Fertility Guide

Last Updated on:

January 11, 2023

Know to Ask:

Struggling to conceive, and dealing with any type of infertility is an overwhelming, stressful, and emotional process. Although 1 in 8 couples suffer from infertility, many still feel a deep sense of loneliness when struggling to expand their families. While there are no guarantees, Israeli healthcare offers an array of heavily subsidized fertility treatments. Receiving coverage for these treatments involves a series of steps within the kupot cholim and hospitals.

We hope this guide can ease the burden of this journey, by empowering you with the knowledge to ask the right questions, and manage the situation. In addition, this page includes helpful and important employment rights for men and women going through fertility treatments. B’hatzlacha!

Diagnosing Infertility

It is recommended to seek a diagnosis if a couple has not conceived after actively trying for 12 months. (For women over 35, it is recommended to see a doctor after 6 months). You can get a referral from your primary care physician or gynecologist to make an appointment with a fertility specialist.

Before a couple under 35 has been trying to conceive for more than a year, most doctors will not check for factors contributing to infertility unless there are known pre-existing conditions or diagnoses.

Tip: Appointments for fertility specialists often have long wait times. If a couple has SHABAN (kupah higher level insurance plans), they may want to consider private specialists through SHARAP (private specialist services) or other private clinics, which are often heavily subsidized by the kupot, to try and avoid long wait times.

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Types of Infertility:

Primary Infertility- couples who have never conceived a pregnancy.
Secondary Infertility- couples who previously conceived but are now unable. This can happen to couples of all ages, even after 1, 2 or more successful pregnancies/births.

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Causes of Infertility:

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1. Female Factor Infertility- diagnosis of infertility related to the woman.

Some diagnoses of Female Infertility may include:

PCOS (Poly-Cystic Ovarian Syndrome)
Blocked fallopian tubes
Uterine fibroids/endometriosis
Previous cancer, chemotherapy, or other medications
STDs
Diabetes
Other hormonal factors
Autoimmune diseases

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2. Male Factor Infertility- diagnosis of infertility related to the man.

Some diagnoses of Male Infertility may include:

Low sperm count (fewer than 15 million sperm per milliliter of semen)
Low sperm motility
Autoimmune or genetic diseases
Previous cancer, chemotherapy, or other medications
Diabetes
STDs (Sexually Transmitted Diseases)
Other hormonal factors

3. Male & Female Factor Infertility- diagnosis of infertility is related to both the man & woman

4. Unexplained Infertility- no medical explanation or diagnosis of infertility of either the man or woman is present, but they are still unable to conceive.

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According to Israeli research, 20% of couples were given a diagnosis of unexplained fertility. Of the remaining 80% of couples, 55% had female factor infertility, and 45% had male factor infertility.

Infertility Testing

Below is a chart of commonly performed tests when seeking a diagnosis for infertility. The chart includes whether the test requires a hafnaya (referral) or hitchayvut (payment voucher), as well as information on co-payments.

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Hormonal Blood Test (בדיקת דם הורמונלית)	A simple blood test to check for levels of estrogen, testosterone, progesterone etc. This test can determine any hormonal imbalances as well as indicate if the woman is not ovulating (anovulatory cycle), depleted ovarian reserve, or PCOS.	A hafnaya from any kupah doctor will be valid. Go to the regular clinic lab during blood test hours.
Transvaginal Ultrasound (אולטרסאונד וואגינלי)	Internal ultrasound that may indicate PCOS, anovulatory cycles, or other ovarian abnormalities.	The hafnaya must be from a gynecologist or fertility specialist. Make an appointment through an ultrasound department that performs women’s ultrasounds. Co-pay of 34 NIS.
Follicle Tracking (מעקב זקיקים)	Internal ultrasound to track follicle growth or ovulation. Must be done at specific times of the month. Often done in conjunction with a treatment.	The hafnaya must be from a gynecologist or fertility specialist. Make an appointment through an ultrasound department that performs women’s ultrasounds. Co-pay of 34 NIS.
Hysterosalpingography (צילום רחם)	Evaluates the condition of the uterus and fallopian tubes and looks for blockages or other problems. X-ray contrast is injected into the uterus, and an X-ray is taken to determine if the cavity is normal and to see if the fluid spills out of the fallopian tubes.	Some kupot offer the exam within their clinics. In this case, only a hafnaya from a fertility specialist in required. If you kupah sends you for the test in a hospital, or another external clinic, a hitchayvut will be required.
Pelvic Ultrasound (אולטרסאונד אגן)	This ultrasound is used to determine any pelvic diseases and/or any abnormalities in the uterus.	The hafnaya must be from a gynecologist or fertility specialist. Make an appointment through an ultrasound department that performs women’s ultrasounds. Co-pay 34 NIS.
		Co-pay 34 NIS.
Hysteroscopy (היסטרוסקופיה)	Imaging test to determine uterine abnormalities or diagnose endometriosis. A camera is inserted into the vaginal canal. This can either be imaging only or combined with a surgical procedure (polyp removal, e.g.). Note that these are considered two different hysteroscopies, and require different types of hafnaya/hitchayvut.	Requires hafnaya and hitchayvut.
Laparoscopy (לפרוסקופייה)	Surgery using small incisions to explore the pelvic cavity/remove external uterine tissue (in the case of endometriosis).	Requires hafanaya and hitchayvut.
Genetic Testing (בדיקת גנטי)	To determine the presence of any genetic abnormalities in one or both of the partners.	Make an appointment through the kupah with a genetic counselor who will give you a hafnaya for the relevant tests. Cost will vary depending on the number and type of tests required.
Semen Analysis (בדיקת זרע)	In certain cases, a biopsy will be performed to determine any testicular abnormalities, or to retrieve sperm.	Requires hafnaya and hitchayvut.

Fertility Treatments (non IVF)

Generally, IVF is considered the last resort, and the following options must be exhausted before IVF is covered by the kupah. In certain diagnoses, and if the woman is over the age of 39, the couple may go straight to IVF (see below). Co-payments vary slightly by kupah, and may also be reduced with SHABAN.

Clomid (איקקלומין)	This hormonal pill is often the first treatment given, and is used to regulate or induce ovulation. Doses range from 50 to 200 mg per day, and it is usually taken for 5 days. Depending on the diagnosis, Clomid may be used with either timed intercourse or IUI, and you may be sent for transvaginal ultrasounds to determine the growth of follicles (מעקב זקוקים) and width of uterine lining. You may also be prescribed Ovitrelle, an HCG injection to induce ovulation of a ripe follicle. It is not recommended to use clomid for more than 4 consecutive months, and after 6 months of unsuccessful pregnancy with Clomid, alternative options will be pursued. There is a 5%-8% chance of conceiving multiples with clomid.	Requires a prescription, and can be acquired at any pharmacy with an agreement with your kupah. Costs about 5 NIS for 10 pills (50 mg each). Ovitrelle also requires a prescription, and can be acquired at any pharmacy with and agreement with your kupah. Cost is about 25 NIS.
FSH Injections (Gonal-F) (זריקות גונל)	Internal ultrasound that may indicate PCOS, anovulatory cycles, or other ovarian abnormalities.	The hafnaya must be from a gynecologist or fertility specialist. Make an appointment through an ultrasound department that performs women’s ultrasounds. Co-pay of 34 NIS.
Follicle Tracking (מעקב זקיקים)	These hormonal injections are much stronger than clomid, and are self administered. It is important that the injection is given at the same time every day. Your doctor will determine the initial dosage, and will monitor follicular growth via blood test and ultrasounds. Dosage will be adjusted throughout the treatment until 1 or more healthy follicles are produced. If more than 3 follicles are produced, the cycle may be cancelled. Depending on the diagnosis, Gonal-F may be used with either timed intercourse or IUI. Once the desired number of follicles have matured, Ovitrelle will be administered to trigger the release of the follicles. If ovulation and/or pregnancy do not succeed within 4-6 months, your doctor may pursue other options for treatment. There is a 15%-30% chance of conceiving multiples when using FSH combined with timed intercourse or IUI.	Requires a prescription from a gynecologist or fertility specialist, and can only be acquired at your kupah pharmacy. Additionally, you must receive special approval to get coverage for this medication. This requires a letter from your treating doctor explaining why Gonal-F is needed and will be submitted through your kupah secretary. Approvals for Gonal-F are generally easy to obtain and are given for 3 months at a time, after which, they must be renewed. Cost depends on the number of vials and dosage required, but ranges from 120-250 NIS per vial. 1-3 vials may be required per cycle. Ovitrelle also requires a prescription and can be acquired at any pharmacy with an agreement with your kupah. Cost is about 25 NIS.
IUI (Intrauterine Insemination)	A semen sample will be collected and washed in lab in order to separate the semen from the fluid. The washed sample will be brought to the hospital or out-patient clinic, where it will be placed in a catheter and inserted through the woman’s cervix, uterus, and up towards the fallopian tubes. This treatment will be timed with the woman’s ovulation, by monitoring either her natural cycle, or hormonal follicle stimulation. After 3 unsuccessful cycles of IUI, most doctors recommend moving on to IVF.	A hafnaya and hitchayvut will be required for the man to retrieve his sperm sample in a lab. An additionally hafnaya and hitchayvut is then required for the woman for insemination to be done in the hospital.

IVF (In Vitro Fertilization)

In Vitro Fertilization (IVF), also referred to as artificial insemination, is the most advanced fertility method. The ovum is extracted from the woman’s body, and is fertilized with sperm cells under laboratory conditions. The newly formed embryo is then inserted into the womb while administering supportive hormonal treatment. IVF is fully covered by the kupot cholim (with relevant co-pays) for the first 2 live births. Those with SHABAN insurance can do IVF for additional children for an additional co-pay. Without SHABAN, those interested in IVF after 2 children must pay all expenses out of pocket.

Who is eligible?

Couples who do not have children from their current marriage.
Women who have exhausted all other fertility treatments (including multiple cycles of IUI).
Women over 39.
Women up to age 45 with their own eggs, and up to 54 with a donor egg.
Women with a diagnosis of a blocked fallopian tube, or other diagnoses where other fertility treatments are not possible.
Women without children who are interested in becoming a single parent (after 3-4 cycles of IUI).

Preparation For IVF:

Diagnostic tests to determine uterine health, semen samples, and genetic tests.
Blood test to rule out any potential harm to the fetus (such as Rubella, CMV, etc).
Baseline hormonal blood test.
Contraceptives: Your doctor may want the woman to use oral contraceptives in order to regulate her period before treatment begins.
Ishurim: You will need to get approval for IVF coverage from the kupah, and hitchayvuyot for the tests and hospital admission for egg retrieval and/or other procedures. To get initial approval, you must provide a letter from your fertility doctor explaining why IVF is the correct course of action at this point (because of your diagnosis, because other methods did not work, etc). You will submit this through the kupah secretary to receive approval for coverage.

Process of IVF:

The woman will begin hormonal treatment to stimulate her ovaries, and be closely monitored via blood tests and ultrasound.
Once multiple ova have reached maturity, the woman will be scheduled for egg extraction. This is done in the hospital under anesthesia. The woman can go home that day.
At the same time, the man will provide sperm.
Once the eggs have been extracted, fertilization is conducted in the laboratory..
After 3-5 days, if there are viable embryos, the embryo(s) will be inserted into the woman’s womb via a catheter. Remaining embryos may be frozen for later use.

Regulations on embryo transfer (as currently determined by Misrad Habriut):

In the first 3 treatments, up to 2 embryos may be transferred to the woman.
In no case may the number of embryos transferred exceed 4 embryos.
Transfer of more than 2 embryos may be considered in the following cases:

After 3 IVF treatments in which 2 embryos were transferred without a pregnancy.
After 2 unsuccessful transfers if the woman is over 35.
On the first transfer if the woman is over 41.

Preimplantation Genetic Diagnosis (PGD):

Genetic diagnosis to determine the genetic makeup of the embryo before implantation, that is meant for couples with a high risk of conceiving a child with a genetic disease/defect.
Gender selection for those families who have more than 4 children of the same gender and mental well being of one or both of the couple is at risk. Special approval by a committee is required.
For those women who are carriers of BRCA1 or 2 (the gene associated with breast/ovarian cancer) are eligible for subsidized PGD in Shaare Tzedek Medical Center.
See the complete list of approved PGD labs from The Ministry of Health.
Contact your kupah for information on coverage for PGD.

Limitations of IVF:

Following 4 consecutive unsuccessful embryo transfers (3 if over age 42), or after 8 IVF treatments that did not end in pregnancy, a committee must determine the reason for the lack of success, and what, if any, treatment should continue.
A woman may not undergo more than 10 IVF cycles in one year.

Additional Options

Sometimes, it is not possible to use both or either partners’ genetic material, or woman is physically unable to carry a pregnancy. In those cases, there are the following options:

Sperm Donation

A couple who are interested in receiving a sperm donation are required to contact a Sperm Bank which has been accredited by the Ministry of Health.
There are public sperm banks which operate from within hospitals as well as independent sperm banks.
The donation is anonymous.
There is an option to receive a sperm donation from a non-Jew overseas. In this case, the international sperm bank must also be accredited by The Ministry of Health and can be brought to Israel. he sperm donor can either be known or remain anonymous.

Egg Donation

A woman between the ages of 18-54 who has a medical reason where she can not use her own eggs or get pregnant, is eligible to receive an egg donation.
A formal application to receive an egg donation must be submitted to the IVF department, with a letter from your treating doctor.
The egg donor must gift the egg altruistically, and must be anonymous. (If the egg donor is known beforehand, they must apply through the Exceptions Committee).
There is a payment for receiving the egg implantation of 10,158 NIS, paid directly to the donor.
The couple must sign consent to have their information registered. If the couple is not married, that must sign an additional form of consent.

Egg Freezing

Women between the ages of 30-41 are entitled to freeze their eggs as a method of fertility preservation.
As of 2022, the kupah will cover egg freezing for women at risk of early menopause, or other medical factors, until the age of 39.
Those who are freezing eggs for non-medical reasons, or for any reason between the ages of 39-41 must pay out of pocket for the treatment.
Women are entitled to do egg freezing up to 4 times or until 20 eggs are collected. (There is an exception for Fragile-X carriers who may do up to 6 rounds of egg freezing or collect up to 40 eggs).
Currently, Meuhedet is the only kupah whose highest-level supplemental plan (Meuhedet C) offers discounts and partial coverage of egg freezing for non-medical reasons.

Surrogacy

Is an option in Israel if the woman can demonstrate that it is dangerous to her health to become pregnant. It requires government approval. Click here to read more about surrogacy.

Adoption- Click here to read about adoption through The Ministry of Labor & Social Services.

Employment Rights

Employees are entitled to be absent from work for fertility treatments if they have a written letter from the treating physician, and if they have informed the employer in advance.
Employees may be absent from work at the expense of his/her accrued sick days.
Regular sick day laws apply, unless a different agreement exists with your employer (such as full pay from the first day).
Female employees who work 5 days a week may be absent for up to 4 cycles per year, totaling 64 days per year, at the expense of her accrued sick days.
Female employees who work 6 days a week may be absent for up to 4 cycles per year, totaling 80 days per year, at the expense of her accrued sick days.
Male employees may be absent for up to 12 days per year, at the expense of his accrued sick days.
Employees can miss specific hours of work, without losing a full sick day, for up to 40 hours with full pay.
Government employees are entitled to an additional 2 days of absence per cycle for fertility treatments.
An employer may not fire or change the salary of an employee during the time he/she is undergoing fertility treatments, or up to 150 days after, without special dispensation.

Helpful Resources

Yad L’Olim Healthcare Division
Chen Patient Fertility Association
Kivunim - Information Center for Medical Rights
Bonei Olam
Puah Institute - Helping couples with fertility, medicine, and Jewish Law
Merkaz Panim
Keren Gefen

A Few Tips:

Get to know your secretaries: A relationship with the secretaries at the Women’s Health Clinics and Fertility Clinics in the hospital will help make the process run more smoothly. They’ll help you get ishurim, explain what documents you need, and help you get appointments.
Get to know your fertility nurses: These nurses will do your blood tests, help administer certain medications, and will sometimes advise you with how to proceed with your treatment.
Find a doctor you trust: Fertility treatments can be an extensive process, and open channels of communication with your treating fertility specialist is of the utmost importance. Some fertility doctors may even be willing to give out their cell phone number to make sure all your questions are answered.
Get to know your kupah’s local women’s/fertility clinic: Many time sensitive blood tests and ultrasounds must be done specifically at a merkaz briut haisha or fertility clinic. Reach out to your kupah to see which one is closest to you.
Find support: Undergoing fertility treatments can sometimes lead to anxiety and depression, as well as a general sense of isolation. We recommend finding a family member or friend to support you (in addition to your spouse, who is also dealing with his/her own challenging infertility experience). You may also want to seek professional help, and see a therapist through your kupah or privately.