Israel is the leading country in terms of the number of medical tests conducted during pregnancy, specifically aimed at ensuring the best possible outcome for newborns. This was discussed by four prominent experts at the Ynet and Yedioth Ahronoth health conference where they shared insights on the various tests, stages, technologies and controversies within the field.
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"In Israel, we observe two extremes - there is a population that surpasses all others worldwide in the scope of medical tests during pregnancy," emphasizes Prof. Roni Maimon, director of the women's and obstetrics department at the Shamir Medical Center and chairman of the Israeli Association of Obstetrics and Gynecology.
"This population undergoes an extensive range of ultrasound examinations, sound tests throughout pregnancy, MRI tests, fetal echocardiograms and, of course, genetic tests - services that are not as widely available in many other countries. The individuals within this group have a strong desire for a perfect child, and in this particular domain, Israel unquestionably leads the way, setting the standard for others to follow.
"On the other end of the spectrum, there are populations that, due to ideological reasons rooted in religion and belief, choose not to partake in these advancements even when the technology is readily available to them," Prof. Roni Maimon explains.
"They consciously opt out of this process. As a medical community, we must address and accommodate both these groups - those who prefer not to seek certain knowledge and remain outside the realm of comprehensive information, as well as those who eagerly embrace and make use of all available resources. This duality presents our challenge."
Where do you draw the line?
"There is no line. The ethical considerations, the scientific advancements, and the dilemmas they pose shape our decisions, and we continuously adjust our stance in accordance with a substantial portion of these factors.
"In practice, we often find ourselves stating 'up to this point' as our limit, but as time progresses, we push beyond that limit and set new boundaries. For instance, currently, we don't routinely offer oncogenetic tests, nor do we explore the possibilities of assessing conditions beyond childhood, but these developments are right at our doorstep."
What happens when expecting parents find out the fetus has a genetic defect?
"There exists a notable disparity between Israel and other countries. In Israel, it is legally permissible to terminate a pregnancy in cases where the fetus is afflicted with genetic or morphological abnormalities," clarifies Prof. Tal Biron-Shental, director of the Department of Women and Maternity at the Meir Medical Center.
"There are couples with whom we don't broach the topic at all because it is irrelevant to them; they have no desire to delve into it, and we respect their choice. We would never impose an abortion on anyone. On the other hand, there are couples who are deeply invested in pursuing the path toward having a 'perfect' child.
They are willing to take any measures necessary to ensure the birth of a healthy baby, even if it means facing various uncertainties and complexities that arise during the process, leading to extensive consultations and, at times, pregnancy terminations. Throughout the monitoring of pregnancies, numerous dilemmas arise.
"At times, we encounter unequivocal test results, but frequently, both in genetic testing and ultrasounds, we encounter tests that are not definitive, making it challenging to predict the precise health or medical condition of the baby upon diagnosis. As a result, the ultimate decision lies with each individual woman, granting her the autonomy to choose what she believes is best for herself.
"Our responsibility is to convey the medical information in a manner that can be comprehended by our patients, even those without a medical, scientific, or biological background. We strive to use language that allows anyone to grasp the essence of the information and make informed decisions tailored to their unique circumstances."
A resurgence of in vitro fertilization
In the realm of fertility treatments, modern medicine now offers solutions and opportunities previously nonexistent. Prof. Roni Maimon elaborates, "Fertility preservation, a widely recognized concept in today's public discourse, along with treatments for same-sex couples, surrogacy, sperm donation, and egg donation - all of these paths lead us in directions that were previously uncharted.
"Throughout my professional career, I have witnessed these developments unfolding before my very eyes, alongside the emergence of 'medical tourism,' where individuals travel abroad to various destinations worldwide in pursuit of parenthood. These advancements undoubtedly push the boundaries in all aspects."
"Numerically speaking, their contribution may not be substantial, as fertility treatment children account for only 5-7% of all births in Israel. However, each child represents an entire world, and the efforts made to bring them into existence are significant individual stories," he adds.
"In recent years, we have witnessed significant technological advancements in fertility preservation," emphasizes Prof. Machtinger, a senior physician in the in vitro fertilization unit at Sheba Medical Center. He elaborates, "Eggs are formed while a woman is still a fetus inside her mother's womb, and unlike sperm, which renews itself every 80-90 days, a woman is born with a finite reserve of eggs that gradually decreases in both quantity and quality over time.
"The decline in a woman's fertility becomes noticeable after the age of 35 and even more so after the age of 40, leading to a substantial decrease. Presently, we have the means and opportunities to provide women who may not be suitable for conception, especially those aged over 30, with the option of fertility preservation.
"Fertility preservation entails undergoing in vitro fertilization procedures for a comprehensive approach. The Ministry of Health has approved performing 5-6 cycles and freezing between 25 and 35 eggs, depending on the woman's age. This volume is comparable to the numbers we encounter in IVF treatments. In fact, around 30% of individuals reaching out to us express interest in fertility preservation," he notes.
"We face limitations concerning infrastructure. Although we are fortunate to have outstanding public facilities, they are operating at full capacity, leading to waiting periods of two to seven months for women seeking treatment," explains Prof. Machtinger.
"The decrease in private facilities exacerbates the situation, impacting a substantial portion of women who find themselves in prolonged waiting periods. For a 27-year-old woman, this can be distressing and painful to endure, particularly when she has embarked on the journey of motherhood. However, for a 38 or 41-year-old woman, waiting for seven months can significantly impact the chances of success in fertility treatments."
"With technological advancements, there have been notable developments in knowledge and awareness," points out Prof. Tal Biron-Shental. "Over the years, birth mothers themselves have undergone significant changes. In the past, they were often very young and less informed, lacking easy accessibility to medical information. Today, every patient holds a wealth of information at their fingertips, readily available through smartphones and other means. While some of this information is accurate, not all of it can be trusted. Nevertheless, patients now have tremendous access to information.
"Furthermore, from a socio-epidemiological perspective, there has been a shift in the age at which women choose to pursue pregnancy. Many prioritize their careers and education first, leading them to approach family planning later in life. As previously mentioned, this shift often coincides with a decline in reproductive productivity, which puts additional strain on fertility clinics and may prompt some women to consider fertility preservation.
"This combination of women who are increasingly self-aware, have access to medical knowledge, and actively participate in their treatment, which is indeed positive, necessitates a different approach in preparing our health system. It requires significantly more time, for instance, for doctors to engage with their patients.
"However, this presents a significant challenge due to the widespread shortage of doctors across Israel and the limited time available for doctors to spend with each patient. The allocated time often falls short in allowing comprehensive discussions of all options and providing the necessary information to make patients genuine partners in their medical decisions.
"We firmly believe that patients should receive complete information and actively participate in decision-making; this is a legitimate expectation of today's generation, and we support it wholeheartedly. To fulfill this vision, our healthcare system must be adequately equipped with sufficient resources.
"This will enable us to deliver reliable information, have meaningful sit-downs with patients, and engage in thorough discussions, fostering a collaborative approach to healthcare decision-making. Patients' desire for this level of involvement is entirely justified, and we share the same goal."