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Halachic Issues in Infertility Diagnosis

Abstract: Infertility diagnosis is likely to raise questions in three areas of Jewish law: the laws of niddah, hotza'at zera levatalah, and laws of Shabbat and festivals. Health care providers should be aware of these issues and attempt to accommodate the needs of halacha observant patients as much as possible.

Discussion:

Female Factors

Procedures for evaluation of female factors may cause the woman to become niddah, either from bleeding or from cervical dilation.

Bleeding that is clearly caused by instrumental intervention does not in principle make a woman niddah. Nevertheless, some rabbis are hesitant to disregard bleeding from the uterus (as opposed to the vagina or external cervix).

Instrumentation that involves the dilation of the cervix beyond a certain minimum (opinions range from 6-19 mm) can make a woman niddah even in the absence of bleeding. It is best to discuss the planned size of the instrument with the patient prior to the procedure so she can consult with her rabbi as to his halachic opinion. If a smaller instrument can be used, she may be able to avoid becoming niddah.

Even when bleeding does not render a woman niddah, it can create halachic difficulties at certain points in her cycle. In particular, she may be unable to obtain the blood-free internal examinations (bedikot) required to complete the seven clean days before mikveh immersion. Therefore, when possible, it is best to discuss the impact of the procedure on a woman's niddah status before it is undertaken and attempt to schedule it so that she will not remain niddah longer than necessary.

Male Factors

Evaluation of male infertility centers around sperm sampling [1]. Obtaining a sperm sample raises several concerns in Jewish Law.

First, ejaculation of semen outside the vaginal canal may violate the prohibition of hotza'at zera levatalah, generally translated as wasting seed. Many authorities maintain that producing a semen sample for the eventual purpose of procreation does not constitute wasting. However, some disagree with this position.

Even rabbis who permit sperm sampling often prefer that basic non invasive testing be done first on the wife. Some will also insist on a minimum time of marriage prior to allowing male testing. This approach does not indicate a mistaken assumption that infertility is more likely to be due to female factors. Rather, it arises from a desire to minimize halachic difficulties as much as possible.

Masturbation, which is often used to produce a semen sample, is also a serious concern in Jewish law. For this reason, rabbis will often suggest beginning with alternate methods of procurement that are less problematic. One such method is post coital sperm retrieval [2]. As intercourse takes place in the natural manner, this does not violate the prohibition of wasting seed.

Halachic concerns should be taken into consideration when scheduling this testing. Jewish law indicates that intercourse should be private, minimizing the possibility of anyone other than the couple being aware that it is taking place. Having intercourse in a medical facility is thus quite uncomfortable for the couple. Jewish law also discourages sexual intercourse during daylight hours. Scheduling the testing in the early in the morning and allowing the marital relations to occur elsewhere during the night (post coital sperm retrieval is medically acceptable within 8 hours of intercourse [3]) will alleviate these concerns.

If direct sampling of semen is needed, some rabbis will suggest that the sample be obtained during intercourse by using a condom (with or without a small hole). Others will allow ejaculation into a specimen container as long as the stimulation was provided by marital relations [4]. Discussion of the testing with the couple's rabbi will enable the couple to undergo such testing in the most culturally sensitive manner [5]. If the physician does not have the time to talk directly with the halachic authority, he can aid the couple by providing written indications as to the need for the sample and why it needs to be produced in a particular manner for this case.

Testing for male factors sometimes requires testicular biopsy or surgery [6]. This presents additional halachic concerns with damaging the testicles, which could prohibit the couple from having relations in the future. A rabbi should be consulted as to the halachically preferable option in each individual case. Most situations can be handled by a rabbi with understanding of the medical procedures working in concert with a physician sensitive to the halachic needs of his or her patient.

Sabbath and Holidays

Certain activities are prohibited on the Jewish Sabbath and Holidays. Some of these raise issues in infertility diagnosis. For example, certain home diagnostic procedures, such as the use of dipsticks that change color or digital thermometers, are problematic. Performance of most office procedures will involve prohibited activities, such as use of electricity and writing. Travel to the physician's office by any method other than walking raises problems as well. A rabbi should be consulted as to how to proceed if a problematic procedure must be done on the Sabbath for diagnostic purposes.

Implications for Care: To provide culturally sensitive care, it is important that health care providers be aware of issues of Jewish Law of concern of to their patients.

Laws of niddah, procurement of semen and laws of the Sabbath and holidays can impact on the scheduling and performance of infertility diagnosis procedures.

Medical References

[1] McLachlan RI, Baker HG, Clarke GN, Harrison KL, Matson PL, Holden CA, de Kretser DM. Semen analysis: Its place in modern reproductive medical practice. Pathology 2003;35: 25-33.

[2] Glazener CM, Ford WC, Hull MG. The prognostic power of the post-coital test for natural conception depends on duration of infertility. Hum Reprod 2000 Sep;15(9):1953-7.

[3] Speroff L, Glass RH, Kase NG. Clinical Gynecologic Endocrinology and Infertility. 6th ed. Baltimore: Lippincott Williams & Wilkins, 1999:1037-39.

[4] Gerris J. Methods of semen collection not based on masturbation or surgical sperm retrieval. Hum Reprod Update 1999 May-Jun;5(3):211-5. Review.

[5] Serour, GI. Attitudes and cultural perspectives on infertility and its alleviation in the Middle East area. In Vayenna E, Rowe PJ, Griffen PD (eds.) Current Practices and Controversies in Assisted Reproduction. Report of WHO Meeting, WHO Geneva 2002;50-54.

[6] Speroff L, Glass RH, Kase NG. Clinical Gynecologic Endocrinology and Infertility. 6th ed. Baltimore: Lippincott Williams & Wilkins, 1999:1152.


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