Open Access

In Vitro fertilization (IVF) treatments in Maccabi Healthcare Services 2007-2014

  • Shahar Kol1Email author,
  • Lucia Bergovoy Yellin2,
  • Yaakov Segal1 and
  • Avi Porath1
Israel Journal of Health Policy Research20165:14

https://doi.org/10.1186/s13584-016-0072-9

Received: 17 December 2015

Accepted: 30 March 2016

Published: 8 April 2016

The Commentary to this article has been published in Israel Journal of Health Policy Research 2016 5:23

Abstract

Background

Israel reports the world’s highest IVF cycles per capita. However, clinical outcome data of these treatments are scarce. In a previous publication, we summarized IVF results among Maccabi Healthcare Services members for the years 2007-2010. The main findings included an increase in mean patients’ age over the period studied, a 50 % increase in cycle numbers during this time, and a decrease in success rate (live birth) from 18.8 % in 2007 to 14.8 % in 2010. The purpose of the current publication is to summarize IVF outcome for the years 2011-2014, and to explore possible changes in the trends we reported previously.

Methods

IVF and live births data were collected from Maccabi Healthcare Services’ fertility treatments registry. Analyses were conducted by treatment year and patients’ age at the initiation of treatment cycles. Autologous cycles, were included (ovum donation cycles and frozen-thaw cycles were excluded). A successful cycle was defined if a live birth was recorded within 10 months of its initiation.

Results

In accordance with previous data for the years 2007-2010, mean patients’ age continued to rise (from 36.2 in 2011 to 37.1 in 2014). In contrast to previous years, during which a continued increase in treatment cycles was recorded, we found that treatment number decreased from a peak of 9,751 in 2011 to 8,623 in 2014. Contrary to that trend, the number of patients over 40 years of age increased from 3,204 in 2011 to 3,648 in 2014. Success rate fluctuated between 14.4 % in 2014 to 16.4 % in 2013. The majority (78 %) of treatment cycles were conducted in four private medical centers.

Conclusions

The decrease in treatment cycles in recent years notwithstanding, Israel is still leading the world with IVF treatments relative to population. Success rate is relatively low compared to international data. Given the steady increase in patients’ mean age, and particularly, the increase in patients over 40 years of age, we maintain that the low success rate reflects a growing number of treatments that a priori have a low chance of success.

Keywords

In-vitro fertilization Assisted reproductive technology Maccabi Healthcare Services Israel Infertility registry

Background

The number of IVF cycles performed in Israel (relative to population size) is the highest in the world [1]. The main reason is the unprecedented Israeli IVF health basket, which provides practically unlimited IVF treatments to eligible infertility patients who are under 45 years old and have no more than two children, including single mothers [2]. While this policy was challenged by professional organizations, it seems that for many years politicians were reluctant to limit IVF treatments. Moreover, the Ministry of Health as the regulatory body stated in 2014 that given medical considerations, IVF treatment could be regarded as first line of treatment for patients over 39 years of age [3].. When professional considerations to stop treatments before the 45 year age limit were challenged in court [4], the judge decided in favor of the patient, stating that the maximal age for treatment (45) was decided based on medical considerations and the current medical literature. Of note, the pertinent professional body (The Israel Fertility Association) recommended lowering the upper age limit for IVF treatments.

The relative low “out of pocket” cost, and the high availability of IVF services in Israel [4] contributed to the popularity of IVF treatments. Currently, IVF services are available in all Israeli public medical centers (excluding Zefat, the 3 Nazareth medical centers and Eilat), in addition to four IVF units in private medical centers (Elisha, HMC, Assuta Tel Aviv and Assuta Rishon LeZion).

IVF activity is monitored by a long list of national and international organizations, most notably the Society for Assisted Reproductive Technologies (SART) [5] and the Centers for Disease Control and Prevention (CDC) (http://www.cdc.gov/art/reports/) in the United States, and the European Society for Human Reproduction and Embryology (ESHRE) in Europe [6]. Currently, an effort to establish an Israeli IVF registry is underway, though periodic comprehensive reports are not yet available. Professor Liat Lerner-Geva presented preliminary data on clinical pregnancy rate at the 2015 annual meeting of the Israel Fertility Association. The Ministry of Health publishes limited retrospective annual reports [7]. According to these reports available from 2000 to 2013, live birth rate per treatment cycles ranges between 14.9-17.2 %. These results fall significantly short of the reported live birth rate per treatment cycles as published by the above registries.

Previously, we summarized IVF results among Maccabi members for the years 2007-2010 [8]. The main findings included an increase in mean patients’ age over the period examined, a 50 % increase in cycle numbers during this period, and a decrease in success rate (live birth) from 18.8 % in 2007 to 14.8 % in 2010. The purpose of the current communication is to summarize the IVF outcomes for the years 2011-2014, to explore possible changes in the trends we reported previously, while deepening the analysis and exploring the policy implications of the findings.

Methods

Maccabi Healthcare Services is the second largest Health Maintenance Organization (HMO) in Israel covering 433,711 women in fertility ages (15-45) according to the National Insurance Institute report of November 2014 [9], or 25.7 % of the total fertility age population (1,687,873 women).

In an attempt to gain further insight on IVF activity in Israel, we analyzed data generated from the Maccabi Healthcare Services fertility treatment registry. The responsible HMO reimburses all IVF treatments for Israeli citizens (in public and private medical centers alike); therefore, reliable information is gathered on the number of cycles performed in all IVF units.

All IVF treatments of Maccabi members are routinely registered as part of the reimbursement system that serves the financial infrastructure to all treatments performed. Live birth is reimbursed by the National Insurance Institute of Israel, and therefore is not directly reported to the pertinent HMO. However, as a default, the newborn is registered to his/her mother’s HMO, generating a significant financial movement for the HMO (one more member). A cross-match between these two financial movements (paying the medical center for IVF and adding a new member to the HMO) can yield a good estimate (though not perfect) of live birth rate post IVF, if a live birth occurred within 10 months from the IVF treatment.

In the current publication we included “fresh” cycles, defined as ovarian stimulation + oocyte retrieval (“phase 1”) followed by fertilization and embryo transfer 2 – 6 days after oocyte retrieval (“phase 2”). We collected data on patients’ age on the day of IVF treatment, the specific medical center where treatment was given, and number of cycles performed in each medical center.

Data for 2011-2014 were collected and summarized in late September 2015; therefore, we assume that all pregnancies achieved in 2014 have ended by that time.

Results

Treatments and live birth rate

The 8 years surveyed can be divided into 2 periods: A steady increase in the number of treatments from 2007 (6,242 treatments) to a peak in 2011 (9,751 treatments), and a moderate decrease in treatments thereafter. Live birth rate decreased from 18.9 % in 2007 to 14.4 % in 2014 (Table 1).
Table 1

Number of IVF treatments performed, number of live births achieved from these treatments, and success rate by year (2007-2014)

Year

Number of patients

Number of treatments

Number of live births

Cycles/patient

Live birth/cycle

Live birth/patient

2007

4,061

6,242

1,182

1.54

18.9 %

29.1 %

2008

4,410

7,041

1,295

1.60

18.4 %

29.4 %

2009

4,867

8,336

1,356

1.71

16.3 %

27.9 %

2010

5,282

9,297

1,384

1.76

14.9 %

26.2 %

2011

5,479

9,751

1,429

1.78

14.7 %

27.9 %

2012

5,375

9,314

1,438

1.73

15.4 %

26.7 %

2013

5,360

8,455

1,386

1.58

16.4 %

25.9 %

2014

5,577

8,623

1,238

1.55

14.4 %

22.2 %

Total

40,411

67,059

10,708

1.66

16.0 %

26.5 %

Treatments and live birth rate according to patients’ age groups

From 2011 to 2014, a steady decrease was noted in the treatments performed in the younger age groups (25-39), with a parallel steady increase in the 40-45 age group. A sharp decrease in live birth was noted for patients over 40 years of age (Table 2, Fig. 1).
Table 2

Number of IVF treatments and success rate by year (2011-2014) and age group

Year

Age group

Number of treatments

Number of live births

Success rate [%]

Distribution by age

2011

15-19

4

0

0

0.0 %

20-24

226

56

24.8

2.3 %

25-29

1,086

277

25.5

11.2 %

30-34

2,104

449

21.3

21.7 %

35-39

3,082

479

15.5

31.8 %

40-45

3,204

168

5.2

33.0 %

2012

15-19

7

2

28.6

0.1 %

20-24

187

49

26.2

2.0 %

25-29

947

273

28.8

10.2 %

30-34

1,905

437

22.9

20.5 %

35-39

2,772

468

16.9

29.9 %

40-45

3,466

209

6.0

37.3 %

2013

15-19

4

0

0.0

0.0 %

20-24

188

45

23.9

2.2 %

25-29

832

235

28.2

9.9 %

30-34

1,657

452

27.3

19.7 %

35-39

2,470

425

17.2

29.3 %

40-45

3,271

228

7.0

38.8 %

2014

15-19

4

0

0.0

0.0 %

20-24

184

52

28.3

2.1 %

25-29

804

203

25.2

9.4 %

30-34

1,547

380

24.6

18.0 %

35-39

2,411

386

16.0

28.0 %

40-45

3,648

217

5.9

42.4 %

Fig. 1

Age distribution of cycles by year, 2011-2014

Mean patients’ age

A steady increase in patients’ mean age was documented from 2007 (35.1) to 2014 (37.1).

Mean patients’ age by type of medical center

From 2007 to 2014, 16,004 and 51,055 treatments were performed in public and private medical centers, respectively. Patients’ mean age was 35.5 and 36.5 in public and private medical centers, respectively (Table 3).
Table 3

Mean age of IVF patients by medical center type (public/private), 2011-2014

Medical center type

Mean age

Number of treatments

Public

35.46

16,004

Private

36.50

51,055

Total

36.25

67,059

Detailed outcome for the 40-45 age group

In all the years surveyed, a steady decrease in live birth rate was noted from age 40 to 44. Two thousand two hundred and three treatments were performed in women 44 years of age from 2011 to 2014, yielding 35 live births (1.6 %). (Table 4).
Table 4

Number of IVF treatments and success rates for women ≥40 year old age group, by year (2011-204) and age

Year

Age

Number of treatments

Number of live births

Success rate [%]

2011

Total

3,204

168

5.2

40

660

68

10.3

41

736

38

5.2

42

716

31

4.3

43

555

21

3.8

44

537

10

1.9

2012

Total

3,466

209

6.0

40

716

89

12.4

41

789

52

6.6

42

741

37

5.0

43

649

21

3.2

44

571

10

1.8

2013

Total

3,271

228

7.0

40

635

74

11.7

41

757

72

9.5

42

736

57

7.7

43

599

20

3.3

44

544

5

0.9

2014

Total

3,648

217

5.9

40

781

77

9.9

41

855

59

6.9

42

759

43

5.7

43

702

28

4.0

44

551

10

1.8

Live birth rate by medical center

Since outcome of a small number of treatments has limited statistical significance, we decided to include medical centers with >100 treatments per year in the analysis. There are significant changes in success rate between medical centers, and significant changes within the same medical center during the 4 years surveyed (Tables 5 and 6).
Table 5

Number of IVF treatments and success rate, by year (2011-2012) and medical center (only medical centers with ≥100 cycles per given year were included)

Year

Medical centera

Number of treatments

Number of live births

Success [%]

2011

Total

9,751

1,429

14.7

A

914

93

10.2

B

561

40

7.1

C

673

114

16.9

D

1,958

387

19.8

E

3,908

502

12.8

F

223

49

22.0

G

120

24

20.0

H

307

48

15.6

I

161

40

24.8

J

303

18

5.9

K

170

37

21.8

2012

Total

9,314

1,438

15.4

A

889

101

11.4

B

420

44

10.5

C

637

112

17.6

D

1,988

371

18.7

E

3,574

522

14.6

F

248

42

16.9

G

109

25

22.9

H

321

48

15.0

I

152

34

22.4

J

346

37

10.7

K

189

28

14.8

aMedical center: in order to protect the confidential information, the names of the medical centers were recoded into random letters

Table 6

Number of IVF treatments and success rate, by year (2013-2014) and medical center (only medical centers with ≥100 cycles per given year were included)

Year

Medical centera

Number of treatments

Number of live births

Success [%]

2013

Total

8,455

1,386

16.4

A

809

123

15.2

B

250

29

11.6

C

448

94

21.0

D

1,851

347

18.7

E

3,262

505

15.5

F

231

40

17.3

G

105

21

20.0

H

291

53

18.2

I

156

27

17.3

J

290

40

13.8

K

184

21

11.4

L

149

22

14.8

2014

Total

8,623

1,238

14.4

A

1,136

176

15.5

B

268

27

10.1

C

459

75

16.3

D

1,957

352

18.0

E

2,877

347

12.1

F

187

37

19.8

G

115

18

15.7

H

195

26

13.3

I

178

36

20.2

J

312

39

12.5

K

262

26

9.9

L

188

33

17.6

aMedical center: in order to protect the confidential information, the names of the medical centers were recoded into random letters

Treatment distribution between public and private medical centers

In 2007, 2,401 and 5,896 treatments were performed in public and private medical centers, respectively. Treatments in public medical centers increased marginally from 2007 to 2014 (2,618 treatments in 2014, a 9 % increase). Treatments in private medical centers increased significantly from 2007 to 2014 (9,211 treatments in 2014, a 56 % increase) (Fig. 2).
Fig. 2

IVF Treatments distribution between public and private medical centers, by year for 2007-2014

Discussion and conclusions

In the current publication, we update a previous report [8], and present an eight-year summary of IVF treatments in Maccabi Healthcare Services. Since Maccabi covers approximately 25 % of the population in Israel, the data herein reliably represent the total IVF activity in Israel. We report a modest decrease in treatment cycles in recent years. The Israeli success rate is low compared to international data (http://www.cdc.gov/art/reports/) [5, 6]. Of note is a steady increase in patients’ mean age, and particularly, an increase in patients greater than 40 years old. While both live birth per cycle and per patient show a steady decline from 2007 through 2014, there is a marked decrease in the number of cycles per patient from the peak in 2011, suggesting possible changes in practice.

The health policy decisions that culminated in an unprecedented coverage of IVF treatments in Israel reflect societal and political considerations, as opposed to pure professional, evidence-based considerations. Naturally, these health policy decisions have a significant price tag. Updated in 01-September-2015, according to the Ministry of Health, an IVF treatment reimbursement costs 12,000 NIS [10]. We report herein that 2,203 treatments (26,436,000 NIS) were performed in women 44 years of age from 2011 to 2014, yielding 35 live births. The cost of a single live birth in that age group was 755,314 NIS (not including fertility medications supplied by Maccabi).

Previous efforts of professional organizations (most notably The Israel Fertility Association – IFA) to divert resources in a more cost effective way (i.e. ovum donation) have failed. Moreover, previous professionally based guidelines by the Ministry of Health itself to minimize futile treatments were not implemented. Although in 1999, such guidelines were adopted (http://www.ayala.org.il/?CategoryID=239&ArticleID=77) based on recommendations made by a professional committee, nominated by the Minister of Health, the guidelines are not currently implemented. Moreover, a timely update was not published. Given current IVF health policy, the practice of IVF shifted from a medical treatment bearing indications and contra-indications, into a social, age-related right [11]. This shift was fully endorsed by the legal system [12].

Economic costs of IVF treatments have a significant impact on the Israeli HMO’s finances. A survey conducted in Maccabi in 2006 found that 5.4 % of health expenditures for women related to fertility treatments, more than was spent on diabetes (3.5 %) and comparable to expenditures on cardiovascular diseases (5.9 %) [13].

Naturally, IVF health policy raises significant ethical considerations. The Israel Fertility Association ethical committee published its position regarding futile IVF treatments in February 2015 [14]. The committee defined a “futile treatment” as a treatment in which the chance for live birth is <1 %, and strongly denounced performing such treatment. Yet, experience shows that these considerations are defeated when challenged.

In the current publication, we detail the live birth rate achieved in different medical centers. These data must be interpreted with caution given the lack of pertinent individual clinical information i.e. indications, number of oocytes retrieved, number of embryos obtained and their quality, previous IVF failures, usage of specific technologies (pre-implantation genetic diagnosis, testicular sperm extraction, in-vitro maturation etc.). We speculate that units differ significantly as to their patients’ treatment prognosis. In addition, some units impose a 44-age limit, though, as mentioned above, the IVF national health basket covers women until 45 years of age. Notably, the number of treatments performed in “Clalit” public medical centers is low; therefore, these units are under-represented in our data.

According to the Ministry of Health, 39,174 IVF cycles were performed in 2013 [7], with a live birth rate of 15.7 % (comparable to our data of 16.4 % for that year). According to the CDC (http://www.cdc.gov/art/reports/) 163,212 cycles were performed in the US in the same year with a live birth rate of 33 %. In our opinion, this comparison highlights the fundamental problem that erodes IVF clinical outcomes in Israel: Too many cycles are performed despite a very slim chance of success.

IVF health-related policy is a subject of public and professional debate, in which the question of resource allocation should be thoroughly and openly discussed. As pointed out previously [15], the existing policy of assisted reproduction in Israel, that is, of unlimited rounds with IVF, should be further questioned and assessed. Possible conclusions of such an assessment may be that IVF treatments should cease before 45 years of age, and/or limiting treatment number for an individual patient.

Notes

Declarations

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Maccabi Healthcare Services
(2)
Department of Health Services Research at Chief Physician Office of Maccabi Healthcare Services

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Copyright

© Kol et al. 2016

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