Halachah · Modern

A Lifetime Companion to the Laws of Jewish Family Life, Part Four; Medical Issues, Chapter 2; Infertility/מדריך להלכות טהרת המשפחה·חלק ד·פרק ב

1INFERTILITY¹. (Jerusalem: Toby Press, 2005).2) Finkelstein B. and Finkelstein M. The Third Key: The Jewish Couple’s Guide to Fertility (Jerusalem: Feldheim, 2005).

2Difficulty in conceiving is a trying situation in any marriage.² This is true even more for the halachically observant couple, because of the stress in Jewish law on the commandment to be fruitful and multiply (see the section on birth control, pp. 159–161, for further discussion of this issue). Societal norms in the observant community of having children sooner after marriage, more closely spaced and greater in number than is usual in secular society, add to the pressure. While a full discussion of infertility diagnosis and treatment is beyond the scope of this book, it is important to discuss this topic and its interplay with halacha.

3Definition of infertility

4About 20% of couples conceive during the first month of trying, and an additional 20% each subsequent month; thus, by six months 86% of couples will have succeeded. General medical practice is to wait until one year of lack of success before initiating a medical evaluation, unless the woman is over 35, in which case the evaluation would start at six months. These statistics are based on the general population which is often sexually experienced (either due to delaying childbirth after marriage or premarital relations). With the young and previously inexperienced couple,³, one to two months can go by before a couple begins having frequent enough intercourse at the time of the month the wife is most likely to conceive. there is reason to allow a few more months before beginning medical evaluation.

5Infertility is sometimes divided into two categories – primary, in which no children have been born yet, and secondary, where the couple has already become biological parents but are experiencing difficulty in conceiving further children.

6Evaluation of infertility

7There are many reasons that can cause a couple difficulty in having children. Some are due to factors in the husband, some are due to factors in the wife, and some are due to both. In order to offer treatment it is important to determine the cause of the problem. This evaluation begins with the taking of a thorough medical history and physical exam of both members of the couple. Two situations, which are often not addressed in the medical literature, need to be taken into consideration in dealing with couples who observe halacha.

8Effective marital relations

9In dealing with a young couple married for the first time, it is quite important, before embarking on an extensive medical work-up, to verify that sexual relations are taking place in an effective fashion. Exposure to sex is so prevalent in the general community that physicians often assume that their patients know the basics. However, while sex is a natural behavior, it also needs to be learned. Due to concerns with modesty, sex education is often not provided in Jewish education. Availability of sexually explicit literature and media may be limited as well. Essential information about anatomy and physiology should be provided to both members of the couple prior to the wedding as part of teaching the laws of family life (see Appendix C, pp. 200–204). Unfortunately, this is not always the case, and the possibility of the couple having had relations in a manner that will not lead to pregnancy should be delicately explored.

10Halachic infertility

יא

11A fertility problem unique to women observing the rules of niddah is ovulation prior to immersing in the mikveh. The date of ovulation can be determined by a number of methods. One such method is for the woman to measure her temperature before arising every morning (“the basal body temperature”). There is generally a rise of about half a degree Fahrenheit at ovulation. This method can be cumbersome for women who wake at irregular times, and body temperature can be affected by other factors, such as illness. Women can learn to recognize other signs of their fertility as well, such as changes in their cervical discharge.⁴ (New York: Perennial, 2006). Laboratory tests are also available. One such test is a kit that measures the surge in lutenizing hormone (LH) that precedes ovulation by 12–24 hours. These kits are readily available in pharmacies as “ovulation prediction tests,” without a prescription, and can be used in the privacy of one’s home. Another method uses serial ultrasounds, which follow the development of the ovarian follicle and can directly record whether ovulation has taken place. Other methods, such as measurement of serum progesterone on approximately day nineteen of the cycle – by when ovulation should have taken place – or biopsy of the uterine lining, can determine that ovulation has taken place, but are less practical regarding timing.

יב

12From a medical perspective, the woman who ovulates prior to day twelve of the menstrual cycle but ovulates regularly does not have a fertility problem. However, if because of halacha she cannot have relations until after this point, she will have difficulty conceiving. As mentioned in part one, fertility problems are one reason that even Ashkenazi women would be permitted to wait eleven days rather than twelve, especially if they do not have intercourse right before the onset of their menses.⁵ Assia, 2009; 22:63–81. If she ovulates on day 10 or earlier there are other halachic solutions,⁶ YD 4 17:22. and a rabbi should be consulted. However, she still needs to have an appropriate hefsek taharah, and thus these solutions only help women who bleed for 2–3 days. For a woman with early ovulation whose menses last five days or longer, the above suggestions do not help.

יג

13A woman who suspects she is ovulating before mikveh use should begin by verifying that her menses really last as long as she thinks. Any findings other than bright red on the hefsek taharah should be brought to a rabbi to check whether they are, in fact, problematic. The rabbi should be informed that halachic infertility is suspected. If they are, then medications to delay ovulation are often used. These include estrogen, combination estrogen/progesterone and clomiphene citrate. All these medications are prescription only, and should be used under the supervision of a physician.

יד

14Halachic solutions, if the medical approaches fail, are more difficult, but exist.⁷ 2 EH 1., ⁸.” Sefer Assia 5 (Jerusalem: Machon Schlesinger, 1986) pp. 112–42. A rabbi with experience in this area should be consulted.

טו

15Order of diagnostic procedures

טז

16The history-taking and physical exam are generally followed by a series of diagnostic tests. As infertility may be due to problems in either spouse, in the general population the examination generally starts simultaneously with the husband and wife. However, as evaluation of the male factors raises more halachic problems,⁹ 5758; 18:161–169. a rabbinic determination should be obtained prior to embarking on this testing. Often rabbis will require that the basic, non-invasive tests be performed on the wife first, and only if these tests do not reveal the cause, then proceed to evaluate the husband. They may also stipulate that a minimum time of marriage without children elapse before permitting such testing.

יז

17Evaluation of male factors

יח

18Evaluation of male infertility centers around sperm sampling, which requires dealing with the halachic issue of hotzaat zera lebatalah (removing semen for naught).

יטאָסוּר לְהוֹצִיא שִׁכְבַת זֶרַע לְבַטָּלָה. (שולחן ערוך; אבן העזר, כג:א)