“You’re so battered by this situation, laden with hormones and hopes, embarrassed, disappointed with your body, feeling like a second-class woman,” says Miriam, who has undergone 13 cycles of fertility treatment in less than four years. “Amid all this, to find room to investigate, to inquire, was beyond me. A department head I saw privately once told me, ‘Even a broomstick can get pregnant’ – so if I’m a woman of 41 and far from a broomstick, I’ll do 100 treatments and will get pregnant. It’s irresponsible to let women do dozens of treatments.”
Miriam’s story is one of many similar ones told in Sarit Magen’s Hebrew-language book “A Child of your Own – Behind the Curtain of Fertility Treatments in Israel.” It came out in March, but hasn’t received the attention it deserves.
Though it’s billed as an account of the economic and emotional costs of fertility treatments, a more apt description would be an investigative report into the problematic way the public health budget is spent.
Magen interviewed dozens of women who underwent in vitro fertilization, as well as senior doctors, Knesset members, health ministers and other policymakers in Israel. Most spoke with rare candor.
She describes women’s ignorance about IVF, and doctors who perform treatments that have no chance of succeeding, sparking vain hopes. She also explores why Israel is the only country in the world whose national health insurance program funds IVF for women up to age 45, for up to two children.
Magen says there’s no public discussion about the economic costs of this, at a time when vital drugs go uncovered and hospitals put patients in corridors for lack of ward space.
Though Magen is a veteran health journalist, her motive for writing this book was personal: at 36, she began IVF treatments. She underwent 15 cycles over the next five years and had three miscarriages, until one doctor finally told her to consider using donated eggs.
“It’s embarrassing how blind I was, despite my journalistic background,” she tells Haaretz. “I myself fell for the delusion that anyone who’s treated can succeed if she keeps persevering.”
Over the past few weeks, Haaretz asked random people the following question: Two women, one 35 and the other 40, undergo IVF; what are their chances of becoming pregnant? Estimates ranged from a low of 30% for the 40-year-old to a high of 80% for the 35-year-old.
Here are the real figures: The 35-year-old has a 23% chance of getting pregnant; the 40-year-old’s chances are just 11%. A woman of 44 has a negligible 1.8% chance of conceiving.
For anyone, the chances fall dramatically after the first six attempts, partly because repeated treatments can create new fertility problems. (By the way, regular periods say nothing about one’s chances of conceiving.)
Though our respondents weren’t a representative sample, various studies show that their ignorance and excessive optimism are widely shared. And precise knowledge has become even more important now that women are marrying later. In the 1970s, only 13% of Jewish-Israeli women aged 25 to 29 were unmarried; by 2014, that figure was 50%, with 22% still single at ages 30 to 34.
Reinforcing the illusion
Contrary to popular belief, neither nature nor medicine has yet adapted to rising marriage ages. IVF was developed to solve “mechanical problems like blocked Fallopian tubes, not as a solution to genetically impaired eggs – whose proportion rises steadily from age 30 onward,” Magen explains.
Her interviewees reflect this ignorance. Rona, for instance, said she began a series of failed treatments at age 30 after reading about women aged 50 and older who became pregnant.
“Nowhere was it noted that this wasn’t their genetic child, and that medicine has never overcome the issue of the age of the eggs,” Rona says in the book. “The result is that the media and doctors together create the illusion that technology has overcome nature.”
The fact that the state pays for IVF up to age 45 reinforces this illusion, she added.
A key section of the book is devoted to explaining the IVF process and the heavy toll it exacts. It lasts a month to six weeks and “completely dominates” women’s schedules, notes Magen.
The hormones must be injected at a fixed time, “so if they’re invited to a wedding in the evening, they inject in the bathroom.” In contrast, the moment when the eggs must be extracted is unpredictable. And once they’re implanted, “you’re warned not to schlep or exert yourself, since you may be pregnant,” says Magen.
This process, which involves both hormone injections and surgery under general anesthesia, also has a physical price. The most common complication is ovarian hyperstimulation, whose symptoms range from stomach pains and bloating through vomiting and diarrhea, to, in the worst cases, thrombophlebitis and renal insufficiency.
One interviewee’s weight soared to 110 kilograms (242 pounds) due to the hormones. Another had a quadriplegic baby because her multiple fetuses were born prematurely. A third developed uterine fibroids and had to have her uterus removed. None of them was aware of these risks when they began the process.
Addicted to IVF
Many interviewees described IVF as an addiction they couldn’t stop. Hila, for example, said her husband “took me aside one day and said, ‘Hila, enough. We’ve already done 16 treatments, seven years. I can’t watch you like this, crying, broken, your stomach blue from shots; I can’t find any more sources of income. How long will you go on like this?’ I screamed at him, ‘That’s what interests you? I’ll be a mother and I don’t care about anything else!’”
This is a syndrome known as IVF psychosis, in which “women aren’t capable of seeing anything except getting pregnant,” says Dr. Janet Takefman, of Montreal’s McGill University, in the book. “They’ll barter their health, switch jobs, do anything to get pregnant. It’s the only focus of their lives.
“As long as there’s any chance, even the slightest, they can’t give up – because if they give up, it means they don’t care enough,” Takefman continued. “People are afraid that if they stop, they’ll never have a normal life; their marriages will collapse and they’ll remain alone all their lives. It’s based on fear, of being invisible, of not being part of society.”
Takefman counsels couples on when to end IVF treatments. But this vital service isn’t offered by Israel’s health system. Many doctors, especially in private practice, are neither able nor willing to do so.
The price of this ignorance is paid not just by women, but by Israeli society as a whole. Israel has the world’s highest number of IVF treatments per capita, and it’s the only country where women can go through 10, 15 or even 20 cycles on the public’s dime. Yet its rate of live births per cycle, at 19%, is one of the world’s lowest – below the European average of 22% and far below top-ranked countries like the United States (33%), Austria (29%) or Britain and Portugal (27%).
This isn’t because Israeli doctors are less skilled, but because Israel funds treatments for thousands of women whose chances of success are near zero. Last year, more than 36% of publicly funded IVF treatments were for women over 40, and 13% were for women 43 or older.
Infertility isn’t a life-threatening disease, but the absence of an option. Yet since the public health budget is limited, funding for IVF comes at the expense of funding for genuine medical treatments. It’s a zero-sum game.
Magen believes that even just lowering the maximum treatment age from 45 to 43 would save 50 million shekels ($14.2 million) annually. That’s a sizable sum when the national health plan’s total annual budget for new treatments comes to 300 million shekels.
She cites several alternative uses for that money – from covering new leukemia and Parkinson’s drugs that the health plan doesn’t currently cover, to lowering copayments for common drugs to treat blood pressure or diabetes. Today, many poor Israelis who need the latter drugs simply don’t buy them because of the high copayments, which come to tens of shekels per month, according to Prof. Haim Bitterman, a former chief physician of the Clalit health maintenance organization.
Magen exposes several troubling practices by Israeli fertility specialists. One particularly mind-boggling one is that the fertilized eggs are implanted in the woman’s womb after just three days in an incubator, even though this is liable to be counterproductive.
At three days, she explains, it’s extremely difficult to determine which fertilized eggs will be viable. But if left in the incubator longer, most of the fertilized eggs will stop developing, and the ones that remain will be those with the highest chance of producing a healthy pregnancy.
So why do Israeli doctors implant the eggs after three days rather than five? Sometimes, it’s because the IVF unit in question isn’t technically capable of incubating them until the fifth day. But there’s also an outrageous, patronizing reason which doctors term patient psychology.
“If a doctor implants the embryos on the third day and a pregnancy doesn’t develop, the patient tells herself, ‘What can you do? The embryo didn’t attach,’” says IVF specialist Dr. IIya Bar. “But when a doctor keeps the embryos in the lab until the fifth day and then comes to the patient with empty hands, that’s a completely different situation.”
Prof. Shlomo Mashiach, who heads the gynecology department at Sheba Medical Center, Tel Hashomer, and performed the first successful IVF treatment in Israel, added another reason. “Under Health Ministry instructions, the treatment stops if embryos weren’t implanted four times,” he says. “Doctors aren’t Don Quixote, they say: ‘Why should I be the bad guy? If I tell her I won’t implant, she’ll go to someone else who will.’ So they implant.”
Magen adds that, furthermore, many doctors say letting a woman undergo three or four unsuccessful IVF treatments so she’ll “be psychologically ‘ripe’ for an egg donation is just fine. Do you know of any other treatment where they put you in the operating room just to ‘ripen’ you for another treatment?” he asks.
She also charges that whereas doctors have an interest in studying the efficacy of most treatments, with IVF they have an interest in keeping quiet.
“One reason is that it’s kind of taboo,” she notes. IVF may look like a medical procedure, but “in many respects, they’re treating not just biological barrenness but spiritual barrenness – the open wound of the Jewish people, its feelings of oppression and victimhood, the existential threat.”
Magen recalls that in 2003, the Finance Ministry tried to reduce IVF funding. When a treasury representative showed a graph of the number of IVF treatments in Israel, “MK Marina Solodkin [Kadima] thundered, ‘You wouldn’t bring a graph about the Holocaust!’ That’s the atmosphere in which fertility treatments take place in Israel – and that’s why fertility treatments are spared the fate awaiting every other medical treatment.”