Ep 163: Mosaic Embryo Transfers and the Future of Fertility with Dr. Phillip Romanski
Fertility Forward Episode 163:
How can data enable doctors to best support their patients? Reproductive endocrinologist and associate research director Dr. Phillip Romanski joins us in conversation to discuss the annual Pacific Coast Reproductive Society Conference (PCRS), everything he learned, and what he spoke about. Tune in to hear Dr. Romanski’s perspective on mosaic embryo transfers before we dive into the complex world of segmental mosaic embryos and fully segmental aneuploid embryos. We discuss Preimplantation Genetic Testing, how to personalize care on an ongoing basis, and how in vitro maturation and in vitro gametogenesis will shape the future of fertility. Join us today to hear all about the topics covered at this year’s conference, the developments RMA doctors are focused on today, and more. Thanks for listening.
Rena: Hi everyone. We are Rena and Dara and welcome to Fertility Forward. 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 Forward 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.
Dara: Today on our podcast we have one of our fellow reproductive endocrinologists, Dr. Romanski, who is also an Associate Research Director at US Fertility, and he's here today to speak about the annual conference, the PCRS, the Pacific Coast Reproductive Society Conference, and what he learned and what he spoke about. So we're really happy to have you on today. Thank you so much.
Dr. Romanski: Thank you for having me. I'm really excited to be here.
Rena: Yes, dope to have you on! Tell us what you learned, what you saw. Tell us everything from the West Coast.
Dr. Romanski: Yes, absolutely. So, yeah, I just got back from PCRS, which is one of our large sort of national society meetings, and that's held in in March every year. You know, if you've heard of ASRM before, this is another society similar to that that really serves the larger reproductive health community. The society is made up not only of a lot of physicians, but also, you know, there's a lot, always a lot of attendance from genetic counselors and embryologists and lots of fellows and residents. And so there's a whole large multidisciplinary team that's involved in this society, which I, I think is one of the things that makes it really exciting because the conversations, you know, are always very enlightening. There's always different viewpoints from, from different folks around the country and so it is always a really educational conference. So it's one of the ones that I like to attend each year. It's an opportunity, you know, that we have, you know, in addition to listening to some of the different, you know, conference lectures, but we also are able to attend and present a lot of the research that we're currently working on as a practice and as a large fertility network. And so it's, it's one of the opportunities where we get to get out there and show everybody, you know, what we're doing and what we think is really exciting and how we're trying to help change the field.
Rena: Amazing. So tell us maybe some of the top most exciting things both that you saw and then also that we're working on in-house here.
Dr. Romanski: Yeah, so the conference itself has quite a lot of variety in the different topics that were discussed. There was one particular talk by Dr. Andrea Besser regarding, you know, the utility of mosaic and segmental abnormalities with PGT tested embryos. And this is a, a topic of conversation that has been at the forefront of our field now for the last five to 10 years. As we see, you know, more and more embryos are PGT tested. A lot of times we get results back that are pretty clear on how to proceed, but sometimes we get these results that are sort of in a gray area. That's these mosaic embryos or more recently the conversation about segmental embryos where a portion of the chromosome may or may not be abnormal. And so this was a really interesting update from Dr. Besser who, you know, reported on the outcomes that we have thus far regarding embryo transfers with these types of results. And so we're all very eager to see whether these embryos certainly can yield, you know, successful pregnancies, whether these are potentially usable embryos. We've known now for the last few years at least, that we do see healthy embryos, healthy pregnancies that are born from mosaic embryo transfers and, and certainly always a complex conversation. And so she spoke about, you know, similar to what we do here at RMA when we have patients that have this type of result. You know, this is a longer conversation with the physician, with the genetic counselor, you know, to talk about the likelihood of success with these embryos and, and also the potential risks with them. But you know, now we have more and more data that helps us to understand, I should say, more specific outcomes regarding the type of the abnormality or, or how significant it is, what the chance of live birth is with that embryo. So that was a really cool update. And then she presented some newer data regarding transfer outcomes of segmental mosaic embryos or, or fully segmental aneuploid embryos. And this is something that I would say is a little bit newer, even the transfer of, of some of these embryos that previously were not considered usable or, or not transferable. And they've seen that even with some of these embryos, that there are some healthy live births that come from them. So one thing we certainly have learned is that with the PGT testing, while you know, it certainly very much helps us to select embryos and helps us to improve patient outcomes, it's certainly not a perfect test, just like any test that is out there. And we have to be very thoughtful with how we interpret these results, how we counsel patients, and then how we handle these embryos. So I thought that that was a really, really useful and interesting conversation.
Rena: That's fascinating.
Dara: t gives some reassurance I would think, to people who may not get the results that they were hoping to receive, that there is still some hope and some potentially positive outcomes even with that.
Dr. Romanski: Yeah, I think it really does. I mean, any data that we have that potentially increases the usable embryo cohort that somebody has is ultimately what is going to improve their chance of being successful. And so it's very reassuring to see. Absolutely. You know, sort of in line with that conversation, there was a lively debate just about the utility of PGT, whether patients, you know, should be using that to screen their embryos or should not be using that, you know, some of the pitfalls. And that was a debate, which was actually a repeat from Dr. Paulson and Dr. Scott who had this debate some 10 years ago. So they came back now with the advances that have occurred over that period of time and sort of rehashed it out, which was very interesting to hear both sides of it. And they brought up a lot of the same points that Dr. Besser did. That again, no test is clear black and white, that there's always a gray area and it is just important that patients understand what those nuances are and what the potential outcomes are when they're deciding to utilize PGT to help screen their embryos.
Dara: That's great. And so on the RMA front, I am interested in hearing what we presented.
Dr. Romanski: Yeah, absolutely. So we had a large contingent from our group that went this year and, and from our larger US Fertility network. So that was really, really exciting to see. And of all of the different research presentations, you know, over 10% of them came out of our network, which was really impressive. What we've seen in some of the powerful data that we have, you know, just based on the number of patients, you know, that we've been fortunate enough to care for is that we've got, you know, a lot of data over the last decade or two just looking at overall outcomes among patients, how different interventions might impact the patient's outcomes positively or or negatively. But we're getting to the point in our field now where we have enough data that we can start to ask more patients specific questions or more granular questions that really help us to further individualize a patient's care rather than saying to a patient, you know, you're 35 years old and this is your ovarian reserve. So this is sort of the general treatment approach that we'll begin with. We can now look at more specific things in that patient's, you know, reproductive history or their family building desires to help tailor their treatment a little more specifically. And so some of the research that we presented, you know, that sort of gets to that point. There was one study that we presented that where we looked at different types of sperm and success rates of creating embryos with where that sperm came from. So most data is using sort of conventional insemination or ICSI, sperm that comes from the, but there's cohort of patients with really low sperm counts or maybe they've had a history of a vasectomy where the sperm has to be surgically retrieved. And just historically it's sometimes felt that if the sperm is being surgically retrieved, perhaps it, it's not as competent as sperm in the and perhaps it doesn't fertilize well or create embryos so well. But in this study what we observed was that there was a very good fertilization, very good ability to create an embryo using this surgically retrieved sperm, which again is just very reassuring for patients and, and definitely helps, you know, when we're counseling patients regarding what their likely success rates could be, what expected outcomes they might have, I find this data to be really useful 'cause previously this was an area that was really under explored and we had to sort of extrapolate a lot more than we do now with this new data. So I think this is really useful, especially when having conversations with our male infertility patients. Another study that we were able to get a little more granular with now was looking at patients who came to freeze eggs with us and then later came back to utilize those eggs to thaw them. We're usually counseling patients on what the general outcomes are for using those eggs in the future, depending on the age at which they freeze them. Because for quite some time there wasn't a ton of long-term data looking at egg thaw outcomes because number one, you know, only the quality technology that we have to freeze eggs hasn't been around all that long. And, and then of course it takes some years for patients to come back and decide to use those eggs. But we counsel patients that when we thaw those eggs, the chance of survival is on average about 85% somewhere in that range. And, but what we don't know is that does that risk change for patients when they're coming to freeze the eggs? Is it possible that somebody that's freezing their eggs at a little bit of an older age, maybe in their late thirties, early forties, perhaps those eggs are a little more fragile, maybe they don't go through the freeze and thaw process so easily. And if that's the case, that's really important information because then we might counsel those patients on the need to try to freeze even more eggs so that they don't come back to use them and then now have very healthy few eggs remaining. So we were able to stratify these patients who thaw their eggs based on, you know, their age into many different age categories and ultimately saw that the survival rates were, were very stable even for patients in their forties. And again, this was reassuring because we can, you know, more confidently counsel patients on what their fall survival rates would expect to be, you know, on average. And also means that patients can feel confident in the treatment that they've done and what their success rates should be if they need to use those eggs in the future. So all of that was, I felt really useful. And again an area that had been under explored and, and a gap in the field that now we can better counsel the patients.
Dara: I love the follow up. I think that's so important is, you know, you go in with good intentions with the hope, but if we don't necessarily understand what can potentially happen, I mean this is, it's great to see that follow-up and not only to see the follow-up, to see the follow-up be much more successful than perhaps anticipated. I'm sure they’re people wanna have that success, but to actually have the data now to show that it isn't something that people need to be as worried as perhaps they may have been, it's great.
Dr. Romanski: Yeah, definitely. I mean, when there's an absence of data, we always wanna be conservative. Yeah. And we always talk to patients sort of about the range of possible outcomes and you know, being conservative, we always lean towards the side of perhaps this won't be as successful as we just don't know until we actually go through with the treatment. And so a lot of the times we now are able to do the research and really be able to better describe what the true outcomes are and, and oftentimes we are ultimately reassured that okay, things really are as good as we thought they might be or as kind of that initial data had suggested. And so it's always really great to see when we get these outcomes that are really reassuring.
Rena: Yeah, I think what you said that you're, this is gonna allow you to look at patients much more individually, which I know will be so appreciated. And I know sometimes that's a big part of the struggle is patients feeling sort of just like they're under an umbrella and not seen and heard. And so this is fantastic news I think across the board.
Dr. Romanski: Yeah, completely. And as you said, I think that it's easy to feel that way a little bit when somebody's going through fertility evaluation or for fertility treatment because of the nature of it. You know, we have many things that we can evaluate, but so much we learn along the way. And so sometimes, you know, we don't learn that somebody has, you know, unexpected poor egg quality until we've actually retrieved the eggs and, and looked at them under the microscope. And, and so, you know, certainly we're always learning in real time and often making these day by day small nuanced decisions always with the goal of optimizing the patient's outcomes as much as, as we possibly can. But the more data we can get upfront that specific an individual to a patient and their history, the better their experience will be and the better their treatment outcomes will be.
Rena: For sure. Anything you've heard about that might be coming up in the next year for people to look forward to?
Dr. Romanski: Well, I don't know about the next year, but maybe at some point we'll be hearing a little bit more about number one, in vitro maturation, or number two, in vitro gametogenesis. There were actually a couple of presentations this year on in vitro gametogenesis, which is essentially, you know, the process of taking cells and creating stem cells and then reproducing a gamete, you know, being able to produce an egg or a sperm from that. You know, at this point, this is one of the major limitations in our field. You know, once somebody has, has run out of eggs, we know the ovary doesn't produce new eggs. You know, we don't have any good treatments to improve egg quality or egg quantity. And that's kind of the whole point of fertility preservation and egg freezing in the first place, is to try to get ahead of, of any of those declines that occur as age increases. And so there's lots of exciting research being done right now in basic science labs to be able to take a cheek swab or a blood sample from somebody to then, you know, produce stem cells and be able to produce an egg that could be fertilizer, produce a sperm that could be used to fertilize an egg and then create a healthy embryo. There's still some things to work out with the science there. And even more importantly, you know, from the regulation standpoint, when reproduction gets so simple and so easy, then we have to be very careful about how that's controlled and who has the ability to do that. And those are really a lot of the major regulatory concerns regarding, you know, that type of reproduction. But it's really fascinating science and, and it's incredible to see, you know, the ad advancements that have been made in that particular area of, of reproductive medicine. And at the very least, it certainly allows us to have a much, much better understanding of early embryology and early cyte development, early sperm development, early embryo development. 'cause By being able to create these things rather than using the very limited pool of eggs that we, you know, have from a patient or an animal model, we can explore things in a much more in-depth way. That's really fascinating.
Dara: Yeah, I was gonna say, there's, I'm sure a lot of ethical considerations with that and it seems like it's probably not gonna happen overnight. I would assume it, it's probably something far off, but the fact that it's even being brought to our attention of the potential possibility is exciting.
Dr. Romanski: Yeah, I would agree that that's not something that's gonna be in the clinic anytime soon, but certainly we are going to continue to learn a lot from that research and it'll be interesting to see how that develops.
Rena: Yeah, and I think a great takeaway for people is that things are changing so much and to have hope. You know, I know both Dara and I have been in the field for a long time and it's pretty incredible to think how much things have changed since I started here and you know, there's so many advancements happening all the time.
Dr. Romanski: Absolutely. Yeah, absolutely. I mean, when you look at our field and compare it to other areas of medicine, it's still such a relatively young field. And as you said, you know, we're, we're constantly learning. We're constantly improving and doing everything we can to help patients be successful.
Rena: Well, we're so grateful to have you and our wonderful team at RMA and USF working for our patients and pushing ahead to improve care.
Dr. Romanski: Thank you. Thank you again for having me. It was really fun getting to talk to you all and, and see you again. And thanks to everybody for listening.
Rena: Thank you. The way we like to end our podcast is by a statement of gratitude, so something that you are grateful for today.
Dr. Romanski: Oh, that's amazing. Today I am really grateful for my team here at RMA, which it's been just like any day I couldn't do anything that I do without the full support of my team, you know, my nurse coordinator, financial, but then the entire system that we have here, all of our clinical assistants, embryologists. I mean, it's just amazing to see them all work, you know, together in concert to help our, our patients. And it's been a day where I very much have appreciated having, you know, such a, a great team atmosphere. That is my gratitude today and every day.
Rena: That's beautiful!
Dara: So nice.
Rena: Yeah. What about you?
Dara: I typically speak about, piggyback on, on what everyone else says, but today is my 19th anniversary with my husband, so I am very grateful for my husband and how much we compliment each other and how he's such a great support in my life. So yeah, I'm very reflective today.
Rena: Oh, that's so beautiful. And happy anniversary.
Dara: Thank you. I appreciate that. What about you, Rena?
Rena: I'll say, I guess sort of a combination of the two, but I'm super grateful just for human connection, so teamwork and just human relationships and being able to cultivate those and just have those in my life.
Dara: That's beautiful.
Dr. Romanski: Perfect. I love that.
Rena: Well, thank you so much everyone for listening, and thanks so much for coming on Dr. Romanski. It's been a pleasure.
Dr. Romanski: Thank you guys. Take care.
Dara: 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 @fertility_forward and if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.