Ep 1: Optimizing Patient Care, with Dr. Alan Copperman
Fertility Forward Episode 1:
Today on the Fertility Forward Podcast, we introduce your hosts Rena and Dara, and they share some background about their own struggles with infertility. Rena Gower is a licensed social worker here at RMA. She is currently a state advocate for RESOLVE: The National Infertility Association where she lobbies for healthcare reform and improved insurance coverage for those needing infertility treatment. Dara Godfrey is a registered dietician at RMA. She supports patients’ nutritional goals at every stage of infertility treatment and pregnancy, including pretreatment health and weight loss, polycystic ovary syndrome (PCOS) and thyroid conditions, as well as pregnancy nutrition during each trimester.
Rena: Hi everyone! We are Rena and Dara and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patience because knowledge is power and you are your own best advocate.
Dara: Dr. Alan Copperman serves as our Medical Director here at RMA of New York. He’s also the Director of the Division of Reproductive Endocrinology and Infertility, as well as the Vice Chairman of the Department of Obstetrics Gynecology and Reproductive Science at Mount Sinai Medical Center. He's an experienced and respected clinician, has published numerous manuscripts and book chapters on reproductive medicine and has co-authored hundreds of scientific abstracts on infertility, in vitro fertilization, egg freezing, ovum donation, and genetics. He is also our boss! In this recording, we discuss optimizing patient care, helping patients find hope, redefining success, looking at overall perspective, and empowering patients to take steps forward. Enjoy!
Dara: Dr. Copperman, so happy to have you on today!
Dr. Alan Copperman: Really a pleasure to be here.
Rena: Thank you so much for being here, we so appreciate it.
Dara: We have lots of questions, but let’s start from the beginning. How did you get involved in this world of fertility when you went to medical school?
Dr. Alan Copperman: I was just a medical student and I was on a rotation and there was a woman who suffered from a miscarriage and I was really curious about what could have caused it so I began to do research and did a presentation and then I did microsurgery and I was actually using a suture that is a fraction of a width of a human hair and I was putting together a fallopian tube with an attending physician and thought wow this is this incredible area of medicine that you can have such technical thrill from the challenges that human reproduction presents and yet such a human connection to people and transform their life and I was just completely hooked.
Rena: You have so much passion about the job and it’s so clear you know what you just said and how you got into it. Is that one of your favorite parts of your job? The human connection that you get?
Dr. Alan Copperman: It really is. I think I was originally drawn to some of the technical and surgical but these days it is just so clear that the emotional connection that I get to have with patients as I go on the journey with them and as you know as a therapist sometimes when a patient suffering in front of you you feel it, and your empathy comes through and then when they succeed you can really celebrate and rejoice with them and that journey makes this field among all the others that I know in medicine just really unique.
Rena: Sure, I think sometimes it can be a catch-22 also. I mean do you find yourself taking home cases with you? You know I do sometimes, some cases really stay with you, you know you want somebody to get that positive result so much and it's almost devastating for you too when they don't so I think it also can be you know very difficult I think, this is such a humanistic field.
Dr. Alan Copperman: There is such a human impact of what we do that is always self-reflection. So if the cycle for example of in vitro fertilization doesn't succeed. I would want my physician to go home and think about what can go better the next time and to come back re-energized with a way to achieve success and I think that's part of that connection that we get to have in this field.
Rena: Dara, do you find that also in nutrition? I mean I know it's a little bit different but I would imagine too that you are so involved with your patients working so closely with them as an important part of their journey.
Dara: Of course I take it home with me. I work with patients who email me on a daily basis what they're eating and how they're feeling emotionally and why they choose certain foods. And so I do see it quite often, I definitely feel it everyday and also being a patient myself here, it’s on my mind and I want to make sure on both sides being a dietitian but also understanding what they're going through in some capacity.
Dr. Copperman: You're so incredible with our patients when you connect with them and you talk about health and wellness. How do you manage to bring that kind of energy every single day to every encounter?
Dara: I just have the passion for helping people and I love talking about food and the connection between our body and how what we eat can really make a difference. Hormonally and physically and mentally.
Dr. Copperman: Yeah, I think that you are right. I think that both of you just connect so much with our patients. This team that we're building has got to be unique and I think that we got one goal in common and thats what will help them achieve success and this is with mind, this is with body, this is controlling whatever we can control in the environment because there’s so much to reproduction that’s beyond control.
Rena: I think you just hit on something that I see so much you know in my work with patients and that’s the loss of control. I think as you said, both Dara and I bring a perspective into our work as we both were patients and both went through it ourselves. So we know exactly what it's like and what it feels like and I find in my work you know as a therapist you often have to be very careful and they teach you in school you don't disclose about yourself, you don't disclose personal information because thatI can kind of muddy the waters with patients. But I think this type of work is so unique and I found throughout my years of work that it really resonates with patients and they appreciate so much when I share with them my journey because it helps them feel not alone and they look at me and I say oh wow I didn't realize somebody else felt this way you know they see hope because I had success and they love it and so I've really learned over the years that it is okay to share a little bit and of course of every patient it's different but it really resonates with people.
Dr. Copperman: Yeah, we used to have baby pictures on the wall and due to HIPPA and some other sensitivity issues we don't anymore but many patients found them to be aspirational and they look forward to that moment when their picture could be hanging on the wall. I think that it part of what you do well, is you help patients instead of seeing other people's successes as their own failures to see that as a way to understand that the journey isn't always the direct line and to see that there's an end inside and to help them to have hope we're even on days that they feel despair.
Rena: Sure, and that’s one of the questions I always ask people on day one is do you have hope? Do you believe in this process? And we talk a lot about how you know you start your life and most people have a picture where they want to end up you know they want to get married, have two kids, go to college, whatever that may be and this journey and this process often totally strips you of that picture makes you really think. So I always work with patients to say look sometimes it's about reframing and it doesn't mean that you can't get to where you want to go but it's about reshaping that image.
Dr. Alan Copperman: And redefining success sometimes.
Dr. Alan Copperman: Success can be an IVF baby even if you thought it was going to be a candlelight conception. Success can be using a donor egg if that means having a baby in your arms. Success can be preserving your fertility if that relationship didn't work and you’re not exactly where you want to be. But to help you just respect and grasp onto where you are right now and that's what you do well with our patients, as you just help them see that big perspective and it's not always where their thought they were going to be at that moment but it’s embracing where they are and empowering them to take steps forward from there.
Rena: Right, and I think as you said you know so much of this field is about empowerment and people come in and Dara, I’m sure you see this too as a nutritionist, how do I come in and take control of what I'm putting in my body and Dr. Copperman, you touched on the loss of control and it's about showing people that they do have power and so much of this field does allow you to empower yourself and does allow you to take control. And so I think that’s really powerful but you know, as us in the field you have to show patients you know that they have that.
Dr. Copperman: I think Dara what you’ve done well is that sometimes when a patient has hypothalamic amenorrhea and you've helped them gain some weight in a healthy way and help them ovulate naturally it really is incredible how the mind and the body and the environment can come together to help health and wellness.
Dara: Yeah, and empowering them. I think giving them something to grasp, something to be positive with and letting them take ownership of their health.
Dr. Copperman: How do you manage the polycystic ovaries patients? I’d say the most common patients I send to you, is someone to help manage their carbohydrate intake so we can lower insulin levels, lower Androgen levels, restore the normal hormonal milieu. I know what it does on the back end to the physiology but how do you go on a grassroots level take somebody who's carb-loving and turn them into somebody who still loves food but maybe as gently transform the nutritional composition of their dietary intake.
Dara: I think giving them compassion and acknowledging the fact that people with PCOS typically do crave carbs more so than the average person letting them know right off the bat that carbs are not the enemy but realizing the importance of coupling carbohydrate intake with a source of protein are healthy fats to help prevent that blood sugar spike and that blood sugar drop that can perpetuate that constant craving for sugar.
Dr. Copperman: I mean, I love carbs so I'm actually partly asking for our patients and partly asking…
Dara: This is important for anyone but specifically with PCOS specifically in the morning and late at night we have to be extra cautious with the amount of carbohydrates we consume and the quality, the types that we get. So sticking with more of the fiber carbohydrates first in the morning trying to avoid too much fruit or processed carbohydrates like white breads, potatoes and sugary breakfast cereals and focusing more on the foods they should incorporate healthy proteins and a source of fiber coming from oatmeal or flaxseeds.
Dr. Copperman: How do both handle the guilt that patients feel when...I’d imagine that you’ve given somebody strict instructions, they go out to a nice restaurant they eat the bread and they say wow. Dr. Copperman and Dara told me not to and next thing you know they’re at Rena’s desk going Now I'm not going to have a baby.
Rena: I get that all the time. I ate pizza. This didn’t work, that’s because I ate pizza. You know I just work with people and say you have to love yourself, you know? This process I think is so difficult because people know kind of every single step of the way which you don't get if you conceive naturally, right? Most people that conceive naturally don’t know until much later and they may still be out there eating sushi, drinking wine, whatever because they don’t know. Whereas here we know before conception we start the process of trying to conceive before it happens and I think you know because of that people put so much on their selves and they're always looking for something to pinpoint something to blame, right if the process doesn't work and they’ll point to say oh it's because I had pizza a month ago and I shouldn't have. And so I work with people a lot on kind of guilt and shame, learning to love themselves, self care, take care of themselves and say, look you’re human, right?
Dr. Copperman: And humans wouldn’t have existed on this planet for billions of years if it turned out that that Levain Bakery was going to turn a successful cycle into one that’s unsuccessful.
Dara: And also switching the script of ‘did you enjoy that Levain cookie?’ You shouldn’t have guilt if you actually enjoyed it.
Rena: Right. You have so much stress going on. Try to find, i say, you know, work every day, practice gratitude, love and kindness, find something to make you feel good and let's help use the power of, you know, I'm big on positive psychology, help reframe your thinking, help you see the world in a different way.
Dr. Copperman: I love that.
Dara: Yeah, Rena I agree with you. The power of positivity is huge and I always tell patients at the end of the day we often focus on the one thing that we did wrong. I ate that bagel in the morning, why did I do that and then instead of doing that, be kinder to yourself. End the day off with something positive.I avoided that second handful of french fries that I really wanted to go for but I didn’t.
Dr. Copperman: I do like french fries.
Dara: That handful’s OK Dr. Copperman. But instead of saying, you know, acknowledging something you did that you weren’t happy with, flipping the switch. Your mental capacity I think it's important to focus on what you can do better tomorrow as opposed to acknowledging your shortcomings for today
Rena: Well I work a lot with people just sort of being in this moment, you know let's be in the present. People are always looking you know for what comes next what comes next and it's and I work with them and let’s be in the now you know let’s be here today where you're at, go outside, smell the flowers, enjoy the weather. You know, this pregnancy its not your last one which may have ended in a miscarriage. This is a new experience. You’ve never been here before on this day with this pregnancy. This is totally different than your last one.
Dara: Rena I’m happy you said that because mindfulness that’s a key factor in terms of health, in terms of lowering your stress levels, meditation, something as simple as a one minute breathing exercise or listening to an app which I often recommend called Insight Timer.
Rena: Oh you told me about that. I love it.
Dara: It’s great and it's just being in the present focusing on the brebreathast not thinking about what you did yesterday or what your plans are for tomorrow but being in the moment right now.
Dr. Copperman: And I think sometimes we have to face the fact that the cycle might not work and I think some people are so afraif of failure they don’t even try to get pregnant or don’t want to do another cycle. And sometimes having that courage to potentially fail will help propel somebody that otherwise wouldn't have succeeded and put them in the opportunity where they can succeed.
Rena: Are you a Brene Brown fan like I am? I hear a lot of Brene Brown in that speech - being the arena, vulnerability...
Dr. Copperman: Hey you gotta make yourself vulnerable or you’re risking not taking a chance at success.
Rena: Right. You’re not gonna get anything
Dr. Copperman: So approaching the possibility that it might fail can be a healthy technique I find for couples. And what if it fails what's the next step and it may be adoption and it may be embracing the life they have but I find that trying is the most important thing to helping somebody achieve their goal of succeeding. You know sometimes you have to buy a ticket.
Rena: You have to get in the arena and if you’re not in there what are you doing? You’re on the sidelines and I always tell people look it's never a failure I don't like to use that word and I tell patients we don’t say they got a negative result we say it's not what you wanted but I always say that nothing is a failure is always data, it’s always a piece of the puzzle taking you to your next step so the cycle didn't work well it’s still giving Dr. Copperman data on how your body responds.
Dr. Copperman: A cycle that didn’t have the desired outcome we sit down and really have a root cause analysis like I don't use the word system failure but like any other time that you didn't have the optimal result and we go back on what we've learned from that. Were your medications too high not high enough can we go one day more than we should have or not one day more than we should have how many eggs did we get what are the sperm look like and how did the embryo grow and what can we learn to make the next cycle better and I think it makes us better doctors and its we have machine learning algorithms that take big data and turn them into decision support tools so you take somebody who didn't have cycle success that they wanted and turn that next cycle into a more successful one. And that is, you asked at the beginning what I love about this field - using big data, using huge amounts of information, using the - I'm going use the word with your permission - failures of cycles of countless cycles in the past to drive successes in the future evolving as clinicians and healthcare providers and getting better and better at what we do every day that's what I love about
Rena: Yeah. And I always say, look you know it’s hard. I’ve been there myself I was with you I was also you know the guinea pig getting injections, multiple cycles and it was horrible being there but it's never a waste and I wish someone
Dr. Copperman: We don’t like to use the word guinea pig.
Rena: Ok. No guinea pig.
Dr. Copperman: But you feel like it. You feel like it’s an experiment. WHen you mix the medications at home and you’ve got needles all over the place and you don't know whether it's going to work or not.
Rena: It’s scary. You feel like you're in a Duane Reade.
Dr. Copperman: And that uncertainty and loss of control provokes so much anxiety.
Rena: It does but you know what also and I don’t know if you guys both see this in your IUI patients. I actually think IVF gives patients much more a semblance of control than IUI.
Dara: It’s more structured.
Rena: There’s so much more structure. You’re doing the injections you have the control over that you’re getting the real time constant updates they’re no surprises. You know IUI I personally found and I see with my patients very difficult because it's like two weeks of all right see you later and you're like woah I came in a doctor's office I did you know it feels like a very invasive procedure to get pregnant and so I actually think IVF gives a lot more semblance of control.
Dr. Copperman: I’ve had patients say that doing IUIs or IVF gives them more control than just trying naturally, not knowing when they're going to ovulate when they have to have intercourse and the strain that that often puts on a relationship. That structure I agree with you can really be transformative in lowering stress levels and propelling a couple towards success.
Dara: Especially people who like structure.
Dr. Copperman: Yeah.
Rena: Absolutely and you get there's no surprises. You know you come in, you see your follicles you get the ultrasound every day so I think it is sure it does and I've never had a patient come back to me and say I don't agree with you you know you told me IVF would be easier once I started and you were wrong. They come back they say you were right this was not as bad as I thought
Dr. Copperman: And what’s amazing about IVF now is it works so frequently. Now that we can genetically test an embryo the chance of the single embryo working is many times what it was in the past so when we heard about some people that failed multiple cycles years ago the new story is they took one cycle in one embryo it just took me a while to find that one embryo and that's the genomic year we’re in a personalized year where we can find that healthy embryo from a crowd and we can put it in at a perfectly timed cycle and achieve success more than half the time a woman of any age.
Rena: You know that actually I wanted to ask you also, Dara and I were curious, you know you’ve been in the field for what over…
Dara: 18 years?
Dr. Copperman: Yeah more than that.
Dara: 18 years at least with RMA.
Dr. Copperman: Yeah so RMA started in 2001 and I completed my training at Mount Sinai in 1995 so I’ve been doing this for awhile.
Rena: Ok so how has the field changed now 2019 then you started? I'm very curious.
Dr. Copperman: Well entered the field it was still a surgical sub-specialty and we were operating on fallopian tubes a lot and these days we’re actually operating in a dish on eggs and sperm and I’d say 5-10 years from now we’re going to be operating on the genome with crisper cast nine and other molecular tools so we can change an A to a T, we can increase the chance of an embryo becoming a healthy baby so we're going more molecular and more specific and we're going so much higher success rates. You know it used to take multiple cycles to achieve what we can achieve right now so what I’ve seen in our field is one of almost a shotgun anything we can do to maybe help that higher-order multiples being not uncommon to now precision medicine we know quickly what's wrong with a couple is it the eggs sperm uterus or tubes, what we need to do to fix it which embryo’s going to be healthy how to put it in and how to quickly achieve success. We’ve shortened the duration of infertility by an order of magnitude and we’ve increased the number of good outcomes in ways that I just felt impossible when I started here.
Rena: Oh wow. I guess and another question that leads me to would be you know so many people come in and they say wow I had no idea how many people have you know infertility. I had no idea until I started and then people come out the woodwork right and it's so common and so people ask why.
Dr. Copperman: Great point. The awareness is there. People are not afraid to share their stories. Of a generational level there's more transparency. People used to only be curated and share their success stories or their baby pictures and now people are not afraid to share their struggles. You see people that, Dara, I mean all the time that are talking about it. I mean, you’re a social media person and tell me about the culture change that you're seeing.
Dara: There’s a lot more awareness especially on social media in terms of Instagram people are sharing their stories and in terms of different resources I know Rena works with of a lot of women who want to work with different groups support groups so I'm sure you see that a lot as well in terms of spreading the word and not necessarily only sharing their struggles but it's also nice to see that we're seeing a lot of women you know through their struggles and all the other side as well
Dr. Copperman: There was that campaign to say the f word fertility it’s like it's important to discuss these things you can actually find support in places that you never felt imaginable and leaving a dinner party or a work event to go to the bathroom and take a shot of fertility medication there’s no shame in that that's empowerment.
Dara: So I wanted to talk more about research and what we're doing here in terms of research and what you would like to see in terms of the research on fertility.
Dr. Copperman: What’s really excited me in the field is going and taking molecular information and driving better outcomes. So what we’ve done in the laboratories we’ve been able to sequence the genome on embryos we've been able to figure out what genes are turned on and off we've been figuring out which mitochondria are healthy and not we’ve been figuring out what makes a healthy embryo implant and what makes some embryos unhealthy and not implant so using new molecular tools has transformed the scientific world and it's going to translate over the next few years into healthier pregnancy outcomes.
Dara: Super interesting.
Dr. Copperman: It’s just amazing. Next generation sequencing has been revolutionary. In our field we used to test pre-conceptually for 4 diseases like cystic fibrosis and sickle cell. These days were testing for 280 some odd diseases and within the next six months we’re gonna be testing for more than 500 diseases so every couple that comes in we’re gonna talk about health and wellness, we’ll talk about moderation maybe cessation of cigarette smoking moderation of alcohol and caffeine intake we’ll take about measles vaccinations and we're going to be talking more and more about genetics when you and your partner are ready to conceive what is it that you guys are trying to achieve and how can we help you reach there and for couples it's going to be having a healthy child and how do we make sure that we know what the risk is of having an unhealthy child and empower the patients with tools to make sound choices of how to avoid disease in their offspring and how to achieve healthy pregnancies. I mean that’s the transformation in our field. We've gone to a molecular specialty where big data transforms the trajectories of a couple that was either going to be not pregnant or have an unhealthy child into a couple that has a high likelihood of success. It's really gratifying.
Rena: That I mean I’m curious both of your thoughts on this I think about this frequently how you know the research you just talked about and even the field as it currently is how is this going to change our overall population you know with so many people doing fertility treatments and the advent of genetic testing you know we’re weeding out embryos that could have been you know children with serious abnormalities and how is that changing our overall population you know are we now looking at a population of old people that are healthier overall and I think that's an interesting macro question you know is it is that really making a big difference in humanity?
Dr. Copperman: So health policy experts are looking closely at the field of reproductive medicine we're hitting a birth rate crunch in our country where we're at historic lows in the live birth rate per 10,000 women. So in other words we're not hitting replacement anymore and they're worried about the next generation and our population getting older.
Rena: Wow. Why do you know why? Is it...
Dr. Copperman: Because women are having their first child when they’re older and it’s more challenging to have a child and they’re having smaller family sizes. So all that is translating into population shifts and there will be more of a turn towards reproductive medicine as more women struggle and there’s going to be more support I believe at a at a governmental level for fertility because the country really wants to sustain a certain amount of population stability. So with this promotion of access to care and with the super Moore's Law expansion of sequencing technology that's translating into information being available I think we're going to be able to screen more patients and screen more embryos and help more patients who want to have a family have a family and make sure that the embryos that are created in these situations are free of disease that's where I think we’ll go and I think you're right we're going to see that transformation and fewer babies being born with preventable diseases.
Rena: I think that's fascinating and then of course in that sentence you just said touches something very near and dear to my heart which is Insurance reform in the laws and you know I'm really happy we're having Barb and Betsy from Resolve on the podcast in a few weeks too to talk about the new insurance reform that was passed in New York and now that you said that I’m wondering if part of the drive behind passing the bill was because of the population shift. You know I’m excited that we can offer insurance coverage you know to more people. I think it’s so important I didn’t have coverage when I was going through it and it's a huge expense.
Dara: And another stressor.
Rena: Oh sure and I don’t think anyone should not be able to have a family because they can’t afford it. I think that’s it’s so important and that’s so interesting that you said that and I wonder if that plays a role.
Dr. Copperman: Yeah I think that we’re all supporting access to care for as many people as we can.
Rena: Sure. Yeah.
Dara: So on a lighter note to switch things up, what you do on your days off if you have any days off.
Dr. Copperman: I'm not a big fan of the day off. I do like to sneak in SoulCycle.
Rena: What instructors do you like?
Dr. Copperman: I’m an Upper West Side person so Shawn and Sue actually are great they have good classic rock going so that’s that’s a happy place for me because for 45 minutes you get to switch off. When I speak to both of you about self care I think it's important to take care of yourself and it helps you take care of others.
Rena: Yeah that Shawn and Sue ride definitely. I’m a big Shawn and Sue fan myself.
Dara: That’s great. Well we’re so happy that we had you on. Any other points that you would like to end off with any message to our listeners?
Dr. Copperman: I know that a lot of our listeners and our patients have struggled with infertility and it feels alone sometimes and we found that with this sense of community and a little bit of support we can really make that suffering a little bit lighter and we can hopefully provide a pathway to better outcomes and it's just a privilege to be part of this team that leads with compassionate care and leads with science and I'm proud of the successes that we've been able to help achieve and how many families we've been able to help grow and I look forward to doing so for many years to come.
Dara: Well said. We are so proud of what you’ve created here. And we would love to have you back again soon.
Rena: Yeah we’re so grateful to be part of such a wonderful team and I know you know I couldn’t have my job here without your support and you you know behind this position and role and supporting mental health and it’s so great to be a part of such a wonderful place you know you change the lives of so many and thank you so much for sharing your knowledge and wisdom. You know this is just a small small portion.
Dr. Copperman: Thank you Rena thank you Dara thanks to our whole team.
Rena: We have to thank you guys so much for tuning into our very first podcast and unfortunately we let Dr. Copperman leave before we went around and went over our gratitudes for the day which is something I believe so strongly in practicing gratitude I try and do it every day so we lost Dr. Copperman to go back to the very important work but Dara and I are still here and I’d like to say Dara what are you grateful for today?
Dara: Rena I am so grateful for living in New York City.
Rena: You sound very serious about living in New York City.
Dara: I’m Canadian and I love Canada but my dream in life was always to live in a big city so I woke up this morning so happy so grateful the noises the sounds the smells just being in New York City. Something as simple as that.
Rena: I love that I love that just being grateful for where you’re at yeah I love that.
Dara: What about you Rena?
Rena: I guess I will say you know for today mine is also about just sort of being in the present and you know as I said this is our first podcast it's something you know maybe our listeners don’t know I certainly didn't know before we started this that a lot a lot of front-end work went into this and we've been working on this for months we've been talking about this for months you know this equipment this this mixer which looks like I’m a DJ has been sitting on my desk for months my patients all come in and think I have some side hustle going in here running a dance club and so I have to say today I'm just grateful to be here and recording our first one this sort of dream that we had coming to reality and I think it's really exciting.
Dara: I second that. thank you so much for listening today and always remember practice gratitude give a little love to someone else and yourself and remember you are not alone. Find us on Instagram by fertility_forward and if you're looking for more support visit us at www.rmany.com and tune in next week for more Fertility Forward.