Curious about the science, challenges, and business behind fertility care? In this episode, Dr. Rhonda Zwingerman, co-founder and medical director of Twig Fertility, shares her journey in building a national fertility brand. Dr. Zwingerman sheds light on the financial and operational hurdles of running a fertility clinic, especially in the wake of COVID-19.
From IVF and the growing popularity of egg and embryo freezing to cutting-edge genetic testing, she covers the latest advancements in reproductive health. You’ll also hear about the ethical considerations and legal nuances that shape fertility treatments today, along with insights into why cryopreservation is becoming a popular workplace benefit.
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Transcript:
Today we're talking to Dr. Rhonda Zwingerman. She's an entrepreneur and physician. She's the medical director and co-founder of Twig Fertility. She's an obstetrics gynecologist specializing in reproductive endocrinology. Dr. Zwingerman, thank you for joining me today.
Dr. Rhonda Zwingerman (00:21.483)
Thanks for having me.
Dr Jordan Vollrath (00:23.694)
So Twig Fertility, where'd the name come from?
Dr. Rhonda Zwingerman (00:27.465)
it's a great question. So Our tagline is every nest starts with a twig. So the idea was We wanted a name that was kind of fertility adjacent, but not too on the nose. And nest was taken by Google.
So you couldn't search engine optimize that up against Google. And so we did have like a really extensive kind of branding exercise and had hundreds of names. And it was the only one we all immediately gravitated to. And so we went with Twig. It turns out someone owned the trademark. They weren't using it, but we still have to buy it from them. And there was a bit of legal drama at the very beginning of our study. I think you have lawyers who do that.
Dr Jordan Vollrath (01:10.542)
How do you even hunt down the person? How do you find that out?
Okay, okay, you weren't banging on doors.
Dr. Rhonda Zwingerman (01:16.541)
Yeah, but I think now we have the trademark to use twig for like a whole host of things that we won't. Like utensils or I don't know very random things that we had to buy the trademark for. So every nest starts with a twig though. That's the idea.
Dr Jordan Vollrath (01:31.224)
That's funny. When we were naming the company here, we wanted to name it Apple because of the association with doctors and apples. And then my business partner aptly noted that that was already a company as well. So I feel your pain on that. The naming can be tough.
Dr. Rhonda Zwingerman (01:44.809)
It was very hard, right? And with the other thing we very purposely did not want to do is name it after me or after a doctor or after a location, because what we were really purposely trying to do was make a national fertility brand. And so we wanted it to be able to grow and be bigger than any one person or any one place. And that was very purposeful.
Dr Jordan Vollrath (02:05.346)
Very cool. I gotta start with the end in mind. And so tell me more about Twig. It seems like you guys have grown to quite the size at this point, including multiple locations. You guys must be doing something, right? What's going on?
Dr. Rhonda Zwingerman (02:09.121)
Something like that, yeah.
Dr. Rhonda Zwingerman (02:20.577)
So Twig is a full-service fertility clinic and company we launched in early 2022 with our kind of flagship location in Midtown Toronto and that includes our IVF lab here. And then just last like spring of 2024 we opened our first satellite location in downtown Toronto and so that has clinic space, it has diagnostic testing space, it has andrology but there's no IVF
lab and then we're currently in construction for Vancouver, Twin Vancouver, hoping to open like spring 2025. And the idea really is to elevate the fertility care experience to provide better fertility care experience to the people of first Toronto, Ontario and Canada.
Dr Jordan Vollrath (03:11.694)
Congrats on the interprovincial expansion. That's super exciting. What was it like getting started during COVID? How did that impact things?
Dr. Rhonda Zwingerman (03:14.165)
Thank you.
Dr. Rhonda Zwingerman (03:20.373)
Well, I will say I've never started a business not during COVID, so I don't have a lot of comparison. But one thing that was, I suspect, unique is that my co-founders and I
business data on the phone for quite a long time and then by video before we ever met in person. And I think when we all quit our jobs, them on Bay Street and me at my academic center where I was previously, I think we had met in person maybe twice in a backyard, right? Somewhere. And then we had to do all of our interviews and build our team and onboard the team and train the team and try to develop that culture fully virtual because we were in construction. So we didn't have a physical
space even if we could safely gather together and I think that really it made us be really thoughtful about how we do that and how do you build culture and how do you get that sense of of team and I think that actually set us up for success in many ways it also made us quite nimble in terms of like hybrid working and adapting to the realities of how patients like to see their doctors today.
What was challenging was the actual construction project and sourcing things that you couldn't go to see. And so you had to choose everything based on like a tiny thumbnail print on some picture on a computer and then hope when it showed up, it would show up like you wanted it to. So I think for actually building, it's much nicer when you can go to showrooms and vendors and touch the things that you're going to spend hundreds of thousands of dollars on.
And there was that little bit where lumber was worth its weight in gold, which was challenging. But I think for the most part, just kind of like any entrepreneurial journey, you just kind of make it work, right? You just do it because that's how you do it. I don't know if that makes sense. You just kind of do it. Yeah, you're like, we just got to get it done. How do we make this work kind of attitude.
Dr Jordan Vollrath (05:16.202)
figuring it out on the fly, definitely.
Dr Jordan Vollrath (05:23.507)
How did you get connected with your co-founder then during COVID virtually? How does that even come about?
Dr. Rhonda Zwingerman (05:29.921)
Yes, it was a little bit before COVID. was January or February 2020 when I got an email from a mutual friend and she said, hey, I have these two guy friends and like they're interested in maybe doing something in the fertility space, but they like are trying to speak to as many like fertility docs as possible to figure out like, you know, they kind of don't even know what they don't know at this point.
And so I said, sure, talk to them. And we actually had a coffee date in person that was planned for March 13th, 2020, which was of course the day the NBA closed and everything unraveled. And so we rescheduled to a phone call two weeks later and kind of the rest is history. I mean, obviously there's a lot, but after that first phone call, really just kind of snowballed from there.
Dr Jordan Vollrath (06:15.906)
And did I hear you say it cost a few hundred thousand dollars to set up a fertility clinic? Is that right?
Dr. Rhonda Zwingerman (06:20.809)
no, it costs a few million dollars to set up a fertility clinic. Yeah, so the clinic itself is the clinic, but the IVF laboratory, this is a capital intensive business, which is why I have two co founders who are from the business side of things. And what they do have to do is raise capital.
Because I obviously didn't know a lot about raising capital or valuing companies or any of that before I started this process. I really like I do like to say I got him and be by fire like a real life
just by living it. And so yeah, we did an initial friends and family round to build the first site. And then we've done a series eight with some venture money to back our expansion to downtown and to Vancouver.
And the reason there's not a lot of new entrants in this space is because it's the combination of capital and regulatory. It's like a pretty scary combination, I think.
Dr Jordan Vollrath (07:22.242)
Yeah, no doubt. Holy smokes. Okay, now I see why it's referred to as the startup then and a lot of the documentation there is just truly going on that like raising capital growth trajectory and then the expansions make sense. All right, I think I'm following. What cost the most then out of those millions of dollars? Are there DaVinci robots hanging from the ceilings or what does that actually go into?
Dr. Rhonda Zwingerman (07:33.728)
Mm.
Dr. Rhonda Zwingerman (07:37.16)
Mm-hmm.
Dr. Rhonda Zwingerman (07:43.753)
Yeah, there's no DaVinci robots. A lot of it actually is the HVAC system and the mechanical.
Dr Jordan Vollrath (07:51.982)
Really?
Dr. Rhonda Zwingerman (07:53.025)
Yeah, so the better the air in the lab, the better the embryos grow. And so there's some really fancy air systems that go into maintaining, into cleaning and filtering and having like a high turnover of air in the lab. And the incubators are very expensive.
what's called the Ixie rigs, so the fancy machines where you get to inject one sperm into each egg are very, you know, those obviously cost money. And then you need a lot of alarms and checks and sensors for all of your equipment, but also all of your tanks that are storing people's eggs and sperm and embryos, right? So you also need a really robust backup generator, backup alarm systems, like all of that.
adds up and then you have the clinic side and then we also have an in-house pharmacy as well. So it's all of it together.
Dr Jordan Vollrath (08:47.712)
Is there a more expensive clinic in the province of Ontario right now?
Dr. Rhonda Zwingerman (08:53.109)
I mean, there are fertility clinics that have built bigger footprints than us. We were actually really mindful to be as efficient with space as possible. So there are clinics that have a much bigger footprint that have been built since ours in Canada. I don't know what their price tag was, but you know, I suspect if it's twice the square footage, I have no idea what a plastic surgery clinic costs, but that would be the only one I would think of that's comparable in a way. But I have no idea. So.
Dr Jordan Vollrath (09:21.518)
That is wild. That is wild.
Dr. Rhonda Zwingerman (09:22.069)
Ask them. Yeah, it's it's complicated of a business. That's for sure. Yeah.
Dr Jordan Vollrath (09:29.263)
How did you even go about getting that all set up with like the HVAC and the cooling and all the cryo things? I'm assuming they don't just teach you all this in residency how to go and DIY it.
Dr. Rhonda Zwingerman (09:42.205)
No, so the answer is we hired an unbelievably amazing lab director as our employee number one. And how we found her is amazing because it's totally serendipitous as well because she was working at a genomics company and we were trying to do a financial model. So we cold called the genomics company to ask them about their prices and she picked up the phone.
And next thing you know, she was our employee number one. And she also had not had firsthand experience designing her own lab, but we had all worked, we had worked in embryology labs and we just kind of, that's why I didn't do clinical work for 14 months from when I quit my job till when I open their doors to patients. we talked to everyone. We took every call. We virtually went to every vendor and conference and thing we could and just had.
11 p.m. on Friday nights we're on the Google meets with the whiteboard you know with the floor plan and like be like no we need a sink in that room and kind of how do we what can we move if you know that was our life for a while and the whole time I was like I love this so much what if I love this more than
clinic, like what if when I go back to seeing patients and then I went back to seeing patients and it's also great, but I truly love both. And that surprised me so much, right? Like I had no inkling that I would love that part of the adventure.
Dr Jordan Vollrath (11:12.846)
And then at this point, how much of your week is clinical patient facing versus ops and behind the scenes?
Dr. Rhonda Zwingerman (11:20.905)
I would say my clinic volume right now is pretty close to a full patient load. And then I also do all the stuff on top. So I work more hours maybe than an ideal world, but again, kind of startup life. Like the other physicians on my team are amazing. Some of them are relatively newer to the team. Like we've just grown fast in terms of physician size as well. And so until we have, I would say a group of physicians with more mature practice, it's hard for me to.
step back. So I'm still basically 100 % clinical plus all of the leadership and management and that's okay. It's not going to be like that in five years from now, I hope. And also hopefully in five years from now, I'm also overseeing doctors in more than just Toronto and Vancouver, right? As we continue to grow. So I think the more locations, the more docs that we're managing, obviously the more of my time that that will probably take up.
Dr Jordan Vollrath (12:16.056)
Yeah, I imagine. Well, I bet the hours probably weren't much of a shock to you. I remember doing my OBGYN rotations and honestly, I feel like there was very few days during my training where it was like the full 26 hours, just relentlessly without sleeping. Like usually even on surgery, you'd get a little nap here and there, but yeah, Ob's kind just, the babies, they don't stop coming.
Dr. Rhonda Zwingerman (12:24.64)
Yes.
Dr. Rhonda Zwingerman (12:42.311)
stop. mean, I haven't done OB since I started my fertility fellowship in 2015, so that part of my life is behind me, but I don't think you leave your day job to start a new fertility center in the city that already has a lot of fertility centers to like, you know, not work hard, right? So I think that part was not a
surprised me. What was a surprise to me? It was truly like how much I enjoyed the non-clinical parts of it, of the building, of the company.
Dr Jordan Vollrath (13:20.162)
And like, did you always grow up wanting to be an REI specialist? Or at what point during the process did you figure out like, this is pretty cool. I could see myself spending a lot of time figuring this out.
Dr. Rhonda Zwingerman (13:34.057)
Yeah, so I definitely did not grow up always being like, I wasn't like four years old saying I'm going to be a doctor actually thought maybe I'd want to be an engineer, but then I really did not have an affinity for physics. So that kind of dashed my hopes and
then I ended up going into medicine, but I did always have an affinity for Opskynie since I was kind of early, I would say, in med school. And yeah, I always had this interest in kind of reproductive health and reproductive physiology. And REI, one of the reasons I love it.
I mean, to do OB, you really have to enjoy the chaos. You have to be kind of just game for whatever flies your way. And that's not as much my vibe. I much prefer to have a little bit of a day list. These are the things I'm going to do today and then I'm done. That's really nice.
I also like the short, quick procedures and being able to do a lot of them rather than the really, really big, long, big cases. So just on a technical level, REI appealed to me, but it's also just a lot of counseling and a lot of just sitting down across the desk, across the Zoom and just talking to people. And that's what I like.
And then layered onto it, there's all this tech and all this innovation and there's all this like legal and ethical layers. And so just found it super fascinating. Kind of why it appeals to me so much.
Dr Jordan Vollrath (15:04.502)
What's the legal aspect to it?
Dr. Rhonda Zwingerman (15:08.097)
A lot of these, what we would call third party reproduction, so donor egg donor sperm and gestational surrogacy pieces, you know, that involves Health Canada. So that's a whole nother regulatory framework that's federal and not provincial. And, you know, there's questions that come up about embryo ownership in the case of divorce, for example, or, you know,
all of these different scenarios should we allow intergenerational egg donation? Can your niece be your egg donor? Can your mom be your surrogate? Like, and I don't have the answers, but these are the questions that not infrequently come across our, like our doctor group. And I find that fascinating.
Dr Jordan Vollrath (15:56.578)
Is there a lot of gray area still, like when it comes to these types of things, or is it all fairly explicitly laid out?
Dr. Rhonda Zwingerman (16:03.585)
There's a lot of gray area. I think there's the law. And so that's pretty black and white. You know, you have to be 21 to be a surrogate, you to be 18 to be an egg donor. Can't pay for somebody's eggs or, you know, can't pay someone to give you their eggs. You can't pay for the sperm, et cetera. But there's still a fair amount of like the field of medicine. This field of medicine is new. And so there's still a lot that
we're learning and that is not black and white for sure.
Dr Jordan Vollrath (16:36.526)
I had a close friend go through the process recently, actually twice now, of being a surrogate. And it was kind of interesting just finding out kind of like how it works in terms of, you can't pay people to do it. can't, you can buy them presents. You can buy them gifts, apparently, or at least they've been accepting them. I don't know if that's gray or maybe just outright black. Yeah.
Dr. Rhonda Zwingerman (16:43.178)
Interesting.
Dr. Rhonda Zwingerman (16:57.375)
Mm-hmm.
Dr. Rhonda Zwingerman (17:00.929)
I leave this to the lawyers. The lawyers tell me to stay in my lane, I think the law is receivable expenses. I mean, this, yes from this, from a gestational carrier, surrogacy point of view, know, we help, obviously.
Dr Jordan Vollrath (17:05.762)
Don't ask questions.
Dr. Rhonda Zwingerman (17:19.433)
get them pregnant, follow them till the end of the first trimester, and then they do transition to OB care, right? We take care of people here only until the end of the first trimester. And so a lot of what we do is kind of that initial part of the process. And so I don't always know the details of some of the drama. Maybe that happens afterwards, maybe that you heard about from your friend.
Dr Jordan Vollrath (17:39.906)
Hopefully not too much of it. What do you guys do more of in general then? Is it IVF? Is it the cryopreservation? Is it kind of the good old fashioned clinical infertility treatments that don't require the million dollar lab?
Dr. Rhonda Zwingerman (17:57.139)
I would say, think we do, well, no, I know we do more elective or let's call it like egg freezing due to age related fertility decline than some of the other centers. And that's because I think our brand resonates with people who don't.
have infertility, like they don't want to over medicalize it. They're not sick. There's something pathologic. And I think coming into a space that is more welcoming, it's less scary, it's less medical feeling does resonate. And also just that we have that capacity to reach out to them and specifically target that, you know, create an environment for that group of people versus, you know, if there's other clinics and they're full seeing people with infertility, then why would they go to try to, you know, reach out to,
the you know 30 somethings out there so we do a lot of egg freezing we also do a lot of embryo freezing electively like young couples just got married not ready to have babies yet but they know they want however many babies they have good coverage through work like way more of that than i was expecting but of course like the majority of our referrals are still for like trouble getting pregnant
and whatever treatment they may need. And then we do a fair amount of recurrent pregnancy loss assessment and testing and treatment as well. Those are probably our main reasons for seeing people.
Dr Jordan Vollrath (19:29.044)
Very cool, quite the diverse set of things to be doing in a day.
Dr. Rhonda Zwingerman (19:32.913)
Mm-hmm, yeah. And then we will see people who have like, you know, both the egg and the sperm provider, both intendant parents or carriers of a genetic condition, they don't want to pass it on. And some people would like to make embryos and test the embryos for that. And so we'll also see people for that. Yeah.
Dr Jordan Vollrath (19:51.86)
It sounds like people, whether it's due to economic factors of just not being able to afford having kids earlier in life, know, are pushing it further and further back. at what point or What kind of factors go into deciding whether egg freezing or embryo freezing is actually like a recommended option for a couple.
Dr. Rhonda Zwingerman (20:14.017)
Well, that's such a great question. I think I see our job as gathering as much information as we can, especially knowing the tests are perfect, right, and they are snapshots in time, and then kind of laying out people's options and then kind of depends on their risk tolerance or how they're feeling about the whole situation. So I think important factor is like, yes, we would check the sperm.
And if there's any issue with the sperm, we can either try to improve it or talk about treatment options. And then we will check people's account, right? We'll do an AMH hormone, we'll do an antral follicle count with the important caveat that those tests don't predict natural fertility rates. They don't predict your chances of getting pregnant if you try in a given month, but they do predict your response to IVF medications or attempts, as I tell patients, these are the words I use with them. I want to try to get you
to make more eggs all in one cycle so I can take them out, how easy or hard is that going to be for us to do? And that's related to how much I can help you if you run into trouble getting pregnant on your own. And so if someone's, you know, 35, they haven't started yet, maybe they're not going to be ready to start trying for another two years, but they want more than one kid.
Like it's not a bad idea to be thinking about this because the chance you have trouble when you're 38 or 39 or 40 is higher and my ability to help you, the older you get is lower because the age of the eggs is the single greatest prognostic factor of basically everything we do. Versus if you're 28, you want one kid, you think you'll try the next four years, like you can freeze your eggs if you want, but there's a very low chance you'll use them or you'll need them.
Right? And so it's just about kind of helping people understand and like work through their options in hopefully a way that's not, doesn't cause them added stress or doesn't make them feel like pressured. think that's really important.
Dr Jordan Vollrath (22:09.152)
And so age is the number one deciding factor. What would number two be?
Dr. Rhonda Zwingerman (22:15.743)
I mean, in terms of fertility preservation for the future, probably ideal family size, I would say. Right, because if someone's 30, but they want four kids, and they don't have a partner and they think it'll be a bunch of years before they'll start trying, like that's way different than if you want one. And then your ovarian reserve does play a role because it speaks to how much I might be able to help if we run into trouble in the future.
Dr Jordan Vollrath (22:42.68)
Interesting, interesting.
Dr. Rhonda Zwingerman (22:43.401)
Yeah. And then unfortunately, like for a of people finances, like financial situation and employment benefits play a role too.
Dr Jordan Vollrath (22:51.456)
How common is that now? I've heard this is like the greatest new productivity hack at a company is to provide cryo preservation as a employee perk.
Dr. Rhonda Zwingerman (23:01.757)
It's way more common than when I started in this field, like way more common. think it started with the tech companies, you know, the, the metas and the, Uber's Pinterest Salesforce, you know, Googles of the world and then spread to the big banks. And now it's the big accounting firms, the consulting firms, the big law, like law firms. and it's really nice, right. For just people to have that option.
Dr Jordan Vollrath (23:04.599)
Yeah.
Dr. Rhonda Zwingerman (23:30.205)
we can debate what it does to society and what it values and all that maybe another time. But unfortunately this is expensive and so it's really nice when that doesn't have to be the thing that's like driving the decisions but people can just make the decision that's right for them.
Dr Jordan Vollrath (23:50.584)
takes a lot of pressure off.
Dr. Rhonda Zwingerman (23:53.045)
You can't, yeah. I think what's important is that it's not a guarantee. Like, you know, it's medicine, right? Like, should rarely say never always, right? And so I think that that's why the counseling is so important.
either can, you know, could freeze a number of eggs or a number of emeralds that gives you a very good chance of a future life birth, but it is never a guarantee. And so you want to make sure people aren't relying on that entirely to then delay their family building more than they otherwise would have. Right. And so it's a kind of delicate balance of giving people that optionality. But then I always tell people
that I'm a little bit biased and my job is to try to nudge them to not wait too long to try.
Dr Jordan Vollrath (24:38.594)
And then like vaguely familiar with how the process itself actually works. Like, could you elaborate on just how you actually go about getting the live tissue and getting it into storage and how you keep it safe and stable and resurrecting it again from the depths of the fridge? Yeah.
Dr. Rhonda Zwingerman (24:56.117)
All of those things. Yeah, so we do our egg retrieval procedures here at our Midtown Clinic. They're done under like minimal sedation.
And it's all done under ultrasound guidance, like vaginal ultrasound. And the whole procedure only takes about 10 or 15 minutes. And basically we visualize the ovaries on ultrasound and they're full of big follicles and those look like big black circles on the ultrasound machine. And we basically just put a very small needle into those follicles vaginally and it's attached to a, a vacuum, like a suction. And so the fluid drains and goes into little test tubes.
And then immediately on the other side of our procedure room is the lab, is the IVF laboratory. And so those tubes get, test tubes get passed off to the laboratory in real time. And they in real time examine the fluid under the microscope to look for eggs. And so hopefully each follicle, each big black circle has a mature egg inside. If the plan is to freeze eggs, then that afternoon, a few hours later, the eggs are frozen.
If the plan is to try to make embryos, then that afternoon, a few hours later, the eggs and sperm are combined. Embryos are cultured in one of our incubators for five to seven days. And then either five days later, we put an embryo back in the uterus or more commonly, we would actually freeze those embryos for an embryo transfer at a future date.
Everything's frozen in these tanks called Dewars that really look like kegs on wheels. Like that is a good image if you just want to have them in your mind. And it's liquid nitrogen, it's like minus 70. And like I said, it's all alarmed and back-up and, you know, made sure that everything at all times is well sealed and well taken care of and everyone's...
Dr. Rhonda Zwingerman (26:57.331)
reproductive materials kept safe until they need it again. And the other thing is all of the gametes and embryos in the lab are tracked with an RFID tracking system. And so the patients, when they come in, get an RFID card. And then that's kind of tagged to like all of the test tubes and dishes and everything in the lab so that we can totally track chain of custody through the entire process.
Dr Jordan Vollrath (27:24.834)
Very cool. And is this like a general anesthetic intubation thing where you just spray some lidocaine and how does this go?
Dr. Rhonda Zwingerman (27:29.011)
It's not, no, no, it's neither of those things. It's a little, it's medasolum and fentanyl through the IV and that's it. Yeah. It's a little sedation. Yeah.
Dr Jordan Vollrath (27:39.064)
That is cool. That is cool. And why would somebody choose to go for embryos versus eggs alone?
Dr. Rhonda Zwingerman (27:46.205)
Also a great question. I think what I tell people is I usually look the person with eggs straight in the eyes, even if they have a male partner who's on the call, and I say if you're 1 million percent sure who you want to have babies with.
does sort of make sense to freeze embryos for reasons I'm about to explain. If you're not one million percent sure, then best to freeze eggs and retain your reproductive autonomy. So benefit of eggs, choice in the future, they're yours. They're yours alone. You can do whatever you want with them. You don't have to be in a Sofia Vergara situation where, you know, her and her ex-husband had years and years and years of legal battles over their embryos. The benefit of embryos is that there is unfortunately a lot of attrition
through the IVF process. And that's why we don't do IVF with no fertility drugs, where we just start with one egg that we take out. We give people strong fertility drugs so they can make 15 or 20 mature eggs at a time that we can take out, because sometimes only 80 % of the eggs are mature and then only 80 % of those fertilize and then only half of those turn into embryos and then half of those embryos are chromosomally abnormal and
We started with 20 and all of a we end up with, you know, three chromosomally normal embryos to, to transfer. So the benefit of freezing embryos is if you pause the process further along.
It's easier to know what you have and for me to counsel you about what are the chances that leads to a baby in the future and therefore should you do more? Should you freeze more embryos or is that like a really good number? Because if you freeze 18 eggs, it's kind of upstream. So I'm just kind of guessing like I don't know how many embryos that will be. I don't know what chance of future live birth, especially because remember like sperm is really important too. So it's like I can't comment on that. And so
Dr. Rhonda Zwingerman (29:36.329)
It's the people who are like, they're engaged or they're married or they're kind of very sure that they want to have kids together. Sometimes it's just easier to counsel them if we pause the process later on.
Dr Jordan Vollrath (29:49.022)
Could a person do both? Like, just in case, the eggs individually as a backup? Does that cost a lot more or is it technically a lot more challenging to have both?
Dr. Rhonda Zwingerman (29:55.52)
Yep.
Yeah, it's not, it's, there's some very kind of specific reasons why that's not our preference, but a lot of people do end up needing more than one cycle to reach their goals. So some people will do one cycle of eggs, one cycle of embryos.
Dr Jordan Vollrath (30:13.262)
Gotcha. And then how much, how has the genetic testing, I guess, evolved over the years that you've been doing this? Because there's just been so many advances with gene technology.
Dr. Rhonda Zwingerman (30:21.009)
So many. Yeah. So very interesting. So we actually have two genetic counselors who are on staff. And I think now most fertility clinics have in-house genetic counselors. I don't know how people do REI without genetic counselors these days. They're so integral to my life. And
We offer genetic testing at different phases of the patient journey. And I think having really robust reproductive genetic offerings is also one of the things that helps us stand out a bit from some of the others. Like, you know, our philosophy is really like, can, how much comprehensive care can we provide under one roof? Right. And so I'll get back to your genetics question in a second, but like we have a reproductive urologist who comes, we have a general OB-GYN who does our preconception counseling.
consults and it's we have an in-house social worker so it's really about like what can we provide here to make it as good of an experience for patients. We offer routine genetic carrier screening to everyone who walks in the front door should they want to do a panel of 500 genes to see what their carriers for and then anyone who's doing IVF has the option to do what's called pre-implantation genetic testing so that's testing of the embryos that
that are made in the lab before the embryos transferred into somebody's uterus. And that's because even at age 35, half the embryos that are made are chromosomally abnormal. And that's just how humans are. And so there's that. And then of course, once people conceive there's prenatal screening, which I'm sure you're more familiar with as a family doctor, but even that's increasing in complexity in terms of NIPT offerings and microdeletion add-ons.
know, 22Q and all of these different offerings. And so our genetic counselors really play a key role in all three of those, like kind of before, during, and after phases of the patient journey.
Dr Jordan Vollrath (32:24.45)
Very cool. Is there any difference between the ethics and the legalities of it? Like if somebody is, I want to definitely have one boy and one girl. Like is there any...
Dr. Rhonda Zwingerman (32:36.946)
you can't do that in Canada.
Yeah, so one of the things that's in the law is that Sex selection is illegal in Canada, so you cannot, when we do genetic testing of the embryos, our reports don't include any information about sex chromosomes, unless there's the wrong number of sex chromosomes, right, where it would be reported as aneuploid. So I truly, nobody at the clinic knows which embryos are XX or XY. And when patients ask, I just kindly remind them I don't want to break the
go to jail for them, they're usually okay with that. And then if people, because it's a federal criminal lawsuit, like it's not like a regulation, you know? And then in extreme situations, people can go to the states if they want. What we call family balancing is the euphemism for like, I've had two girls, I want a boy. But for that you have to go outside the country.
Dr Jordan Vollrath (33:30.956)
Why has Canada drawn that line in the sand so firmly versus right there?
Dr. Rhonda Zwingerman (33:32.641)
why have they done that? I don't know. You'll have to ask. You'll have to ask someone who is involved in that. In that, I suspect it is not unrelated. Well, actually, I don't know. But I think, you know, sex-left abortion is obviously an issue in some parts of the world and not wanting to tread into that, that area of ethics.
but we can do sex selection from medical indications, like hemophilia, like for example, like hemophilia or something that's clearly a sex selective medical issue, you can do it for those reasons only.
Dr Jordan Vollrath (34:12.428)
What would be the next most common genetics ethical dilemma that you come across with patients' requests?
Dr. Rhonda Zwingerman (34:20.393)
it's interesting. think one of the things that's coming up more and more as we test more and more embryos is the request to put back in abnormal embryos. And I'm just going to leave that out there because I obviously don't have the answer. But, you know, what if you do genetic testing and then people want to transfer an embryo that has trisomy 21?
Dr Jordan Vollrath (34:45.43)
And what is the law currently state?
Dr. Rhonda Zwingerman (34:47.029)
There's no, there's no law, right? So that's like individual clinic policy. And those are some of the, like that's, there are bioethicists in this field and that's their full-time job and they advise clinics and they advise hospitals and these are the sorts of questions that come up. I think, you know, what qualifies as a sex selective medical issue.
Dr Jordan Vollrath (34:51.907)
Yeah.
Dr. Rhonda Zwingerman (35:15.137)
you know is also one of those but again you should you could another episode you could talk to a bioethicist that would probably be fascinating.
Dr Jordan Vollrath (35:23.054)
I'll have to get one's card after we're done here today. That is very interesting stuff though. Okay, cool. And then what about on the IVF side? How does that process typically go?
Dr. Rhonda Zwingerman (35:27.625)
Yeah.
Dr. Rhonda Zwingerman (35:37.409)
Yeah, it's the same as embryo freezing. it's, it's the same as what I basically walked through. Like it's drugs, fertility medication to try to make there be lots of eggs at a time. Eggs come out, mix them with sperm, make embryos, whether you test those embryos or not is obviously a personal choice. And then instead of those embryos being frozen and on ice for the future, you would then put one back in either immediately or the next month or whenever people are ready. And so in many ways, you know,
egg or embryo cryopreservation or IVF, the process is extremely similar. There's nuances, but for the most part, it's basically a very similar journey.
Dr Jordan Vollrath (36:18.274)
Do you want having like a significant drop off or like attrition rates as you go through the freezing step versus if you just went straight to the IVF and then put it back in vivo?
Dr. Rhonda Zwingerman (36:30.379)
Can you say that again, sorry?
Dr Jordan Vollrath (36:32.59)
Like when you take the egg out and the sperm out and then if you do IVF, combine the two and then just go straight back into the uterus versus going through the process of the cryopreservation. Like does that, do you actually lose viability by going through the freezing or not really?
Dr. Rhonda Zwingerman (36:35.625)
Mm-hmm.
Dr. Rhonda Zwingerman (36:39.242)
Hmm.
Dr. Rhonda Zwingerman (36:50.899)
Not really, actually. I mean, egg, it's so embryo freezing technology has been around a lot longer than egg freezing technology. And as not an embryologist, I will do my best to explain this, but.
An egg is a very big cell, right? It's the only cell you can see with the naked eye when it has its cumulus cells around it, and it's mostly water. And so technically to freeze it without it causing crystals on the inside that then break up the mitotic spindle is hard. And so that's why embryo freezing was like mastered as a technological skill basically decades before egg freezing was. But now we've gotten very good at egg freezing too. And so what I would quote patients here, and I can't speak to other clinics,
is at least a 90 % survival for eggs that are frozen and thawed, but for embryos it's about 99 % free-thaw survival. And there are some circumstances where putting an embryo in to the uterus that has just not been, that has not just been exposed to extremely high levels of hormones might actually be better.
And so most clinics in North America do predominantly frozen embryo transfers now. Of course, not exclusively, it's medicine. There's always exceptions to the rule. but
answer a question, it's usually not such a big downside or detriment. And with sperm, if you freeze thaw, you lose about half the sample. But if you start with 200 million sperm and then you have 100 million sperm, you still have lots of sperm to deal with. So in most cases, except with very severe kind of sperm factor, it's not an issue either.
Dr Jordan Vollrath (38:27.126)
Very cool. And dare I ask, what is like the low end and the high end in terms of cost or how do you actually even price it out? it like over time or is it just a lump sum for having the procedures done?
Dr. Rhonda Zwingerman (38:40.895)
Yeah, every clinic is different. I think our philosophy from the outside and we talked about this for hours and hours and hours because we wanted to get it right and we didn't want it necessarily just
default to how others were doing it, if that's how we ended up great, but we kind of needed to go through the motions to arrive at how we want to do this. So first we said, okay, what are our pricing principles? Like what are our values here? And we're like simple and transparent. Those are our values. Like how can we make this as simple as possible? And how can we be very clear and upfront about it? And so we made a decision early on to publish most of our costs on our website. And
One of the things that I always, one of my co-founders always said was a rising tide lifts all boats, right? And it sounds cheesy, but since we've done that, more and more clinics have also done that. And I don't for a moment say that that's causative, right? But it's nice to see, right? Like it's nice to think maybe that that had some market pressure and improve the transparency for all people at different clinics. For us,
There is basically, I mean, egg freezing actually right now, it's not a secret. It's $8,000 plus the drugs. That's what it costs. And for IVF, it's 13,000 to make the embryos plus the drugs, plus the genetic testing. If you want to do it, it's kind of the numbers.
Dr Jordan Vollrath (40:07.854)
Because it's not bad in terms of peace of mind, yeah.
Dr. Rhonda Zwingerman (40:11.227)
So an embryo freezing, yeah, so that's what it costs. And then, you know, there are obviously other things that are covered in Ontario BioHIP and then other things that are private. When Vancouver, know, pricing is set, that information will be available. But obviously these prices are also dynamic and will evolve over time as anyone's way for any service, right?
Dr Jordan Vollrath (40:32.814)
when you get the fancy steak at the restaurant market price.
Dr. Rhonda Zwingerman (40:38.176)
Yeah, no, we're not doing that. That's not transparent, right? But it's really interesting, or at least I think it's really interesting. One of the issues obviously with this field of medicine is it's not accessible to everyone because of the cost. And I'm so excited that the Ontario government just made an announcement a few days ago to increase the budget for the Ontario Fertility Program and bring in a tax credit in 2025 to make fertility care more affordable.
affordable to Ontarians. It sounds like BC might be also getting some IVF funding in the spring. And so I think the momentum is really great. But one of the tensions that I'm watching is will all of the additional technology that's coming drive down the price or drive up the price? Because it kind of could go either way. And it's a complicated
kind of space to keep an eye on.
Dr Jordan Vollrath (41:43.382)
Interesting interesting and then Is anybody freezing sperm like how common is that?
Dr. Rhonda Zwingerman (41:49.209)
Very common. Yeah, that's been around like, you know, it's probably been doing that for five, six decades. Yeah, I don't think it's technically nearly as challenging as eggs or embers. And also when you're dealing with hundreds of millions of sperm, like I said, if you lose half on average in the free stock, that's just kind of how it is. You know, a lot of
Some people will freeze from truly electively, know, men are always making new sperm. People with sperm are always making new sperm. Unlike people with eggs are born with all their eggs and they never make more. So there's more of a biological imperative to freeze. But of course, before cancer treatment or before, I don't know, for the form of a second means, I don't know. Like there could be lots of reasons you may want to have a backup.
Dr Jordan Vollrath (42:37.134)
Is there much of an age trigger like there is at the 35 cutoff for women or not so much?
Dr. Rhonda Zwingerman (42:44.093)
There is a decline in sperm quality with age, but it is not as marked as with eggs. The other thing is there's also an increase in some, like de novo.
Autism will dominate conditions with really advanced maternal age. So we generally think with sprains major over 45 or 50, there is an increased risk of autism and schizophrenia and also some autism will dominate conditions. And I don't think we talk about that very often.
Dr Jordan Vollrath (43:19.99)
No, no, it's usually just the female-sided factors.
Dr. Rhonda Zwingerman (43:23.253)
Just the eggs. Yeah, just the eggs. So yeah, so we offer that for sure. And we definitely see the other reason we do sperm freezing, I should just call it is for people who are about to start gender affirming hormone therapy. Yeah.
Dr Jordan Vollrath (43:38.776)
Gotcha. And then I'm not familiar with the case, but who did get Sofia Vergara's embryos? How did they split that one up?
Dr. Rhonda Zwingerman (43:45.933)
I don't remember what happened. think, I think what happened, I have to look at the latest because it in the courts forever. They had two embryos and she did not want to use them and he wanted to use them with a surrogate or with his new wife to have babies. It was very messy. I will say the wrong thing if I try to say more than that.
Dr Jordan Vollrath (44:08.792)
Okay, we won't try to paint you into a corner on that one. Well, this has been...
Dr. Rhonda Zwingerman (44:11.156)
Thank you. My pop culture knowledge is like mediocre, I would say, you know?
Dr Jordan Vollrath (44:18.604)
Well, this has been very enlightening though, nonetheless. I do appreciate you taking the time to chat this afternoon. I've learned quite a bit. I don't know unless you have anything else to shout out. I mean, if anybody's interested in the fertility treatments or in having some eggs frozen or going through the IVF process, what's your guys website? Where can they find you?
Dr. Rhonda Zwingerman (44:36.969)
Yeah, they can find us at twigfertility.com. You can also follow us on Instagram at twigfertility. We're very active there and those are the best places to stay up to date on all the happenings.
Dr Jordan Vollrath (44:50.35)
Do they need a referral or can they just show up?
Dr. Rhonda Zwingerman (44:53.694)
Neither, but you can self-refer through the website. So if you go to our website and click book now, then we can help you.
Dr Jordan Vollrath (45:00.014)
All right, Dr. Rhonda Zwingerman, thank you so much for joining me today. I appreciate it.
Dr. Rhonda Zwingerman (45:04.939)
Thank you for having me.
About the Author
Cherry Health
Canada's Medical Network
About the Author
Cherry Health
Canada's Medical Network
About the Author
Cherry Health
Canada's Medical Network
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