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!