Fertility Forward
Fertility Forward
Ep 178: Dr. Stein & Dr. Reckhow on Their Latest Research for ASRM
Joining Rena and Dara on the podcast today are two special guests, a reproductive endocrinologist and partner, Dr. Daniel Stein, who leads a team at our West Side office, as well as an RMA Fellow and native New Yorker, Dr. Jensen Reckhow. Our guests have co-authored an abstract titled ‘Predicting treatment futility in patients undergoing autologous IVF’, which they’ll be presenting at the ASRM Conference. Join the conversation today as they expand on their study, diving into what inspired the topic, what they based their research on, the details of the study, and the intended application-related goal of the outcome. They also share the most surprising takeaways from their findings, how their findings will influence future treatment plans, and we end our podcast by sharing what we are grateful for today. Thanks for listening!
Hi everyone, we are Rena and Dara and welcome to Fertility Ford. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Ford podcast brings together advice from medical professionals, mental health specialists, wellness experts, and patients, because knowledge is power and you are your own best advocate.
SPEAKER_03:Hi, everyone. Today we have two special guests on our podcast. I had the pleasure of having one of our fabulous reproductive endocrinologists and partners, Dr. Daniel Stein, who leads the team at our Westside office, as well as one of our RMA fellows and Native New Yorkers, Dr. Jensen Rechau, who have both co-authored an abstract entitled Predicting Treatment Futility in Patients Undergoing Autologous IVF, of which they will be presenting this abstract in a number of weeks at our big conference, the ASRM conference. So thank you both today for being here. I appreciate it.
SPEAKER_01:It's a pleasure.
SPEAKER_03:Thank you for having us. I'm curious what initially inspired you both to research this topic.
SPEAKER_01:Well, so the question I had is for years, we have seen many, many patients who have maybe come to us from other places who've had multiple, multiple cycles of IVF that in our experience we have felt were not useful cycles. They were not going to lead to a successful pregnancy through IVF. And we felt that it was important that these patients know what are the parameters for success, what are the parameters, however, also for non-success. And what are their options? Because it's very exhausting physically, emotionally, and financially for people to go through cycle after cycle after cycle if there's really not a reasonable chance it will be a successful outcome. And so what I had spoken with Dr. Reco about was can we determine the parameters by which patients are very unlikely to conceive with their own eggs? And can we create some sort of guidelines to be able to counsel them appropriately? And Dr. Reco did an amazing job and has done the very vast bulk of the work here. And so I'm going to leave a lot of the detailed data to her, but we did put this together and I think it's very worthwhile. But I will say just one thing. When we say that we can't help with IVF in your case, it doesn't mean that it's impossible that the right egg can drop, you know, a few months later and the right sperm can be there and a pregnancy can occur. But it does tell us that we're not going to be offering anything more than a chance of you getting pregnant naturally.
SPEAKER_03:That's good to know. Great advice or or good insight to give to patients that this is research based in the clinic, but that doesn't necessarily mean that there isn't a possibility on their own that that this can happen. So this is research based from the patients at the clinic.
SPEAKER_01:Right. And research based on many, many, many cycles. You know, the one advantage that we do have here, a couple of advantages we have here, are reproductive medicine associates of New York is that we have a very high volume practice, one of the highest volume practices in the country. And we also have over 20 years of experience and also many years of very, very good pregnancy rates, you know, among the top in the country. So we have the numbers to give us some important data.
SPEAKER_03:So that's what the research appears to be is looking at our patient population. And so, Dr. Reco, I would love to hear from you a little bit more of the details of the study.
SPEAKER_02:Absolutely. So as Dr. Stein described, we kind of approached this in from two different angles. We wanted to see both what are the absolute limits in our highly successful clinic of kind of what is the oldest age where a patient has been able to achieve a live birth, what's the oldest oocyte age, what's the poorest set of ovarian reserve parameters that have led to a positive outcome, but also looking at for all comers that are kind of in this more extreme group. So our patients of advanced reproductive age, what can they realistically expect? We know that outcomes kind of become more and more positive outcomes become more and more rare as we get older. And so we wanted to say, be able to say both what is our true limit, but also at what point is the chance of a live birth or the chance of a pregnancy 1% or 5%. And ultimately our goal was to be able to construct a tool that we can use to counsel patients to say, you know, here are your metrics and here is what our prediction is for your chances of success, looking at our years of experience in the clinic and our overall good outcomes. And so we found a ton of information from this. This is a really rich data set, and we were able to look at a lot of different metrics here. But what we really focused on was the group of patients who are in the early mid-40s. So patients, we started at patients who are 42 and above, and we found that this is the group where the outcomes really start to trail off. So most, a majority of patients who initiate an IBF cycle above the age of 42 will have that cycle be canceled. And cycles can be canceled for a number of reasons. They can be canceled prior to the oocyte retrieval, prior to the egg retrieval because of a poor response to stimulation. They can be canceled at the time of retrieval. If no eggs are retrieved, they can be canceled during the embryology development stage if we get eggs but they don't fertilize well or they don't turn into healthy embryos. And then finally, patients can end up with not having anything available to transfer or have an unsuccessful transfer. So we found that this 42, 42 years is kind of the threshold after which outcomes start to be more increasingly worse. We found that above the age of 46, all of our patient cycles were canceled. So there weren't any patients who underwent autologous IBF beyond the age of 45.8 who had ended up developing an embryo that they could then attempt to transfer. Every single one of those patients had their cycle canceled.
SPEAKER_03:And autologist, I know auto means one. So is it that they are able to carry using their own eggs? Using their own eggs.
SPEAKER_01:It's using their own eggs. We're not extending this to the use of donor eggs.
unknown:Okay.
SPEAKER_01:And I don't want to emphasize what Dr. Recco was saying. So one of the big strengths of this study is the sheer size of it. Okay. So we looked at over 20,000 cycles and 18,000 of them with live earth data. That's an enormous, enormous data set, as I think Dr. Jensen said a per Dr. Recco said it perfectly, which is that it is a rich data set. It gives us a tremendous amount of information. And the vast majority of programs in the country don't have that kind of data. So I think this is very, very helpful to all centers to get a pretty good guideline for when you should be strongly recommending patients consider alternative options.
SPEAKER_02:And for the data that we analyzed here, we were looking at autologous IVF cycles because what we're really looking at is the patient's metrics at the time of IVF. So their FSH levels, their ovarian reserve, their AMH, their age. And so those things are really intrinsically tied to the patient as a person versus if they're using a donor oocyte, a donor egg, donor gametes, then we would want the data about where those eggs came from. That would kind of be the more informative piece. So the goal of this research project really is to help us figure out how do we counsel patients in a transparent and with their best interest in mind in that kind of way. And saying, does it make sense for us to do a cycle with your own eggs? Or if your goal is live birth and efficient and effective care, maybe it makes sense for us to start with a donor egg. And so trying to figure out which patients fall into which group and really just to give patients the information that will help them decide what makes sense for them because not everyone makes their decision based on okay, what are my chances of having a live birth? Sometimes it's I want to be able to experience different steps of this process and I want to feel that I've done everything I can for myself before I move on to a donor egg. Some people say I want to go with whatever's most successful. So we really just wanted to kind of leverage this massive amount of information we have and try and use that so that we can give the information back to the patients and they can use it to figure out what makes sense for them.
SPEAKER_01:Yes. And you know, just give you sort of a real life of scenario. It'll be very common for a patient or a couple to come into your office and say, I know I'm older, I know I don't have many eggs, etc. And I know you're telling me that chances are not high, but even if I have a 5% chance, even if I have a 5% chance, I want to do this. Well, that's fine. But is there a 5% chance? There might not be a 5% chance. There might be a 0.5% chance. There may be zero chance based on our data. And so you have to be able to tell people that. Now, some people will push and say, I need to do this. It's important for me to do this, it's important for me to make sure that I've done everything possible with my own eggs to have a successful pregnancy before I even consider the possibility of using donated eggs. And it doesn't mean that it's wrong necessarily in some cases to give patients that understanding, but you have to be able to counsel them very, very appropriately. And even the American Society for Reproductive Medicine has a statement about the ethics of doing what they call futile cycles. We just want to stay very evidence-based. We want to provide excellent information, which Dr. Reco has done here. And we want to be able to let people know all their options. This is the most, most important thing. And people may make decisions that we don't always necessarily agree with, but at least we know that we've done our job to strongly, strongly counsel them with the best data that there is at this time.
SPEAKER_03:Yeah, and it's one thing. Look, recommendations that have been passed down is one thing, but to actually have these recommendations based on our clinic and with such, I think such a large group of people and cycles, I think is pretty remarkable. But you're right, I do think that this information is really valuable information for people. People do like to hear numbers and not necessarily to manage their expectations, but yes, to give them kind of our experience of what we've seen collectively, you can help give them all the options so they can make the best decision for themselves. I think that's great. My question also is in terms of, I know you had said, Dr. Rackow, I'm not sure if this is uh that important, but in terms of even like fresher or frozen cycles, does that make a big difference in terms of because I know you said there's many different things that you look at in terms of, you know, where their hormones are. But I was also, yeah, I think that the fresher frozen cycles is that something do we typically, the older the patient is, do we work with fresh or frozen or both?
SPEAKER_02:We work with both. I will say most of our patients will undergo a frozen embryo transfer cycle just because it's more likely to have a positive outcome in that setting. The reason for that is really that synchronizing the lining in the uterus and the hormone levels and the embryo in a fresh cycle is more challenging. So we do it in kind of there's a small set of patients for whom the outcomes will be the same if you do a fresh cycle or frozen cycle. And that's when there's that perfect constellation of factors where everything lines up where your hormone levels are appropriate to be able to proceed with a fresh cycle. So we did look at both in this data set because we looked at many years of data, and our practice has kind of shifted over the years to favor more of the frozen cycle so that we can have better control over the process and then kind of optimize the outcomes for our patients. But we did include both because there are those real life scenarios where someone, maybe someone's even planning for a frozen embryo transfer, but based on the embryos that they have available and how the cycle is going, we end up proceeding with the fresh transfer. And at the end of the day, what matters to that patient is potentially did I get to experience the embryo transfer? Did I have an opportunity to become pregnant? And then what was the outcome of that pregnancy? And that matters just as much to the patient, whether it was fresh or frozen. And so we looked at both, and ultimately we saw consistent with our years of experience that the frozen outcomes tend to be better. And we have more of these fresh transfers in patients who have a poorer prognosis or who have a lower chance of success to begin with, that they're more likely to end up in that camp just because it's a less ideal treatment scenario in 2025.
SPEAKER_03:Thanks for clarifying that. Yeah, I was curious. And that's what I had thought, but didn't want to make that assumption. So, overall, were these findings something that you had predicted, or was there anything that kind of stood out to you that was not what you had predicted?
SPEAKER_02:Yeah, so I was honestly impressed by our numbers, the numbers of patients that we have at these higher in these higher age groups, just in my more limited experience, we have thousands of patients that have attempted IVF above the age of 42. And I was surprised by how high the cancellation rates are. What was reassuring about this though was looking at the time when patients experience cycle cancellation, it looked like in all of these age groups, the majority of cycles were canceled before retrieval, which I think is important because that's the point where the physician kind of has the insight to be able to say, this is very unlikely to end in the outcome that we're hoping for. And so let's cancel before we've invested all of this even more emotional, physical, and financial resources into this process. We saw that the a very small percentage of patients get canceled at the time of their retrieval, which was really reassuring because that means that we're doing a good job of communicating with each other and saying, you know, if a cycle is unlikely to be successful, we're recognizing that and we're able to reach a decision together rather than having a patient go through a surgical procedure that isn't successful for them. So it was in a way reassuring to see that that we are clinically pretty good at predicting what outcomes are going to be and being able to counsel patients in that regard to kind of quit while we're ahead. But I was surprised by how quickly the pregnancy rates drop off in this upper age group. And we do have good data to show that the rates are quite low and to be able to counsel patients on your chances at this point are less than 5%, I think, for this really for this whole group. But being able to see it step by step and be able to tell people this is what we've seen of patients who get canceled before the cycle and of the patients who end up proceeding to retrieval, this small percentage will end up going to live birth. The numbers are surprising to see always, I think.
SPEAKER_01:Yeah, I emphasize that yes, I agree 100% with what Dr. Rakow just said. This is the cancellation rates were very impressive to have almost half of patients over 42 end up with a cancel cycle that is certainly very, very significant. And that's prior to agreeable. But I think the thing that is most telling to me here is just how much this has encouraged me to encourage others to freeze their eggs because it is so obvious, and we've always known this, and I've been doing this for 30 years. We've always known that advanced age, low AMH levels, low follicle counts, high FSH levels. We've always known these things were significant parameters. But oftentimes it's not just the patient, sometimes doctors can be convinced that oh, they heard about a patient who did well with this scenario or did well with that scenario. And we'll have a doctor even say, No, I'm sure I had a patient like that who got pregnant. Well, we can say, Well, no, you didn't. Okay, you didn't that that didn't happen. Okay, that didn't happen. But it does emphasize the importance of freezing your eggs if you're not ready to try to get pregnant. Certainly, certainly by the time a person turns 35 and preferably earlier.
SPEAKER_03:Well, you but you answered my question. I was gonna say, Doctor side, both of you guys, would you be canceling your patients any differently from these findings? And you definitely answered that, promoting egg freezing at an earlier age, if possible.
SPEAKER_01:For sure.
SPEAKER_03:I told my young, my teenage daughters, I want to freeze your egg. They think I'm crazy.
SPEAKER_01:But no, no, no, it's not a great deal, although I don't think you have to do it as a teenager. I still wait till they're a little bit older. Exactly, exactly. They're not at any great risk in their teenage years. Yeah.
SPEAKER_03:But look at it, it's still, I love that RMA. We are so robust at doing research. And we really, even someone like this, where it seems like such a simple retrospective study, which is not that simple, but the fact that we're honing in and really getting to the nitty-gritty to give our not necessarily reassurance, but to give the data that we're collecting so we can best advise them and guide them and give them all the information. So again, collectively come up with some guidance of how to proceed, I think is great. Also for people in their wake, for for the patients that have yet to come, we could definitely better support them.
SPEAKER_01:Yeah, for sure. Absolutely. I do want to emphasize that while the actual analysis of the data here is not so complicated, the volume of the data and organizing it in a way to be analyzed takes a lot of work. Takes a lot of work. And Dr. Recko did that work and she did it very, very well. And I would definitely I keep my eye on Dr. Recko. She's gonna be producing a lot of good stuff over the next several years.
SPEAKER_03:I wanted to ask Dr. Reckau, or even Dr. Sai, is there any type of follow-up that you would love to do with this? Absolutely.
SPEAKER_02:Yeah, I think it really it's just the more data the better, because the stage we're at right now is we're trying to build this predictive model. And the challenge with these models is they're really they're more accurate when you have more data points. And because what we're the people we're trying to counsel are in these extremes of age group, and so there aren't as many of them. And so even with our large pool of data at RMA, we still, you know, it's 1,300 patients that are 42 and older. And so that's probably the highest number of any clinic, I would imagine. But ultimately, it's not a ton for building a really reliable model. So I think being able to pull data from multiple centers throughout the network would be really helpful. And the more information we get, the more accurate our predictions become. And that's really an important next step here is making this something translatable. But even before that, I think one of the really helpful parts of doing research like this, aside from the obvious of being able to have the information to back up our counseling for patients, is it's also helpful for us as clinicians to reflect on actual factual information of what has happened in the past. Because, like Dr. Stein said, you remember things a little bit differently. You know, you remember the patient who had the incredible outcome and that sticks in your mind, and you maybe don't remember exactly how many didn't have that outcome. And so being able to go back and look at the data and analyze the numbers and the fact that we do this all the time at RMA, looking at every question under the sun, and we're just constantly looking back on what our experience has been and what our outcomes have been. I think it it helps us have a more realistic understanding of what our practice is like. And I think that piece alone is helpful for counseling patients because you just have a better sense of what's really going on.
SPEAKER_03:Absolutely. That's beautiful. I'm very excited for you both to be presenting in a couple of weeks and also to see where every year, this is my favorite time of the year to record because I really do love to hear what we're studying. There's always something to be learned. I really appreciate you both taking out the time of your busy schedules in October to record this. But before I finish, Dr. Swine probably knows, we end our podcast with words of gratitude. So I'm going to put you on the spot, Dr. Rakau. What are you grateful for today?
SPEAKER_02:Oh, I love this. So today I am grateful for, honestly, I'm grateful for doing this podcast because this gave me an opportunity to take a step back from the project that we're working on. I've been really in the weeds with the data analytics and taking a step back and looking through the different patients and who had what outcome and trying to think about where we take this going forward and how we can improve our counseling. It's just, it's making me really excited to be part of such a data-driven field and such a rapidly evolving field, looking at outcomes from 10 years ago versus today. It's just, it's really inspiring. And I feel really lucky to be in this field. And it's nice to, while we're gearing up for ASRM, and it's a very busy time and there's a lot of work to be done. And so being able to step back and say, like, actually, I'm really, really grateful to be here, it's a good feeling.
SPEAKER_03:How beautiful. So nice. Dr. Stein, what about you?
SPEAKER_01:Well, first of all, I'm grateful to Dr. Echo. Now that's the first thing. Okay. Because I have good ideas, but she's a major force in making these things happen. So that's great. But I'm very grateful that RMA has been dedicated to data capture for so long. That there was an understanding and a vision many, many years ago to be able to continuously capture data, to follow data, to use data. And that has been really tremendous uh over the last two decades that RMA has been functioning. I do definitely congratulate those who, even before I got here, were doing a tremendous amount of excellent clinical research, and that there is this continuous dedication to do that. We have a separate clinical research team here. This is not just a one doctor doing it or another person doing it. We have a whole infrastructure for it. And it also allows us to train our fellows and our fellows come out of here superior, really superior. So that is what I'm grateful for. And I'm grateful to you for having this podcast.
SPEAKER_03:Thank you. I guess I'll piggyback on that. I'm really grateful that we, I mean, that I get this opportunity to meet with so many incredible people, learning so much about this field. This time is a year of reflection for me. It's a big Jewish holiday, Yom Kippur, about reflection and repentance and how we can level up. And I'm just so amazed, you know, I've been at RMA for 15 years and to see the evolution in what we've accomplished and what we are accomplishing, what we are discovering and what we are continuously discovering. It's it's it's very much aligned with this time of year of how we can continue to do the great work that we're doing, to show up every day, to give back. I'm honored to be a part of it. I really am. Well, congratulations to you both. I'm very excited for you both to be presenting in the next couple of weeks and to see what lies ahead for you both. So thank you.
SPEAKER_01:Thank you so much. Thank you so much.
SPEAKER_03:Thank you. Thank you so much for listening today. And always remember, practice gratitude, give a little love to someone else and yourself. And remember, you are not alone. Find us on Instagram at fertility underscore forward. And if you're looking for more support, visit us at www.rmany.com and tune in next week for more fertility forward.