Fertility Tests and Treatments - Rabbi Chaim Pruss shlita

00:02 Speaker 1 You’re listening to the “Lema’an Yishme’u” podcast from Machon Halacha Chabad.

00:09 Speaker 2 Our topic today is fertility problems after marriage. What is considered a fertility problem? When at least a year has passed—and some say two years—after marriage without a pregnancy, that is when we begin to investigate. It’s important to explain that the age at which a couple marries makes a big difference to when we begin that investigation. A twenty- or twenty-one-year-old man marrying a woman his age is not in the same situation as someone marrying at thirty or older. When a couple marries young, of course, they can wait the full two years. Many rabbis have held that no investigation should begin during those first two years. But if the man or woman is older—and I mean over thirty—the investigation can begin earlier. If the couple already has information, for example, that her periods are irregular, particularly short or particularly long, then we know from the outset that there is something to look into. In general, fertility problems can be divided into categories: some are on the woman’s side, some on the man’s side, and in some cases there are problems on both sides. I would say almost every doctor gives different percentages. Some say 35 percent of problems are on the man’s side and 35 percent on the woman’s side. Blocked fallopian tubes. In some cases, the cause is unknown. But the percentages are less important for us than knowing how to begin investigating when something like this happens to us.

02:19 Speaker 2 So I’ll start with the Rebbe’s instructions. The Rebbe says that when this happens, it is advisable to review the relevant halachos and be meticulous about the laws of family purity—to consult a rabbi and ask what needs to be done, and so on. Once we’ve done all that, before beginning the medical investigations, I want to offer a practical suggestion that will make the process easier later on, because it can sometimes be very taxing. It’s important to be organized. Being well organized makes the whole lengthy process easier. What does that mean? Prepare a folder or binder for all the medical tests. Print out the result of every test from the computer and file it neatly. Put the woman’s tests on one side and the man’s on the other. That way you have an orderly binder containing every blood test and every result. If, for example, either person has had surgery or takes medication, get a summary of their medical history and put that in the binder too. Anyone who can should consider seeing a private doctor. We know that, more often than not, money gets the system moving faster. I would also suggest arranging supplementary health insurance through your health fund beforehand. It’s worth checking—even through Bonei Olam—which health fund is best. Some health funds cover more tests and others fewer, so sometimes it’s worthwhile for the woman, or even both of them, to switch from one health fund to another. Sometimes there’s a three-month waiting period, so you wait those three months.

04:19 Speaker 2 That’s a general introduction to these matters. Let me add that, under normal circumstances, it is commonly understood that a woman has about a 20 percent chance of becoming pregnant in any given cycle. After a wedding, in most cases a month or two passes—sometimes longer—before the couple can have marital relations regularly at all. So those first two or three months after the wedding should really be left out of the calculation. Of course, there are cases where a woman becomes pregnant right away, but the first few months needn’t worry us. Some are also concerned that medication taken before the wedding to delay ovulation and regulate the period can cause various disruptions, and that it may take time for the body to clear it. When we begin looking into why a woman has not become pregnant, we investigate both sides: what is happening with the woman and what is happening with the man. First, we need to find out whether her periods are regular. What do we mean by irregular? A cycle shorter than twenty-five days, or longer than thirty-five to thirty-seven days, gives us a first clue to work with. We can start looking at what is happening, and I’ll explain what the problem might be. For most women, ovulation occurs, on average, fourteen

06:39 Speaker 2 days before the next period. In other words, we measure ovulation not from the previous period but from the one to come. Ovulation occurs fourteen days before that next period. So if a woman’s cycle is twenty-five days, fourteen days before that is day eleven. If she ovulates on day eleven, the window for becoming pregnant after going to the mikveh is very tight: five days of menstruation plus seven clean days bring us to day twelve, so she immerses a day too late. There are also many cases where a woman does not immerse on time because of various instances of bleeding. Even if her cycle is not twenty-five days but, say, twenty-eight or thirty days, she may not be able to become tahor until day fifteen or sixteen. I remember a case from some time ago. A woman called me and said that for quite a while she had been unable to become tahor. On the fifth or sixth of her seven clean days, she would always see a bloodstain and start counting all over again. She told me she hadn’t been able to become tahor for three months. I asked her to come and show me the stain, and I saw that it posed no halachic question at all. In other words, there are cases where women are stringent with themselves for no reason, delaying immersion. Then they cannot become pregnant because ovulation took place many days earlier. So the first thing, when there is, there is

08:35 Speaker 2 Staining during the seven clean days: don’t be stringent on your own, and don’t decide on your own that a particular stain is forbidden. You need to ask a rabbi whether the stain makes the woman impure or not. That’s the first important point. In the initial assessment, we start by finding out what’s happening with the menstrual cycle. Is she getting a period? Is she not? There’s another point we need to discuss, and it isn’t so comfortable to talk about: whether the couple is actually having intercourse in a way that can lead to pregnancy. Because if they aren’t, there won’t be a pregnancy. These are subjects that aren’t pleasant to discuss. But when you go to a specialist, an adviser, or a rabbi who works with a specialist in this area, you need to know that you have to put everything on the table and speak about it clearly, so they can identify what’s preventing pregnancy. If bleeding lasts more than five days—prolonged bleeding—then they need to check whether the woman has a polyp in the uterus, a fibroid, or an overly thick uterine lining. In some cases, the problem needs to be addressed regardless of why there’s no ovulation, why ovulation is late, or why there’s staining. Ovulation can be checked in several ways. There’s a home ovulation test kit you can buy at a pharmacy and use according to its instructions. Using it on Shabbos presents a problem. Halachic authorities differ over whether it may be used on Shabbos, but during the week it certainly can be used. Some people measure their temperature, which rises after ovulation, so they take their temperature first thing every morning. So there are

10:37 Speaker 2 ways to check ovulation yourself and find out when it occurs. Otherwise, we go to the health clinic for blood tests and ultrasound follicle monitoring to see when ovulation occurs. We also check the general health of both spouses. What’s going on with them? I’ll give a few basic things we check to understand what’s going on with the woman. First, being overweight can lead to polycystic ovaries, which we’ll discuss later, and that can also make it harder to conceive. We do a blood test called a hormonal profile, which checks the woman’s hormone levels. We do this test at the start of her period. After that, she may also be asked to have an ultrasound called follicle monitoring, to find out whether a follicle is developing even though she isn’t becoming pregnant. Now, if a woman notices that she has certain symptoms—and I’ll give a short list of symptoms that raise questions for us—then, if she isn’t becoming pregnant and has these symptoms, they need to be investigated. We mentioned irregular periods. A woman who has a lot of acne may be showing signs of polycystic ovaries. Excess facial hair, oily skin or dandruff, as well as diabetes, high cholesterol or high blood pressure. If she has become pregnant but had miscarriages, or has a greater tendency toward depression—all of these things, or some of them; they don’t all have to occur together—can tell us that there may be an ovarian problem that needs to be checked. Later, if the ovaries are examined and they’re fine, with follicles and so on, they move on to another, less pleasant test: a uterine X-ray.

13:05 Speaker 2 That’s to make sure there’s no blockage in a fallopian tube. For a pregnancy to occur, the sperm travels from the uterus into the fallopian tube, and it’s in the tube that it meets the egg coming from the ovary. When the sperm reaches the fallopian tube, that’s where the egg and sperm meet. Now, if the tube is blocked, that meeting can’t happen. For many women, the problem is a blocked fallopian tube, which can have various causes. For the uterine X-ray, a substance is introduced into the uterus and flows through it. In the past, they would do this by inflating the uterus. In many cases, the procedure itself resolved the problem: the tube opened, the egg and sperm could meet, and the woman became pregnant. But this is a very important test, because it can tell us whether or not there’s a problem with the fallopian tube. Sometimes there’s a problem with the uterus: a uterine septum or a bicornuate uterus. Some women with a uterine septum can become pregnant, and others can’t. It depends on how far the septum extends into the uterus. There can also be uterine adhesions that prevent the pregnancy from taking hold, or the uterine lining may be too thin. The woman undergoes a series of tests to make sure everything is functioning properly. Now, from a halachic standpoint, there’s no problem with the woman having these tests. The question is whether a particular test makes her impure or not. It’s important to know that there isn’t a consensus among rabbis about all the tests. As with any subject, we know there’s kosher and there’s mehadrin kosher; there’s a tendency toward stringency here too.

15:14 Speaker 2 On this subject, there are differing opinions. So it’s important for every woman to call her rabbi and ask whether a particular test makes her impure or not. Generally speaking, an ultrasound does not make a woman impure. But again, with any examination, there’s the question of whether blood appeared during it. Whenever you go for an examination, it’s worth asking the doctor how thick the instrument inserted was, whether the doctor saw blood during the examination, and whether the doctor caused any injury. Regarding a uterine X-ray, I can say that among the people at Bonei Olam, and in what I would call the charedi community, the halachic approach is that a uterine X-ray makes a woman impure in every case, whether blood was seen or not. There are other approaches as well. So every woman should ask her rabbi what the ruling is: whether a uterine X-ray makes her impure or not. A uterine X-ray isn’t the most pleasant test compared with the others. But I’ll say that it’s also a very important test for a woman, to make sure her entire reproductive system is functioning properly. A woman going for a uterine X-ray should also call her rabbi beforehand and ask a few questions, because he may advise her about when to have it done. In most cases, it’s done during days when the woman is impure anyway. But it’s preferable to do it before she performs a hefsek taharah, because according to our approach, if she has the test, she’ll need to

17:07 Speaker 2 To do another hefsek taharah. But if she saw blood, or if she was injured, and so on, then we need to determine whether the blood came from a wound. That affects whether, going forward, we need to be concerned about the wound or not, and so on. Once the woman has had all the tests available to her and everything has been found to be normal, we begin testing the husband. Today, doctors tend to investigate both sides at once. When a couple comes to a doctor, the doctor sends the woman for tests and, at the same time, sends the husband for tests as well. We do not accept that approach. First, the woman should have all the tests she can have, and only afterward, when everything has been found to be normal for her, should we begin testing the husband. But there can be exceptions. If, for example, we know for certain that the man has had various infections of the testicles, or has had mumps or other illnesses, then we have more reason to suspect that the problem lies with him. Even then, though, we would still require some of the woman’s tests to be done. The question will always be about a uterine imaging test, because that is a more invasive procedure. Should we require it before proceeding to test the husband? In such a case, I would say to refer the question to a rav and consider each case on its own merits: may the husband be tested before the woman has that test? Now, when we talk about testing the husband, we need to understand that the tests are unpleasant. In fact, even discussing these subjects is uncomfortable.

19:08 Speaker 2 It is not something pleasant to sit and talk about. But when a couple wants to bring children into the world and cannot do so in the usual way, we do need to pursue it. As the Tzemach Tzedek said, to bring children into the world one must be prepared to make sacrifices. As for the woman, the problems, broadly speaking, may be a blockage in the fallopian tubes; a problem with implantation in the uterus, where for some reason the uterine lining does not support it; or problems with ovulation. These are generally the main issues for the woman. Ovulation may be late, or there may be no ovulation for one reason or another; there may be a blockage involving the ovaries or a problem with the uterus. When we turn to the man, the question is: Is there sperm at all? Once we establish that there is sperm, there may be a problem with the way it is released. That could be due to various mechanical or other issues, and we need to investigate what can be done. So with the man, we need to check two things: Are there sperm cells or not? And if there are, what happens when they come out—how are they released? On the first question, we would ask: Has the man undergone chemotherapy? Has he had infections of the testicles? Has he had mumps? There is a genetic condition called Klinefelter syndrome, in which there are two X chromosomes and one Y chromosome. There may be an enlarged vein that requires a minor procedure to correct it. There can also be a problem for people who work sitting down all the time, such as truck drivers. They say that the area gets too warm, which can cause problems with sperm.

21:22 Speaker 2 Obesity, drug use, or heavy alcohol consumption could also raise questions about why a pregnancy is not occurring. As for how to do the tests, there is no problem as long as they are physical examinations of the man. The difficulty arises when he is asked to provide a sperm sample. How is a sperm test done? There are several methods. Again, when a doctor recommends this, one should go to a rav and ask what to do: what is permitted, what is forbidden, and how to do it. Even if the doctor tells you, “I work with this institute,” or “I work with that institute,” and says that many people do it this way or that way, do not rely on that. Call a rav and ask: “We were advised to do A, B, and C. May we go ahead with it?” In fact, throughout this process of investigation, it is worthwhile to call before every step, or to remain in regular contact with a rav who understands these halachos. At each stage, you should know: We are going to do procedure A, B, or C—which are permitted and which are forbidden? Sometimes the woman or the man will be given medication and the problem will be resolved. The question arises when the problem is not resolved and more extensive measures are needed. What is permitted, and what is forbidden? Broadly speaking, when the direction is toward insemination—artificial insemination—or in vitro fertilization, those are procedures that are permitted. They too are not simple, but they are procedures that can be permitted in our community. The question, then, is how to carry them out in a permitted way, without

23:37 Speaker 2 any concern. There are several letters from the Rebbe on this subject. Returning to the tests for the man, I want to repeat that they present more halachic issues than the tests for the woman. Therefore, it is very advisable to consult a rav before every test the man is going to have, and ask whether that test is permitted or forbidden. And I repeat: Do not rely on something someone opens and reads on one website or another. Every case must be considered on its own merits; you cannot draw conclusions about our case from those other cases. Particularly, I would say, someone who observes halachah meticulously in every aspect of life and eats only mehadrin kosher food should approach these matters the same way—as G-d-fearing Jews who want everything they do to be in the best possible way. So I will not go into the details of the tests for the man here. I will just say, generally, that there are tests for the man, and one must seek guidance on when to do them and how to do them. May Hakadosh Boruch Hu help everyone receive good news. And as we said at the beginning, the Rebbe says to start by studying the halachos. Through studying the halachos, the problem will already be resolved, and everyone will merit to see children and grandchildren engaged in Torah and mitzvos. We spoke about couples who have difficulty bringing children into the world. Here, we will discuss some of the available solutions. Let us begin this way: When the problem is with the man, and he has sperm, while everything is normal with the woman, and we do not actually know what the man’s problem is but we do know that he has sperm, then the doctors’ recommendation

26:07 Speaker 2 Usually, the next step is artificial insemination. What does that involve? It is done after the husband has a semen analysis, which looks at three main factors: the sperm count, the shape of the sperm cells, and their movement—their motility. Usually, when doing artificial insemination, they focus on the count and motility, and less on the shape. The method of collecting the semen also requires a rabbi’s approval. We’ll explain later which things require approval. Artificial insemination means that the husband has marital relations using what is called a halachic condom, and the semen is collected in it. He removes the condom, empties its contents into a small container, closes it, and it has to reach the laboratory within about an hour. When the husband and wife arrive at the laboratory with the semen, it is inserted into the woman’s body. This procedure is done when no problem has been identified with the husband—he has sperm cells, and everything is normal with the wife. We think that perhaps the semen is not being deposited where it needs to be. So we collect the sperm cells and insert them into the woman’s body with an instrument. In many cases, this artificial insemination—meaning that the wife is inseminated by an artificial means, but with her husband’s sperm—results in pregnancy. Of course, for this to be done by having marital relations, the wife must be tahor. There is no way for the husband to provide the semen in this manner unless his wife is tahor. If they expect that she will not be tahor on the required date, so that they cannot collect

28:37 Speaker 2 the semen using a condom, they must wait until she is tahor and then collect the husband’s semen. If the wife is not yet ready for insemination—because she needs medication to prepare her for the optimal time—they may freeze the semen until the following month. Then they will thaw it and insert it into her body. The artificial insemination procedure does not render the woman impure, because the tube inserted into her body is extremely thin. There is a disagreement among the poskim as to whether artificial insemination is permitted when the woman is not tahor, even if frozen semen is available. This situation arises when the woman ovulates before she immerses in the mikveh: if we wait until after immersion to do it, ovulation will already have passed. In such a case, they look for solutions. If they can delay ovulation until after immersion, that is good. When that cannot be done, there is a disagreement. After all, they are not having marital relations; the semen is only being inserted into the woman’s body. Among our community, in any case, the practice follows the Rebbe’s response to Rabbi Heller, which required artificial insemination, too, to be done only when the woman is tahor. But every case must be considered on its own. One must obtain a rabbi’s permission, explain the circumstances, and determine whether the procedure can be delayed. It depends on the woman’s age and how many times they have done this. So this, too, is something that must

30:37 Speaker 2 be asked about. There will be cases where they are told explicitly that there is no alternative: they must freeze the semen, or not yet thaw the frozen semen, and wait for the next cycle. Sometimes that is not very convenient, because the woman has to start taking injections and pills again, and so on. But if we want everything to be done in accordance with halachah, that is what must be done. Sometimes, in addition to collecting the husband’s semen, they also want to do sperm preparation—to bring the sperm into a better, more optimal condition. They do this when the sperm count is very low. When the count is very low, meaning there are very few sperm cells, they prepare the sperm to make the best use of what is available. There are other cases where sperm preparation is done: couples in which the woman has ovulation problems and is receiving hormonal treatment to increase the number of follicles, or cases where both spouses apparently have normal results but no one knows why the woman is not becoming pregnant. They will do sperm preparation in those cases as well. How do they first assess the quality of the sperm for this preparation? As we said, sperm quality is measured by three important factors. One is concentration: how many sperm cells there are in each milliliter. There should be between fifteen and twenty million sperm cells for the result to be considered normal. A lower concentration can result from various problems, including hormonal disturbances or genetic changes. So that is concentration: the question is how much sperm we find. In some cases, they find none. If they find none, then there is no

32:42 Speaker 2 sperm at all. But if they find fewer than fifteen million—one million, or fewer than a million—that is a very serious problem that needs attention and a solution. Then there is sperm motility. The sperm cells move; they swim like fish. The proportion of sperm cells with normal movement should be about forty to fifty percent of all the sperm cells. They have a kind of chart that they use to count how many sperm cells are good and how many are not, and calculate the percentages accordingly. The books say that if fewer than thirty-two percent of the sperm cells are motile, that already indicates a likelihood of a fertility problem. Sperm motility can also decline if a couple does not have marital relations, or because of infections or various other factors. Then there is morphology—the shape of the cells, what they look like. That is somewhat difficult to assess, and there are several methods of doing it. The results are not uniform from one laboratory to another. Again, a lower proportion of normally shaped sperm cells can result from abstaining from marital relations or from various other medical causes. After all these tests have been done on the husband’s semen, if we find that his sperm count is low, as reflected in one of the three factors we discussed, sperm preparation will be recommended. For this preparation, the semen must reach the laboratory within about an hour of marital relations. First, as we said, they assess its quality according to the factors we discussed earlier. Then they transfer the semen

35:02 Speaker 2 through a kind of filter that leaves the poorer-quality sperm at the top and lets the better sperm pass down to the bottom. That way, from what is available, you can obtain the better sperm cells. At the end of this process, a solution has to be added to the sperm—antibiotics and other substances. These substances allow the sperm to be introduced into the uterine cavity through a thin tube during the woman’s insemination, so that the sperm cells can be taken up inside the uterus. In artificial insemination, the sperm that enters the uterus still has to travel on to the fallopian tubes, meet the egg there, and then return to the uterus. This, too, raised a halachic question: when something is added to the sperm during sperm preparation, we have to make sure no cells from someone else are being introduced. We need to know what substances are being added, and whether any of them came from another person’s sperm. That is why sperm preparation requires supervision by someone knowledgeable, who can ask what substances are being added, what they are made of, and so on. When sperm preparation is combined with insemination, the reported success rate for achieving pregnancy is between fifteen and twenty-five percent. Of course, other factors have to be considered alongside those figures: the woman’s age, and what the initial sperm results were that led the husband to undergo artificial insemination. So supervision is needed to make sure that it is the husband’s sperm entering the woman’s uterus, and that no other sperm is introduced. There is another issue here as well, concerning lineage—the relationship between a son and his father. The question always comes up; the Gemara discusses it. Why do we need to know a person’s lineage? Who his father is? So that we know

37:41 Speaker 2 that a brother does not marry his sister, or a father his daughter. That is why, for example, a woman who is divorced or widowed must wait three months after the divorce or her husband’s death before remarrying, to distinguish between the sperm of her previous husband and that of her new husband. This applies even if a divorced woman had not lived with her husband for six months or a year before the divorce. The Sages did not distinguish between cases where a woman might have lived with her husband the day before the divorce and cases where they had not lived together for a long time. They established a general rule that she must wait three months. These are called the three months of distinction: to determine whether a child was conceived from the previous husband’s sperm or the new husband’s. Even though today a pregnancy test can show whether or not a woman is pregnant, this halachah remains in force. The Sages made no such distinction, and the requirement to wait three months remains. Each case may have its own circumstances. If the woman can no longer have children, for instance, some would permit her to remarry sooner. But in principle, the reason for the wait is to distinguish between one husband’s sperm and the other’s. When a woman undergoes artificial insemination, we must establish with absolute certainty that the sperm entering her body is her husband’s. Otherwise, how do we know who the father is? We know who the mother is at birth, but how can we know who the father is? Some people ask how we can know who the father is in any case. But we have a principle: a married woman is presumed to be faithful to her husband, and the husband to his wife. So if she becomes pregnant, she has certainly conceived from her husband and not,

39:39 Speaker 2 G-d forbid, from someone else. In the language of the Gemara, this is called “most acts of intercourse are attributed to the husband.” But with artificial insemination, we cannot apply that principle, because we know explicitly that conception did not result from intercourse. It happened through a medical procedure. Here, then, we need certainty. We need testimony—not necessarily two witnesses; one reliable witness is sufficient here—but there must be definite halachic supervision establishing that this child really is the father’s child. And if he is the father’s child and is a firstborn, then he is this father’s firstborn. If the father is a Kohen, the child is a Kohen. If the father is a Levi, the child is a Levi. Take the example we discussed in the previous lesson of a woman who conceived in a bath. How could we know who the child’s father is? Again, we would need witnesses to establish that, from the time the bath was filled, no one other than this father had been in it. Then we could know that he is the child’s father. Otherwise, we cannot know that he is the father. This is the important reason that, in all these procedures—the medical procedures, as I call them—when artificial insemination is performed, and, as we will see later, with in vitro fertilization as well, the moment sperm is introduced into a woman’s body, we must establish with absolute certainty that it came from her husband and not from someone else. Human errors can happen; deliberate wrongdoing can happen. It is absolutely forbidden to do these things without halachic supervision. Suppose we are dealing with a couple who have undergone artificial insemination several times without success. Or there are cases where the problem is not with the man but with the woman, particularly if we know that her problem involves

41:42 Speaker 2 the fallopian tubes. In such a case, even if we perform artificial insemination and introduce sperm into the uterus, it cannot reach the fallopian tube if, for example, the tube is blocked and we have been unable to open it. Pregnancy cannot occur, and a different procedure is needed. Earlier we were talking about cases where everything is normal with the woman and the problem is with the man, or where we do not know what the woman’s problem is. In those cases, artificial insemination, or sperm preparation combined with artificial insemination, was tried. There is another method called in vitro fertilization. It begins in the same way as artificial insemination: the man provides the sperm using the halachic condom. But afterward, another procedure is performed on the woman. Fertilization takes place outside her body, after eggs have first been retrieved from her. The woman is given medication to help the follicles mature. The follicles in the ovaries are monitored by ultrasound, and then a needle is inserted through the vagina. At a certain point, the needle is passed through the tissue into the ovary—not through the uterus—and the eggs are drawn from the follicles. This is called egg retrieval. The retrieval is always done under anesthesia, in the great majority of cases under general anesthesia, and the eggs are collected. Before retrieval, to make sure there are enough eggs to collect, the woman receives hormones to increase the number of follicles in the ovary and promote their development. Having more eggs increases the chances that embryos will develop.

44:12 Speaker 2 And for the success of the whole treatment. So the treatment will be a combined one. First, we take sperm from the husband. Once we have that, we retrieve the eggs from the woman. At that stage, the eggs are placed in a laboratory dish under the right conditions, and the sperm cells that have been prepared—meaning cleaned of contaminants—are added. Then they wait for a sperm cell to enter one of the eggs. How many eggs they place there depends on how many they want to transfer back into the woman’s body. If they place one egg with many sperm cells, only one egg can be fertilized. If they place more, they can transfer two eggs back into the woman’s body; at most, there would be twins. They can also freeze some of the fertilized eggs. In other words, in IVF we take sperm from the man and eggs from the woman, place them together in a special dish, and there the sperm cell tries to join with the egg naturally. We’re talking about the beginnings of a baby, in a sense: the sperm cell joins with the egg. When we see that an egg is dividing, we place it in something like an incubator with all the right conditions. Once it divides, we can see that fertilization has taken place. We then know that the egg is fertilized, and it begins to divide. In those first days, we can call it a pre-embryo. After several days—anywhere from the second to the fifth day—they take it out of that environment and transfer it into the woman’s uterus. Now, throughout all these steps of bringing the sperm

46:35 Speaker 2 together with the egg, placing them in the device where they are kept, taking them back out, and transferring them into the woman’s body, a woman must supervise and watch to make sure that what is transferred back into her body is her own egg and her husband’s sperm, and that nothing else gets mixed in. The uterus is also prepared from the outset with hormonal treatment so that it has the best possible conditions for receiving the embryo. If, for example, we’ve retrieved eggs and fertilized them, but for any reason we see that the uterus is not in optimal condition, they will freeze these pre-embryos and transfer them the following month or two months later, as needed. Today, several embryos can be frozen. This is a very significant benefit: the husband does not have to provide sperm again, because we already have fertilized eggs and only need to transfer them into the woman’s body. It is easier for the woman, too, because egg retrieval is a procedure performed under general anesthesia, and that is not easy for her. So if several eggs have been retrieved and fertilized, we can transfer just one back into the woman’s body and freeze the rest. If this pregnancy does not succeed, they can be used in later attempts. If it does succeed, they can remain frozen for several years and be used a year or two later. That is what we mean by embryo freezing. There is also the case of women who, for various reasons, have not married at a young age and are afraid they will lose

48:38 Speaker 2 their eggs and the ability to have children, so they freeze their eggs on their own. Or a woman may, G-d forbid, be about to undergo treatments that could damage her eggs, so she freezes them on their own as well. Eggs can be frozen on their own, and it is also possible to freeze what are called embryos or pre-embryos. Once the egg and sperm have come together, the egg has been fertilized and has developed for a few days, it can be frozen and later transferred back into the woman’s body. There are also several ways to bring the sperm and egg together in the dish. We spoke about them meeting naturally, but often the sperm cells did not enter the egg. Researchers and doctors then began looking for a way to get the sperm into the egg so that fertilization could take place. This is called micromanipulation. One interesting method is ICSI. They take a single egg and a sperm cell and, using needles, insert one into the other: they make a tiny opening in the egg and introduce the sperm cell into it. That is how fertilization begins. After repeated successful attempts, we now see that this method has increased the success rate of IVF, particularly when the problem lies with the man. Even if they find just one good sperm cell, they can insert it into an egg, and a child may eventually be born from it. That also depends on the quality of the sperm cell. The more advanced the laboratory and its equipment, and the more expert its staff, the more closely they can examine that sperm cell and determine that it is completely healthy.

50:56 Speaker 2 Then what they transfer back into the woman’s body is an egg into which such a sperm cell has been inserted and in which fertilization has begun, with a better chance of implanting in her body. That is to say, even when we succeed in fertilizing an egg in vitro, it does not necessarily mean the uterus will receive it. In many cases, fertilization in vitro succeeds—the rate of success at that stage is higher—but when the embryo is transferred back into the woman’s body, her body does not receive it. Her body rejects it. Researchers are also trying to understand why the uterus does not receive the fertilized egg. In most cases, it is still beyond our understanding, beyond medical understanding, what exactly prevents the uterus from receiving it. Of course, the whole process of IVF carries a number of risks, as does any invasive medical treatment. But if, in the end, it can enable a woman to become pregnant, all of this is worthwhile. We also have to bear in mind that, as we mentioned at the beginning, the woman receives hormonal medication to increase the number of follicles in the ovaries. Her estrogen level may then rise, and her mood may change somewhat. There are risks involved in the ovarian puncture as well. But when everything is done under proper supervision, in most cases it succeeds. When you talk about success rates, are those rates really relevant? Let’s put it this way: for someone for whom it succeeds, the success rate is one hundred percent; and if it does not succeed, then the lack of success is one hundred percent. So the overall chances are

53:03 Speaker 2 Well, just to give the statistics: fertilization in the lab succeeds about 80 to 85 percent of the time. But fertilization in the lab is not enough for us. We then need the pregnancy to take hold, and that rate drops to 20 to 25 percent. The chance that the pregnancy will take hold and continue to term drops to 15 to 18 percent of all treatment cycles. So if a woman goes through cycle after cycle, statistically, after a number of cycles it should succeed. But again, you never know where any particular woman falls within those statistics. How many embryos should be transferred back into the uterus? This is a complex question. You can transfer one embryo or two, but each option has advantages and disadvantages. A multiple pregnancy is also a high-risk pregnancy, and one pregnancy may interfere with the other. So there are no fixed rules. It needs to be the couple’s decision how many they want transferred back. In some cases, the doctors also recommend transferring just one to increase the chances of success. Even though, seemingly, if it does not succeed, that one is lost, whereas if there are two and one is lost, the other remains. But there are differing opinions on this, and recommendations from the Israeli association and from medical associations in Israel and around the world. In any event, whenever we have fertilized eggs—as we said, when there are more fertilized eggs than we need—we have an early embryo ready for transfer that we do not want to transfer. What we do is freeze it again. As we mentioned earlier, freezing it has

54:59 Speaker 2 an advantage: if this pregnancy does not succeed, it can be used again, and even if this pregnancy does succeed. A woman who has had her first child through IVF is quite likely to need IVF again, and then there is already an embryo ready, so she does not have to go through the entire process again. There is also a discussion about parentage in IVF, similar to the discussion about artificial insemination. Here, even those who agree that with artificial insemination the child is the child of both the father and the mother have a further question, because in this case no sperm was introduced into the woman’s body. The entire fertilization took place outside the body: the egg was taken from the woman and the sperm from the man, and only afterward was the embryo transferred into the woman’s body. But in fact, there is a letter from Rabbi Wosner from 5770 in which he writes that, according to the Torah, these children are their parents’ sons and daughters in every respect, and through them the parents fulfill the mitzvah of being fruitful and multiplying. There is also a discussion about whether they may be circumcised on Shabbos. His opinion is that these children may be circumcised on Shabbos as well. And that is how things stand today. I would say it is accepted by nearly all opinions that the child is considered the child of his or her biological father and mother; only the initial joining took place outside the woman’s body. Everything afterward continues inside her body. Therefore, a firstborn son resulting from IVF is redeemed as usual, with a bracha; he is considered a son in every respect. There is also a question if several eggs were retrieved at the same time, and suppose the first egg retrieved was frozen, while the second was transferred. Then, with regard to

57:10 Speaker 2 which child is the firstborn, we look not at which egg was first retrieved from the mother’s body, but at which egg led to the earlier pregnancy. What matters is the time of birth, not the time of fertilization. It makes no difference which egg was fertilized first in the lab; what matters is which one was transferred into the woman’s body and led to the birth. The egg that came first but remained frozen for a later time does not determine the firstborn. The firstborn is the child born first. Of course, IVF requires halachic permission. There were times when it was not permitted until after ten years; later, some moved away from that position. So there are discussions on both sides and many opinions. In the responsa Tzitz Eliezer, volume 15, responsum 45, there is a very lengthy discussion of all these opinions. He discusses how important it is to be meticulous about supervision, particularly because in earlier years he saw much greater cause for concern regarding supervision. Today, with higher success rates, doctors are not looking to introduce someone else’s sperm or mix other sperm with the husband’s. But because of these concerns, many were very wary of all this, and some said not to do it at all. Some rabbis did not want to either prohibit or permit it. We also know that the Rebbe’s initial position was to oppose it, and only later, after all the clarifications received from the rabbis and all the conditions put in place, did the Rebbe agree to it. We have discussed several of the problems involved. In addition to the first question—whether this involves the wasteful emission of semen, a question that applies to all these procedures—the major concern here is ensuring that there is no mix-up, with someone else’s sperm or another woman’s egg being used. Therefore, in practice, the vast majority of contemporary halachic authorities permit IVF, on condition

59:29 Speaker 2 that the couple has no other way to have children. They would not undergo IVF in order to have a boy, or to choose whether the child will be a boy or a girl, or for reasons like that—only if there is no other way to have children. Now that we have reached the subject of IVF, there are other procedures used in the medical world, but the Haredi community does not engage in them. I will mention them only briefly. One is egg donation: for example, a woman who has no eggs of her own can receive a donated egg. It is also possible to receive donated sperm. Perhaps these subjects will be covered in a separate class: what sperm donation and egg donation involve. There is another procedure called surrogacy. If a woman cannot carry the embryo in her own uterus, a surrogate carries the child in hers. In such a case, the sperm can come from the father and the egg from the mother, but after fertilization the embryo is transferred into another woman’s body. That raises all sorts of halachic questions. We will not address that subject now. What we discussed as halachically possible are the two procedures we spoke about at the beginning: artificial insemination and IVF. Haredi halachic authorities permit them under the conditions we mentioned: before each and every step, one must consult a rabbi with expertise in these matters about how to proceed, and, in general, there must be halachic supervision at every stage of these procedures.