Embryo Freezing in Israel? Amira's Experience Helping Friends
By: Amira Hasenbush, Esq.
As you all know, I am a fertility lawyer. I help people with surrogacy, sperm donation and egg donation agreements. But, this winter, I decided to peek behind the curtains into the medical side of family formation. I helped one of my dear friends (we'll call her "June" to protect her privacy) as she went through embryo freezing with her husband (we'll call him "David"). But, this wasn't just any embryo freezing - this was embryo freezing with an international twist. June and David are Israeli citizens living in the US, and given the massive price difference, they decided to undergo the process while visiting family in Israel. Given their current work obligations (they both have very busy professional lives), we decided that I would fly out early with June and help give her her injectable medications, and David would meet us after he finished a conference he needed to attend.
To keep the post logical from start to finish, I'm going to detail the events in chronological order, but in case you just want to read about specific topics, you can click the italicized links to jump to sections that focus on:
price differences between Israel and the US
communication with the medical staff - here AND here
deciding whether to freeze eggs or embryos
challenges with injectable medications
Israeli-specific considerations
Sunday (Day 1)
Since she knew that she had a limited window in which to do the embryo freezing while traveling, June decided to take hormonal birth control pills for a few months before leaving for Israel to try to get her cycle to align ideally with her travel dates. Unfortunately for June, the pills make her nauseous, and they didn't work perfectly at starting her period as hoped, so we were nervous that it would not be the right time to start the injectable medications. Since David’s mother tongue is Hebrew, he had taken the primary role communicating with the hospitals in the months leading up to the embryo freezing.
Unlike the US, embryo freezing and fertility treatments in Israel are primarily covered under standard universal health insurance for up to two children. Because June and David were freezing their embryos proactively to preserve their options for the future and not to immediately move forward with IVF due to diagnosed infertility, they did have to pay some of the costs, but it was still significantly less than in the states. Here's a breakdown with approximate comparison numbers from the US:
Note that the Israel numbers came from June and David's experience and may vary a bit from person to person, especially because June used less medication than some others may use (read on to find out why!). Also, this is based on current shekel to dollar ratios, and currency exchange rates fluctuate.
So, Day 1 arrived, and David advised us that we needed to go to the Sheba Tel HaShomer hospital's fertility clinic in the morning to get the first blood tests and ultrasound completed. Because fertility is covered in Israel, the clinic is part of a standard public hospital (in fact, this hospital happens to be a military hospital, though it is open to the general public), and is not a private clinic like one would use in the United States. When you arrive at the clinic, you take a number - very much like one would do at the DMV in the United States - and wait to be called to the reception and then given a number for the blood tests and ultrasound. Unfortunately, none of us realized that blood tests and ultrasounds are done between 7:15 and 8:30 in the morning at Sheba, so when we arrived at 10:30 am, we were told that we were too late for the day. However, like any typical Israeli interaction, a little bit of persistence went a long way, and after some explaining (and maybe a little bit of begging), June convinced them to do her blood tests and ultrasound that morning, even though we were late. We were told she would get a call to let her know whether she was ready to start injectable medications. Since I was going to be the one administering the shots, I got a demonstration from one of the nurses, and we were sent on our way with a prescription to fill.
Sheba Tel HaShomer Hospital Josef Buchmann Gynecology And Maternity Center
Later, as we were walking to the pharmacy, the hospital called and told June she could start that evening with her first injectable medication, Menopur. June was very nervous, but I tried to keep her calm by reminding her that I used to give my ex-husband his hormone shots, and I help people go through this process legally every day. While she may be very special in my eyes, she is not special when it comes to this process, and this is a very standard procedure. First shot went in without a hitch and we were off and running!
Monday - Wednesday Days 2-4
Days two through four were pretty calm. We were able to consistently give June her shot every evening at the same time, and her side effects were moderate: gas, cramping, bloating, dehydration/thirst, some tiredness and irritation, but nothing severe. I made sure to follow each injection with my own rendition of LMFAO's "Shots." At least one of us found it entertaining.
Our very high tech container for used needles: a 1 liter water bottle
Thursday Day 5
On Thursday, June went back to the hospital for her second round of blood tests and ultrasound. This time, she knew to arrive on time, and everything went smoothly and she was told that she would get a call to direct her on whether/how to adjust her medications.
Around mid-day, a nurse called June to tell her that it was time to reduce the Menopur and begin adding in the second medication, Cetrocide. However, the nurse was incredibly difficult to communicate with. June's Hebrew is fluent, but she is not a native speaker, and the nurse fired off speedy instructions like a drill sergeant. In addition to being fast, she was also unclear in her instructions. And to add insult to injury, she talked over June every time June tried to ask a question. After not slowing down after June's repeated requests, June asked for a call back from someone who spoke English or would be willing to slow down. The nurse insisted that she could slow down and told June that if someone else called back, it would likely be after the window for her to start the new medication that afternoon. So, June bit the bullet and continued to struggle to try to communicate with this nurse. The process got so difficult and so frustrating that June finally broke down in tears (which might have also been somewhat induced by the hormones). Only then did the nurse finally slow down and listen enough for June to be able to get all of the information. In the meantime, I pulled out the instructions for the new medication from their box and read them in English and found a YouTube video to help make sure we understood the next set of shots.
After a very stressful call, it was time for the new medication, and unfortunately, this one did not go as smoothly as the Menopur. With the Menopur, there was a bottle of powdered medication, a syringe filled with sterile water and a box of separate syringes for injection. So, I just had to inject the water into the bottle, let the medication dissolve, and then use a fresh syringe to withdraw the right amount of medicine and inject it into June's stomach. With the Cetrocide, there was one syringe for both dissolving the water and injecting the medication, but it had replaceable needles. So, we first had to attach a very large needle to the syringe to inject the water into the bottle and dissolve the medication, then use the same needle to draw all of the liquid medication back up into the syringe, then take the large needle off and replace it with a much smaller attachable needle which would be used to inject the medication into June's stomach. A little more complicated, but still simple enough, right? Wrong.
I first tried putting the large needle on the syringe, but it just fell off. I read the included instructions for details, but all it said was "attach the needle," so I pushed harder, and it seemed to stay in place. The water went in, and the meds slowly dissolved. I struggled a bit with not drawing too much air up into the syringe, but managed okay. But, then, I needed to switch the needles, and this is where things got messy - both literally and figuratively. I put the cap back on the large needle and attempted to pull it back off the syringe, but the needle was stuck. Instead, the cap popped off, and I accidentally stabbed myself in my finger with the needle. Now, I began bleeding all over our sterile countertop - not exactly ideal, and since we were in an AirBnB, we didn't have access to any bandaids. June and I struggled with the needle for a while, but nothing seemed to budge it. Finally, we used an alcohol pad to sterilize her tweezers, and she carefully removed the large needle. (For anyone who uses this medication in the future - it's a twist on attachment, not a push on - please learn from my mistake.)
June at that point decided maybe it would be best for her to attach the small needle to the syringe, which she did successfully (twist, not push). However, the small needle had the cap attached more tightly than we expected, and when she attempted to pull the cap off, it slipped, and she ended up stabbing her finger with the smaller needle. So, now, we were both bleeding from our fingers and completely stressed out over this process. Additionally, we could now see that the smaller needle was very fragile and had bent when June slid the cap off. There were no back ups or spare needles in the box of medication, so we decided to try to use the bent needle. A little more pressure than my usual injection pressure did not get the needle into her skin, so June and I decided to open another box of the medications and use one of those small needles (and worry about the fact that future medication would be missing a needle for another day). June CAREFULLY removed the bent needle and replaced it with another small needle, and about 30 minutes after we began, we finally had the Cetrocide injected.
It was time for an ice cream break for both of us. And that's what we did.
Thankfully, the evening shot of Menopur continued to go smoothly.
Unfortunately, the side effects from the Cetrocide appeared to be stronger. June said that the areas around the injection began to feel hard and painful, and she began to feel more bloated.
Friday - Saturday Days 6 and 7
The morning of Day 6, June and I traveled from Tel Aviv to Jerusalem, so that June could spend the weekend with her in-laws. I taught June's mother-in-law how to prepare and inject the medications, and she took over for the weekend while I went to visit my cousins who live outside of Jerusalem. By the time I returned on the evening of Day 7, June was extremely uncomfortable. She said that she felt like she was trying to glide instead of walk, just so that her ovaries wouldn't get jostled around or bump into anything else inside her body. At that point, she was limiting her walking to about 10-15 minutes at a time. She said she felt like her lower abdomen had liquid inside of it.
Sunday Day 8
The morning of Day 8, June and I drove back to Sheba Tel Hashomer for her next round of blood tests and ultrasound. The ultrasound technician mentioned that she saw a minimal amount of liquid, which verified what June was feeling. She was told she would again get a call from a nurse later that day with updated instructions on how to adjust the medications. Unfortunately, at that point, my legal experience was not helpful in allaying June's medical concerns. A few Google searches for "liquid in abdomen during IVF" later, and we were both down the rabbit hole, worrying that she might be experiencing the beginning of ovarian hyperstimulation syndrome. After her midday dose of Cetrocide, she got a call from a nurse who told her she had enough follicles that were large enough, and it was time for one last dose of the Menopur. While she tried to ask if she was overstimulated at that point, the responses she got were somewhat vague. She was told to give herself the final trigger shots of Decapeptyl at 8 pm that evening, and her egg retrieval procedure would be exactly 36 hours later, at 8 am on Day 10. David arrived by plane that evening, just in time to see the final shots, light candles with us and his family for the first night of Chanuka, and be there for June.
Monday Day 9
The morning of Day 9, David, June and I all piled in the car to make another trip from Jerusalem to Sheba Tel Hashomer hospital. We left at 6 am to avoid the worst of traffic. One blood test and ultrasound later, we all headed back to Jerusalem. They both needed negative COVID-19 antigen tests before the retrieval procedure, and for some reason, they were not available to be done in the hospital with everything else, so they went to an urgent care in Jerusalem to get tested. Since we got such an early start, by 10 am, all we had left to do was wait for the retrieval (and June had to stop eating and drinking at midnight that night). Unfortunately, June was more uncomfortable than ever by then. She couldn't walk more than about 7 minutes at a time (which is a challenge in a city like Jerusalem, which is often easier to navigate by foot than by car). Between her physical discomfort and being pumped full of hormones, June may have had a minor meltdown or two over traffic/exhaustion, but overall, we still managed to make it through the day, including a trip to the Western Wall to ask for blessings/meditate before the procedure. We tried to take it easy the rest of the day and just keep things low key, but of course, enjoyed a hearty Israeli grill dinner before heading to sleep early to be ready to be out the door by 6 am again the next morning.
Tuesday Day 10 - Retrieval Day!
Day 10, we were all up and out early. Typical of any hospital, there was a lot of hurry up and wait once we got there. June and David had a consultation with the doctor before the procedure in which June had to decide what kind of anesthesia she preferred - something that likely could have been explained better and with less stress if the information had been provided in writing ahead of time, but they figured it out on the spot. We were told that June's retrieval would start promptly at 8 am, but she wasn't rolled in until about 9:45 am. At that point, David finally had a job to do and went to make his sperm deposit. We were told that her procedure would only take about 20 to 30 minutes, and David would be able to go in and see her after she had another 15 to 30 minutes to rest, but he wasn't called in to see her for an hour and a half. I had to wait in the recovery room, but minutes after he went in, I got a phone call.
They had been told that after the retrieval, they would have to decide how many eggs to freeze alone as eggs and how many to freeze as embryos. Given June's age (37), we thought that if she had more than 20 eggs retrieved, that would be a very high number, and they had agreed before the retrieval that everything would become embryos. However, I picked up the phone, and June told me that they had retrieved 43 eggs. I nearly dropped the phone! I had always heard that anything more than 30 could be dangerous and likely a result of overstimulation. June told me that she was so surprised, she made the nurses check three times to make sure the number was not a mistake. I was very worried, but tried to focus on the task at hand. Given how many eggs they ended up with, they wanted my advice on whether to freeze some as eggs alone. We talked through their options, and decided they would attempt to freeze a quarter as eggs and three quarters as embryos. (Of course the total number that end up successfully frozen and genetically normal always is lower than the initial number to start.) However, once again, they were not given clear and complete information ahead of time that would have helped them to facilitate the decision. Apparently, the hospital has different procedures when an entire retrieval is made into embryos versus when some are frozen separately as eggs alone:
When the entire retrieval of eggs is fertilized to become embryos, they split the retrieved eggs into two groups. Half are fertilized through traditional IVF, in which they are left in a petri dish with the sperm, and half are fertilized using ICSI, in which carefully selected sperm is injected directly into the egg.
When the retrieval is split between eggs and embryos, the embryologists first select the most mature eggs to freeze independently. They then perform ICSI on all of the eggs that will be used for embryos to give the best chance of fertilization of the eggs that remain.
Once June and David finally got a doctor to clearly explain the different procedures, David and June changed their minds and decided to have everything made into embryos. They did not want to risk giving up the most mature eggs to egg freezing instead of making sure they were used for the embryos.
Slowly, June was allowed to go to the bathroom, have a bite to eat, and get dressed and ready to leave the hospital. On checkout, she asked the nurse what was the highest number of eggs she had seen retrieved. The nurse looked at her and replied, "43." So, June, my always ambitious and overachieving friend, had set the record once again, and went home to rest. While I worried that she might still be overstimulated, she said she immediately felt better after the retrieval, and her recovery was very smooth. I am writing this about four weeks after her procedure, and today she told me she is finally no longer feeling "puffy" or bloated, which she felt from the time she began birth control pills about three months before the procedure.
After the fertilization procedures, June and David ended up with 13 embryos, which are now frozen in Israel. I have also now learned that donating extra embryos to a third party for reproductive purposes is not allowed in Israel, and I will be working on writing up an embryo disposition agreement for them to state their wishes in the event of death/divorce, which we will request that an Israeli colleague reviews and edits.
So, what are the takeaways?
I found the process intimidating, mostly from a language perspective, since my Hebrew was not strong enough to understand all of the details. However, June and David chose a hospital that is not focused on working with American immigrants, because they wanted to go through the experience in Hebrew. With a different hospital, for example, in Jerusalem, I'm sure that the whole process could be navigated in English.
I was also surprised at the lack of hand-holding. In the US, it seems like ultrasounds and blood tests are a bit more frequent, and feedback that I have received has been that there is much more communication between the patient and the medical professionals. However, I think that difference is partially cultural and partially logistical. In the US, embryo freezing is almost always done in a private clinic, where patients are paying tens of thousands of dollars for medical care - you'd better believe that people expect a certain level of customer service and continuity of care. On the other hand, in Israel, this is a general medical procedure (mostly) covered by insurance, and therefore, it is treated with much less concierge-like care - there was not one consistent point of contact, and at times, June received conflicting answers from different people. However, June, in particular, appreciated that the process was affordable and accessible for society at large. She really appreciated that the process was for "normal" people and not for only the elite. She also found the medical part to be excellent; she reported that from her experience, the blood tests, ultrasounds and the procedure itself, were all flawless and efficient.
I was also surprised at the difference in the paperwork. In the United States, there is a TON of paperwork (I know - I often review it for clients) - perhaps too much paperwork, as I believe it gets so long that most people don't even bother to read it. However, the entire process and every potential medical risk is spelled out so that the patient can have informed consent and can set their dispositional preferences in the event of death or divorce. I don't recall seeing June receive any informed consent paperwork (though she may have received it months earlier when she went for her initial testing over the summer), and I know that they were not asked to fill out any death/divorce dispositional preferences. I would have expected more written guidance ahead of time on what to expect from the process overall, and particularly for the day of the procedure. This especially came into play when having to make on-the-spot decisions about anesthesia and whether to freeze eggs or embryos.
But the most special part of the process for me? How women-driven it was. June's shots were administered by her mother-in-law and me. All of the nurses were women. Her doctor who completed the egg retrieval was a woman. The embryologist was a woman. Even the pharmacists we met were women. Some of this was happenstance, and some by design, but it was so special to have this uniquely ovarian experience be guided by the hands, minds and hearts of so many strong and caring women. Oh, and David was there, too. :)