Ep 300: An International View of IVF: How It Is Done in Other Countries

 Fertility Docs Uncensored is hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center. This week, the docs welcome Dr. Nadine Al Kaisi, MD, a reproductive endocrinologist at Eggcellent Fertility, who brings an international perspective to the fertility field. Dr. Al Kaisi has practiced reproductive medicine across Germany, Spain, Belgium, and London, giving her a unique understanding of how fertility care differs around the world. In Germany, for example, preimplantation genetic testing for aneuploidy (PGT-A) is not routinely performed and is used only in specific cases, such as when both partners carry a genetic condition or when sperm morphology is abnormal. Unlike in the US, much of fertility treatment in Germany is covered by insurance, creating a hybrid system that includes both public and private options. German laws impose strict limitations on fertility options outside of IVF. Egg freezing is restricted to married individuals, and same-sex couples are not eligible for treatment. Sperm donation is permitted but tightly regulated, with minimal information about the donor. At age 16, the donor-conceived child is able to contact the donor. Dr. Al Kaisi also explains how clinics in Germany perform natural cycle IVF, freeze embryos at the pronuclear stage, and transfer only one embryo per cycle. Other European countries, such as Spain and the Czech Republic, have more liberal practices—similar to the United States—though surrogacy remains prohibited. This is an interesting perspective on the different ways IVF is done in other countries. This podcast was sponsored by RMA New York. 

Transcript

Susan Hudson (00:01)

You're listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

Carrie Bedient MD (00:22)

Hello and welcome to another episode of the Fertility Docs Uncensored. I am Dr. Carrie Bedient at the Fertility Center of Las Vegas, and I am joined by the two most vivacious vixens that I can call co-hosts, Dr. Abby Eblen from Nashville Fertility Center and Dr. Susan Hudson from Texas Fertility Center.

Abby Eblen MD (00:35)

Hey everybody.

Susan Hudson MD (00:42)

Hello.

Carrie Bedient MD (00:44)

And today we are joined by Dr. Nadine Al Kaisi, make sure I wanna say that, and she is from Eggcellent Fertility. And so we are gonna dive into some of the worldwide differences in IVF and fertility treatment and how that goes. And we are very appreciative to have you with us Nadine today because you have a whole breadth of experience that we don't often...get to hear about. And so it's pretty fantastic. So thank you so much for joining us today.

Nadine Al Kaisi (01:13)

Thank you for inviting me. Thank you so much.

Carrie Bedient MD (01:15)

So you have not lived in the United States all that long. How long have you been here now?

Nadine Al Kaisi (01:20)

So we moved last year in summer in August due to my husband's job. So I'm based now in the Silicon Valley. I think this is very common story, right? My husband is in tech and yeah, so he's in AI and the AI business in America is quite good at the moment. So he got a job offer and yeah, let's go for the adventure, right? I mean, California is also not the worst place to go.

Then we decided to move. So we are now a year, a bit over a year.

Carrie Bedient MD (01:44)

Now what's the master list of places that you have lived? Because it's a extensive list at this point.

Nadine Al Kaisi (01:53)

Yeah, when I was growing up and I started med school, I was kind of curious. And when you live in Europe, some things are bit easier. Within the European Union, you can jump countries quite easy. So that's why I tried to do all my internships and my internal year and a bit also my fertility career to have experience in different countries. Like in my fertility career was more based as a hospitalization. When you do four weeks and spend another fertility clinic just to get some more experience how things are done there. And during my university, I spent time in quite a bit in Norway, in Switzerland, in Ireland, in Sweden, in the UK, in Australia. Yeah.

Abby Eblen MD (02:35)

Wow.

Nadine Al Kaisi (02:36)

I hope I got everything. Yeah, Not all were like a long time. So Australia was six months. Norway was also six months. Ireland was only an internship for four weeks. Sometimes we traveled a bit. So yeah, it was a bit of a mix.

Carrie Bedient MD (02:52)

So after living in all those places, how are you finding your experience in California so far?

Nadine Al Kaisi (02:56)

Honestly, I really like it because I struggled a bit to move here since, as I said, I'm a German fertility doctor, so I'm not licensed here and it's quite hard to get a license from here. So was a bit nervous since I love my job and I love to work in the fertility practice in Munich. I kind of needed to invent myself again. I was a bit nervous about that. But what I can say is that We can only talk now about California, but people here are so nice and also so supportive and so excited about everything you do. So I actually like it. And I feel like they're a bit more positive and a bit more supportive in every kind of way, either your private life or your business life, and of course the weather is unbeatable compared to Germany.

Susan Hudson MD (03:42)

The same seasonality though.

Nadine Al Kaisi (03:44)

Mm-hmm.

Carrie Bedient MD (03:45)

The San Francisco area can get quite nippy. So they're, especially in California, they're, they're a little bit more prone to being, warm and being cold. So you might get a little bit more of it there than certainly you would in LA or San Diego.

Abby Eblen MD (03:47)

Yeah, it can.

Nadine Al Kaisi (03:59)

That might be true. I'm in Palo Alto. So the Bay Area is like really like microclimate. So SF is actually quite foggy, especially during summer, but we're quite lucky here. So here it's actually quite nice.

Carrie Bedient MD (04:10)

That's good.

Abby Eblen MD (04:10)

So of all the places you've lived, and this may be hard because you've lived in so many different places, what's your favorite place and what's the place you would prefer not to go back to again?

Nadine Al Kaisi (04:20)

I must say my favorite place was actually Australia. I was in Sydney and Brisbane. And maybe to be fair, was also in a bit of different stage in my life. So this was right after med school. I was totally independent, no family, no kids, everything. So might be a different. Yes, yes, yes, yes. But I think my second favorite is already California. Must say that.

Susan Hudson MD (04:32)

Less global responsibility.

Abby Eblen MD (04:34)

Really?

Nadine Al Kaisi (04:40)

I'd rather not go again, I think it's Norway, even though Norway has a lot of benefits and there is a beautiful country and beautiful people as well, but I was quite far north and I couldn't deal, I think, for my whole life with this weather, in case of it's quite dark during the whole winter and it's very bright during the summer, so sleeping is really a struggle then as well and people are quite hard to...get to know. So I think once you have a Norweigan friend, I'm sure you have it forever, but it's quite hard to get into their community.

Carrie Bedient MD (05:13)

Mm-hmm. And especially if you're the transition compared to someplace like Silicon Valley where there's much more transients and so people are much more willing to make a friend because everybody needs friends. Nobody's been there forever and ever. And so they're much more willing to say, what new idea are you bringing in? What new set of skills do you have? What new personality do you have that will be a great addition? It's one of the things that makes California in particular very a very warm and fuzzy place to go because they're pretty accepting.

Nadine Al Kaisi (05:44)

Yeah, true. And it's also very international, I must say, right? I I think the first, like really the first American I met was after I think a few months, like who really grew up here or was like really totally American. So yeah.

Carrie Bedient MD (05:56)

I never would have guessed that. Well, I'm so glad that you are finding a nice place to live and a nice place to be and that it's welcoming and that's the goal for everybody. So I'm so glad that you're finding that.

Nadine Al Kaisi (06:09)

Yeah, I mean, thank you to you guys, right? I mean, you make it also quite nice. I mean, I'm kind of an immigrant, right? But I don't feel like it. I feel very, welcome in here.

Carrie Bedient MD (06:17)

Wonderful.

Susan Hudson MD (06:18)

Well, we're a country of immigrants, that's for sure.

Carrie Bedient MD (06:22)

Yeah, down the last one of us. So, all right, so Susan, do we have any questions for today?

Susan Hudson MD (06:27)

I do. And on the theme of international and IVF, have an international IVF question. So our question today is, hello, hello. I love your show. Thank you so much for listening. I'm about to start IVF soon. My clinic, which is in Dubai, has an option of rapid PGT testing and would do a fresh transfer. Is there any risks with this? I know it doesn't allow more time for retesting, but are the results as accurate?

I had a miscarriage in March. My husband and I have done testing since. I have PCOS, a relatively high egg reserve, and my last scan had 35 follicles, AMH 8.7, FSH 5.3. Husband's sperm count has fluctuated from 5 to 1.8 million to 10 million. His results for karyotyping are normal, and he has about 2 % normal healthy sperm.

Carrie Bedient MD (07:20)

Okay. So Nadine, in your experience, what do you think? How does rapid PGT, where they can do it in the context of being able to do a fresh transfer, like how often do you see that? How does that play into, particularly when you were actively practicing in Germany, how does that factor into your decision-making?

Nadine Al Kaisi (07:39)

So unfortunately, Germany PGT is not... Yes, that's the thing. So it rules actually kind of limited to... We only do PTGA testing in Germany if there is an issue with the couple, meaning they get the carrier testing and if they have...

Susan Hudson MD (07:41)

You can't do PGT in Germany.

Nadine Al Kaisi (08:00)

Yeah, if that pathologic or if there is an issue with their genetic or if there's a family history or something, you need to have an ethical committee and they need to confirm that you're allowed to do it. And then they do the PGTA. So it happens only to not a big crowd in Germany. So that's why my experience, least for Germany, is quite limited with PGTA. But what I can say is that even though we don't do that a lot, our success rate is not much less than in other countries where it is allowed. So I think it's mostly important for miscarriages, at least in my point of view, and also maybe that you do less transfers to go to have the success. I must admit I'm not that experienced with rapid PGTA testing.

But I'm not sure if there's such a big benefit to do it since frozen transfers are nowadays have almost the same success rate as fresh transfers. I'm not sure if there is a big benefit to do it. But what are your experiences? I guess you have a bit more.

Susan Hudson MD (08:57)

So I would like to say that I actually did rapid PGTA testing for my daughter who just turned 15. So that technology has been around for quite a while. I would say it's probably still good. It's probably not as good as the testing that takes longer. I mean, obviously there's there's more that goes into the next generation sequencing or the other modalities that are available nowadays. And so if you're in a situation where you very, very much want to do a fresh transfer, which when I did a fresh transfer, we thought fresh was best. And now that we know that you can line up the uterus and the embryo much better in a frozen embryo transfer, especially in somebody who has a ton of eggs.

I think if you really wanted a fresh transfer for some reason, it provides that opportunity. However, in people who are at the extreme, so people who have lots of eggs or people who don't have many eggs, you're the folks who are most likely to have the rise in progesterone that actually closes the window of opportunity for good, healthy implantation.

In a lot of ways, I think it's riskier than using the more common modalities for PGTA testing, at least what's available in the US.

Abby Eblen MD (10:28)

One the other thing too is I have a patient literally this week that really wants to do a fresh transfer and her AMH is probably about seven and she's 29 years old and she has PCOS. The problem is you have to trigger patients with HCG and so if you trigger with HCG, that really sets the wheels in motion for hyperstimulation and so in the first two-thirds of my career we would have probably four to five people a month that would come in and would have to do a paracentesis in our office several times. We probably hospitalized five people a year due to dehydration, vomiting, that sort of thing. I haven't seen that in a long time and I really don't want to see that again. It's really dangerous for mom. And there's also some data to say that it's not optimal for the baby when estrogen levels are super physiologic. I think there's a lot of good reasons not to do a fresh transfer anymore.

If my patient fits into the window where her progesterone's appropriate and her estrogen level's not too high, she really wants to do it. So we're gonna do it, but that's not certainly something I would normally suggest to someone.

Nadine Al Kaisi (11:27)

I think especially since she got PCOS, I think if she would be patient, like I don't know, 40 years old, AMH 0.2 has 3-4 eggs at the retrieval, might be make more sense, as you said, than the estrogen levels, maybe not that high. She doesn't, she maybe doesn't want to waste to freeze them and defreeze them. But with PCOS and 35 eggs or something, she got quite a bit of risk of overstimulation, you're totally right.

Carrie Bedient MD (11:50)

Mm-hmm. Well, also if you're minimizing the risk of hyperstimulation, it also means you're gonna minimize the yield of what you get and there's something to be said if you are Hell-bent on having a transfer as soon as possible There's something to be said for okay. Give it a shot you you don't have a huge amount to lose in the sense of fertility because ideally you're making a bunch of embryos even if you transfer this one in a non-ideal circumstance. As far as fertility goes, you're unlikely to make a huge dent because hopefully you're gonna have a bunch of embryos left. The problem is that you're gonna run that medical risk of hyperstimulation and that is very real. The other problem is that there's a difference between not risking something versus not optimizing something. And particularly if you want a bigger family, you may be doing yourself a disservice by saying, I'm going to try for a fresh transfer so I can get there faster, because it means that yes, you're still highly likely to get embryos, but you may not get as many as you would if you pushed and did a frozen embryo transfer. And so if you just want one child, okay, you've got more room for wiggling. If you want many, then that's where the decision to do a fresh transfer may not serve you as well as the decision to do a frozen transfer.

Abby Eblen MD (13:08)

And to be clear what you're saying, Carrie, too, is that her doctor is probably gonna compensate by lowering her dosage of medicine, therefore getting less eggs if she wants to do a fresh transfer. And that's exactly what I talked about with my patient as well that, what's the priority for you, the fresh transfer, or is it getting a lot of eggs? You have to decide because you can't really have both.

Carrie Bedient MD (13:29)

Exactly. Well, that's a good question. And it dovetails very nicely into our topic in general, which is, Nadine, we want to hear all about what is practiced and what is normal and what are the viewpoints in other places in the world. And so we're very spoiled to have you because you're a fully boarded REI and have practiced the majority of your medical career elsewhere outside of the United States.

What's the standard? What's very common in Germany? What if someone is coming through and they're your patient, what experience are they going to have once they decide they want to do IVF?

Susan Hudson MD (14:06)

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Susan Hudson MD (15:09)

Maybe we start that going through the IVF process and talk about as we go through, how are things comparable?

Nadine Al Kaisi (15:09)

So you mean like with the first appointment and then how it goes on? I think for the first appointment maybe not that much. I think one main difference is maybe that in Germany the doctors are doing all the ultrasounds. We don't have any fertility nurses or ultrasound nurses who do any ultrasounds. So the first ultrasound is done by the fertility doctor who is at the end also treating the patient, but also during the process of IVF when they come for checkups, they always see their doctor and not any IVF nurse or something. I think this is one main difference maybe. Also a difference is that we are not doing a lot of genetic tests. Again, the same topic. So for example, it's not a standard test to do a carrier testing right at the beginning when the couple is coming in. So we are actually only doing that if...for example, risk factors in families or when the sperms, for example, have less quality in terms of motility but also morphology, mostly morphology. So if it's basically an indication for an ICSI, then that's a reason to do a carrier testing. But not only that, we start first only with the genomic testing, like that they have 46 chromosomes.

But not a total carrier testing for the most common genetic diseases. So I think that is one big, big difference.

Susan Hudson MD (16:41)

Okay, I've got some questions already. Let's start off with the morphology issue because we've talked about morphology so many times. I mean, in the United States, we always joke about that we don't even know how much morphology really matters. What is the tie between morphology and carrier screening? That's not something that I usually think of. I think of if you have really, really bad sperm parameters doing chromosomes or Y chromosome microdeletion, but where is that bridge?

Nadine Al Kaisi (17:12)

So I think it's more about that if the morphology is less, there might be also higher DNA fragmentation in the sperms. So they think the risk might be higher that something is going on as well with their carrier, something like that. I think it's also a bit of health insurance thing. if there is an indication for an ICSI.

That is actually a main reason why you are allowed to do a carrier testing or genetic testing. And the education for ICSI's mostly actually motility. Also concentration, but mostly motility as well. Then mostly the morphology is also affected. So it's not only the morphology, but it's one part of it to have the indication for genetic testing.

But I must say it's also a bit history in Germany. So I'm not saying it's reasonable. And I think actually the approach in different countries, like for example Spain doesn't do that. Spain also does definitely more genetic testing with all the patients. The only positive effect is maybe the costs. So you don't have that big costs if you step in a fertility clinic in Germany. What we do is of course a physical exam. We do the ultrasound to see if there's something going on, you know, like cysts, endometriosis, all these, what you can see in the scans. And we do a hormone check with all the hormones you know as well, like AMH, estrogen, like the whole thing, male hormones, female hormones. But the genetic thing is a bit of a difference. So genetic is a very hold back approach.

Carrie Bedient MD (18:44)

Hmm. So if you have someone who has a history where let's say both partners are from the same Mediterranean region or region that has known genetic conditions associated with it, like sickle cell anemia, like thalassemia, like Tay-Sachs, like whatever it may be, would that be an indication to do carrier screening in that couple? 

Abby Eblen MD (19:12)

You can make the argument that anybody in any country, like I'm probably at high risk for cystic fibrosis. So if I marry somebody that's got Irish, English background, that maybe we should both be. So you're saying they could be tested for certain things, but they wouldn't be tested for a panel of 470 different recessive traits basically.

Nadine Al Kaisi (19:29)

I would say it's not a standard test. So it's not like they come in and it's definitely done for everyone. So it's a step. We do more when something comes up. Except if they have history of something, right? But if there's nothing in their story and if they are just a normal couple coming in and do their first appointment because I know they tried for one year, she's 36, he's 40, that wouldn't be the thing that you would do on the first appointment.

You only would do the hormones and the sperm test like the standard one, but you wouldn't do a genetic test right away. But I guess here in America, that's different. Normally that's one main thing you do as a basic test, right? So I don't want to say that's right, how Germans are doing it. So for example, if they do IVF and you have like a failure in fertilizing the egg, like a total failure, then we do a genetic testing. You can say, that's a bit of a weird approach because we first do the things and once something is coming up, then we do the tests. I think it's also a bit of history. Yeah.

Susan Hudson MD (20:37)

I mean, there's definitely a history with World War II and everything like that, but is Germany a socialized medical system or is it a hybrid system or a private pay system? does how does, how is healthcare paid for?

Nadine Al Kaisi (20:47)

It's a hybrid system.

Susan Hudson MD (20:49)

RMA of New York is a global leader in state-of-the-art reproductive medicine, serving as Division of Reproductive Endocrinology and Infertility at the Icahn School of Medicine at Mount Sinai. Led by an integrated team of physicians and scientists, RMA of New York is renowned for its pioneering research in the field and for delivering high IVF success rates. With locations across Manhattan, Brooklyn, Westchester, and Long Island, RMA of New York has helped thousands to build the families of their dreams for more than two decades and counting.

Nadine Al Kaisi (21:20)

Yeah, it's a hybrid system. That's another thing. So mostly for the first checkup, if you are public insured, that's covered by the insurance. Only when it comes to fertility treatment. So that means insemination IVF, ICSI. If that happens, then you need to apply for that. But mostly it's covered like 50%.

And then couples are private insured and then it's basically who whose fault is it? You know like basically if the sperms are not okay then the private insurance of the man is covering it and if the woman has a condition the private insurance of the woman is covering it but they are mostly covering 100 percent but if you do in their opinion unreasonable tests that might be a bit of a fight if they are covering.

Abby Eblen MD (22:06)

I have a quick question. I'm jumping ahead a little bit, but we may not get to this. I just gave a talk about egg freezing. So I'm really curious, does Germany pay for procreative management, egg freezing, that sort of thing?

Nadine Al Kaisi (22:16)

No, no, no, they don't pay for egg freezing, they don't pay for same-sex couples, and they don't pay for not married couples.

Abby Eblen MD (22:22)

That's surprising.

Carrie Bedient MD (22:23)

So what's their approach if a woman is, let's say she's got premature ovarian insufficiency and has essentially no eggs left? Will they, and she's in a heterosexual relationship, married, meets all the other criteria, would they pay for an egg donor for her?

Nadine Al Kaisi (22:41)

No, because egg donation is also not allowed in Germany. But that's allowed. I think you must say in Europe, there's a bit of a tourism going on for treatments. So I think Germany is quite good with science and the lab techniques. So I think they're good in that way because the rumor is true. So we're very focused, very into details and stuff. But since our government is not allowing...everything. For example, sperm donors is allowed but egg donoring is not allowed. Egg freezing is allowed but you can't donate these acts so you only are allowed to use it for yourself. what happens is that I think we are trying... Yeah, so one thing is I think we're trying more with women with ovarian insufficiency before we go to egg donation. I think like for example we do like the...more natural IVFs and try to collect only the one egg she's producing. I think we are going also for the age. I think we're going much further with the age to try to conceive than it is in different and other countries where egg donation is much more common. Like a good countries where people are going for egg donation in Europe is for example, Spain, Czech Republic. And those are the biggest countries because there you have also a wide

range. You have a lot of egg donors as well because they are good in, I think it's a bit of part of their mentality, especially Spain. They have good egg donor banks there. So those are the countries where most people are going. UK is also an option. But UK has, since it's not again in the European Union, it's sometimes also hard to go there. So that's why Spain and Czech Republic is a bit more common.

Abby Eblen MD (24:10)

As a patient, do you have access to any kind of overall registry? In the United States, we have SART. Do you have any idea, when patients pick Czechoslovakia or Spain, like, what the pregnancy rates are, just in general IVF pregnancy rates? Or is there a body that looks at that in each country?

Nadine Al Kaisi (24:35)

So do you mean like if there is like a registration, like a national registration for pregnancy rates?

Abby Eblen MD (24:40)

Yeah, like in our country, if you go to SART, Society for Assisted Reproductive Technology, you can get an overall pregnancy rate in 2023 for the whole SART data, which most IVF centers are registered with SART.

Nadine Al Kaisi (24:53)

Yeah, yeah. So in Germany we do have that too. So we have like a common registration. We even have like a computer system which is already like referring your data to the state. I don't know how to do the government basically who's organizing that. And in Spain I must say I'm not sure but I'm pretty sure they do have that too. I think it's kind of a standard in all the Western countries but. Oh, so.

Abby Eblen MD (25:14)

And patients have access to those numbers or those success rates.

Nadine Al Kaisi (25:19)

In Germany, there is like there's a website and there's a patient portal, but it's not so you can't see specific clinics. So it's not like, the clinic in Munich has these success rates or this clinic has this. It's more like overall in Germany, for example, what is the success rate of overall frozen transfers age of 40 to 43 or something? Yeah, there you have access to, but we don't have a competition between clinics. So you can put that on your website, of course, but it's not any standard or any like that is something covered by the government to make sure that's correct.

Susan Hudson MD (25:46)

It's not as regulated as it is here.

Carrie Bedient MD (25:50)

So what information do you get about sperm donors? Can they be known? Are they required to be anonymous? Can you get information about, there are a ton of information about who they are or is it just they have brown hair, brown eyes and the skin tone and what information do you get from them, about them?

Nadine Al Kaisi (26:08)

So in Germany again not much. So the problem is that it's first anonymous but the kid has a right to know in Germany who their parents are. So once they turn 16 they are allowed to go to the sperm donor bank and ask who the donor was and they need to give her this or him the information. And this makes it harder to get donors nowadays because they might not want to that.

And that's why in Germany, it's quite hard to get donors. And it's also a bit odd. So you don't get a lot of information. So you basically go to the donor bank and then tell them what you want. And they basically are searching for the right candidate, but they are basically deciding for it. So that's why most patients at my clinic went to Denmark. So we basically got sperms from Denmark to our clinic; that was possible. So we could basically order it from Denmark and they do differently. I think they have more like the American approach. There you can basically see everything. You can ask for even a voice example. You can see photos, either child photos or adult photos. You can see they do genetic tests. They give you the risk of family history of all kind of stuff that you would like to know. But that's...depending on how much you want to pay. So the less you pay, the less information you get.

Susan Hudson MD (27:35)

I understand generally egg donors are not allowed. What about if it was a known egg donor? Is that type of thing allowed or no? It's just not at all.

Nadine Al Kaisi (27:43)

No, no, at all. No.

Abby Eblen MD (27:43)

And so how does Germany get away with saying it's okay for you to use a sperm donor, but you can't use an egg donor? That just, to me, that seems like a very big double standard.

Nadine Al Kaisi (27:49)

That is totally right and you know what? Fertility doctors are fighting for that since I think 30 years or something. It's the same as actually for blastocyst transfer. It's also a really, really weird law which also goes back to the second world war and the tests which were made there. So it doesn't make sense. I can't give you good answer on that. It just doesn't make sense.

Abby Eblen MD (27:55)

Yeah, I mean, that's just ridiculous.

Susan Hudson MD (28:12)

So what are you saying about blastocysts? Tell us about this.

Nadine Al Kaisi (28:15)

Yeah, also very weird. So the thing is that you're supposed to not let embryo, too much embryo are developing. So the idea is that only that many embryos are developed how many you want to transfer. And since nowadays we actually want to transfer only one. So that means, if like, have a 34, 35 year old woman and we have 10 fertilized eggs to get one nice blastocyst. On average, say, okay, we need four to five fertilized eggs to get one nice blastocyst roundabout. That's the statistics. So you would only freeze the other five, just fertilized, and the other five you would start to develop at four or like the five days and then see how many blastocysts are there and then you transfer one. And if there are more than one blastocyst, you are allowed to freeze it, but it's a bit of a trade-off. So, for example, in America, we just let all those 10 grow, right? And then have four or five blastocysts, then you would do the genetic testing and then do the transfer. In Germany, would do this. You would freeze five in the pro-nuclear state, then you would let develop the other five. maybe you have two blastocysts and you would transfer one blastocyst and the other one you would freeze. But you're not allowed to do any testing then.

Susan Hudson MD (29:40)

So you're actually freezing pro-nuclear, so you're actually freezing pro-nuclear embryos, not eggs. So you do fertilize all of them, but you freeze at the pro-nuclear stage and then let the rest grow.

Nadine Al Kaisi (29:45)

Yeah, we fertilize all of them.

Because the idea is that in the pronuclear state, are not like, yes, they're not together yet. They're two cells and then didn't combine yet. And that's the idea.

Susan Hudson MD (29:57)

We haven't combined genetic material completely.

Abby Eblen MD (29:58)

Oh, not in Tennessee. That's not the...

It's a special, special thing that happens in Tennessee when an egg and a sperm go together. And it does this too.

Nadine Al Kaisi (30:08)

Yeah, yeah, it's totally yeah, doesn't make sense.

Abby Eblen MD (30:12)

Yeah, nothing makes sense when it comes to that.

Carrie Bedient MD (30:12)

So let's say if you have those 10, you fertilize five, you don't get what you want for whatever reason, they don't grow, they don't stick. If you have those 2pns, the pro-nuclear state, would you then do in the next cycle, would you then say, okay, we're going to thaw these five 2pns and let them grow and see what they develop in a blast?

Would you do a frozen embryo transfer or would you do a fresh embryo transfer at that point and develop the lining simultaneously as when you thaw?

Nadine Al Kaisi (30:44)

Do you mean the first transfer, that's a fresh one or a frozen one? So that depends a bit honestly on the story of the patient. We do more frozen transfers than we did before, since the success rates were pretty similar. And since we know now more data and also the freezing process is more successful. So then we would, I think, depend that on the history of the patient. So we are doing fresh transfers, but not as much as we did like 10 or 15 years ago.

So what is the law and what fertility clinics are doing is kind of like accepted. If you would really follow the law, you actually are not allowed to develop the blastocyst, freeze it and don't do the fresh transfer. But most clinics are doing it and saying then, but we had a risk of overstimulation or the patient wasn't prepared for it or I don't know, the progress to wrong level was not, whatever, right? So then we freeze it. Legally, it would be like you said, would freeze all embryos in the pronuclear state and would do the transfer actually then with de-freezing all of them or like five of them and then develop them to the blastocyst.

Abby Eblen MD (31:29)

Okay.

Well, one thing that I would say is a little bit of a positive is that you have less embryos potentially. In our country, you pay for everything. And so if you freeze part of the pronuclear embryos and then you let part of them go to blasts, then you have to pay for them to thaw. And, it's just, more expensive for the patients when many of them are paying completely out of pocket for all that stuff. It's not quite as tough if the government's going to cover the cost of that, but still.

I'm sure it's frustrating for the patients.

Nadine Al Kaisi (32:12)

We got quite used to that and we also were able to squeeze it a bit regarding the story of the patient. So for example, if I know already that the patient is quite old, you can squeeze it, but then maybe you let eight develop, and you can still argument, hey, but you're 38, or we thought her egg quality is not that good, or blah, blah, So you can still squeeze it a bit, but I must say that the process in total is much cheaper in Germany than in the US, even if they would need to buy and pay everything by themselves.

Susan Hudson MD (32:40)

How?

Abby Eblen MD (32:40)

So if you don't follow the rules, who comes after you? Is there anybody that knocks on your door if you don't follow the rules?

Nadine Al Kaisi (32:46)

So it happened if there's fight between doctors or clinics and saying like, hey, I think these clinics are not following the law or something, then sometimes happens. But I must say, actually, I have never heard anything like a doctor had really problems with it. And only if you really would, for example, do egg donation. There, they are quite strict. Like egg donors or embryo donation.

It is actually legal, but it's a certain process. And there is also a government institution who's organizing this.

Susan Hudson MD (33:20)

You were mentioning the cost of IVF being quite a bit cheaper. Obviously, in the news right now, we have information about, the United States federal government helping brokerage deals to help bring down the cost of IVF medications. What do you think? Do you think that medication costs is a huge factor in why IVF is cheaper in Germany or what do you think are the other contributing factors?

Nadine Al Kaisi (33:45)

I think it's more the other computing factors. I'm actually not sure. So I would say the average patient in Germany, if you would have like a full dosage IVF, taking 300 units per day or something, or 350, it would be around 1,500 euros, which is about $1,200. So I think for the whole simulation, yeah. So this is much less, I would say. Yeah. Yeah. Yeah.

Susan Hudson MD (34:03)

For the whole simulation.

Abby Eblen MD (34:07)

Wow. ⁓ Yeah, that's totally different than here for sure.

Nadine Al Kaisi (34:12)

Yeah. And so I think if you are doing everything, if you think the max cost, if you do an ICSI with all add-ons say like, except PGTA, let's out PGTA, but do embryos, embryo glue, all the add-ons, assisted hatching, whatever we have, right. It's, I would say more than $15,000.

That's the max, max, max, max. And then you've got everything. For PGTA, depends a bit how many you are testing, right? So how many blastocysts you're testing. So that's a bit of more variety of costs. But I would say an average patients pay around $5,000 per IVF cycle.

Carrie Bedient MD (34:50)

So how common are those rules, the situation that you laid out in Germany? How similar is that to what happens in Spain or the UK or Norway or some of these other countries?

Nadine Al Kaisi (35:03)

Germany is most strict about the law. for example, Spain, I think is much more similar to the US in terms of what is allowed. So they are totally fine with egg donor, egg freezing, sperm donors. They also have all the information you can get here. They are allowed to do PGTA testing. I think the only thing what they don't have is surrogacy. Surrogacy is something in Europe.

In my opinion, it's only allowed in the UK, but they don't have a lot of surrogates. I think the law is also quite strict about it, they don't have enough women who do provide that. And as far as I know, it's actually only outside of the European Union, Ukraine. And I think the Turkish part of Cyprus is also having that, but all other European countries, as far as I know, don't.

The Scandinavian countries are also quite good to be very efficient. They have good success rates and they were very good in pushing this idea of only one embryo transfer, the single embryo transfer. I think this was very big advertised in the Scandinavian countries and then influence over the other countries. So they're also bit more open-minded to all kind of treatments. But as far as I know, also no surrogacy.

Carrie Bedient MD (36:11)

That rings true. I know that the majority of our patients who are coming over are primarily looking for egg donation, sperm donation, surrogacy. There's a lot of couples who due to their social circumstances are not permitted to do any of those things in their home countries and also patients who they either need or want that extra layer of genetic testing and evaluation. And in some cases looking for things that are outside the box. So things that are beyond just the basic, you will have this dose and this protocol and that's where you start and that's where you stop. And so they're coming here for some.

Nadine Al Kaisi (36:49)

But I don't know if there's a big difference, but I would say that also European clinics are doing a lot like different things like natural IVF, combined IVF, more with letrozole, clomid, a little bit of FSH. With the protocols, maybe not so much because there we are flexible as well, since there is no law or anything we need to follow. But one big thing is also, as you said with...egg donation, sperm donation, that the information is not that much what you can get from the donors. So I think that's a big issue where people are coming. And the genetic testing, think we're just, I think we are less experienced since we don't do it that much, you know? So I feel always like we are missing something then.

Abby Eblen MD (37:34)

Yeah, I think eight or ten years ago in our country, it was the same thing when we made the jump from, doing instead of doing all fresh transfers, there's sort of a time, at least in our particular office, we would do some of both. And then finally, we made the jump over like we're going to do PGTA on everybody that wants to do it and do frozen transfers. How many people in Europe or how many groups in Europe would you say still do fresh transfers?

Nadine Al Kaisi (37:57)

And so I can tell you from Germany, it's about 30 % fresh transfers, 70 % frozen transfers. And I think Spain is even a bit more frozen ones because I think they have a lot of international patients that makes it also mostly more frozen ones. They might even only have 20 % fresh transfer or even 10%. I would say Germany might have still most of them since we are not testing. But all the countries which are doing PGTA testing as a standard, yeah, have definitely shifted to frozen transfer. I think one big issue maybe why they are going to the US is that they can't decide for the sex because that is also not allowed in Europe at all. So you're not allowed to choose the sex of the embryo. So we are also not allowed to tell them even though there is a PGTA testing. We're only allowed to tell them if...

It is a genetic issue which concerns either the female or the male sex. I'm hunting something right then you want to have maybe the female one. yeah, yeah, yeah, yeah, but that's the only time we're allowed to do that. Otherwise, we're not allowed to tell them the sex.

Carrie Bedient MD (38:48)

Yeah, like a muscular dystrophy or something like that. Next link, right?

It's so fascinating to hear all of these differences because we get all of us, and I think this is even true within clinics in the United States, we get so wrapped up in, well, this is what you do. And then once you start to talk to other people in your city, in your state, in your country, and then in the world, you realize everybody does it just a little bit different. So it's lovely to hear what all those differences are and why and how cultural experiences and expectations shape what can occur medically.

Nadine Al Kaisi (39:27)

Yeah, true. I actually found it quite exciting when I visited here the clinics. I was like, this is actually great. I like that. This is really cool to see how things are different and what can you implement maybe in your treatment as well. Since it's always good to have an open mind, right? That's why we also go to all these big conferences and like the international ones as well. Since, I think it's always a big benefit.

Carrie Bedient MD (39:47)

Well, thank you so much for talking with us, Nadine. For our listeners, we are talking with Dr. Nadine Al Kaisi, who is the founder of Eggcellent Fertility. And we are very appreciative to hear about all of your experiences today. So thank you so much for joining us.

Nadine Al Kaisi (40:04)

Thank you so much for having me. It was really nice. Thank you.

Carrie Bedient MD (40:07)

And to our audience, thank you so much for listening. Please subscribe to Apple Podcast to have next Tuesday's episode pop up automatically for you. Be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.

Susan Hudson MD (40:21)

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Abby Eblen MD (40:38)

As always, this podcast is intended for entertainment and it's not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we'll talk to you soon. Bye.

Susan Hudson MD (40:48)

Bye!

Nadine Al Kaisi (40:48)

Bye.