In this episode of the Egg Whisperer Show, I’m joined by Dr. Steven Palter, founder and medical director of Gold Coast IVF, to explore what happens when fertility care goes beyond quick fixes and becomes true detective work.
Dr. Palter is internationally recognized for his innovative Palter Fertility Method – a systematic, personalized approach that treats infertility as a multilevel disease rather than a one-size-fits-all diagnosis. We discuss how metabolic health, emerging technologies, and surgical precision are transforming outcomes for patients who’ve been told they’re out of options.
Throughout our conversation, Dr. Palter shares how he’s revolutionizing PCOS treatment by addressing insulin resistance through dietary intervention, continuous glucose monitoring, and metabolic coaching: helping women who haven’t ovulated in years achieve spontaneous pregnancies.
We also dive into promising technologies like PGT-P (polygenic risk screening for complex diseases) and rapamycin therapy for improving egg quality in older patients. This is an episode about hope, innovation, and refusing to accept “unexplained” as an answer.
In this episode, we cover:
- The Palter Fertility Method: diagnostic deep dives, success maps, and the “success spiral” approach to personalized fertility care
- How insulin resistance drives PCOS and why treating it like “diabetes of the ovary” can reverse infertility
- The PCOS to Pregnancy Protocol: using continuous glucose monitors, metabolic coaching, and low-carb interventions to restore ovulation
- PGT-P (preimplantation genetic testing for polygenic conditions): what it is, how it works, and the ethics of screening embryos for complex diseases like autism, Alzheimer’s, and diabetes
- Rapamycin therapy for egg quality: the science behind this longevity drug and why it’s showing remarkable results in women over 40
- Advanced imaging and surgical techniques that uncover hidden causes of infertility like endometriosis, fibroids, and uterine abnormalities
- The importance of resistance training, zone-two exercise, and metabolic health for fertility and longevity
Resources:
- Gold Coast IVF: https://www.goldcoastivf.com
- PCOS to Pregnancy Protocol: https://www.pcosbaby.com
- Dr. Steven Palter on Instagram/TikTok/Facebook: @stevenpaltermd
- Dr. Aimee’s website: https://www.draimee.org/
Full Transcript:
Dr. Aimee: If you’ve ever felt like your fertility journey raised more questions than answers, today’s episode is for you. The title of this week’s episode is Beyond IVF: PCOS, PGT-P, Rapamycin, and the Palter Fertility Method with Dr. Steven Palter.
Today, we’re talking about what happens when fertility care goes beyond quick fixes and becomes true detective work, including how metabolic health, emerging technologies, and personalized diagnosis fits into modern fertility care. I’m honored to welcome today’s guest, the founder, medical and scientific director of Gold Coast IVF in Woodbury, NY. He is internationally recognized as a leader in fertility treatment, advanced endoscopy, and surgical innovation. His work focuses on uncovering root causes of infertility through what he calls the Palter Fertility Method, a systematic, personalized approach to diagnosis and care, including metabolic health, surgical precision, and emerging reproductive technologies. Welcome, Steven.
Dr. Steven Palter: Thank you so much for having me here. It is a pleasure to connect, finally, with you on video. It’s just so exciting to come chat with you.
Dr. Aimee: Thank you for being here. You’ve had such a long and influential career in reproductive medicine. I think a lot of patients listen to what you say and take it to heart, they take it back to their doctors and it informs their care. You’re doing amazing things. What first drew you to fertility care and what made you commit so deeply to solving complex infertility cases?
Dr. Steven Palter: From when I was a little kid, I knew that I wanted to be a doctor. Probably when I was in fourth grade, I was obsessed with biology. Seeing people that were sick and how a doctor could heal them, that was just transformative to me. The idea of understanding how the body worked and then figuring out a problem and fixing it is what I was driven by back then and what has become a foundation of how I practice now.
I had this path charted where I was going to go to medical school, and I thought I was going to become some sort of endocrinologist neuroscientist. My father was a psychologist, and I was fascinated about how the mind worked and about hormones, and that there was this thing in your body that could affect your behavior. I went there right out of high school, two years, finished college and was in med school, and I said I’m going to become this endocrine neurologist.
I started doing research and working with the endocrinologists, and I saw what they were managing was chronic disease, and doing it poorly. They had diabetes and thyroid, and they were frustrated saying, “No one listens to us. We can’t fix anything. It’s just really fascinating biology, but people don’t get better.”
Then one day, I walk into an operation and they’re doing a laser laparoscopy and removing endometriosis. They’re like, “We’re going to get this woman pregnant and she’s going to be able to have a child.” I was like, “What kind of magic is this? I love hormones and fixing biology.” They were like, this is where that happens. So, I went back to my mentors and said, “I think I want to become a gynecologist.” They were like, everything that you want to do to help people change their life and work with patients that are motivated, that will do anything to see the miracle of life, to understand psychology, anatomy, and physiology, and solve problems and create the miracle of life, you should be a reproductive endocrinologist, not a medical endocrinologist.
From that day forward, I started running seminars. I was a med student and I found a guide, and I called every reproductive endocrinologist in Boston because I wanted to meet them all. I started doing seminars. That sort of led to this path that never changed.
Dr. Aimee: I love that story. It’s similar to mine. Funny thing… My father was an OBGYN, and he used to say that he was really a “gynechiatrist,” because so much of what we do has to do with psychology.
You often describe infertility as a multilevel disease rather than a single diagnosis. How does that perspective change and shape the way that you practice medicine today?
Dr. Steven Palter: I do a lot of teaching online on social media, both for doctors and patients. One of the things that I always say is, if everyone in the waiting room next to you has the same diagnosis and the exact same protocol and the exact same treatment, something is getting missed.
We have this really complex biology here, and it’s usually multifactorial. You know this, but a lot of patients get confused. They think, “Am I fertile or infertile?” They just want to know if they can get pregnant. We think more of fertility as you have your maximal fertility down to zero. What we treat, often, is subfertility where it’s going to take years and years without help. If you look deep enough, a lot of things that are called unexplained actually have diagnoses and a lot of things that are diagnosed have multiple causes, but you don’t stop looking when you find the first one.
Dr. Aimee: Unexplained is one of the most frustrating diagnoses that I see when a patient comes in with that, because I know that there’s no such thing. There’s always an explanation.
You created the Palter Fertility Method. Tell us more about that, how that solves for gaps in traditional fertility care, and what made this approach necessary.
Dr. Steven Palter: After I did my fellowship at Yale, I stayed there as the clinical chief of infertility. I had a department with a lot of basic scientists, we did great work, but I was the clinical problem solver. I would look at everyone’s cases and try to figure out what could be missed. My obsession in life is understanding how things work and fixing problems. That led to me developing this system that I would teach to doctors and I’d teach patients online. It’s a root cause analysis, but never assume that you’re finished. It’s a constant iterative mechanism to reassess and go to improve what you’re doing.
When people get jaded, doctors will say, “I’ve seen it all. I can tell within five minutes of the patient walking in what is wrong.” What we learned, when you get experiences, the more you learn, the more questions you ask. What if? Why? When something goes wrong, I always say it’s never unexplained and it’s never just bad luck, there’s always a root cause. But can we find it?
The Palter Fertility Method started with getting what we call the diagnostic deep dive. You don’t stop at the first or easiest diagnosis. It’s what is the entire spectrum of diagnoses that could be made. You don’t take any bit of information for granted. Very often, patients will say, “I’ve had that test, and it was normal.” You go back and you look at the records, and you realize that it was never done or it was misinterpreted. The x-ray that was normal, when you look at the films and you see it’s not normal.
You start with this diagnostic deep dive that includes part of the frustration of people we have in our field, the patients, is years and years of trying and failure, and they think, “I’m just going to fail again.” What I say to them is let’s flip that script. Everything that hasn’t worked is the raw material for us to do detective work and figure out what needs to be changed. If you’ve done ten cycles, let’s go through all ten of them and say, “Were they ideal? What did we learn from them? What’s the diagnosis that you didn’t have? What has changed?” Maybe you had PCOS 20 years ago, but now you have low egg reserve because you’re 45. That’s the diagnostic deep dive.
Then we make what we call a success map, because everyone’s path really is different. The goals that patients have of how many children they want and how quickly they want to get pregnant, and what other health issues have to be optimized are totally individualized.
I think the most key part is what I call a success spiral. In each iteration, each treatment, you’re constantly every day while the patient is doing monitoring or testing, I’m looking at the results and saying, “What did I learn new that I didn’t know? What can I modify? Where could I have missed something that we now know?” Either you hit it because you’ve been so thorough upfront, you’re not taking the middle of the road easy approach, you’ve done all of your diagnostics, you do the best treatment, you get it right, and if not, we regroup and say, “Now what did we learn how to differently?” It’s this spiral to success, all based on learning what’s truly happening.
Dr. Aimee: Patients have to go with the flow and take each experience as a learning experience, even if it doesn’t work.
Dr. Steven Palter: Yes. There’s classic work about mindset. The fixed mindset is you got a good hand or a bad hand, and anything that’s hard work is tiring and anything that doesn’t work is proof of failure. A growth mindset says everything is a learning experience and an opportunity for growth. Every obstacle you have is the key to your success, if you analyze it.
Dr. Aimee: I frame it in a very similar way. I say things like this didn’t work, and we had to have this experience because we’re going to eventually get to what will work because of what we learned from this cycle.
Dr. Steven Palter: Yes. I get hundreds and sometimes thousands of messages a day on social media, and I get so frustrated when people say, “They just said it’s bad luck. Let’s do the same thing again. We’ll do X three times, Y three times, and then when that fails, we’ll regroup and figure out what’s missed.” The answer is there. We may not always find it, but if you don’t ask the question, you’ll surely never find it.
Dr. Aimee: Right. Asking the “why” is so important. I want to talk a little bit more about PCOS. You’ve done extensive work addressing PCOS through a metabolic lens. Can you explain how insulin resistance and metabolic dysfunction impact fertility, and how modifying diabetes focused approaches for fertility change outcomes for your PCOS patients and what you do for them?
Dr. Steven Palter: This is great. We could spend the next three days talking about PCOS, so let me frame it in why this is so important. Polycystic ovarian syndrome is now the number one cause of infertility in the United States, and it is one of the only ones that is rising. It used to be 5% of the population. Now it’s 15% of the population.
It is an entire-body disease. It’s not just a reproductive disorder where you don’t get pregnant. I call it diabetes of the ovary, because insulin resistance where your body needs to put out more and more insulin to keep your blood sugar normal is at the root cause of most people’s PCOS. About 80% of women with PCOS have insulin resistance, and 50% even if they’re thin. The mistake in the past was we thought of PCOS as this isolated ovary thing. Even the name, which needs to be thrown away. The cysts are just follicles that are growing and not releasing. The core is hormonal irregularity.
What you have is a vicious circle where there’s severe insulin resistance, insulin levels go high, there’s a cascade of problems, genetics, lifestyle, etcetera, that play into this, and then the high insulin pushes the ovaries to make more male hormones. The woman then has these symptoms where 80% of them will be overweight, 20% will be thin, they have excess male hormones, so they’ll have facial hair, acne, huge rates of depression, anxiety, emotional effects of this. They get irregular cycles, so their period doesn’t come, and then when it comes, they hemorrhage and they have bleeding. They’re using ovulation tests to know when is the right time, and they’re the one woman who gets a false positive on their ovulation test. When they think they’re ovulating, they’re not.
Unfortunately, OBGYNs have treated this, very often, by the symptom treatment, which is giving people birth control pills. Then I always say you can tell you have a skinny doctor because the advice they give them is go lose weight, eat less, move more, then come back. Then they give them some pills, Clomid or Letrozole. That doesn’t work, then they do IVF. But they’re set up for a lifetime of metabolic problems. They have increased uterine cancer, heart disease, Alzheimer’s, fatty liver, every body system that you can imagine is affected.
What I’ve learned, I became obsessed with this interaction between insulin resistance and PCOS decades ago. Remember Dr. Atkins? I met Dr. Atkins of the Atkins Diet. They were using low carb diets to treat obesity and diabetes, and I had just learned that insulin was part of PCOS, so we started trying this. This was back even before I was at Yale. I saw the results. The mainstream was saying that’s crazy, you can’t treat this with diet, you have to eat heart-healthy grains and have your food pyramid. People were getting sicker and sicker.
If you look at our country, obesity is like 50%-plus of the population, diabetes is at a record high, heart disease is at a record high. What’s happening in reproduction? PCOS is going up. It’s the same thing.
What happens is this woman has a genetic predisposition and then you layer on it our horrific American diet of processed carbs and fats, and it increases insulin resistance, so we turn her ovary into a male hormone producing androgen machine, it increases inflammation, and you get sicker and sicker. Then, what people don’t realize is it doesn’t just block ovulation, but it actually makes the egg quality worse, the embryo quality worse, implantation worse, and miscarriage rates go up.
What I started doing was I was learning from the disciples of Atkins and the low carb and the ketogenic communities who challenged the diabetes realm. They said diabetes is for life, you’ll get it and we’ll manage it with insulin until you die of it, tough luck. Then there was this community saying, wait a minute, if carbohydrates and insulin resistance, if you make insulin from eating carbs, what happens if you stop eating carbs and you get rid of the insulin, could you reverse it? They reversed diabetes and got people off of their diabetes medicine. I modified that to PCOS. We see remarkable results where people can start to ameliorate and even reverse their PCOS. We have people who have had eight failed IVFs that within two months they ovulate on their own and get pregnant spontaneously.
Dr. Aimee: Wow. That’s so satisfying.
Dr. Steven Palter: The idea is that by treating the insulin resistance with a comprehensive lifestyle program that’s not just “eat less, move more,”…if you tell someone who is overweight, like I’ve been really overweight and I’ve lost weight following the same kind of program…you have to give people the guidance. They don’t know what’s not working. We use a lot of sensors. We use continuous glucose monitors on patients. We do a lot of extensive blood tests for subtle insulin resistance and for inflammation. We coach them, we have health coaches. You’re going to a party and you don’t know what to eat, you’re stressed out, why are you eating? Most people aren’t gaining weight and eating to excess because they’re hungry. It’s stress, it’s habit, it’s lifestyle. The foods that our system has told them are healthy, this pure carb and low-fat diet, is really detrimental for insulin resistance.
We guide them through a process where you can follow your blood sugar in real time with a CGM. We have a coach that helps you if you don’t know why you’re not losing weight. Instead of doing six-month interventions, we see people turn it around literally in four to six weeks. We have one person who is pregnant now, she maybe hasn’t ovulated in ten years, she was diabetic. We dropped her blood sugar 100 points in one month, got her off her meds, and now she’s pregnant.
You need someone to guide you, otherwise there’s so much noise on the internet of eat this, take this supplement. There’s 36 supplements that all help insulin resistance, and there’s 25 different diets. You have to find one and have someone guide you when it’s not working to know what is the path to success. That’s what we developed.
What I worked on was I had been doing this for my patients, I was doing this for the people who were coming to see me for second and third opinions after failed IVF, and we said let’s get you metabolically healthy. I was seeing all of this disinformation online. One of my patients said, “Why don’t you start talking on social media, why don’t you help educate the patients?” So, I did it. Posts went viral, got a couple million views. Now, a couple of years later, I have 650,000,000 views of my content, maybe 700,000 followers, and people started saying they were getting pregnant just by watching the content. They said, “Could you put this together into a program?”
What we did was I put it together into a remote PCOS program where we separated the lifestyle and the intervention from the IVF. That’s the remote portion that we now have that’s called the PCOS to Pregnancy Protocol.
Dr. Aimee: Nice. What are your favorite tests to order for someone when you mention insulin resistance and inflammation?
Dr. Steven Palter: I think that every woman who is worried about this, there are things that they can do on their own. There’s a lot you can do for PCOS self-diagnosis. You can now see if you have elevated male hormones with acne or facial hair, they can self-diagnose that. They can see that their cycle is irregular, they can self-diagnose that. That gives them two of the three diagnoses. It used to be that you needed an ultrasound to pick up polycystic ovaries. Now, an AMH level can be a good proxy for that.
For the inflammation and insulin resistance, what doctors usually do is a fasting blood sugar. That’s not going to be abnormal until you’re diabetic, so you should have a fasting blood sugar and a hemoglobin A1C to make sure you’re not diabetic today. Every woman should have a fasting insulin, and then they can calculate something called a HOMA-IR, which takes their blood sugar and their insulin and starts to tell you if you’re insulin resistant. We are very avid users of c-reactor protein and sed rates that look for subtle inflammation. We do a lot of other metabolic markers of inflammation, but for insulin resistance, those are the best. The tool that I love the most is continuous glucose monitors because even when they’re normal, they’ll see that their blood sugars are spiking up 100 points and staying up for hours. It’s a great tool to modify your own blood sugar, and you don’t need a prescription for them anymore.
Dr. Aimee: Nice. If a patient is seeing me for IVF, or another fertility doctor, can they reach out to you for this program?
Dr. Steven Palter: Yes. It’s available online at PCOSbaby.com. We have a lot of patients who are doing IVF elsewhere and their doctors reached out to us and said, “Could you do the lifestyle dietary coaching as part of the IVF or IUI process?”
We have a whole group of people who do the program who are just trying to get pregnant on their own, maybe failed IVF and are trying on their own, or they’ve never done medical treatment and they’re trying on their own. Then we have a whole other group that are going to see their local specialist that is managing the IVF, but they want to get that insulin resistance down, they want to get the inflammation down, and they want to be coached through exactly the dietary interventions. We can do that in one to two months, we see a dramatic improvement.
Dr. Aimee: That’s great. I’m so glad that you shared that with me. I didn’t know. Now I’m going to share that with my patients.
When you see patients, I imagine that you spend a significant amount of time on your consults, reviewing the patient history, and also talking to them about their experiences, goals, and barriers before testing even begins. Why is that so important to understand?
Dr. Steven Palter: It comes down to this idea of the fertility deep dive and the diagnosis, and also the pathway to success and the goal. Patients need to be a partner with the doctor in this journey. Whether you want four children or one child, whether you don’t care how long it takes or you need it to happen within three months, what’s going on in your life, what are the issues that guide your path. That’s a whole discussion. I can give you three different pathways to pregnancy, but the one that’s right for you in terms of aggressiveness and time will be different.
Then the time comes, also, in doing the analysis of everything that’s come before. Looking at all of the testing, reanalyzing the root. A lot of it is looking at ultrasounds and x-rays, looking at the raw materials. When they’re not done by specialists, they say they’re normal, but there’s a giant hydrosalpinx. They say you had an ovulation cyst, but it’s a big endometrioma. If no one questions the woman about her painful periods and pain with intercourse, then the signs of the endometriosis have been missed.
Unfortunately, our field is turning into something…I know that you don’t believe this, you practice similarly to how I do…but the field is going into how can we just deliver more IVF cycles faster at a lower cost. What I always say is, how can we deliver the best IVF cycle and do it once? We’re getting to something where there’s a lot of AI questionnaires and a lot of checkboxes done by nonphysician providers that then come up with tests that are not reviewed by a physician, and then you go on a protocol plan. I really believe that we need to gather the data and analyze it all together to make the best diagnosis and treatment plan.
Dr. Aimee: We are very like-minded. My approach to care is, what can I do to fix the problem you have so that you don’t need IVF? Then if you do need IVF, if I only get one chance to do it for you, how can I optimize it so that we don’t go through a cycle and then say I wish I had known that first? Obviously, there are things that we learn through an IVF cycle that we have no way of knowing ahead of time. I’m glad that you’re sharing all of this.
Dr. Steven Palter: Again, all these things. There are so many things that when you see patients for second and third opinions who come see me, and I’m now licensed in almost every state, we start virtually and then people come in to see me in person. We have this situation where they’ll say, “Why didn’t my doctor mention that test? Why didn’t they look for that? Why didn’t they ask me if I have pain with sex?” There are some things that you’ll never find out until the end and other things that we spent an hour talking about. Had I not looked for any of these things, we could have been done in five minutes and you’d be on a treatment, but the treatment wouldn’t work. I’d rather spend the time and do it right.
Dr. Aimee: You mentioned looking at x-rays, ultrasounds, and you’re known for advanced imaging and then also surgical visualization. Let’s talk about how that helps identify disease that isn’t visible on standard testing. Does that change your diagnosis and treatment decisions?
Dr. Steven Palter: What’s changed over the years is there used to be a lot done in surgery. When I was at Yale, I did the first high-definition surgery, the first 4K surgery, and the idea was everyone in the surgery companies told me that you couldn’t adapt these technologies to medicine, so I went to the Japanese film companies, and I went to video conferences of people making movies and said, “Can I get your camera and then hook it up to the OR?” We did pilots, and then all the surgery companies said, “Oh my god, you can see endometriosis that you couldn’t see. We can see better in the OR.” It was always in trying to say how can we see better, and now the surgery part has greatly been removed. We do almost all of it now with imaging, with ultrasound, or office hysteroscopy, 3D saline ultrasound.
I think the high-resolution ultrasound and a 3D saline sonogram are crucial techniques of looking for fibroids, scar tissue, small polyps, inflammatory irregularities of the lining, but so much of that when just a cursory 2D scan is done in five minutes, if no one is looking, will get missed. I think the good news is that we’ve gone where we didn’t do that with surgery, we used to need surgery for all of it, we can do a lot of it noninvasively, even picking up endometriosis and adenomyosis. Now, if the person has it and they end up needing to go for surgery, the visualization and the ability to excise all that disease is so much better than it was a decade ago.
Dr. Aimee: That’s so great. I love how curious you are and how you’re trying to change our field. That’s pretty cool.
Dr. Steven Palter: I’m very fascinated by sensors now, so I met with a company in England that has a sensor that’s not here yet, looking at predicting cycles. I said to them, “I think this can detect things better with PCOS. What is it going to take to get this to the US? If I have to go to London and pick it up, then I’ll go to London and pick it up.” Now I’m testing the sensor.
Dr. Aimee: That is so cool. I have the Oura ring, and there’s a new ring that’s coming out that I’ve preordered. I’m thinking the same things as you, but it’s probably not the same one.
Dr. Steven Palter: There are so many. We’re going to be able to do so much more noninvasively than we could do before. Right now, we have continuous glucose monitors, continuous insulin monitors, and continuous ketone monitors are coming as well. The ability to do hormones, there’s a salivary cortisol and a salivary testosterone now. The ability to do progesterone and urinary kits, and not just a pee stick looking for LH.
Where patients have to be careful is there’s so much noise. They think, “I’m a fact finder and then I try to come up with a new solution from that information.” If you’re just a researcher, you can go down a rabbit hole where there’s 10,000 unproven tests and things, and people trying to sell you solutions, and you get things that don’t change what you do. That’s why they need a doctor like you or someone like me that says, “I’m open to anything new, but I’m going to help guide you of what’s just noise and what’s meaningfully going to change the bar and get you to a solution.” It all has to be solution-oriented.
Dr. Aimee: When you have a patient that, let’s say, is ready for IVF and she shows up, but you think that maybe something else would be needed first, surgery or metabolic intervention, how do you talk to her about that?
Dr. Steven Palter: I’m data-driven and I try to give them all the scenarios. I believe in patient rights, and patients make the decisions, but you have to guide them to make the right decisions.
When I was a med student, I had some transformative experiences. I was working on a cancer ward, and there was a doctor who was beloved by the patients because he would sit at the corner of the bed and hold their hand and tell them that he cared about them. He wasn’t the best doctor, and they didn’t survive, but they loved him because he cared for them. Then there was the hard-ass surgeon who just couldn’t speak to you like a human, but the guy would die for you if you needed something done. There’s a synthesis when you bring these two worlds together.
What I say to people is, I’m very blunt, “You don’t want sugarcoated lies.” Patients will get upset sometimes because I tell them the truth. Or people in the field, I challenge online ideas, and people get really pissed off. Why? Because I told them the truth. What I’ll say to these patients is, “If we don’t do this, here’s the best case and the worst case scenario, and here’s the odds either way if you have this thing.”
We had this recently. We had a woman who had an adhesion in the uterus, a small one in the corner. I was like, “You cannot go through the IVF cycle if you don’t fix this.” She said, “I cannot wait any longer because of what’s going on in my life. That’s it.” Together, I sat there with her and said, “Here’s the odds if you do it and if you don’t do it. If it doesn’t work, here are the things that could go wrong.” Then we helped her make a decision, but she made the decision based on facts.
Too often in our field, where I criticize a lot of things that I don’t like seeing, they’ll say to the patient, “Do you want IUI with Clomid or Letrozole, or do you want to do another cycle, or do you want to switch to IVF? Tell me what you want to do.” Did they tell you what the odds of success with each one, what the cost of each one is, and what’s the involvement? If you take a 45-year-old and you tell her you can do six months of Clomid or do an IVF, and you never tell them the odds of success both ways, they’re not making an informed decision. You’re forcing your patient to make an uninformed decision.
What I do when there’s things that I want them to fix, I kind of give them a here’s why I want to do it. I try to convince them why they should understand my path, but if they say no, then I say then let’s do it the way that can work for you.
Dr. Aimee: That’s so interesting that you said that. I have patients transition their care to me because they felt like their doctor was asking them what they wanted to do rather than telling them what they thought was best given their situation. I think what’s happening is doctors are so busy, patients are often made to feel like the doctor doesn’t know who they are, what their diagnosis is, what their beliefs and goals are, and that’s where patients get really upset and feel like they’re lost in the shuffle.
What I’d love to talk about is emerging technologies, how you evaluate them, and how do you decide when they truly add value for patients versus when they may be premature? Some of the things that I’ve been doing, I know you do as well, and that’s offering patients PGT-P and Rapamycin therapy when appropriate. Talk to us a little bit about both of those things. If you can start off with just sharing with our listeners what PGT-P is.
Dr. Steven Palter: All the PGTs are preimplantation diagnostic testing where we’re testing the embryo’s genetics for something to make a decision about what we might anticipate with that embryo in the future.
The one that most people are familiar with is PGT-A, which is for aneuploidy, which is looking for a whole or partial missing chromosome, the number one cause of early miscarriage and why embryos don’t implant. The second one is PGT-M, where it looks for what’s called a monogenic disease where there’s a single gene, one letter in the DNA code is off, and that causes a named disease, like Tay-Sachs or Sickle Cell Anemia. Dad has Tay-Sachs, Mom has Sickle Cell, you know that the child is at risk from the carrier screening. The carrier screening tells you the parents may be at risk. Then you can test the embryos and say this one has it and this one doesn’t.
PGT-P is the next frontier, where mathematical models and huge DNA genetic databases have allowed us to say, “What about more complex diseases?” The number one thing that people ask me about is always, “What about autism? What about depression? What about diabetes?” Those are these complex diseases that aren’t caused by just one gene, they’re caused by dozens, sometimes hundreds. For a number of years now, there have been mathematical models for adults predicting how well you can predict this disease. There was a landmark study just published for breast cancer saying using these polygenic markers was actually better than just using a protocol mammogram based approach. They’re hugely predictive of risk. For years, we couldn’t do that kind of testing on an embryo, we couldn’t say, testing for a hundred genes, is this embryo high or low risk.
I think when we look at the PGT-P, which I’ve done it for diabetes for about three years now, almost four years, and now we are offering it for the more complex diseases, it’s very important when a patient looks at a new technology or doctor, you have to look at what is all the data, how well does it work, because there’s a lot of treatments put out that are unproven. I say to patients, “This is unproven, this is experimental.” Then there are ones where there’s early results and we say, “The early reports say we have this kind of benefit and this degree of uncertainty.”
With PGT-P, I’ve spent several years following this data with data scientists. In adults, I think the models are there. The ability to do it with embryos, the important thing with PGT-P is it does not say that this embryo has schizophrenia and this one doesn’t. It gives you a relative risk. Those risks are dependent upon the family’s history. If your parent has schizophrenia, or diabetes, or autism, you have significantly higher risks of those than if no one in your family had it. If two parents have it, you have significantly higher risks.
The more embryos you have, the more you have to choose between. You could have something like Alzheimer’s, where with a family history, one embryo could have a 40% lifetime risk and another one could have a 10% risk. It’s not saying that there’s a 40% chance that they have it. It’s predicting what’s the relative risk, how much does it go down. If you have something that’s one in a million, and you cut it by half, that’s not going to change a lot of lives. But if you have a breast cancer gene, in PGT-P for breast cancer, some of the predictions are saying with a mother’s history there could be a 30% risk of the highest risk embryo and a 10% risk with the lowest risk. Those are big changes.
What I would do with the patient then, the important with this is you counsel them about what are they at risk, and very often we’re doing whole genome sequencing on the parents as well, uncovering things that they may not know they’re at risk for, and then say, “Which of these would be meaningfully important for you?” Then people criticize it in some of these professional societies, saying what if they don’t have enough embryos, you’re not going to be able to pick. Absolutely, and I counsel them beforehand. It’s going to be expensive and they’re going to have to pay for it. Of course, they need to know that beforehand. What if it’s unfair and some people can prevent cancer and other people can’t? Organ transplant, cancer treatment, and IVF, a lot of people can’t pay for. You can’t deny people treatment because we can’t deliver it to 100% of the population. That doesn’t exist in healthcare.
For this, my feeling is most patients don’t need or want it. The ones who have a family history are screaming for the ability to reduce this. There are ones where they don’t have a child because they’re afraid of that risk. We have people who have a nonverbal autistic child that is so disabled that they say, “I’ll try to have a girl, because the risks are somewhat less.” That’s a shot in the dark compared to doing potential genetic screening. With schizophrenia, I’ve seen people use a donor gamete because their mother had schizophrenia and was institutionalized.
Our responsibility is to not just say this thing works. It’s really to say this is an unproven technology, and here’s the potential, and then if the patients are smart and you give them the tools, they’ll decide if it’s right for them or not. I don’t like when a group of people tries to say that since we don’t have the answer, no one can do it and no one can talk about it. I would totally be open to discussions and debates where people say the science doesn’t work, it’s too expensive and you shouldn’t do it, maybe it’s unethical to do it. Great, let’s have those debates. But we do gender selection, we pick boys and girls, and that’s ethical. We let a celebrity use a surrogate when she doesn’t want to be pregnant because she’s on a movie set. Is telling someone that I could potentially reduce their chance of having schizophrenia unethical? I think to not have that discussion, we’re in a world where you can’t shut down innovation and you can’t shut down discussion. That’s what I do online. I say, “Here’s the information. Let’s all discuss it openly.” I don’t have the answers, but I want to have the discussion.
Dr. Aimee: For me, if there’s a test that’s available that a patient could benefit from, I think it’s important for her to know. I would feel bad if the patient had a baby with a certain condition and I knew there was a test that could prevent it. That would keep me up at night. Now that there is, I feel like patients can’t give informed consent to choose PGT-A for themselves without knowing that PGT-P is also available. I think it’s wrong that doctors aren’t at least offering it to patients so they can make the decision for themselves.
Dr. Steven Palter: There’s so much that we do in our field that is unproven. I think the problem is a lot of people haven’t read the science that this is based on. They think this is just a company that invented it today, they don’t realize that it’s based on a decade of genetic prediction in adult medicine that’s transforming how adult medicine is done. As long as we’re honest with the patients about what we know and what we don’t know, the patients who are facing these things, these are chances that a lot of them are willing to take.
Dr. Aimee: Right. Let’s talk a little bit about Rapamycin. Rapamycin is also experimental, not a lot of doctors use it, but there is research showing that it could be beneficial. How do you pick a patient that could benefit from it?
Dr. Steven Palter: I like to always share with patients the levels of what we know. I say here’s your diagnosis, here’s your treatment, your history, and here’s your prognosis. Here’s the first level, here’s the standard treatment that we’re going to do, and it’s going to give you these odds. Here’s stuff that is controversial. Here’s the best case and the worst case. Here’s the cutting-edge of what is unproven and controversial, but the ones where I think there’s promise. Now, there’s a lot of stuff out there that I think is BS. I’ll say, here’s the things that you’re going to read about online and why I don’t believe in them.
For Rapamycin, this is a drug that was originally used for immune suppression, found on Easter Island in the dirt. Easter Island was called Rapa Nui, and it was in the dirt there. It was used as an immune suppressant, but it is the darling of the longevity community because it has the biggest promise of extending health span and lifespan in every organism tested.
The way our FDA is set up, longevity trials can’t be done because there’s no outcome. I’m very involved with the longevity community and the biohacking community with the sensors. A lot of them were using Rapamycin for years and years, and I became intrigued by this potentially…it made sense that it could delay ovarian aging. I know you and I have talked about this. There’s a big trial going on called the VIBRANT Trial that said maybe it can delay ovarian aging 20%. That’s for extending the age of menopause.
For fertility, a thing that people are confused about is it doesn’t act as an immune modulator. It’s regulating protein synthesis and the balance between the drive and production of a cell and the rest, reset, and repair. The idea is as these cells get older in the ovary, there’s a dysregulated growth and the eggs that could have been normal become abnormal. By damping that down, the eggs can become more normal. The challenge, and I give you kudos for being an early adopter when we didn’t know, was what if something goes wrong, what adverse effect could this have on a developing baby or pregnancy, and we have to tell the patients that we don’t have long-term data, here’s the observations that people like you and others have done saying here’s what has been seen.
Then a big trial came out of China that I know the authors, this was a landmark trial done rigorously, where they did basic science and then they did a placebo controlled trial. They had significantly greater pregnancy rates in women who had poor prognosis that had failed before, because they had more normal blasts by one, the controls had none, the people with it had one and they had pregnancies. Rapamycin is one of the ones where I used to say to patients that egg donation seems to be our only option, would you try this. Now, anyone where I think that they’re a poor prognosis, where they may not get something that’s normal, I think now that we have a published study, we have an obligation to tell them that this is an option. I have patients who I think will absolutely benefit from saying, “I only want to do what’s FDA approved,” standard therapy with 30 years of follow up. I tell them this isn’t for you. The other ones who say to me, “I’m willing to try anything as long as I understand the potential risk,” then it is for them.
You have such a vast experience, so many people have been guided by you in this. What’s your take on it, how do you counsel your patients to say the degree of benefit that they could get?
Dr. Aimee: I think it’s significant. I think at least 50% will see an increase in their AMH. As far as the difference between non-Rapamycin users and Rapamycin users, I think also, I just submitted and it was accepted by PCRS a case series, and the blast creation rate was 70% difference in before and after, and the euploid rate was at least 40% different. And are you ready? Three of them were 45.
I have more patients who are 45 years old and pregnant today than I ever have before, and that’s because of Rapamycin.
Dr. Steven Palter: Now what has shifted since this publication came out and now we have more information is now I’m more comfortable saying it to people. When it started, I was offering it only to the people that were at the last resort. Now, I think it’s part of every discussion where they’re older or you may not have good results, saying this is out there, how far would you go. I know you’re using it for people that are first tries.
Dr. Aimee: First try, absolutely. Even for my egg freezing patients. I have one patient who had done three egg freezing cycles before meeting me. I put her on Rapamycin, and her fourth cycle, first with me, she got more eggs than the other three egg freezing cycles combined in that one cycle.
Dr. Steven Palter: Right. It’s basically anyone that may have a lower prognosis should be on the radar screen to consider this.
Dr. Aimee: I predict also, I hope this happens, let’s say once you turn 35, if you haven’t had kids yet and you’re still considering it, and you’re taking birth control, maybe even put it into the placebo week, just once a day for seven days. There’s some evidence that episodic use might just be as good as continuous use.
Dr. Steven Palter: This is really important for people watching this to know. We are not clear on the dosage of this yet, so there are different regimens. There’s one regimen where it’s used daily, one where it’s pulsed weekly. There’s studies using it in elderly people trying to potentiate the immune system where they were using it at a certain dose and then at a higher dose that shuts the immune system off.
The key thing here is people always ask how is it like Tacrolimus or Prednisone or Lovenox. We’re not using it here with the immune system being the target, what the dosage needs to be is unclear and is being tested. It needs to be titrated for patients. An important thing is it does block muscle protein synthesis, so anyone who is on it really should be supplementing protein and doing resistance training, especially if they’re on it long-term, it has an adverse effect.
Too many women avoid resistance training, they’re afraid that they’re going to get big. If you go to a guy in the gym and say, “Could you get big if you weren’t trying,” they’re like no, I’d have to take testosterone to do that. Resistance training is so beneficial for women’s health. In our PCOS patients, muscle acts like a sponge for insulin. For longevity, it’s one of the best predictors of longevity. We have lots of high success women that spend their days on the treadmill doing cardio, but they’re afraid of getting muscle. Protein intake and some resistance training is so important for female reproductive health.
Dr. Aimee: Yes. I have my free weights right next to my desk. In between patients, I use them. A patient of mine taught me about these bracelets that are two-pound bracelets to put on my hands when I can throughout the day.
Dr. Steven Palter: As part of our PCOS program, we call it exercise snacks. If you’ve never exercised, people think, “I have to go to the gym for 45 minutes and kill myself.” If you are sedentary and not moving, here’s two things that people use from my PCOS program, but it applies to everyone. If you’re sedentary and not doing anything, if you spend five minutes a day doing resistance training, which could be a sit-up, a push-up, a plank to failure, that could take you one minute. If you add that three times a week, the effect on your overall health is astronomical. You don’t have to run the PCOS out and bike it out. You’re not sweating out the calories. You’re changing your metabolism.
By not eating carbs and doing ketogenic diets, we’re changing people’s metabolism. But there’s this thing called zone two exercise, which I’m sure you know, where you’re exercising to where you’re just slightly out of breath. Just a little bit of effort, that is the sweet spot for mitochondrial health, for fat burning, for insulin resistance reversal. If you do 20 minutes of zone two or five minutes of resistance training, you could dramatically increase your fertility and how long you’re going to live.
Dr. Aimee: That’s so true. With so many of our patients coming in at 40 for their first baby, we want them to live forever so they can see their grandkids.
I want to talk a little bit about learning from every cycle. You talk about repeating the diagnostic cycle and treating each attempt as new data. How does that mindset support patients after failed cycles? And if they’re not seeing the two of us, how can patients go back to their doctor and have them do this?
Dr. Steven Palter: We always ask what could have changed. They’ll say, “They didn’t check my tubes because I had a pregnancy ten years ago.” Did they check your husband’s sperm count? Yes. Why? Because it could have changed. Well, could your tubes have changed in ten years? They didn’t think about that. So, I always ask what could have changed, and how invasive, uncomfortable, or expensive the test is.
I think things related to metabolism, things related to hormones, nutrition, inflammation, ovarian reserve, these should be checked very regularly. Every few months, you should be assessing these sorts of things. Fibroids, endometriosis, scans that are noninvasive, those things change. “I’ve had a fibroid for ten years.” Right. It was two centimeters, and now it’s ten, but you haven’t looked at it. I think those things need to be reassessed. If you’ve had something that should have worked and the cycle didn’t work, then I’d say go back, and if you haven’t looked at all of the raw information the first time around, maybe it’s time to look at it. Like a fluid filled tube, a hydrosalpinx, most commonly things on x-ray because they were read as normal.
The challenge for the patient, I think, is to go back to get a list of the basic diagnostics and just say to the doctor, “Which of these things could possibly have changed? I’d be willing to reassess those.” Then, always say to them, “Is there anything that we could have not understood about the cycle that we understand now having done it that would lead to a change in plan?” If they don’t want to have that discussion, then you’re in a place that’s just following a protocol.
Dr. Aimee: Right. Your promise is to stay with patients until answers are found. I know you’re obsessed with your patients and their success rates as I am. It’s deeply personal work, and we’re so invested. What does that commitment look like when you have someone who has been with you for a long time?
Dr. Steven Palter: One of the patients said to me, she made a video, I think she had been in ten different countries, she said, “You walked with me on this journey.” It’s just guiding them as a partner, saying there may be these things you have to go do and get fixed as surgery, or this other treatment, or we’re going to try a new protocol, but I’m always going to say to you what I think is where you’re going to be and if we should try again. Sticking with the patient means having an honest conversation with them about what we know, what their odds are, and what their alternatives are. I say your goal isn’t to be doing treatments with me. Your goal is to be getting pregnant, having success at the end. It’s me guiding you to the path to success.
Dr. Aimee: I love that. For listeners who want to learn more about your work, your PCOS programs, or care with you directly at Gold Coast IVF, where is the best place they can find you?
Dr. Steven Palter: I’m on all social media, Instagram, TikTok, Facebook. I always say that I can tell the age of my patients based on which platform they see me on. It’s almost 700,000 followers. It’s @StevenPalterMD on every platform. I read the comments, I respond to them, I do DMs. Gold Coast IVF is the practice, if you want to come see me in person, virtually, remotely, in person in New York, or start virtually and end here. If you want the remote program, PCOSbaby.com. You can start whether you’re doing treatment on your own or with a fertility center, we’ll guide you through our metabolic reset.
Dr. Aimee: Awesome. Thank you so much. Is there anything else that you want to add today?
Dr. Steven Palter: We touched upon so much. Thank you so much for having me here. It’s been a pleasure chatting with you. I know that we share such a philosophy on how we approach innovation and care for our patients.
Dr. Aimee: Thank you so much for joining me today and for the work that you do on behalf of patients all over the world.
For everyone listening, links to everything we discussed will be in the show notes. Be sure to subscribe to The Egg Whisperer Show on YouTube and Spotify so you’ll never miss an episode. Remember, no matter where you are on your fertility journey, keep asking questions, keep advocating for answers, and keep sparkling.
