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interview: Dr. Mark Sauer
Dr. Mark Sauer is an infertility specialist and Chief of the Division of Reproductive Endocrinology at Columbia University.  He pioneered methods for achieving pregnancy in women in their forties and fifties using donor eggs from younger women. ... You talk about the [infertility] market. Other people are hesitant to talk about how much this is market-driven.

Doctors are always reluctant to talk about medicine and patients [as] clients and market ... it's an expensive, high stakes business. This program here--and we're just growing--is a $5- to $6 million a year business, and it's projected to be much greater than that within a year or two. No one teaches you these things in medical school. You have to learn these things pretty quickly.

So if you were just ignorant of that, or at least tried to ignore it, you'd be foolish. You'd probably end up out of business, and you're responsible for a lot of people, not just patients, but also a lot of employees, a lot of doctors. As well as the fact that there's the university that I'm also subject to, so I do see this as what it is, which is a business no different than others. It's a very special one, and I like that aspect of it. We're in the business of helping people have children. I don't think we should ever lose sight of that. That's a difficult balance, at times, between marketing, business, good patient care, and being compassionate as a physician. But it does all go together. You can't have one without the other. So if we want to deliver our type of care here, and complete our mission as a university program in midtown Manhattan, then we also have to be able to do good business.

... Is there a way in which New York emphasizes that?

... New York is just more fierce because it's a bigger place. There's more visibility, certainly, here. If you do have a name, people are going to be looking for you both for good and for bad stories. So it's a little higher risk environment ... but it's true in every environment. We can talk about it in Denver, we can talk about it in Dallas, Texas. I don't know of any large city in the United States where my colleagues aren't fighting similar battles to what I do here in New York.

You came into an intense competitive environment. There were stars, as clients called them, and the advocacy groups. How was that for you?

The star thing is tough, because you have to somehow compete against established people in the field. What makes a star, to me, in my field, is just a good, practicing physician who has a good track record. There are several in New York as there are, actually, in other environments. I mean, in Los Angeles it wasn't a dead environment. There were the big names in L.A. as well. So we had to carve out our niche there for many years. We were nobody when we started back in the middle '80s. Nobody knew us, nobody knew about egg donation, the things that we later on became known for and things that actually I allowed my name to carry into New York.

If you lie two infertility programs side by side and  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. 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 direction?

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 that.

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 $10,000.

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 on.

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 reimbursement plans.

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 child.

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 seen?

[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 private sector.

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 nice parents.

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 occur.

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 fertility.

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 cloning technology?

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 year.

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 that way.

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 striking.

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 about that.

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 parents.

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 struggle with.

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 them.

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 middle.

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 step.

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 medicine.

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 important?"

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 transfer.

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 its life.

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.

That's right.

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 guess.

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 physicians.

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 from.

...

I'd like to hear you talk about how you personally decide about pushing barriers.

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 troublesome one?"

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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