Gynecological tools.

Rabbis Send Healthy Women to Get Painful Fertility Treatments – and Doctors Go Along With It

More and more religious women are rejecting the strict interpretation of Jewish law that bars them from getting pregnant naturally

Fertility experts like to say that all that’s needed to bring a child into the world is semen and an egg. That’s the first thing people hear in visits to specialists who have offices adorned with photographs of smiling infants. “A man and a woman – that’s all you need,” they’ll say modestly, as though they don’t have expensive fertility technologies at their disposal. The religiously observant often look upward, hinting at another factor in the equation: semen, an egg – and the Lord. But Naama, a religious woman in her 40s, learned the hard way that the concept of this holy trinity is not as straightforward as it seems.

Naama (her name and those of all the other women interviewed here have been changed) has four children. The first three entered the world thanks to fertility treatments, which, she says, left her body “in ruins.” Her ordeals began after her marriage at the age of 24. “For about a year I tried to become pregnant, but with no success,” she relates. A doctor prescribed medication to regulate the ovulation mechanism, and she gave birth to healthy twins. When she failed to conceive again, she consulted with rabbis at Puah, a Jerusalem-based institute that that deals with issues related to religion, fertility and medicine and offers married couples solutions that accord with halakha (Jewish law).

The institute advised Naama, who is today in her 40s, and her husband to opt for artificial insemination with the aid of a “halakhic condom,” with which semen is collected in a vial without breaching the religious injunction against spilling one’s seed in vain. When this proved unhelpful, they returned to the doctor, who decided on hormone injections. “The injections were painful,” Naama recalls. “My stomach looked like a map of Israel.” But the treatment worked and she gave birth to a daughter.

A few years passed and the couple wanted to have another child. By this time, the biological clock was ticking loudly, so Naama opted for in-vitro fertilization. It failed. “While the eggs were being harvested in the hospital, I developed bleeding in my stomach. I told my husband, ‘That’s it, enough. We have three wonderful children. There’s a limit to how much a woman has to suffer for another child.’ I was bombarded with hormones, constantly irritable, I put on weight. I told myself that if I have 10 embryos and the body doesn’t let me accept them – that’s a sign that it’s time to stop.”

Naama found a solution to her problems a few years later. She joined a fertility awareness workshop intended to help women become more connected to their bodies through a better understanding of menstruation and fertility. The participants kept a log of their monthly periods and learned how to forecast their window of fertility. Naama’s charts immediately showed the workshop’s facilitator, Einat Lev, that she ovulated before the date of her ritual immersion in the mikveh – that is, before she had finished counting the two weeks of the month when she is in niddah (i.e., ritually impure, which makes sexual contact forbidden) – and she concluded that this was why Naama was not conceiving naturally. She referred Naama to a rabbi, who permitted her to move up the time for the immersion.

Naama became pregnant with her youngest child in the natural way – and realized that the fertility treatments she had endured had been unnecessary. One small question, which the doctors didn’t ask, could have spared her the ordeal: When do you go to the mikveh? This is an extreme case, but Naama was apparently suffering from a common phenomenon known as “halakhic barrenness” – or, as physicians express it more delicately, “halakhic infertility.”

Doctors usually avoid the word “barrenness” in cases of this kind, because the women in question are not infertile per se. They are perfectly healthy, with a completely normal reproductive system, but – as it often turns out later – they simply have a relatively short menstrual cycle. Because they maintain ritual purity for two weeks a month (seven additional days of abstinence after the conclusion of menstruation), their ovulation occurs on days when sexual intercourse is prohibited, and they miss the fertility window. In short, they are unable to conceive precisely because of their religiously observant way of life.

One way to solve the problem is to be flexible in interpreting halakha, as in the case of Naama’s rabbi. However, most rabbis are loath to take this course. In the absence of a halakhic solution, most women seek medical assistance – with the result being that many of those who have no health-related problems undergo invasive and painful procedures in fertility clinics. This situation gives rise to serious ethical questions and sharp disagreement between physicians; indeed, some doctors refuse to treat these women.

“A doctor has a mandate to heal,” says Dr. Daniel Rosenak, a religiously observant, Jerusalem-based gynecologist. “But it is wrong to give medication to healthy people.” Many observant women in Israel, too, are now starting to resist the collaboration that’s arisen between rabbis and physicians, and are looking for a way to take back control over their bodies.

“I thought it was only the halakhic world that curbs women, and then I discovered there’s more to it,” says Einat Lev, who conducts fertility workshops. “Women are ready to pay a high price to have a family of their own. We live in a system where’s it’s permissible and logical to intervene in a woman’s body. I sometimes ask myself whether, if men had to undergo these tough treatments, they would be so trigger-happy.”

‘Forget your body’

The Torah stipulates that a woman must observe niddah for the seven days of the menstrual cycle: “And thou shalt not approach unto a woman to uncover her nakedness, as long as she is impure by her uncleanness” (Leviticus 18:19). This admonition is not harmful, as it is consistent with the timing of a woman’s ovulation. But in the fifth century, apparently, a stricture was added extending the period of impurity for seven days – known as “clean days” – after menstruation. It’s this stricter approach, which effectively mandates a two-week niddah, that complicates things.

Most women have a monthly cycle of 28-30 days and ovulate toward the middle of the month, around day 14. They are the fortunate ones: Ovulation occurs after an observant woman immerses in the mikveh and she will likely conceive naturally. The women who suffer from “halakhic barrenness” are those whose cycle is shorter, lasting less than 25 days. Prof. Daniel Zeidman, a specialist in in-vitro fertilization at Sheba Medical Center, Tel Hashomer, encounters many cases of this kind.

“These are young women who haven’t become pregnant after a year or two, and come to find out why,” Zeidman explains. “The tests show that in some cases, ovulation occurs before they have gone to the mikveh.” In his view, he adds, “The problem is that in order to become pregnant, it’s necessary to maximize ovulation and have intercourse the day before or on the day of ovulation. If ovulation takes place on the 10th day [of the menstrual cycle], which is not very exceptional – that woman will never become pregnant.”

“I can’t accuse the ancient sages of operating without the proper knowledge,” says Dr. Channa Adler Lazarovich, a gynecologist at the women’s health center of the Clalit HMO in Afula, who also teaches halakha. “But today, we physicians know more about fertility timing. A woman can’t be asked to do something that conflicts with heartfelt religious precepts, so let’s offer her a halakhic solution.”

Rami Shllush

Even though solutions can be found in Orthodox rabbinic rulings, most rabbis do not demonstrate the flexibility that would allow women with the problem to immerse themselves in a mikveh before ovulation. They often address this subject by coming up with technical tricks to reduce the period of niddah, by recounting the days of the period, and wearing a colored undergarment on which the stains from bleeding are not visible. Such methods can help women whose ovulation is a day or two early, but many are left with no recourse.

“The rabbis are effectively telling the woman, ‘Ignore the bleeding, forget your body, do what I tell you,’” says Rivka Shimon, a bridal counselor. “But women tell me, ‘I can’t lie, I see blood.’”

According to Yifat, a 30-year-old woman from central Israel who suffered from halakhic infertility, “You’re taught that niddah is the most important commandment, that you should commit suicide for it. I was afraid that the sky would fall on me if I had intercourse without going to the mikveh. And I was even more afraid that I would give birth to a defective child. In adolescence, I was overcome with scary stories about what happens to a girl who doesn’t observe niddah.”

Indeed, in Tractate Niddah of the Talmud, the sages discuss the bloodstains of the menstrual cycle, and their comments continue to resonate even today. They distinguished between the stains based on size, color and source of the bleeding. Over the generations, a practice has developed of rabbinic “questions and answers” related to the halakhic minutiae relating to ritual purity. In this context, women have found themselves required to report to them about various menstrual phenomena, and particularly the visible secretions: the stains and their colors. On top of which, the institution of questions and answers also demand submission of the stained woman’s undergarments to a rabbi. The husband will give the sullied pad to the rabbi in an envelope, and he will in turn examine the stains and rule whether the woman is “permitted” or “forbidden” to her partner, and whether she can undergo immersion in the mikveh.

Today there are women who can respond to niddah-related questions, but this is only a very partial solution. The height of the regime involves, in some cases, an examination at the mikveh to determine purity. In ultra-Orthodox communities, a woman who reports the appearance of a bloodstain during the seven “clean days” might be sent by rabbis to be checked by a registered nurse. These nurses, many of whom have undergone training at the Puah institute, and whose services are covered by the HMOs, will carry out an invasive internal examination to determine whether the source of the bleeding is the womb. This has become a full-fledged industry, in which women are told, “You are not ‘permitted,’” and effectively lose their autonomy.

Seeking other remedies to the problem, women are turning to alternative solutions. Medications bearing exotic names, such as Yemenite Chewing Gum, along with folk remedies, are being marketed as helping to reduce bleeding and delay ovulation.

“The rabbis create the problem and then say, ‘We will solve it for you, you unfortunate daughters of Israel,’” Dr. Rosenak says mockingly. “They come up with new gimmicks, like drinking lemon juice to delay ovulation. Ridiculous things. But you can’t fool all the people all the time.”

Thus, even though it’s a problem that starts with halakha, many couples that consult with rabbis will also finally seek medical advice. “There’s no rabbi whose phone favorites don’t include a few senior doctors,” says Prof. Zeidman.

Prof. Ronit Kochman, of the obstetrics and gynecology department of Hadassah Medical Center in Jerusalem, told me, before her death a few months ago, that when she founded the women’s health center of the Maccabi HMO in the ultra-Orthodox settlement of Mod’in Ilit in 2006, she was astonished to discover that “the only problem of half the women who came to the center was the timing of their sexual relations.”

Michal Novoselsky

A study conducted by Kochman in 2012 (in conjunction with Drs. Rosenak, Adler Lazarovich and others) found that among Israeli couples seeking the help of a gynecologist for infertility problems (about 10 percent of the general population), fully 20 percent were suffering from halakhic infertility. “In Jerusalem and other ultra-Orthodox areas, it’s become routine,” she noted.

Zeidman, who says he deals with dozens of such cases every year, notes that 5 to 10 percent of his patients complain of halakhic infertility. He and other physicians who spoke to Haaretz say the phenomenon is growing, since some secular women have also begun to visit the mikveh. “More women are choosing to observe niddah these days,” Zeidman says. “They think it will help in their relationship, or Grandma told them it would bring good luck and blessings. But they’re not told about the other side of this issue: halakhic barrenness.”

In fact, one-third of all infertility cases remain unexplained. Diagnosis is more complicated with religiously observant couples, because 50 percent of the potential causes of the infertility cannot be determined by a physical examination alone. For, if there is suspicion that the problem lies in the man’s sperm count, the halakhic ban on spilling seed in vain prevents many observant husbands from providing a semen sample until an advanced stage of the process.

Zeidman: “The semen might be flawed, but the rabbi is in no hurry. Many times, the rabbi will tell the woman, ‘Try for two years,’ before permitting that procedure.” As a result, doctors are often unable to discover the root cause of the problem early on, and the woman must bear the whole burden, including the arduous treatments and tests, such as a hysterosalpingogram (an x-ray test of the uterus).

Miracle drug

Once a religious woman arrives at a fertility clinic, the physician will rarely consider sending her back to the rabbis, but will treat her with medical means. One of those options, more widespread in the past, is artificial insemination, which includes sperm enhancement. This method removes ritual immersion from the picture, as it doesn’t involve sexual contact. Some women undergo the procedure in an invasive treatment carried out by a gynecologist; others inject the semen into the vagina themselves.

“I agree that this solution, too, is problematic and not natural,” says Adler Lazarovich, who, in any case, prefers the self-injection option. Many couples are reluctant to try artificial insemination, few women choose it and it is rarely suggested. The Puah institute, for example, recommends it only in cases where medicinal treatment is ineffective.

The most common medical treatment for infertility today is the use of hormones to delay ovulation. Ikaclomin (called Clomifene abroad) is no longer widely used as in the past, as it led complications and side effects, but it is still prescribed in some cases. Some sources said that the medication is distributed without a prescription in Haredi locales, and some rabbis even hand it out on their own to women if they are having trouble conceiving.

Today, the most widely administered medication is a form of estrogen called Estrofem, in the form of an estradiol pill,which slows the development of the ovarian follicle.

“The woman takes a 2-milligram pill from the second day of menstruation until her two ‘clean days,’” says Prof. Raul Orbito, director of the fertility and in-vitro fertilization unit at Sheba Medical Center, explaining the method he has devised for treating halakhic infertility. By this means, “I expedite the building of the endometrium, the bleeding time is shortened and inhibits the hormonal axis.”

Physicians view Estrofem as a miracle drug. Zeidman estimates that about two-thirds of women suffering from halakhic infertility will become pregnant within a few months of taking it. If not, he says, “We carry on with the process, because there are apparently additional and congruent diagnoses of infertility. Many cases start off with the diagnosis that the woman isn’t going to the mikveh in time, and in the end it turns out that her fallopian tubes are blocked.”

Orbito notes that, “If there are, nonetheless, women who don’t conceive because of halakhic barrenness, they are minuscule in number.” He tends to play down the problem: “It’s only a matter of the timing of the ovulation, and that can be solved with medication.”

Still, hardly any studies have examined the effectiveness of Estrofem treatment. A pioneering but small-scale study that Ronit Kochman conducted on 23 women found that the medication is very effective in delaying ovulation, but far less so in helping women become pregnant.

Many women, deeply frustrated at being unable to conceive, take Estrofem without asking questions. Adi, a 35-year-old religiously observant lawyer who suffered from halakhic infertility, hesitated before taking Estrofem. She consulted a rabbi, who said: “Don’t take it. Pray, and things will be all right.”

Adi: “I thought, what will be all right? If I don’t have a child, will you give me one?” On the spot, she decided to take the medication. “It affected me badly from the start,” she relates. “I felt like I was down all the time; I would suddenly start crying over something in the middle of work.” To address the timing of ovulation, her follicle development was monitored. “That means getting up early, rushing to the women’s ward [at a hospital]. All the chaos and hysteria around the ovulation disrupted my life completely.”

When Adi complained, her doctor suggested artificial insemination to expedite the process. “That was frustrating,” she says. “From my point of view, it’s conceiving unnaturally.” After the insemination failed, she was given injections to induce ovulation, but they made her feel poorly. “After a time, I decided to stop the hormones – I told myself I had suffered enough.”

Physicians, too, are sharply critical of this hormonal treatment. “Estrofem causes stomach aches and headaches. Where does the permission and the gall to give a healthy woman medical treatment come from, and for a religious matter, too?” Rosenak asks. “It’s not done anywhere.” Adler Lazarovich agrees, adding that she refuses in principle to treat halakhic barrenness with hormones. “If a woman nevertheless wants medicinal treatment, I refer her to another doctor.”

Similarly, Kochman once told me, in no uncertain terms, “It is not medically ethical to give medication to a healthy person; medical treatment for halakhic barrenness seems to me ethically wrong.” Kochman, who headed the ethics committee of the Israel Fertility Association, was particularly disturbed by the fact that Estrofem and Progynova (another name for the same medication) are not well-tested. “We don’t know about their long- or short-term side effects,” she said.

Rabbanit Malka Piotrkowski is also very opposed to hormonal treatment. “Until the present generation,” she says, “there were all kinds of solutions. Suddenly, they discovered the hormones, and now they say, we’ll solve the halakhic problem medically. I’m absolutely against that.” Piotrkowski says that many of the women she has met who suffered from halakhic infertility “began taking hormones, and it completely messed up their systems. Hormonal medication, which come with more than a small risk, are not to be taken.”

Her position on Ikaclomin is even more strident: “There is no reason in the world to give it, it’s a halakhic disgrace for which a solution has still not been found.”

For his part, however, Orbito rejects concerns over health hazards: “These are natural hormones, like those the body creates. They are administered in very low dosage orally, in a way that reduces the risk.” He adds, “With Estrofem, we achieve levels of estrogen which the woman already has in a regular cycle.”

Zeidman, too, says he uses this treatment for women suffering from halakhic infertility “with no qualms”: “To talk about risk in administering Estrofem is demagoguery. There’s no hesitation about prescribing those same hormones as contraceptives. There’s no reason to be against giving Estrofem to a religious woman – that’s her way of life. Some physicians don’t give girls contraceptives; I find that self-righteous. I will give a 15-year-old girl [birth control] pills and not preach to her. That is my ethos. And by the same token, I will not say to a religious woman, ‘Tell your rabbi that he is doing something wrong.’”

Prof. Avinoam Reches, veteran neurologist and former head of the Israel Medical Association’s ethics bureau, rejects the position taken by Orbito and Zeidman. “Every hormonal and other manipulation in order to subordinate a woman’s biology isn’t right,” he told me. “Giving hormones to a woman involves side effects, suffering and even sickness. It is not proper and not ethical to engage in manipulation for religious purposes.”

Tomer Appelbaum

However, the highest levels of Israel’s health establishment seem unfazed by the practice. A spokesperson for the Health Ministry stated that it is a purely clinical issue that is at the doctor’s discretion. Dr. Tami Karni, current chairwoman of the IMA’s ethics committee, also sees nothing wrong with giving medicinal treatment to women suffering from halakhic infertility.

“Generally, medicine is not enlisted to serve the demands of faiths and religions,” she says. “On the other hand, health today is defined not only in terms of long life but also of a high quality life. From this perspective, if a woman can’t conceive and medical treatment improves the quality of her life, it’s legitimate to administer it, provided that she chose it and that it’s not harmful to her.”

Unfortunate daughters of Israel

I met with Dr. Rosenak at the end of a long day, during which he saw dozens of patients at his clinic. The most acerbic of the critics, he has for years been saying in a clear voice that the rules of niddah are baneful for women. They disrupt not only natural fertility processes, but also marital relationships, he says. He’s also critical of his medical colleagues whom he accuses of collaborating with the rabbis: “So you succeeded in getting a woman to conceive after a month, but what treatment did you give her?” he asks, adding, “The campaign against halakhic barrenness has become a life mission for me.”

A religiously observant person himself, Rosenak has an unusual and courageous approach to the phenomenon – set forth also in his book “To Restore the Splendor” (Hebrew) – which has made him more foes than fans. Still, it’s hard to write off the views of this veteran, esteemed gynecologist who’s well-versed in halakha and has a great deal of clinical experience from work in two Jerusalem hospitals, Hadassah Mount Scopus and Bikur Holim. “The Torah does not need prosthetics. If these people were men, medications wouldn’t be given,” he says, adding, “Call me a feminist.”

Emil Salman

Rosenak said his wake-up call came when one of his patients, who had been taking hormones, suddenly had a stroke. Nonetheless, if a patient suffering from halakhic infertility insists, he will prescribe hormones, but only after explaining his reservations concerning the hazards involved in taking them. “If I don’t prescribe them, someone else will,” he says.

Rosenak has devised a boldly simple and hormone-free solution. The Torah stipulates observance of niddah during the seven days of menstruation, which is consistent with the timing of ovulation. The fact that it was the rabbis who added the seven “clean days” leaves an opening for forgoing the extra week. That idea is seen by religious conservatives as a dangerous breach of the rabbis’ authority, and Rosenak is constantly vilified by those circles. Even Dr. Adler Lazarovich and well-known educator and Gemara scholar Malka Piotrkowski – both of whom strongly oppose medical treatment for halakhic infertility – are convinced that it is not permitted to forgo the halakhic injunction of the seven clean days. However, as Rosenak told me victoriously, “In the meantime, no one is boycotting me – I have hundreds of patients.”

Indeed, his ideas, which once sounded off-the-wall, are apparently trickling down.

Five years ago, Yifat, 38, from the country’s center, started to reconsider her observance of the ritual-purification laws. One reason was halakhic infertility, which she realized she had suffered from since age 25, a year after her marriage. “The gynecologist asked me when I went to the mikveh. That’s how I found out for the first time that my ovulation preceded the day of immersion. The skies fell. I thought I wouldn’t be able to have children because of the mikveh.”

Her doctor prescribed Clomifene, she conceived and gave birth to a son who is now 10. When Yifat and her husband thought of having another child, she decided to consult a rabbi first. “I realized that my problem was caused by observing niddah, so I wanted to see if there was a solution in the halakha. The rabbi permitted me to go to the mikveh early. But it didn’t work.” Eventually her doctor prescribed Estrofem, and she soon became pregnant. Looking back now, she regrets taking hormones, considering that she was in a group that was at risk for cancer.

“Over the years, you realize that you took hormones for no good reason and endangered yourself,” she says. “And it’s not because you have a fertility problem. That understanding has given me serious doubts about observing niddah.”

Of all people, Yifat, who for years, when living in Africa, made supreme efforts to get to the nearest mikveh – involving a plane trip to another country – became disillusioned: “It was terrible to grasp that you are actually alone in this,” she observes. “The niddah is ‘on’ me, the prohibitions are on me. I am doubly to blame. It’s very aggravating to know that I am actually missing out on my husband with my niddah. It’s a chauvinistic idea. I started to ask questions. Why am I the one who is impure, who is forbidden?”

She and her husband studied the subject, and when they discovered that the extra week was a stricture laid down by sages that became fixed in practice over the generations, they decided to go back to the original Torah injunction – and saw that it was good.

In fact, growing numbers of observant woman have been abbreviating the niddah in recent years. Sisters and sisters-in-law, female friends and acquaintances – all are spreading the news by word of mouth, Yifat relates. The trend of forging the seven “clean days” is reflected also in confessions by women on Facebook and has spread from the bastion of the liberal followers of Orthodoxy in Jerusalem to the religious periphery, and even has fans in the more conservative settlements. Has the great niddah revolt begun? “It’s a quiet revolution, Yifat says.

Rabbanit Rivka Shimon (her real name), too, has become convinced that the only solution is to stop observing the extra week of niddah and not ask for what she calls fabricated authorization to shorten the time until ritual immersion. An extravagant woman in her 60s, Shimon is a matchmaker and bridal counselor. She currently heads up a group of women who are trying to obtain rabbinical consent to return to a week-long niddah, and in her spare time is busy supporting the Temple Mount lobby.

Shimon: “There are rabbis who permit [a shorter niddah] for secular and traditionalist women, out of the rationale that a secular couple will have a hard time keeping apart for two weeks. For them, the rabbis say, a week is all right. No one ever died from stopping for a week. So why not permit other women, who miss their ovulation window? There are many couples who aren’t willing to live like this, with that tension, unable to realize their love.”

Indeed, the benefits of forgoing the “clean days” week is enormous. It means that a couple can enjoy intimate relations most of the month. “It’s more human,” said one of the women I spoke with.

Yifat agrees: “At some point, the penny dropped, and it came to me that the prospect of conceiving is not the only thing that you lose by observing niddah. Extending the niddah days also disrupts sexual pleasure. A woman has other needs, too. I am not just a machine for having babies.”

In addition to shortening the niddah period, other initiatives relating to women’s bodies and sexuality are also gaining traction among the Orthodox public in Israel, and are attracting the interest of Haredim as well. There are sex-education workshops in schools, advice on “marital relations” (meaning sexual intercourse) for women and couples, and workshops for women about their “sexual journey.”

One Friday a few weeks ago, about 20 women gathered around a large dining table in a private home to discuss their fertility. The participants, most of them religiously observant, some newly married, and others in their 30s and 40s, are part of a growing tide of women who are wondering how to resolve the contradictions that the niddah laws create in their world – of which halakhic barrenness is one – and regain autonomy over their body and their sexuality.

Yifat, for one, says she has acquired a feeling of control over her body. After she stopped observing the seven clean days, she conceived naturally. “I showed them,” she declared. “I knew all along that I was right. It’s not that something is messed up in my system – I know my body.”

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