Ep 103: Fertility Care For All with Dr. Brent Monseur
Fertility Forward Episode 103:
The expense of infertility treatment is a costly one. It is even more costly when you are an underrepresented minority with minimal benefits and advocacy. Dr. Brent Monseur, an endocrinologist and LGBTQ+ community member, is here to discuss a fascinating and important topic by sharing some of their research, data, and findings. We hear the benefits of their research and how, despite being a small sample size, the information and data collected mirrors what Dr. Monseur believes is the nationwide situation. As an advocate for better coverage, insurance benefits, and health care, we understand why Dr. Monseur is pro-insurance reform, believes in highlighting health disparities, and provides education for everyone. Plus, we hear what their future holds with empowering and providing the LGBTQ+ community with access to safe, informative family planning.
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 from medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
Dara: Today on our podcast we have Dr. Brent Monseur, who is currently a fellow in reproductive endocrinology and infertility at Stanford University. He trained as a reproductive biologist at Johns Hopkins Bloomberg School of Public Health, completing his Master of Science degree while investigating molecular mechanisms behind the eggs membrane block to polyspermy and completing coursework and reproductive epidemiology and demography. Dr. Monseur received his medical doctorate from the Medical College of Virginia after completing a Bachelor of Science degree in biochemistry with a minor in Spanish at the University of Mary Washington. Dr. Monseur is an openly gay provider who focuses his clinical research and practice on lesbian, gay, bisexual, transgender, queer, LGBTQ+ family-building. As an inspiring physician scientist, his commitment to research is exemplified by completing several original research projects resulting in many prestigious awards and he has published several peer reviewed articles in a variety of journals. He's board certified emeritus, the Family Equality Council, formally Path to Parenthood, and Medical Students for Choice. Wow, what an accomplishment - all of those awards and degrees! We're so happy to have you today on our podcast.
Brent: Yeah, thank you so much for having me.
Dara: Well, we are super excited to discuss your abstract that you just recently presented at ASRM and then after, we'll have to go back because I noticed when I was looking you up online that you also have done work with NASA, which I am very fascinated and so we'll have to go back to that. But first, the sort of initial impetus for having you on was to discuss the paper you just presented at the recent ASRM conference and the title is Multi-Center Case Series of Transgender Men with Fertility Benefits, Access to Care and Navigating Obstacles. So let's start with that and tell us about that study and what it looked at and what you found?
Brent: Absolutely. I mean, I wanna start by acknowledging that it was very much a collaborative effort. So I had the opportunity to work with Progeny, which is an employee sponsored fertility benefits company before, and I recently published the largest dataset on cisgender gay men using assisted reproductive technologies to build their families. And so I kind of dreamed up an idea of using that same fertility claims database to start looking into transgender and gender-expansive individuals. So with the help of my colleagues at Progeny, RMA Connecticut, RMA New York, as well as Oregon Health Sciences University, we were able to actually take a dive and to look and see what pathways transgender men in particular use when building their families. And the reason we chose this approach is that because sexual orientation and gender identity is not routinely collected in any hospital system that I'm aware of across the board, it becomes challenging to actually study these individuals except on a pretty small scale. So by using a multi kind of center database, we thought that we could expand those numbers, though interestingly you'll see in our end it's still relatively modest. We only were able to have 17 patients included despite the fact that we used a nationwide database. But the huge benefit that we see here is we were able to study, albeit a small population, but a population in which all of the individuals included did have fertility coverage for treatment. And this is a really kind of unique angle. And so it kind of blends into this idea of access to care and health services research and not just kind of filling the clinical epidemiology data deserts. So what we were able to show, which I think many providers will at least anecdotally understand, is that we often see patients for an initial consultation and they never come back. And a lot of times we suspect that's to cost or they may tell us, tell us it's because of cost, but we're not really sure. In this study of 17 individuals, 15 out of the 17 actually pursued treatment. So that's one of our really big takeaways, which is kind of obvious, but it also needed to be said and needed to be studied. When you have inclusive fertility benefits, almost 90% of transgender patients will pursue with treatment. So that's a big finding just in of itself.
Rena: Yeah, I mean Dara and I were talking before you came on and we said, Oh, we don't know what is Brent's connection to RMA? So you just explain that to us. And then we also, I always look at sample size and so I noticed that this was, Yeah, you know, your sample is 17, which is small and that's so interesting that you weren't able to collect more data. And do you think that speaks to the number of people overall seeking treatment even if they don't pursue it?
Brent: I think there's some limited information that shows that the amount of transgender men that want to have biologic children maybe lives in a range of around 40 to 60%. We're not sure, but my suspicion is that these are actually underestimates for a variety of reasons. One is that our clinic response rate wasn't as high as we'd like, so we didn't hear back from all of the clinics that we reached out to to get information. And then also because of all of the structural stigma and historical stigma and discrimination that takes place in the LGBTQ community, many individuals may not want to disclose their sexual orientation or their gender identity in their medical record as it becomes part of their legal record. And they may also not wanna disclose that to their insurance provider because even in this case that they provide inclusive benefits, patients might not know that. So they might not disclose the fact that they're transgender to their employee, which then would disclose it to the employee sponsored fertility benefits. So we're probably missing a lot of patients that aren't even including the fact that they're transgender or gender expansive on their kind of claims report.
Rena: So is that something, could an insurance turn you down and say, well, we would've covered you, but knowing that you're transgender, now we won't.
Brent: Well, that's a great question. And so what we can do is we can kind of take our lessons that we've learned from the rest of the LGBTQ community, which is that for example, if you are a same sex female couple, both egg producing ovary bearing individuals, and you actually have coverage for infertility diagnostic workup and treatment, you may be able to access your diagnostic benefits. But then when you try to access coverage for treatment, the insurance company can say back to you, not because you are a lesbian per se, but because you haven't met the clinical definite definition of infertility, which is 12 months of penis and vagina intercourse without a conception, you are unable to access those benefits. And so I think that it's a very real fear that aspects of your own kind of sexual orientation and gender identity may inadvertently then impact your ability to access benefits. And this is a similar struggle that was seen by a recent couple that is, has an ongoing legal battle in the state of New York. They also had fertility benefits through their, I believe it was a state sponsored program through their insurance, but they wouldn't cover fertility with the use of a gestational carrier. But for a cisgender gay couple, that was kind of a necessary part of their treatment plan to have children, biologically-related children. So again, it wasn't really the sexual orientation itself, but it was the specific treatment that you needed because of your kind of relationship structure and your sexual organ inventory with your partner that then resulted in not being able to actually use those benefits.
Rena: Ugh, this is, So it's taking me back to thinking about recently. I mean it was only what, I don't know, maybe three or four years ago I was working with RESOLVE a lot. We were lobbying to improve insurance reform in the state of New York and we had the Fair Access to Fertility Treatment Act pass or FAFTA. And that felt, you know, so huge and like such a win for this state. But then fast forward and now, you know, talking about your study and we've had a couple of other guests down to talk about studies involving transgender and it just feels like we're so behind in…
Brent: Yeah, I mean another kind of interest in California, in my own home state of California, is that we passed Senate Bill 600, which had really broad language on purpose, right? That was a policy and an advocacy tactic. But the bill was targeted towards individuals who needed to do fertility preservation in the setting specifically of cancer treatment, but more broadly gonadotoxic treatment. So treatment that was gonna be damaging to the gaits and potentially then future fertility. And really the way that the bill is written, it is such that that should include someone who perhaps is going through a gender affirming hormone therapy. But the reality is we've even had struggles getting people covered, even in kind of clear cases of cancer, which the bill was actually written for. And the reason is, is because I think insurance companies are kind of acknowledging they need to cover this, but that doesn't mean that you don't have to go through a process of preauthorization and approval. And sometimes I've had patients who have had to not go through not one, not two, but three appeals just to get the benefits that technically is written into law that they should have. And so it's not easy, and I think transgender and gender expanded individuals are used to things not being easy. And so that's a perfect example of why if they don't have to disclose this information, then why would they?
Dara: That's just so disappointing. Even though there's, there's been lots of great advances that were so, so behind with this. It's very disappointing.
Brent: Yeah. But I do think part of the reason why we underwent this study is if it's not written, sometimes people don't kind of like, see the obvious, which was that we really wanted to be able to have some data that says when patients have coverage, they actually go through treatment. Right? Because this is kind of ammunition then to kind of advocate for better coverage, both for fertility services, fertility medications, and just regardless of sexual orientation, gender identity, marital status, racial, ethnic, you know, anything really. It should just be fertility care for all.
Rena: Yeah, totally. And I feel like that statement, you know, when patients have coverage, they generally go for treatment. I mean that applies across the board regardless of sexual orientation or gender, marital status. We see all the time, people not pursuing treatment because they can't afford it. And that's so upsetting and something we talk about a lot on here, how, you know, cost should never be a barrier to care and especially to family-building.
Brent: Yeah. I mean I definitely, you know, as a society we've come a long way in terms of really recognizing how important that is. And I think that part of the struggle, right, is that these issues that we're talking about aren't specific to the LGBTQ community. Like, infertility care is cost prohibitive for many people across all different backgrounds just because it is so expensive. I think the fact that reproductive medicine has had a heterosexual, cisgender, and infertile focus just makes it that much harder for groups that don't fall within that because they're kind of like coming to the game late because there's already been years of great advocacy by organizations like RESOLVE that have been focused on this kind of historic population that they've, now they've expanded of course, and now everyone is advocating for more coverage for all. But it's still kind of like you're, you're later at the table when you haven't really been in part of those advocacy conversations until now that I'm really hoping that we can kind of take what we learn from these minority communities and demonstrate the importance across the board, right? We want everyone to have access to these services, not just one group. So I think the, the more information we can get like this, the better.
Rena: Absolutely. So where do you see this going? I mean, any sort of goals for future next steps with the study?
Brent: Yeah, so one next step is that we, when we originally did the study, we didn't include transgender female patients. And part of that is because a lot of times those individuals might present specifically to a sperm bank if they're sperm-producing individuals or they might go to reproductive urology or kind of other colleagues. But the reality is, is that reproductive endocrinologists are really the individuals that are often best positioned to have these early conversations about what treatment options are and what you can do. And part of the reason why I changed my kind of attitude of whether or not we should have these individuals in the same study or not, is I had a, you know, a transgender sperm-producing individual present to me for care. And it was clear that they felt like they actually had no idea where to go. Like their primary care doctor didn't know what to do, they went to a urologist, they weren't really sure. They went to this sperm bank and they didn't have a lot of options for them. And so again, it's another opportunity to think about, what does care look like in that population that actually has benefits, right? They actually show up and they have coverage for something and then when they come to someone like me, I'm able to come up with ideas like, well, we can either have you do this, we can refer you to this person to do this specific procedure. And you know, thankfully thinking about that specific individual, they now have a healthy pregnancy with their partner. There are options, but we just have to make sure that people know what they are and, and they're able to access them.
Dara: You make a good point. You know, people need to be aware and educated all around, not just patients but also you know, the medical community.
Brent: Yeah, I mean I think a another thing I wanted to highlight, and I don't recall if it was in the access to care or the health disparity section, but there was a great talk, I think it was from the University of Pennsylvania that was looking at attrition in fertility care after initial consultation. The idea being, patients might show up for the first visit and then never come back again or not complete the workup. And they highlighted that there were some racial and ethnic disparities in that - black patients being less likely to continue after having that first visit. And I'd like to recreate that analysis with a focus on LGBTQ individuals because I think we will have similar findings that individuals that are gender and sexual minorities are less likely to continue after that first visit. It may be all explained by cost, but I do think it's again important to highlight that because it's like why are we losing these patients who actually might have already had a lot of barriers even to make that first appointment? It's like where do they go after that?
Rena: I think something definitely interesting to consider and really interested in following along with your study to see what you uncover and hopefully this will enact some change. I know we're always all trying to push for insurance reform and coverage and you know, increasing access to care across the board.
Brent: Absolutely. Yeah.
Dara: And I'm also hoping to see that, I think it was a great start in terms of your sample size, but now I think with results and with the exposure, I'm hoping more centers will respond to you next time and we will have, we'll get some more information not just from from those places, but from much more.
Brent: Yeah, absolutely. And we've actually, we've already reached back out. We kind of used the kind of buzz of ASRM to kind of help with that. The other thing that we're planning to do is there are some other fertility benefits companies that are employee-sponsored, that we wanna reach out to those companies and see if we can recreate the study and then maybe kind of group it all together.
Rena: Oh, that'd be great. Yeah, you'll have to keep us posted and if you do that we'll have you back on to share the updated results of findings
Brent: Yeah, absolutely would love to come back.
Dara: So now we need to ask you how are you connected to NASA? I mean is this super fascinating? Is it, you know, an interest that you've had for, for a long time?
Brent: Yeah, I mean I've always been interested in space and I think that I became interested in this idea of kind of occupational exposures in the reproductive space in terms of cosmic radiation, exposure to microgravity. So when I was a medical student, I kind of just on a whim wrote a proposal to NASA about what are we doing for the fertility preservation of our astronaut core? And I kind of came up with the idea partly because they had released some reproductive demographics that showed that while about 85% of men in the astronaut core have children, only about 15% of women do, which you, you can imagine right? There are kind of restrictions. You can't be pregnant when you're in training, you can't be pregnant when you're in space and and so then you and you also end up kind of delaying childbearing. Astronauts are an older community as a whole, so they might not finish all of their training, everything, until their forties when they might have already been beyond their kind of peak fertility years. So that's how I got plugged into them. I'll tell you, when you show up to NASA as like an intern, they're not necessarily interested in what you wanna do for NASA but what you, what you can do for them. And so I ended up doing some projects that were unrelated to fertility preservation, but it was a really amazing experience. I made some great connections that I still have and I still remember I went to go see The Martian in Houston with astronauts in the movie theater with me. It was a very kind of surreal experience. It was a great time. I would definitely recommend any medical student who's interested in that program. It's called the aerospace medicine clerkship.
Rena: That's fascinating. And what an interest, I never obviously considered female astronauts not really being able to have children because of the training. I think that is wildly interesting.
Brent: Yeah, it's just another example of a health disparity that I think has to be highlighted. I mean I will say that they now, I mean it's been maybe like 5 to 10 years now, they are covering some fertility care for the astronaut core and I think a lot of the astronauts are now able to get their care through OBGYN who practice in the area, like near the Johnson Space Center. So, you know, I think there are some avenues for it, but it's something that we need to monitor and keep our eyes on because we just don't know what the outcomes are after those exposures.
Rena: Yeah. Oh wow. That's super interesting. We're gonna have to talk after to see if you can connect with someone to have on the podcast to discuss cause my wheels are turning about this. I mean the more you know, we can expose disparities like this, the better.
Dara: Exactly. That wasn't even on my radar And now you've I'm sure put it on, you know, all of our listeners’ radar.
Brent: Yeah, absolutely. I love thinking outside the box.
Rena: Likewise. Well, we're so happy that you came on and and devoted your time to us and your wisdom. This was super interesting and we definitely look forward to keeping up with you and your studies and having you back again once you've done more research. This is fascinating and such an important topic.
Brent: Yeah, Thanks again.
Rena: So the way we like to end our podcast is by saying a gratitude. So something that you are grateful for today.
Brent: Something that I'm grateful for? I would say that I am grateful that after a long process I have finally kind of reached a decision and I'm gonna be joining faculty at Stanford. I'm excited to just have made it to this point in my career that I've like, I'm actually about to kind of enact the vision of what I've always wanted, which is to have a platform to create an academic center specifically dedicated to LGBTQ family-building. And I'll be doing it in, you know, the San Francisco Bay Area, which has the largest queer population in the country, if not the world.
Rena and Dara: Congratulations!
Rena: That's incredible! Dara, what are you grateful for today?
Dara: I am grateful for celebrations. I have lots of family and friends who are celebrating special birthdays. Yeah, so it's nice to have an excuse to celebrate those people that are nearest and dearest to my heart. And today we're recording on Halloween, so of course appreciative for a day of, of sugar once in a blue moon. Yeah. So something simple. What about you, Rena?
Rena: I will say, I'll kind of piggyback on yours and say celebrations. You know, it was my daughter's sixth birthday this weekend and so we had a party and especially post-pandemic, I'm just always so grateful for anything we can do in person. She missed out on so many celebrations and parties and so I'm just so grateful to have the chance to celebrate and do it with people we love, old friends, new friends, and be able to come together.
Dara: Oh, nice. Rena. Well we had a great discussion. Thank you so much Dr. Monseur, and we're excited to have you back down the road to keep us abreast and updated on your latest research.
Brent: Great. I look forward to coming back.
Rena: Thank you so much.
Dara: 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 @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.