a few observations on cultural differences in fertility treatment - part 2

I thought I would write a little bit more about the differences between fertility treatment in America and Israel. In Israel we benefit from what is likely the most generous set of fertility benefits in the entire world. There is a cultural value that places a huge importance and value on family and the ability to have kids and that cultural value is no doubt backed up with a lot of money allocated to fertility treatment within the public healthcare system. All Israeli women are entitled to fertility treatments, including IVF, for up to two live births through our public healthcare system (however, I believe after age 40, all IVF attempts must be made with donor eggs in order for the public system to fund it…someone please correct me if I am wrong about the age cap here).

All Israelis, including Israeli Arabs, are entitled to the benefits of the socialized healthcare system (which we all pay into with very high taxes), making fertility treatment available and affordable to every segment of society. The availability of fertility treatment to everyone has made Israel an interesting testing laboratory in terms of the more ethical and sociological aspects of treatment - should a doctor perform IVF on a 16 or 17-year-old infertile girl from a very religious Arab village where it is the norm to get married at 14-15 and start having children immediately after? Is it in the place of the doctor to refuse treatment to a couple who he thinks are unfit to be parents? What parameters are used to make that judgement?

While I fully celebrate the availability of many treatments to everyone and feel strongly that the good outweighs the bad, there are also the practical ramifications such as much heavier patient loads than U.S. fertility clinics and overworked and overwhelmed doctors and nurses. Unlike American patients, us here in Israel (even those who choose to go privately or semi-privately for treatment - an option that is still at least partially covered by the health fund), aren't shelling out large sums of money for our treatments. On one hand, we are part of a culture that places a higher social and medical value on fertility treatments than our American counterparts, so IF is taken very seriously and no one is made to feel as if her desire for a child is akin to seeking plastic surgery. On the other hand, precisely because IF treatment is part of the norm and we aren't shelling out big bucks for a service, there is a lot less incentive for clinic staff and physicians to hold your hand or make you feel good (except out of pure altruism and then only if time allows:) I guess this typifies socialized medicine in general - the great thing is that care is accessible to everyone but it also means that no one is going to lay out the red carpet for you in terms of making sure you are a satisfied "customer" because at the end of the day, your business means a lot less to them than it does to the typical American fertility clinic.

Speaking of what incentivizes American vs. Israeli REs, I think that Israeli REs on the whole are more conservative in treatment than their American counterparts, which is probably often a good thing from a medical perspective and a financial perspective, but sometimes more frustrating for the patient. In the U.S., a patient who wants to be more aggressive in her treatment (within reason) is often attractive to the RE, because if she has a good chance of a positive outcome from even a single IVF cycle, the RE raises his/her SART stats (good for him) and the patient gets pregnant more quickly (good for her). In addition, since so many IVF cycles are OOP, there is much greater urgency to achieve success during any one particular cycle. The guidelines for the number of treatments that must be attempted for the public health funds to approve IVF in Israel tend to be more stringent than what I believe is typical in America. In Israel, based on my experience and from talking to other women, it is not uncommon for women to undergo 6-9 IUIs as long as there is no tubal factor or severe male factor, whereas in the U.S., 3-4 medicated IUI cycles seems to be the norm.

Also, I think my doctors have been on the whole more conservative than American REs in terms have how many follicles they aim for during a FSH injectables/IUI cycle. In general, doctors and patients aren't running up against the obstacle of a limited number of treatment cycles with limited funds in Israel, which allows them the luxury to be a bit more conservative. On one hand, this probably places patients medically speaking at less risk for adverse effects and results in the least invasive treatment choice, but at the same time, it also fosters an attitude of complacency of "well there's always next time" where no single cycle is viewed as very high stakes. I think this attitude is unfortunately sometimes true of IVF cycles here, which are in some ways viewed a dime a dozen. I worry that because of this attitude of their always being next time, the expectation for a positive outcome during any one particular IVF cycle is quite a bit lower here than in the U.S., where the expectation to achieve a live birth from a single IVF cycle is quite high, especially for younger patients. In Israel, we have no equivalent to SART and clinics aren't required to officially report their success rates, so the whole system is not so transparent.

On the whole, I am a big supporter of socialized medicine and the system we have here, but inherent within the system is of course the idea that the welfare of the group as a whole comes at the expense of the individual - as a whole group we are getting quite good care, but this is at the expense of truly excellent care for any given individual who would normally have good access to high quality care. Of course I am no expert and I am making a lot of vast generalizations based on anecdotal evidence, but I still find the topic of cultural differences in the way medicine is practiced interesting. I would love to hear from others in Israel to know whether you agree or disagree with my perceptions and I would also be very interested in hearing about the fertility treatment experiences of people from other countries as well!

All about my missing plan

I was feeling pretty angry and despondent about things last time I posted. I have definitely calmed down a lot since then, though I do really wish I was using our treatment break more productively. I keep telling myself I am going to start going to yoga, run more regularly, and order some relaxation/meditation tapes. So far, I have done exactly none of those things. Truthfully, I have been really exhausted the past week and I am not sure whether I am still jetlagged (if so, I suppose this will be solved since we are going to the states next week for Passover!), whether I have been fighting a virus of some sort, or whether perhaps my exhaustion is more of the psychological variety (quite possibly it is a combination of all 3).

My disappointment and frustration with my recent appointment got me to thinking more about the differences between the fertility treatment experience specifically and the healthcare system in general in the United States compared to Israel. While I have been living in Israel for 5 years now, I think that I still have very American sensibilities and expectations when it comes to healthcare and this cultural disconnect is often a source of my angst.

In Israel, everyone functions flying by the seat of his/her pants. There is very little advance planning for anything in general, big or small. There is a very strong cultural mentality of living today as if it is your last and not worrying about tomorrow (in large part, likely due to the by-the-seat-of-your-pants instability and uncertainty that has unfortunately defined our 62-year-old history as a country). While this mentality has served us not so shabbily as a small Middle Eastern country, it is sort of a neurotic infertile's worst nightmare. I am very American in my planning in that I like plans. I love plans. I really love having a plan. Very little cultural value is placed on having a concrete plan for the future - even next month. Shit happens. Our whole country could be annihilated next week, my right ovary might explode, our city might blow up, my next menstrual cycle might take 97 days to begin. But if the world as I know it is still standing next month, I want to have some vague idea of what the plan is, even if the plan might change.

In America, we are very good with plans and also with numbers. We love having dates and numbers even if they end up being totally changed or utterly meaningless. We are excellent at even making make-believe or pretend plans as in "This is your hypothetical IVF calendar for next month assuming everything goes to plan and you respond exactly as we hope." (It is my understanding that this actually happens approximately never.) When it comes to IF, we all know that the cliche proverb "Man plans, G-d laughs" is the ultimate truth and yet, when it feels like we have so little control - over our bodies, our lives, our dreams for the future, it is hard to underestimate the comfort one can find in having a plan. Some patched together semblance of how the future might look next week or next month or the month after that. No such thing in Israel. For someone as neurotic as myself, this is all very unsettling. I must learn to become even more adaptable and flexible than living here has encouraged (haha, more accurately 'forced') me to become so far, or I will continue to resist going with the flow and flail helplessly kicking in every direction in the process, likely making myself and Y and to a lesser extent my doctors and nurses miserable in the process.

More to come on differences between treatment in America and Israel soon...

Our IVF consult SUCKED

Today was the equal parts highly dreaded and highly anticipated IVF consult. It totally and completely sucked. The only thing we all seemed to be on the same page about is that moving on to IVF is the most reasonable thing to do at this point. At least there was that. I am so upset by the care (or lack thereof) I am getting, though, and it's difficult to know exactly how to proceed. I typed out all of my questions in advance so I wouldn't get flustered but since the whole appointment lasted literally, I kid you not, 3 minutes, I didn't get the chance to ask more than two or three questions and all of those two or three questions concerned only logistics.

Here are the facts: I left the appointment with orders for a bunch of tests that I already had done in the past, which could be easily accessed by looking up my ID number in the computer system or by opening (oh my!) my paper file. The 'notes' field of one of the orders read "secondary infertility", even though my one and only brush with pregnancy (after IUI#2) ended in a bloody mess induced by Cytotec at 7.5 weeks when no fetal heartbeat could be detected at my 2nd ultrasound. I left today's appointment with no start date for IVF #1, no clue as to what protocol we would be doing, and no script for BCP (RE says he doesn't believe BCP is necessary - maybe he is thinking antagonist protocol, but who really knows!?).

I was told that they are booked up for the foreseeable future for IVF cycles, so there is no chance of starting in April/May. At the beginning of May, I can come in for a clinic appointment and at that time they will set up my calendar. If everything goes well, I can start IVF #1 with my June cycle. However, since there is actually no plan and no protocol decided upon (that I know of, anyway), I have no idea whether that means I can begin the suppression phase (i.e. Lupron) at that point, or whether that means I can actually start stims at the beginning of June.

I was really hoping that we could start stims during my May cycle so that this wouldn't be competing head-first with my best friend's wedding at the beginning of July. I asked Y how he felt about postponing cycling until August/September so that we could still go to the states at the end of June/beginning of July, but he feels strongly that if he is postponing his fellowship 1+ year(s) in order for us to continue treatments, then it's not cool for me to selectively decide that I want to postpone cycling for the wedding. I understand his logic, but I am crushed and dreading discussing it with J. I am already missing my college reunion at the beginning of June, and I really had my heart set on going to the states for at least one of the two (I had picked the wedding), but now it looks unlikely either will happen and if I can indeed make it to one or the other based on the whims of my cycle, it will probably be super last minute. I decided what feels like a very long time ago that I wouldn't plan my life around TTC, but now, hypocritically, I feel that the stakes are so high that I must give in to have any chance of making this work for us. Does that make any sense at all?

I am so upset by how curt and unwilling to spend any time at all with us (not even enough time to refamiliarize himself with the very basics of our case) the RE was today. He was really great when I was pregnant and very compassionate when I had my miscarriage. Since I have been tossed around to quite a few REs in the clinic over the past 9 months and have had little continuity in my care, I didn't necessarily expect him to remember me, but I did expect him to give us a lot more information at this juncture, which feels very significant to us. Even Y, who is not so easily flustered, left feeling irritated, upset, and confused.

Not so much will be happening treatment-wise for me over the next month, but I will be doing some soul-searching as to whether I will be sticking with this RE (in reality, I will likely continue to be tossed around a fair deal during clinic visits, but just as I have been proactive about seeing this particular RE until now for the big decision making-type appointments, I can be more proactive about seeing someone else in this context). I am not willing to consider switching clinics at this point, since my current clinic is (a) at the same hospital where my research lab is located (can't beat that!) and (b) largely regarded as the best IVF clinic in the area. I hope I have more positive things to say next time - I am still waiting for my big break.

IUI #6 = BFN

My period came today. What else is there to say? I never had reason to believe that things would get this far. I am still in the states and I miss Y. Tomorrow night I head home. Our IVF consult is Thursday. Onwards we go.