I’m joined by Dr. Brian Levine, founding partner and practice director of CCRM New York, and founder of Nodal, to discuss the future of fertility care. We explore how artificial intelligence is transforming embryo selection and improving clinical outcomes, and we take a transparent look at the true costs of egg freezing and what patients should expect. Dr. Levine also shares how Nodal is revolutionizing surrogacy by streamlining the matching process and lowering costs for intended parents.
From technology-driven advances to policy-level changes, this conversation highlights the many ways fertility care is evolving and how we can better support patients at every stage of their journey.
In this episode, we cover:
- How AI is being used to improve embryo grading and IVF success
- The true costs of egg freezing and what patients need to know
- How Nodal is changing the landscape of surrogacy matching
- What to expect from recent government efforts to make IVF more accessible
- Why tech and transparency are reshaping the future of fertility care
Resources:
Find Dr. Levine at CCRM Fertility of New York
Find Dr. Aimee’s Fertility Essentials & Supplements
Full Transcript:
Dr. Aimee: Welcome to the Egg Whisper Show. The title of today’s show is “The Future of Fertility: AI, Egg Freezing Costs, and Modern Surrogacy” with none other than Dr. Brian Levine. Welcome Brian.
Dr. Brian Levine: Hi Aimee. Thanks for having me.
Dr. Aimee: I’m so glad you’re here today because we’re diving into some of the most cutting edge and important topics in fertility care: everything from artificial intelligence and embryo selection to the economics of egg freezing, to the evolving world of surrogacy and third party reproduction. My guest today is world renowned Dr. Brian Levine, founding partner and practicing director of CCRM New York, one of the country’s leading fertility clinics.
He’s a double board certified reproductive endocrinologist and OB GYN, and a recognized innovator in reproductive technology and patient care. Internationally recognized for his expertise in LGBTQ plus family building, treating female infertility, complicated secondary infertility, and third party reproduction.
He’s also the co-founder of Nodal, a platform working to modernize and streamline the surrogacy matching process. Based in New York City, he brings a unique perspective on the trends shaping fertility treatment today, both from a medical and tech savvy angle, and I’m so glad that he’s joining us. Brian, let’s start with AI and the future of fertility.
You’re working with advanced AI tools like Erica. How is machine learning actually helping you identify the best embryo for transfer, and what patterns can it see that humans might miss?
Dr. Brian Levine: I know that we don’t have 24 hours for this podcast because I feel like that’s how much time we would need to actually talk about the role of AI and embryo selection. But what I can say is that I am super excited by what the future has in store for us when it comes to embryo selection. What many people may not realize is that the most subjective thing that we do is grade gametes, normal sperm, sperm, normal eggs, bad eggs, nice embryos, ugly embryos. These little statements that I just made might seem like I’m making them off the cuff, but this is actually what trained embryologists do every day, and we make clinical decisions based upon these morphological or shape related assessments. Here’s the problem: everything that we do is fraught with subjective bias, right? So like what I call a 3BB in my lab, which means a mature embryo that looks almost perfect on the outside. It looks almost perfect on the inside, 3BB may be in another lab, a 4AA because they might have a little bit of a different interpretation. So that’s where AI comes in. What AI can do is either help benchmark a lab so that there can be consistency, so you can actually feed the model with what everyone does in the laboratory to make sure that you’re grading everyone consistently. Or what it can do is it can use national de-identified data based upon pools of data from multiple centers, from multiple grading objectives, and you can actually take that data together to say, what does the AI engine think this looks like?
And is it matching up and corroborating with what the doctor is seeing? Why does this all matter? We’re actually seeing this really cool pendulum swap go across the way. what I mean by that is over here is the genetic testing of embryos. And over here is this whole theory of just “leave them the hell alone.” And so what happened is that we went through this whole pendulum swing to this. One side was saying, “let’s test everything.” Now we’re seeing, you know, as a result of the class action lawsuits, we’re seeing as a result of patient requests. You know, that patient who makes only one embryo on day seven, and of course they wanna transfer it. So now the pendulum swings this other direction saying, “Can we figure out some other ways to assess that embryo?” And I think that’s where AI is gonna help us give the patients more information to make a better decision.
Dr. Aimee: And then is it helping you also tailor your IVF protocols for your patients as far as medication dosing?
Dr. Brian Levine: So to date, I’m actually not using AI in the lab because I think that the models are not robust enough for clinical utilization, but I think they’re getting there. When it comes to answering your question regarding the clinical indices of success and how are we actually getting there? I cannot wait for the day that the patient comes to your office, she sits down in front of you, and she has all of her labs. And we put her little labs in and somehow in the cloud it zips up the labs, and zips down the answer: four cycles, three like this, one like this, three embryos at the end. She’ll be a mom by 39. So like we’re not there yet, but I think that’s where we’re getting with the technology and what I think that technology is actually going to do is help people understand on subsequent cycles, what can you do to optimize. I mean, look, you and I see probably some of the most difficult patients in America, if not around the world. And you know, and I know, that the first cycle of IVF that someone does is both diagnostic and therapeutic because you learn a lot about that patient, right? You learn how they stimulate, what happens when you retrieve their eggs?
What happens when you fertilize their eggs? What do their embryos look like? How many are normal, abnormal? And therapeutic because you actually hope to throw that data away and just get them pregnant. And so, I think what AI is going to do is gonna help us make an assessment and a plan for the patient, that’s tailored to the patient.
Dr. Aimee: I agree. I have that same dream that we can just input data and then you get a really nice analysis that kind of forecasts what could happen for that patient. And that’s really helpful for them too, as far as knowing how many cycles that they might need to do in order to be successful. So I wanna talk a little bit now about egg freezing and some of the behind the scenes realities that patients might not always hear about.
I mean, one of the things is the cost and patients often feel surprised by the true cost of egg freezing. What do you think clinics should be more transparent about when it comes to pricing?
Dr. Brian Levine: So egg freezing, I truly believe is the only opportunity that a woman can take to protect and preserve her fertility. Full stop. There is no other technology that’s out there today. You can take a ton of Metformin, a ton of Rapamycin. You can take a ton of acai berries or CoQ10. You can do whatever you want to supplement. But as you get older, your egg count goes down, and as you get older, the quality of your eggs goes down as well. And the only way to stop the clock is to freeze your eggs. However, you have beautifully hinted at the fact that many people have sticker shock. And it’s not sticker shock at the cost of egg freezing.
Right? Egg freezing costs around $10,000 pretty much everywhere in America, and the medications cost around $2,000 to $3,000 almost everywhere in America. What people don’t realize is that you can’t just pop your eggs back into you to get pregnant, and that the unspoken costs are: One: the storage for as long as you’re gonna leave them stored. And two: the actual utilization costs. Every egg that is frozen is denuded, which means that all the outside cells are removed. As a result of that, every egg that is frozen must be fertilized with ICSI, which means intracytoplasmic sperm injection, or taking a single sperm and putting inside a single egg. And every egg that’s frozen not only requires ICSI, but requires a laboratory to culture it, to blastocyst ultimately for transfer. So the laboratory costs can be as high as $5,000 to $6,000 just to make the embryos. And then, there’s the cost of the transfer, and that could be another $5,000. So you’re really looking at the first half of IVF, which is how I counsel patients, both financially and the experience.
Dr. Aimee: That’s a good point. I often say egg freezing is IVF without the effing, but you’re right, it’s the first half of IVF more so. yeah. And then success rates are a big part of marketing egg freezing, and they can be often misleading. And how can a patient interpret success metrics and what are the most important numbers for them to focus on?
Dr. Brian Levine: So, I know you’re gonna agree with me on this one, which is, I think we’re all incredibly grateful to Dr. Goldman putting out her study in the mid-2010s talking about the rubric for how many eggs a woman would need to freeze to be able to have a successful outcome. But here’s the problem: the United States is a heterogeneous population, and our clinics have a high degree of heterogeneity contained within them. And the only thing that’s consistent within each of our clinics are the laboratories themselves. And what I think every clinic needs to do and should do, and what every patient should want them to do is to have the ability to share their own internal data on their success rates with egg freezing. Now, look, I’m part of a network of clinics, right?
We have 17 clinics across America. So, what I do with patients all the time is I talk to them about benchmarking data. What is our success rate for our thaw, compared to our national thaw rates, compared to what should be projected across the country? But what many people are shocked to learn is that the national standard for egg freezing is that for a hundred eggs that are frozen in aggregate, around 80 to 90% will wake up. There is a loss rate on day zero. The moment you go to use them, you lose some, and then there’s a loss rate when you go to fertilize them. And then there’s a loss rate when you go to create embryos. And then there’s a loss rate when you genetically test them. And then not every embryo perfectly implants. So, this top of funnel to bottom of funnel conversation is so critically important. And what I think as doctors we need to do is to have a data derived decision tree that the patients understand. What is the data that my doctor can provide me? What is the data that my clinic can provide me? But most importantly is what is the data that’s appropriate for me to help guide my journey?
Because everyone’s journey’s a little bit different.
Dr. Aimee: I agree, and I imagine you’re like me in that you counsel patients to freeze more eggs, especially if they’re planning on using them at an age where they’ve run out.
Dr. Brian Levine: Absolutely. And one step further, I ask patients what their plans for kid number one are, if you’re sitting in front of a 32-year-old who tells you, “Look, I am about to make partner Goldman Sachs, and when I make partner, I plan on taking my foot off the gas only when I’m 40. Now I’m not going to start trying to have kids till 40 41.” That’s a very different conversation ’cause she’s more likely to require her frozen eggs for kid number one than the 32-year-old who’s dating someone who’s just not sure about him and will likely try to reproduce at 35 and be okay. And then she’s freezing eggs really for kid number two.
Dr. Aimee: Right. That’s a great point. Let’s talk about Nodal and what you’ve done to revolutionize surrogacy matching.
With your work at Nodal, you’ve seen how surrogacy is evolving. What are some of the biggest innovations in how intended parents and surrogates are matched today, and how is Nodal helping with that?
Dr. Brian Levine: Thank you for bringing up Nodal, because you know it’s funny to wear two hats as a doctor, right? I always joke that I wear three hats, right? My proudest job is being a dad. My second favorite job is tied. It’s either between Nodal or CCRM, and the truth is, the average doctor in America is probably doing around 10 to 15 surrogacy cases a year. And in my clinical practice at CCRM, I’m doing around three surrogacy cases a week. That means three embryo transfers to surrogates a week. So, it’s a huge part of my clinical practice. And in 2021, gestational surrogacy was illegal in New York. Most people don’t realize that, right?
So as a doctor in New York City, I was incapable of transferring an embryo into gestational carrier by a function of the laws and regulations of the state. And then in 2021, two cool things happened. One was that employer-based benefit solutions became a mandate for the state. So, every company that a hundred employees or more had to be able to provide fertility services. And two gestational surrogacy became legalized. Once it became legalized, I was jumping all over it, right?
I’m the only boy in my practice, so as a function of being the only boy in my practice, I see so many same-sex male couples and so many couples who require this. And now that they had employers paying for embryo creation, I was like the happiest guy on earth. And then very quickly I realized that supply and demand economics took hold. And what I realized was that the cost of surrogacy was outpacing the actual supply of surrogates themselves. And so, the number one bottleneck in America for gestational surrogacy is matching. And by matching that means setting up an intended parent to work with a gestational carrier. By the way, you’ll notice I said “work,” and not “use.” Because in this country, we do not use women. We work with gestational carriers, and we support these heroes who help people. With that said… so what I did was I built this platform called Nodal, which is the leading online surrogacy platform in America. And what I was able to do was to allow for high throughput medical record review for easy onboarding of surrogates. By having this capability to easily onboard a surrogate to get her onto a platform quickly and then giving her the opportunity to make the first move and pick the intended parents that she wants to move with, we were able to both improve the process, the quality, and ultimately the relationships between gestational carriers and surrogates. To give you some fun data, the average agency in America today requires nine to 18 months to match an intended parent with a surrogate. On Nodal, we match people inside of 45 days. The average agency in America today has gone from $150,000 to $250,000 at the blink of an eye. On Nodal, the average intended parents spends around $110,000.
Dr. Aimee: Wow.
Dr. Brian Levine: Most importantly is: we’re in network with the three major fertility insurance companies, Carrot, Maven, and Progyny. But I think our biggest innovation has been addressing the biggest pain point for every intended parent, which is just speed and efficiency.
Dr. Aimee: Wow. That’s impressive, Brian. I’m so impressed. All the work that you and… I imagine it has just been very rewarding to see your hard work pay off in this way, and for families to become parents from Nodal. That’s incredible.
Dr. Brian Levine: We have almost a baby being born every week right now, which is crazy.
Dr. Aimee: Wow. That is. A huge congratulations. So as someone working at the forefront of AI, egg freezing and third-party reproduction, what do you want patients to understand about how these technologies and systems are evolving and how can they learn more?
Dr. Brian Levine: So first and foremost, I think you could learn more by just following a bunch of great people online, right? So, there’s so many great content generators today from people like Dr. Aimee. Follow the people you like because we’re all going to be talking about it.
Second, if you go to the Fertility and Sterility website, there’s actually an entire patient side on the Fertility and Sterility website and actually on the ASRM website as well. And you can, as a patient, actually go in there and find, lay information to help you understand about all these great innovations that are occurring.
But third, what I think is happening in our field for once finally, and this is on the heels of the executive order going live this week, is that people have finite resources. And, while REIs or Reproductive Endocrinologist and Infertility Specialist have always been committed to helping build families. We’ve always had this hard part of our job where we recognize that there is, it is a great possibility that someone can go through multiple treatments and end up with an empty wallet and an empty nursery, and that’s a true failure of the industry and a failure of our profession. And so, what I think is happening today is that you’re seeing that AI and all these cool disruptive technologies are all focused on one thing, which is efficiency and affordability. And by being more financially efficient with people’s dollars that they have to deploy, we’re actually helping people have the dollars that they need to raise these kids, and I’m so excited for what the future has in store.
Dr. Aimee: So, tell us how the executive order really impacts patients today.
Dr. Brian Levine: I love your question because I don’t know the answer. The truth is the executive order that was issued by President Trump on February 18th is the first time that a presidential executive order directly related to me. It’s the first time I could say to my mom, “Hey mom, there’s a piece of paper that directly impacts what I do for a living.
Like here it is.” So then like any Jewish mother, she says to me, “What does it mean?” And I was like, “I have no idea.”
The answer is that the executive order that came out only basically said that the government is going to prioritize IVF in the United States. That we’re going to make it on the forefront to help make it more affordable and more accessible.
Here’s my predictions of what I think will happen. I do think the government is going to follow through with their commitment to making IVF more accessible. But you must start somewhere, and you can’t mandate that every insurance company covers IVF because you’ll actually go broke really fast, right?
We know that IVF is expensive and there’s no way specifically that you can get each state to agree because we’re talking about many state-related insurance plans. But here’s what I think is going to happen and here’s what I think is really cool, and I’m willing to bet you a nickel on this one.
I think the government’s going to come out with a program to help support our government employees and our military with their family building programs. And I think that’s an easy low hanging fruit where they’re going to be able to help a population or two populations with their goals. I also do think that it’s about time that pharma is put in check,
Dr. Aimee: Yeah.
Dr. Brian Levine: I think that the American government is going to take a big magnifying glass to look at the pharmaceutical costs because you know, and I know today that if a patient’s using insurance, it is a different pricing scheme than if they’re paying cash for their fertility drugs.
And what many people who are watching this podcast may not know is that it’s cheaper to pay with cash than to use your insurance. Said otherwise you can burn through your entire insurance plan on just the drugs because of the markup that’s negotiated between pharma and the insurance company, and instead have no money left to pay for the procedures required. While if you just paid cash for your medications, maybe $2000 or $3000, you could have your full bevy of $20,000 of services there and maybe get one or two IVF cycles to have the baby that you dream of. And that’s what I’m excited about.
I am actually excited for the government to take a deep dive to say, “How do we fix this broken system today and how do we scale this so that every American who dreams of having a child can actually do it?”
Dr. Aimee: Yeah, I mean, Americans are being price gouged, and I’ve been saying that for years. I mean, you can take the same vial of Menopur that we get here for $80- $90 a vial, you can get it overseas for $20 a vial. I mean, it just makes no sense.
Dr. Brian Levine: I love that you said overseas, but you can just take a car ride north or south and go to Mexico or Canada
Dr. Aimee: Yes.
Dr. Brian Levine: Get it for less than $20.
Dr. Aimee: Yeah.
Dr. Brian Levine: And it’s the exact same drug,
Dr. Aimee: It might be just wrapped, your five vials might be wrapped in Saran wrap. You don’t get the box, in the box, in the box. You know, Americans love their packaging, but I think most patients could care less about the packaging if it means not paying $6,000 for their medications.
Dr. Brian Levine: And you know what’s fascinating is that we’re the only country on earth that provides IVF resources where the doctors are not allowed to distribute the medications. And the reason that that’s interesting is that, you know, I do a lot of international work and I, of course, go to India quite a bit. But, if you talk to physicians, they know the prices of drugs, because they’re selling it out of their clinic, and they’re able to help patients make ends meet because when a patient can’t afford the treatment, they can help discount one side or the other to make it affordable. In this country, we’ve decoupled the medications from the treatment plan, even though they’re inextricably linked. We have no transparency into the pricing of medications whatsoever.
And as a result of that, I think our patients sometimes get frustrated with us when we have no control over it, when we can’t share with them what the intrinsic cost of the cycle will be, because we don’t have transparency into their medication costs. So, I do hope the executive order allows for a giant magnifying glass onto big pharma, and I hope ultimately that our patients are the ones who are able to benefit from the plans that their employers are providing them.
Dr. Aimee: Yeah, absolutely. And oftentimes patients end up with thousands of dollars of unused medications from their cycle because medications were over ordered. I imagine when patients are getting drugs from the clinic in real time, they’re going to pay much less in the end.
Dr. Brian Levine: Yeah, it limits the wastage, you’re correct.
Dr. Aimee: Well, Brian, thank you for such a fascinating and interesting conversation.
I really appreciate your time, and I hope to have you back again soon.
Dr. Brian Levine: Thank you, Dr. Aimee. It’s always a pleasure to see you and I hope you have a great day.
Dr. Aimee: Thank you, you too.
