Lorne Brown:

By listening to the Conscious Fertility Podcast, you agree to not use this podcast as medical advice to treat any medical condition in either yourself or others. Consult your own physician or healthcare provider for any medical issues that you may be having. This entire disclaimer also applies to any guest or contributors to the podcast. Welcome to Conscious Fertility, this show that listens to all of your fertility questions so that you can move from fear and suffering to peace of mind and joy. My name is Lorne Brown. I’m a doctor of traditional Chinese medicine and a clinical hypnotherapist. I’m on a mission to explore all the paths to peak fertility and joyful living. It’s time to learn how to be and receive so that you can create life on purpose.

Today on the Conscious Fertility Podcast, we are with Dr. Al Yuzpe and I know Al personally. I’ve worked with him in the Vancouver area since I met him back in 2002, but I want to give an introduction because he has been around from the early days of practicing reproductive medicine. And we’re going to get some insight and hear some stories about where this medicine was and where it is and where he thinks it’s going. So Dr. Yuzpe has been the recipient of numerous awards including the Canadian Fertility and Andrology Society Award of Excellence in Reproductive Medicine, the Society of Obstetricians and Gynecologists Presidents Award and this is for distinguished career at academic reproductive endocrinology and infertility and his dedication to women’s health in Canada and abroad and also the Royal College of Physicians and Surgeons Speakers Award.

Dr. Yuzpe is the co-founder and co-director of Olive Fertility Center here in Vancouver, BC. They also have clinics in Victoria, Surrey, in Kelowna and are constantly expanding. When I was sitting with him recently at a conference, I found out he had a satellite even in the Prince George area that he’s affiliated with. So Olive Fertility Center has a great presence in British Columbia, which we’re fortunate to have. He’s Canada’s most senior reproductive endocrinologist, which is why I wanted to have a conversation with him because he is the most senior reproductive endocrinologist in Canada and he’s been involved in IVF. Now, Al, when I read, it says, “He’s been in IVF for the past 30 years,” but I don’t know when that got posted, so you’ll have to correct that, “and he’s been in the field of infertility for the past 43 years,” and again, I don’t know when they posted that bio, but I think it’s been a few years since then. So probably you can tell us when this all started.

Now, he received his MD and his Master of Science and completed his fellowship training in obstetrics and gynecology at Western University in London, Ontario. We’re both alumni of Western. During his training, Dr. Yuzpe was a fellow of the Medical Research Council of Canada for two years with his research focusing on the development and refinement of fertility promoting drugs including clomiphene and human gonadotropin. So a lot of the fertility drugs he was involved in the early research. So I got questions around that as well. He joined the Western University Faculty of Medicine, Department of Obstetrics and Gynecology in 1970 and passed through the academic ranks of full professor, retired from the university in June of 1995 and he now holds the distinguished academic appointment of Emeritus Professor of Obstetrics and Gynecology.

Dr. Yuzpe then went on to found the Genesis Fertility Center in Vancouver, British Columbia and then went on to help found Olive Fertility Clinic, which he’s involved in till this day. He’s pioneered the development of the emergency contraceptive pill. So that’s interesting. He went from one side of the spectrum, the emergency contraceptive pill, to fertility, bringing life into the world and that method is often referred to as the Yuzpe method. So if you guys have ever heard of the Yuzpe method, here’s your founder, the inventor, Dr. Al Yuzpe. And this method has been listed by the Canadian Child and Youth Center Coalition as among the 10 Canadian discoveries with the greatest impact or the greatest potential for impact on health outcomes for children and the youth in the last hundred years. Al, thank you for being a guest on the Conscious Fertility Podcast.

Al Yuzpe:

Oh, thanks, Lorne. It’s a pleasure to be here. Hearing all these accolades, you don’t have to tell people all that stuff. What I’d like to do is talk about where we are now and where we came from.

Lorne Brown:

You worked with clomiphene, Clomid. Now, tell me your role in clomiphene. Where did this start and what was your role with that drug for ovulation induction?

Al Yuzpe:

When I started my residency training in 1965 at the University of Western Ontario, my mentor and lifelong friend, Dr. Earl Plunkett, who’s the Father of Reproductive Medicine in Canada, in my opinion, told me that he had obtained a Medical Research Council fellowship training program for me and my research was going to be with the new drug that was being developed to make women ovulate. Until that point, you should know, our ability to treat women for infertility was terrible at the best of terms. We didn’t have anything that really worked. We didn’t have any treatments for women other than surgery and most of those things didn’t work either.

And so this was a revelation at the time and so I was very happy to have the opportunity to do some basic research on clomiphene, which is the first drug that was developed. And the purpose of the drug was to induce ovulation or help women who didn’t ovulate. So it was used in women who had very irregular cycles, with polycystic ovaries. We didn’t know what else it did. So we treated everything and anything with the drug because we knew it was safe. So we treated women with endometriosis. We treated women with ovarian cancer, endometrial cancer, all types of things, conditions in gynecology to see what it would really do. And that resulted in my master’s thesis and me getting a Master of Science in Medical Research because of that work with clomiphene.

Lorne Brown:

I have a couple questions around Clomid because now one of the other ovulation drugs that often uses letrozole. So today, we’re recording this in late April of 2023. What’s your preference for an ovulation drug? Is it Clomid or letrozole and how do you choose?

Al Yuzpe:

Well, I have a love for clomiphene because it was the beginning of my career. I also have a love for letrozole because its use in ovulation induction was introduced and pioneered by one of my students and my resident and my former partner, Doc Bob Casper in Toronto. So I have a great respect for that drug and it’s close to my heart as well. The advantages of letrozole are that the multiple pregnancy rate is slower with letrozole than it is with clomiphene. And as a physician, I can say that we much prefer to have a singleton pregnancy than a multiple pregnancy. And I’ve seen, with clomiphene, pregnancy as high as quintuplets. And so it is not just twins, and the more fetuses there are, the greater the risk of the pregnancy is to its existence and to the mother herself.

So I think the letrozole is always better to use to begin with. The side effects are less as well, but for some people, letrozole doesn’t work and clomiphene does and vice versa.

Lorne Brown:

So you have two choices to treat ovulatory disorders. Now-

Al Yuzpe:

We have a third. We have a third.

Lorne Brown:

Okay, what’s your third?

Al Yuzpe:

Those two drugs induce the body’s own release of a hormone called FSH and LH as well, which are the two hormones. FSH grows eggs and LH triggers the release of the eggs, which is ovulation. We also have those two hormones that we can use as individual hormones. We have FSH, but it has to be given by injection. We don’t use the hormone LH. We use a drug that works like LH called HCG, which is a natural hormone that the body produces in pregnancy, but it also has the ability to cause the egg to be released. So there are really three things. Letrozole, clomiphene and gonadotropin are called them.

Lorne Brown:

And you had some research in your early days with those drugs as well, no?

Al Yuzpe:

Yes, I did. When I was doing my research with clomiphene, I attended a lecture by Professor Carl Gernzell from Uppsala University in Sweden, who is the pioneer of isolating and FSH and treating women with it. And I asked him at the end of his lecture if he would take me as a research fellow and he said, “Yes, come July 1st.” I arrived on July 1st, but nobody works in Sweden in July, so I didn’t start work until August, but I got to see the country. So I did work with that as well in the very beginning. But you have to realize something. I said at the beginning of our discussion, we need to know where we came from. In the field of fertility, we came from nothing. We had nothing. We were like the Wright brothers and their little airplane and compared that to Elon Musk’s satellites now and rockets. We didn’t have ultrasound, we didn’t have hormone tests.

I remember when I was in Sweden, Dr. Jimmy Brown in Australia was the first one to produce a test that we could measure estrogen. We’d measure estrogen routinely now in IVF and in so many other places and we didn’t even have that at the beginning. So we came from really nothing. So it was quite an adventure from then on.

Lorne Brown:

And it sounds like you guys are in, like you say, the SpaceX compared to where you were in the ’60s. I have a question about the ovulatory drug story. I don’t know if you remember this, but once we had a conversation, this is decades and I was asking you about … and I wasn’t aware of your background, your research involved in Clomid and I had asked you about, “Is it okay for somebody to do consecutive cycles of Clomid?” And this is part of my question because I had read and I’d heard from other reproductive endocrinologists that you need to take a break as it will impact the lining, the quality of the lining, the thickness of the lining.

And you had responded saying, “I pretty much helped invent the drug. I think I know how to use the drug,” and then you went on to tell me a little bit about when you should or shouldn’t take a break. For our listeners, because that is out there, what is, as of today, from your background with the research to all the studies and clinical experience with Clomid, is there a time to take a break because some of the side effects are how it impacts the lining? How would you use that drug? Should somebody be doing multiple cycles without a break? Is there a time in your mind where they move into something like IVF? Can you give us a practical clinical picture of how you would have somebody use that drug when they take a break and when you would think if time and money was an issue, they move to something else?

Al Yuzpe:

That’s a good question, Lorne, because the drug is still misunderstood. If someone has a problem with the drug, now what are the problems? Side effects and the most common side effects are hot flushes as far as the way a woman feels. But the other major side effect is thinning of the lining of the uterus. And if you take, as you refer to very fertile soil and convert it to sand, an embryo isn’t going to implant as well. So we don’t want to change the thickness of the lining of the uterus, which we believe is still very important in conception. And if a woman is not experiencing hot flashes or other side effects as some women will experience things, and sometimes if somebody experiences something that they haven’t experienced before and they’re taking medication, they say, “Well, that’s because of the medication,” but that’s not always the case.

But if someone thinks they’re having a side effect of the medication and it’s uncomfortable, then you need to take a break. But if the lining isn’t thinning, if the medication is doing what it’s supposed to do and there are no side effects, then there’s no reason why someone can’t continue taking one cycle after another. The old concept of saying you can’t take it more than six months, for example, is not really … There’s nothing that’s based on that. As a matter of fact, we used clomiphene and clomiphene can still be used in changing the lining of the uterus that shows premalignant change to removing or getting rid of that premalignant change by inducing ovulation because that change usually occurs in women who don’t ovulate.

So there’s no restriction as to the length of time. The drug is safe. The biggest problem with clomiphene is that in some women there are multiple pregnancies and multiple pregnancies may seem quite exotic and exciting to some people, but we know that the risks of multiple pregnancies, twins, triplets and more are much greater than a singleton pregnancy. Our goal is to help women become pregnant and our goal, when we want women to become pregnant, is for them to have a healthy baby in delivery. And to do that, the best way to do that is through a singleton pregnancy.

Lorne Brown:

And with the lining, as you said, there’s no side effects. If the lining isn’t thinning, then they don’t really need a break. Is the way to know this is just some of the monitoring that you would do then, that’s how you would know because you would look at the lining to see if it’s thinning or not?

Al Yuzpe:

There’s only one way to know if a lining is thin and that’s to do an ultrasound. And again, I refer to Dr. Casper in Toronto, he was the one that showed the thickness of the lining to be important. We know now that that’s not 100% true in some cases, but for the most part, it’s important.

Lorne Brown:

When you talk about the field of reproductive medicine where you said you basically had no tools, where do you see it today? Where are we today and what excites you? Are we allowed to tell them around how old you are because you still have the passion? I have to tell our listeners. So I was with Al, Dr. Yuzpe, here at a conference just on Friday before we’re recording this on a Monday and he was still like some … Before the words came out of their mouth, they were talking about a study and Al would talk about the issue with the study and what’s going on and then all of a sudden the person goes, “And here’s the issues with this study.”

Then they’re talking about recurrent pregnancy loss and then he threw a stat to me about how many of those women would go on to have pregnancies. And then the person said, “And this is how many people go on to have pregnancies.” So in your eight-plus decades, you are still loving this medicine. You show up still and you share and you’re involved. So what are you excited about today? And then the next question is, what are you excited about tomorrow?

Al Yuzpe:

First of all, Lorne, let me tell you that if I didn’t do what I’d do now, I’d have to work for a living. I love what I do and I’ve been doing it for 53 years. And 53 years ago, when we started, as I said, we didn’t have any of what we have now. What’s exciting now is we’ve gone from minimizing the involvement of surgery in fertility promotion. People should know that a number of years ago, when I first started in obstetrics and gynecology, women were having their uterus operated on if they were having difficulty and their uterus was retroverted or tipped backwards. We now know that a third of women have a uterus tipped backwards. We know that a third of women are not infertile, but we didn’t have anything else, so people were doing these surgical procedures called uterine suspensions, which brought the uterus from this position to this position. Not much of an involvement.

Women were having multiple, multiple surgeries for endometriosis and were still not conceiving, but we didn’t have anything else to offer them. So we progressed from there to the medication with clomiphene that was introduced in the 1960s, the injectable drugs, the FSH drugs that came to fruition and it became approved in the early 1970s. Then we went for a laparoscopy. And I always thank my parents for giving birth to me, conceiving me and giving birth to me at the right time and I was in the right time in the right place. So in the early 1970s, a very close friend of mine who was from Quebec City was just returning from France doing some studying there and he learned an operation that nobody knew about here called celioscopy or as it was renamed laparoscopy, which is now a household word in surgical procedures, but he brought back the laparoscope and he did some postgraduate training before he went to France and learned this from Professor Raul Palmer.

He came back to where he had done his training in the States, which was at Johns Hopkins University and he was trained by the Father of Reproductive Medicine in the United States, Howard Jones, who passed away at the age of 103, I think, and who was responsible for the first IVF baby in the United States. And Howard Jones said, “Show me this operation, Jacques” So Jacques did the first laparoscopy at Johns Hopkins University in 1969. So in 1971, when he came back here, he taught me how to do the procedure and he and I started a training program and all the gynecologists in the country had to train with either him or me to learn how to do the procedure.

And then we had a window to the abdomen, we didn’t have to do a huge abdominal incision. We could see what things were going on. We learned a great deal. And so that was another milestone. There was an organization called the American Association of Gynecologic Laparoscopists, that was a mouthful, and Jacques was a founding member and I was a board member and there was a guy that came to our meeting, his name was Patrick Steptoe and Steptoe was doing this procedure in England and we became friends and he told us about collecting eggs with the laparoscope. And he was working with a scientist named Robert Edwards at Cambridge England and he was going to try to fertilize these eggs.

So together, they worked and that’s what gave rise to the first IVF baby, Louise Brown, was born on July the 25th, 1978. So that’s 45 years ago now. Louise has had her own children since then. So we evolved and now the IVF field is evolving and we did … It was used originally to treat infertility. Now we use it for so many other things. We have patients who have genetic diseases that they carry or have a child who has an affected condition, genetic condition. We can test embryos now genetically. And then now we can preserve fertility by freezing embryos or freezing even eggs before they become embryos. And now we’re using artificial intelligence and artificial intelligence is helping us choose the best eggs. It’s helping us choose the best embryos. We have new ways of growing the embryos. So there’s been an incredible evolution. It’s gone from small motors to rockets, same thing.

Lorne Brown:

So I wanted to just review some of that. So I’ve known you for a while since 2002 and I wasn’t aware that you were involved in training the laparoscopic procedure here in Canada or in BC. I didn’t know that you were involved in that.

Al Yuzpe:

Well, there were three of us, Jacques Rioux in Quebec City and I worked together, but Victor Gomel, who was a professor here in British Columbia and still a very close friend of mine and you were with him on Friday as well, Victor really did the same thing out here on the West Coast because I was in London, Ontario at the time. And Victor was the first one to successfully operate on ectopic pregnancy through the laparoscope. Victor also was one of the world authorities in microsurgery in repairing fallopian tubes. And Victor worked with some of the most incredible microsurgeons in the world in Europe and he’s been rewarded with, I forget the name of the award. He was presented by the president of France for the work he’s done. He’s traveled all over the world with his work. So microsurgery risk really is the biggest bailiwick, although laparoscopy was important for him too.

Lorne Brown:

So grateful for the work that they did and Victor did and I didn’t know that you’re one of the early adopters, pioneers in Canada on the East Coast anyhow for this. And then you shared which gets you excited today, you talked about genetic diseases, so that you guys can test now. So you don’t put back an embryo where that child will have that serious illness, so you can prevent those transfers now.

Al Yuzpe:

This is what I look at as the good and the bad. We can do things now that can prevent the transmission of diseases. And take for an example, Huntington’s disease, it’s a disastrous disease. It’s a killer for people who have that disease and it’s a terrible condition. You would think that our provincial government would say, “Gosh, if we didn’t have to treat people with Huntington’s disease because we didn’t have any that had Huntington’s disease, they would jump at the idea of saying, “Well, we’ll pay for an IVF cycle for you, so you have a baby or one or more babies from an IVF cycle that aren’t going to have Huntington’s disease, so you’re going to save money down the road.” Unfortunately, politicians are employed now. They don’t worry about the future so much.

That’s been one of the most distressing things that I’ve encountered in this whole field here in British Columbia and that is the lack of support for people who suffer from infertility, from people who have genetic diseases. In some ways, because IVF is not covered by provincial healthcare, even these genetic conditions, treating or preventing the transmission is not covered. And that’s a shame. In 1985, while I was still in Ontario, I was able to get the provincial government to fund IVF and then the federal government, in its great wisdom, set up a Royal Commission and the Royal Commission report called Proceed with Care, said that IVF will only work for women with blocked tubes, which couldn’t be further than the truth, but they stopped funding IVF.

In more recent years, they’ve reestablished the funding, but they fund one cycle of IVF and other provinces fund IVF as well. Quebec has funded, ran out of money, stopped, and now is funding again. I believe that the government should be funding IVF with refundable tax credits, meaning that the money doesn’t come out of the Ministry of Health, it comes out of the Ministry of Finance. If it doesn’t come out of the Ministry of Health, we’re not antagonizing everybody who’s waiting for treatment who can’t get it because we don’t have the money to support what they need in the healthcare system. So I don’t know how I got on this.

Lorne Brown:

Well, we talked about it because of the genetic diseases and that they’re preventable through IVF where you don’t have to have a child with and it’s not only, like you said, disastrous for the individual with this death sentence, but for the people that have to care to watch somebody suffer and deteriorate like that. That’s also tragic and it can be prevented.

Al Yuzpe:

And we have to look after these people too and I’ve seen this. One of the most satisfying events that I’ve ever experienced is a couple where the father carried a gene or a condition called hypertrophic cardiomyopathy. That’s where the heart is affected. The muscles don’t work properly, and often, these young people just drop dead. And this gentleman had hypertrophic cardiomyopathy. We treated him and his wife gave birth. In those days, we used to put in two embryos. We tried to put in a single embryo now in IVF in order to avoid multiples, but they had twin pregnancy, and then a few days later, he went on to have a heart transplant. So I think we do good things.

Lorne Brown:

Can I ask you a question about that? Just to put it into perspective, if somebody has a genetic disorder and you do an IVF, the goal is you’re going to have several embryos and you can test these embryos. So there’s the chance that some of those embryos will have the disease, but some will not and you’re going to put in the ones that don’t and that’s how you’re avoiding passing on that hereditary disease. Is that-

Al Yuzpe:

That’s true. And this is where we come under criticism and I suppose it depends on how you look at it. There’s morality, there’s ethics involved. I remember when IVF first started, it was a great moral dilemma. And you’d read in the newspaper, “Now doctors are going to be able to clone people. They’re going to be able to pick one of their blue-eyed babies.” That’s not what we do. And as a matter of fact, I said to Bob Edwards, who was the scientist involved in the beginning of IVF, who received the Nobel Prize for what he did, I said, “Bob, what do you think about the cloning issue?” And he said, “I’ve never met anybody that’s worth cloning.” I thought that was a very good comment.

Lorne Brown:

I want to share … Again, we’ll continue on what you’re, you talked about, you love what you do, it doesn’t feel like work and we’ll talk more about where IVF is and going because there’s so much testing. It’s amazing. I didn’t realize, when you started practicing, you couldn’t even test the hormones, when now you’re biopsying the uterus looking for issues that can cause implantation failure. That’s incredible, but I got to share with the audience. So Al’s been doing this for a long time. I met him in 2002 and I’m going to share this story, Al, I don’t know if you remember this, but the reason we met is, in 2002, I’ve been in practice since 2000 and I thought I wanted to meet Al and his team at the clinic because I provide acupuncture and I want to support their patients going through IVF.

And Al and I, when we met, he put me like he’d put any medical doctor through rounds. He questioned me and challenged me, which any good health professional doctor does. But later on when we got to know each other over years, it took years to develop this relationship. You had shared with me that when I first sent in a request to connect with your team and your nurses acupuncture, you’re ready to throw it away. And then you saw I had CA. Now they called it CPA and you had told me that, “The only reason you had me come to the office because you had to figure out how somebody who was a chartered accountant could end up being an acupuncturist. So you just wanted to …” I don’t know if you remember that story, but that’s what you shared with me in 2002.

Al Yuzpe:

Well, I remember that, but what really intrigued me was how, what you did might impact fertility. And at first, I was more skeptical than anything else because we’ve grown up in Western medicine and we didn’t know where I was training or working and nobody knew anything about traditional Chinese medicine. You open my eyes to some things I think that are very important. If you’re going to have a garden, you might as well have the best soil you can have. If you say to me, I think I still believe that, if you say to me, “I’m going to help you get pregnant,” I don’t know if you’re going to help me get pregnant. I know that you’re going to get me in the best shape to get pregnant and I think that’s really important. And I’ve seen this time and time again that you fertilize the soil, you nurture the soil and I’d rather stick a plant in your soil than in the sand because I think that’s really important and you opened my eyes to that. And I must say I’m not the easiest person in the world to change my mind.

Lorne Brown:

No, well, at the beginning, as I said, Al was pretty in a hurry to get me out of his lunch and learn that first day and I was persistent. And then about five years into practicing and working with mutual patients, you once said, “I’m surprised you’re still here. I didn’t think this acupuncture thing would stick around. I’m pretty surprised you’re here.” Now, we’re in 2023 and it was 2002, so we’re almost 20 plus years into this. And that soil idea, we bring the watering of the soil, so blood flow, bringing down those inflammatory stress hormones. And we saw at a talk that we’re at high cortisol levels and pregnancy rates and supporting the body’s absorption of nutrients and calming the nervous system. There’s so many things and it’s been the integration and you share how you’ve seen where it’s evolved.

In 2002, there was no communication between the reproductive endocrinologist at the IVF clinics and so the patient was negotiating with both health professionals. And now at all, you guys, patient-centered care, we go on site to do the acupuncture and we communicate with all of the docs. So we really make sure we’re on the same side and we have the ability to even disagree to find out the best approach for this as we learn about each other’s styles for that patient. And again, it’s been your support because being the leader of the clinic, when you had that openness and at least you had the curiosity to say, “I’m skeptical I don’t get this, but let’s see if this can help our patients and we can start seeing some evidence. Let’s get open to it.” So thank you.

Al Yuzpe:

Well, I’m not the only one, I must say, excuse me, that my partners, some of them were more eager to embrace the concept than I was at the beginning, but we’re all very supportive. And one of the most important things for us, maybe we can even talk about this, I don’t want to direct your questioning or your information, but one of the most important things is treating patients, having the patients be happy and having the patients be comfortable that they know they’re in the right place. And that’s one of the things that really is important when patients are choosing a clinic that they’re going to attend. Choosing a clinic that’s going to meet an individual’s needs is just as important as what the clinic has to offer and I think that’s really important.

Lorne Brown:

Agreed, and that’s where you get that individualized medicine and that’s where our integration has helped with that because of the patient-centered care. And together, we get a very holistic approach to them where we’re taking care of most of their needs and supporting them in making that decision and in the education aspect of it. I have a couple follow-up questions, just about if you can share a bit. We were talking about how you guys can screen for genetic disorders. You had touched on that now technology has egg freezing because back in the day the freezing technique wasn’t so good, so the eggs couldn’t freeze and thaw well. And then with vitrification, it’s become much better for both embryos and egg freezing.

And now for example, two ways, one is I’ve seen it multiple times where a woman has been diagnosed with cancer. You guys often will come in and support them and get those eggs out and if she’s with a partner, create embryos so she can go in to have her cancer treatments without damaging her eggs. And then women that aren’t ready to have a family haven’t found Mr. Right or rather than settling because that guy can give her children or giving up her career, women are now coming to you to freeze eggs, so they can continue to do their careers or wait for the person they actually want to spend their life with before they create embryos. And so that’s great advancements as well.

Al Yuzpe:

You talked about Mr. Right, there’s not even Mr. Left so. No, I think this has been a great advancement because who am I? I remember again when I was training and we would see young women, even before they were even 20 years old, would come and the doctor would say, “You have endometriosis.” And the patients say, “So what do I do?” The doctor would say, “Go get pregnant.” Well, we know that pregnancy helps endometriosis, but that’s so impractical. And it’s the same thing today with women who are employed, who are pursuing a career, who are pursuing their education, it’s really unfair for anybody to say, “Well, just go ahead and get pregnant.” “That one’s not the right time.”

And for some of them we know that fertility decreases as women become older. And so for some of them, there’s an issue that they want the best of both worlds. They want to have the ability to conceive at the rate that they are now, at their age and not later, but they don’t want to be pregnant now, so we can preserve their fertility. And if a woman has a partner, we preserve embryos. If they don’t have a partner, we preserve eggs. And the analogy I use, and it’s a bad analogy because nobody freezes cake ingredients, but my analogy is you want to have a cake. You can either freeze all the ingredients and then when you’re ready to have the cake, you thaw the ingredients and hope that they’ll make a cake or you can freeze embryos, which is the equivalent of freezing the cake. Because usually when you freeze the cake and you thaw, the cake comes out okay. So there’s a difference. And what works for one woman doesn’t work the same for another woman.

Lorne Brown:

And you have seen where most of the transfers were day three fresh to now you grow them out to blastocyst and most of your transfers are now frozen. Have you found from your experience, there’s the data that you can quote, but your clinical experience, are you getting better pregnancy rates and life birth rates from frozen transfers versus fresh transfers?

Al Yuzpe:

For your audience that are listening to this, replacing an embryo on day three, the embryo has only developed to approximately six to eight cells. If they’re growing a little faster, they may be 10 cells, but you don’t know the potential of that embryo or what the potential of that embryo is to get to the point where it can implant an embryo. Where it implants is called the blastocyst. That is an embryo with hundreds of cells and it’s totally different from a day three embryo. We can only transfer embryos or replace embryos into the uterus on day three or on day five. We know that day six or seven is not good. So we transfer on day three or day five if we’re doing a fresh embryo.

So if the embryo is only six to eight or 10 cells on day three, I want to be sure that I’m giving that patient the best chance she has of becoming pregnant, so I want to transfer it on day five to know that the cake is there, not the ingredients. Some embryos are still not fully developed by day five and so we can continue to grow them in the laboratory for another day or two to day six or day seven. And many embryos that we freeze are day six embryos or blastocysts on day seven blastocysts. And we don’t transfer those fresh. So I personally prefer to grow all the embryos. If they don’t get to where we want them to get and they stop growing, that’s hard pill for the patient to swallow at that point, but at least we’re not putting it in, having a failed cycle of freezing some other day three embryos and the patient coming back two years later and they don’t work.

So I’m a proponent of transferring day five embryos if a patient wants a fresh embryo transfer, if it’s at the right point. If not, I think we should grow all the embryos to blastocysts, then freeze them.

Lorne Brown:

And then what I think is, at the time of this recording, I don’t know when somebody’s listening to this, so maybe what we’re about to share is like old news, but today, this artificial intelligence, because that’s just really starting to ramp up in the IVF and reproductive medicine field, what are you guys using it for now and what’s your insight of what your thinking is going to happen in the future, how this is going to help men and women have children with this AI?

Al Yuzpe:

Well, artificial intelligence is amazing what it can do and it’s just based on, rather than one or two experiences, they’re based on a hundred thousand or a million experiences when you pull all that information. And what they do in artificial intelligence when they’re assessing eggs and embryos is they photograph them. And a photograph could look at so many things in the field that we don’t even think about or see. So to me, the biggest development so far has been to evaluate the eggs and I think that’s really important. Say you’re a patient coming to me to preserve your fertility and you say, “I like to have two or three children, but not for another five years.”

So we treat you with IVF and you get nine or 10 eggs, let’s say. With artificial intelligence, we can now evaluate those eggs and say, “Based on artificial intelligence, your chance of this egg becoming fertilized, forming a blastocyst, which is the end stage of embryo development before we put it in and the chance of having a pregnancy is X percent.” But these are still just estimates, but I say to you, “Look, you got 10 eggs and four of these have the potential to make a pregnancy at the most or three,” and you say, “I want three children.” You say, “Well, I better do another cycle and freeze some more eggs.”

So I think it has some really important role to play in assessing egg potential. It probably has the same effect with embryos, but we haven’t been using it with embryos to this point. We don’t do this. There are companies that have programs that you send the photographs to, they give you the results. Interestingly, the one is called Magenta, for example. And then we will also be able to do that in the laboratory. In the laboratory, they’ll be able to assess the eggs and the embryos as they’re developing. So artificial intelligence is going to play a major role in the evaluation and what people do in the evaluation of their eggs and their embryos and even with sperm, selecting the best sperm and then what they will do as a result of what that information provides.

Lorne Brown:

Because now when you are looking to choose the best-looking embryo, you look at your image using your eyes or you have to do something of an invasive procedure and take some cells and send those away to get tested for your screening. And the future of this for embryos, I hope, is that through a noninvasive photograph that you’ll be able to pick those embryos in the same way.

Al Yuzpe:

Well, the noninvasive issue is a whole different issue. We have a procedure called PGTA, that’s preimplantation genetic testing. The A stands for aneuploidy, which is too much or too little chromosome material. And every cell that’s been fertilized, every human cell, has 46 chromosomes, but there are a lot of errors in chromosome numbers and separation, because when the cells unite and then divide, there are errors that occur. And when these errors occur, you can get what they call aneuploidy. And with an embryo that’s aneuploid, it either won’t work or it will cause a miscarriage or it will cause it in certain chromosomes like chromosome 13, 18, 21. They can cause abnormalities, but the pregnancy will go on to deliver and you can have an abnormal baby as a result.

So with the noninvasive testing, we can do that PGTA without making an opening into the embryo and taking out some cells for that form, so that placenta does not interfere with the embryo. And that’s what we do now and it’s quite safe for the embryo. But if we don’t have to do that at all, it’s much easier to just get a few cells from the culture medium that’s a liquid that the embryos are growing in. Just take a few of those cells and study those instead of invading the embryo.

Lorne Brown:

So I want to unpack that a little bit because currently the most common procedures, the PGTA, where they biopsy some of the cells and send it away, and what I’m hearing you share is there’s even a newer procedure that you are doing at all of that’s not invasive where you’re not touching the embryo, whether the part that’s going to become the baby or the … Well, you don’t do that now, the part that becomes the placenta, you’re not touching that and you’re now taking cells from the medium, the culture that the embryo is in and that is what you’re testing. Can you elaborate a bit?

Al Yuzpe:

Yeah, that’s exactly what we do, but what we have done is Dr. Nakhuda in our clinic has been spearheading a research project where we’ve been looking at these cells and seeing how they compare with what we get with an embryo that we’d biopsied as well, so we have a comparison.

Lorne Brown:

So in your research, you are biopsying like PGTA, and at the same time, you’re looking at the cultural fluid.

Al Yuzpe:

Yeah. So that’s just research and we don’t know where we’re going yet. If they’re not equivalent, if the noninvasive method is not as accurate, then it’s not as good because we don’t want to miss things.

Lorne Brown:

But do you have any data or any sense of what it’s looking like when you’re comparing it?

Al Yuzpe:

Well, it seems to be fairly correlated, but until the study’s finished, it’s very hard to give an opinion, but we would love to be able to not invade the embryo. One, for not invading the embryo. Two, for reducing the amount of work that the embryologists have to do in the laboratory. I don’t know whether people realize, everybody thinks about the doctors and the nurses in IVF, the laboratory is the heart of an IVF clinic. The laboratory are the people that deal with the eggs, deal with the embryos, grow the embryos, biopsy the embryos. They are so much involved in it. I wish there was some better way that we could recognize these people than we do because they’re behind the scenes. They’re in the locked-up laboratory where nobody else can do this sort of thing.

Lorne Brown:

Well, let’s honor them a bit now and talk a little bit about what they’re doing, and as you said, it’s the heart of the clinic, the lab and your embryologist. From egg retrieval, so the doctor, you guys retrieve the eggs and then you give it to the lab. How long from getting the egg disseminating, hoping it fertilizes, all the stuff they have to do before they put it in to do its thing and grow over the next five days, how long is it per egg on average?

Al Yuzpe:

How long is per egg?

Lorne Brown:

Or per retrieval? When somebody has their eggs retrieved, are they done with their eggs in five minutes or is it … How long until they put it into culture because they had to strip the eggs and they had to disseminate?

Al Yuzpe:

Well, there’s a procedure that we do in IVF called ICSI. ICSI where we inject the sperm in the egg. IVF, we just add the sperm to the egg and let the sperm do their own thing. But ICSI makes sure that one sperm gets into an egg and we use ICSI in cases of sperm factors that are causing the fertility problem. We do it in the genetic testing because we don’t want a whole bunch of sperm stuck on an egg, which can confuse the genetic testing of the embryo in the future. But it really depends on what you’re doing, Lorne, as to the length of time. When the eggs are retrieved, they go into the laboratory and the first thing the embryologist does is look for the eggs. And that isn’t an easy process by any means. And the eggs are placed into an incubator that has a microscope. It’s controlled by temperature and humidity and carbon dioxide and oxygen content and so on.

And then once they find the eggs, then it depends on whether they’re going to be doing IVF or whether they’re going to be doing ICSI. If they’re doing IVF, they are taken by the embryologists and the sperm, which has been prepared by our laboratory in the andrology department, that’s a sperm part of the laboratory, they take a specific number of sperm and add it to the eggs. And these are placed in little petri dishes in little droplets of oil that keep the air away, the humidity away from them. And then they are checked the next day to see whether the egg is fertilized. If they’re doing ICSI, the egg is surrounded by a collar of cells that nourish it during development, and through ICSI, they first have to get rid of all those cells, which they do by specific techniques that they use.

And then they take a single sperm and they inject a single sperm directly into the egg in a very specific way, away from the nucleus, the DNA content of the cell and it has gotten quite meticulously and this takes a great deal of skill. He uses an instrument that’s hydraulic and we have two of these in our laboratory and there are several hundred thousand dollars each. People want to know why IVF is expensive and IVF is expensive because we have a lot of people that we have to pay. We have to pay rent, but we have very expensive equipment as well.

Lorne Brown:

And with your embryologists in the lab as you shared, skill and focus and patience because they’re spending a lot of time with those eggs and embryos, so a good shout out to all the embryologists and andrologists that work in all these IVF clinics as you wanted to share.

Al Yuzpe:

Well, that’s true and I have to pay homage to our laboratory director, Dr. Salah Abdelgadir, who’s been doing this for many, many years and he has had extensive experience. There’s no school for embryologists. They’re all trained by apprenticeship and he has trained all of our embryologists. I think, Lorne, we have a total of 10 embryologists now at all of our … Eight or 10. And these are highly trained people. Dr. Abdelgadir and at least two of the other embryologists have PhDs, their master’s degrees. They’re well-trained people, so they don’t come from being a car mechanic to an embryologist in a day, highly trained and they have to pass through the different skills that they perform before they move on to the next step.

Lorne Brown:

We’re getting ready to wrap up and I just wanted to share with our audience that we’ve been talking to the most senior reproductive endocrinologists in Canada and we’ve heard how AL has gone from in the early days when everything was surgery and they didn’t have much to offer to being involved in the invention or the drug of Clomid, early in the research with the gonadotropins, the Yuzpe method. So that emergency contraceptive pill is your invention, right? That’s part of your invention and as well training people with laparoscopic surgery, being one of the early adopters and pioneers of that small group of people when it came to Canada.

Al Yuzpe:

Lorne, there is no end to what we’re going to be able to do. I can’t even guess what the world would be like in the field of fertility promotion. I think one thing we didn’t touch on and I want to … You cut me off when you think we were at a time, but to me, I mentioned it earlier, choosing a fertility clinic is not like just walking into the first clinic you do. When people shop for cars, they don’t necessarily go to one dealer. When they are shopping for clothing, they may not go to one store. And I think it’s the same thing with IVF clinics. Not every IVF clinic is for you and I think that your patients need to meet their physicians and say, “This is what I think I need. I need to be able to speak with you or email you or contact you. Can you tell me how you do that? Can you tell me about your success rates?”

One of the biggest things that absolutely drives me crazy is when people talk about success rates. When you buy a car, they always tell you to get miles per gallon. Some don’t tell you it’s feet per second and miles per gallon, kilometers per hour, whatever. Know the enumerator and the denominator that you want to know about, “Is this pregnancy rate that you’re taking, is it a clinical pregnancy rate? In other words, is there a fetus and a heartbeat or you’re talking about a live birth or an ongoing pregnancy?” They’re all different and you need to know, “Per what? Is it per embryo transfer, per cycle initiated?” because a lot of people start a cycle, but a lot of the statistics aren’t given to you unless you have an embryo that’s put back.

So know these things in advance. One isn’t any better than the other as long as you know how to compare them. Otherwise, how can you judge if this clinic is for you? Is this service that the clinic offers patient-centered? Is the patient the center of things? You may want to look at the costs that are associated with the treatment, but be sure that you’re looking to see that you’re comparing the same things because many clinics will hide their costs of certain things in other areas and you don’t get that information. You need to know all kinds of things that are suitable to what are going to make you happy. And not every clinic is right for every patient.

And if you’re not happy with a physician, say you need to see a different physician. I know there are people that don’t want to see me. I practice very differently than my younger colleagues. My younger colleagues are very polite. I’m old. I say what I say. Those that can tolerate me are okay with me, but those that can’t like someone else. You want a female physician. There are some clinics that don’t have females. If having a female physician is important to you, then make sure the clinic you go to has a female physician and so on and express your feelings. And if sometimes females aren’t on call or working that day, “What do I do?” Can you deal with a male physician that day? Think about all of those things before you commit to a specific clinic.

Lorne Brown:

And I know you care about the patients and you’re sharing this and you’re also sharing this because all the fertility checks, all those boxes. And so it’s easy for you to ask patients to do that because your clinical check those boxes off for that patient-centered care. And evidence of that is, again, one of their early adopters of the multidisciplinary integrated approach where with Acubalance, in our clinic, starting to support the patients together in those early days and so much so that we go onsite at Olive. So patients, if they want naturopathic and Chinese medicine, acupuncture, you’re open and we have that cross professional discussion for the patients. So again, they get that holistic approach, integrative approach and you check those boxes, patient-centered care and you’re borrowing from Chinese medicine because we call it individualized care as well. So everybody doesn’t get treated the same because nobody is the same and that’s personalized.

Al Yuzpe:

That’s really important too. Yeah, you hit another important point. Patients will say, “Well, my friend did this,” or, “My friend did that. I want to do that too.” Not everybody is the same. Everybody is an individual and what you do with one is not necessarily what you do with another.

Lorne Brown:

So we’re going to wrap up here. Al and I could continue talking and would continue talking and telling stories forever. I just think of all the history. Another, we used to do, talks together in the early days as well and that was always fun. And then I remember Dr. Kali came along and she gave a talk with you and at first, because you didn’t know her, you were not sure if you’re going to be comfortable with that, and then after, you said, “She’s smarter than you. Can I do all my talking with her?” So as they say, Al says it as it is. He doesn’t hold anything back and she is smarter than I am, I agree.

Al Yuzpe:

I have to thank you for your association for what you’ve done for us and I know I’ve influenced you because you named your two sons the same as my two sons.

Lorne Brown:

That’s right. So we didn’t know this, but my kids and Al are the same. We both have two boys, the same names, except that the names are reversed based on age. So his oldest is the name of my youngest and his youngest is the name of my oldest, but yeah, our children are named the same. I know that, but I had forgotten about that as we’re having this conversation.

Al Yuzpe:

Well, thanks, Lorne, for asking me to participate in this. I’m not sure that anybody’s learned anything, but it was fun recollecting a lot of the old times.

Lorne Brown:

I enjoy history and I think it’s important to know where we come from because it helps us know where we’re going. And it’s nice to talk to somebody firsthand that was there versus somebody else telling me it. So it was a pleasure to have you come on the Conscious Fertility Podcast to give us a little history and to share with patients some tips and ideas when choosing clinics and explaining some of the difference between letrozole and Clomid and the lining issue and just where you see things going that I know our listeners may not be aware of, especially the artificial intelligence, picking, looking at eggs when you freeze them and also the part about the research you’re doing looking at that, the culture medium to screen embryos versus hopefully not needing to biopsy the embryos.

So I’m sure at the time of this recording that people are going to be listening to this. This is going to be some new information 10 years from now. This will be another little history podcast, of course.

Al Yuzpe:

I hope I’m around to do it.

Lorne Brown:

We hope so too. You’ll be in your ninth decade by then, so it’d be a pleasure. So should we set up a date in our calendar for a 10-year little reunion for our podcast and we’ll do another interview?

Al Yuzpe:

I’ll make a note of it. Thank you.

Lorne Brown:

Thanks, Al. All right. You’ve been listening to the Conscience Fertility Podcast with Dr. Al Yuzpe from the Olive Fertility Center here in Vancouver, British Columbia, Canada.

Speaker 3:

If you’re looking for support to grow your family, contact Acubalance Wellness Center. At Acubalance, they help you reach your peak fertility potential through their integrative approach, using low level laser therapy, fertility, acupuncture, and naturopathic medicine. Download the Acubalance Fertility Diet and Dr. Brown’s video for mastering manifestation and clearing subconscious blocks. Go to acubalance.ca. That’s A-C-U, balance dot ca.

Lorne Brown:

Thank you so much for tuning into another episode of Conscious Fertility, the show that helps you receive life on purpose. Please take a moment to subscribe to the show and join the community of women and men on their path to peak fertility and choosing to live consciously on purpose. I would love to continue this conversation with you, so please direct message me on Instagram @lorne_brown_official. That’s Instagram, Lorne Brown Official, or you can visit my websites, lornebrown.com and acubalance.ca. Until the next episode, stay curious, and for a few moments, bring your awareness to your heart center and breathe.