Ep. #39 - Can Geographic Location Have An Impact on Fertility Success? An Interview with Dr. Alex Quaas

Fertility practices across the United States can vary greatly based on state mandates and regional culture. But think of the differences across the world--it’s hard to fathom! On this episode of Inside Reproductive Health, Griffin Jones and Dr. Alex Quaas give us a glimpse into (literally) the world of fertility. Having practiced in numerous states and countries, Dr. Quaas shares his experiences, diving into the biggest differences in care he witnessed in Europe and here in the USA.

Welcome to Inside Reproductive Health, the shoptalk of the fertility field. Here, you'll hear authentic and unscripted conversations about practice management, patient relations, and business development from the most forward-thinking experts in our field.

Wall Street and Silicon Valley both want your patients, but there is a plan if you're willing to take action. Visit to learn about the first piece of building a Fertility Marketing System--The Goal and Competitive Diagnostic. Now, here's the founder of Fertility Bridge and the host of Inside Reproductive Health, Griffin Jones.

GRIFFIN JONES: My guest on Inside Reproductive Health today has been around the globe. Dr. Alex Quaas completed medical school in Manchester, England. He earned a PhD from Freiburg, Germany. He completed his OB/GYN residency at Harvard and his REI fellowship at USC. He went on to spend four years on faculty at the University of Oklahoma. He went to spend time back in Switzerland at the University Hospital of Basel and in 2018, he returned to the United States to join Reproductive Partners of San Diego and he also serves as a clinical assistant professor at the University of California at San Diego. You might know him from chairing the Pacific Coast Reproductive Society, of which he was program chair for the 2017 meeting, or you might know him from the many peer-reviewed publications and book chapters that he's authored and co-authored--the most recent of which is on the topic of geographic variations in research and clinical care in the field of REI. Who better to talk about that! That's why he's on the show today. Dr. Quaas, Alex, welcome to Inside Reproductive Health!

DR. ALEX QUAAS: Thank you so much for having me.

JONES: Now, you have some good data to talk about some of the differences and we're going to get into that. I wasn't even expecting that when you had sent that over. I just figured, here's the guy that has practiced in a lot of different parts of the United States that are really different from each other, in parts of Europe that are different from each other, and across these continents in different places, would have a good idea, anecdotally, of what it's like to practice in different places. You have some data and I want to get into that, and then I want to get into an anecdotal conversation that you were and I have had about the quality of life of choosing certain areas because I talk about that on the show quite a bit. But let's start off with just some of the anecdotal experience you've had. How much difference is there in practicing reproductive medicine in one part of the world, or one part of the country, versus another?

QUAAS: There are quite a lot of differences and actually, so some people spend most of their career in one place and there's absolutely nothing wrong with that. In fact, there's obviously some positive aspects to stability in your professional career, but if you do get to switch place from one place of training to another, I think it helps to see how different things are done in different places because it gives you a perspective--which parts of the process are the most important ones. Because for example, let's say as an example, I recently mentioned to my fellowship director, Dr. Rick Paulson, that it was really quite an insight for me to practice with five different attendings at USC because every single one of them was telling me how to do the egg retrieval slightly differently. And so I said to him, “Well, what that taught me is that maybe the technique is not quite as crucial, and that they still all had very similar success rates.” So, when you see practice being done differently in different parts of the world or even inside of one institution, it helps you put into perspective which parts of the processes are the most vital to success.

JONES: So you noticed from that point, that there's just a difference to begin with. You’ve got five different attendings and five different ways of learning about egg retrieval. You learned, okay, so there's not a uniform way that every single person does it every single time.

QUAAS: Right. That's probably because those people have trained in different places under different mentors. And those were subtle differences, you know, it was like, do you twist the probe a little bit that the end? Or you know, for example, for the embryo transfer, do you stay inside the uterus for 30 seconds before you take out your catheter. These are small differences that you see from maybe one, or subtle differences from one attending to another, from one practitioner to another, that we learn from. But then, moving from the East Coast to the West Coast to the Midwest, or moving from America to Europe, made me realize that there are also more, like, striking differences between places. And I that I got a pretty good perspective which of these differences are actually impacting care and which one of them are maybe more of a style point. Like for example, how it exactly do you perform a procedure may just be how you trained and maybe people have the same success rates with that, but then there are maybe more striking variations that actually do have an impact on care. For example, when I first arrived in Basel, Switzerland, you know, all the egg retrievals were done without anesthesia or just with local anesthesia. And so at first, I thought well, let me see how that pans out, and I was able to form an opinion about this and what I realized is that because it was done under local anesthesia, the patient might have felt some discomfort at times--you had to be extra gentle--and maybe the egg yield may be lower and maybe that may actually have an impact on success rates. And actually midway through the year in Basel, we changed it there and ended up using Propofol like is the standard of care in the United States for the egg retrieval. Another example is, for example, that the mentor I worked with in Basel was insisting that we use a tenaculum to grasp the cervix for the transfer, which is something that in the United States every time I talk to somebody about that, they were kind of appalled about that. So anyway, that probably has also been shown to not be beneficial for patients. And so it showed me--these kind of observations showed me that where you live in the world, as a patient, obviously offer as a practitioner because how are you’re trained has a profound impact. And I felt like this one area of medicine where the differences maybe more striking than anywhere else because we're a young field--like IVF is only 41 years old. We're an emerging field. We are a field that every year there are new developments. And I feel like what I've also observed is that there's a lot of different ways to interpret the literature because, you know, in Europe there were certain schools of thought taught to people that were almost fundamentally different to the way I was trained in the United States.

JONES: So how do you know for certain that this is not just something that was at this hospital in Basel. How do you know that it's--the local anesthesia example, for instance--that that’s something is practice continent-wide, or at least countrywide, or broader than just the program that you’re at. When does the difference strike you? That this isn't something that's just happening here this program, but rather happening at a national or multinational level?

QUAAS: Oh, I think that what was actually fascinating was that within Europe, there are massive differences, in the space of a hundred miles! You cross the border from one country to the next and you might have a completely different way that people practice, and completely different legislation, ethical views on things, cultural differences. And so, even within Europe there's a lot of differences and that was actually quite fascinating. And by the way, I don't want to say that the standard of care was necessarily way lower in Basel, Switzerland for example, but that there were just differences. So for example, in this paper that I wrote for JARG that you mentioned about local privileges and not universal rights, which basically was the description of the geographic variations in the science and clinical practice of reproductive medicine. I mentioned that, for example, for hypothalamic amenorrhea, so for women who do not ovulate because of hypothalamic causes, in the United States, we always had to do gonadotropins or use gonadotropins. In Europe, it’s a pump that is licensed in many places and it's a pulsatile GnRH pump that very elegantly, basically, treats the underlying cause which is the insufficient secretion of GnRH, which has to be given in a pulsatile nature. And that pump could just as easily be used in the United States, it's just not available. So that, for example, was an advantage there. So not everything was necessarily worse, but for example in Switzerland, since you asked whether that was just a local phenomenon, these differences in care, or more like continent-wide or country-wide to Switzerland, I would say the practice of IVF is probably relatively uniform within the country of Switzerland. There's only like four or five universities that offer IVF and then some private practices. So within Switzerland, there’s probably relatively homogeneous and a small community of practicing REIs. Within Europe, for example, let’s say if you compared Switzerland to Spain, or you compared Switzerland to Belgium or other countries, there are marked differences and these are usually due to culture and legislation. And then also, the insurance landscape and the healthcare system as a whole. So for example in Switzerland--I was very fascinated by this for years and years--they had a relatively restrictive reproductive law, that at the core of it all, it restricted the freezing of blastocysts because what they basically legislated was that it was only allowed to develop as many fertilized human eggs outside the female body as can be immediately implanted. So what this means is that they differentiated between a zygote, which is basically the day after the egg gets fertilized. So, on the day of the retrieval we have an egg, we inject the sperm into it, and then the day after--we call it a 2PN--so it's a fertilized oocyte at the 2 pronuclear state or zygote. And essentially for the Swiss and this legislation said, it still has the 2 pronuclei. So the male and female genetic material hasn't really properly fused yet and therefore, that can be frozen. But you can only grow as many of these to the blastocyst stage as you can immediately implant. You're not allowed to freeze them. So what they did is they had this relatively suboptimal system where, let's say a patient has 15 eggs retrieved, 12 fertilized. Three of them which the petitioners felt like was a quantity that would develop into a reasonable number of blastocysts, three of them could be cultured and grown to blastocyst stage and the rest will be frozen at this 2 pro-nuclear or zygote stage, which they didn't consider consider an embryo yet. As far as, you know, like when the I thought once you put the sperm in basically, you fertilized the egg. This is like the philosophical and ethical question, when does life begin? And in this country, there's a big discussion about this, too. But essentially, what that meant was that women sometimes have this very cumbersome treatment course where they might have had 12 or 15 of these fertilized oocytes, but every time three were thawed, it was completely unpredictable how many of them would become embryos. And sometimes, it was too few, and sometimes it was too many, so some of them, sometimes all of them, would arrest and then the transfer would have to be cancelled. And sometimes three of them would go to the blastocyst stage. And then occasionally, there was a decision made to transfer two blastocysts, even though the young patient with good blastocyst quality, you shouldn't transfer more than one. So it was basically this unpredictable lottery and either it didn't work at all, or often times, it was associated with twins. So then, thankfully, they changed the law. In Switzerland when something is changed, the population always has these referenda. So basically they have a popular vote for certain things. So let's say if you feel like all the street signs should now be blue and they were green before then you can collect signatures from a certain number of people and then it goes to a popular vote.

JONES: A popular vote on the ballot?

QUAAS: Yeah.

JONES: The same time that they're voting for nationwide candidates and those are all nationwide referenda or are they local referenda?

QUAAS: Yeah, exactly. So there's certain dates where all these questions are being put up for ballot and then you go into your voting booth and you vote on like 20 questions. And this reproductive law came up for a vote--

JONES: What do you have a legislature for then?

QUAAS: Well, you know, they actually have a very interesting political system and basically the Swiss believed in that every voice should be heard and I mean, obviously, there's still some things that the legislators still have to do. But anyway, so finally, luckily, in June 2017--sorry, June 2016, it came up for vote, and then in September 2017 because the vote was won to change this reproductive law. Basically, this kind of obstructive rule was done away with and now it's possible to culture all embryos to the blastocyst stage, and then transfer one embryo at the blastocyst stage, and freeze the rest. And also in the process, pre-implantation genetic diagnosis was also something that was allowed going forward. But there were many interesting things, like for example, same-sex female couples or single females are not allowed to use donor sperm. Donor sperm in the legislation is only allowed for straight married couples where the husband has a sperm problem. That's the only indication were donor sperm is allowed. And so then what happens is that single females who want to become pregnant or same-sex couples, they go to Denmark, for example, because in Denmark, there's a lot of midwives practices that offer donor sperm insemination. That was an interesting thing. And the last very interesting--it was a very curious law that I thought was also a little bit subject to interpretation--was that it was written somewhere in the legislation that when you assist a couple with conception, there should be a reasonable expectation that both parents--so the father and the mother--reach the babies, their child's 18th birthday. Which was supposed to mean if one of them has, like, terminal cancer, or was like 97 years old, then in your judgment it’s not a reasonable expectation that both parents will live to the child's 18th birthday and therefore you should not provide fertility services. How can you ever really assess that these two people that are wanting to become parents will reach the 18th birthday? Like ,where do you draw the line? If you have a overweight, type 2 diabetic with a BMI of 50 in front of you, how do you know is this person going to live another 18 years? So anyway, there were some laws that were, in my opinion, a little bit almost patronizing and of course, that changes the way that you practice. Then there were a lot of, for example, egg donation wasn't allowed either. Then there were a lot of Swiss people who would then travel abroad for fertility services. So if they've single or same sex and they need a donor sperm, they would usually go to Denmark. And if they were advanced maternal age or decreased ovarian reserve, premature ovarian insufficiency, they would travel to either Spain or the Czech Republic.

JONES: What you're pointing out is how all of the potential ethical questions, meeting with the public, meeting with legislation can come to affect the standard of care and that plays out in different areas when you have different legislators, and different electorates, and different concerns among the constituents. I guess, in one hand it’s sort of refreshing to know that everybody's struggling with this and it's not just our country. I see other speakers from other countries that share their frustration. I can see that we’re not the only one. I had Melissa Brissman on the show, reproductive health attorney here in the United States, and she mentioned that one of her ethical concerns is that in many states, in many cases, is we don't have an age limit for parents to talk about the exact scenario that you talked about or that the potential for one. There’s this real gamut that can change based on politics, based on fellowship programs, and that plays into how care is delivered. Can you also talk a little bit about just how patients are different? And this would be more anecdotal, but how do you notice patients differ from place to place? And then what are the common themes that you always see as being the same?

QUAAS: Well, I think that, obviously,depending on where you practice, you have a slightly different demographic of patients. The breakdown of the different causes of infertility, for example, may be slightly different depending on where you practice. I mean, I would say there were certain things that were similar. So for example in Switzerland, just like in the United States, sadly we don't have universal access to infertility services--not universal fertility coverage. I think in the United States, I heard at one point that only 10% of patients for who IVF is indicated, actually get access to it. So there is, of course, a difference in the people that end up presenting to you for IVF treatment and just like in the United States, sadly, it's often more middle- to upper-class educated couples from a certain demographic. And they asked the same questions everywhere, like as you probably know all patients are very educated, they’re very good at following instructions because they have this great goal of conceiving, and they're willing to do anything for it. So these were similar themes. I would say one thing that I thought was interesting is that infertility in America is a bit more out in the open. You know, nowadays it's normal to speak about it, blog about it, to post about it on Facebook and Instagram, to raise awareness for it, and to chat about it at dinner, and I feel like almost everybody knows somebody who went through IVF, and people are a little bit more open and public about it. I would say in Germany and Switzerland, I've noticed that people are a little bit more private about it. They almost a little secretive. This is something that they're almost a little bit embarrassed about. IVF might have still been associated with a bit more of a stigma that they don't necessarily want to share more with your peers and your family then you have to. That is one thing that I've noticed about the patients. But basically other than that, I would say patients ask the same questions everywhere. What happened in Basel, one thing that was really quite refreshing and inspiring was it's a very international city, so there are several pharmaceutical companies that are based and headquartered in Basel. So I patients from all over Europe and it could be that in one afternoon, I would have to speak Spanish, Italian, French, and English with various people because it's such a great mix of a very international population. That was very fascinating. But at the core of it, people have the same type of questions. One thing I've noticed, as you probably know, as population Switzerland is much less obese than the United States. So for example, the United States, I would say when I saw patients with polycystic ovarian syndrome, 80% plus were obese. And for example at the University of Oklahoma where I had more of a younger patient population, patients who were under 30, it seemed like in Oklahoma people have more pressure for you to conceive earlier than maybe on the coast. So most of my PCOS patients in the United States, specifically in Oklahoma, were obese or overweight as a majority. In Base, I saw, like, all of my PCOS patients were small lean PCOS. So I would say less obesity in Europe, although it does exist. So, that was definitely a difference.


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JONES: Those cultural differences really can change the way one practices or the way one distributes information because one of the things that I've seen recently--there's some fertility doctors that have talked about this on social media and I've had the conversation with a few practitioners and clinically, I can't contribute enough to where the conversation is going--but I hear them talking about obesity and the way we address it, and the way we treat it, and one of their concerns is that there is just so much outside of people's control. That the ways in which we counsel on obesity should be much different from how they have been. Hearing you talk about a different experience in Europe, it seems to me that perhaps it is something that's more cultural or that there are variables that can be controlled for?

QUAAS: Yeah, I mean, I think it's obesity is the problem all over the world almost in every developing country, but it's particularly an epidemic in the United States. And I do think that it's our responsibility to talk to our patients at length, and without judgment, and in a very empathic, and friendly, and nurturing, and inviting way about ways to work on it. I have always made it a big focus of my practice to help and assist patients with that without making them feel uncomfortable. That was definitely less of a focus in in Switzerland. We had the whole spectrum of infertility diagnoses, male factor was a big part of it, unexplained infertility And actually unexplained infertility, I mentioned in my article that one practice difference is that in the United States, our bread and butter, first line approach for unexplained infertility is intrauterine insemination. This is what I've been taught over the years and basically, after attempting to conceive for 12 months or more in a patient, in a couple that has unexplained infertility, you offer intrauterine insemination. So in Europe, there's a lot of discussion about this because you know the professors there that are some of the biggest names in the field--I saw lectures, for example, by a professor from Holland that said that you know IUI is a waste of everybody's time. Basically, it's no better than regular intercourse. He actually made this interesting analogy: he cited a novel by an author called Céline, a novel called Voyage au bout de la nuit, and he based in that novel, there's a quote that, “Since most disease resolves spontaneously after five days, the smart doctor starts to prescribe medication on day 3.” He made that quote so to basically say, “Well, right around the time that we recommend to have an IUI is when that couple would get pregnant anyway.” Now I find that really hard to believe and luckily--I had some academic discussions about this with some of the people in the field from Europe--luckily right around the time that I was actually in in Basel, a randomized controlled trial did come out that finally showed--because they always argue but argued that there was no randomized controlled trial evidence demonstrating that IUI does anything for unexplained infertility. And it was interesting because in England, the National Institute for Health Care Excellence or NICE, advised that IUI should no longer be offered. And then was a study that, guess what, showed that 96% of fertility clinics ignored that recommendation probably because deep inside, they felt like it was effective. So anyway, that was very interesting to me because to like--

JONES: What did the control show?

QUAAS: So that was actually one from New Zealand. It did show that IUI was superior to intercourse alone in unexplained infertility. So, you know, I feel like that was a step in the right direction to prove that maybe we shouldn't do away with intrauterine insemination just yet, as NICE had recommended.

JONES: There is another culture--you talk a little bit about the differences within patients: less obesity in Europe, younger patients in Oklahoma, some older patients in cities on the coast. I see a cultural difference on social media, both with practices that we work with clients, and those that aren't, but if you look at the most powerful social media presences in infertility at the practice level, not the physician level, but at the practice level, many of them are from Midwest, smaller markets, and my hypothesis is it's because these places are more tied into--I feel comfortable saying this I'm from Buffalo, New York--it's less about career here, than it is on the coast. It's more about family. And so the pressure that puts on potential patients is a bit different, not that both don't have patients, but it also adds a community aspect of it. So if I'm looking at Cincinnati, or Michigan, or Buffalo and some of these smaller Midwest markets, I see massive social media presences that I need to spend a ton of money on advertising, and content creation, and getting other things going to replicate when I have clients on the coast. And so I wonder if you seen that, sort of, maybe community or family focus versus career focus--of course, there’s both in both small markets and large markets--but I wonder if you seen that difference and if that plays it all into how you interact with patients.

QUAAS: No, I absolutely saw that! And patients would tell me that! I had 28-year-old patients in Oklahoma telling me that both of the spouses’ families had started to freak out that she was 28 years old and didn't have a baby yet and that she was the only one in her community who wasn't a mother yet. And so I think that people put definitely different emphasis on family and when to have children in different places, and of course, that's also depending on education and career aspirations and so on. But I definitely think that the average age of our patients at the University of Oklahoma was a little bit lower definitely than in Los Angeles, or in Austin, or now here in San Diego. I mean I will never forget in my fellowship at USC, there was a couple both 43 years old, both with like striving careers, and they literally said to me, “Yeah, we just about a month ago, we started thinking about maybe starting a family. “ And so I mean, I obviously didn't say this, but it was like, “Well, what have you been thinking about in the last 10 years?!” So I mean this is this should not be something that you start thinking about at age 43, but obviously the outlook is very different in different places, but I think that, obviously, you can't just generalize this. So I'm sure that even in the greater area of Boston, there are some people who are more family-minded and some people are more career-minded. I do think that with the awareness of fertility, maybe there are also more people who place more of an emphasis on creating a family or starting a family earlier, even if there's never really a right moment because I mean I tell my patients having children, I mean, when is that ever, like, a perfect moment for it? But I do think that there were differences in different places. And then, of course, with respect to coverage within the United States, there's a lot of differences. So for example at the University of Oklahoma, fortunately, there was no mandate, so in the state of Oklahoma, there's no mandate for infertility coverage. Where as in Massachusetts, so when I was working in Boston, there's a mandate to cover infertility services and that really changes the treatment. And it also changes the general management of patients. So in this paper that I wrote, I mentioned that, for example, with respect to whether to remove or not remove a tube at the time of an ectopic pregnancy was a big practice difference that I witnessed from residency to fellowship. In my residency, you know, 98% maybe of the surgeries for ectopic pregnancy that we did involved removing the tube. So that means you have a slightly lower natural fertility in the future, but also a low risk of that ectopic coming back. At USC, where that's another patient population that we took care of that was--at the County of Los Angeles, we took care of a lot of underserved patients and sometimes illegal or illegal residents who were covered for their healthcare there, but didn't necessarily have access to the full spectrum of infertility services and, for example, would be most likely not to be able to afford IVF. So in those patients, we had like discussions at the M&M conferences, and if anybody wanted to take out a tube, that was, like, a high crime because you know you wanted to preserve fertility for these patients and you accept the fact that they might have a slightly higher risk of another ectopic while trying to preserve the natural fertility because that's most likely the only option that they have. So likewise in the treatment of unexplained infertility, we easily have a sequence. Okay, a couple tries at home, timed intercourse, then you try IUI cycles, and then if that doesn't work you go through IVF. In Massachusetts, the insurances regulate how many IUIs you have to do before you're eligible for IVF. And so that's usually what people do. For example, again at the University of Oklahoma, price-wise, an IUI cycle was about $600, maybe. An IVF cycle was $15,000. So because the population of Oklahoma is not you know, the most affluent, oftentimes patients would want to do five or six or seven IUI cycles before maybe considering IVF. So that was definitely a practice differences that I observed.

JONES: There are a small number of insurance plans that call for the same--if any United or Aetna reps are listening, there are certain plans that they call for the same before someone can have IVF coverage. So it does and I do see that change what providers are--New York state providers, for example, will do far more IUI than most other people because the mandate up to this point has insurance covering IUI, but not IVF. I can't let this interview end Alex until we talked about--we've talked about the differences in the delivery of care. We talked about the differences in more common patient habits, but I want to talk about the choices which affect where doctors decide to live. This is a conversation that you and I have had at PCRS a few times. And it started, I think, when you when you moved back to Southern California, you talked about moving back to the quality of life. And I think of Southern California, for example, and gorgeous weather almost year-round and to me, that's where the quality of life ends. And so I really do want to unpack this because I see many REIs moving to the coastal cities, a few are moving to the smaller markets. So I want to talk about what that quality of life is because, to me, if you're a top 20% wage earner in a small market, you are royalty. You send your kids to the nicest private schools. You can go to the big cities whenever you want. You have a nice house. There's probably a cool lake or beach or sports community that you can buy a summer home in. And even if you are earning double that in a larger market, you're still paying triple or quadruple for your cost of living and you're stuck in traffic, even if you live a mile from home. So I want to talk about what quality of life means because I definitely see it. I definitely see a pattern of where doctors are going and I want to hear more from you.

QUAAS: Yeah, that's a great question, a very interesting question. And some people might ask well, why did this guy move around so much. Why did they keep going to different places? And of course, life happens. You don’t plan everything ahead of time. I always had this dream of doing my residency in the United States, and specifically in Boston. And so I did that and then moves out to LA for fellowship to USC and really enjoyed my time there, but exactly what you just mentioned happened. That the big city, lots of traffic, and long commute potentially, so spending hours and traffic rather than spending time with your kids. High cost of living with high, high prices for housing. And all of this did make it very attractive for us to move to the University of Oklahoma when we had this opportunity. My wife is an OB/GYN, too and so we both were able to get a faculty position in the same department. So it's a perfect setup and we really did have a wonderful life there. We did. We did have great friends and the very high quality of life. And the people of Oklahoma are extremely friendly and I loved my colleagues, loved my staff, patients were wonderful. We basically moved back to Europe to be a little bit closer to family and then because of the quality of life in Europe was excellent, and we were close to our families, but then the professional aspects were not as satisfying. Like for example, if I can’t do egg donation treatment, if I can't offer to treat single or same-sex patients, if I cannot have access to the full spectrum of opportunities, then that is definitely a downside. And then of course, the other factor for moving back to the United States was also that my wife's professional home is also more here than in Europe. She learned German, which is wonderful, but still in the system over there, it was harder to get a footing. So when we made a decision to move back to the United States, we did take all those aspects into account and I do think that the quality of life--so, one thing when I was living in our Oklahoma, I had a friend who is living there from England and he made a restaurant analogy. So because he was saying the people in Oklahoma, they always say, “You know, I never get stuck in traffic because the roads are always empty, and the houses are cheap.” And so he was saying, “Well, guess what, when you go to a restaurant and the restaurant is empty, that's because nobody wants to eat there.” So, you know at the end of the day--so there is something about the quality of life in the different places. And the reality is, when you live in Oklahoma and you have relatives from Europe, only your very closest and most dearest relatives will come to visit you. When you live in San Diego, I mean every week somebody will visit. That’s sort of the difference. Oklahoma was a wonderful time, but also, you know, frankly states that have no restrictions with respect to gun laws for a European like me and my wife, is scary. I don't want my children to walk around and and know that everybody around them is carrying a gun and that the kids in the playground are obsessed with guns already. So that was one of the other things. And also with the current political climate, I don’t think it’s very hard to know where I stand because you know, I'm from Europe, the current president, I’m not a major fan. So the political attitudes and the cultural differences within the United States, obviously, were a factor, too, for us. But I understand your point, if you’re purely about making maximum amounts of money and living in as big of a house as you can, then you should rather move to Texas than to California.

JONES: I don’t just think maximum amounts of money, but I just don't see where the extra time or where the extra things are. I have one client in Seattle and I talked with him and he loves shows, music shows of bands that are both up and coming and are sort of in scene. And so I guess if it is something like that, where there's so many of them and you go so frequently, then it make sense. But I just wonder--I think of myself as a guy who spends most of my week, I spend most of my week working, I spend the rest of my time traveling. I don't have a lot of time for the extra stuff. The time that I do have extra for, there's enough nice restaurants, here's enough museums, there's Broadway shows, and professional sports teams here. And then if I want anything extra, then I just go to Toronto, or New York, or LA, but there's not enough of the extra to me to justify, for one, the traffic, two, the extra cost of living. It’s not even about money, I think most people will have more time with their families in a smaller market.

QUAAS: I agree with you a hundred percent. And so for example, I agree with you that if you live in Manhattan, in New York, and you have all this wonderful culture, it's not like you go to a Broadway show three times a week. And at the end of the day, the life of a busy person, a busy professional with children, it’s the same everywhere. You know, you go to work in the morning, you work all day, you come home, you make dinner for your kids, maybe you have dinner with your kids, you read them a story, and then you watch a little bit of TV or like work a little bit on your computer or something, and then you go to bed. So you could do that in Wyoming, or in New York, or in Delaware, I mean, it doesn't really matter. It's just that when you're in New York, you pay a much higher price for it. Then when you're in a less populated and less quote-unquote desirable place. But that is also one of the reasons why like, my wife basically said she would like to either go back to Boston or to Southern California. And so San Diego is a little bit less congested. It's a little bit less expensive than LA. So I do think that, for example, within Southern California, San Diego has a better quality of life than LA. It’s a little bit more of the advantages that we had at the University of Oklahoma.

JONES: Well, the fact is that many of the people that I'm talking to agree with yourself and your wife by the way that they're voting with their feet. When I talk to most of the fellows at ECRS or MSRI, they're going to often to bigger programs and usually in the coastal cities. You can give Chicago and asterisk to lump them in with the coastal cities, but I don't see a whole lot of people going to the Oklahomas or the Ohios or the Buffalo, New Yorks, or the Nebraskas. And I've talked about this, that maybe brain drain or issue of delivery of care with Dave Sable, with Rob Kiltz, but do you see this as being a problem? Do you see a tale of two countries even more where a certain group has access to better care because that's where all the doctors are because there are fewer younger doctors who want to move to the other places?

QUAAS: I definitely think that can be a problem because in places like LA or New York on every street corner seemingly, there's a fertility practice opening up and maybe there's more, at some point more supply than demand, whereas in other places--I seem to remember papers that showed the density of REI physicians per population according to the United States, I definitely think that that is an issue. I do think that for somebody who is graduating from fellowship, looking to open a practice, if they're a little bit geographically flexible, then I think it's a great move to start a practice in a place where there's more unmet demand than in the same place where there's already plenty of other practices around. So I do think that those are points to be weighed against each other. And for us, this has been a process that we've talked about a lot. But in my specific example, in San Diego, there's a German School, like a German immersion school for my kids where I can have them at a bilingual German school. That was a big factor. So these type of things may not necessarily be found in smaller places, naturally.

JONES: Well, we've talked a lot about the differences in patients’ habits, between countries and continents, between the delivery of care, between how doctors make their choices to live in different areas. Alex Quaas, how would you want to conclude with regional differences in fertility care?

QUAAS: Well, I just would like to say that, in summary, what I've noticed is that where you're born and where you live when you're trying to conceive matters enormously in maybe your chances to make your dreams come true if you’re struggling with infertility because you may live in a place where the standard of care is higher or lower, or with certain treatments are available or unavailable. And so I think to me, that was something that I hadn't realized as much when I first started. As a patient, I think there are massive differences in where you live and this is highlighted by the fact that so many people in Germany and Switzerland have to travel to Spain to do egg donation, because egg donation is something that hasn't really found its way into the legislation. It's still illegal in both countries. And you could wonder, why is sperm donation, at least to a certain extent, allowed and not egg donation, and so on. Also genetic testing is another thing that we haven't mentioned yet. So one of the reasons why in Germany there is a bit of an ethical discussion about this is, of course Germany, everybody knows the history of Germany and what happened in the Holocaust and the Second World War, and was a very dark period of time where there was a eugenic movement and things like that, and so the reservations about genetic testing in Germany come from very complicated historical circumstances. And that leads to the situation where it's more progressive in some ways and then less progressive in others. So as a patient, I think you definitely have a very different access to services, depending on where you live. And then as a physician in our field, maybe more than in any other field, the differences which services you're allowed to offer. And so I think that was the main finding of my career so far.

JONES: And you have found out from doing it in person from traveling and living and working and experiencing it firsthand, as well as comparing it against data. Thank you for sharing that experience with us today on Inside Reproductive Health. Dr. Alex Quaas. Thank you for coming onto the show.

QUAAS: Thank you so much for having me, Griffin!

You’ve been listening to the Inside Reproductive Health Podcast with Griffin Jones. If you're ready to take action to make sure that your practice drives beyond the revolutionary changes that are happening in our field and in society, visit to begin the first piece of the Fertility Marketing System, the Goal and Competitive Diagnostic. Thank you for listening to Inside Reproductive Health.