A Health Ministry advisory council recommends that women under 40 have greater access to in vitro fertility treatments through the public health system, while limiting treatments for women over 41 – effectively ending a unique policy.
Public funding for in vitro fertilization in Israel is the most generous in the world, and the technology is highly advanced. The public health system provides unlimited IVF treatments for any woman between 18 and 45 for her first or second child and funds fertility treatments using donated eggs through age 54.
The new recommendations, which have been obtained by Haaretz, come from the National Council for Gynecology, Neonatology and Genetics. The council is also recommending that the ministry and the country’s four health maintenance organizations let women freeze their fertilized eggs as part of the publicly funded health system.
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Over the years, the Health Ministry has feared that limiting public funding for IVF could spark angry protests, but, amid failure rates among older women, medical experts are increasingly recommending that limits be set.
Some sources in the health care system doubt that the recommendations will be adopted. “No health minister wants to be the one to sign off on such a step,” one senior source said.
In light of new data on low IVF success rates among women 43 to 45, the council is recommending that the maximum age for IVF be lowered to 44 from 45. Figures from 2017 from the Israel Fertility Association show an IVF success rate of just 3.8 percent among women 43 to 45, compared with 11.4 percent for women 40 to 42 and 23 percent for woman 35 to 39.
About 5 percent of births in Israel – around 9,000 babies a year – are the result of IVF. The only country coming close in public funding is Denmark, which funds IVF up to age 45 but limits it to three rounds. On average, the Israeli government spends about 400,000 shekels ($115,000) for every successful IVF birth to mothers 43 and older.
“Ultimately, it’s difficult for both the system and the doctors to oppose the strong desire and the social pressure to have a genetically related child at any price,” said Dr. Etti Semama, who heads the Health Ministry’s medical technology division.
More than 40,000 rounds of IVF treatments are administered in Israel annually. The Health Ministry has calculated the annual cost – including hormone treatments, the extraction of eggs, laboratory fertilization and the implantation of embryos – at 400 million to 500 million shekels.
Professional sources estimate that about 75 million shekels of that sum is for treatments where the success rate is negligible. This includes both women at the upper age limits and women who have undergone a number of unsuccessful treatments.
The national council has sought meetings with officials from the ministry and the HMOs on its recommendations, but Israel’s successive general elections, keeping a caretaker government in place, have delayed these deliberations.
The effort to curb public funding is not new. In 2005, the national council recommended that public IVF funding be limited to women up to 44 instead of 45, and in 2013, the council recommended not only lowering the age but limiting funding to three IVF cycles for women 42 to 44. The recommendation was not adopted, on the argument that most of the treatments were not provided to women in that age range.
The 2017 figures from the Israel Fertility Association show that 3,881 IVF treatments were administered that year to women between 43 and 45, producing the 3.8 percent success rate.
Focusing on the best chances
The National Council for Gynecology, Neonatology and Genetics consists of 36 experts with a variety of specializations. The council’s recommendations would limit the extraction of eggs from women between 41 and 42 to eight (without possible approval for further attempts, as is now possible).
For women 43 and older, the number of treatment cycles would be limited to six. The council is recommending that treatments be available in quick succession and that the HMOs’ current 45-day waiting period between treatments be eliminated.
“The current policy of the HMOs is not to approve more than four to six treatment cycles per year,” said Prof. Talia Eldar-Geva, a member of the council and the fertility endocrinology and genetics chief at Jerusalem’s Shaare Zedek Medical Center.
“The idea is to focus the effort as much as possible on where the prospect of getting pregnant is the highest. From age 35 to 39, we suggest that the HMOs allow continuous treatment cycles and change the policy regarding the freezing of embryos. Currently every extraction requires the immediate implantation of the embryos. We’re telling the HMOs: Allow another extraction to save the frozen embryos for a few years.”
Figures from Israel and abroad show that when a woman begins fertility treatments at 41, the average chance of having a child is about 10 percent, Eldar-Geva said.
“For a woman who begins treatments at age 43, it’s at most 5 percent. After five cycles, the success rate doesn't increase with every cycle,” she said, adding that if the woman gets pregnant, it is usually within the first three IVF cycles.
‘My lottery ticket’
The rate of IVF treatments performed in Israel is the highest in the world in proportion to the population, according to a 2018 survey published in the Israel Medical Association journal Harefuah and coauthored by Semama, the head of Health Ministry's medical technology division.
“I still don’t think we’ve been successful in having these women get more wisely helped by these treatments and for them to have a better understanding of the risks and the prospects. The Israeli public has great respect for a woman who endangers herself for pregnancy and childbirth. It’s perceived as almost a heroic sacrificial act. And genetic parenthood is also sacred,” she said.
“There are success stories in the media of women who got pregnant at an advanced age, but they downplay the fact that sometimes it involves egg donations and ignores the high rate of failure in treating older women. Ultimately, many women begin a process in which the chances of success at their age is a fraction of a percent. They tell themselves: ‘This is my lottery ticket. Even if the chances are 1 percent, I’m going to be that 1 percent.’”
In their journal article, Semama and her colleagues show how Israel’s generous government keeps the status quo going. “The pattern that keeps repeating is that once women reach 45 and the public funding ends, they switch to the option of donated eggs, and then they get pregnant.”
In 2014, the Health Ministry ruled that the medical team had to reconsider the woman’s case after eight unsuccessful egg extractions and make recommendations on whether she should continue. A circular on this issue triggered a backlash and the ministry quickly announced that this did not mean that further treatments could not be given.
It has been rare for women to face limits on the number of IVF treatments. A case filed by a woman 44 and a half against Maccabi Healthcare Services is currently before a labor court.
Following eight unsuccessful treatments, this woman was advised to opt for an egg donation. Maccabi was acting according to the Health Ministry’s directive and refused to provide any further IVF treatments before she turned 45, when public funding for these treatments ends.