You would be forgiven if Nablus was not at the top of the list of places that come to mind when you think about IVF treatments. But for many young Israeli couples, the West Bank city is the preferred solution to what can be a very painful problem.

Dima IVF is a fertility clinic operating in the city. Every year, dozens of young Israeli couples seek treatment at the clinic. Most of them are from Israel’s Arab community, but there are also Jewish clients. According to various estimates, around 70 percent of the clinic’s clients are Israeli. To begin with, the war stopped people from traveling from Israel to the Palestinian territories for treatment, but that did not last long and the situation has now almost returned to normal.

Why Nablus of all places – and why pay anything up to 15,000 shekels (around $4,000) for something that the State of Israel provides for free as part of the HMO’s healthcare basket? Shomrim spoke to couples who underwent IVF treatment at Dima and discovered that the main reason for choosing a Palestinian clinic was the treatment they received in Israel, the slow pace and complexity of the process within the Israeli health system and also the possibility of choosing to have more than one embryo and even the sex of the child – a dangerous and problematic procedure from both a health and social perspective.

While Dima is the most popular of the fertility clinics in the Palestinian territories, it is not the only one used by Israelis. Medical officials who spoke to Shomrim were highly critical of couples who decided to get IVF treatment in the territories. They say that the protocols used in Palestinian clinics in the West Bank are not as stringent as those used in Israel, leading to situations whereby pregnant women who chose to have more than one embryo have ended up in Israeli hospitals due to complications. “We have treated a number of patients who underwent IVF in the West Bank,” says one physician who is familiar with the issue. “During their pregnancy, there were complications and they arrived at the hospital in a great deal of pain. The pregnancy endangered their lives and the lives of the fetuses but it was too late for us to perform fetal reduction. In these cases, we had no choice but to perform a Cesarean section and the fetuses were kept in incubators for several weeks.”

Ayman and Huda, residents of northern Israel aged 50 and 45 respectively, went to a clinic in Nablus after they say they were treated poorly in Israel. “We were at a hospital in the north and we were treated very unpleasantly. The doctor said, ‘Save your money and go for a vacation in Eilat.'"

‘The Doctor Told Me That Nothing Would Come of the Treatment’

According to Health Ministry figures, around 4 percent of all births in Israel are the result of IVF treatment. In 2021, 49,699 embryo transfers were performed by Israeli clinics and healthcare organizations. Of them, 13,561 led to pregnancies – but only 10,693 ended with a healthy birth. The vast majority of these treatments were conducted at the fertility clinics operated by Israel’s public hospitals. The state covers, with certain conditions, the entire cost of the process for a couple – but makes it very hard for them to demand to choose the sex of their baby. Only couples who already have four children of the same sex are allowed to choose the sex during IVF, but even then, it is not easy to pass all the Health Ministry’s tests. The alternative can be found just an hour’s drive from Tel Aviv.

Hassan and his partner, who live in one of the Arab communities in northern Israel, managed to conceive without IVF treatment. When they tried to have a second child, they were less successful and, after 10 years, they decided to seek IVF treatment. Having obtained the necessary permission from their HMO, they began fertility treatment at a hospital in northern Israel, but the treatment was not successful. They told Shomrim that they tried treatment at a different hospital, where they say they were treated disrespectfully by staff. So, they decided to turn to a private clinic, which they say demanded a fortune for its services. Just one semen examination, they said, cost 5,000 shekels. For exactly the same examination at a clinic in the West Bank, they would later pay 250 shekels.

“We went through hell in Israel,” Hassan says. “Our HMO referred us to IVF treatment because we were not able to conceive a second child naturally. It’s a long and complicated process which is emotionally draining. But the hardest part was how the physicians at the hospitals talked to us; it was unpleasant and disrespectful. That was why we decided to look into other options.

“Everything was great in Nablus. The whole process was easy and not at all problematic. It’s true that we had to drive to Nablus a few times but the price was excellent, it was a one-time payment and they treated us amazingly. After treatment there, we had twins.”

Ayman and Huda, residents of northern Israel aged 50 and 45 respectively, went to a clinic in Nablus after they say they were treated poorly in Israel. “We started the process several years ago,” Ayman says. “We were at a hospital in the north and we were treated very unpleasantly. The doctor said, ‘Save your money and go for a vacation in Eilat. Nothing’s going to come out of this treatment,’ and so on. Moreover, we had to wait a long time for treatment – several months, in fact.

“We went to three other clinics in Israel and the treatment did not work each time. At one point, we were told that, for the treatment to work, I would have to undergo a certain medical procedure that cost me more than 20,000 shekels – but that didn’t work either.

“Later, we arrived at a different hospital in the center of Israel, where one of the doctors told us about the possibility of fertility treatment in Nablus. ‘Why are you here and not there?’ he asked us. ‘Go to Nablus – they have really high success rates there.’ We thought about it and decided to give it a go. We got excellent treatment there – humane and respectful. The doctors told us that there was hope we could have the child we longed for.”

“Everything was great in Nablus," Hassan says. "The whole process was easy and not at all problematic. It’s true that we had to drive to Nablus a few times but the price was excellent, it was a one-time payment and they treated us amazingly. After treatment there, we had twins.”

More Fetuses, More Problems

The main problem with the fertility treatment offered in the Palestinian territories is the large number of embryo transfers performed. This increases the risks that the pregnancy will take but, at the same time, it increases the risks of medical complications, C-sections and premature births.

A position paper published by the Israel Fertility Association in 2018 states that the risks involved in a pregnancy with more than one fetus increases the more embryos are transferred. As a result, the IFA published standing instructions governing when and how it is acceptable to transfer more than one embryo. Hospitals are under strict supervision to ensure they comply and doctors try to avoid multiple embryo transfers whenever possible. In the event that the pregnancy does not last, the process is repeated from the beginning.

The situation in Nablus is completely different. “We have had a few women who underwent fertility treatment in the West Bank. During the course of the pregnancy, they experienced certain complications and ended up here,” says one doctor from a hospital in northern Israel. “They were at an advanced stage of their pregnancy, with twins or triplets, and were suffering terribly. Not only did the pregnancy endanger their health and the health of their fetuses, but it was already too late for us to perform fetal reduction. In these cases, we had no choice but to perform a Cesarean section and the fetuses were kept in incubators for several weeks.”

“The Palestinian Health Ministry does not supervise closely like we do here in Israel. The IVF mix-up that happened at the Assuta Medical Center, for example, would never even have come to light there,” adds another senior doctor who is the director of a fertility unit in northern Israel and who knows the workings of the West Bank clinics first-hand. “Our hands are tied,” he insists. “We can’t do anything about this phenomenon of transferring too many embryos. In the end, a multifetal pregnancy will end with a C-section and neonatal intensive care. Efforts were made to reach out to the Palestinian Health Ministry but to no avail.”

This doctor has much to say to couples who opt for a multifetal pregnancy. He believes that many of them are unaware of the risks involved – or prefer to ignore them. “Many couples try to put pressure on us to transfer twins into the womb,” he says. “I have witnessed many conversations between Arab women on social media, saying how much they want twins. There were also cases when the husband’s family pressured the women to get pregnant straight after the wedding or women who thought that they had a medical problem just because of lack of knowledge.”

This criticism is shared by the director of a fertility clinic in central Israel, who has dealt with many cases of women who underwent IVF treatment in the West Bank. “We encounter Israeli women who underwent IVF in the West Bank and even in Jordan,” he tells Shomrim. “What scares us, as doctors, is that there are many more premature births with the increased possibility of complications in adulthood. Around half of all twins are born prematurely – before Week 37. When it is triplets, around 90 percent are born prematurely. Our goal, as a healthcare system, is that there are as few multifetal pregnancies as possible. When we transfer more than one embryo, we do so in order to increase the chances of a full-term pregnancy, but that happens only in very specific cases and only when the Health Ministry’s criteria allow for it. Our main problem is that there is no treatment that can prevent premature birth. There’s just no way to stop it.”

"We transfer one and if she’s over 30 or has already undergone more than one round of IVF treatment, we transfer another one," Dima IVF responded. "We do not transfer two embryos into each woman – just into women who have undergone several IVF treatments, to increase their chances.”

The phenomenon of West Bank IVF treatment began to emerge some 15 years ago under rather extraordinary circumstances: in August 2012, the first Palestinian baby from fertility treatment was born to a security prisoner serving a life sentence in Israel. Since then, 119 babies have been born to security prisoners. These babies even have an official nickname in the Palestinian Authority: “Ambassadors of Freedom”.

These babies introduced many Palestinians to the option of IVF treatment and led to an upsurge in interest. Today, in addition to the Dima clinic in Nablus, there are several IVF treatment centers operating in the West Bank. The largest of them is the Razan IVF Clinic, which has four branches across the West Bank and enjoys an excellent reputation. “There are also some perfectly good clinics in the West Bank,” says one senior gynecologist from northern Israel. “The problem is that there are also many clinics which take a lot of risks. It’s a serious problem for parents and for the Israeli health system.”

Shomrim called Dima IVF in Nablus and spoke to one of the receptionists. She said that they usually offer four rounds of treatment at a cost of between 6,000 shekels and 15,000 shekels. During a second conversation with the clinic, we were told by someone who identified herself as the director, that “many people come to Dima because they were not given the right treatment in Israel. Our success rate is very high and that’s why people come to us. We offer people the option of choosing the sex of their child, like in Israel. Rather than the couple having four children until they finally manage to have a boy or a girl, they can choose from the outset what sex their baby will be. We make them smile and that’s what matters to me.”

Asked about the medical issue with transferring multiple embryos, the director responded: “We always tell the woman how many embryos she has. We transfer one and if she’s over 30 or has already undergone more than one round of IVF treatment, we transfer another one. We do not transfer two embryos into each woman – just into women who have undergone several IVF treatments, to increase their chances.”

The Israeli Health Ministry said in response: “Israel's healthcare system is among the best in the world, but there is nothing preventing Israelis from traveling anywhere else for IVF treatments. The Health Ministry attaches great importance to the health of women receiving treatment and newborns and invests much effort in reducing the rate of multifetal pregnancies as a result of fertility treatments. The Ministry uses and monitors a national quality index, which examines the rate of multifetal pregnancies in fertility treatments in order to reduce it as much as possible.”

Asked about fertility treatment in the Palestinian territories, the Health Ministry said that it “has no oversight whatsoever over these doctors and clinics and the State of Israel has no way of intervening or guaranteeing the quality and safety of the treatment they offer.”