Great work by the international group that published their work in The Lancet renaming polycystic ovary syndrome, or PCOS, now called polyendocrine metabolic ovarian syndrome, or PMOS.

Three points:

First, this was an enormous achievement, combining science, medical history -- and politics. The international group did us a real service.

Second, the new name is better. It more accurately reflects what clinicians and patients have known for years: this is a complex syndrome with endocrine, reproductive, and metabolic dimensions.

Third, the new name is better, but it is still not good enough.

Lets talk medical history.

It’s 1935. Michael Resse Hospital in Chicago.

Irving Stein and Michael Leventhal publish a case series of seven women with enlarged ovaries identified at laparotomy, along with irregular cycles, hirsutism, and obesity. That report gave rise to what became known as Stein–Leventhal syndrome.

Of course “syndrome” suggests a superficial or observational understanding, not precision medicine.

Medical knowledge travels from the vague to the precise, from analog to digital. With hormonal assays and pelvic ultrasound, the PCOS picture emerges. The role of androgens gets clarified. Then, the metabolic dimension—particularly the role of insulin resistance. PMOS reflects that shift.

This is progress; medicine advances as it moves toward precision. We begin by naming clusters of symptoms. Then we define disease anatomically. Later, if we are successful, we define it by pathways, cells, molecules, and genes. That is what precision medicine promises, and patients deserve nothing less.

Women living with Stein–Leventhal syndrome, PCOS, or now PMOS still deserve a more precise understanding of the complex set(s) of symptoms that they have endured for 300,000 years.

Why? Because better understanding leads to better management. The earliest surgical approach—ovarian wedge resection—was crude and not all that effective. Later, systemic treatments such as oral contraceptives, clomiphene citrate, and gonadotropins improved care, but often imperfectly and sometimes with substantial risk, including multiple gestation and ovarian hyperstimulation.

The future will be better than the past. And the new name signals both progress, and the work still left to be done, work that will define, more precisely, what drives this heterogeneous condition in different patients.

I find a seat in the back of the auditorium at the Boston Public Library. I put my backpack on the floor and stuff my white coat inside, being careful not to disturb the two books that I brought with me. I don’t spend many mornings during fellowship at the Boston Public Library, but this was an event I did not want to miss.

Amy Tan is in town for a reading.

Three years before, I sat in the back seat of the livery car that shuttled us between New York Hospital and LaGuardia Hospital in Queens, our affiliate hospital, where for the prior 24 hours I was the only obstetrician-gynecologist in house.

The car radio was tuned to NPR, and a young author named Amy Tan is reading from her book, The Joy Luck Club. Suyuan Woo describes her escape from the invading Japanese army at Kweilin to her daughter Jing-Mei.

“I packed my things and my two babies into this wheelbarrow and began pushing to Chungking four days before the Japanese marched into Kweilin.”

The scene is a flashback. We learn at the start of the book that Suyuan Wu has just recently died, and Jing-Mei takes her seat at the mahjong table during meetings of the Joy Luck Club, four women from China who emigrated to San Francisco after the war. Each has a young adult daughter.

“I didn’t have enough feeling left in my body to cry. I tied scarves into slings and put a baby on each side of my shoulder. I carried a bag in each hand, one with clothes, the other with food. I carried these things until deep grooves grew in my hands. And I finally dropped one bag after the other when my hands began to bleed and became too slippery to hold onto anything.”

The other three women have a message for Jing-Mei.

“By the time I arrived in Chungking I had lost everything.”

“What do you mean by ‘everything?’” Jing-Mei asks.

“What happened to the babies?”

My plan is to attend the reading, rush home to Saint Germain Street, shower, pick up my suit and fly back to New Jersey. On stage, Amy Tan is reading from her second novel, The Kitchen God’s Wife. I lose myself in her storytelling, the plot and vivid characters, and in her mechanics: the strong sentences and flow of the paragraphs.

We planned the wedding in early July, shortly after Priya’s graduation from the New England Conservatory, and at the midway point of my two year fellowship in reproductive endocrinology and infertility at Brigham and Women’s Hospital. It has been an eventful year. I met Priya at the Trident Bookstore on Newbury and we were engaged six months later. Professionally, I had my own patients for the first time, women and couples for whom getting pregnant, being pregnant. or staying pregnant was the most important part of their lives.

Sujuan Wu’s friends have news for June-Mei, who knows very little about her mother’s life in China. Sujuan, exhausted and fearing death, left the babies at the side of the road, with a note for someone, anyone to take care of them.

I have very little time after the reading and a q and a session, but I stay anyway, and join the receiving line to greet the author.

Later, on the plane home, I reflect on the year past. As a resident at Cornell, I took care of others doctors’ patients with infertility, but had never realized just how much suffering it caused, how brutally it shoved the rest of life aside, and how it robbed people of the lives that they had always counted on.

How it made them question everything.

I reach the front of the line, and thank Amy Tan for the gift she gives her readers. I open my backpack and show her my well-worn copies of The Joy Luck Club and The Kitchen God’s Wife.

Sujuan Wu escapes to America, remarries, and gives birth to June-Mei. But Sujuan never forgets the baby girls she left behind in China. With the help of the other three members of The Joy Luck Club, searches for evidence of their survival.

The plane descends into LaGuardia. Infertility is suffering, but there’s more. My patients are in mourning too. They grew up picturing their children, picturing their lives as parents. Then infertility, or habitual pregnancy loss, forces them away from the life that they assumed would always be there. The babies, the children, the family, all left at the side of the road.

Shortly before she dies, Sujuan finds that her two daughters are alive and well and living in China. She never gets to see them. Instead, Jing-Mei travels to Shanghai to meet them in her mother’s place.

The livery car driver didn’t mind that I wouldn’t get out of the car back at New York Hospital. He wanted to hear what happened in Shanghai too. June-Mei and her half sisters do meet in the airport, fulfilling Sujuan’s dream.

“And although we don’t speak, I know we all see it: Together we look like our mother. Her same eyes, her same mouth, open in surprise to see, at last, her long-cherished wish.”

Priya and I have been married for 35 years. Amy Tan signed my copy of The Kitchen God’s Wife, “To David and Priya, Joy and Luck in your life together.”

If we ever meet again, I’ll thank Amy Tan for the wisdom that a young infertility doctor found in her story about Sujuan Wu, her daughter June Mei, and the babies left on the side of the road

It’s 2014. Ice Bucket Challenge. Shake it Off. The carpooling app Via.

David Stern, now CEO of Kindbody, and I are on an industry panel together (for a while conference organizers seemed to think we were the same person, which I took as a compliment.) He asks me if I knew Piraye Beim, the CEO of Celmatix.

At the time I am working on version 1.0 of the IVF million baby a month project, and looking at the IVF world through the lens of the biotechnology industry. It was year 10 of my one year sabbatical from medical practice, and the lowly status of women’s health and reproductive medicine in the venture world was pretty clear, relative to oncology and immunology.

I dig in and find that a big part of this is traditional neglect, an inequitable crime of omission that leaves women out of clinical trials and ignores diseases and conditions that disproportionately affect women.

But in 2014 there is another part of the problem that took me a while (too long) to recognize: our 1980’s level understanding of women’s health.

Modern medicine, from the use of the microscope on, has traveled from the general to the specific, from big to small. I stole a lecture slide from my colleague Richard Scott years ago, that demonstrated the magic to precision medicine continuum.

21st century medicine travels along an analog to digital continuum, from systems to organs to cells to genes, but not all parts of our anatomy travel at the same speed. The elucidation of the genome and the rapid, cheap gene sequencing are rocket fuel for disrupting areas where tissue and cells are easily obtainable.

Areas like oncology: when we biopsy a piece of tumor, we can take it to the lab, chop it up, sequence it, assay for expression, and precisely map the inflows and outflows, where and how it gets its energy and what it produces and how its growth gets turned on and off.

Unfortunately, disorders of menstrual function, reproductive biology, pregnancy and menopause are not as easy to study. The type of large datasets that fuel both quantum jumps in understanding and in funding for further research, have to be built slowly and painstakingly.

In the 1990’s and early 2000’s, genome-based platform companies like Millenium, deCODE Genetics, Human Genome Sciences mined newly available sequencing data for disease target discovery, enabling more focused and better defined patients populations and a movement from non-specific approached to treatment (think chemotherapy or high dose steroids) to key in a lock precision.

But it was not until 2009 that a similar approach, modified to address the difficulties in dynamic monitoring of conditions under the “women’s health” umbrella, addressed reproductive medicine.

It’s 2009. Avatar at the movies. Mad Men (Priya and I) and Glee (Tarana) at home. And a freshly minted PhD named Piraye Beim launches Celmatix, adopting a playbook that, used in oncology, had produced Velcade to treat multiple myeloma and Ibrutinib to treat CLL (chronic lymphocytic leukemia).

From the start, this was a heavy lift. It seems counterintuitive, but data interpretation in benign disease can be more difficult than in malignancies, where the genetic signal is surrounded by less physiologic noise. And remember — this was 2009. iCloud did not exist and the first IPad was a year away. Netflix made money renting DVD’s through the mail in red envelopes. The terms AI and Big Data had yet to enter the sound cloud.

Undeterred, Celmatix built Polaris, a first of its kind database. Numerous collaborations on proprietary targets later, it announced this week the acquisition of its discovery portfolio, including next generation FSH, JNK and AMH targets by Gedeon Richter.

David Stern did me a favor introducing me to Dr. Beim, pointing me to a front row seat to watch a fearless innovator push the hard science of women’s health into an at times unwelcoming but inevitable digital world.

Massively Better Healthcare

About a million years ago (it was actually 2017), I wrote a price for Forbes called “How IVF Can Be A Laboratory For Free-Market Healthcare,” describing our healthcare system where “the combination of huge purchasers, the insurance companies, and huge providers, hospital systems, has resulted in a marketplace with no price transparency, little educated consumer choice and the type of expensive, wasteful treatment that efficient markets are supposed to avoid,” then went on to talk about how the IVF world, still largely a retail marketplace, was a wet lab of sorts for a patient-controlled, incentive-driven, efficiency-catalyzing mini healthcare system.

A lot has happened in the million (nine) years since, including the parallel emergence of both consolidated supply (through private equity consolidation) and to a lesser extent consolidating demand (through employer-based insurance, AND an entrepreneurial ecosystem in IVF that will redefine how IVF is delivered.

The rest of healthcare? Forget it — too hard.

Unless your name is Halle Tecco.

A couple of weeks I ago, Halle, who I know from her own work in reproductive medicine, released her book, Massively Better Healthcare, in which she takes on the structural inefficiencies of the entire healthcare system, making the case that — like an IVF cycle — patient care as a whole can be engineered, taking advantage of interpretable, population-scale data, improved understanding of disease processes leading to more accurate diagnoses, and patients, armed with digital health tools, real-time access to their medical data and ever-greater access to comparative data to sort out both site and provider and treatment choices — awakening what she calls “healthcare’s sleeping giant.”

What doest this emerging massively better system look like? One that meets her SSI checklist: sustainable scalable and impactful. One that follows four rules: build from inside out (know the problem you are trying to solve), align mission and margin (something we will eventually learn in IVF when patients pay to have a baby, not to endure a treatment cycle independent of outcome), be a steward of health data and invest in (and believe in and be obsessed with) metrics.

There are well-placed Rock Health anecdotes and mini cases studies (I will never tire of reading about Kate Ryder and Maven.) I learned a lot from Massively Better Healthcare. Enjoyed it too. Well done Halle Tecco.

The Lucky Egg

_“I vividly recall going against the very advice I give to my patients (‘Take a Zen moment the morning of your transfer and ensure a good night’s rest!’) when it came time for my own embryo transfer day. Instead, I stayed up late the night before, guzzling Diet Coke while answering emails, and then ran around all day seeing patients and performing more than 10 embryo transfer procedures, all before hopping up on the exam table to take my turn.”_

There was no greater compliment in the Sable household when I grew up than when mother Arlene Sable described someone as a Tough Cookie: smart, fearless, and authoritative, with kindness sprinkled in as needed. Training in obstetrics and gynecology and then reproductive endocrinology in the 1980s and 90’s, I was taught and trained by a squadron of tough cookies.

Mom would have enthusiastically endorsed Lucky Sekhon. Her book, The Lucky Egg, is both an encyclopedic tour through reproductive physiology, pathology and treatment, and gentle/tough cookie guide to surviving infertility care and IVF. Her mission: to fight the fertility knowledge void — to be a “fertility GPS.”

It’s all here, readable and well organized: the biological clock, what to expect, the normal vs the abnormal vs the we just don’t know, the give and take between answers and results, the workup, the treatment, the aftermath and the questions along the way. Answers range from here’s-the-reference data-driven to we really have no idea but I can’t see how it would hurt. I love the supplements section, the advice to avoid the temptation to “shock and awe” your fertility through supplement overload, and the counterintuitive wisdom that natural doesn’t mean safe.

Even better is what could be the hardest chapter of all, on troubleshooting failed embryo transfers, the chapter for “those who’ve been on the receiving end if that “not this time” call: fifteen pages of no BS this is what we know, this is what we don’t, here are the rare things that may be a factor and here’s a list of things that seem to be worthless and here’s why.

I’ll spare everyone the pithy phrase combining the words “tough cookie” with “lucky egg.” I do know that I’m going to recommend The Lucky Egg to a lot of friends and family in the future.

_I received no assistance from artificial intelligence. The clumsy sentences, split infinitives, dangled participles and inconsistent tenses are mine and mine alone._

I’ll get to business in a bit.

But first a story.

There is a special kind of quiet after the last student walks out the door and the teacher is left alone in the classroom, to erase the chalkboard, to load the backpack, and just before turning out the lights, to take one last look at the rows of empty desks.

It’s 2011. I sit at my desk—a grid of PowerPoint slides on one computer monitor, my course outline on the other. I am a novice again, midway through preparing the 28 lectures that I will make up Entrepreneurship in Biotechnology.

For the next fourteen years, the “Entrepreneurship in Biotechnology” classroom at Columbia becomes a laboratory, an operating room and a mini-think tank. It starts as a linear, step-by-step, list of science-based company startup how-to’s: how to pitch, how to hire, how to develop, how to advance and how to to fund, then morphed into a theme park for problem-solving, asking the right questions, gathering data, drawing conclusion and — most important — effectively communicating what you believe to be true.

One after another, the students deliver a pitch, and line by line we take the pitches apart: rejecting unsupported or arbitrary numbers, sharpening descriptions. Our ecosystem has no syllabus (does entrepreneurship have a syllabus?) and the students do not know how they will be graded. I collected notebooks unannounced, and gave exams sporadically, if at all.

Ten guest speakers come in each year, some famous, most not, all asked only one question: walk us through how you got from the students’ side of the classroom to where you are now.

Over the course of fourteen years, a few universally accepted truths emerged, and became the Rules of Entrepreneurship in Biotechnology. Sharing them below.

I have a few decades of work in front of me, and I’m sure I’ll find my way back into a classroom at some point. What have I learned so far? That teaching, like business, maybe like life, is ultimately a pass-fail test, and what you need to do to pass is show up every day, never stop trying and never give up.

Regarding the fund’s performance this year: we did just fine.

Wishing you all the best for 2026.

David

Why? Let’s start with three broad areas.

1) Hubris. Humans have been around for 300,000 years, accounting for 15,000 generations of evolution. The notion that we can do better 25 years after the human genome project, armed with WGS reports and a mixed bag of genetically and non-genetically characterized trait sets (what is the word “syndrome” if not an admission that we don’t know understand cause and effect) is a bit aggressive.

(To be clear, I am talking about unenriched populations, not families that carry arithmetically-defined genetic disease.)

2) Practical: who’s going to do the IVF or future equivalent to produce 130 million babies a year? Our 25 billion dollar, less than one million babies a year industry manages 4-8% growth a year. I worship at the temples of standardization, automation and scale as much as anyone, and I marvel at what AI can do, but sufficient growth in ART and sequencing throughout to achieve ART dominant human reproduction doesn’t model.

3) Opportunity cost. A lot of really smart and committed people are working their tails off to get the cost of an IVF cycle (without sequencing, embryo analysis and the requisite genetic counseling down to the mid to low thousands of dollars (regardless of who pays.) if we drive the cost down to $7500 per baby, not per cycle, including the genetic work, the bill (which someone has to pay) approaches a trillion dollars.

I am an amateur bioethicist at best, so I will leave the *many* issues of reproductive justice, fairness, medical overreach and resources being triaged away from medical indications (infertility, recurrent pregnancy loss, onco-fertility, LGBTQ fertility) to consumer discretionary uses to those better trained.

I am no Luddite. I did my first PGD cases (as they were called back then) in the mid 90’s and cofounded (with Santiago Munne and Jacques Cohen, as fine a scientists as our field has ever produced) one of the first reproductive genetics companies, Reprogenetics, later acquired by Cooper. We should be doing a hell of a lot more IVF than we do now, and a lot more disease prevention.

But most of our babies from IVF so that every can pick and choose what seems to be the optimal combination of 10,000 genes based on that particular year’s understanding of genetics?

Ain’t gonna happen.

(To be clear, I’m not calling for a ban and I’m not telling anyone what they should or should not do. Just handicapping what I think is a misguided, albeit fairly common, prediction.)

My first ASRM was in 1988, in San Francisco and while we have learned much and do a better job serving patients every year, there is still much to accomplish.

(Delphine’s gluten detection skills are progressing nicely, thank you)

New to the meeting? Here are some ongoing themes:

1) There is more to reproductive medicine than IVF. Our colleagues are doing great work on non-fertility hormonal disorders, reproductive surgery (I am still in awe of out colleagues who have successfully performed uterine transplants) and menopause care.

2) We don’t talk a lot about our Trans patients, but we should. We are the doctors who see scared and confused seventeen year olds who have never had a period, who present with a parent or parents with an abnormal karyotype. Is there a group of people more unfairly mischaracterized? And is there a professional group better prepared to correct that than reproductive medicine specialists?

3) At a loss for what to talk about? How about “In the future all babies should be born from IVF so we can check their genetics before hand and sex should just be for recreation and mating.” (My take: be cautious when ignoring 15,000 generations of human evolution and assuming we can do better ourselves, armed with a WHS* report.)

4) I’ll be talking a lot about innovation in San Antonio, and it’s important to look at other sectors for perspective. Over our 300,000 years of existence, the last 250 have been a high The early Sunday morning Delta flight from JFK to San Antonio is like and ASRM school bus. So nice to be surrounded by friends and colleagues heading to the American Society for Reproductive Medicine - ASRM yearly meeting.

My first ASRM was in 1988, in San Francisco and while we have learned much and do a better job serving patients every year, there is still much to accomplish.

New to the meeting? Here are some ongoing themes:

1) There is more to reproductive medicine than IVF. Our colleagues are doing great work on non-fertility hormonal disorders, reproductive surgery (I am still in awe of out colleagues who have successfully performed uterine transplants) and menopause care.

2) We don’t talk a lot about our Trans patients, but we should. We are the doctors who see scared and confused seventeen year olds who have never had a period, who present with a parent or parents with an abnormal karyotype. Is there a group of people more unfairly mischaracterized? And is there a professional group better prepared to correct that than reproductive medicine specialists?

3) At a loss for what to talk about? How about “In the future all babies should be born from IVF so we can check their genetics before hand and sex should just be for recreation and mating.” (My take: be cautious when ignoring 15,000 generations of human evolution and assuming we can do better ourselves, armed with a WHS* report.)

4) I’ll be talking a lot about innovation in San Antonio, and it’s important to look at other sectors for perspective. Over our 300,000 years of existence, the last 250 have been a high speed modernization sprint compared to the prior 299,750 years. One example: it takes 1/750th the amount of energy to produce wheat now than it did in 1800.

5) IVF is ~50 years old. Thinking that we have arrived at the best IVF model now would be like assuming that the future of shopping is bigger and bigger malls back in 1990, when the internet was brand new and Amazon referred to a river in South America. What happened 50 years after DNA was discovered? We sequenced the human genome and out the DNA to work. Fifty years after the Wright brothers? The first commercial jets were still toddlers.

*whole genome sequencing

Hope to see you in San Antonio. And yes we will be making comparisons between artificial intelligence and training a service dog.

Think of her as a walking, tail-wagging, joy bringing, seizure-preventing example of automation and quasi-artificial intelligence. Delphine will be making her debut at ASRM in San Antonio next week.

Not in person, alas.

But she will be assisting me in silico during the ASRM Innovate forum, and might make an appearance during the one hour MBA.

Topic 2: IVF policy.

I put on my politician for a day hat (don’t even try to characterize my politics — I can upset anyone, regardless of where they reside on the political spectrum) and offer the following business-friendly, small government suggestions for improving IVF access:

1) using the existing interstate commerce act, guarantee patients the right to move embryos created in any state to any other state, no questions asked. This prevents states from limiting their citizens’ access to best practices IVF, and costs tax payers nothing.

2) knowing that IVF data still has a little ways to go before it can be considered actuarial, and therefore can be the basis for professional underwriters to confidently underwrite the risk if negative cycles (ie you pay for having a baby, not for the chance to have a baby), offer tax incentives to the underwriters to tip that developing IVF underwriting towards profitability.

3) given the importance of reliable data, reinstate the six person CDC IVF statistics staff! (I know I’ve mentioned this before, but it bears repeating.)

See you in San Antonio!

Since fertility invariably declines with time, many of our patients prefer the practical decision to use the most aggressive treatment first -- one that is also the most diagnostically comprehensive, and the only way we can make time stand still through cryopreserved eggs and embryos.

Not all patients have these priorities; perhaps REI's see a biased sample of self-selected patients for whom having a first baby quickly, while also maximizing the likelihood of future siblings, is the primary goal.

Of course we all need to listen to our patients when they tell us exactly what problem they want us to solve, and the order in which we triage our efforts when they present with more than one problem.

I did my first preimplantation genetic diagnosis case for an aneuploidy in 1995. I did my first cystic fibrosis prevention case shortly thereafter, and was part of the initial case series reported for translocation testing in the late 1990s and early 2000s. Suffice it to say, I am a card-carrying member of team, genetic disease prevention using preimplantation genetic testing, or PGT.

Fast-forward to now. We do aneuploidy testing in about half the IVF cycles in the United States, and while there were still controversies regarding the overall benefits from one program to another, PGT has become part of mainstream IVF infertility.

Alongside this, sequencing technology has advanced rapidly. We sequence tumors as a matter of routine, and we use sequencing as a means to diagnose, obscure unidentifiable syndromes from pediatrics through geriatrics.

The laws of physics, biology, and economics all point to a scenario where we expand the use of genetic testing in vitro fertilization laboratories beyond what we've done for the past three decades: screen out aneuploid embryos to improve implantation rates, preferentially select euploid embryos to address habitual miscarriage, select embryos that do not carry disease-causing mutations, and identify structural rearrangements that are incompatible with term pregnancy.

In each of these cases, the data is pretty clear, and the math is straightforward. For a given genetics report, the patient or a couple sitting across the desk from me and I can have a very clear conversation about the benefits of adding a genetic test to their in vitro fertilization cycle.

But I'm a little concerned about where we are going from here.

Should we be doing IVF for the sole purpose of choosing "optimal" embryos in couples that are not at increased risk for genetic disease, and not suffering from infertility?

Secondly, for the couples who do come to us for infertility, should we, using "we might as well while we're in there" justification, apply whole genome sequencing to the embryos that we create to treat infertility in order to go beyond infertility treatment and rank them either by some complex scale of future disease risk, or, in order to choose traits that are considered desirable: IQ, athletic ability, musical ability, height, weight, hair color, eye color?

One of the big challenges we face in the coming decade in reproductive medicine is to constantly ask ourselves: What problem are we solving?

I have no desire to be the genetic testing czar for the infertility industry, and I think every IVF program and every patient needs to make decisions for themselves that are well informed.

What I do hope is that we avoid thinking that the most advanced genetic testing is an inevitable and necessarily good thing for the vast majority of people to come to us to solve the more straightforward problem of infertility.

What's the harm? Isn't all more information always better?

The harm?

The harm is that we end up choosing embryos to give us a lesser probability of having a baby then we would have had we not done the testing.

The harm is that we use the limited resources that the couple or individual has to start a family, that could be used for a second cycle for example, for something that may not be a priority.

Isn't more information always better?

It depends on the quality of the information.

Much of the disease risk stratification that is being extrapolated is based on small numbers, in some cases based on twin studies, and it’s a mixed bag of risk: diseases with known genetic causes, and others with a mixture of genetic and environmental causes, and some that are poorly characterized syndromes that are based on symptoms and not on molecular mechanisms.

I don't want to be a Luddite, but I don't think the data is good enough in an unenriched population (in other words, people with a very high risk of a false positive reading) to make this a standard of care.

As the sophistication of the testing improves and the size of the data set that we have information to draw from increases, this may change.

For now, we need to be careful not to let our understandable excitement over how medicine, healthcare, engineering, and science can intersect and what we should be recommending to our patients now.

So if my credentials for Team Disease Prevention using IVF are a little tarnished now, so be it; let's not lose sight of the problem that our patients ask us to solve by using their time, energy, and resources to address something that was not a concern of theirs in the first place.

Let's talk about restorative reproductive medicine.

First thing, could somebody tell me what the hell it is?

Is it: 1) good old-fashioned painstaking, step-by-step, thorough diagnostic, blocking and tackling, treat the underlying factors and wait for a good result?

Or is it: 2) fertility care, doing everything we can to avoid doing an IVF cycle?

Well, as a reproductive endocrinologist wanting to have,

wanting to solve the problem of people that can't have a baby, you wanna get them pregnant quickly and you wanna give them answers if you can.

Unfortunately, true today as it was when I started practicing years ago, we are much better at giving results now than we are at giving answers.

Here’s my recipe for Restorative Reproductive Medicine.

I first met Joshua in 2018, when he and his partner, Alan Murray, called to ask my opinion about a startup idea: to apply advanced robotics to cryo-storage for IVF oocytes and embryos. It was a timely idea, catalyzed by a friend’s unfortunate experience having lost cryopreserved oocytes, relying on the traditional manual process, one that the rapid acceleration of egg freezing had made obsolete. New to the field, Joshua was a quick study. He and Alan tackled cryo-storage, then tackled automation for the rest of the embryology laboratory.

A gifted speaker and storyteller, Joshua was also one of the best listeners I've ever encountered, catching detail and nuance, later to return my ideas to me, polished and improved.

There will be many stories traded amongst his friends, colleagues and family, but I can only speak for my own experience: from the time I met Joshua, there was a gravitational pull towards exchanging ideas with him, looking with him into the future, and, above all, feeling privileged to have him as a friend.

A big part of what I’ll miss are the first meetings with new founders, those brave and brilliant souls committed to making the IVF world a better place. I’ve had hundreds of these meeting, and they are the fresh air, pure water and dark espresso of the world of entrepreneurship.

If done right.

So to make myself feel less irrelevant on this New York City morning, I’m passing along a few tips on getting this right.

1) I want to hear your words. Clichés belong to others. Please please expunge phrase like “out of the box” from your pitch. Similarly, not everything is “game-changing” and almost nothing is “revolutionary.” Tell me what you do that’s different and potentially better and then let’s walk through whether and how it’s a good, or maybe great, business.

2) Show me your commitment, passion and enthusiasm without being promotional. What is promotional? It is when you pass everything you say through “what does he want to hear?” Try not to retrofit your business plan into “he likes hardware so how do I pitch my digital health business in a way that will make him care?” Let me decide whether I am a fit by hearing your best story, not some watered-down version of it.

3) You don’t need a script, but it helps to have structure. The approach I find most helpful is to lead with the problem you are solving (the specific problem, not “IVF needs to be more accessible”). When we agree on that, we’re on the same team — finding a way to best work together. Paint a picture for the people you are helping — at the moment they are being helped. (My fellow Aristotle fans recognize the adding pathos to the ethos of defining the problem.)

4) Once we are fellow members of Team Let’s Solve The Problem Together — then hit me with your idea. Time for Aristotle’s logos. What specifically - concretely and quantitatively — are you producing. This is the time when you win the next meeting and the ongoing relationship. AND THIS IS WHEN I AM MOST ASSESSING YOU. Make me a partner by being extremely specific in your language — expect me to ask “what do you mean by (insert somewhat vague and nonspecific term)” and to be aggressive asking you to define and redefine your terminology. (Don’t roll your eyes when I ask “what do YOU mean by artificial intelligence.” The term has far too many meanings. Don’t assume I will insert the one that correctly clarifies your business plan.)

5) Most important — KNOW YOUR NUMBERS. Be prepared to provide (and be able to discuss the substance of) the source for any number in your presentation. Even better — be prepared to derive it. A good answer to “where did that number come from” can be the start of a long relationship. (Needless to say, if I think you’re making the number up or pulling it out of this air the meeting will pretty quickly.)

Enjoy Paris and enjoy ESHRE!

1. Expand the Department of Defense and VA fertility coverage to include IVF. Currently it doesn’t.

2. Fund the approved but un-funded REI fellowship programs that currently are not accepting fellows. (investigating this now.)

3. Initiate and fund two pilot programs: one exclusively dedicated to providing IVF for the prevention of monogenic disease, and one dedicated solely to fertility preservation for young men and women undergoing fertility-depleting treatment for cancer or other diseases.

4. Mandate that the movement of embryos across state lines cannot be limited by state law.

5. Provide a priority review incentive voucher at the FDA for gene therapy treatments for monogenic diseases that can be prevented using IVF with PGT-M. Companies will qualify if they establish a mechanism to fund egg freezing for affected couples in order to prevent the disease that the gene therapy treats. Gene therapies costs can cost millions of dollars per patient. Setting aside $25,000 for disease prevention is a rational public health investment. Vouchers for a similar program for pediatric rare diseases have been valued at over $100 million dollars.

6. Reinstate the small CDC division that collected and published IVF outcome data. You can’t scale without data.

Open to other approaches. Let’s start moving forward.

And if you needed help starting a family, whether finding someone in your area code to talk through the stress of treatment, or finding that you have more insurance coverage than you thought you did because you live in one of the states that passed fertility insurance mandates under Barb’s watch as CEO and President of RESOLVE: the National Infertility Association, or because everyone from SART, the CDC, US Fertility, Serono, Ferring, Cornell and RMA answered Barb on the first ring and jotted down what she said because it always mattered, or because she coordinated swat teams that parachuted into state capitals to walk state senators through the realities of how possibly well-intended but ultimately harmful statutes affected their own neighbors and constituents, or because of the respect she commanded in Washington when face-to-face, I’m ok you’re ok, she reminded congressmen and women, senators, and presidents just how important, life-affirming, patriotic and party-affiliation agnostic support for sons and daughters can be.

When Barb assumed responsibility for RESOLVE, George W. Bush’s President’s Council on Bioethics, dubbed “all embryos all the time” by Leon Kass, the council’s first chairman, was still in place. Egg freezing was still considered experimental. IVF clinics in the United States were owned by doctors and hospitals. RESOLVE was the voice of the infertility community during these transitions. States would not enforce gestational carrier agreements and permitted discrimination against gay parents-to-be. RESOLVE fought all of these fights, often turning adversaries into allies — all a testament to its leadership.

And that leadership was Barb Collura.

I was privileged to serve on RESOLVE’s board of directors during Barb’s tenure, and learned up close the Collura leadership lessons, and I’m a better doctor, teacher, investor and manager because of it. I treasure our yearly Tuesday morning breakfast at ASRM.

Barb Collura will soon be passing the leadership of RESOLVE to a new generation. If the world is wise, it will tap into her knowledge and energy and savvy and ability to cut through BS and get things done and (sorry Barb) take advantage of her inability to say no to anything that helps someone else. It will reserve board seats, pencil “BC” for the keynote, make her first call for the op-ed. There will be portraits, a stature somewhere, certainly awards in her name, maybe a Kennedy Center honor.

But ultimately Barb Collura’s legacy will be the many children of future generations whose parents were nudged over the finish line into parenthood in no small part because of her decades of work and fearless leadership helping her neighbors, colleagues, friends and fellow citizens created families.

Thanks Barb! See you in San Antonio. Breakfast is on me.

(no paywall, registration is not required)

When you perform a vaginal delivery , there is a very brief moment, right after the baby’s head emerges, where you and the baby are the only people in the world.

It lasts only a second or so, and when you do your job correctly you make note of it for less time than that. As an obstetrician, you make yourself invisible. You quietly prevent tears and lacerations, react to early signs of hemorrhage, clear the baby’s airway, ensure safe passage of brand new arms and collar bones, and prepare for the separation of the placenta.

You leave profound contemplation to someone else. You collect the cord blood and move on.

Except that’s not really true.

I used to silently whisper “welcome to the world little one” behind my mask, just after the baby’s forehead and eyes emerged. Whether the next minutes progressed to serene bonding of parents and child, or to the havoc of immediate postpartum emergency, there was always time to greet the baby, and hold open the door to the world.

I performed my first delivery as a second year medical student. Fourteen years would pass before I became a parent myself, almost a decade and a half during which I evaluated and treated people for whom either getting pregnant or being pregnant or staying pregnant was the most important part of their lives.

Textbooks and teachers, and the patients themselves sometimes, trained my fingertips to suspect a high risk for a precipitous delivery hours later, on the basis of a single internal exam, and kept my voice soft and heart rate steady when encountering a prolapsed umbilical cord, whose management meant that I had to hop onto the gurney with the patient, hand frozen mid vaginal exam in order to keep the baby’s head from descending and choking off its own blood supply while the two (three?) of us were wheeled into the operating room for an emergent cesarean. But I brought no insights about what would happen in the years and decades after I went off to wash my hands and write the post delivery orders.

Nothing during those fourteen years prepared me for the journey from the foot of table to the Dad-to-be spot at the head of table, from the fleeting irrelevance of an anonymous greeting while holding open the door to the world, to the enormity of the “we’ll take it from here” that Priya and I thought to ourselves as the rest of the room faded away.

I delivered babies for nine years, and stopped long before Nikhil and Tarana were born. I never carried the experience or nascent wisdom of fatherhood into the delivery room. Maybe that was a good thing, making it easier to focus on the purely technical aspects of fetal monitoring dynamics and the subtleties of arrests of descent through the birth canal. If circumstances take me back to the foot of the table I will need to relearn those skills.

It took me fourteen years to get from “welcome to the world little one” to “we’ll take it from here.” Many of the little ones who I welcomed to the world years ago are now parents themselves. Maybe some of them may deliver babies.

I was an obstetrician once.