My guest on the podcast today is pushing the envelope on the next big thing in fertility, including MRT, PRC, polygenic screening and more, and that’s exactly what we’re talking about in this episode.
There are so many cutting edge advances being made in the field of fertility, and Dr. Catha Fischer is one of the people bringing those advances to patients everywhere. She is a fertility doctor and the Director of Fertility Preservation at Spring Fertility New York. She is also board certified in reproductive endocrinology and OBGYN.
Dr. Fischer is committed to providing exceptional care and a compassionate experience for patients. I truly love and admire that. I am just so impressed by all that she does–her research, the thesis project she has published–and I am absolutely thrilled to share this wonderful conversation with you.
Dr. Aimee: I am so excited to have Dr. Catha Fischer on today. Hi, Catha.
Dr. Catha Fischer: Hi, Aimee. I’m so thrilled to be here. Thanks for having me.
Dr. Aimee: I love asking guests about how they became interested in studying and practicing fertility medicine. Can you tell us a little bit about your story?
Dr. Catha Fischer: Of course. I come from a household of two physicians, so I always came to medicine knowing it was an amazing profession. My parents were both super happy and loved what they did, so work was never work. It also gave me a really early insight into the kinds of physicians one could be, which I feel like most medical students don’t really know.
The world of fertility came to me when I was doing a rotation at a big cancer hospital. I thought I was going to be a surgical oncologist, I was sure this was what I wanted to do. I sat in with breast cancer patients who were incredible. They were powerful women who were able to balance it all. It was mostly pretty sad stuff, a 30-year-old having breast cancer and going through it.
I remember a surgeon saying to me, “This is a good one, we cured her. Come listen to this consult, you’re going to be wowed.” Great. I went. She was 35, she had Stage II breast cancer, she had come through chemo and radiation, had surgery, and she was there with her husband. She said, “This is great. When am I going to get my period back, and when can I have kids?” The room sunk. I didn’t know what was going on. The surgeon said, “I’m not sure that’s going to happen for you. Chemotherapy and radiation is a lot.” The woman lost her mind, she was sobbing, she was angry. She said, “I would have taken the cancer any day if I could be a mother,” and she really felt wronged.
They left. The surgeon, who was a really smart woman, said, “I didn’t even think about it.” She didn’t even think about fertility preservation. That was a decade ago at this point, but it was one of those a-ha moments. I thought, “we can do better, I can do better.”
So, I really came into fertility thinking more fertility preservation. Luckily, we got better at that, so patients are counseled more. Not perfectly, but more than they were when I was a medical student.
That’s really how I went into the world of fertility, was with that in mind.
Dr. Aimee: Wow. I can tell your passion just from hearing that story, for sure. Now you’ve opened Spring Fertility New York, which is the east coast location for them. Congratulations on that. Can you tell us a little bit about Spring Fertility and the New York practice and how patients can find you guys?
Dr. Catha Fischer: Yes of course. When I graduated fellowship, I actually first started at a place called RMA. RMA New Jersey was for me like Willy Wonka’s Chocolate Factory, it was where this amazing research came from, and I thought, “I want to go there.”
If your listeners know anything about New York and New Jersey, it’s really like two separate continents almost. I would still drive from New York City to New Jersey to go to work every day.
I loved the medicine, but I didn’t love who I was as a doctor. There were a lot of patients, and I didn’t get to do that personalized care that I really wanted to provide. Peter Klatsky from fertility said, “I’m going to open up in New York. What do you think?” I said, “I think you’re crazy. But I think I’m crazy, too, so this sounds great.”
We were able to open up just a few weeks ago in New York. Spring Fertility provides the kind of medicine and the kind of care that I’ve always wanted to do. It’s really individual. I get to see all of my patients and perform all of their procedures in this high touch clinical experience where they know their whole team. The medicine is exceptional and the outcomes are out of this world.
It felt like New York really needed this. All of my friends who would never cross the Hudson River to come see me back here in New York City were lacking this. So, I love it. I love everything about it so far. I love what Spring can provide. We are in Bryant Park, which is so easy to get to. You can email [email protected] and reach any of us.
It’s so far, so good. It’s exciting.
Dr. Aimee: I can’t imagine how hard that was during the pandemic to get that all set up. I applaud you guys, and I am so happy that patients have you.
Thank you for sharing your general approach to fertility care. I think that more and more patients need that individual type of care, especially now more than ever.
Now I want to dive into some of the next big things in fertility. As the audience knows, I love to pair technology with care. Tell us, what are the big things you are seeing on the horizon for fertility care?
Dr. Catha Fischer: I think in general we are all trying to understand why our success rates are somewhat plateaued between 65% and 73%. Us Type-A people in general who are fertility physicians are obsessed with this somewhat failing grade. How can we get better? What are we missing? So, I think there’s advancement on all different fronts.
There are advancements in how the embryo talks to the uterus, how we can improve egg reserve and egg quality, and how we can improve the way that we select embryos, and embryo screening. I’m grateful we have tremendous minds in our field attacking this. I think these are all of the avenues that we are trying to go down to figure out how we get to 80% or 100%. Let’s shoot for the stars.
Patients are certainly asking me all of the time about modalities like PRP (platelet rich plasma) or MRT (mitochondrial replacement therapy) and different ways to screen embryos and what is the best path. My approach to those questions is really just an honest conversation, because we don’t have those answers yet. We have a lot of information that we’re trying to figure out what may be the best approach, so it’s about knowledge.
Dr. Aimee: Why don’t we talk about the first one that you just mentioned? PRP, which stands for platelet rich plasma. What is it and how is it being used in fertility treatments?
Dr. Catha Fischer: The concept of platelet rich plasma really came from the orthopedics literature. It’s a way to take peripheral blood, so it’s just a venous puncture, we will spin it in a centrifuge. When you think of blood, it’s a really thick liquid. We separate out the parts that are necessary for cells to come and be attracted and form more cells to grow. In the orthopedic literature where it came from, what we discovered is this really helped generate cartilage and improve joint health. It has tremendous success there, so much that it’s covered by insurance.
Then we borrowed this and thought, “Could this help the ovaries?” What we know is that women are born with all of our eggs, and the blood supply to the ovaries is somewhat fixed. The question was is there a way for us to inject more growth factors, more blood flow, potentially even stem cells, which are really not found in the ovary support where you could make new eggs, and might we see some improvement?
Essentially, what you do when you do PRP therapy is you take the patient’s own peripheral blood, a really easy procedure, just like having your blood drawn for any other hormone, you spin it down, you separate out the growth factors and the platelets, and then you take that and inject it back into the ovary in the same way that you would do an egg retrieval, transvaginal with a large needle, you’re asleep and you never feel it. Then you monitor over a couple of months and see if you increase the number of antral follicles seen.
What the literature has shown us so far is you can increase AMH that way, so that would make us believe that we’re increasing that egg pool. And that you can decrease FSH, making us think that the brain thinks we’re doing something right, because the brain is no longer yelling at the ovaries. Then we’re hoping that is going to translate into more eggs retrieved and more embryos, and hopefully more healthy embryos.
This is all still really cutting-edge. There aren’t huge trials and are proving efficacy. This becomes kind of the gray in medicine, which is do we not offer it because it’s not 100% ready for prime time yet, or do we offer it with caveats and say we’re not so sure, but maybe, and the harm is minimal and this might make sense for you. I think who it’s going to make the most sense for is the young woman who has diminished ovarian reserve. I think that patients are really going to benefit from PRP therapy, but certainly the jury is out on efficacy at this moment.
Dr. Aimee: What I would love to do is somehow do an egg retrieval, especially in patients who have decreased ovarian reserve who need to embryo bank, and somehow with their retrievals perhaps do PRP while they’re asleep for their first retrieval to see if it could help for future retrievals. I wish for that. Maybe one day.
I want to talk about something that you’ve actually done quite a bit of research on, and that is MRT, mitochondrial replacement therapy. It can be considered controversial, but it seems to me like it’s a matter of time that maybe it’s going to be something that’s more widely practiced. I certainly have patients who have talked to me about it, and I actually wish that I could offer it. Can you tell us what it is and who it’s helpful for?
Dr. Catha Fischer: Mitochondrial replacement therapy, we need to understand what the mitochondria are. They are the energy producing organelles of a cell. An egg is the largest single cell in the body, and it’s the point where the mitochondria is segregated away from the DNA. Think about it like the brain of the egg. When you have that separation, you can replace the mitochondria without harming one’s DNA or blueprint for an embryo or for the egg.
So, there are really two different classes of patients that MRT may help. There are the patients with mitochondrial diseases, which invariably are lethal, they have really early onset, they’re catastrophic, and they’re always handed down because the mitochondria are handed down maternally.
For mitochondrial replacement therapy, what you can do is remove the nucleus, so the DNA and the brain, and put it into a shell which is mitochondria, replace it entirely. The reason that this has hit some roadblocks is because it’s a therapy for disease, and when it’s a therapy for disease, the FDA gets involved. Unlike a lot of our other treatments, like intracytoplasmic sperm injection or PGT, mitochondrial replacement therapy has hit roadblocks because there is a lot of oversight on it and the FDA felt really strongly that we should not be manipulating gametes, and basically blocked it and said we can’t offer this.
So, we are left with other ways of trying to assess mitochondrial disease. The problem with it is you can’t really screen an embryo for it. We’ve tried. Mitochondria dramatically increase after implantation, so at the level of an embryo it might look okay, but then at the six-week mark of a pregnancy it could be catastrophic again. There’s no way to predict it, so it’s really challenging unless you can say actually there’s no disease mitochondria, it’s zero, but still there’s expansion. The only treatment we have for mitochondrial disease is mitochondrial replacement therapy. We’re at a roadblock there with that, unfortunately.
The other population is a population who is older. The energy of the egg, and I think of an egg as a battery, it’s an imperfect metaphor admittedly, but if you say I can replace the battery or recharge it and not change the actual DNA, that seems like everybody should do this, this is amazing. We’re just not quite there yet.
But the procedure itself is no more challenging than ICSI. I’ve seen it hundreds of times, I’ve tried to perform it myself. I’m no embryologist, so don’t let me do your MRT. But it’s really not that complicated. If it’s a possibility and if we don’t have oversight, because we’re not saying we’re curing disease, it’s for a different reason, I think people are going to want this as an alternative to egg donation, which at the moment is really tried and true. When you’re of a certain age, your egg quality is of a certain type, that’s really what we talk about is egg donation. This may be an alternative.
Dr. Aimee: I would argue that if we had the President of the United States as a woman, and let’s say she was over 40 and wanted a baby, I have a feeling the FDA might allow it. I think you and I need to run for President soon, maybe.
Dr. Catha Fischer: A job I would never want, but I think things like egg freezing, embryo banking, birth, all of these things would be different if we had a female President.
Dr. Aimee: Not that I’m encouraging anyone to go overseas or leave the country for treatments like there, but are there places that people could go now to actually access this technology?
Dr. Catha Fischer: There are places. This was really pioneered in England, at New Castle. They offer it for couples who have mitochondrial disease. It’s a lottery, it’s a challenging center to get into, and they only offer less than 10 a year. They haven’t published outcome data that I have seen recently. But you can go to England and have this done, and it’s screened by HFEA. It’s allowed there, but again, a very select population, which I can see the US doing at some point, just not yet.
Dr. Aimee: Not yet. I want to talk about polygenic testing and polygenic risk scores. What do people who are trying to conceive need to know about polygenic testing and what does it tell us?
Dr. Catha Fischer: Polygenic testing is a way to assess embryos to try to find their risk of having diseases such as asthma, diabetes, and certain mental illnesses which are really not from one genetic mutation, but rather a certain variant or combination of the different genes. What we are trying to assess with polygenic screening is based on the DNA footprint, what is the risk of the specific embryo having these polygenetic (or multiple gene) diseases. It’s telling you embryo A has a 60% chance of having asthma and embryo B has a 50% chance of having asthma. It’s basically putting the onus on the patient to say that this matters.
It’s separate from embryo grading, so where I find this is going to get really gray for all of us is what are you going to use to make your decision for embryo selection. Is it going to be the polygenic risk score that’s very much not ready for prime time, is it going to be the embryo grade, is it going to be the PGT-A? We’re going to have all of these different variables that are going to go into selection, and it’s probably going to make us all crazy.
I think it depends on what’s important to the patient. I’ve certainly been in a room with couples who have said to me, “My brother committed suicide at 15 from paranoid schizophrenia. It is imperative that this doesn’t get passed on. This is it, this is my thing that needs to happen.” You say okay. So, it’s going to be a very individual thing.
The data and the science is lacking a bit now, but like everything else, I’m sure in 10 years this is going to be like bygones and they’re going to wonder why we ever talked about it.
Dr. Aimee: Right. I really wish we had whole genome sequencing of embryos. I think what people don’t understand is we can only see chromosomes, we can’t see these genes. It’s really difficult to figure out what’s going on in an embryo.
Right now, we have tests. The carrier screening that we have today is basically the same technology that we’ve had for the last almost 15 years. I think people think that what we do is a little bit more precise than it really is. Don’t you think?
Dr. Catha Fischer: Absolutely. So much of that data is junk, it doesn’t mean anything to the embryo or us. It’s sifting through to understand what parts of this is coding, what of this is important, how does it get spliced, and we just don’t know that stuff yet. When you have all of this information, we just can’t make heads or tails of it. It’s really challenging.
Dr. Aimee: Right. I know there are a lot of other big things down the road for fertility. Is there anything else that you think we should be on the lookout for?
Dr. Catha Fischer: I think what’s going to be fascinating is the research into the crosstalk between the embryo and the endometrium. There have been many tests trying to get at this. The ERA test is one that people always know about, and that I’m sure we all have different feelings about. The goal of it is to understand what we are missing. They must talk to each other, and there’s going to be a lot of information there.
I find gut microbiome and microbiology fascinating because I think our diets have changed so much and I do believe that there is inflammation that may be playing a role in this. We all have anecdotes. I’ve certainly seen patients clean up their lifestyle, change their diets, and three months later achieve success without my help, which I still count as a win because it’s great. I think that’s going to be an area that will get more traction and we, hopefully, will see improvements that are easy to do and inexpensive. Because everything we’ve talked about today is incredibly expensive. Changing your diet is relatively inexpensive.
Dr. Aimee: Right. For people who can try at home, that’s a lot more fun than trying in our office.
Dr. Catha Fischer: Absolutely.
Dr. Aimee: Thank you, Catha. It has been such a pleasure talking to you today. I really appreciate your time and your expertise, and the compassion that you show to people, and the precision of care that you’re offering. Can you tell us again where people can find you?
Dr. Catha Fischer: Yes. I am at Spring Fertility in New York City. We’re in Bryant Park. You can email us at [email protected]. We would be thrilled to see you.
Dr. Aimee: Awesome. Thank you, Catha. I hope you have a wonderful rest of your day.
Dr. Catha Fischer: Thank you, Aimee. You as well.
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