Every year, thousands of Dutch people travel to Belgium for a fertility treatment. Is the care different there? And what does this say about Dutch fertility care?

By Zvezdana Vukojevic , Jop de Vrieze, this piece appeared in the Dutch edition of ELLE, December 2023

While one baby after another is being born in their environment, thirtysomethings Jonathan and Maite have still not succeeded after two years of trying. “We started avoiding children’s birthdays and baby showers,” says Maite. “And no one understood us.”
They end up at the fertility department of the hospital. Jonathan’s sperm counts are fine. Maite does have some endometriosis on her ovaries (mucous membrane that is normally only found in the uterus), but this should not cause any problems. The diagnosis is unexplained reduced fertility . ‘Don’t worry,’ says the doctor at the start of the IUI process*, ’this will work.’”

In the following months, their lives consist of hormone injections, ultrasounds and inseminations. Maite tries to plan everything around the hospital appointments, she has a demanding job. Two years and about ten IUI attempts later, the fertility doctor therefore suggests a few more rounds – they were a few times off in terms of the timing of ovulation – due to weekends and holidays. And no, they cannot switch to another medication or another protocol. “While we kept doing the same thing without success.”

After much insistence, they are allowed to try IVF*. Sixteen eggs are harvested in the first round and after test tube fertilization there are eight viable embryos. After implanting the best embryo, Maite is briefly pregnant – but suffers an early miscarriage. A second implanted embryo also does not remain in place. Maite: “Sad, but there were six more in the freezer.” On the day of the third implantation they receive a call. Jonathan: “All six embryos had died. “That sometimes happens during the process of thawing,” the doctor said.

The doctor suggests removing the endometriosis anyway. Both ovaries are treated at the same time. After the operation, Maites’ AMH value* (which indicates how many eggs have matured enough to be fertilized) appears to have dropped enormously. She gets hot flashes: “Did they burn off too much? Was I going through menopause?” In the consultation room they ask if the operation went well. “We started with quite a few eggs,” Jonathan tells the doctor. “Now our chances seem to have been lost for all kinds of stupid reasons. Decreased fertility has not been mentioned as a risk, but Maite now has hot flashes.”

“Hot flashes?” the doctor responds. “That’s not good, no. AMH can recover, but sometimes that doesn’t happen.”

After much deliberation, they decide to make a second IVF attempt. So hormone injections again, after which mature eggs will be harvested. It is around Easter and that is why Maite’s cycle is extended from four to five weeks with medication. Zero eggs. “This felt like the end point,” she says.

To make matters worse, Jonathan turns out to have colon cancer. Maite: “I was a mental wreck. At the same time I had to be strong for Jonathan, but how?”

When Maite asks for psychological help for the umpteenth time, one of the fertility doctors makes a cry-cry-cry gesture. The couple is completely stunned. “I did finally get that referral for the psychologist in the hospital.”

In a later conversation, the couple tentatively suggests whether it might be better to stop. The doctors confirm this.

After about six months with the psychologist though, Jonathan and Maite regain their composure: “Are we resigned to a life without children? Or are we going to make one last attempt?” Jonathan had undergone successful surgery for his cancer. After a week of online research, the couple makes an appointment at a fertility clinic in Leuven.

For most Dutch couples, a few months of ’trying’ is enough to become pregnant. But for fifteen percent of them things become more difficult and ten percent end up in a fertility process. The majority of these will have a healthy baby, but a small group will not succeed. Every year, several thousand couples seek refuge abroad, often in Belgium. Why is that? The answer is not black and white. There appears to be a strong medical cultural difference, a difference in how the two countries deal with scientific evidence and guidelines, in ways of financing and the role of health insurers. What are the experiences of patients and treating doctors on both sides of the border and can it be worthwhile to continue there if things get stuck here?

Endometriosis is a condition in which tissue similar to the uterine lining (endometrium) also occurs outside the uterus. Usually in the abdominal cavity, on the peritoneum and the organs in the pelvis.
IVF (in vitro fertilization) is a fertility treatment in which fertilization occurs outside the body in a test tube.
IUI (intrauterine insemination). With this fertility treatment, processed sperm is placed directly into the uterus. If necessary, the woman’s cycle is hormonally supported.
ICSI (Intra Cytoplasmic Sperm Injection). Form of IVF in which one sperm cell is injected into the egg.
MESA (Microsurgical Epididymal Sperm Aspiration). In the event of a blockage in the vas deferens, a doctor surgically removes sperm cells from the epididymis.
TESE (Testicular Sperm Extraction). If there are problems with sperm production, a doctor may try to extract sperm directly from the testicle.
AMH (Anti-Müllerian Hormone). Measuring AMH in blood is a diagnostic tool to predict a woman’s number of matured eggs, which is normally associated with egg supply. If the AMH falls due to, for example, surgery on the ovaries, the egg supply has not decreased, but the number of eggs suitable for fertilization has.
Progesterone is a female sex hormone.
English traffic light system for fertility treatments: https://www.hfea.gov.uk/treatments/treatment-add-ons/

Exodus

It is not new that prospective parents from the Netherlands try their luck at birth across the border. In the 1980s, couples traveled to Belgium for the new IVF technique, among other places, because there was resistance to it in the Netherlands and only a handful of clinics offered that treatment. Then there is a second wave of Dutch people who go there because of new techniques for men with poor sperm quality. These techniques have impressive names such as ICSI*, MESA* and TESE*. It will eventually take approximately ten years for each of these techniques to become available in the Netherlands.

But In those years, it is not just techniques that couples in Belgium turned to. The Netherlands is -still- stricter, for example because you are no longer allowed to start an IVF process from the age of 43 and by only reimbursing three IVF cycles per baby, while Belgium reimburses a total of six. This is a political choice because of the costs: most couples manage to have a baby within three attempts. But after that third attempt, the chance of becoming pregnant is not that much lower for the other couples. The desire to continue is therefore understandable. But unlike Belgian clinics, Dutch clinics and hospitals did not offer (and do not offer) the option to pay for a fourth or fifth attempt themselves, because they argue this would be unfair for those who cannot afford it.

In 2003, gynecologist Petra de Sutter of Ghent University Hospital compared the Dutch and Belgian patients who had been treated in her hospital over the previous ten years. What turned out? The Dutch – some of whom had completed treatment in the Netherlands, given up or simply refused treatment due to age – scored almost as well as the Belgians treated there (25.3 percent) with 23.2 percent ongoing pregnancies. Striking, because the Dutch women were a few years older, had been trying for a longer time and had had unsuccessful fertility treatments in their own country. Yet they ended up having a baby here about as often as the Belgians. According to the researchers, the exodus showed that the Dutch healthcare system is inadequate for this group and that it was justifiable in terms of costs, but also from a medical and ethical point of view, to treat these patients.

Shooting at a mosquito with a cannon, doctors in the Netherlands believe. ‘A shot with buckshot,’ says the Belgian, ‘one always hits’

In 2023, Belgian fertility clinics still treat more or less the same groups of Dutch patients. Gynecologist Marieke Schoonenberg from the Nij Geertgen fertility clinic in Elsendorp in Brabant investigated the motives of couples traveling abroad in 2021. Their main reasons are that additional research and treatments are not offered in the Netherlands, and that, according to them, the care is of inadequate quality and is not patient-oriented enough. They also experienced a lack of emotional support.

The average success rates for IVF in the Netherlands and Belgium hardly differ. There is therefore no point in traveling to Belgium in advance for a fertility treatment. Sometimes people come to Belgium after one failed IVF attempt, says Frauke Vanden Meerschaut, gynecologist at Ghent University Hospital and chairman of reproductive medicine at the Flemish Association of Gynecologists: “As soon as they notice that we don’t do much else in Ghent, some people go back to The Netherlands.”

And it doesn’t always work in Belgium either, Vanden Meerschaut emphasizes: “Our work is also psychological. When a couple ends without a baby, I like it when patients thank our team. Sometimes I appreciate that more than a birth announcement. Then you know: we have done everything we can together and these people are at peace with it.”

That does not mean that traveling to Belgium is never worthwhile. In the Netherlands, fertility doctors work with fixed protocols and their colleagues in Belgium work more tailor-made and continue to search for solutions longer, says Vanden Meerschaut, who worked in the Netherlands during her training. Even when the chance of success is not high and the patient has to pay for the treatment himself. “Sometimes it is necessary to make that last attempt. Even if your chance is only five percent, for example. Who am I to say: you are not allowed?”

This article appeared together with a podcast by stylist Nicole Huisman about her own Belgian fertility journey

Hyper spurt

Maite and Jonathan are now in Leuven for their ultimate attempt. After an extensive intake, blood tests and a long ultrasound session, the Belgian doctor tells Jonathan and Maite: “The ovaries look good, the AMH value has indeed recovered somewhat, which means that there are eggs to be fertilized again. It won’t be easy, but it’s certainly not impossible.”

He is shocked that the Dutch doctor operated on both ovaries at the same time. “What if they both had irreparable damage?”

From the start it has been a night and day difference in approach, says the couple. Maite: “We were seen as people and not as numbers.” The doctor switches protocols and medications several times: “Everything was adjusted to my body and cycle instead of my body having to conform to the protocol.”

Guidelines

The strict treatment protocols with which Dutch gynecologists and fertility doctors work are based on the guidelines of the gynecologists’ association. New treatments and tests are only included in the guidelines when there is sufficient scientific evidence for them – ‘evidence based’. The most convincing are studies in which half of the patients receive the treatment and the other half do not. But these studies are expensive and take years.

The problem is that there is not enough money to properly study all new treatments and diagnostics, “as a result of which many fertility treatments will never reach the level of evidence-based,” says Wim Decleer, who works as an independent gynecologist in Aalter, Belgium. and at the Jan Palfijn Hospital in Ghent.

Of all the people who come to Decleer, he says he gets more than half pregnant through the tailor-made application of ovarian stimulation, insemination with processed and enriched sperm cells, through laparoscopy, hysteroscopy, by making the fallopian tubes patent and removing a septum or endometriosis. to take. “IVF is only for the difficult cases.”

Decleer remembers his talk at a conference for Dutch and Flemish gynecologists. He presented the results of a new treatment, with which he achieved success in 357 women with recurrent miscarriages. “It’s a shame that I hadn’t given half of them a placebo,” the Dutch thought. But you can’t say: we hope you have another miscarriage, because then we have proof? That borders on the ethically unacceptable.”

Compared to countries such as Belgium, the Netherlands conducts many of these studies, which gives it a good scientific reputation. At the same time, several Belgian and Dutch doctors indicate that the Netherlands is lagging behind in many innovations. It is crucial what you do until the ultimate proof for that new treatment or test is available: do you wait or do you already apply it? “We are cautious in the Netherlands, we want to have it proven before we do it,” says Smeenk. “And abroad they are already doing it before there has even been a study. I think the truth lies in the middle.”

Smeenk mentions a traffic light system in Great Britain. There is convincing evidence for a test or treatment with a green light. If the traffic light is red, the treatment or test is proven to be worthless or dangerous. “But it has not yet crystallized at a lot of orange traffic lights,” says Smeenk. “And those are the things my patients ask for.”

Dilemma: if you already offer such ‘orange’ treatments, studying them becomes difficult. Both doctors and patients already ‘believe’ that it works and patients do not want to end up in the placebo group, according to Sjoerd Repping, head of Reproductive Medicine at the AMC until 2019 and now professor of sensible care at the Amsterdam UMC: “And at the same time, there are examples that something that was already completely established abroad, but turned out not to work or was even harmful.”

Perfect proof

On social media, Dorothy (35) sees Dutch gynecologists be dismissive of women who want to have children: “’If you tell them to stand on their heads, they do that.’ What they tend to lose sight of is what an unfulfilled desire to have children does to you as a person.” Dorothy and her husband Alfred have already had five unexplained miscarriages and are in despair. Their Dutch gynecologist says: ‘My hands are tied here by all the protocols. Try it in Belgium, they can and are allowed to do more.” The gynecologist in question does not want to give an interview. Possibly because they should not refer to a foreign country and should not cooperate in a foreign process. At least that is what they have agreed with each other in the professional association. “At the same time, we have a duty of care and information, so that is problematic,” says Jesper Smeenk.

Before Dorothy and Alfred ended up at the Ghent University Hospital, they had already suffered two miscarriages. Once there, they notice that they receive more blood tests and examinations than in the Netherlands. Breda gynecologist Jesper Smeenk confirms this difference. When he started his subspecialization in 2009, he still put a lot of crosses on the lab form. “We have now limited this to a checkboxes, because so little came out and the relationship with any chance of pregnancy was so small. It simply costs money and that is money from you and me.”

How can care be so different? In Belgium, doctors also work evidence-based, but the guideline is a starting point for developing a treatment program together with the patient. Because everyone is genetically a little different, says Vanden Meerschaut. “If someone does not respond well after one or two attempts with a certain drug, we switch. There is no scientific evidence for this, but it can make a difference individually.”

In addition to scientific evidence, something else plays a major role in the Dutch guidelines: cost-effectiveness. This is why couples who have been unable to conceive for at least a year are often told to keep trying for another year and then have IUI first. The hope is that this will get many of them pregnant. This may be followed by the more effective but expensive IVF process. And take, for example, the chromosome map, which a doctor can have made. About 2 percent of couples with recurrent miscarriages are carriers of an abnormality that reduces the chance of a successful pregnancy. If you discover such an abnormality, you can screen the embryos for this before implantation. So you have to examine many people to detect one case and if you find one, you incur additional costs due to the treatment that follows. Not cost-effective, is the reasoning in the Netherlands.

Question marks

A Belgian doctor is more likely to propose additional tests or new treatments, some of which must be paid for by the patients themselves, says Vanden Meerschaut. “Especially in those files where there are still many question marks. Why does it fail time and time again? Then it may be interesting to inspect the uterine cavity or take a biopsy to determine whether the endometrium may be chronically inflamed,” she says. In Belgium, for example, they are more likely to consider a chromosome map after a number of miscarriages or failed implantations. “For some patients who have already undergone failed IVF treatments in the Netherlands, it is sad to find out that they have such a hereditary defect,” says Vanden Meerschaut. “But that happens, yes.”

During such an additional examination, Maite’s Flemish doctor discovers that Maite’s eggs do not respond for a very long time and then suddenly make a hyper spurt. “He had also missed the first ovulation. We then had an extra number of ultrasound scans to detect ovulation.” It helps that the nurses, laboratory technicians and doctors in this Belgian hospital work on weekends and around public holidays.

After the second IVF attempt, the result is ‘pregnant’. Unfortunately, Maite has a miscarriage after three and a half months. The Leuven doctor immediately schedules a Zoom appointment: “How are you doing?” he asks. “Take time to recover, but your eggs are now of good quality. If the stars align, we’ll try again.”

A shot of buckshot

Dorothy’s blood test shows that she has a clotting disorder. In the Netherlands it was within the normal range, but her Flemish gynecologist prescribes blood thinners. This example shows a difference in thinking between Dutch and Belgian doctors: when you encounter abnormalities in a patient that in themselves do not explain the reduced fertility, you can put them aside or try to address them to improve the chances. to increase. Doctors in the Netherlands think of these practices as shooting a mosquito with a cannon, says Dorothy. But her Belgian doctor described it jokingly: “We prefer to see that as a shot with buckshot, one always hits and maybe that’s just the right thing!”

Dorothy’s Belgian doctor also performs a hysteroscopy, a keyhole operation on the uterus. It turns out that she has an almost complete septum in her uterus. Such a septum, the doctor explains, can increase the risk of miscarriage. At home, Dorothy, who has a scientific background, starts reading up.

Partition

Normally, a uterus is shaped like an upside-down pear. Due to a congenital abnormality, approximately 3% of women have a wall in the middle of the uterus, sometimes a few millimeters long to almost the entire length. Women who have had repeated miscarriages are five times more likely to have such a septum. And women with a septum have a three times higher risk of miscarriage, probably because such a septum makes the implantation of the embryo more difficult. Based on these insights, the number of vaginal septum removals performed worldwide has increased enormously in recent years. Various studies show that these operations can lead to bleeding in exceptional cases, but these operations appear to increase the chance of a successful pregnancy by tens of percent.

But there is also criticism, especially from the Netherlands. For example, the fact that women with a uterine septum have more miscarriages does not necessarily mean that the septum is the cause. Let alone that its removal helps. There are also women with a septum who did give birth to a child. Amsterdam researchers set up their own study in which they operated on half of the women and not on the other half. The study takes a long time. The results of that study will be published in 2021: removing the septum does not increase the chance of a healthy baby, according to the researchers. But colleagues from England, Poland and Turkey, among others, react very critically: the study included only 79 patients, of whom 40 received surgery and 39 did not. Partitions ranging from a few millimeters to complete and were lumped together. Moreover, not only women with recurrent miscarriages participated, but also women with previous premature births and women with unexplained infertility, where all kinds of other factors could play a role.

The new European draft guideline for the treatment of recurrent miscarriages is published at the beginning of 2022. It states that this Amsterdam interim study is too small and too weak to be decisive. The European guideline contains cautiously positive advice to remove the septum in women with recurrent miscarriages. But Dutch gynecologists who reviewed the draft express fierce criticism, and the final European guideline from early 2023 states that doctors must decide with their patients whether they think it makes sense. On the other hand, the Dutch guideline, which is also published in early 2023, advises against the operation based on the Amsterdam study. “But in some cases, as a doctor, you do want to be able to remove a septum if it is estimated that it could help,” says gynecologist Jesper Smeenk of the Elisabeth Tweesteden Hospital in Breda.

If you do more or deviate from the guideline, you simply will not get paid in the Netherlands. On the other hand, we sometimes see people returning from Belgium whose uterus has been tampered with in such a way that permanent damage has been caused.

After consultation with Dorothy, the Belgian doctor removes her septum. Shortly afterwards she does indeed become pregnant, but unfortunately: miscarriage number eight – there is probably more going on. The doctor then has Alfred’s sperm cells analyzed. He appears to have a relatively large number of abnormal sperm cells. They undergo prenatal genetic screening, after which the gynecologist transfers an embryo. “That became miscarriage number 9, but now after eleven weeks,” says Dorothy. They consult with the doctor. During the keyhole surgery, spots were also seen, which indicate a chronic inflammation of the uterine lining. She is given antibiotics and progesterone to stimulate the growth of the uterine lining.

Dorothy becomes pregnant for the tenth time. She passes six weeks, ten weeks, twelve weeks. Slowly they dare to hope. Twenty weeks. No abnormalities on the ultrasound. Then, in the last trimester, things become blood-curdling. She suffers from severe preeclampsia, but with the help of blood pressure-lowering medication they get to 35 weeks, after which their baby is urgently delivered. At the birth, the gynecologist looks stunned – it is the same one who sent the couple to Belgium at the time: “Did you ever think this or had you also given up hope?” asks Dorothy. ‘I can’t answer that.’” Dorothy gets the feeling that the doctor does not want to admit that it would never have worked in the Netherlands.

Financial incentives

Why do doctors in the Netherlands seem to be able to do less for ‘complicated cases’ such as Dorothy and Maite than their Belgian colleagues? There are financial incentives in both systems. Schoonenberg: ‘Money ultimately plays a major role.’

In Belgium, the doctor declares all individual consultations, treatments and any medication separately to the health insurance fund. So it pays to do more. In the Netherlands, when a patient meets a certain diagnosis, a doctor creates a ‘diagnosis-treatment combination’ (DBC). For such a guideline-based DBC, the care provider receives a standard reimbursement – for the average of what such treatment entails. You will do more with one patient and less with another, but the reimbursement remains the same. So it pays to stick to the protocol and not do anything extra. “If you then do more or deviate from the guideline, you simply will not get paid,” says Jesper Smeenk. “On the other hand, we sometimes see people returning from Belgium whose uterus has been tampered with in such a way that permanent damage has occurred.”

Doctors such as Smeenk and Schoonenberg who do try to go the extra mile for the patient are currently not supported by the Dutch system, but limited. Smeenk would prefer to implement certain additions that have not been proven to help, provided they are not harmful. “To be able to support my patients. Especially because they sometimes get reimbursed for the same actions abroad by their insurer.”

In Dorothy’s case, her Belgian treatment was first refused by the health insurer: “Their argument? I simply became pregnant in the Netherlands. That was true, but I kept having miscarriages.” Crying and with a dictionary in hand, Dorothy explains several times that being fruitful is not only the ability to bear fruit, but also the acquisition of it. “After being transferred five times and calling a lawyer, it was still reimbursed.”

Customized care

All in all, Dutch fertility care is excellent for the largest group of prospective parents. But for the group that needs more customized care, it would be good if they could also get it in their own country and would not need to travel abroad. In her research, gynecologist Marieke Schoonenberg recommends entering into discussions with health insurers to expand and reimburse additional research in the Netherlands. She is thinking about an extra package with a budget for, for example, the third IVF attempt, to be able to do additional things in the gray area, such as extra blood tests or administering hormones.

In a Nieuwsuur public television broadcast from April this year, gynecologist Annemiek Nap says on behalf of the NVOG that they would like to do more for Dutch patients who are now going to Belgium. They will discuss it with the association for people with fertility problems, Freya. But nothing concrete emerged from that conversation, says José Knijnenburg of Freya. “It was just about the fact that if there is no official code for something, it cannot be reimbursed.”

Nap mainly wants to focus on accelerating European research, so that we can learn more about the usefulness of, for example, add-ons to IVF. In the meantime, she advocates better explaining to patients why they don’t do things, also because they are willing to go far because of their desire to have children: “I sometimes ask what they mean by ‘having done everything’? Because you only want to do things that are useful. If you start that conversation, they often understand.”

Knijnenburg understands very well that scientific research is important. “But I would also like to give everyone with an unfulfilled desire to have children a fair chance.”

If it were up to Sjoerd Repping, conducting research would become an integral part of healthcare: “We would then ensure that new care that we hope works, but only within research. Then we won’t have to wait 20 years, as with that septum study, and then deliver a bad study. Then we ask a question today, give half of the patients that treatment and the other half not, and then we will have the answer in a year.”

Maite’s phone rings. It’s been eight years since they started trying. “There are four very good eggs, two of which are fertilized,” says the doctor on the other end of the line. “Would we like to have one or two implanted? Two of course!” After confirmation of well-growing twins, they return to the Netherlands. They meet a super nice gynecologist. With two kids in diapers, the couple says, “I wish we had known this sooner.” They advise stuck couples to look further: “Ask for a second opinion. It is tailor-made. And that is difficult in the Netherlands.”

A few years after their first birth, Dorothy and Alfred go for it again, with the same cocktail. It works again. “In total, we have been pregnant seven times in the Netherlands and remained pregnant zero times. We succeeded with the help of Belgian gynecologists.” A Dutch gynecologist noted that it does not have to be related. “While we had four demonstrable factors that people in the Netherlands did not take notice of. The fact that I remained pregnant in Belgium was due to the other examinations and the other treatments. As a result, I had two healthy children. Not by ‘just keep trying.’”

The names of the couples have been changed for privacy reasons. For this article we spoke background with more than a dozen gynecologists at home and abroad. Their names are known to the editors.

This article appeared in the December 2023 issue of ELLE.

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