Israel is a leader in IVF, funding reproductive assistance for all couples who need it

TEL AVIV, Sept. 29 (JTA) — The waiting room at the IVF clinic at Ichilov Hospital fills up as the morning stretches on. Women and men fill out stacks of forms and nervously eye the nurses as they call their names for examinations. Some say silent prayers.

Behind the walls of the clinic’s labs and treatment rooms, the science fiction of in-vitro fertilization unfolds: A woman’s eggs are extracted through a long syringe, then mixed with sperm in a glass dish in the hopes an embryo will be created that can be implanted in the uterus. For the lucky, pregnancy and, ultimately, a baby will follow.

Israel is a world leader when it comes to fertility treatments. As the only country that pays for infertile couples to have two babies, it has the highest number of IVF procedures per capita in the world, and its doctors are behind several cutting edge procedures.

But the race to conceive, driven by demographic concerns and a family-focused culture, has its downsides. Some public health advocates and doctors argue that fertility treatments are pushed too aggressively even when it might be medically unwise. There are concerns that repeated exposure to fertility drugs could increase the risk of certain types of cancer.

“It’s a two-edged sword. We have the technology, but the question is how to use it wisely,” said Julie Cwikel, a professor of social work and director and founder of the Center for Women’s Health, Research and Promotion at Ben-Gurion University of the Negev.

The subsidized cost of IVF treatment in Israel, even for those who are treated privately, is about $3,000 per procedure, compared to $12,000 to $15,000 in the United States. The lower cost and Israeli doctors’ vast experience with IVF has attracted so-called “fertility tourists” to the country.

For Y., 33, who tried for nearly two years to conceive, IVF was the best hope for getting pregnant. She was not deterred by the potential drawbacks of hormone shots and the emotional and physical upheaval that can follow treatment.

“You need to feel like you are doing something, and IVF lets you feel like you’re doing something proactive,” said Y., who is now eight months pregnant. “It’s a daunting task, but then suddenly you get pregnant and you think, ‘Yes, it was worth every second.'”

On average, about 20,000 IVF procedures are done annually in Israel, compared to about 100,000 per year in the United States, which has a population nearly 50 times the size of Israel’s. According to some estimates, as many as 5 percent of Israeli kindergarteners today were born through IVF.

“Be fruitful and multiply,” God proclaimed to Adam and Eve in Genesis. Later in the Bible, the issue of infertility was dealt with at length: Three of the four biblical matriarchs were infertile until God decided to “open” their wombs. Israel has taken the biblical injunction to reproduce seriously. Covering fertility treatments costs the government-subsidized HMOs about $57 million a year, much of which goes toward IVF procedures. Having IVF treatments paid for by one’s HMO makes it available for all Israelis, regardless of financial status.

In the United States, by contrast, the treatment is the prerogative of those with financial means.

“If our society can help these situations by bringing a child into the world, what could be better than that?” Health Minister Yacov Ben Yizri told JTA.

Beyond the traditional importance Judaism places on family life, the cold calculus of demography perhaps best explains the policy of funding fertility treatments. Israeli Jews fear for their majority status in the country, concerned they could eventually be overwhelmed by the Arab sector’s higher fertility rate. Figures released in September by the Central Bureau of Statistics show that the relative number of Jews in Israel has been dropping, while the percentage of Arabs is on the rise. About 76 percent of the population is Jewish, and 20 percent is Arab, according to current figures.

“If you are in Israel surrounded by Arabs whose mean family number is four or five children, and you still want Israel to have a majority of Jews, then there’s no other way” but to fund fertility, said Dr. Alex Simon, director of IVF at Jerusalem’s Hadassah hospitals.

The focus on fertility also is colored by the memory of the Holocaust and Israel’s precarious political situation. “There’s more pressure here to have families than anywhere else, and it comes from the post-Holocaust mentality that everyone needs to populate the country and that we’re under a sort of siege mentality,” Cwikel said.

State encouragement for families to have children is not a new phenomenon in Israel. In 1949, a year after statehood was declared, Prime Minister David Ben-Gurion instituted a reward of 10 lirot — a handsome sum at the time — to women who bore 10 children. The reward was canceled when it became clear that more Arab women than Jewish women were eligible for it. Still, Ben-Gurion continued to speak of the importance of what he called “internal immigration” as a way to combat Arab demography.

In Israel, a society that is highly divided on most topics, the issue of state-funded fertility treatment elicits little public debate.

“No one is against it,” said Dr. Frida Simonstein, a medical ethicist at Jezreel Valley College. “It’s incredible, there’s no division of opinion whatsoever.”

Simonstein fears that part of the reason there’s no debate is that women don’t take into account the potential health risks of treatment. For many, access to virtually free IVF treatments is viewed as a godsend. Patients, not doctors, are the ones clamoring for as many treatments as it might take to conceive, doctors claim.

“I’m very grateful to my HMO. I cost them so much money,” says Hava Yael Schreiber, only half joking. A gynecologist and fertility expert, Schreiber had 11 IVF procedures before giving birth to a child. It’s not unheard of in Israel for a woman to go through as many as 20 IVF procedures before either conceiving or giving up.

IVF usually is among the final steps in fertility treatment after other methods have failed, including fertility drugs, surgery and artificial insemination. Egg donation, a technique pioneered by Israeli doctors, can only be done abroad, however: Israeli law does not permit women to donate eggs for money in the way that men may sell sperm, so Israeli women who need egg donation usually travel to Eastern Europe for treatment.

Some public health experts suggest doctors might be pushing IVF on their patients too quickly, without giving adequate time for other methods to work.

“Doctors love a high-tech solution,” said Cwikel, who has done research on the link between stress and depression during fertility treatments. She argues that women need to be more aggressive about getting the information they need before deciding to undergo IVF, which requires repeated rounds of hormone treatments that can be physically and emotionally debilitating. Studies are inconclusive, but there are concerns that repeated exposure to fertility drugs could increase the likelihood of breast and uterine cancer. Furthermore, multiple births, often a byproduct of IVF — where more than one embryo usually is implanted in the uterus — can endanger the health of both mother and fetus.

But Simon said the push toward IVF often is patient-driven: “They say, ‘I don’t care about my body. I want a pregnancy here and now.'”

Shahar Kol of Elisha Hospital in Haifa, who sees Israeli and foreign patients in his clinic, agrees. “I don’t see patients in Israel or from anywhere else that don’t want IVF because of some increased risk,” he said.

Simon views IVF as the best tool to bring about conception and predicts that in the next few years the other, less effective methods, such as artificial insemination, will fall by the wayside.

Cwikel, on the other hand, fears IVF will be seen as a cure-all and that women in Israel, who know they don’t have to pay for the procedure, will delay childbearing. Age, she notes, is the most important factor in predicting fertility. And just as the odds of natural conception drop off as women age, so does the chance of IVF working for them.

“We don’t talk about it, and act as if it doesn’t happen,” she said. “This is what feeds the IVF machine.”