Infertility counseling for Orthodox Jewish couples
Ronit Haimov-Kochman, M.D., Daniel Rosenak, M.D., Raoul Orvieto, M.D. and
Arye Hurwitz, M.D.
Fertility and Sterility April 2010
“Religiosity is another aspect to be considered in Jewish observant couples among the many factors that should usually be taken into account. When counseling patients with different values and norms, a well grounded understanding of marital and sexual concepts is required to increase adherence to fertility treatments. Unveiling traditional Jewish concepts and practices of reproduction and discussion of problematic aspects of fertility work-up and therapy will allow a knowledgeable dialogue between Orthodox Jewish patients and caregivers”
A fantastic recent review by group of researchers from the Reproductive Endocrinology and Infertility Unit at Hadassah Hebrew University Medical Centre in Jerusalem and the Reproductive Endocrinology and Infertility Unit at Barzilai Medical Centre, Ashkelon in Israel discusses basic traditional Jewish concepts and reviews infertility diagnoses and reproductive practices, and define the problems that may arise with their use in Orthodox Jewish society.
The authors discuss several principles which dictate the nature of sexual activity of a married couple within the framework of the Halachah:
The Sacredness of Marital Life
‘‘it is not good for man to be alone’’ (Genesis 2:18) and ‘‘Therefore shall a man leave his father and his mother and shall cleave unto his wife and they shall become as one flesh’’ (Genesis 2:24), represent the emotional imperative for marriage, which is viewed as the completion of each human being.
Marriage is usually contracted between families within the Haredi community according to educational and social status. Hereditary diseases are more prevalent within the Ashkenazi Haredi Orthodox Jewish community, which tended to marry within itself for many generations.
The sacredness of marital life obligates premarital screening for prevalent genetic diseases to match the right couple and avoid conceiving unhealthy children. This premarital matching process is very well rooted in observant Jewish society and has not changed even in the era of pregestational diagnosis of hereditary diseases.
The major factors of female infertility in the Haredi community are anovulation and short menstrual cycle. Because pre- and nonmarital contacts are strictly forbidden, the frequency of sexually transmitted diseases that may lead to tubal infertility is exceptionally low. In infertile Haredi men, sexually transmitted epididimo-orchitis is a rare cause of testicular dysfunction and male infertility.
The second purpose of marital sexual relations, apart from procreation, is providing the wife with sexual pleasure (onah). Therefore, even when reproduction is impossible, intercourse is still encouraged.
Orthodox Judaism minimally regulates spousal sexual activity, with one notable exception: ejaculation must be vaginally contained. Extravaginal ejaculation, including masturbation, is condemned by Jewish law and is referred to as hash’-
chatat zerah (destruction of seed). This taboo is rooted in the Biblical story of the sin of Onan (Genesis 38:6–9). Onan had to marry his brother’s widow according to an ancient Jewish tradition. During intercourse he ‘‘spilled his semen on the ground’’ to prevent conception, as his first son would have been attributed to his brother. Onan was punished, presumably because he refused to follow God’s rule; coitus interruptus later was regarded as sinful because of the specific act of extravaginal ejaculation being ‘‘brought forth in vain.’’
Although the infertile couple should undergo diagnosis as a single unit, the halachic limitation of producing seminal fluid for analysis leads to first examining female infertility factors. Evaluation of the semen is initially done by postcoital test (PCT), which identifies motile sperm in a cervical mucus sample collected from the cervical os after coitus. The PCT is subjected to many biases which lead to false negative results. In modern fertility investigations, the use of PCT has long been in decline since semen analysis by WHO criteria proved to be better predictive of sperm quality. In religious infertile couples, when the PCT results are repeatedly abnormal the ejaculate collected after coitus interruptus with a special nonspermicidic perforated rubber condom is being analyzed. Masturbation is rarely approved for semen collection.
Niddah: the Laws of Separation
Sexual activity may not take place during the woman’s menstruation (Niddah) as well as for a full week thereafter (7 days of cleanness). The duration of the menstrual prohibition is 5– 7 days, even if the duration of bleeding is much shorter. The complete cessation of menstrual blood flow is ascertained by inserting every day a clean white cloth into the vagina. During this period no physical contact is allowed between the spouses (tum’ah). Coitus is allowed to resume after the woman has immersed herself in a ritual purity bath (mikveh).
In case of unexpected spotting or bleeding (Zavah), the woman should consult a rabbi and a doctor to determine the origin of the blood. Uterine bleeding entails that intercourse is forbidden for 5–7 days thereafter.
In practice, any minute bleeding or spotting regardless of the timing during the menstrual cycle invokes the stringencies of Niddah and Zavah rulings. Even physiologic occurrence such as midcycle ovulatory bleeding or spotting
renders the woman Zavah and prohibits sexual intercourse at the optimal time for conception.
The laws of family purity, which regulate coitus among Orthodox Jews according to the phase of the menstrual cycle, have a potentially important impact on fertility.
Menstrual cycle length is determined by the rate and quality of follicular growth and development, that is by the length of the follicular phase of the ovarian cycle, whereas the luteal phase is fairly consistent and lasts 13–15 days. In 60% of women of childbearing age the menstrual cycle lasts 25–28 days. Thus, the
majority of cycles are potentially exposed to coital activity during a fertile period for women. However, in about a fifth of women with short cycles of 21–25 days, ovulation can take place during the days of ritual impurity (tum’ah interval)
before day 14 of the menstrual cycle, potentially leading to diminished fertility as a result of restricted coitus. Furthermore older women in their 40s experience the shortest cycle length. In women with cycles of 21–25 days, if sexual intercourse is not resumed until day 15, the proportion of cycles wherein coitus is restricted to the postovulatory phase increases from 30% to 41%, thus lowering fecundity
Because the desire for a child is enormous, the resultant halachic subfertility and infertility is quickly brought to medical attention.
Medically lengthening of the preovulatory phase using clomiphene citrate
(CC) is a common practice, because shortening the count of the tum’ah days is nonnegotiable. Oral estrogen supplementation, starting on the second day of the menstrual cycle until the first two clean days, was recently shown to restore
the normal (23%) fecundity rate, by effectively delaying ovulation
beyond the time of the ritual bath. Midfollicular phase use of CC can also postpone ovulation beyond the day of the mikveh.
When prescribing gonadotropins for controlled ovarian hyperstimulation
(COH) cycle, attention should be drawn to several unique factors for the patient management:
1) The relation of the day of hCG administration to the day of immersion in the mikveh;
2) The unavailability of follicular follow-up tests during the Sabbath and holidays; and
3) An addition of GnRH antagonist to the stimulation regimen to delay follicular development, but with a possible impact on the receptivity potential of the endometrium .
Another law in the codex of the laws of separation instructs the man to withdraw from coitus from the 30th day of the cycle with expectation of the coming menstrual period. This may be an obstacle to anovulatory patients who are intentionally treated with a long course of small doses of gonadotropins
for COH to avoid the risk of ovarian hyperstimulation. The whole treatment cycle could eventually be futile if no intercourse takes place after the 30th day.
With regard to physician-patient communication, modesty could be misinterpreted as a token of discomfort toward the discussion of physical intimacy or as a lack of accurate sexual information. Marriage at young age, avoidance of premarital sexual contacts, as well as ignorance and lack of sexual education may lead to sexual dysfunction sometimes disguised as infertility. Ejaculatory dysfunction may take place during timed intercourse after follicular development follow-up or COH cycles and can be assisted by sildenafil use.
The Sacredness of Life
The fetus is not considered to be a person (Nefesh) until it is born. Moreover, 40 days after conception the fertilized egg is considered to be mere fluid. Abortion on demand is unacceptable by Halachah rules for fetal causes; therefore premarital screening for prevalent genetic diseases is performed for every
Ashkenazi couple to avoid conceiving unhealthy children. Termination of the pregnancy is mandatory when it endangers the life or health of the mother.
Conception in older age entails the risk for chromosomal aberrations of the fetus. The risk of Down syndrome is 1:20 at the age of 45. Because termination of pregnancy is prohibited, older women should be informed of that risk at the
start of any fertility therapy.