Inside Reproductive Health, Ep 28

Can IVF or Egg Freezing Vacations Abroad Reduce Stress or Financial Woes? An Interview with Joseph Davis, MD

GRIFFIN JONES: Today on Inside Reproductive Health, I am joined by Dr. Joseph Davis. Dr. Davis is a member of the RESOLVE Physician Counsel. He is an advocate for early public education and fertility preservation options for women. He has practiced in New York City, as well as elsewhere in the United States. He now practices in the Cayman Islands in order to offer patients high quality care in a region of that world that has very few fertility specialists. Among other things, Dr. Davis has become a member of the Guideline Development Group for the World Health Organization. He has worked for human rights and ethics guidelines for infertility and was part of the group that expanded the definition of infertility to be inclusive of sexual orientation and to be more gender fluid.

Dr. Davis still serves on the ASRM Ethics Committee and he is a member of SREI and ACOG, and I want to find out what more he has been up to across the international community. Dr. Davis, welcome to Inside Reproductive Health.

DR. JOSEPH DAVIS: Great! Thanks very much for having me. I’m happy to be here.

JONES: It’s good to have you, Joe. I’ve known you, since--for a few years now. And you are in a unique position where you’ve gotten to see how medicine is practiced in a lot of different places in the United States and, in--elsewhere in the world and I want to unpack that some more, but kind of talk to us about how one decides how to practice in the Cayman Islands because when I’m talking to people leaving fellowship, for example, I don’t even think that’s something that occurs to them that they could do. And for those docs that are in practices in the United States, I don’t know if it has ever occurred to them that they could do that either. So, how did you get to open up your practice in the Cayman Islands and what was that journey like?

DAVIS: Sure. Yeah, no, I--I agree with you. I think that, I mean, Global Health and, sort of, Policy, Global Health Policy is always something that has been of interest to me and I struggled a bit in training to find how to make that mesh with conventional American education. And a lot of the training these days, and I know this also working when I was in my practice in New York, working with fellows directly that were in our group, they would ask about, you know, “Oh, I’m really interested in the global health aspect or the policy and advocacy aspect, how can I incorporate that because it’s not really part of our training?” So it’s definitely a piece that is not really taught or a major component at least of most fellowship programs. Even in residency, in OBGYN residency, before reproductive endocrine fellowship, global health takes on this sort of place where may go spend a few weeks or a month in another country, generally, you know, in a part of the world that has really limited access to any kind of healthcare and maybe you work in labor and delivery or you do surgeries, or you provide some sort of short-term band aid to an area. And to me that was, I mean, it was really noble and great, but it wasn’t really what excited me. What really excited me was saying, “How can we improve healthcare globally? How can we really change things?” And coming out of fellowship I was fortunate to be in an academic program that was supportive of that. My first job outside of fellowship was in Wisconsin at Medical College in Wisconsin and they really opened up the option to say, you know, we want to support academic endeavors. And I reached out with some colleagues at World Health Organization and there was a need there for someone to bring more experience not just to the reproductive medicine side of it, but also to the ethics side of it. And I was involved in the ASRM Ethics Committee as I am currently. It was a wonderful way to bring all these pieces together to say, “How can we address the unmet need for fertility care globally? How does it differ in different parts of the world? What are the ethical concerns and considerations? And, you know, what do we as providers--how can we give back to different societies and different areas of the world?” And that was such an eye-opening experience that I knew I’d always wanted to explore the practical side of it, you know, in bringing care to places that don’t have access. And fertility tends to find this unique position in the world because of the technology and the advancements and the costs associated with it, often times, in vitro fertilization is relegated to areas of the world that either have robust medical systems and it’s sort of hard to find that place in these areas that are really underserved to make that fit. So one of the aspects that I wanted to bring was to say, “I want to bring the same quality of care that we provide in New York City, or Michigan, or Wisconsin, or wherever, but bring it to a country that doesn’t have access, where people are, by virtue of a lack of care in their area, having to travel long distances or spend money to go cross-border in order to get IVF care or fertility care as a whole. And really, Grand Cayman was a perfect fit for that because it’s a country that has really great health care. It’s got a lot of experts and specialists that travel down, many of which may travel down for a month at a time and then go back to their respective homes in New York or Miami or wherever, but there are also amazingly great quality providers on island that live there and the hospital systems are very good, but what they didn’t have was anybody who specialized in reproductive medicine and had not had IVF or fertility treatments locally. So, it actually ended up being a way to bring the quality to an infrastructure that was already ready to support it to a part of the world where the Northern Carribean is really, has a huge void of reproductive care.

JONES: In the United States, I volunteer for Big Brothers Big Sisters, which most people are familiar with, but I also volunteer with an organization called Nuestros Pequenos Hermanos which is a network of orphanages for orphaned and abandoned kids and we have 9 homes in Latin America and the Carribean. When I went for the first time to do my long-term volunteer term, some people said to me, “Why are you going abroad to help children in poverty or need? You are in Big Brothers Big Sisters, there are children who are in poverty and need here. Why leave these children to go help others?” And I imagine the same speculation you might have come across of, “We’ve got access-to-care issues here? Why go abroad and not work on the access-to-care issues in the United States?”

DAVIS: Absolutely, and you know, it’s a question I’ve gotten, but it’s also one that I’ve, you know, personally sort of struggled and tolled with. And I felt with this even going to the World Health Organization, it’s overwhelming the amount of need that there is all over the world. And in so many different places and in so many different capacities, that it’s easy to almost get paralyzed with the idea of like, “Wow, there is so much to be done, and there are so many places that need it. I’m just going to give up. I can’t even find a place!” So, I kind of, I guess, came to the realization that, you know what, you just have to find a place that you feel you are going to do the most benefit and be able to actually make a difference and that’s going to mean that there are other places that aren’t going to get that quality. But--but as long as we are doing something and as long as we as providers are making that effort even if it is in a small portion, than that’s good. And for me, you know, I mean, Grand Cayman was a great opportunity, not only because the country itself doesn’t have fertility care or IVF, but many of the surrounding countries and areas that were able to get there fairly inexpensively didn’t either. And so for the people of Grand Cayman, they would automatically be socioeconomically and economically separated by those who had the resources to leave the island to get care in the US, which also is a much more expensive system than a lot of the countries outside--in the immediate outside areas. And then those that were on island just either couldn’t get care or just couldn’t afford to get it. So that really resonated a lot with me. But it also has the opposite effect, too. Is that I’m finding, in a place like that where we can manage costs and we can get the same quality care that you have in the US, but for a much more manageable price. Even with people from the US where they may not have insurance coverage--as is a big problem in a lot of states in the US--they, you know, for a modest amount of money, can travel down to Cayman, get high quality care, and ultimately be even less money than they would have spent if they paid out of pocket locally. So, it still does have that effect of increasing access-to-care for people in the US, it just kind of a reverse of what you would typically think. Where instead of bringing the care into the communities in the US and knowing that the care that you’re bringing is going to be, possibly, economically out of reach for many of the local people, to say, “Well, how can I bring good quality care to a place where I can also keep costs under control so that the local people get the care and the people that aren’t quite local can still get more affordable care even by coming if they have to travel. So, it’s an interesting, sort of, solution in my mind and it’s actually seeming to work really well.

JONES: How does serving those two groups work in tandem? You have folks in the islands or neighboring islands who need care. You have folks that are coming from the United States. They might be coming because of cost or simply because the Cayman Islands is a very comfortable place if you have to go through something as stressful as fertility treatment. And to your point, if you could also do it for the same or less than you could at home, then it’s essentially a vacation in which you have--that you might not have been able to take or to pay for otherwise. But how do those two--how do you serve both groups at the same time? Does one group have to subsidise the other? Does one group end up just by nature of the growth of the practice end up serving one more than the other?

DAVIS: No, it’s a--it’s a great question and I don’t feel that there is that, sort of you know, “one feeds for the other, one pays for the other” kind of idea. But you’re right, they’re two different sort of experiences. You know, the patients that are local that otherwise would have spent a lot of money traveling off island--and not just for the travel costs, but for the higher cost of care coming to some of the major cities that, you know, where cost of care is more expensive--now have the ability to not only stay local and not spend that money or save that money, they also have the ability to sort of, you know, take a little bit of less time off work so they can manage their personal lives. The flip side of that is, and I saw this a lot in New York, was patients would come in and they would be, “Ok, you know, we are going to do the IVF.” This is great, but they work extremely stressful jobs. It takes a lot of their time, you know, early mornings to late evenings. And to come in for an ultrasound or an egg retrieval or even an insemination meant taking time out of their day, taking time off work. And for a lot of people it wasn’t always just about the time and the cost, but it was also about privacy. And it was about, you know, not feeling like they were in a place in their career where they could openly talk about their family-building needs. There’s--and this is one of the huge societal differences that I’ve seen being all over the world and practicing in different places is, you know, there’s a lot of this sort of mindset in major urban centers in the US that your career comes first and you have to really focus on that and family-building is really sort of not as well regarded as it may be in other parts of the country. And that’s a gross generalization, of course, but what I found was that was a stressor, you know, for a lot of patients they be like, “Gosh, I really want kids, but like, I’m not comfortable telling my boss that I’m going to have to miss these meetings every other day for an ultrasound or I’m going to have to take a day off for an egg retrieval.” And what they would do is say, “Yeah, I’m just going to take a week off and blow my vacation sitting at home because I’ve got some ultrasound appointments to go to.” And that adds stress. And at the end of the year, they have no vacation left and they’ve spent it all, you know, staying at home. One of the sort of nice things about the affordability and accessibility in Cayman is that patients can say, “Look, I’m going to take the same amount of money I would have spent. Now, I can go on vacation, a proper vacation. Nobody--if I don’t want to share that information with my boss about what I’m doing just, you know, that I’m going away and taking my vacation that I’ve earned, they can maintain that privacy. They can actually destress. They don’t have to have that runaround of you know, trying to duck out for a meeting or an ultrasound appointment and it ultimately gives them sort of a better sense of well-being. And we all know, you know, the adage of “oh, just go take a vacation, you’ll get pregnant” that’s not true. But that doesn’t say the benefit of stress reduction of being on vacation during your fertility treatments, there may be some benefit there as well, if for no other reason, just for mental well-being.

JONES: This is almost the flip of a conversation we had on an earlier episode with Lori Whalen from HRC where we were talking about international patients coming to the US typically for family-balancing, sex selection, and donor egg. Now we are talking about more access-to-care reasons and, in some cases, maybe affordability, in some cases, privacy, US patients going to--going abroad for treatment. So I’m interested to explore some of the logistics behind this because I think it could also help some of the people that are serving populations in rural areas. We have--we have fertility specialists listening to this show that serve patients that have to drive 8 hours to see them. And so, when someone comes to see you, do you have partners in the United States, in select cities, that are doing monitoring and doing any types of FSH test or AMH tests and doing that before they come? How do you connect with other folks so that the time in the Carribean can be as little as possible?

DAVIS: Sure. It’s been my experience--and I’m assuming that I’m speaking for many fertility providers in the US--is that we’ve always sort of had this understanding that if patients were travelling to our city or to their city and they’re in the midst of a cycle, then they would be able to go in and get that care that, you know, they would be able to get their ultrasound or their blood work done, even if they were there for a few days for a meeting. And I know this when I was in New York, I would have patients that would, “Oh, I’ve got to go to LA for a few days. I’ll check in with the IVF center there to get my ultrasound, to get my blood work,” and that way, you know, their cycle isn’t disrupted. And it’s always sort of been one of those understandings that if patients needed it, they could reach out to those practices and without a proper written agreement or contract. Same kind of holds for this. You know, and I’ve been on both sides of it--I’ve had patients that were not our practice patient, but were traveling through the area and said, “You know, I’m really in the middle of my IVF cycle and I need an ultrasound.” And, you know, we take care of that for them, and we send the results off to their doctor. With, you know, patients in the US seeing me in Cayman, I mean, it’s virtually identical. We have them either do their baseline testing with their gynecologist or with a fertility center, if there is one nearby. Many patients also that are looking to--looking outside of the box or outside of the area of fertility treatment, may have already dabbled in their local resources and either they had benefits that they’ve exhausted or they’ve you know, found that they don’t have coverage and the costs are expensive. So they may already have a relationship with the local RE and, for whatever reason, they are not continuing care there. And so some patients will, they’ll do that: they’ll see their local RE and say, “I need this AMH done. I need an ultrasound. Can you get me the results and send them off?” and it’s sort of a fee-for-service kind of idea. But then, yeah, the goal is, of course, that they will be able to travel down when they are getting closer and closer to their egg retrieval time to minimize the amount of needed time away or vacation time that they have to spend. Because not everyone has a lot of vacation time in their job or their career. But we want them to be able to come down at a time so that we can properly monitor them prior to the egg retrieval, perform the egg retrieval, safely monitor them after. And, of course, if they’re, you know, in a PGT cycle and they need to do a frozen embryo transfer, then, you know, they can come back for a shorter visit for the transfer because it’s, you know, less monitoring involved in the days prior to it. So all of that we coordinate, but a lot of patients find that even their local OBGYN, or their primary care even, can sometimes get the bloodwork, so their ultrasounds started prior to them beginning their medications.

JONES: How often do they have to come down prior to egg retrieval? Is it a few days?

DAVIS: Yeah, generally it’s--what we do is we bring them down after one week of injections. So, basically, you know, 6 or 7 days worth of medications and then they fly down. And most people are ready within, you know, a few days to be triggered for the egg retrieval. So they--maybe there are one or two ultrasounds before the egg retrieval. Maybe even they show up and they are about ready for trigger in a day and, you know, the egg retrieval is a couple of days later. So often times, most people stay for roughly seven days, maybe about a week, plus or minus a few days. If they’re planning a fresh transfer, which a lot of people when they start looking at travelling for IVF, they start looking into fresh transfers depending on how, you know, the travel and their time and so forth. It may be easier to do it all in one as opposed to coming back for, you know, a frozen embryo transfer. And that’s another phenomenon that I’ve sort of seen more and more with those that travel for their fertility care is trying to get everything done in one shot. So those patients may stay a bit longer if they are planning to do a day-5 transfer, plus the retrieval, they may be here for 10 days or 12 days, even.

JONES: Do you find that you’re doing more fresh transfers than you otherwise would have in the United States because, for someone else, it would be a second trip to come back for their transfer if it wasn’t?

DAVIS: It definitely--I mean it’s one of those things where I came from a practice in New York where almost all of our patients were PGT/frozen embryo transfer cycles. So, anything different from that is going to seem a bit more unbalanced, I would say. But in reality, I’d say it’s about 50/50. Half the patients are interested in PGT for many different reasons: you know, they’re older, they have good AMH, so they know they are going to have a lot of embryos and they want to find the best selection. Others may be younger and they have, you know, they have really good fertility, but maybe they have a tubal occlusion, so they’re fine with a fresh transfer because, you know, we are going to select the single best embryo and it’s, you know, if it doesn’t work, they can come back for the frozen later. So, it’s a lot more--I would say I find it’s a lot more diverse in the reasons that people come to us than it may be in certain, you know, isolated areas if a lot of your patients are directly local and they tend to cluster in either, you know, a lot of diminished ovarian reserve or, you know, ovulatory problems. It’s a much more sort of dynamic group of patients. And so, you know, we keep those options open and discuss all probabilities and pros and cons to it.

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JONES: We have a lot of fertility specialists that may want to court international patients. We have some from small markets that want to attract patients from the large expensive market that is six hours away. A question that they often deal with is, “Well, how much of a travel agent do I have to become?” And in your case, is it something that you’ve found that your practice, working with hotel partners, flight partners, any other types of restaurants or excursions to make it a one singular package, or at least, one place where people can choose from options? What have you done?

DAVIS: So, we offer all of the above. We’ve found that--and again, I’ve always practiced medicine with the idea of “I’m going to put myself in the place of the patient” and say, you know, “What is it that I would expect? And what is it that would help me? And how can this journey be a little bit more manageable?” And for me, I’ve traveled all over the world and know that, you know, there’s something about finding your way and exploring and creating everything anew, but there’s also something about saying, “Look, if I’m going to go through healthcare in another country, there’s going to be some differences that maybe I want to be prepared for.” And if I can in any way help smooth that over, that’s just going to make that experience more positive. So we offer both. We have, obviously, the cycle itself and the procedures and that sort of cost structure. We also have arranged deals with hotels and rental cars, and we even have a, you know, there’s a service in Cayman to expedite customs. You know, there’s a person who meets you at the customs and gets you through quickly so you don’t have to stand in the line for 45 minutes. All of these are things that if, you know, someone wants sort of the, for lack of a better term, the sort of all-inclusive approach to it, we can do that, we’ve got that set up. But, at the same time, if somebody says, “Look, I want to find my own AirBnB and get my own way.” That’s great, too! It’s--you can choose either direction. And I’ve seen both--I’ve seen patients that have both interests. Some are like, very much, you know, “I’m the deal finder. I’m going to go online and, you know, arrange everything myself.” And you know, what we have found is that a lot of people like to book their own airfare, mainly because of air miles and travel times and personal schedules. That’s just almost universally, patients just want to take care of that themselves. So we don’t really get much into offering airline packages, because there’s so many different routes there. But hotels--everyone is always looking for, you know, what’s the most--best quality, most affordable option for a hotel and then, “How do I get around the island? Is it cabs? Is it bus? Is it rental car or whatnot?” We found that the hotel, the car rental, and the expedited customs are, you know, the sort of the three key ones that people wanted. But we also have arrangements with like acupuncturists on island that do really great fertility acupuncture. Because I’ve had many, many patients over the years--as being a sort of a holistic provider myself--where really most of my patients are at least open to doing acupuncture prior to or during their cycle and I don’t want that care to be compromised either. When they arrive on island, they can continue their holistic care. We have arrangements with the massage and spa places to kind of get you to unwind when you are on vacation. And we also have some activities to explore the island for those who want to really say, “Look, I’m making a vacation out of this. Yeah, I’m coming down to freeze my eggs, but I also want to swim with the stingrays or go out on a catamaran.” So we’ve arranged, you know, packages that can help make that a little bit more affordable. And also, but honestly for us, it gives us the opportunity to say, “We want people to see, you know, the best parts of our island and to really enjoy the experience.” And, heaven forbid, they get--they book an event that wasn’t what they expected and that reflects badly on the whole place.

JONES: Maybe this is a silly question, but I asked the same one to Lori a few weeks ago when she was talking about international patients on the show. But because people are traveling so long distance, and you’re the only one that they might know or have any kind of emotional connection to--you or your team. Do you ever encounter an expectation of, “So, Joe, we wrapped that up and I’ve got five more days before transfer, what are you up to?” Is there ever an expectation that you or members of your team are to spend more time with folks?

DAVIS: Not that I’ve seen. I mean, I can imagine there are. I mean, there’s always going to be people--I mean, I don’t at all, you know, take offense if someone is this way--because I had these patients all the time. They feel like they are really, really connected. You know, you spend a lot of time caring with them, you know, working through difficult experiences, you know, especially loss or challenges during their cycle--that you do kind of develop that bond. But I think, you know, as always, we--we’re professionals and we say, “You know this is what we are here to help you with-- is your medical care, and we can give you some idea of some places you might want to go to explore the island.” But, I’ve not had anyone directly ask me to hang out directly after their egg retrieval. But I’ve had people that they tend to want to spend more time in the office than you think they need to, but it’s--I take that as a compliment. That they feel comfortable with us and they are happy with the care that they are getting and our staff. So, I don’t see that as a bad thing, but I can see what you are saying.

JONES: So between training and practice, you have seen a few different areas of the United States including the midwest, should we call it the mid-Atlantic, New York (which is it’s own animal), and now the Cayman Islands. Am I missing any others in REI or maybe can we go back even further, but among those, and this is of course speaking in very broad strokes and generalities, do you notice differences in, I guess, patient expectation? I guess, what I’m looking for is, what ultimately becomes the patient-physician relationship? What can you speak to about those?

DAVIS: Absolutely. I think, you know, it’s a really--to me, it’s always been sort of a very obvious that every part of the country, every practice I’ve been in has a very different sort of local theme, if you will--or not theme, but local sort of vibe. You know, and I see this surprisingly in different ways. Like, I would say that I’m always expecting it to be a bit different everywhere, but the way that it’s different always kind of surprises me. And it’s exciting! You know, in the midwest, I’ve practiced in two different places in the midwest--one in a little bit of a larger city and one in a little bit of a smaller city and, you know, there’s very much, like, everyone in the community grew up together. So there is a lot of, sort of connection and everyone goes to the same stores, and the same, you know, many people work in the same businesses. And that especially played into, you know, if you have insurance coverage through your employer, if there’s an employer that’s really pro-family and we would have a lot of patients from the same employer. So they all worked together, they all know each other. And that’s kind of encouraging, too. But--and yet, I’ve been in the exact opposite situation where people don’t want their coworkers to know. And honestly, that’s one of the things I’ve noticed most in Cayman is that it’s a very small local community--it’s a very small island--and a lot of patients, so there’s not a lot of openness to talk about your fertility and that’s just a cultural aspect. And so, it’s a group of people that are very much not open to sharing their stories or sharing their experiences. Whereas, you know, I’ve been in other places where it’s almost like everybody wants to tell all their friends about their great experience that they had and, you know, have their mom come with them to their appointment. And it’s very much a different sort of environment. So, yeah, it’s all different types. I also find that the type--the reason for infertility varies somewhat regionally and that’s always interesting as well. You know, I don’t have proper sociologic data on that, but it does seem like there are certain parts of the country that have an overabundance of one type of infertility diagnosis, if you will. And, of course, not universally, but there tends to be clusters. I’m sure it ties into all different aspects of nutrition and wellness and access to healthcare, and also, you know, the sort of the structure of the society. If you, you know, work long hours and you’re expected to build a career, then you’re going to delay pregnancy later. And so we’re going to see an overabundance of diminished ovarian reserve or even male factor for older gentlemen, versus other parts of the country I’ve worked where the expectation is you have children in your 20s. So people are seeking fertility care younger and younger because they only have two kids and they want five. And, you know, so it’s very interesting and it’s always a--I think a really nice way to get to know a community is by, sort of learning about what their nuisance is, or what their differences are.

JONES: So for those that might be considering pursuing treatment abroad, what do you often find is--do they have a hang up? Is there something that--are there common two or three concerns that they often have before they decide to go see a specialist abroad?

DAVIS: Yeah, I would say that, you know one of the biggest challenges for a lot of people in looking to go abroad is, you know, not feeling completely certain that what they’re seeing either online or through the communications is exactly what they are going to get. So, you know for me personally, I know I like to do video consults with patients so they can see my face, so they can hear my voice, and they know I’m a real person. And, you know, for--there is an up-tick or an up-surge in people travelling for fertility care for lots of different reasons globally, into the US as well as out. A lot of the other locations around the world, they tend to be further, so one of the other challenges is time zones, you know, people travelling across multiple time zones and that affects, of course, when you are taking your medications and so forth. But also, language. You know, there are larger practices in a couple places in the world that the primary language is not english. And as a patient, that might be a big concern for you as I’m signing consent forms, I’m agreeing to use my eggs and sperm in this person’s lab and they don’t speak my language natively--they have a translator. And those can be huge stressors and huge barriers for people. And then, of course, the other side is cost. A lot of people do look at going abroad for fertility because it is more affordable, but that doesn’t always mean, you know, best quality. Some people may see a really affordable IVF center, but in reality, they are affordable because they’re not necessarily going by the rules and they are cutting corners to make it cheaper. And having, you know, a top notch New York-style practice in another country, I get asked that question a lot is, “Your prices are very reasonable. What are you not doing that I should be looking out for?” Or what are the--how are you, you know--basically, sort of questioning the quality. And I always value those questions because it really gives us opportunity to have an open conversation. But you know, those are the questions most people have struggled with is, “Can I get there? Am I going to understand what’s going on? Why is it so affordable? Does that mean it’s not good quality?” And the other big question is, “I’m going to leave potentially frozen embryos, frozen eggs, or frozen sperm in someone’s lab somewhere in the world. How safe is that? How likely is it that they’ll be there in a few years? Or is this, you know, practice going to close up shop?” Same questions arise in the US, too, but it feels different when the practice is down the street, versus, you know, four or five time zones away or on an island.

JONES: Was that a learning curve? Or are there different laws of parentage, or gestational carriers, of donor gametes, was that a learning curve of discovering what that all is in the Cayman Islands and how it affects the people who are coming from different states, different provinces, different countries, and all kinds of different jurisdictions?

DAVIS: Absolutely, you know and one of the things that, to me, there was a lot of learning of starting a new practice for a field of medicine that didn’t exist in a country before--that was a big learning curve. And a lot of it was is that there isn’t any legal precedent for a lot of these questions. You know, within the US, we have a lot of variation state to state, which makes it challenging for patients who are trying to sort of navigate these different laws. But in Cayman, they’ve never been asked these questions before. So, when we initially started the practice, you know, we, of course, went through all the proper channels to get, you know, the licensure and get the approvals through the Ministry of Health. And the questions that I was asked always kind of surprised me because they were sort of things that I would have--I feel like as an American Fertility Specialist, are kind of already answered questions about the field. But they were very, sort of, clearly questions coming from a place of concern on one part by the politicians, but on another level of not fully understanding what fertility care entails and how that doesn’t necessarily, you know, relate to, you know, becoming a citizen of the country, you know, and things like that. Most of those questions and concerns revolved around donor--either donor egg, donor sperm, donor embryo. Gestational care is one of those things where in the Carribean there’s not a lot of support for it. There’s many countries actually prohibit it. Cayman does not currently have laws one way or the other about it, but there’s also a big cultural sort of question about that. And I know, I mean, within the US gestational surrogacy is a huge topic that varies so much by state to state. And you know, that causes a lot of legal questions that arise with patients that travel across borders.

JONES: I wouldn’t have considered that, but that does make sense that fertility treatment at large is something that you have to educate about it. If we ask most laypeople in the United States what an REI was, they wouldn’t know. And if we ask them what are fertility doctors, most of them would think that their OBGYN is a fertility doctor, or OBGYNs are fertility specialists when they need to be, and wouldn’t even know anything about the subspecialities. So having to educate to bring that to a country, that includes politicians and lawmakers and almost starting from a base in that sense, that makes sense. That’s not something I would have considered.

DAVIS: Well, yeah, and it’s one of those things, that I mean, I think fortunately, I’ve had a lot of diverse experiences that maybe prepared me a bit more for it. I mean, even the work with RESOLVE and Advocacy Day, you know, there are a lot of elected officials in the US that, truthfully, it’s not their speciality. They don’t fully understand it, so their questions are phrased in a way that you have to kind of give them the background, and also in avery polite, respectful way to say, “You know, I think what you’re asking is this, but let me kind of give you some context,” otherwise, you know, you don’t want to set off a sort of antagonistic relationship with somebody because they don’t fully understand, but at the same time you need them to understand. And also, I’ve found that with--even with some of the medical professionals, they’re in a small place where a particular aspect of care hasn’t been available. They may have over the years modified their procedures and treatments because of the lack of resources was such a huge issue. So, you know, from a fertility standpoint, there were a lot of people doing, you know, laparoscopies or surgeries for fertility because the alternative was that patients had to leave the country and get IVF. And now that I’m on island and have talked with a lot of them they are like, “Oh, thank goodness we no longer have to do kind of do these other options that really aren’t first line anymore, and we know they’re not first line, but we were kind of in a bind where this was what was readily available to us and most cost-effective approach for the patient.” And they’re being cognizant of the patient’s concerns, too. So it is! It’s a very interesting educational experience for all of us, myself included. And I still get questions daily from people in the community saying like, “So you like, actually do fertility like here, right? You’re not just like talking to people and sending me to Miami?” I was like, “No, no, no! We are actually here. We have a full-fledged IVF center with PGT and everything else. We can do everything you can do in the States.” And it is like such a sigh of relief. They’re like, “Oh my goodness, because I’ve read online about all this stuff and all these things I can do and it’s so nice to know that it’s here and available.”

JONES: So you don’t have a crystal ball of your own life of where you’re going to be doing that , but do you see yourself staying put in the Cayman Islands for a little bit? Do you see yourself moving to the next place that also needs access to care and opening up a center there? And the next one after that? And moving onward? Where do you think life leads Joe Davis in the next 10 years?

DAVIS: Yeah, I mean, it’s always an evolving thing. I would say that, I mean the common thread for me has always been access to care and education and, you know, being able to help people take ownership of their own sort of fertility journey, and I think the first step in that is always learning. You know, and learning what you need to do where you are. And there’s always going to be areas of the world, of the US, of the Carribean, that there is just a lack of understanding and education and I saw that when I was at World Health Organization. There’s so many parts of the world that just--it’s the basic understanding that we need to start with. We don’t need necessarily need an IVF in, you know, XYZ region of the world, but we definitely need trained professionals or at least, access to good, reliable content and information that can help them understand their fertility. So, wherever that leads me, whether it’s continuing this journey to start new IVF centers in areas that could benefit, or if it’s, you know, incorporating more education, broader education, I think, a little bit of everything.

JONES: Dr. Joe Davis, what haven’t I asked you that you would want to conclude that our listening audience consider about regional and international differences in access to care?

DAVIS: You know, I’d say the big thing, and this kind of ties, I think, it back into sort of some of the reasons people consider going abroad for care--and this is globally, this is not just, you know, people coming to Cayman from the Carribean, from the US--is really about getting the quality of care and the access that you want and that may be going to a place that you feel listened to, you feel supported by your provider, and having that connection with the provider, as well as the quality. But for a lot of people, too, it’s also about any kind of regional or local barriers to their particular situation. And I see this a lot with, you know, in certain countries, access to care is extremely limited by sexual orientation or gender identity or even marital status, relationship status. And patients will go through great lengths to be able to get care that seemingly should be available everywhere, but in their country it’s restricted, or in their state it is is restricted. So, I guess, I would leave people with the idea of looking outside of their direct immediate sphere is never a bad idea, but always, of course, going into it with the same expectations that you would get anywhere. You want the quality, you want the connection, you want the understanding, but you also need the equality and the access that we expect everyone should have.

JONES: Dr. Davis, Joe, thank you so much for coming on Inside Reproductive Health.

DAVIS: Absolutely. Thanks so much for having me!

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