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Special Considerations in Treating the Halacha Observant Infertile Couple

Abstract: Difficulty in conceiving is a trying situation for any couple [1]. Because of the centrality of children in Judaism, and the biblical commandment to be fruitful and multiply [2], infertility is often especially painful for Jewish couples [3]. Societal norms in the observant Jewish community - such as the tendency to have children soon after marriage and to have larger families with births more closely spaced than is usual in the general society [4] - can add to the pressure. The point at which to initiate infertility diagnosis, and the details of protocols, may need to be adjusted in this patient population. The medical history should include evaluation and timing of marital relations.

Discussion: Judaism includes a commandment to be fruitful and multiply. The biblical commandment is fulfilled by having one son and one daughter. This commandment severely limits the use of contraception for couples who have yet to start a family. Therefore, it is often assumed that couples are attempting to conceive from the moment of marriage and thus the family and society may become aware of a fertility problem sooner in this patient population than in the general public.

Rabbinic law states that a couple should continue to have children as long as they are able. Larger family size than the general public is common in this patient population. Therefore, secondary infertility can be quite painful for the couple as well.

General medical practice is to initiate a medical evaluation only if a couple has not conceived after one year of trying, or, if the woman is over 35, after six months [5]. This norm is based on the general population, which is largely sexually experienced (either due to delaying pregnancy after marriage or to premarital relations). In the case of a young and sexually inexperienced couple, there is reason to allow a few additional months before beginning a medical evaluation. Since hymenal bleeding at the time of marriage renders a woman niddah, a situation in which relations are prohibited by Jewish law, a month or two can elapse before a newlywed couple begins having sufficiently frequent intercourse around the time of ovulation.

When 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. Because of modesty, sex education is usually not included in formal Jewish education. Exposure to sexually explicit popular literature and media may be limited and is hardly to be recommended. 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. Unfortunately, this is not always the case, and in cases of infertility, the possibility of the couple having had relations in a manner that will not lead to pregnancy should be delicately explored.

It is probably best to start with a description of effective marital relations. This can be prefaced by a statement such as "this may be obvious but at times I have seen infertility problems due to misconceptions. I therefore make it standard practice to review the basics of conception with all my patients." As modesty in Judaism includes the use of modest language, some members of this patient population may not be familiar with the clinical terms for body parts. They may be assisted by the use of diagrams. However, photographs or very graphic drawings are likely to make many of them uncomfortable. Line drawings are generally are sufficient and are likely to be more accepted. The following line drawing of female anatomy may be downloaded and freely reproduced for this purpose.

The timing and frequency of marital relations should be explored. Talmudic proscriptions as to frequency of marital relations are at times undertaken by couples without realizing the impact that this may have on their ability to conceive. Traditional premarital education often stresses the ideal situation where a woman is most likely to conceive by having relations on the night she used the mikveh. Not all women will have fully learned the workings of the menstrual and ovulatory cycles. They may not be aware that ovulation takes place 12-16 days prior to the next menses, and thus women with longer cycles could also be ovulating later that cycle [6]. While trying to conceive, they may be putting the stress on relations at the incorrect time of the month.

Some women may ovulate sooner than they are halachically allowed to have marital relations. This situation, known as halachic or religious infertility, is discussed in two separate articles. Implications of Jewish law for infertility diagnosis and treatment are discussed in separate articles.

Implications for Patient Care:  Requests for infertility diagnosis may come sooner than average in this population in comparison to the general population.

Decisions when to embark on medical intervention should take into consideration the fact that a few months may pass before a couple is having regular relations.

Medical history taking should include evaluation and timing of marital relations. Understanding of common terminology should not be assumed.

Medical References

[1] Greil A. Infertility and psychological distress: a critical review of the literature. Soc Sci Med 1997;45:1679-704.

[2] Semenic SE, Callister LC, Feldman P. Giving Birth: The Voices of Orthodox Jewish Women Living in Canada. J Obstet Gynecol Neonatal Nurs 2004 Jan-Feb;33(1):80-7.

[3] Gold, M. And Hannah wept: Infertility, adoption, and the Jewish couple. Philadelphia: Jewish Publication Society 1988.

[4] Friedlander D, Feldmann C. The Modern Shift to Below-Replacement Fertility: Has Israel's Population Joined the Process? Popul Stud (Camb) 1993 Jul;47(2):295-306.

[5] Speroff L, Glass RH, Kase NG. Clinical gynecologic endocrinology and infertility. 6th ed. Baltimore: Lippincott Williams & Wilkins, 1999:1013-14.

[6] Speroff L, Glass RH, Kase NG. Clinical gynecologic endocrinology and infertility. 6th ed. Baltimore: Lippincott Williams & Wilkins, 1999:187-224.


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