AHLA's Speaking of Health Law

After Dobbs: The Impact on Reproductive Medicine

November 04, 2022 AHLA Podcasts
After Dobbs: The Impact on Reproductive Medicine
AHLA's Speaking of Health Law
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AHLA's Speaking of Health Law
After Dobbs: The Impact on Reproductive Medicine
Nov 04, 2022
AHLA Podcasts

The field of reproductive medicine is beginning to feel the effects of the post-Dobbs landscape. Delphine O’Rourke, Partner, Goodwin Procter LLP, speaks with Dr. Brian Levine, Founding Partner and Practice Director, CCRM New York, about how the field is reacting, particularly as it relates to innovation, surrogacy, and access to treatment. Dr. Levine is a leader in the field of reproductive medicine and the founder of Nodal, a surrogacy platform that is driving transparency between surrogates and intended parents.

Listen to all of the episodes in AHLA's "After Dobbs" series here

To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.

Show Notes Transcript

The field of reproductive medicine is beginning to feel the effects of the post-Dobbs landscape. Delphine O’Rourke, Partner, Goodwin Procter LLP, speaks with Dr. Brian Levine, Founding Partner and Practice Director, CCRM New York, about how the field is reacting, particularly as it relates to innovation, surrogacy, and access to treatment. Dr. Levine is a leader in the field of reproductive medicine and the founder of Nodal, a surrogacy platform that is driving transparency between surrogates and intended parents.

Listen to all of the episodes in AHLA's "After Dobbs" series here

To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.

Speaker 1:

This episode of ala Speaking of Health Law is brought to you by ALA members and donors like you. For more information, visit American health law.org.

Speaker 2:

Hello and welcome to ALA's After dos. Today we're gonna be discussing the impact of DOS on reproductive medicine. I'm Delphine O'Rourke, a partner with Goodwin in our New York office, an adjunct professor at Columbia Law School. I'm thrilled today to welcome Dr. Brian Levine, who is founding partner and practice director of CCRM in New York. He's a leader in the field of reproductive medicine and founder of nodal, a surrogacy platform, which is driving transparency between surrogates and intended parents. Um, Dr. Levine joins us, uh, just completed an embryo transfer, um, which is, you know, just shows how, um, relevant this conversation is going to be. As I said, Dr. Levine is a leader in the field of reproductive medicine, and that's really a humble description. Um, patients come to see him and his colleagues from all over the world, um, to receive the best in reproductive health. And we therefore, we are very fortunate to have this opportunity today to discuss the impacts on reproductive medicine well beyond what we've been hearing about fertility. So, again, thank you Dr. Levine. And, you know, let's jump right in and talk about the impacts. What are you seeing, um, and what are you seeing particularly in the areas of innovation?

Speaker 3:

So, first and foremost, just I'll say, uh, thank you, uh, Delphine and ALA for, for having me this afternoon. Um, life after Dobbs has been a weird one. As a fertility doctor, there's a lot of social media, um, frustrations that we've all experienced, a lot of emotional heartache that we've all felt. Um, and I can tell you that after coming back from the American Society for Reproductive Medicine, um, there's a sentiment across the country, or people are still confused to this day, when the decision regarding DO was coming down the pike in June, a lot of us started prepping ourselves to say, what does this mean? Um, what is this going to do for our patients today, our patients tomorrow? And our previous patients, When we think about the do's decision of what actually happened was that we knew that there was gonna be a series of trigger laws that were gonna go into effect where states almost immediately were going to have new regulations and new views on, um, what was permissible and what was advisable and what was even to be thought about as a potential treatment plan for a patient, no matter how she got pregnant. Um, and right, we've seen lots of media descriptions of the awful things that people might have endured, um, and become pregnant and and whatnot. What it meant for us in the reproductive world, though, was that when we started seeing the news, it started bringing up the old discussions of personhood. Mm-hmm.<affirmative> and personhood almost becomes a biblical conversation, um, because it really, at its crux is when does life begin and when are we looking at an individual entity as opposed to a bunch of cells together? Now, for those of us who have, you know, seen the movie Legally Blonde, we know that, you know, one of the, the key arguments used in that movie is that she said, Look, men have been discarding condoms for, you know, years and years. And so discarding of gammy is something that we could think about. But if you think about actually the personhood, they're not talking about discarding gam. They're actually discarding embryos, and that feels different. And the reason that frozen eggs or frozen sperm feel different than embryos is because when it's embryos, people feel like that is a potential life to be had. Well, I could tell you that life after Dobs has led to a lot of social media craziness. There have been people who've put their emotions out there and their emotions become perceptions. And perceptions appear to be reality for many, where people worry about the state of their embryos sitting in cryo-preservation tanks today in fertility clinics across America. I don't think that's actually a worry, but I can tell you that as a fertility doctor and also as an owner operator of a clinic, this is a phone call that we get almost on a daily basis. How can I move my embryos from Texas? How can I move my embryos from Georgia? What we're seeing though, is also a lot of people saying, Well, if dobs is a decision that's about the pregnancy, and people are extending that onto embryos, and we're having the conversation about embryos being individuals in personhood, what's this gonna do for innovation? Which is the second part of your question and with regards to innovation is I think this is going to really stink. I think we are in, for a real terrible couple of years, maybe longer ahead of us, where we are gonna see a couple steps backwards on embryonic stem cell research, on basic science innovations and research on allocation of research dollars from the nih. Um, and what I think you're gonna end up seeing is all of the great research is gonna end up in the privatized side, right? It's gonna come from either, uh, private dollars in clinics or private dollars from pharmaceutical companies, but the untoward effect of DOS will be slowing down of biomedical research for sure.

Speaker 2:

So let's, there's a lot to unpack there. So, couple, couple follow ups. Um, when I was talking to, and, and we did a, we did a podcast, um, with, with a, a, a physician and where she talked about this confusion that physicians were being placed in the role of having to interpret the laws and not knowing what they were able to do. When you talk about still confused, are you talking about patients, physicians, everybody? All of the above. Um, and is it to the implications of dos generally? Are you seeing certain areas, I mean, privies an area where there's so much squirrel going around over what is covered, what is not covered by hipaa, for example, but where are you seeing really where the confusion is having a negative impact on care?

Speaker 3:

A lot of places, and I think, you know, delphy, you're hitting on such an important topic about data, right? Because people hide behind HIPAA all the time without even knowing what HIPAA really is. Uh, and I share with patients that are like, Look, I've stopped tracking my periods because I don't want to know, uh, I don't want anyone else to know when I'm getting my period, because if I need to have a termination, I don't want that data being used by the government. And I'm like, Okay, that is a, you know, sensational statement. You need to really think

Speaker 2:

It's, it's the common, it's common thought process and the thought process that was pushed out on Twitter right after the decision dropped.

Speaker 3:

And you see this on social media all the time. Yeah. Well, in reality, what we do know is that when you sign up for these apps, you sign a user agreement. So it's not that your HIPAA is being violated, you actually gave them permission to look at it. And in fact, many of these menstrual calculators that are out there are solely data sources so that the ttc, the time to conception can be better described for certain demographic populations. And so you've been giving research for years and my argument is you never needed an app to track your periods, right? You actually can just use the calculator or the calendar app that's in your phone or on your desk and if you literally just circle on a paper calendar every time you get your period, or if you write in your calendar app a word that you can search for. So I always tell people, pick your middle name. So if your middle name is Betty, just say you got your period on October 3rd, just write Betty. Cuz then you can search your calendar for all your Betty's and you'll find all of your periods there without someone tracking your menstrual cycle. Cause as a fertility doctor, this is one of the symptoms that we use for helping people understand the scope of their fertility treatments that they may need or understanding their diagnosis. But one step further, we are actually now hearing from employers who are saying, Look, we're against dos. We will support our patients driving or our, our employees driving out of state mm-hmm.<affirmative>. But now they're saying, how do we put that into a benefit that's not trackable?

Speaker 2:

Exactly.

Speaker 3:

And I think this concept, if we, if we take a step back, if we think about this trackable data, well we leave breadcrumbs everywhere, right? We leave breadcrumbs on social media. People going through IVF do this all the time to look for support, to look for people out there because they're hurting on a really personal private topic. And I think this is going to be an unfortunate side effect of do is that people may not be willing to share and to build community and to reach out for mental health support like they may have in the past. I think that we use, um, media and social media and our other like, you know, different aspects of our phones and our devices almost in a, you know, willy-nilly way where we don't think about the ramifications. And maybe a terrible silver lining is that maybe we're gonna think before we agree to the next user agreement, maybe we're actually gonna read those three pages of text that you have to click, I accept before downloading an app or using an app or entering into a social media forum. What's also interesting though is that in the world of surrogacy, which is completely dependent upon ivf, I do think that the quality of embryo transfers and the embryos that will be transferred as a result of dos might be better. Now, I don't mean we're gonna supercharge embryos and we're gonna add, you know, glue and glitter and something that's gonna make the whole thing more sparkly and and more attractive. What I mean is that the downstream effect of dos is that for those surrogates that are gonna live in at risk states or trigger states, um, those surrogates could be in a real bad position if they need to have a termination, either because it's a chromosomally abnormal pregnancy or it's an unsuccessful pregnancy or whatnot. And we do know that the efficiency and efficacy of embryo transfers is far improved with genetic testing of embryos. So if we put in a single genetically tested embryo, right? We're not putting in cohorts of embryos anymore, we're not putting in multiple embryos anymore. We put in one single genetically tested embryo, we can limit the risks to that potential surrogate and risks that potential family and prevent that surrogate from being in a bad situation, especially if she lives in one of those trigger stakes.

Speaker 2:

So tell me a little, and then like you go back to sort of the concept, the cohort of embryos, but tell me a little bit about nodal in the platform. I mean, you recently launched, is there October of this year? I don't think there's a similar platform, you know, paid surrogacy recently, um, past couple of years became legal and for example, the state of New York. Tell us a little bit more about, because that's one of the areas that, you know, first it started, Oh, DOBS is gonna impact, uh, abortion services then Oh yeah. It's also gonna impact ivf. Oh yeah. It's also going to impact primary care access. You talked about mental health support. We're seeing chilling a a across the, the range of services surrogacy is yet another unintended consequence. So what, what's nodal doing?

Speaker 3:

Great. So thank you, um, because, and again, we could probably do an entire hour long podcast about nodal and surrogacy, but at a high level, um, surrogacy is still a novel tool in the state of New York. Most people are surprised to learn that surrogacy only became permissible in February of 2021.

Speaker 2:

Mm-hmm.<affirmative>

Speaker 3:

With that legalization of surrogacy where the contracts were now viewed as legally binding and protective, right? That was the big deal. You could do surrogacy before that for altruistic, but now for compensated surrogacy, it was now protective for both intended parents andal carriers. Um, as that happened, the city of New York, which is the busiest IVF market in America, right? More IVF occurs within the five square miles of Manhattan than anywhere else in America, became a hotbed for surly inbound interest. People started wanting to do this right away because we have employer-based benefits in New York. And New York is always viewed as a, you know, favorable liberal state. Mm-hmm.<affirmative>. Well, it ends up that last year I became incredibly frustrated that supply and demand economics were taking hold and Right. We all know on this podcast that the last time supply and demand economics took hold in healthcare, the pharma bro went to jail. Right? We can't have supply and demand economics. It is not ethical to do that. It is not the right thing to do in healthcare. But because surrogacy is poorly regulated, some might even argue it is unregulated. Um, because all of the liability goes back to the doctors doing, um, either the retrievals or the transfers and the clinics associated with those procedures that the middlemen or the agencies that are doing the brokerage here kind of went unchecked in the supply and demand economic world. And as I watched this continue to happen, I became incredibly frustrated because my patients were coming back and saying to me, It's cost prohibitive, it's time prohibitive, and it's emotionally exhausting. And when I started calling agencies that say, What is your secret sauce? Like what makes you better than your neighbor? What makes you better than your competitor? They all said the same thing. That they can match people faster, they can match people better, that they do a better background check than anyone. So if the bottleneck is supply and the match is the golden ticket, I attacked that head on with nole. And the reason why we're called nole is because we're connecting different nodes of information along the way, right? We're putting different nodes together to build one decision tree to help us understand who is the best potential surrogate. And so what we do is we attack that, um, by using really cool tech and really cool ethical advertising to increase the supply side. But ala Bumble, right, the dating site where the women make the first move, because the women are the ones who feel at risk in the dating relationship. We let the surrogates make the first move on our platform. So on our matching platform, we let surrogates choose which intended parents they want to work with, empowering them to feel that they have the decision and they have optionality, and they have the agency themselves to choose which families they wanna help with. And of course, we can geek out about how we do this and you know, all the criteria people use to select each other. Um, but what I will say is that the unintended dos, um, consequence for surrogacy is that people are looking to do it in the favorable states. People are looking to do surrogacy now in a place where they view that it's going to be safer. And I will tell you that as a result of that, because New York is still an expensive place to do surrogacy because the rules are very, very strict. There is a premium for a California surrogate, and literally it feels like almost it's like a brand name right now for someone who lives in California who is a surrogate, they can probably ask between 20 to 25% higher on the total compensation solely because they reside in the great state of California.

Speaker 2:

So they're de-risking the proposition.

Speaker 3:

Yeah.

Speaker 2:

So are you seeing that, so you're seeing per surrogacy, are you also seeing that for ivf or are you seeing an increase in demand? I mean, New York, you know, Manhattan was already the, the sort of center of the IVF market, but are you seeing that increase in demand that we anticipated? You know, I just read, um, over the weekend that legalized abortions have gone down already 6% since dos. Are you seeing a, a measurable increase in ivf you, and we'll talk about access next, but at least demand for IVF services in favorable states?

Speaker 3:

Yeah, so, you know, again, I saw the same sobering article this week and I said to myself, if we're seeing a 6% reduction and we already know that there was unmet need in abortion care services, I can only imagine how many people are suffering. But, um, yeah, we are seeing inbound interest from people who are greater than driving distance. So when I was at the A S RM last week, I started talking to people to say, Hey, what's your inbound look like? What are you seeing? And what it's interesting is that to my colleagues, they too are seeing the same patterns, which is people who are outside of the typical catchment of driving distance of their clinic are now inbound calling because they're like, Hey, I live in a state that's questionable. And the example would be people who live in Pennsylvania, even right now are saying, if I'm gonna make embryos, I wanna leave my embryos in New York because I can get to New York. It's a hundred miles away, I can drive easily. And I don't know what's gonna happen in this crazy political race is happening in Pennsylvania right now. Um, and it's fascinating to see how politics are dictating families even at what I would call the preconception stage before people even make the move, before they even make a phone call. They're thinking about the political milu of where they live and where they will continue to live when hopefully pregnant.

Speaker 2:

And you know, what we were talking about gene funding for, for clinical research and, and you know, embryonics, this isn't new that it's connected with with political ebb and flows. I mean, this isn't a same with with restrictive abortion laws. We've seen multiple attempts with the various administrations that largely were parallel to, uh, efforts to decrease funding or to limit embryonic research generally, and it continues, continues to be the case. Um, any thoughts on that?

Speaker 3:

Yes, I mean, you know, it goes, it goes without saying that embryo research is a highly political topic and you can't have IVF without embryo research. And for as many presidents as I am old, their lives have been touched by reproductive health services. And it's, you know, we talk about core family values being the core of each party. Well, IVF and embryo research is kind of how you do that.<laugh> really, for some people who have a medical condition called infertility that we estimate is 15% of the population, which probably is even higher because we don't know the rate of infertility in the LGBTQ population. And I think if you even go back to, you know, Bill Clinton in, in the nineties and embryo research, um, and the NIH embryo research panel, right? And they reviewed like, what does embryo research look like? They recognize that we were devoid and deficient in adequate funding and adequate opportunities to move the needle. Mm-hmm.<affirmative>. Um, I mean, think about in our field of reproductive health and fertility, we haven't had a new drug come out since I graduated medical school. And I've been doing this now a long time. That's crazy because unfortunately, clinical trials are expensive and they're incredibly difficult to run and they require a lot of work. But more importantly is you need to get heterogeneous population and if the country's heterogeneous on their views of embryos and IVF and associated with it, you can't have a well powered clinical trial, um, by just treating the, what I call the bicostal population, right? Yeah. You can't do this with just a New York LA approach. So this is the, this is the problem. Um, and, and again, I think, you know, to look at the future means you have to look at the past. And if you look at what happened in the nineties and you look what happened with the nihs policies and their approach, and you look back at the Dickey Wicker amendment, um, making it possible in making impossible to fund embryo research. This is a political hotbed. Oh, it's, um, and it's sad because I think patients suffer as a result of it.

Speaker 2:

Yeah. And we, you know, we talk a lot in the industry about social determinants of health. And what we are now clearly in is your legal determinants of health. And, you know, whether you add that to the, the diagram of social determinants of health, but where, where you reside, um, what are the laws that are gonna be applicable to you? Um, more and more we talk about the elections and I, and I hope folks see the connection. I mean, there's been a big push to vote on women's health issues, the connection between voting. I hear this all the time, you know, I wish I could do something after Doz. Well, you can, you can vote. Um, you know, there's a study by the World Health Organization that looks at the, you know, correlation between maternal mortality rates and, and restrictive abortion laws. So this is not an issue that's unique to the us this connection between policy, legal framework and maternal health outcomes. Um, you know, yet we see the same patterns over and over. What we're also, you know, you talk about bicoastal and fertility is not a bicoastal issue. I mean, fertility impacts, you know, middle America, it impacts, I mean, middle of the United States, it impacts, um, every, every socioeconomic background, LGBTQ families of color. I mean, this is not an elite issue. Um, and we're seeing let's talk about access because what we do know is that access was, was a challenge before dos. Um, IVF is is very expensive for most Americans, even if they have coverage access. You know, when you're talking about patients coming from outside of your catchment area, I'm thinking, well, you know, how do they get the treatment in a, in a, in a, um, you know, if you're flying out to receive treatment in New York, that creates operational and and clinical challenges in addition to increased costs. So let's talk about the access issue because we have access and abortion access infertility. And I think, you know, this is also women who have had cancer. I mean, the range is broad and what this is doing, um, across the country, I think is underestimated.

Speaker 3:

So, you know, look, I think you hit the nail on the head. Access is the name of the game. We know that if you make infertility treatment difficult to seek, let alone the diagnosis of infertility difficult to obtain, all you're going to do is lead to increased rates of depression, increased rates of poor employee work, right? It becomes almost all encompassing. And for those people who have grappled within infertility, they will tell you that it starts to become, um, uh, a vicious cycle where you don't wanna be around friends who have kids because it's so painful and you start becoming introverted and then you kind of just focus on your little nexus at home. And it's sometimes until you actually get to see the doctor and see the clinic and seek treatment, that you start to see there's a light at the end of the tunnel. And it's very isolating, right? If you think about what we're talking about here, either end of the spectrum, getting pregnant, staying pregnant, or not being pregnant, those are all very personal decisions. We've actually seen a contraction in the number of fertility clinics. We have 450 fertility clinics at the start of 2021 and at the close 2022 looks like we're only gonna have about 400 fertility clinics in America. And we know that there's a large unmet need. And the unmet need is in urban centers as well as it is in middle America. We know that the access to reproductive health is limited in the traditional black and Hispanic and immigrant communities in America because people don't view fertility as a medical condition, as viewed as a luxury by many. But in reality, as you and I are just saying, infertility is a big deal. Well, if you layer on top the fact that people now think it's illegal to seek treatment, that's even a bigger problem, right? If people start to think that now it's not permissible or possible to go seek treatment because again, the fear mongering that's occurring as a result of life after dos, well now we're gonna end up in a bigger pickle. And so access is the name of the game. But my one caveat to access is if people don't have access to wifi and people don't have access to technology, don't just preach that telehealth is the only solution. There is something to be said for brick and mortar clinics where people can go and seek care because that is the familiar way that they seek care. And I think that it's incumbent upon the American College of ob gyn to advise OB GYNs, which I was first, right? All for to doctors or ob GYNs. First is that we all need to be comfortable discussing reproductive health and fertility with our patients.

Speaker 2:

So we talk about telehealth because, you know, this is, as you say, we hear over telehealth has been fantastic in certain areas. It's not necessarily the solution for everything, nor do I think it was ever intended to be a full replacement of brick and mortar. And we're already seeing concerns about, you mention, you know, depression, you mention anxiety, mental health support of women being less willing to engage in mental, you know, mental health services over telemedicine because of a fear of privacy. So, um, and, and you also touch on, you know, what we know is the technology gap, which we saw during covid, both in the healthcare context and the educational context. Great to have a telemedicine option, but if you don't have reliable broadband, um, then your kids aren't going to learn or you're gonna not gonna be able to access that care. Uh, we saw, you know, telemedicine expanded dramatically during covid in response to a need. You know, and I've brought this up over and over innovation by necessity. Now, you know, you touched on, you said you think innovation in clinical research is going to fall back. How about innovation other areas, you know, whether it's embryo testing or, um, you know, potential treatments prior to ivf. Is there, do you see any hope there?

Speaker 3:

I do. So one of the themes that I also took away from last week's ASM meeting was that more and more we're seeing that people are relying upon physician extenders to allow for increased access and reach of classic clinics. We are starting to see that in the reproductive health world, that if the rate limiting step is going to be access to a clinic, well then maybe it's time to have a satellite that's more geographically accessible to certain populations. Well, unfortunately there's only about 40 of us who come out of training a year on an annual basis as fertility doctors, right? It's actually a very small field. And we know that there's a,

Speaker 2:

You repeat that. They're only just so make sure that everybody hears that only 40 physicians are trained in the US per year

Speaker 3:

For reproductive endocrinology in fertility. Yeah. It's one of the smallest fields out there. Um, 40, 45, 39, like depends on which year because some, uh, some fellowships are two fellows a year, some are one a year, but it's less than 50 and closer to 40. And we know that the retirement rate right now is approximating 15 to 20 a year. So we're losing people and we're not gaining by that much. And so what we are seeing now is that people are using alternative models, including but not limited to physician assistants, nurse practitioners, nurse midwives to be the front lines of reproductive health. And I do think that is both a cautionary tale and an innovative tale cautionary because classic things and common things are seen commonly. So sure the patient would be, you know, bread and butter infertility will be picked up. But I do think that those nuanced patients will not be seen as easily. And you might have IVF inefficiency, cuz I think people might be pushed towards IVF cuz it might just seem easier because they don't wanna end up with twins and triplets where they need to reduce down. They don't wanna end up, because especially if you're on a, you know, a trigger state, getting a fetal reduction is impossible. The other thing that's interesting is that you have to look back at what happened during the pandemic with telemedicine. You have states such as Florida, that require a provider to have a license in that state to speak to a patient in that state for telemedicine. And that hasn't gone away. Wow. And so, you know, if a doctor in New York is in New York and their patient's living in Florida now and they wanna continue care with their doctor in New York, if that doctor's not licensed to practice medicine in Florida with either a telehealth license or a full medical license, they are breaking the healthcare law and they have no coverage at that point in the state of Florida. Those laws aren't going away. And I think we might see more of those happening, especially with trigger states and non trigger states. And I think OB GYNs may not be able to provide the telehealth services to the patients they want everywhere. So you wanna counsel a patient that they can travel to you for a termination or they can travel to you from wherever they live. They may not be even able to get that telehealth consult that's happening today because the laws may change on the, you know, the parody laws of telehealth may change. Um, so I do think that innovation is, is not, you know, modernization of the fertility clinic. It's actually the fact that people are gonna use a model that's been used for, you know, 40 years now in, in general internal medicine and pediatrics use, nurse practitioners use physician extenders, use PAs.

Speaker 2:

And you, you know, you mentioned statistic that there were 450 fertility clinics in 20 21, 400. Now what's causing it? Is it the combination of the insecurity plus physicians retiring? Cause that's a significant decrease that only exacerbate the access challenges that already exist.

Speaker 3:

Great questions. So it's a multifactorial decline. The first one that you're seeing is that there is the continuous efforts of the private equity world of, you know, consolidation, collaboration and rollups, right? So now you're seeing the clinic that was a standalone in a certain market can no longer stand alone because now the competitors come in and so they're either being undercut on price or outperformed on quality or whatnot. The second reason is, is that in this postops world, as people are now having to move on with the, um, the life after dos, there is a push for genetic testing of embryos. Mm-hmm.<affirmative>, Well, not every clinic is set up to do that. Not every clinic has robust embryology services that they can provide for, for extended glasses culture for the freezing and thawing of embryos for the JAG testing of embryos. It's not part of their workflow. So for some, the modernization of their clinic is price prohibitive to the volume and the market that they serve. So we see clinics closing and then of course you said it best people have a right to retire<laugh>, like you can call it quits. You can get to the point where you realize that you are not at the top of your game and that you might be putting people at risk and it might be time to focus on other, you know, avenues. And so you decide that you wanna leave and people don't wanna buy old clinics anymore. People want new modern, shiny fertility clinics. So clinics are closing. And I worry about the contraction that we're seeing today. I worry about this because the name of game is access, right? If you think about why did I start nodal, why are we talking about clinics? It's all about access and supply. And if you can, if you limit supply and you limit the number of clinics that are out there and you limit what people can do because it's dependent upon the state that they live in, right? We learn from jobs, the state that you live in dictates the care that you can receive. Well, who knows what's next.

Speaker 2:

So in, you know, and we talk about access, I mean there's so many, so many different aspects and we talk about, you know, health deserts, food deserts, OB deserts. I mean we're creating fertility deserts across the country where it will in fact maybe become, you know, just in, in coastal uh, cities. It might be a New York LA conversation. Those are the only places to go. And there's been a movement over the past 10 years to try to make fertility, uh, more accessible, more affordable. Um, but even if you could, you know, theoretically pay for the care, you know, it's going to be practically prohibitive for many families. You know, thinking, you know, working, working family to travel to New York or even when you need to receive the care and you need to be able to, you know, be tested or whatever the case may be on a regular basis. I mean, you just can very quickly see how the gap in access increases.

Speaker 3:

Yeah. You know, the, the funny part about fertility is that people think of it as a punk tape moment in someone's life. That single moment, call it six months or three months or whatever, it takes people to get pregnant. It doesn't unfortunately have the societal view that infertility is a chronic healthcare condition. Yeah. People suffer from this condition for a prolonged period of time. And the same way that it's palatable for us to talk about diabetes and it's palatable for us to talk about hypertension, those things happen later in life. We're talking about something that happens earlier in life and the, the unfortunate side effect of the silos of care that we're talking about, right? Where there's like these little centers of care here and centers of care. There is that, you're right, we are missing the bridge between those two silos and that bridge is the access part, right? We're missing access. And so until there's a societal view that infertility is a disease, right? It is a condition worth treating, it is something your employer should support. It is intrinsic to, again, our core family values of this country that people want to have families and they might need help to do so We're gonna have problems. Um, I love the idea of, you know, discussing fertility island or fertility deserts. Um, cuz that's the right way to feel. It's isolating and it feels very isolated today. And as you know, someone who loves their job, my biggest frustration is I worry about all the people I don't get to see.

Speaker 2:

Yeah.

Speaker 3:

It's a, it, it's a challenge.

Speaker 2:

And you know, and professional women, um, have been able to postpone, uh, childbearing while they put their careers first and relied on ivf and this is gonna have an impact on the advancement of women in, in the professional world. So what can we do? You know, we need sort of societal change, legal change, anything in our closing thoughts. What, what can we do tomorrow? You know, or next week obviously vote. But what would be really helpful as this audience is mostly healthcare lawyers, is it explaining to our clients, is it getting out there and explaining the impact of the laws? How can this community be helpful?

Speaker 3:

So I think you're doing the right thing today by having a podcast such as this because there is so much rumbling but very little discussing that's occurring. And we need to take those one off conversation to start putting them in places that people can listen to'em at the right time when they're ready to listen. Mm-hmm.<affirmative>, right? We always remember that the email that you send is not the same email that I will read depending upon where I am in my day in my life and what's going on. So I think having podcasts like these is so important. I also think that it is incumbent upon healthcare lawyers to educate themselves on this state and the local milieu that they're in and the environment that they work in because they are so drastically different, right? New York is so different than Pennsylvania and we are only separated by the state of New Jersey in between and in some places New York and Pennsylvania touch. Um, but it's important for people to understand where their clients are physically, geographically and also where their clients want to grow to. Because I think that a lawyer should be viewed as a important part of a practice's growth plan. People should view their lawyer as the person that they pressure test what they hope to do and the lawyer can guide them on the right way to do that or not to do that. And so I think that it is intrinsic in that relationship between attorneys and clients when the clients especially are healthcare clients to say, Hey, you could do this, but do you know about that? Yeah. And that excites me. Um, I think we're about to see some really cool conversations happening and some cool collaborations happening where people are saying, Hey, my client is here. Let me go connect you to someone else there because we need to figure out how to get around this system because the system's not working today. So I'm excited by the future and I am grateful that people are dedicated to times such as you Delphine, um, to really getting these topics out there cuz hopefully more people will discuss unless people will just rumble.

Speaker 2:

Well, I think today was a really cool conversation and uh, one of our many points of collaboration. And on behalf of a HLA wanna thank you for joining us, Dr. Levine and uh, for all that you're doing in this space.

Speaker 1:

Thank you for listening. If you enjoy this episode, be sure to subscribe to ALA speaking of Health Law wherever you get your podcasts. To learn more about ALA and the educational resources available to the health law community, visit American Health Law dot.