In Vitro Fertilization IVF & ICSI

Fertility problems and the clear process

A fertility problem is defined as failure to achieve pregnancy after a year of unprotected sexual intercourse.
About 15% of all couples may suffer from fertility problems. In order to clarify the problem, a diagnosis will be made on both partners at the same time.

The process of clarification for the woman:

Relevant laboratory tests

Ultrasound examination of the uterus and ovaries

physical examination

Medical history review

The process of clarifying the mechanical cause

Infertility due to a mechanical problem means an anatomical disorder in the pelvis that prevents the sperm and egg from meeting, or prevents the embryo from implanting.
Pelvic adhesions and blocked fallopian tubes are examples of such an anatomical disorder.
Pelvic adhesions are most often caused by past infections or surgeries for the following reasons: ectopic pregnancy, ovarian cysts, cesarean sections, or fibroid removal. A condition called endometriosis, in which pockets of endometrial cells are found outside the uterus, is a common cause of pelvic adhesions and mechanical infertility.

The following tests may help diagnose the mechanical problem:

A picture of a uterus

The test is performed in an X-ray center under mirroring. During the test, a contrast agent is injected that fills the uterine cavity and, if there is no blockage in the fallopian tubes, the agent passes through them into the pelvis.

Sono-HSG

The sonohysterosalpingography test is performed by instilling physiological water (saline) or a special foam into the uterine cavity and through the fallopian tubes.
Filling the uterine cavity with fluid allows for optimal visualization of the cavity, very similar to that obtained with hysteroscopy, and allows for the detection of intrauterine findings such as adhesions and polyps.
The advanced approach also incorporates 3D uterine imaging, which allows for the detection of congenital uterine defects (septums, bicornuate uterus, fibroids, etc.). Part of the examination includes an ultrasound examination aimed at imaging the ovaries in order to diagnose abnormal findings there.
The test does not involve the injection of contrast material, making it suitable for women who are sensitive to iodine or fish. Also, there is no exposure of the test subject to radiation. The main advantage of the test is that the test is almost painless.

Diagnostic hysteroscopy

Direct viewing of the uterine cavity using an optical fiber connected to a camera and screen. A normal cavity is defined as one that does not contain any findings such as polyps, fibroids, septa, or adhesions that may reduce the chances of the fertilized egg implanting in the uterine lining. During the procedure, gas or liquid is introduced into the uterine cavity to spread the walls apart and better visualize the uterine cavity. This procedure is performed without anesthesia or under brief general anesthesia.

Surgical hysteroscopy

It is performed in cases where a problem has been diagnosed in the uterine cavity that requires surgical treatment. This procedure is usually performed under anesthesia in an operating room.

Laparoscopy

A surgical procedure performed under general anesthesia in an operating room. After the abdomen is inflated with air, an optical fiber connected to a camera and a screen is inserted into the abdominal cavity through a small hole in the navel area. This examination allows direct visualization of the pelvic organs: uterus, fallopian tubes, and ovaries and/or other pathologies that may affect fertility. In cases where a problem that can be corrected/treated is found, additional sleeves are inserted into the abdominal cavity through which medical equipment used to perform the surgery can be passed.

The clarification process for men:

The medical history is clear

physical examination

Relevant laboratory tests

Semen test and, if necessary, hormonal tests

In some cases of abnormal semen analysis, an ultrasound of the testicles may be performed to rule out a condition called varicocele.

The sperm test

The semen analysis report includes various indicators related to sperm health. The main ones are concentration, motility, and morphology. The results of the semen analysis will dictate the further course of treatment.
During the consultation meeting with Dr. Shlomi Barak, a discussion takes place regarding the clear results of male fertility and a decision is made regarding the continuation of treatment.

Additional activities at the clinic

Freezing eggs and embryos for fertility preservation

Egg or embryo freezing is done for two main reasons:

medical reason

When a medical condition is discovered that may impair ovarian reserve and future fertility, it is recommended to perform fertility preservation – which includes extracting eggs and freezing them, or creating embryos from them and freezing them, for future use when necessary.

choice

In 2011, a law was passed in Israel allowing women aged 30-41 without a partner to undergo in vitro fertilization treatments for the purpose of extracting eggs and freezing them before fertilization for future use.
It is worth remembering that freezing eggs for fertility preservation does not guarantee the survival of the eggs after thawing or achieving pregnancy. The quality and quantity of eggs decline with age, so it is recommended, if possible, not to postpone the issue of family planning.

People

In this process, a deliberate “scratching” of the uterine lining is performed before treatment begins.
The assumption is that a healthy and normal uterine muscle will respond to a scratch (a kind of small scrape) by infusing blood with self-healing substances into the scratched area. Through this action, we may improve the mucosa’s ability to absorb the embryos before the embryo transfer stage.
The decision to perform this operation will be made based on the medical data.

Preimplantation genetic testing

PGD Preimplantation Genetic Diagnosis – PGT-M
PGS Preimplantation Genetic Screening – PGT-A

An operation in which a biopsy is performed on an embryo of approximately 8 cells (day 3 after aspiration) or a blastocyst (5-6 day old embryo) and a sample of one cell of the embryo or a group of cells is taken. The sample is sent for genetic testing and only a healthy embryo is returned to the uterus.
This procedure is performed, among other things, in couples with a specific genetic/chromosomal problem/after implantation failures/repeated miscarriages.

before starting treatment

Before starting treatment, all relevant laboratory tests and an expanded pre-pregnancy genetic screening must be performed (referral forms will be provided at the clinic).
All administrative procedures must be arranged, such as: a commitment form from the health insurance company or the insurer (we will assist you with this), a parenting agreement signed by a notary attorney for an unmarried couple, a consent form for IVF treatments signed by both spouses, prescriptions and additional forms as needed.
You must purchase the medications needed for treatment in advance and ensure that you have all the prescriptions needed for continued treatment.
A man who is a candidate for sperm retrieval surgery will undergo all the tests necessary for the operation.
When opening the file at the clinic, you will be asked to sign informed consent forms relevant to the procedure you are scheduled to undergo.
The clinic staff will guide you regarding the treatment plan and verify the validity of your general tests. If any test or form is missing, you will be asked to complete it before the start of treatment in order not to delay the start of treatment.

the beginning of treatment

After completing all the required tests for both partners, Dr. Shlomi Barak will determine the appropriate treatment protocol and medications and their dosage according to the medical data, the woman's age, the cause of infertility, or the quality of the response to previous treatments.
Starting treatment during the ovulation induction phase is intended to obtain multiple eggs per treatment cycle (as opposed to one egg in a natural cycle). To this end, hormonal stimulation is given that recruits multiple follicles in the ovary.
The daily dose of injections is adjusted based on monitoring of hormonal and ultrasound tests and according to the ovarian response to treatment. In addition, medications are combined to prevent premature ovulation and egg loss.
When the data on the thickness of the endometrium, the size of the follicles, and the hormonal levels indicate the existence of mature follicles, an injection based on the hormone HCG (Obitrel) or Decapeptyl is given. In order to bring about the final maturation of the egg in the follicle. This injection is given 34-35 hours before the extraction.
There may be situations in which Dr. Barak will choose to perform a single egg retrieval in a natural cycle without hormonal stimulation. This treatment is called NATURAL CYCLE, and is intended primarily for women who respond less well to hormonal stimulation, have a low ovarian reserve, older women, and women with multiple failures.
In cases of inappropriate ovarian response or concern for premature ovulation, the treatment cycle may be canceled and no aspiration will be performed.

As a general rule, there is no prohibition against having sex during treatment unless otherwise recommended.

Fertility drugs/drug treatment

A wide variety of medications are used for in vitro fertilization treatments.

Medications that stimulate the ovaries to create follicles

Gonadotropins (sex hormones)

Manofor, Purigone, Gonal F, Pregobris. These medications act directly on the follicles in the ovaries. The goal of the medications is to recruit a number of follicles in the ovaries while trying to avoid an overreaction that leads to the development of ovarian hyperstimulation syndrome. The medications are administered under the guidance of Dr. Barak by subcutaneous injection in the abdominal area, which allows self-injection by the patient.

Some medications come in dedicated “injection pens” and some come in ampoules that contain a powder of the active ingredient and a liquid that is used to dissolve the powder. The clinic will provide personal guidance on how to use the medications relevant to you before starting treatment.

Antiestrogens

Clomiphene, letrozole. They are given in pills and act indirectly on follicle development.

Medications that prevent premature ovulation

The drugs cause a temporary and reversible inhibition of the hormone GnRH, which is responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland. Thus, these drugs prevent premature ovulation before egg retrieval. The drugs used in Israel are Decapeptyl, Superfect, and Synarel from the group of drugs that are similar to GnRH (agonists) or Cetrotide and Orglutran – from the group of drugs that oppose GnRH (antagonists). Some of the drugs are given by subcutaneous injection and some by nasal spray.

Medications to induce ovulation

Obitrel and Decaptil, which aim to time ovulation during treatment, are given by injection between 34-35 hours before egg retrieval.

Medications that support the uterine lining in preparation for implantation

These medications contain the hormone progesterone and are given after egg retrieval. They are administered directly into the vagina in the form of tablets/gel (Endometrin/Utrogestan/Crinon) or by intramuscular injection (Prontogest/Progesterone Retard/Gaston) or taken orally using pills (Duphaston).
Sometimes tablets or patches containing the hormone estrogen (Avorel, Estropam) are also used.

Information about fertility drugs

the name of the medicine	active ingredient	Mode of administration	Common side effects	comments
Decapeptide 3.75	triptorlin	intramuscularly	Hot flashes, redness on the skin, headaches, irritability, sleep disturbances
Decaptil 0.1	triptorlin	subcutaneous	With prolonged treatment, hot flashes, vaginal dryness, and decreased libido may occur.
General	Naperlin	nasal spray	Hot flashes, vaginal dryness, acne, muscle pain, joint pain, nasal mucosa irritation, headaches, mood changes, difficulty sleeping, depression.
Cetrotide	Cetrullix	subcutaneous	Mild local reactions at the injection site: redness, itching and swelling. Nausea, feeling sick, headache.
Orglutran	Generics	subcutaneous	Mild local reactions at the injection site: redness, itching and swelling. Nausea, feeling sick, headache.
Gonell F	Polytrophin alfa	subcutaneous	Injection pen Headache, nausea, redness and swelling at the injection site, widespread rash and itching.	Injection pen Available in doses of 300/450/900
Furygon	Polytrophin beta	subcutaneous	Headache, nausea, redness and swelling at the injection site, widespread rash and itching.	Pen for injection. Insert cartridge into pen Available in doses of 300/600/900
Pergobris	Polytropin alfa, lutropin alfa	subcutaneous	Headache, nausea, redness and swelling at the injection site, widespread rash and itching.	injection pen
Manopur	Menotropin	subcutaneous	Headache, nausea, redness and swelling at the injection site, widespread rash and itching.	The powder is the active ingredient. Available in doses of 600/1200
Obitral/Pregnyl	Choriogonadotropin	subcutaneous	Fatigue, pain and local reaction at the injection site, lower abdominal pain, nausea, and headache.	It is usually given 34-36 hours before pumping. It is sometimes also given as support after pumping.
Endometrin	Progesterone	vaginal	Acne, vaginitis, nausea, drowsiness, headaches, changes in appetite and weight, breast tenderness, depression, nighttime urination, swelling in the legs.	White watery vaginal discharge You should lie down for about half an hour after insertion
Crinon	Progesterone	vaginal	Acne, vaginitis, nausea, drowsiness, headaches, changes in appetite and weight, breast tenderness, depression, nighttime urination, swelling in the legs. With prolonged use, small, brown, wax-like lumps are released from the vagina.	After inserting the medicine, it is recommended to move around so that the gel spreads throughout the vagina.
Utrogestan	Progesterone	vaginal	Acne, vaginitis, nausea, drowsiness, headaches, changes in appetite and weight, breast tenderness, depression, nighttime urination, swelling in the legs.
Dopestone	Progesterone	oral
Frontegest	Progesterone	Intramuscular injection
Progesterone retard	Progesterone	Intramuscular injection
Proginova	Estradiol	oral	Headaches, depression, breast pain, nausea, stomach pain, loss of appetite
Astrophem	Estradiol	Oral/vaginal	Headaches, depression, breast pain, nausea, stomach pain, loss of appetite

Side effects from hormone therapy

As mentioned, the purpose of hormonal treatment given to a woman is to induce ovulation in cases where the woman does not ovulate or to allow for the recruitment of more eggs, thereby increasing the chances of pregnancy. The side effects and complications of hormonal treatment include, among others:

Sensitivity to hormonal preparations - rare, but in any case of an unusual phenomenon - the clinic staff should be informed as soon as possible.
Multiple pregnancy - Multiple pregnancy is a consequence of the number of embryos transferred to the uterus. The rate of multiple pregnancies (twins and triplets) in hormonal treatments is relatively high (up to 30%) depending on the type of treatment. Multiple pregnancies are associated with a higher incidence of gestational hypertension, gestational diabetes, preterm labor and premature birth, and consequently complications of prematurity.
Miscarriages and ectopic pregnancies - In pregnancies conceived after ovulation, there is a certain increase in the incidence of miscarriages and ectopic pregnancies.
Ovarian torsion, rupture, or bleeding from the ovary - are relatively rare, but sometimes require surgical intervention.
Additional complications - To date, no causal link has been proven between ovulation induction and ovarian cancer. Pregnancy is known to help reduce the incidence of malignant ovarian tumors. Following treatments given for various fertility problems, a slight increase (1-2%) in the incidence of birth defects or genetic disorders is reported. This may be due to the cause of infertility itself and not necessarily the treatments.

Ovarian hyperstimulation syndrome is a complication of ovulation induction treatments, characterized by significant enlargement of the ovaries and the release of fluid from the blood vessels and its accumulation in various body cavities.

Signs and symptoms of ovarian hyperstimulation syndrome:

Ovarian hyperstimulation syndrome has a wide range of clinical manifestations, which are characterized by two main phenomena: (a) significant enlargement of the ovaries resulting from the effect of hormones on significant recruitment of follicles in the ovaries and (b) increased permeability of membranes and blood vessels, which causes fluid to leak out of the blood vessels and their accumulation in the third compartment cavities (abdominal cavity, chest cavity, heart and subcutaneous tissue). This fluid transfer is actually responsible for the morbidity associated with the syndrome. Following the transport of fluids from the intravascular compartment to the third compartment cavities, there is a decrease in the volume of fluid within the blood vessels, which is expressed in both an increase in viscosity and blood clotting, phenomena that may lead to excessive clotting. In addition, there may be disturbances in the balance of fluids and salts in the body, a decrease in urination and even kidney failure.
Ovarian hyperstimulation is most often manifested by bloating and abdominal pain, the development of ovarian cysts, ovarian enlargement, and even a slight accumulation of fluid in the abdomen.
Usually, the symptoms go away with rest and plenty of fluids. The incidence of mild ovarian hyperstimulation is 10%-25%. Moderate or severe hyperstimulation is rarer and usually requires hospitalization. Moderate stimulation also includes the appearance of nausea, diarrhea, and vomiting, and the incidence of its appearance is 5%-15%. Severe hyperstimulation, in addition to the above symptoms, also includes shortness of breath and the accumulation of excessive fluid in the abdominal cavity, chest, and heart, which requires sometimes abdominal acupuncture is repeated to drain the fluid. The fluid leaking into the cavities may also cause embolism. Other rare complications include heart failure, kidney failure, and even life-threatening complications. The incidence of severe ovarian hyperstimulation is 0.1%-5%. The severity of the phenomenon may lead to discontinuation of treatment.

before pumping

Make sure that all necessary tests and forms (informed consents) have been completed.
If donor sperm transfer from the sperm bank is required, we recommend that it be performed a week before the extraction in order not to delay the process.
It is recommended to purchase all the medications required for continued treatment (support).
The day after the administration of HCG (Obitrel) / Decaptil is a day without any medication.
The clinic team will invite you to perform the procedure at Assuta Rishon LeZion. The egg extraction is performed approximately 35 hours after the date of receipt of HCG (Obitrel) / Decaptil

pumping day

Egg retrieval is performed under general anesthesia, except in rare cases, so the patient must be completely fasting for at least 6 hours (eating, drinking, chewing gum, and smoking should be avoided).
The extraction is done under the guidance of a vaginal ultrasound transducer. Immediately after the extraction, the follicular fluid is transferred to the laboratory, and upon the patient's awakening from anesthesia, the number of eggs retrieved is known in real time.
Since egg retrieval is an invasive procedure, complications may occur very rarely, such as rupture of the ovary, damage to a blood vessel, bladder, or intestine, which in rare cases will require surgical intervention.

Instructions to the spouse

The partner must bring the sperm sample with an ID card for identification purposes.
Semen will be collected in a sterile container only (a sterile cup designed for urine culture, available at any pharmacy/health insurance company). Before delivering the cup to the laboratory, make sure that a sticker with the exact details of both partners is attached to it.
It is advisable to give the semen sample at home and bring it to the unit within an hour and a half to two hours of the time of administration. Alternatively, a semen sample can be given at the unit in a room designated for this purpose.
Wash your hands and genitals before giving semen.
Do not use soap or other lubricants other than baby oil/paraffin. Be careful not to get the oil into the sterile container.
Do not heat or cool the seed dose. Keep the cup at room temperature and in a shaded place.
It is advisable to avoid intercourse during the two days before sperm donation (or according to the clinic's instructions).

after pumping

After the extraction, the patient will remain under observation for about one to two hours. Egg extraction may involve some pain, light vaginal bleeding, and pressure in the lower abdomen. If you notice that the pain or bleeding does not subside or worsens during the first few hours after the extraction or if symptoms such as: severe abdominal pain, feeling faint, difficulty breathing, fever, extremely swollen abdomen or any other unusual complaint appear, you should contact the clinic staff or the emergency room (with a letter of discharge from the extraction).
Vaginal bleeding following acupuncture is a common occurrence and is usually not significant. This bleeding is not post-partum bleeding since it does not come from the uterine cavity but from the vaginal wall.
Important: Driving is prohibited for 6 hours after suctioning under anesthesia. Please plan accordingly.

During the days following the pumping

The day after egg retrieval, the patient and her partner will be provided with the following data: information regarding the number of fertilized eggs, the planned return date, and the adjustment of drug treatment.
Two days after the extraction, treatment with the progesterone preparation (tablets/gel) should be started according to Dr. Barak's instructions until the pregnancy test is performed. If the pregnancy test is positive, the support should be continued according to the instructions of the clinic staff.
In the days following the pumping, you should drink plenty of fluids (about a liter and a half a day).
You may be asked to take additional medications after pumping (antibiotics, etc.).
If necessary, you can take painkillers (such as paracetamol or Optalgin) if you are not sensitive to the medication.
If you feel well, it is recommended that you return to work and your normal daily routine the day after the pumping.
Two to five days after the extraction, the embryos will be returned in accordance with Dr. Barak's instructions.
If reactions appear such as: severe abdominal pain, feeling faint, difficulty breathing, fever, extremely swollen abdomen or any other unusual complaint, the clinic staff should be notified as soon as possible or go directly to the emergency room.

Embryo transfer and after

The embryo transfer can be done on the second day after the extraction when the embryo is 2-4 cells, on the third day when the embryo is 6-8 cells, or on the fifth day when the embryo consists of about 100 cells: a blastocyst.
The return date and the number of embryos returned will be determined by Dr. Barak, according to a number of criteria, including: the quality of the embryos, the woman's age, the number of treatment cycles, and additional medical data.
For the embryo transfer or thawed embryo transfer procedure, you must come with your partner, and in his absence, you must ensure that there is a "Power of Attorney for the Number of Embryos Returned to the Uterus" form signed by you in the presence of the person signing it and valid for one year (which you sign when signing the consent forms at the clinic).
No return will be made without the presence of the spouse/his valid power of attorney.b
The partner is invited to be present in the room during the transfer, according to the couple's wishes. The transfer of the embryos is done without anesthesia and is performed using a fine catheter inserted into the uterine cavity through the cervical canal.
The procedure will usually be performed when the bladder is full, so it is recommended not to empty the bladder for about two hours before the procedure, unless otherwise recommended by the clinic staff.
After the embryos are returned, Dr. Barak and the clinic team will be updated with the latest instructions for continuing drug treatment.
If, after the return, there are any surplus embryos of good quality left, they will be frozen for future use.
It is important to know a few things: not every treatment cycle allows you to freeze the excess embryos, not all embryos are suitable for freezing, and not all frozen embryos survive after thawing. Freezing will be done according to Dr. Barak's instructions.
In any case, after the return/freezing of the embryos/freezing of the eggs, a personal laboratory report will be entered that includes information regarding the freezing of the embryos: whether embryos were frozen and if so, how many and on what day. Access to the report is in the personal area of Assuta's website called "Assuta Personal". Entry to this area is done by entering a telephone number and ID number and receiving a personal code for the mobile phone.
Light spotting is common in the days following the return and even in early pregnancy. You can contact the clinic staff for treatment instructions.
Important: Do not stop the support before the date of the pregnancy blood test without receiving explicit instructions from Dr. Barak. (Even if bleeding has begun)

12-14 days after return

The blood test for pregnancy will be performed between 12-14 days after the embryos are returned.
If the pregnancy test is performed at the maternity unit, a referral from the unit must be obtained in advance.
If the answer is positive, it is recommended to take another pregnancy test two days after the first test.
Please inform the team in response.
If the answer is negative, an appointment must be made at the clinic for a discussion.
It is recommended not to stop or change medication without the guidance of Dr. Barak.

Together we will find a solution that is tailored just for you.

For a consultation with Dr. Barak, leave your details and we will get back to you as soon as possible.

Meet Dr. Shlomi Barak

Director of the Multidisciplinary Center for Female and Male Fertility and Director of the Fertility and In Vitro Fertilization Unit at Assuta University Hospital in Ashdod. A specialist in obstetrics and gynecology, female fertility and IVF, he has super-specialty in andrology, male fertility and microsurgery.

Dr. Barak has many years of rich experience in managing one of the largest and most successful fertility clinics in Australia, which has gained a world-wide reputation in the fields of female fertility and IVF, male fertility, and providing second opinions to patients suffering from low ovarian reserve.

He also engages in clinical and basic research and has published dozens of articles in the world of medicine.

Dr. Barak’s credo is personal attention alongside creative and innovative treatment.

We do everything we can to ensure you have the highest chance of success.

patient empowerment

At our center, patients are full and active partners in the medical process and in decision-making throughout. We are committed to partnership and full transparency, and in our eyes, they are an integral part of successful treatment.

Personalized treatment

We believe in personalized care that is precisely tailored to the patient's journey so far and to provide a comprehensive response to their needs and concerns.

Support envelope

A skilled and professional team is at the disposal of patients, including special personal support in complex cases. For us, a sensitive and compassionate envelope of support is an integral part of the service and care we provide.

Progress and innovation

The center operates in ongoing collaborations with leading centers in Israel and around the world in the field of fertility. We are up-to-date with all the latest scientific and technological innovations and developments in the field.