SPEAKERS
Eloise Drane
David Sable
00:00
Welcome to Fertility Cafe, the home for every conversation exploring alternative family building through IVF, surrogacy, egg, sperm, and embryo donation. Our host Eloise Drane, alternates episodes between educational shows covering specific topics and guest narratives for further insight. For a mastery understanding and confidence in all things alternative family, subscribe to Fertility Cafe.
Eloise Drane 00:28
Hey there, Welcome to Episode 100 of Fertility Cafe!
Eloise Drane 00:33
As Fertility Cafe’s 100th episode, we’re looking ahead to the future of the industry and the future of humanity’s fertility as a whole. What challenges are we currently facing and how will they evolve over time? What new challenges do we anticipate on the horizon? How will changes in fertility on such a massive scale affects society, culture, and the way the world views third-party reproduction? What science or technology needs to be advanced in order for us to experience true, impactful change that’s scalable?
My guest on today’s show is David Sable. David is a highly accomplished and influential figure in the field of reproductive medicine. With degrees from the Wharton School and the University of Pennsylvania School of Medicine. He has excelled as an obstetrician and gynecologist specializing in reproductive endocrinology. As a co-founder of the Institute for Reproductive Medicine and Sciences, and Reprogenetics, he played a pivotal role in their successful acquisitions.
He is a respected educator, teaching at Columbia University and delivering lectures on healthcare investing and biotechnology business development at renowned institutions. He has also appeared on major news networks to discuss reproductive medicine innovations. With numerous board positions, advisory roles, and a wide range of publications to his credit, David has made the lasting contributions to the field and is recognized as a distinguished leader in reproductive medicine, health care policy, and entrepreneurship.
Eloise Drane 02:17
Welcome David to the show. You have, as I mentioned, quite an impressive background. Thank you for joining me today.
David Sable 02:24
Oh, it’s a pleasure to be here. Thanks for inviting me.
Eloise Drane 02:26
Perfect. So, I am going to jump right in, as I have a lot of questions to ask. And this show is about the future of infertility. And as we look ahead to the future of the fertility industry, it’s important to address the challenges it currently faces and how they evolve over time. Could you share your insights on the current and anticipated challenges in the field?
David Sable 02:54
Yeah, IVF has come so far. I started doing it in the late 80s, early 90s. Frankly, it wasn’t that good a procedure, every you know, 10 million babies over 40 years, everyone’s a miracle each one is an honor to be able to participate in care of people. But the chance of getting pregnant each time we did it was lower than we would have wanted it to be. There were enormous groups of people that we weren’t treating at all, who could have benefited hugely, both for infertility and for other indications like habitual miscarriage, and genetic disease prevention. And over time, we’ve just gotten better and better at it to the point where now the biggest problem isn’t making the procedure work. Most of the time, although we still have a lot of work to do there. The biggest problem is getting it to people, it’s access, we really need to kind of run the technology playbook and make it from a superbly scientific, not very well engineered system to one that works, you know, kind of like clockwork, you know, it’s like a hotel industry where we just have the four seasons and the Ritz Carlton, and everybody else has to sleep on people’s couches. Really now the biggest challenge we face is one where we need the engineering of IVF to match the science of IVF.
Eloise Drane 04:22
What scientific or technological breakthroughs do you think is necessary for us to achieve that change?
David Sable 04:30
Well, we break them out into two areas. You’ll, one are things that have already been discovered that are being used elsewhere in other industries. And this goes back to fluid handling cell handling, efficient labeling, replacing, people doing repetitious tasks that some people do the well some people don’t do them that well and everybody if you do too much with you get tired. A lot of these things can be automated, and this is going back to the old Henry Ford assembly line. Things just make it fast, make it measurable and make it reproducible. Just in an efficiency standpoint. On the scientific side are things that have been vexing for us for dozens or hundreds of years. Learning things about what makes a good sperm cell versus what doesn’t? How do we take care of people whose eggs are not responding to stimulation? Or they don’t, once fertilized, they don’t divide well? Things of that sort, and how do we figure out what makes for an embryo in planting and continuing to grow? Rather than in planting and then stopping? Some of these things, we have some answers, but not complete answers. More importantly, we don’t have a way of taking the knowledge that we’ve gained from the scientific advancements and necessarily use it, so that an individual has a higher chance of conceiving when they need to, when we do an IVF cycle, or even more importantly, fixing things that don’t need IVF at all.
Eloise Drane 06:09
One of the things that I know that is in rapid progress is genetic research screening technologies. Can you discuss how these areas can contribute to improving those outcomes?
David Sable 06:24
I was really fortunate to work with some of the pioneers in this area, going back as early as the early 1990s. And when we first started doing IVF, you know, we would kind of put the sperm and the egg close to each other and hope for the best. And once fertilization happened, we didn’t touch the embryo, we put all that sacrosanct, you don’t touch it, because you don’t want to mess it up. And then over the years, we found that we actually could be quite aggressive in doing things to the embryo to help it implant, the embryo as being the for the fertilized egg, helping the embryo implant. And then we kind of made this breakthrough where we found that we could remove a cell from an embryo and get genetic information from it. And some of the very beginning in the 90s, we did things like we would test for five chromosomes, chromosomes that were most likely to be abnormal. And if there was an abnormal head normality, it would keep the embryo from implanting. And from there, you know, fast forward 20 years, we’re now taking a number of cells without harming the embryo and doing a genetic sequencing. So the same information we can get from sending a saliva sample to one of the commercial labs, and everyone knows the names. 29 million people have done that in the United States. So we can find out, if the chromosome count that the person carries is normal, we can find out if they carry a risk for a genetic disease, cystic fibrosis, sickle cell anemia, spinal muscular atrophy, these are things that not only do they make the probability of getting pregnant lower. But equally or more importantly, the babies that are born have a, in some case, 50% or 25% risk of developing these very serious diseases, some of which calls childhood death. So, the ability to use IVF for fertile couples, whose families have been plagued by diseases over generations, is something we can address with the procedure now. Now the challenge we have there is, as we said before, again, is one of the one of access, you know, all of it, most of IVF being done all over the world, is to treat chronic infertility. And that’s a wonderful thing to be treating. And that’s yeah, you can, you can relieve amazing amount of suffering by helping families overcome that. But on the same hand, we’ve got these other very worthy things that we could be doing IVF for. But in order to kind of increase the throughput through IVF worldwide, we need to better engineer it. I’ll give you some numbers. We’re doing worldwide, we’re doing about 3 million IVF cycles, and we’re helping families create somewhere around 600,000 babies. That sounds like a lot. But if you add up the numbers of people that need IVF, again, we’re talking worldwide. We’re somewhere between 20 and 30 million babies versus a little bit more than half a million. And that’s a, that’s a real public health challenge.
Eloise Drane 09:37
So, what can the fertility industry in the policy makers do to join forces because obviously, this is a significant issue, not just in the fertility industry, but as you mentioned, the world as a whole and especially with the U.S., we know that insurance covers nothing pretty much the majority of insurance companies cover nothing when it comes to fertility care. So, what can we do? Like what is an effective way to collaborate with these policy makers so that it’s beneficial for everybody?
David Sable 10:17
That’s a great question. When we started mapping out the world of IVF innovation, so we’re back around 2015, we came to the conclusion that the best way to deal with policy is to make it as easy as possible for them. So that it’s not only a good decision for public health reasons, it’s not only a good decision for relieving suffering, but it also makes a lot of economic sense. And the way we do that is also the way we address just the mechanics of making it possible to do 20 or 30, or 40 million cycles a year, instead of 3 million. So, the first thing we wanted to do is we wanted to automate and standardize things as much as we can. And here we’re just following the technology playbook. The same thing that went from nobody owning a computer in the 1980s, to everybody having one of their pockets 30 years later. Standardization, automation, driving costs down, making things as efficient as we can in terms of innovation and manufacturing. Second thing we needed to do, which is very specific to IVF, is we need to make the data tighter, the best IVF clinics in the world, right now here in the U.S., some of them have pregnancy rates and live birth rates actually, well over 60%. By putting back one genetically normal embryo, the rest of the world is probably 1/3 to 1/4 of that, and there’s a lot of clinics that are 1/10 of that. So, by engineering and standardizing it, we’re going to try to bring everybody up to that higher expectation. When everyone is doing about the same, in terms of outcomes, suddenly it’s a lot easier to talk, insurance speak. You know, we call something actuarial data. And the insurance industry is, you know, it’s really, they’re just they run a casino. You know, when you go to a casino, the casino knows exactly the odds of every blackjack hand and every poker hand and the likelihood of a payout. Every time someone pulls the arm on a, on a slot machine. The insurance companies use similar logic, in order to cover the enormous number of people for something that a relatively smaller number we’ll need. So, with IVF, one of the things one of our goals is that nobody has to pay for an IVF cycle to have a baby. Back in the 90s, some of my patients used to say, no baby, but broke. And that’s, that’s, that should be an unacceptable outcome. So, when you talk to people in the insurance industry, and also people in the government policy side, the currency that they need is expectations. They don’t want a lot of surprises. If you give them numbers that they can predict outcomes with very accurately, they will be more than happy to underwrite the financing of IVF for the world. You know, people have used the argument for decades that oh, nobody wants to cover IVF because it’s not a disease, or infertility is not a disease. Well, that’s, to me, that’s kind of a fruitless argument. It’s suffering, it’s something that people need access to. So, let’s find a way to bring it to them. And insurance companies cover car wrecks, that’s not a disease either. Correct. But they do know for a given population of millions of people, and a given number of cars, what the expectation is, in terms of accidents and damage and liability and things of that sort. They feed them into their actuarial equations, which are, frankly, not all that sophisticated. And if they start with good data, they can very efficiently provide coverage. Similarly, governments can look at those data. And they can say, okay, here’s the amount of cost we’re opening ourselves up to. And here’s the, you know, they can also model things like population shrinkage and people having children, those children growing up becoming productive members, the economy, it all sounds very dry. But that’s kind of the, you know, that’s the language we need to speak, in order to get policy people to take this all seriously. Luckily, right now, we’re kind of in this pivotal stage of IVF, where the engineering is catching up to the science, the data will become actuarial, it’ll become the type of numbers that you will go to an insurance company and they’ll say, okay, we’re comfortable with this. Now we can talk. And our own attitude was if the insurance companies or the insurance industry is reluctant to take this on, well we’ll just start one ourselves. We have seen over the past five, six years, a number of companies that are looking to administered in for infertility and IVF coverage for big employers. And they’re actually finding that the employers are very welcoming to that, because they find that offering coverage for IVF and infertility is good business, really helps in employment and recruiting workers helps retaining workers. So, and we’re not doing this is not just Google and Microsoft and Facebook, right, Walmart is doing it, Starbucks is doing it. So, I think we’re going to see a lot more on the policy slash macro side of people getting involved in this.
Eloise Drane 15:56
What do you think, though, about, you know, unfortunately, we’re in a very political divide in this country and what do you think about the ethical concerns and the dilemmas that arise with people’s views on science and creating embryos outside of the body, and scientists are trying to be God and all of these things, and then that kind of really evolves into even the political arena, and how that can effectively be navigated.
David Sable 16:30
That’s such a great question. And something we’ve been dealing with, since the first IVF baby was born in 1979, the kind of major question of IVF good or bad, and creating an embryo outside the body. That’s one where, thankfully, that ship is sailing pretty quickly, as you know, or up to 10 million babies now. And even the people that have been most critical of in vitro fertilization as a procedure, most of them find themselves only one or two degrees of separation for a baby that was born for that technology. And that’s a pretty convincing argument. You know, it’s like, what’s the joy is the miracles of having children creating a family are, you know, they kind of speak for themselves. And you find that people that have theoretical concerns, in an abstract sense, when faced with someone in their family not being able to have a child without the procedure, somehow, they seem to be pretty well convinced. Yeah, I was really privileged to be on the board of directors of RESOLVE for a number of years. RESOLVE is the patient advocacy group, that does just a fabulous job. And speaking for people trying to have families that have difficulties, over the years have been a number of laws that were proposed in state legislatures. That would limit access to IVF or limit the ability to do IVF. And they find that really, which is very, for all the good reasons, just education. Here’s what IVF is all about, here’s the number of people that are affected. Here’s what it does. Here’s our experience with it. And again, being able to point two the 10 million babies have been born worldwide. It’s, it’s been an extremely effective, call it lobbying, call it education, whatever it is, there’s been very effective and kind of swaying, or getting people to look at it in a much more favorable light, who’s if their initial reaction was, oh, that’s kind of strange, that’s kind of a unnatural, and they feel an aversion to it. And it’s been, it’s been really kind of a positive experience, for whom it’s so important to talk to people and see that they, you know, once that they see the, the human face of it, it tends to often change the way they look at it.
Eloise Drane 19:01
I mean, we’re sitting here talking about all of these changes in all of the care and the new technology. But we also know though, that there is a shortage of reproductive endocrinologists and the people who are able to hopefully try to make this possible, embryologist there’s a shortage. There’s a shortage of reproductive endocrinologists. How do we as a society really combat that, especially given the recent statistics that the health organization came out that 1 in 6 people are dealing with infertility? Now, I don’t know how accurate that is or how vast their study was. But it’s still a very telling number given when I got into this industry 23 years ago. I think it was like 1 in 16 or something drastic that we go from 1 and 16 to 1 and 6.
David Sable 19:56
The numbers are very difficult to pin down. I guess the way I look at it is that whatever the number is, it’s a lot. If it’s 20 million babies worldwide a year, if it’s 15 million babies, that’s an awful lot. So, the so we do really have a kind of a need to increase the ability to access treatment for it. The way yeah, kind of the way we look at it is, we did a very formal Canada silly, real wonky here kind of an input output analysis, looked at every step of the journey from a woman and just discovering she’s having a hard time having a child or having a healthy child, and all the things that steps you need to do to be treated, and be on the other side of that. And we identified 30, approximately 30 inefficiencies that were just organically keeping the industry from growing. Even if we had, let’s say, overnight, we just passed along IVF is free. Well, that doesn’t mean we’d be creating 20 million babies the next day, because we need to establish a way to have the procedures done, had them done well. And pick them, pick the type of thing that you can do, your patient loses access to something like IVF, for three reasons. One is, she can’t afford it, it’s just too expensive. Second, it just takes too long to do. And the third is that the life disruption is too big, you have to give a thing, you think of a third-grade teacher who can’t have children of her own, because she spends all her days taking care of other people’s children. It’s heartbreaking. But even if I made IVF, absolutely free tomorrow, an IVF cycle requires almost two weeks, where you have to take two or three hours a day out of your workday, to go to the office, have your blood drawn, and ultrasound center procedures done. So, we need to fix all of these things. And that is, you know, again, kind of the kind of the tech playbook. When we looked at those 30 inefficiencies, we were able to group them into four different areas. The first one was that we had doctors doing all sorts of stuff. Some of that requires extreme amounts of training, some of it, things that anybody can do. And I can be very critical this because I was one of those doctors, I oversaw 1000s and 1000s of IVF cycles during my career. Secondly, we need to free up the embryologist, the scientists, from doing repetitive procedures, that machines would be better off doing. They would do them more, more efficiently, they would, they don’t get tired, they could do 24 hours a day. And they’re cheaper. And the embryologist should be overseeing 1000s of cycles instead of doing hundreds. Same thing with the doctors, the doctor should be overseeing 1000s of cycles instead of doing 200. And we can do this. This is technology. This is not rocket science. It’s, it’s less, it’s less complicated technology than rocket science. Thirdly, IVF has grown up. So, the procedure is done in these big expensive laboratories. And they were really good reasons that it would grew up that way. But now we have ways of taking the procedures closing them into a closed box that’s not exposed to air and light, and then temperatures, temperature fluctuations and humidity, things that are not good for eggs and sperm and embryos, we can put it into a controlled box that we can take into a different setting, plug it into the wall, and take away the need for a laboratory that cost maybe $2,000 a square foot, those big laboratories are the biggest barrier of entry for more people coming in to doing IVF. And the fourth thing we do is we just need to bring the book, the drug prices down. And there I’ve had conversations with CEOs of the drug companies. And I say okay, we’re doing 3 million cycles a year worldwide. If we can do 20 million cycles that need your drugs, I think we can find a happy medium somewhere. Because these drugs cause nowhere near to make what you charge for them. So are you know, we took those four areas and then we just started chipping away. Say, Okay, what needs fixing? And one of the first things that needed fixing was freezing. Okay, let’s be, let’s, let’s take freezing from just using big old milk tanks and pouring liquid nitrogen into them, too. Let’s take some of the robotic technology that exists elsewhere in cell biology and carve that into IVF and that’s being done. Then we set our well, what do we do about all these blood tests that people are getting done? Every single day that your third-grade teachers, she’s got to drive to the IVF clinic and sit there in the big waiting room, wait to have her blood drawn, have her blood drawn, drive back, maybe deal with traffic. She can’t show up for school at 10:30 in the morning, every day for two weeks. So, what if we replace all those blood tests with, she sits down, pardon the expression she pees in a cup puts a little dipstick into the cup, the dipstick talks to her phone, the phone sends the results to the cloud, the IVF clinic gets the results 6:30 In the morning, you don’t have to go to the office at all. It’s another thing we can do, it’s cheaper, easier, you don’t need to big, build the big waiting room, you don’t have to people waiting there to draw the blood, you don’t have to send the blood to the laboratory, just do a simple urine dipstick. Now if we address all 30 of those little bottlenecks with solutions like this, and then we tackle the next 30, then we bring the cost of IVF, way, way down. At the same time when we automate this stuff, you start to pull, we start getting things that we can measure out of the automation. That tells us why one clinic has a 60% pregnancy rate, one has a 16% pregnancy rate. And we teach this pregnancy at the clinic with a 16% rate, how to get up to the 60.
Eloise Drane 26:04
But do these technologies already exist, or is it something that we still have to go and create?
David Sable 26:10
All of the above. Some of them, some of them are in the marketplace now. Yeah. And they’re making their way in. Some of them are in, you know, being tested and developed. And some of them are kind of in waiting, because other technologies need to be developed alongside of them. You know, for example, once we close up the laboratory work, that goes from retrieving the egg to freezing the egg. And we put that into a suitcase. I’m being a little facetious, but we put it into a suitcase, plug it into the wall, and then we retrieve the eggs, the eggs go right into this machine. So, we can take that all out of the laboratory. And if I’m a bit if I’m running a big IVF clinic, and I’ve got this 2500 square foot laboratory that working at capacity, so I can’t take any other patients, maybe I can take that suitcases thinking the procedure room that costs 200 dollars a square to build. Or maybe I could put it out into a satellite clinic, closer to where my third-grade teachers live. So, they don’t have to travel out to the IVF clinic in a big city. Or maybe, I can contract with a big OBGYN group that doesn’t have an infertility specialist. And to be honest, there’s nothing technically that difficult that a reproductive endocrinologist does that a well-trained OBGYN, or surgical assistant or midwife can’t do. That the oh the, again, that the reproductive endocrinologist would be overseeing, let’s get them off the shop floor and get them up and doing executive function overseeing 1000s of cycles, we can move that suitcase that landed in a suitcase, into the procedure room in the IVF clinic pretty easily, we can do it out to their satellite office that has a doctor a reproductive endocrinologist rotating through every once in a while to get it out to the OBGYN and the other group. There we need like, some support software and things of that sort. There, we need to kind of bring artificial intelligence to crunch through all the lab numbers and all the hormone levels that the urine testing generates, to help tell them what to do. So that the reproductive endocrinologist don’t have to flip through 10s of 1000s of charts each day, and all these lab tests. Now this is all doable and frankly, there’s 24 companies worldwide, that are working on perfecting artificial intelligence use within the IVF field. It’s kind of grown up organically. It’s like we think of Silicon Valley and computers and things like that same kind of ecosystem exists in life sciences, and very much so in IVF. So, this stuff is happening. Of course, it’s not happening fast enough. Of course. Never does. It’s always bothered me because we’re developing new technologies. And even the 90s and early 2000s, I was kind of went to sleep a little bit unhappy at night, knowing that there’s people that tomorrow they’re gonna lose their ability to use this stuff. And you know, they can’t wait till next year. But yeah, we’re, nice thing is now it’s working a lot faster than it used to, the pace of innovation is coming a lot faster than it used to.
Eloise Drane 29:26
I mean, we’re talking about innovation, millions of babies being born by IVF. But we also need to probably incorporate in the conversation third-party reproduction, because in some cases, this is not going to be possible for many without the assistance of third-party reproduction. But we also know now that there is a shortage of gestational surrogates or carriers. There is, in some instances, shortages of donors or, you know, lack of women who want to go through that process of becoming an egg donor. I mean, it is, it’s, it’s a lot to go through for your body, you want to help somebody, but it’s just like, I don’t want to have to go through that process. There’s a shortage of specific sperm donors, where people in various diverse backgrounds don’t even have the capability to be able to have someone that looks similar to them to be able to complete their family. So how can these advancements that we’re discussing, even overlap into the third-party world and be able to, you know, help the dynamics there?
David Sable 30:36
Great question. And here, we have to break into two areas. There’s the stuff we can do now. And then there’s the stuff that we’ll be doing, sort of not the distant future, but we need to take a couple of big scientific jumps before we can. Now the virtuous part about the stuff we’re doing now, which is just the kind of boring engineering to make it easier to do an IVF cycle to do it and easier and make it easier to do an IVF cycle closer to where you are. And to just increase the number of people that can go through safely and effectively and have a, you know least bad experience. Ideally, nobody thinks that IVF is a good experience, but try to make it at least tolerable. Each of those makes it easier to do a donor cycle as it is to a non-donor cycle. Makes it easier to take the process of being able to donate eggs closer to where you live. You know, one of the problems with IVF in general, for no matter how you do it, is it’s really centralized in big urban centers. You know, it’s like you can’t, I’m in New York, and you can’t you there’s, there’s an IVF center next to every Starbucks, it seems, you know, it’s like it’s very, very accessible, which is great. If you live in New York, if you need egg donors in New York, it makes it easier for the egg donors that are in New York. But if you’re a donor, potentially, even if you’re something that you are willing or want to do, if you’re living in a rural area, then it’s really difficult. And you can’t, yeah, there, it’s not even a matter of driving back and forth for an hour or two each morning, it’s you kind of literally move somewhere for a good period of time. So, all the technologies that we’re developing now, to make IVF more effective, make it work better, and make it more accessible, both in terms of being more inexpensive and closer to where the individuals are, that’s going to help that’s going to help a lot of the donor community. Even on the male side, yeah, there are some men who would be appropriate donors who their sperm doesn’t freeze well. They can only do it fresh. If you do it fresh, you’ve got to be there where, where it’s needed to do the fertilization. So, moving IVF closer to individuals make it more geographically diverse, helps the entire third-party IVF part very, very well. Now, that said, there are, there is a limited number of people that will donate eggs, donate sperm, or even more limited who will act as a surrogate, even, even for surrogacy if we can bring that process closer to where they are. That’s a help. But that’s one that’s probably going to be the toughest one. Yeah, that’s it is a, it’s a nine-month commitment. It’s a pledge to live in a healthy way. And it’s, surrogates that we’ve met are just wonderful people. On the same hand, it is a relatively small number of people. There, I don’t know if we’re ever going to get to the point where we don’t need to, you know, we’re going to be incubating babies to maturity out of the body, that still right now in science fiction. But one of the things that we started seeing just the past few years, absolutely amazed me, which I didn’t think we’d ever see, was effective uterine transplants, which just blew me out of the water. And like, I try to think I’m pretty open-minded. And there’s nothing I think can happen. Well, hats off to the people and I believe there were scientists in Sweden that did the first cases, but they’re being done, you know, in limited places all over the world now. You can take a uterus from one person transplanted to someone else, and that person can carry a healthy baby. I, to me, that’s something I never thought I would see in my lifetime. Will it become routine? I don’t know because it’s still in its very early stages. But that is something that if we can get it to being a cost effective and uniformly safe intervention, that could be an enormous step forward for everyone.
David Sable 35:02
Now, on the egg and the sperm side, we are working with technologies like stem cells, that will allow us to either exactly or functionally recreate eggs and sperm. Now, this also sounds like science fiction, but we will get there. It’s something that is going to get, there’s going to be a lot of hurdles, scientifically, technically, and then very much so in the regulatory sense that we have to figure out just how do we safely start making human embryos that may turn into babies and know that we’re competent enough that we’re not doing harm in order to get there. But that is something where the who the scientific tools are there, we just have to do it methodically, carefully, ethically, and in a way that again, does no harm.
But these are things that will, you know, will become available to us at some point in the future. Now, the growth of using egg donation, since IVF, was invented has been really remarkable. And the best way that we’ve scaled that so far is that the number of eggs we need for each baby born is much lower than it used to be the year we’d make we retrieved 20 eggs, fertilized 12 of them, we pretty much had to use all of those to get one baby, we were putting back three or four. Of course, that meant that the twins, triplets, quadruplets were too high, but that was just because it was a very inefficient procedure.
Now in most cases, we put back one and we save others. You know, again, this is gonna sound very crass, I’m using very, you know, pretty dry terms, the yield, for each time we retrieve eggs is much higher. And you I recognize that these are very painful things that we’re treating, we’re really meeting an enormous need for people. I always hate trying, pulling out engineering and accounting terms. But you know, that’s what we need to do it, you know, if we want to do it effectively, not only we have to be good, compassionate doctors, but we need to be good scientists and good engineers to make all this happen.
David Sable 37:30
So, both on the, the egg side, the surrogate side, the sperm side, just by making IVF work better, make it more efficient per egg or embryo created. Making the probability of getting people that would want to be surrogates or donors make it easier for them to do so. And inventing new stuff, the same way we invented an ability to transplant uterus over the recently, we’ll find other ways to do that as well. Very long-winded answer your question.
Eloise Drane 38:05
No, but it’s great. Like, I’m so fascinated, this is great. My last question is I’m going to have you like peer into the future. And 20 years from now, what do you hope will have transpired from this conversation to, you know, 20 years where hopefully, I’ll be talking to my grandchildren about all the technologies and advances in this field?
David Sable 38:34
Well, hopefully in a way IVF will be boring. Hopefully, yes. When we sat down to map all this out, we said, okay, what do we want the system to look like? Well, first of all, we knew we wanted as ubiquitous as available as dentistry. So, if you need it, it’s there. And it’s close to you. So, it’s like you don’t have to try. It’s like, it’s just not a remarkable thing to have to do. Secondly, we want the outcomes to be the same no matter where you go. So that everywhere you go, there’s a level of certainty, it may not be 100%. But we’ll be able to tell you exactly what the likelihood is, you’re not going to have to, you know, do tremendous amounts of work to try to find where you should go. You said that confidence that it’s being done to a standard of care that really works no matter where you go. It’s something like laser eye surgery. It’s not a perfect procedure. But when it was first introduced, there’s a little operator dependency there. Now it’s pretty much plug and play. Thirdly, we want to say we want it to be affordable in two ways; we don’t want not being able to afford to do IVF a barrier to having a family, you actually it’s just too important. You know, it’s one of the, it’s, if you’re hungry, there’s always a place to go to at least not be hungry again. If you need to sleep, you know we’re we it’s a responsibility we should be undertaking as a society to provide people a safe and safe, warm and dry place to sleep. Similarly, having children is right up there. In that, yeah, I like worked with people that couldn’t have children for a very, very long time. And this is not consumer discretionary, as we say, in the business world, this is this is true to healthcare. So, you don’t want the affordability of an IVF cycle to keep anybody from having a family. The other part of that is, we get to a point where you’re paying for an outcome, you shouldn’t be buying IVF cycles that don’t work. And again, this comes down to risk management. It really it’s like, IVF, and this is it’s, this isn’t because anyone’s evil, you know, but the way IVF grew is that you pay for an IVF cycle. And if it works, great if it didn’t work well, unfortunately, it was a knowledgeable consumer decision that he made. But the problem was that that limited IVF to a tiny percentage of the people in the world. That’s not fair. Yeah, it’s like IVF hurts no matter who you are, you know, what neighborhood you live in, if you live, if your ancestors came from Northern Europe are from somewhere else. And unfortunately, it’s been very much one demographic that’s had access to IVF. So, let’s change that. And let’s change this that’s close to you. It’s affordable. And you don’t feel that, you know, it’s a lot of people, even if they can’t afford IVF, we’re going to do an IVF cycle, don’t want to do it. Because that kind of optionality, the unfairness of paying and coming up with nothing, is the thing they just can’t face. So, let’s take that off the table too. Years ago, we’re talking to somebody who say, Well, it’s a big deal. It’s like IVF was cost of a small Toyota, I say, well, you know, frankly, not everybody can afford a sort small Toyota. But even if you can, if you walk into a Toyota dealer with $17,000, I think that’s the cheapest sticker price, you will drive out with a Toyota. If you pay $17,000, for an IVF cycle, you’re getting a chance of having the cycle work. A lot of people even if that $17,000 is sitting in their bank account, don’t want to spend it and come away with nothing. So, let’s risk manage that. Let’s pay a little bit more when it does work. So that nobody pays a tremendous amount for nothing. So, these are, these are kind of the kind of the three pillars of what we saw what the future IVF world should look like. It’s available everywhere. It works at the highest level everywhere. You don’t pay if it doesn’t work. And that’s what I’d like to see you said 20 years. I’d like to see it before then. But if it’s 20, 20 years okay, well, we’ll settle for that. But let’s, let’s, let’s see if we can do that in 10.
Eloise Drane 42:53
That would be amazing. I mean, that would just be amazing. And I mean, we’re sitting here talking about the, you know, all of these abilities. The other thing about if we’re not reproducing, country, the people that are here will eventually die away. If we’re not repopulating, who’s going to keep the world going?
David Sable 43:12
That’s a really good question. We studied that over the past couple of years. There are 4.2 million 32-year olds, and about the same amount of 33-year olds, and 34-year olds, most babies in the US now are born to people over 30. Well, last year, we made 3.7 million babies. That’s a big difference between the people that are making the babies, the number of babies were having. And in some cases, people don’t want to have as many children, that’s an individual decision. That’s okay. But most of that is because it’s on the waiting to get pregnant till a little later in life, which is a rational decision. And the chance of getting, having a child each time you try to get pregnant, your 30s is a heck of a lot lower than it is in your early 20s. We looked at the 16 biggest economy the best developed economies in the world and looked at the what’s called the total fertility rate, TFR, which is the number of children a woman would has during her reproductive lifespan. And population replacement is 2.1. That’s the magic number. You’d think well, two, because you’re replacing yourself and your partner. Well, the point one, unfortunately, is because of childhood mortality. So, if you have to be 2.1, every one of those 16 were below that, in some cases very below that. And if you, if you multiply the just the difference between your TFR and the 2.1 times the population, you come up with the yearly population deficit. Yeah, those 16 countries up 10 million babies per year that, China, and the United States, and Japan, and a lot of countries all over the world are not replacing the current populations. And you asked a very good question. Well, in countries like Japan, Taiwan, South Korea, and there’s a very major problem in that, who takes care of the people as they get older? Yeah, who really, who provides for the economy, to support people as they leave the economy, you can only do so much with technology. So, it is it’s this is a big policy issue. And something that I took some, some countries already addressing it. Japan is going to make IVF extremely accessible. China is essentially making it free now, in Israel IVF is free until you’ve had two children. In Belgium, and Sweden, IVF accounts for 10% of the babies that are born, in the US about 2%. So there’s a lot of ways, a lot of country variation that’s going to be needed to have creative solutions to address this new like we’d look at it from the point of view of families. Yep, they’re trying to fill enormous void in their lives. But from a policy standpoint, yeah, if I’m, if I’m thinking, what’s the United States going to look like 15,20, 25 years from now, I’m concerned about how we keep our population growing or at least stable. And there’s only two ways to do it, you know, have more babies or increase net immigration. And I happen to be a big believer in the benefits of immigration. But unfortunately, it’s something that a lot of people aren’t too enthusiastic about. So okay, if you’re not going to do it that way. Let’s address it in terms of the population we have now, who are not having children that they want to have. You really nailed it, nailed the enormous societal question with that question.
Eloise Drane 46:53
Yeah. Wow. David, thank you so much for your time in this discussion. I knew when I saw you at the conference, I was like, that’s who has to talk to us on the 100th episode about the future of fertility. So, it has been my pleasure to have you join me today.
David Sable 47:09
Oh, what a privilege it was to talk with you and I’m happy to answer your questions anytime.
Eloise Drane 47:14
Thank you so much.
David Sable 47:15
Take care now.
Eloise Drane 47:21
Thank you so much for listening. If you found this episode helpful, please rate Fertility Cafe on your favorite listening platform, and share this episode with anyone you think could benefit from hearing it.
Eloise Drane 47:35
Tune in next week for another amazing episode on Fertility Cafe.
Until then, remember, “love has no limits — neither should parenthood.”
