. Certainly in
New York, it's been more spotlighted. When we came into this marketplace, I
carried with me a way of soliciting donors and a way of building a program that
worked. We were paying about $1,500. When I first came to New York for donors,
we built up fairly quickly a small stable of patients that we could go back to
over and over again. That price went up to about $2,000 within about a year and
a half of being in New York, as certain other groups started matching this fee
and going above that.
What caught everyone's attention was last spring, when a major competitor in
this program jumped the price to $5,000 per cycle ... basically twice the going
rate ... We saw defection of our donors to that program because it was
literally twice what we were paying them for the same service. As predicted,
within a short time thereafter, other groups were advertising for $7,500 and
So it's becoming what the market will bear type of a mentality for egg
donation. But the unfortunate thing about that is the service is the same, and
so the cost goes up. Therefore, fewer and fewer patients have access to the
care. So patients that today can afford egg donation may or may not be able to
afford it a year or two years from now if this phenomenon continues to go
Is that your objection to it? Do you have any other ...
I've got a lot of objections to it. One is that it's just unnecessary ... it's
like the old gas station wars when I was a kid, where one lowers their price,
the other one does, and how low will it go? Except it's the opposite, how high
will it go? It doesn't seem to be the interest of these programs to try to keep
these things manageable. They want the market. They don't want a piece of it;
they want all of it.
So I have been very outspoken, I know, saying this, but these groups are very
selfish. They're out to capture the economics and capture the patients. This
isn't in the best interests of the patients. So I would argue with anybody that
this is in the best interest of a patient, to pay more money for the same
service. There are a lot of good programs that can do egg donation, but not
every program is willing or is going to be able to compete with those kind of
Secondly, when we started doing egg donation--and maybe this is even more
important--a good 15 years ago, we were paying donors about $250 for
participating. That was based upon what the institutional review board at UCLA,
where I was at the time, would allow. Anything more than that was considered an
enticement, or perhaps, even be considered coercive at the fee that we're
paying now, because some people will look at it as a quick way to make a lot of
money, which it certainly is.
Now, people can argue about $5,000--maybe it is or isn't too excessive. Well,
what about $10,000? What about $15,000? What about, recently, $50,000? I mean,
to me, somewhere you have to draw the line as to what is considered reasonable
compensation for expenses and time. Even at $5,000 a cycle, you're looking at
paying people on par with about a $300 to $400 per hour participation, which is
more than most of the physicians are making delivering the care.
So I have a hard time believing that this is reasonable compensation, as stated
by the ethics committee of our governing society that it should not be greater
than that. I also remind people, at least my own colleagues, that in most
places in the world it's illegal to pay donors. In fact, in many places in
Europe, it's illegal to do egg donation outright. So we're not really in
compliance with our peers outside of the United States. In fact, when I travel
abroad and give talks on commercialization, it is roundly accepted by people in
the audience that we are the Wild West, and that we are, indeed, way out there
and ethically not on very solid grounds.
Where do you draw the line? You started paying people early on. You were one
of the pioneers of egg donors.
We started paying people early on because it was the only way we could attract
women to take what little risk they do have to take. And there is time
involved. I think that was fair. Women should be paid for their service. But
the question becomes: When is the payment excessive? When is it more than just
compensation for reasonable risk and time? When does it become an enticement?
When does it become a solicitation or as ... one of my colleagues in the U.K.
said, "Are you pimping for patients?"
It gets to be that way. I mean, you're just throwing money at young women more
and more to get them to do something. It goes beyond the normal way we, as
physicians, have treated donors. So it's a fine line. I'm fully in favor of
paying donors to some point. But I'm not in favor of seeing it unregulated if
it has to be that way. So that it becomes so pricey as to exclude 99% of our
patients from being able to ever access this type of care.
You talk about pricey. You're very concerned about this issue as a whole ...
What do you think is happening to this area of medicine?
It's becoming somewhat like cosmetic surgery. Maybe certain aspects of plastic
surgery, where you just have expensive care being paid for by people that can
afford it. Fertility's something very different to me. This is elective, I
agree, as is plastic surgery, but the difference is the end result. We are very
fortunate as physicians to be able to be giving this gift of life to people.
It's a great instrument to be able to be in that position of allowing these
things to happen for many couples that just wouldn't happen.
That quality of life, thereafter, is so enhanced by what we do that it's
unfortunate the insurance companies, or even the states, don't recognize that
as something more important than just an elective decision to have a child. It
goes well beyond that. There's something inherent to everyone wanting to have a
So coming from the Midwest and working class people, I have a harder and harder
time just seeing wealthy people as my patients. I know full well that the
people that I grew up [with] and I still feel very in tune with, just wouldn't
even be able to afford to see me anymore. And that's really sad ...
You've been in this area for 20 years. Has it changed from being a more
academically based area of medicine to something else? What changes have you
[It has changed]. I think in the '90s is where most of this change occurred.
The universities were always the hub for high-tech infertility care and the
advancement of infertility care. As we trained more and more sub-specialists,
and there was a need for them to go into the private community, and there was a
lot of money being made, we saw a transition from the university to a more
And that was interesting, because the competitors that you trained, your
fellows, would end up being in somewhat of an advantageous position, because
they had newer centers, usually outpatient centers with lower overhead than a
university would have. They would set up in the best parts of town, and they
were fiercely competitive. There's a lot of money, again, to be made.
We saw this in all the major metropolitan areas. Then, of course, this trickled
down into other less large areas in the country. That was inevitable, but
unfortunately, it's led to the commercialization of this. People now are
looking at a more or less on the economics of a business, as opposed to the
academic pursuit of a university. That has changed the nature of the way we do
things in this field.
Is that any different than any other area of medicine?
I don't know if it is or isn't. I mean, I sense that there are some
similarities in other aspects, cardiovascular surgery, other things. I sense
it. But I guess it's not in your face quite as much. It seems like there's a
fertility story in the news every other week. I get called all the time to
comment on anything from cloning to the newest treatment in freezing and on and
on. So it never goes away. I'm not sure why there is such a preoccupation with
it, but certainly there is in this country.
As long as the media focuses on this field as it has over the last couple of
years, it will continue to perpetuate this image and this need to develop the
best rates and the classiest looking center and the most diverse practice you
can to try to attract every single patient you possibly can attract.
Is the media feeding on a kind of fascination that people out there have
about reproduction, about creating life?
Well, it's unique. There's no doubt ... and it's a wonderful job. I mean, [to
be] able to work with the bringing in of life, as opposed to the caretaking for
life as it exits, which is the more the tradition of medicine is. It's a great
thing to be able to be involved with. It's a happy field in general. There's
always a spotlight always on that baby at the end of the story.
Unfortunately, there's another side to this field which is also very prevalent,
which is the failures, and the people that don't get pregnant and they're
angry. They spent a lot of time, a lot of money. Of course, they don't see it
as necessarily having been worth anything if they don't have that child. That's
also very much a daily part of what we do.
It really is kind of the push and pull and that drama that goes on every day in
our trenches, working with patients on this level. It is an exciting, rapidly
growing field, and the scientific advancements have been very interesting and
very rapid also. So the dynamic of this is certainly worthy of some of the
spotlight. But at times, some of these stories are overly spotlighted, and
perhaps, not even told accurately, which gives people the wrong impression,
good and bad, of what we're trying to accomplish here.
Talk about this area of medicine. There is some way in which this area of
medicine is unique.
There's some unique aspects of our field in that we are really in the
spotlight. It's unusual for a practitioner to have to report their outcomes
every month for everybody to view, you know? For instance, you don't go to your
cardiologist and say, "I'd like to come here, you seem like a good guy, and I
like your site, but how many patients died under your care last year?" It would
be highly inappropriate. But when we have to report our successes, as if there
is a failure--that's part of the problem. Everybody looks at the success and
they assume, "Well, then, how come you fail?" They don't seem to understand
that reproduction is a difficult thing to reproduce in the laboratory,
especially under the circumstances of patients that are ill, in the sense that
they haven't been successful having a baby the natural ways. So they want to
know, "Why doesn't it work for everyone? If it can work so easily for this
patient or that patient--why not me?"
So you have this difficult time educating a patient to the fact that even
though you do good work, it isn't guaranteed. That we can't foresee the future
and how well you'll do. I don't know of any field in medicine where that even
comes into the relationship like it does with the very first visit with our
patients. Our patients are coming at you with the idea of, "How can you prove
to me that you are worthy of us, and make us pregnant somehow, when maybe in
many cases others had failed?" That's a little difficult to get around. You
just try to reassure them that you have the experience, that you do good work,
that you take on difficult cases like their own; hopefully, put some of those
fears at ease.
Were you hurt by the SART statistics in 1996?
Oh yeah, our '96 statistics, I'll be the first to say it, are terrible. It's
interesting too, because again, you're looking at a program that was in
transition with brand new doctors. In fact, the embryologist nurses, the
laboratory itself, everything from those old data aren't even pertinent to what
we do now. It's a whole different team basically.
Unfortunately, you still have people, our competitors, that will say, "Well,
that's that program, take a look at that." And they know better, you know? So
that collegial help isn't very much appreciated, but people are doing that. You
can't get around it. All you can do, which is what we do, is give our patients
the '98 data, which is the only thing that really matters ... It's on par with
all the other programs in this town. That's also part of being in New York
What's New York like?
New York's tough. There's no prisoners. I can say that because I'm not a New
Yorker, you know? I grew up in the Midwest. I spent a good deal of my
professional career in a competitive Los Angeles market. That wasn't an easy
place to work either, but nothing like New York. [In] New York, you're always
being judged. Patients are always looking for the best rate, the best price,
the best location, the certain doctor, the image of the doctor in charge. These
are really big items in New York, bigger than, perhaps, they need to be.
There is an image of the doctor, isn't there?
Oh yeah, it's huge. I see it in my own practice. It becomes a liability. People
follow the doctor in this field. Whether it's Cornell or other places, they're
following the doctor more than they're following the institution. So when
patients come into your program, because they want to see you, they may wait
seven, eight, and I think right now it's a nine-week waiting list to see me.
They should be just as comfortable seeing any of my colleagues that work with
me. We all follow the same protocols. I'm the director of the program. I still
do the same work right alongside them. They aren't comfortable, because they
want to see you.
Again, this is true of our field, the way it's evolved. It's "that one guy can
do it for me" attitude the patients have. They're looking for some legitimacy
to that image so if they see you on TV, if they read your name in the
newspaper, anything that sort of underscores this image of, "Well, he can do
it." He could be a she, by the way, but it's this kind of following that, it
makes your ego quite big if you let it. But it really is more of a liability
because you don't really want patients to think that without you making every
single decision, something bad is going to happen to them, and that bad thing
is that they're not going to have a baby. That's unfortunate. Most good
programs are geared to be able to run very well without one person watching the
store quite that closely.
Some people describe this as the "Wild West" of medicine. Do you know what
they're talking about?
... where the Wild West comes from usually is from Europe, where they look west
at the States as the Wild West. That's partly because we aren't regulated on
groups. Canadians are the same way. I've heard that said about us from Canada.
So in countries where you have national authorities governing and regulating,
and there's law behind the practice of infertility, you see a very different
practice. It's not driven by economics. It's not driven by just success rate.
Inevitably, as you look at the registries in these environments, they're lower
rates of success.
There's a good side to it, as well. The lower rate's not good, but the fact
they have less multiple births, probably overall less complications, speaks to
the fact that they look at the mandate that they're trying to follow, which is
good, safe, infertility care, just a little bit differently than we do.
That's not to say that we don't do it as well. I actually think that, today, in
the States, you have much more diversity, and probably better care than
anywhere in the world. The difficulty is that there's such a drive to always
have the best rate, that you sometimes have to balance taking a little more of
a chance than you normally would to get that woman pregnant.
I've said publicly when you come to guys like us--it is our mission to get you
pregnant, no matter what--we have to be held accountable, because otherwise,
"no matter what" will lead to certain irresponsible practices, and you will
see the septuplets and the octuplets. These are preventable complications.
These are iatrogenic, doctor-induced complications. They're always with a good
intent--a woman wants to have a baby--but unfortunately, you don't always see
such nice outcomes. Some people are injured, some babies are injured, and some
babies die as a result of this type of care.
Is that the biggest "no matter what" to you?
Well, to me, there really is a "no matter what. "The multiples is one of those
issues. Perhaps, selection of patients is another. It's getting harder and
harder to say no to a woman if she's paying all this money, even though there
may be certain things about her or a couple that would disturb you normally.
And you can be critical of that, too. Which is, "Well, if they can afford the
care, so what if they have somewhat of a checkered background." To me, that's
not a "so what," it's a huge issue.
And they will find care. They may not get it from you, because you feel that
they're not acceptable, because you do have limits and regulations within your
own program for who you would treat. But they will find care. They'll access it
elsewhere. I've seen that over and over again.
You're a guy that's known for pushing the envelope on these issues. First of
all on post-menopausal women. You've got a lot of women pregnant who people
would say have no business being pregnant.
Well, I like pushing envelopes. That to me is the fun of being in academic
medicine. If I'm going to be in academic medicine, I better be pushing some
envelope, or I don't know why I would be doing this. That's kind of the calling
of being a professor in an academic center, is being able to do the clinical
research, and being able to change the standards, hopefully in a responsible
way. Hopefully in a way that people in my own field would agree.
For instance, using menopausal pregnancy, if you went back 10 years ago, people
wouldn't have performed this treatment on more than half of the women presently
under treatment in egg donation. So we were able to change a practice to
something which now makes sense to many people. But what I'm really speaking
at, with respect to drawing lines and limits, isn't so much necessarily
arbitrary assignment of age or even marital status, or whether they're a
lesbian or heterosexual couple. Those things really don't bother me. They might
bother others, but they don't bother me. Those patients are always welcome
here. HIV [discordant] couples are welcome here. Those are not necessarily
patients where everyone in this country would feel comfortable treating;
therefore, they shouldn't treat.
What I'm really speaking to are people that, in our own little term inside our
office, are just nasty people, mean spirited. They're infertile too. It's
difficult to treat them. Just because they have the money, for them to come in
and abuse our staff and our physicians, because they think you should wait on
them because they have a lot of money. I always marvel at that. It's like,
"Why, just because you're spending $20,000 for egg donation, do you think you
have the right to be so damn abusive?"
So those kind of patients I see more and more of, unfortunately. I think
that's, again, a by-product of this expensive care. You will attract a certain
small subset of patients who are used to buying whatever they want. And they're
not always very nice people. It makes me wonder if they're going to be very
Describe a couple like that.
... oh, there's all kinds of varieties of these kinds of couples. In general
... if I had to describe the kind of typical one, they're going to be women and
men who are in their late 40s, professional couples, well-to-do couples.
They've been successful in every aspect of their life. They're not used to
getting a "no" for an answer, whether it's buying a car, or a hotel, or booking
a plane flight.
They literally come in and sort of reserve a baby. And when it comes to egg
donation, where you have to be discriminating as to who you're going to match
them to, what donor makes the most sense for them, they have a real hard time
with the relinquishing control. You see this tug of war between wanting to
direct their own care, and what they have to relinquish to us, which is total
trust that we're going to do the job for them.
What do they want? What are they saying to you?
Well, it usually gets down to money, again. People will say, "I paid all this
money, and I expect a phone call. I expect a nurse to do this or that for me."
Now, there's a lot of things that we do automatically. It's not that we're not
doing these things already. It's beyond that. As if, because they have paid a
high fee, which they do, that they should get more than just the normal,
professional courtesy that we give all our patients.
What are they asking for in terms of the egg donors themselves?
Most couples coming in are most interested in an intelligent, healthy,
nice-looking, young woman. I'd like to think everybody that we have in our
donor program meets that basic criteria. You will see a step up from that.
You'll see people say, "Well, in addition to that, I want the SAT scores above
a certain limit. I want the Ivy League pedigree. I want something artistic in
their background, if it's music or dance or something." Within certain
boundaries, we're willing to accommodate that. I always make sure they
understand we do not think piano playing is a genetic trait. But if it makes
you feel a little more comfortable ... fine.
You know, it's a hard thing for these couples to do. I'm sure it's extremely
difficult to give that kind of trust over such an important decision as the
genetics of the child that you're going to carry and deliver. But it still has
to be somehow put into reason. You know, the glamour head shot and the bio
sketch that are handed out over the Internet--it's just a distasteful practice.
I know people really buy into it. They really think that that helps them with
closure--that's another word I hate--over this issue of the big, anonymous
donor. But it's unfortunate that it's not really what it appears to be. You can
configure a bio sketch and make a nice head shot that looks very different than
the Polaroid ...
To me, that's not what's important about this. What's important is that a well
screened, healthy, young, intelligent woman does the right job for us, for this
couple, that results in a pregnancy ... just as important, that donor can go
back home, feel good about the experience and can look back, hopefully, in 10
years and say, "Boy, that was a real good thing I did when I was a co-ed." Not
say, "Oh, what was I thinking? I was so foolish when I was 21 years old." It's
all part of the same plan that everything has to work just as well for the
donor as it does for the recipient.
How much are you paying the donors?
Now we're paying them $5,000, because when we tried to hold the line for about
two weeks, at $2,500, we were seeing donors defect to these other programs ...
so we, as a group, had to soul search. I had gone on record and public, saying
to people that this was a bad practice and this would lead to, and I still
believe, the downfall of egg donation as it currently is practiced in the
United States. But I'm also pragmatic. I came to New York to establish a
program. I'm known for egg donation. I had to do something or I would lose my
program. I went to my own ethics committee at Columbia University, presented it
to them. They thought it was quite disturbing, but they said that, under the
circumstances, it was reasonable to match that fee.
You said it may lead to the downfall of egg donation.
It will lead to the downfall in global sense of the term. Meaning that it's
unusual now, for most couples that could access egg donation, to really be able
to afford it. How does the average American afford one or two cycles of egg
donation? That may cost them close to $50,000 cash. It's like a down payment on
a house. I don't think the average American can easily afford that. So how do
they do it? They take out loans. They take out second mortgages on their home.
What's unusual about this, it's bad enough when you do this, for any reason,
but there's no guarantee that you'll have a child from them. So you do have
people out there doing these things time after time, and ending up with nothing
to show for it in the sense of a baby. Maybe that money would have been better
served either through an adoption or something more tangible that they could
have accessed ...
What do you see on the horizon?
Well, some of the things that are on the horizon come about pretty quickly. The
best example, most recently, has been both egg freezing, perhaps ovary
freezing, and the use of testicular sperm that have been aspirated ... This was
something even three years ago, certainly five or 10 years ago, which really
wasn't even discussed, because it wasn't even clear if such a thing could ever
So as we look forward from here, ideas such as nuclear transplant, to sort of
revitalize older eggs, which might change the way we currently do egg
donations. So it would be optimal to be able to use the genetic material, from
an older woman's egg, for a younger egg switch. That'd be great ... despite the
hype, it's yet to really occur. I don't see any good evidence that we have
success with either one of the methods that are talked about, but it does have
the promise of that. That's one issue that may change the way we do
Certain aspects of cloning, especially the embryonic splitting. Being able to
duplicate high quality embryos and bank high quality embryos along cloning
lines, has some merit, despite the fact that no one wants to talk about
cloning. So these are things are fairly easy to project, because we know the
technology already exists, and the animal work has already been done that would
tell us these things will indeed be successful.
Talk about the cloning issue. People have said that it's going to come out
of the infertility work in some way.
It will. The groups that can do cloning, such as the Dolly sheep experiment,
this is an IVF type of procedure. So it would normally occur in an IVF
laboratory setting. Whether or not any of us would take that bold step is hard
to predict. My gut feeling is when there's a challenge, and you put it in front
of people like us, someone will always take that challenge and take it to the
next step. When that will occur and under what circumstances, I really don't
know, but I'm sure it will happen.
Are these things that are happening now around the egg, are we talking about
We are. Not so much intracytoplasmic transfer as the nuclear transfer. That
requires a certain electrofusion type of an approach that is extremely similar
to cloning methodology. It unfortunately gets a little confused along the way.
People have looked askance at some of this research, thinking that it was a
kind of smoke and mirrors for cloning, and I don't think that was the intent of
people doing this kind of work. The idea is to try and change the dynamic of an
aging egg, which there is certainly a great demand among age-related
infertility patients, and that's somewhere between 5,000-10,000 women a
What do you think of cloning?
I see cloning, in general, as a major step in the right direction, but not
necessarily along adult cell lines. I don't see much purpose in cloning adult
cell lines. That, to me, is an exercise in supreme narcissism, to just want to
have an identical twin that's so many years younger than yourself. I don't see
any real purpose in that ...
We've taken sex out of the bedroom and put it into the petri dish or into
the little tube, and with successful cloning, you actually take the man out of
the picture, presumably. What do you feel about that as a profound change in
sexuality and reproduction?
I suppose we're dealing with such a small, theoretical subset is not to be too
disturbing. To be honest, sex will always be part of behavior as long as
there's males and females, so I'm not too worried about that ... Certainly, the
fabric of society gets changed by these types of paradigms, and taking males
out of reproduction, which we do these days when we're dealing with lesbian
couples and inseminating them with donor sperm. I don't think that's that
troubling, because it's a small group of the population that we're servicing
People would like to have this image that Americans are this "Ward Cleaver and
his wife" type families, and they're not. There's all types of women and men
wanting to have children. We see it first-hand because these couples come to
us. Many times these couples are just single women. So if that became an
option, and it was a reasonable one, and society accepting cloning, I would
guess practitioners would probably not think that hard about it either. We're
not there. I mean, there's no question that that's not where our heads are at
right now. But then we weren't willing to probably put embryos into 50-year-old
women 15 or 20 years ago, so who knows?
So things are changing pretty profoundly?
Things have changed very profoundly.
Talk about those changes.
Well, we're a lot more accepting of the different alternatives for parenting.
People don't raise their eyebrows, at least to me anymore, about 40-year-old
women having babies. It wasn't that long ago that they did ... People are still
are a little reluctant about the 50-year-olds, or more recently, the
60-year-old. I mean, there is an ageism in reproduction that's pretty
You could take it a different way and talk about lesbians or single women
having children without a partner. Some people are very bothered by that. Other
people might say, "Well, maybe that's for the better. Maybe they're better
parents than they would be if they were trying to parent with some male that
they didn't want to be with," and that's probably true. I don't have any doubt
You have gestational carrier states now where people carry the genetic
offspring of other couples, and they're paid to do this. Rent a womb, as I was
told. It does happen. It happens every day. So these are no longer kind of
interesting wish lists of things that could be done with the technology. These
are things that we do in this field every day. They have become somewhat
accepted, and I think that's for the better.
We have a lesbian couple in our piece where one has donated the egg to the
other, and they may do it the reverse next time for the second child. People
may raise questions about that child as that child goes through school. What do
you have to say about that?
They're tough questions, there are going to be a lot of tough questions,
because these are not normal scenarios. But a lot of these questions have
always been there. There's always some group of parents that have been
challenged as to whether or not it was conventional, or correct, it's hard to
know what makes a good parent. I personally think what makes a good parent
relates to the love that comes from that individual, no matter what their
background is, or their age, or anything else. We have to be very careful about
discriminating too much about what makes for a good parent ...
There's another case of a couple where the man has Kartagener's
syndrome ... Because you can't test for this disease, they ran the risk of
passing that on to the child. What do you feel about that?
Well, as we get more savvy with being able to diagnose certain syndromes, and
certain genetic illnesses, because we haven't gotten so good at treating them
pre-implantation, we're going to have scenarios where couples knowingly risk
carrying disease to their offspring. We see this with, for instance, the
HIV-positive males that we do IVF treatment on here to asexually help them
reproduce with their negative wives. These are risks that all parties are going
to, at times, be willing to take with good, informed consent. They're adults
and it's something that is acceptable as long as the risks are well understood
There may come certain disease states where you have to really struggle a
little bit as to whether or not a child is placed in too great of harm. Not
just in terms of carrying a disease, but being orphaned for illness in their
These are part of our field of medicine. It's more than just getting people
pregnant. It's making sure that these dynamics in the family are in place, and
making sure that there's some longevity, hopefully after the birth of this
child, that will carry on into this child's life into these parents' lives.
Treating a couple that have HIV certainly would be one of those issues you
It's a tough issue. It's typical, though, of what I get asked to do. I'm sort
of the guy that does things others won't do. Sometimes I will and sometimes I
won't. But as I looked at this scenario, healthy HIV-positive men with their
HIV-negative wives, wanting to have a child, seeing a future with these new
medical treatments that allow them longevity. In many cases, a better chance at
longevity than some illnesses that we also allow people to enter into programs,
knowing they have terminal illness, for instance. We don't discriminate against
So it's hard for me to look at this on the issue of they've got a terminal
illness, and therefore, they shouldn't be treated. I don't believe that. If
they have a good quality of life, and they have good, informed consent, that
was a reasonable project to offer them ...
The child didn't sign an informed consent, right?
Well, children never do, you know? And they're born into all kinds of
scenarios. I know from all my work, for many, many years, there were some
families that weren't all that happy later on after the birth of their
children. Many couples come into therapy thinking that if they just have a
child, everything will just be great. That maybe their not-so-great marriage
will become better. Or maybe their not-so-great husband will be a better
husband. It doesn't always work that way, and the children get caught up in the
Certainly with disease, I wouldn't argue that no child deserves to be inflicted
with a disease that he or she wouldn't have chosen, but it's a risk we all have
of being born, for that matter, too. You can't guarantee a healthy baby to
anybody. So we hope for the best, and we do it with what we think is logical,
minimal risk. But you have to be willing to be bold enough to take that
I look at it as we did with women in their 50s wanting to have babies. No one
was sure when we started this that it would be safe. We certainly didn't
promise that it would be safe. Yet now, looking back almost 10 years at this
type of work, I see almost exclusively good outcomes and that's reassuring,
that we thought it out well ...
When we see people going onto the Internet and choosing their sperm donor,
their egg donor, by looking at a profile of this person and picking them for
certain attributes, even intellectual or creative attributes, the word
"eugenic" springs to mind. How do you feel about it?
... The Internet's a great thing. I find myself on it all the time. Whether or
not you should pick the genetic traits for your future children off the
Internet, I have major doubt about the wisdom of that. It's a great way to
market your program. It's a great way to sell sperm, perhaps, in a sense, egg
donation. But it takes out sort of the human drama of it which is part of
When you come into an office and you meet the people that are really doing the
work, and they have the real life experience of having worked with hundreds, if
not thousands of couples and donors, to me, that has a lot of importance. Much
more than what you can ever convey off an Internet page.
I also would always warn people about what you read and what you get are
oftentimes very different types of things. Even if there's truth in what's
being profiled, how does that really equate with this child that's going to be
the product, most likely, of your husband and this donor? So it's not quite
that cut and dry. The eugenics is to me more or less a pseudo-eugenics. Meaning
that it's one thing to look for certain traits that we know are likely to be
passed to a child. Height, coloring of skin, certainly, but playing the piano,
dancing, athleticism, science background, I know of no genetic trait known to
convey these things to the offspring.
So even though we provide patients with that type of information that reassures
them, gives them an idea who is this woman. This unknown mystery woman
providing this great gift for me to have a child. I think that's important. But
when it becomes a pedigree ... I've been asked where her grandfather graduated
from college. That is so presumptuous, that it makes it distasteful. Who cares
where her grandfather went to college? What does that have to do with anything?
I'll usually ask that right back, rather than make excuses. "Why do you think
that's important? What textbook did you read that makes you believe that that's
This is where the commercial side of our field and the medical side clash.
Because physicians never delved into that type of sales and that type of
marketing. But when you're competing with commercial groups who compete on that
level, they don't have to be responsible genetically. They don't have to be
responsible medically. They're portraying a product, and this product happens
to be human being. But if you're a physician doing the same work, you know when
you're crossing over those boundaries of what is reasonably good medical care
and what is sales, and it never feels good.
The lesbian couple chose their sperm donor over the Internet and got a
profile of him. What do you feel about that?
... It doesn't bother me as much for sperm donation as egg donation, to be
honest with you. Partly because sperm donation has always been handled
differently. It's always been somewhat of a catalogued group of choices that
you could go to a site and pick from. Traditionally, there's been a lot less
information given about sperm donors than egg donors. So I could see where you
could get most of that information from a web page, different from a donation
where most of this has been through a program, and through the screening, and
the on-site screening by the group that's going to be providing you the embryo
I always worry about it, though, either way, whether it's sperm or egg, because
these are real human beings that are giving their gametes, sperm or eggs. They
have attributes and they have flaws. It's hard to give people an adequate
representation of these people as people. Increasingly, the patients are asking
for that. They want to get a feel for who these men and women are. That's a
positive thing, but you can take it to lengths that are not necessarily so
positive and somewhat absurd if you start believing that certain traits are
destined genetically to be in the offspring. Even worse, if a group markets
those traits as if they were guaranteeing a certain attribute in a child,
that's what we have to be careful to avoid.
A bioethicist and a number of people have said to us, when you get into
gamete donations, that's where the divide is ... there's something that defies
the natural world in this.
Well, everybody has their opinion, right? I'm not sure I'd agree with that. I
see them as different dilemmas. Each has its own problems and attributes.
There's been a lot of third-party parenting going on out there for a lot longer
than IVF's been around. People just don't always want to talk about it. You can
find it in illegitimate, or at least children of people's spouse that they
didn't want to talk about all the way back in history. If there is a desire to
have a child, people will find a way to reproduce.
What's different about what we do is there's no mistaking whose gamete went
with whose gamete. We have to do things very deliberately here. There is no
cover-up. There is no closeted tail. So when you choose to have a child, and
one or other of the partnership, can not produce a gamete, be it an egg or a
sperm, you have to very deliberately and full knowledge choose this scenario.
It brings up all kinds of issues between the couple as well. And a couple, the
sexual identity, which is wrapped up with reproduction for males and females,
is challenged in these kinds of scenarios.
It's somewhat more healthy that way. There aren't any surprise secrets that
come out down the road. We know, and the couple knows, exactly what went on
here. They can choose to control for how that story is told later.
There's an awful lot of people who are carrying babies supposedly as a result
of IVF that was, indeed, egg donation. It's up to them to decide if and when or
who they tell, if anyone. It gives them a lot more control. So those things are
positives. I don't see those as threats or anything negative.
Those stories could be equally closeted.
I'm sure they are ... but when it comes to your children, you have every right
to be protective that way. It's not necessarily everybody's business to know
how a woman got pregnant and whether it's with assisted reproduction or on her
own. I don't think it really is anybody's business. It's up to the woman to
decide how she tells her children, if she ever tells her children, how she
decides to do that.
Some people would say there's a real good reason why a 55-year-old woman
shouldn't have a baby. That child's not necessarily going to have parents all
Well, you tell that to the 55-year-old, I guess. I don't necessarily agree with
that. A lot of people historically have been raised by their grandparents,
which I suppose is the closest example of that, historically. There's a lot of
cultures today in this world that the older grandparents are literally raising
these children. They do it quite well.
I understand the issue of longevity, but unfortunately, none of us have that
guarantee. So you can be a parent to 25, and not necessarily be well-equipped,
or even physically healthy to see that child through. So as I look at
prospective parents, I somehow have to judge whether or not they're going to be
a good parent. That's very hard to do. Age is important and their health is
important, but it's just one of many different things that we're looking at in
making a decision to extend that therapy, and to provide them with this gift.
This gift is nothing more than an egg, but it's a pretty special one when it
results in a baby.
Right, but this is one area where this person wouldn't have a child because
it would be difficult for them to adopt.
So what's the justification for that?
I guess the justification is somewhat arbitrary. I remember asking my
institutional review board back in Los Angeles, to give me an upper age limit
of 55, and that, at the time, was based upon what my grandmother at the time
was, which was about 75, at that time of her life. And thinking, well, that's
about as far as grandma could probably care for this kid.
I have four children. I would never argue that it's not a lot of dedicated work
raising children. And not just at the baby stage, it's even more so at the
teenage stage, where I'm at now with one of my children. So I do appreciate,
maybe because I'm getting older, how difficult it is to raise a family, or even
a single child. I don't think I'm ignorant of that, but people should give the
older women, who oftentimes never had a chance to have a child. They were too
old for IVF when it came of age. They were even too old for egg donation when
it first came of age. Now they have a therapy that really works. We know that,
from our own clinical experience that they can become pregnant with the same
rates of success. We know that from the obstetrical outcome data that they're
doing just as well. So I don't see objective measures that would tell me that
these women won't do well.
If you hadn't broken the barriers with the older women, 55-age group, you
wouldn't have had a patient who actually lied about her age to you. Could you
talk about that person?
I think that's not unusual. When you place a limit on care ... you're going to
have people trespass because they want access to care, which means they're
going to tell you what you need to hear in order to gain access. In fact, what
was interesting about the early egg donation experience, when we had limits of
40, the first five or six women that we treated, in their 40s were women who
said they were all 39 ... It makes it important as you get farther and farther
towards the limit, to be more and more careful about your medical screening.
But you can't control for that. People are always going to deceive their
doctors if it means that they're going to get treated or not treated.
You wrote an editorial where you were worried in that case.
Sure, I was worried about that particular case for several reasons. One, there
was a tendency to celebrate the birth, and I'm happy for this couple, I know
them. I was originally their physician. I'm sure they'll have a lot of love for
this little child. But that's different from saying that, "Oh, now everyone up
to the age of 63, or make it 65, or maybe now it's going to be 70." Like it's
against some stake of your program's, worth, by getting the oldest and oldest
pregnant. You're going to reach a time where someone's going to get injured.
Either the mother or the child. And for what reason? Just to prove a point, I
So we showed and I think people in our field accept that age and reproduction
are not linked between ovary and uterus. That you can take an older uterus and
get good success with a younger egg. That was an important scientific lesson to
be learned. But to drive home the point by grandstanding, and having press
conferences to highlight your patient, in that case, turned into a witch hunt
for her identity is unfortunate. I don't think that's where we should be as
We are using technology to break barriers of family structures and natural
selection. People have a fear of that because they're afraid of what we don't
know. Are you afraid of that?
I'm not afraid of crossing those kind of barriers, because there's more than
what people want to talk about that we do know. People do know that there are
lesbian couples having children and raising children. People do know there's a
lot of single women having children out of wedlock ... When you bring it out
into the open forum because you actively intervened and provided a treatment,
then you get the critics that don't like these messages that are eroding away,
I guess, as they would see it, at the fabric of our society. But it's just a
reflection of what's going on in our society. These requests are coming from
Americans that, of course, they're going to want to have children regardless of
their social or sexual situation.
You either ignore it, because you decide to be discriminatory about it, which
you have a right to do. Or you accept it and you embrace it. I don't have a
problem with that. I guess my general feeling is that these people all know
what they're doing, and they're doing it for the right reasons. So we're here
to provide them with safe, effective care, regardless of where they're coming
I'd like to hear you talk about how you personally decide about pushing
I've always tried to look at each of my patients as an individual with their
own special needs and special backgrounds so that I don't come in with a fixed
view of what is appropriate and what is inappropriate care. If that was the
case, I'm sure there would have been patients over the years that have had
children that I feel very proud of, that I wouldn't have treated.
So it's important to me ... not to be overly discriminating. To really let them
be their own advocate. Tell me why it is. What's the compelling reason I should
offer them a very special treatment? Especially in light of what may be
circumstances that are not the norm. Most of the couples I see are single women
that I take care of. They understand when their requests are beyond the
conventional, and then we discuss it quite frankly.
Sometimes I'm willing to go forward and it's been a breakthrough. Other times
it goes unnoticed because it's not such a newsworthy event. Other times we've
said, "No." It's certainly harder to say, "No" than to treat a patient. Even
though you'd think treating some of these women would be very difficult all the
time. IVF is what we do everyday. So it's always easier just to say, "Oh sure,
let's do it and let her go on." But we've always tried to avoid that. We've
tried to really look into the future and say, "Well, if we do this, and she
gets pregnant, then what might happen? Is that a good road? Or is that a
How far will we go? I don't know how far we'll go, because it's very hard when
you look back. I've been in this field now almost 20 years, and I just am
amazed at where we are. We do things so well compared to what we did 10 years
ago, just the routine things. We've extended care to people that we just
wouldn't have believed could have become biologic parents, without certain
methodological improvements and technical advances in the last few years. So
it's very hard to know.
I'd like to think where we're going is that we could see everyone who accesses
care become pregnant. That we could open it up to people that need it, of all
different socioeconomic strata. Because I'm concerned about that. I'm concerned
we're just treating a small subset of patients with a small subset of problems.
And this field has a lot more to offer than that.
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