Spend 10 minutes walking the streets of Prenzlauer Berg – once rumoured to have the highest birth rate in Europe – and you might get the impression that Berlin is full of babies (and their accompanying infrastructure of strollers, scooters and stray sneakers).
The neighbourhood was once a symbol of Berlin’s baby boom, but its birth rate has since fallen, and Berlin’s is the lowest of anywhere in the country. In fact, the birth rate is dropping Germany-wide – in 2023, the number of births fell to a 10-year low – and plummeting globally. At the same time, fertility struggles are on the rise, with 17.5% of people worldwide affected, according to the World Health Organization. Berlin is no exception. That abundance of prams in Prenzlauer Berg? That’s a bit of an illusion.
In Germany, it’s biology vs. bureaucracy.
Germany, like many countries, is a complicated place to struggle to become a parent. Publicly-insured people have a legal right to coverage for “measures to bring about pregnancy”, but like everything in Germany, this comes with rules and regulations galore. The country also has some of the most restrictive and outdated regulations on fertility treatment, and the system is intensely heteronormative.
Berlin offers a slightly easier time navigating the minefield – its 12 fertility centres are more than exist in any other place in Germany. But in a city full of multinational people, even a routine brush with the healthcare system could involve language and cultural barriers. And like so much in life, very often only the deepest pockets prevail.
Stories about fertility are ultimately stories of want. Not everyone wants children, but everyone understands what it’s like to want something. To want something that another person might be able to get easily, or even stumble into accidentally. To be kept out of the clubhouse for reasons you can’t control, of which there are a thousand when it comes to becoming a parent. In Germany, it’s biology vs. bureaucracy. But exactly what alternatives do same-sex and reproductively-challenged couples in Berlin have, and how much do they cost?
Against the Clock
Last year, Judith and Nicholas Engels found out they couldn’t conceive a baby naturally. Both of Judith’s fallopian tubes were blocked and unable to be surgically fixed. The couple didn’t hesitate long before deciding to go for in vitro fertilisation, or IVF, a procedure where an egg is fertilised in a lab environment before the resulting embryo is transferred into the mother’s uterus.
But then they discovered the price tag: a single cycle of IVF can range from €5,000 to €10,000, depending on additional procedures like intracytoplasmic sperm injection (ICSI) or preimplantation genetic testing (PGT) to select the best embryo. In Germany, public health insurance will typically cover about half the cost of the first three cycles – but only for married couples. Judith and Nicholas had to get hitched.
“For us marriage wasn’t important, until it became essential in order to become parents. We actually even switched insurances, because our current Krankenkasse is covering 100% of the basic treatment if we are both insured by them,” says Judith. She and Nicholas have been together for eight years and had initially planned never to wed, but tied the knot in December before starting treatment.
Before any assisted fertility treatment there is a psychological evaluation and session where doctors inform all prospective parents of the possible outcomes of the treatment and encourage them to keep trying even if the first attempt fails. But nothing can prepare someone for the hormone-hazed desperate wait that follows an implantation.
The Engels managed to fertilise three eggs during the first cycle, but none of them led to a successful pregnancy. The process was so rough that they considered ending the IVF. “Shoving hormones into my partner’s body and watching her waste away in the stress of it made me question whether it’s worth it,” Nicholas says. But the couple decided to try again, and Judith’s second egg extraction was set for mid-May. Again, the process failed.
This time they’re done, they say – it’s too stressful. They’ll freeze the remaining viable eggs in a clinic in Brno, Czechia, which is cheaper than Germany, and begin preparing for another long, potentially frustrating maze of appointments and paperwork: adoption.
In Germany, the ages of adoptive parents and children must amount to a “natural age difference”, and Judith is turning 36 this year. The Engels don’t want to run out of time. “Also, it is just too much pressure on our relationship. I think many people don’t realise how big of an emotional strain it is to be struggling with infertility when everyone around us seems to be popping out babies,” says Judith with a bitter smile.
That feeling of being on the clock – or off schedule – is a common one for couples enduring fertility treatment. Timing is a big factor, one that can lead to frustration. This was the case for Debora*. “I chose insemination because it’s not invasive and it was also the cheapest way, and because my body was able to get pregnant this way,” she says. Her wife, Claudia*, is slightly older than she is, so they decided Debora would be the one to get pregnant.
It was fairly easy to gather information, the couple says, and their initial consultations were free at the Kinderwunschzentrum (fertility centre). At the sperm bank, they were also required to be married, presenting their marriage certificate in order to choose a donor. When she reached the insemination stage, Debora was monitored to time the implantation around her cycle. This was when things got more difficult: the clinics were often closed on weekends, and her doctor kept scheduling inseminations for Mondays even though Debora knew she was ovulating over the weekend.
“It was hard not agreeing with the insemination appointments. I felt like I was already ovulating and then they would only do it on a Monday and it wouldn’t work, with every attempt being around €500,” she says. Debora has now had two successful inseminations; their son Sam is about to turn three, and their daughter Lisa is nine months old. Both were conceived on a Friday.
Very often only the deepest pockets prevail
Debora and Claudia wanted their children to have the same sperm donor, but by the time they were trying for a second child, their original donor’s sperm was gone. “I wish I knew that my son’s donor was running out so I could have reserved it,” Debora says. But reserving the sperm would have cost an extra €1,000-1,500 per year on top of the relatively high costs of insemination. The final bill: about €6,500 the first time, and €5,500 the second, because they were already registered at the sperm bank. Debora wasn’t able to get a cent of that reimbursed by her insurance, because there was no underlying medical condition of infertility.
The whole process required not just time and money but advocating on her own behalf to medical professionals to get the care and results she wanted. “The second time around they were telling me that my progesterone levels were a little low but still within the normal range. Before the fifth attempt, I suggested taking extra progesterone and they agreed and that one stuck,” Debora recalls. “But it was frustrating that I had to figure that out myself. So one needs to be pushy sometimes.”
Un(Re)productive system
According to Fertility Europe, an umbrella organisation present in 28 countries and representing associations dedicated to infertility, less than 3% of babies in Germany are born through assisted fertility treatments. This number is lower than many other European countries; for example, Denmark, where egg donation and surrogacy are legal, ranks as high as 10%. In Germany, such methods are prohibited by the Embryo Protection Act, which was passed in 1990 and is considered one of the most outdated fertility regulations in Europe.
Changing it would make it possible for thousands of couples to have babies. The German National Academy of Sciences Leopoldina and the Union of German Academies of Sciences and Humanities called for new reproductive health laws in 2019 – focusing particularly on easing restrictions around egg donation. Though the German Medical Association supported the reforms in 2020, it’s not clear when such a law might pass.
Berlin doctors are left to advocate for their patients however they can
Berlin offers some resources to help guide people through their options. There’s an annual Fertility Fair in Berlin in March, and the Wish for a Baby expo invites international companies to talk about issues like artificial insemination, surrogacy, adoption, egg freezing, male infertility, pregnancy after 40, endometriosis, PCOS, sperm donation, fertility coaching, alternative treatment and options for the LGBTQ+ community.
In the meantime, Berlin doctors are left to advocate for their patients however they can. Dr Anja Mutz, a specialist in reproductive medicine and endocrinology with over 20 years of experience, opened her clinic, the Kinderwunschzentrum am Potsdamer Platz, in 2012, with the goal of breaking down the stigma and isolation a lot of infertile couples experience. “Only about 10-20% of the people experiencing difficulties end up talking to their doctors and making their way to a Kinderwunschzentrum at all. We want to change that,” Mutz explains.
Age is the biggest factor when people struggle to conceive, she says. “The second biggest factor is male infertility, which many people don’t know contributes to 40-50% of cases. And the third one is the female factor such as [fallopian] tube problems due to endometriosis or an infection.” Mutz’s clinic has found social media especially helpful to spread awareness. “Instagram has emerged as a powerful tool for education and support. We also share stories of our patients to encourage others.”
Mutz finds the German reproductive health system outdated and conservative; health insurances cover initial steps but subsequent treatments are only accessible to heterosexual married couples. “I often suggest marriage to my patients during consultations, after discussing the costs and what a significant difference being married makes,” she says. Depending on the treatment, at her clinic costs can vary between €500 and €7,000, and insurance often covers about 65%.
Mutz and her clinic cofounder Dr Hanadi Awwadeh, who speaks Arabic, also emphasise providing comfort and support for people where the system doesn’t always. “We have a lot of Muslim patients because it’s important that they can talk to someone from their own culture, [their] own religion,” Mutz says. “This is the only medical field where we mostly work with not only one person but two – a couple – and not only treat the physiological problems but the psychological, too… it’s a profession I would choose again and again.”
Adoption Option
This is the only medical field where we mostly work with not only one person but two
Some Berliners are willing to take drastic measures to meet the requirements of the system. Rita* and her now-ex-husband Jonas* initially tried IVF to combat multiple fertility issues, but after several failed rounds and a good deal of heartbreak, their relationship was strained. They began talking about adoption and met all the requirements – even managing to hide their crumbling marriage from a therapist during a psychological evaluation – but their seven-year relationship couldn’t recover, Rita says. “I don’t think our story is unique. We desperately wanted to become parents and when it didn’t work out, our relationship started to suffer. We kept blaming each other, we were running out of money, and we just realised that we no longer love each other,” she says. “But we sat down and agreed to adopt a child together anyway, because I wouldn’t have any other chance.”
Adoption in Germany is governed primarily by the Adoption Law (Adoptionsrecht) and the Civil Code (Bürgerliches Gesetzbuch), with additional guidelines provided by the Youth Welfare Act (Jugendhilfegesetz). To begin the journey, Rita and Jonas had to meet criteria set forth by the German adoption authorities, such as age, marital status, financial stability, space and the ability to provide a nurturing and supportive environment for the child.
Throughout the adoption process, the Youth Welfare Office (Jugendamt) plays the main role. They are responsible for assessing prospective adoptive parents, providing support and guidance and ultimately approving the adoption placement – a process that can take some time.
“It took us two years. And in those two years we had to live under the same roof and pretend to be a stable couple. So that’s exactly what we did. Anything to have a baby!” says Rita. None of the options are immune from the toll that fertility treatment takes on a relationship, but this circumstance, and the charade they were pulling off, was particularly draining. “As the months and years were going by and I watched myself age through infertility and IVF treatments and a failed marriage and then waiting for a baby who may never come, I was losing hope,” she recalls.
She and Jonas didn’t want to entertain the idea of foster care either, because they didn’t want to risk another potential heartbreak if the birth parents wanted the child back. “We wanted a child no older than two and that can be difficult, even if we didn’t care whether it was a boy or a girl – we didn’t care about their skin colour and didn’t mind whether it was domestic adoption or Auslandsadoption (international adoption). I didn’t want to adopt a child with special needs, though, not because I wouldn’t have loved them but because I knew I would soon be a single mom and that would have been too much.”
In December 2021, Rita and Jonas finally got a call: there was a two-year-old girl in Bulgaria waiting to be adopted. They travelled to meet her and decided immediately that she would be their daughter. “I looked at her and thought she was born to be our little girl,” Rita says. Jonas moved out of their apartment not long after they brought their daughter home but remains in the now-five-year-old’s life. The pair plan to tell her their story in a few years, when she’ll have a better understanding of it. “I don’t want her to not know, I just don’t want her to know it yet, because I don’t want her to get the wrong idea. It’s such a complex question and story – she is only five. She knows we love her. And her father recently had a baby with his second wife, so she is delighted to have a sibling. We are not ready to tell her just yet.”
The fruits of her labors
Berlin is a haven for queer couples, and those who want children inevitably face the labyrinth of the German reproductive healthcare system. With egg donation and surrogacy banned in Germany, many queer couples for whom fertility treatments like IVF aren’t an option look beyond the country’s borders to start a family.
“Where I come from there is a saying: ‘a woman would do anything to achieve two things: to have a child and to not have a child’. I’ve come to realise that that can be true to a man as well,” say Arthur*. He’s sitting in his apartment overlooking the Spree, holding a picture of a pregnant woman carrying his daughter, thousands of kilometres away. The Romanian-born, Munich-raised lawyer and his partner, Martin*, have been married since 2019, two years after same-sex marriage was legalised in Germany.
They were originally planning to adopt, a route that became available to queer couples when the 2017 law came into effect. But Martin has been diagnosed with early-stage Multiple Sclerosis (MS), a health issue that can preclude someone from being allowed to adopt. In the absence of other options, the couple turned to surrogacy.
It’s not a big sum considering we’ll have a lifetime of happiness
So-called ‘fertility tourism’, the process of travelling internationally for fertility solutions, varies widely by country. Like in Germany, all forms of surrogacy – including ‘altruistic’ surrogacy, where no money is exchanged – is illegal in countries including Spain, Bulgaria, France, Italy and Portugal. Commercial surrogacy is banned in Canada, Denmark, New Zealand, Brazil and Australia. The UK allows it but doesn’t have a legal framework to enforce agreements if something goes wrong. According to Reuters, Ukraine and Georgia have been a hub for international surrogacy, though the Russian invasion has hindered the process in Ukraine, and Georgia only allows surrogacy for heterosexual couples. Surrogacy in the US varies by state but the majority allow it, making the US a popular destination for couples going this route.
This is where Martin, an American who moved to Germany in 2012, suggested he and Arthur turn. They found a woman who was willing to carry their baby, using Arthur’s sperm to lower the chances of passing on the gene for MS that Martin likely carries. The cost of surrogacy depends on the country, but the average cost in the US can be as high as €230,000. “It costs us about €100,000, not counting the trips we take. I don’t care, though, we want to raise a child and we have a means to, it’s not a big sum considering we’ll have a lifetime of happiness,” Arthur says. His daughter will be born in August, and he and Martin will bring her back to their Spreeside apartment shortly after. “I think regardless of the legal complexities, surrogacy is ultimately a profoundly human experience,” he says. His outlook towards the path he’s had to navigate to become a parent is an ultimately positive one. “It’s a journey of hope, love and the unwavering desire to create or expand a family. While the legal landscape may present hurdles, the human spirit remains resilient.”
* Names changed or shortened to protect privacy
