Fertility Preservation

Egg preservation could offer women the choice of when to become mothers.  Egg freezing and fertility preservation give reassurance to women who like to postpone the family planning  for various reasons and to women with low ovarian reserve or with family history of premature ovarian insufficiency, endometriosis, cancer, carriers of fragile X and for unexplained infertility – funded by the Health Funds. Like any other fertility treatment, in its first stage, most fertility preservation procedures require hormonal ovarian hyperstimulation in order to produce multiple eggs from the ovarian reserve, followed by retrieving the eggs in the operating room  After harvesting the unfertilized eggs, their temperature is reduced to freezing levels using vitrification method and kept for five years free of charge with an option of keeping them frozen for additional five years with fee.  Once there’s a desire to use the frozen eggs it must be thawed and fertilized in a technique called Micro-manipulation (ICSI) and then the fresh embryos are returned into the uterus in the ideal timing for them to implant Recently a law has been passed whereby women with low ovarian reserve on medical basis, genetic abnormalities or without apparent cause that meet the criteria defined by the Ministry of Health would be entitled to free fertility preservation treatments funded by the Health Funds Although until recently it was a tabu, Rabbi Burstein, founder and head of the Puah Institute recommended traditional and orthodox unmarried women to preserve their fertility by freezing eggs at an early age and have the option of starting a family in an older age after marriage.

Preimplantation Genetic Diagnosis / Screening

PGD/PGS are techniques allowing women / couples with a family history of a particular inherited condition to pass it on to their children and for women who are interested in returning only genetically healthy embryos for various reasons. The procedure requires the growth of all the embryos in the laboratory for 5-6 days, then a biopsy from the embryo is taken and tested for the abnormality and all the tested embryos are frozen. The next month, only embryos without chromosome abnormalities are transplanted into the woman’s uterus.  Women / couples with a particular genetic condition that apply for the test are eligible for full funding by the Health Funds. In all other cases PGS will be performed only in cases where the woman so wishes and will be privately funded. The screening is recommended for women with a relatively large number of embryos to be sampled, for women with a history of unexplained recurrent miscarriages who want to avoid another miscarriage based on chromosome abnormalities and for those who wish to maximise their chances of a single embryo implant and a healthy pregnancy.

In Vitro Fertilization - IVF

IVF is a form of treatment offered for couples with severe semen problem that does not allow natural fertilization, in cases of bilateral tubal obstruction and previous fertilization failure using artificial insemination. In cases such as advanced endometriosis, women over 40 and absent ovulation as occurs in cases of polycystic ovaries, IVF is used as first line of treatment. The procedure includes egg retrieval in the operating room (usually after hormone therapy to encourage release of several follicles) followed by fertilization of the eggs that can be carried out by conventional IVF or micro-manipulation, depending on sperm quality. Once the embryos have developed in the lab they are transferred back into the uterus at different stages between day 2- day 5 after the retrieval of the eggs, according to different factors. The good quality embryos that are not transferred will be frozen. The egg retrieval procedure, fertilization, developing the embryos and returning them into the woman’s uterus take place at Assuta  Hospital. Factors such as the woman’s age, treatments history, number and quality of embryos and hormonal and uterine condition prior to the egg retrieval – will determine if and how many embryos will be returned or frozen and when.

Intrauterine Insemination

A recommended treatment for couples with relatively mild reduced semen quality, unexplained infertility and for single women as a first line of treatment for pregnancy. The technique consists of insemination of the sperm, which has been prepared in advance in the laboratory, inside the woman’s uterus in order to shorten the distance between the sperm and the egg and to increase the potential of fertilization. The Intrauterine insemination treatment consists of two stages : first ,  the natural ovulation cycle is monitored or a hormone therapy, given by pills or injections, in order to encourage the recruitment of one or a few follicles. The next stage occurs when the leading follicle reaches the size of 17-18mm diameter, the uterine lining has thickened and blood tests show an adequate level of hormones. According to these findings, the insemination procedure is scheduled.

Uterus cavity diagnostics

In my clinic and at Assuta Hospital I perform three diagnostic tests of the uterus cavity and the fallopian tubes: Uterus X-ray(HSG( , diagnostic hysteroscopy and Hysterosalpingography (an equivalent to uterus X-Ray). During the uterus X-Ray procedure, I place a catheter with a balloon at the opening of the cervix and fill the uterus with a contrast liquid (iodine) through the catheter and into the uterus. This method involves minimal discomfort for the patient opposed to the old method where the opening of the cervix was physically held in order to allow the catheter through, which could cause pain for the majority of patients. Women with suspected obstructed / inflamed fallopian tubes, or with a history of endometriosis or past laparoscopic surgery are advised to undergo uterine X-Ray as it clearly shows the flow of the contrast material in the pelvis. In case of suspected abnormality in the uterus cavity (Septate uterus seen in ultrasound scan, intrauterine adhesions, thin endometrium without known reason or post uterus surgery such as curettage procedure or surgical hysteroscopy) diagnostic hysteroscopy is recommended. Diagnostic hysteroscopy is performed in the clinic without the need for sedation and allows direct camera vision of the uterus cavity and the opening of the fallopian tubes (whether they are open or blocked, shed light on the quality of the endometrium, diagnosis of Septate / Subseptate uterus, endometriosis and adhesions in the cavity). At the end of the procedure and depending on the results, a recommendation is made whether to refer the patient to surgical hysteroscopy in order to treat the diagnosed problem and how to continue the treatment. The continuation of the test, Salpingography, intended for women who are interested to ensure their fallopian tubes are healthy and for patients who haven’t been able to conceive naturally and want to ensure that moving on to insemination treatments would be effective in achieving pregnancy. During the procedure a specific fluid is dripped, showing the flow in the fallopian tubes and into the pelvis by an ultrasound The procedure is done in the clinic and its significant advantage is that is takes place in a “friendly” environment and without exposure to radiation (although uterine X-ray also involves only minor radiation with no dangerous/ harmful exposure), and without any iodine, to which some women are sensitive. Taking the three tests increases the chances for pregnancy in the month they are performed due to the washing effect of the uterine cavity and the fallopian tubes.

ERA- Endometrial Receptivity Analysis

A genetic test which helps establish the best time for embryo transfer in order for it to implant The test is recommended for women who have suffered recurrent failed IVF, for women who are about to undergo embryo implantation and are interested in maximising their chances by finding their optimal implantation window and for women who like to determine if their endometrial lining is receptive and its worth while keeping embryos implantations or to look into the possibly of surrogacy. The procedure requires ordering a special kit from Spain and performing a mock test, that mimics the embryo implant but instead a uterine biopsy is taken and sent to Spain for a genetic analysis of the endometrial receptivity. The test results allows women who worry of not able to conceive decide if to continue returning embryos or to look into the surrogacy option and to women who have previously got pregnant and failed to fall pregnant with IVF for an unknown reason, to determine if their window of implantation is displaced. In such a case the embryos should be returned into the uterus in a different timing (before or after the estimated window of implantation). It is important to know that approximately 25% of women experiencing repeated failure in IVF treatments actually suffer from displaced window of implantation and wrong timing in returning their embryos to the uterus.

Egg Donation

Egg donation allows women who are unable to produce viable eggs to get pregnant with their own eggs.  The most common reason for this is older age, other reasons include chemotherapy, Premature ovarian insufficiency, severe endometriosis, poor quality eggs and more. I refer my patients in two main directions: The first is unknown egg donation from Kiev and the return of the frozen or fresh embryos is done by me in Israel. The second, is using a known egg donation in Cyprus. In this option I plan the treatment according to the date of the egg retrieval / return of the frozen embryos in Cyprus  and the patient travels to the clinic in Cyprus for the return of the frozen or fresh embryos procedure. In both options the embryo transfer   is based on the woman’s ovulation cycle or on hormone therapy