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Fertility Guidance, Ovulation Testing, Ovulation Testing, Women's Health

Ovulation Testing

I. Introduction: the Biology of Ovulation
The timing of intercourse plays a crucial role for all couples attempting to conceive. While sperm live for two to three days, the egg is viable for only 12 to 24 hours. Therefore, marital relations should ideally occur in the days prior to ovulation to give the sperm cells enough time to travel as far into the fallopian tubes as possible by the time the ovum is released.
On about day 12 of an average 28-day menstrual cycle, one of the ovaries releases a mature ovum into the fallopian tube leading to the uterus.  If the ovum encounters sperm cells early enough in its journey through the fallopian tube, the two cells can meet while both are still viable, and proceed toward implantation and pregnancy.

Complexities of Ovulation

Although people commonly assume that a woman’s peak fertility coincides more or less with her immersion in a mikveh, this is only true for an average menstrual cycle of 28 days and an average menstrual period of 5-7 days.  If ovulation occurs later, the couple should adjust their attempts accordingly. If testing reveals that ovulation occurs before the woman will immerse in a mikveh, a number of halachic considerations come into play.

Lack of ovulation (anovulation) or irregular ovulation are a different type of challenge and a number of treatment options exist for inducing and regulating ovulation.

In this article we will describe methods of testing when ovulation occurs.

II. Ovulation Testing
A. BBT testing

Basal body temperature testing is the simplest and least invasive method of determining ovulation.  All that is required is a thermometer and some means of tracking daily temperature variations. Basal body temperature (BBT) – a person’s temperature at rest – rises about one degree Fahrenheit at mid-cycle and maintains that increase through the second half of the cycle (not all women are equally sensitive to theses changes).

To track BBT, a woman will generally take her temperature orally every morning before engaging in any activity, then record the reading. The couple can choose to attempt conception immediately upon detecting the rise in temperature, but as mentioned above, the odds favor intercourse that precedes ovulation by at least a day. If her cycle is reasonably regular, the couple will know for the following cycle how to time their attempts.

B. Home ovulation testing kits (LH tests)

Although helpful, BBT charting has its limitations, especially for those women whose BBT changes do not clearly indicate ovulation. A more precise test is to check for lutenizing hormone (LH) in the urine. LH triggers ovulation; if it is absent or too low, ovulation has not happened. Under normal circumstances, the development of a “ripe” ovum prompts the release of significant amounts of LH. The increased LH level precedes ovulation by 12-36 hours, usually on about day 14 of an average 28-day cycle.

Using a home testing kit, a woman can determine her LH level and thus anticipate ovulation in order to optimally time intercourse. Using the test requires dipping a color-coded stick into a urine sample; the colors indicate different levels of LH.

C. Ultrasound Testing

Many specialists use ultrasound testing (sonograms) in addition to other ovulation testing. The test can help provide an additional indication whether ovulation is taking place, and what her egg supply might be.  In the test, a probe is inserted into the vagina up to the cervix, but no farther.

III. Halachic considerations
A. Testing on Shabbat

Each of these methods present challenges with regard to Shabbat:

BBT.  The most obvious hurdle is that of recording the temperature, as writing is a Biblically prohibited melacha. Fortunately, one can easily circumvent the issue, either by remembering the figure and writing it down only after Shabbat, or by preparing number pieces before Shabbat and selecting the appropriate ones.

The other problem involves taking temperature, which might violate the Rabbinic prohibition to measure on Shabbat (part of the prohibition against commerce, which itself is prohibited lest one write). The Tzitz Eliezer rules leniently in this case and allows a standard mercury thermometer1.  Rabbi Moshe Feinstein and Rabbi Shlomo Zalman Auerbach both note that temperature is not associated with commerce at all, and therefore not included in the prohibition2.  One must, however, avoid using creams, lotions or the like to assist in taking temperature rectally, for example, and avoid soaking cotton in alcohol to clean the thermometer afterwards; even dipping the thermometer in alcohol is problematic unless one intends to use the thermometer again on Shabbat.

Home ovulation testing kits.  Coloring of the test strip is a formidable challenge, as coloring is a Torah prohibition. Rabbi Shlomo Zalman Auerbach’s recommendation is to cause the color change in the test strip indirectly by dipping only the edge of the stick in the urine and letting the urine diffuse into the rest of the stick on its own3. Once this is done, one may not handle the urine sample again until after Shabbat, as it is muktzeh4.

Ultrasound testing.  Ultrasound equipment runs on electricity, which may not be used on Shabbat except to save a life. The test can generally be scheduled for some other day of the week; if it cannot, it is generally forbidden to have the test performed on Shabbat. A competent halachic authority should be consulted for each case, as it may involve additional Shabbat considerations such as transportation and commerce beyond the technicalities of the sonogram itself.

B. Niddah status

BBT and Ovulation testing kits.  Neither of these pose any niddah-related problems.

Ultrasound testing.  The ultrasound procedure, as noted above, involves inserting a probe into the vagina. Any such contact of an outside object with the vaginal canal can be cause for halachic concern, as it may induce bleeding.  In this case the concern is minimal as (a) bleeding as a result of a vaginal ultrasound is rare; (b) since the probe does not penetrate beyond the vaginal canal, any bleeding that might result is not significant as far as the laws of niddah are concerned.

IV. Summary
  • The ideal time for intercourse is a window of 5 days concluding with the day of ovulation.
  • Methods of predicting ovulation vary and couples may encounter Shabbat and niddah related considerations.
  • On Shabbat BBT testing may be performed with a mercury thermometer.
  • On Shabbat the test strip of ovulation testing kits should only have the edge dipped in the urine.
  • Ultrasound testing should be scheduled for days other than Shabbat and in most cases does not raise niddah problems.
1. Tzitz Eliezer Vol. IX no. 38 and Vol. XII no. 44:5.
2. Igrot Moshe Orach Chaim 1:128, and Shmirat Shabbat K’hilchatah, Vol. I, 40:2 and footnotes 2-3.
3. Shmirat Shabbat K’hilchatah, Vol. I, 33:20, note 83.  More lenient sources are also cited along with Rav Auerbach’s opposition to these lenient rulings.
4. Shulchan Aruch, Orach Chaim 308:34-35 and Mishna Brura ad loc, 134 and 136.
Fertility Guidance, Preimplantation Genetic Diagnosis (PGD)

Preimplantation Genetic Diagnosis (PGD)

We live in an incredible age. With modern technology, we have the ability to virtually eradicate the occurrence of many genetic illnesses. We encourage premarital genetic testing to preempt this problem, when possible. However, a major tool in achieving this goal is the use of Pre-implantation Genetic Diagnosis (PGD).
What is PGD?
First off, PGD can only be performed in conjunction with In Vitro Fertilization (IVF).  As in all IVF, an egg is fertilized in the laboratory and allowed to grow for a few days. Before the fertilized egg is reintroduced into the mother, one or more cells are removed from the egg.
The genetic material (DNA) of the extracted cell contains information about the way the egg will continue to grow and develop. In PGD, the DNA of the extracted cell is expanded and analyzed to see if this specific egg has the characteristic we are trying to find.
If the fertilized egg contains the desired characteristics, the IVF procedure resumes and the egg is reintroduced/implanted in the mother with the hope that she will become pregnant and carry her child to birth.
PGD can be used as a tool to identify thousands of characteristics. If the DNA marker for a characteristic has been identified, we can search for that specific marker to “guarantee” a desired outcome. As such, we can not only use PGD to prevent genetic illnesses, we can also use it to determine the gender or eye color of the future baby as well.
You said you can get rid of the occurrence of many genetic illness with PGD. How does that work?
Before we talk about PGD, we need to present a simplified overview of basic genetics.
  • A baby receives half of his genetic identity from his mother and half from his father.
  • A person who carries a genetic abnormality within his DNA but will never be affected by that abnormality is generally called a “carrier” of the abnormality.
  • The exact nature of an abnormality will determine if the child is affected by the disorder or if he is unaffected and (like his parents) remains a carrier of the abnormality.
  • In recessive genetic disorders (such as Tay Sachs disease), a child will only be ill with the disorder if he inherits the abnormality from BOTH parents.  If he inherits the abnormality from only one parent, he will be a carrier of the gene. If both parents are carriers and he does not inherit the abnormality from either parent, he will be unaffected and cannot pass it on to his children.
  • In dominant genetic disorders (such as Marfan’s Syndrome), a child can be ill even if he only inherits the abnormality from one parent. Whether or not the child is ill from the disorder depends on the nature of the abnormality. Some dominant disorders are gender linked, while others are not. Other dominant disorders are passed on by an affected parent with ALL of that parent’s offspring being affected by the abnormality as well.
When a couple is aware that they have a genetic abnormality, PGD can help. Until recently a couple in this situation had few options.  They could decide to not have children, or to have children who would likely be affected.  Or, they could consider prenatal testing and the possible termination of a pregnancy, with the attendant halachic problems. With the onset of PGD we can now offer a better solution.
With PGD, the couple undergoes an IVF treatment, with PGD performed as described above. The DNA is examined for evidence of the abnormality and only those eggs that will not result in an ill child are used for implantation.
Are there genetic disorders that cannot be prevented via PGD?
Unfortunately, there are some rare dominant genetic disorders in which the affected parent passes the disorder on to ALL of their offspring. Since every single fertilized egg from this couple will contain the abnormality and disorder, PGD will not be effective.
In such a case, the couple needs to turn to their medical professional and their PUAH counselor (as well as possibly their personal Rabbi) to explore and discuss their options.
You said before that I can use PGD to choose the gender, eye color or other characteristics of my child. Can this really be done?
Yes, the technology for this is available via PGD. Any characteristic that is genetic and has been identified can be selected for using PGD. However, just because we can do something doesn’t mean that we should do it. On the other hand, there are some instances in which gender selection is critical, which we will discuss later.
Aside from the ethical and moral issues, PGD involves tampering with the fertilized egg, which may raise the chance of birth defects. Additionally, IVF requires the introduction of hormones and other medications to the female body, which may result in unwanted side affects as well. Finally, IVF treatments are not always successful and the financial expense of IVF and emotional cost of failed treatments may be a deterrent from embarking on PGD for gender selection or some other superficial characteristic unless it is specifically indicated.
Anyone considering undergoing PGD should consult with their medical professional and PUAH counselor to determine if the treatment is indeed indicated in their case.
Are there any risks or other reasons not to do PGD?
As noted above, any performance of PGD is invasive and can raise the risks for defects and other undesirable side effects.
There are also no guarantees that the procedure will work. IVF success rates are certainly less than 50% in most cases. Additionally, PGD technology is not 100% effective. This can be attributed either to the limits of the technology or to something called “mosaicism”.
Mosaicism is an occasional occurrence where not all of the cells of the fertilized egg have the same genetic makeup. The PGD sample may therefore not have same characteristics as the egg, leading to a misleading result.
Another impediment to the use of PGD is financial. The cost of PGD can be prohibitive and in most cases the chance that the couple will not have a sick child exceeds the probability that their child will be ill.
Are there other applications of PGD? 
There are definitely other applications of this technology. For example, a couple with a cancer stricken child who has no genetic donor match could use PGD to create a sibling for the child who could serve as the older child’s life-saving donor. The only limit to what we can do with PGD is the extent to which we have mapped the genetic markers used to identify genetic characteristics.
There is also a new technology known as Pre-implantation Genetic Screening (PGS). In PGS, a fertilized egg is screened for a variety of the most common genetic abnormalities without any prior indication that there may be a problem with the egg. If a genetic marker is identified, the egg can be discarded.
This application is highly controversial. Embryologists claim to have seen embryos that seem to have an abnormality, but when left to develop, result in healthy pregnancies and live births. This suggests that a natural mechanism exists that sometimes addresses and repairs a potentially problematic embryo. Excluding these embryos may actually limit, not enhance the couple’s ability to become pregnant.
PGS is currently most often used in cases of advanced maternal age. It is recommended because the eggs of a woman of advanced maternal age have a higher incidence of genetic abnormalities. However, many of these women cannot produce a high volume of eggs. As such, we may be better served to rely on standard IVF without PGS, unless there is reasonable concern for a specific abnormality. Each specific case needs to be reviewed with a medical professional and PUAH counselor to determine the recommended action.
Halachic considerations
PGD technology is truly remarkable. We have been given the tools to engender profound and significant changes in the fabric of our society. Issues and factors that once created severe stigmas in some portions of our communities can be dealt with in a responsible and effective manner. Still, great care must be made to use this tool in an ethical and moral manner for the good of society.
PGD also raises several distinct halachic issues that require clarification. Some issues may be universal to all cases of PGD, while others must be adjudicated based upon the criterion of the case involved.
Since PGD involves the use of only those eggs that we select as “good”, what should be done with the undesired eggs? Can we destroy them?
The Gemara states that an embryo is considered to be halachically equivalent to water (fluid) for the first forty days after conception. This should not be construed as a lack of concern for the value and sanctity of life itself. It should also not be misunderstood to mean that up until that time it is not really a pregnancy.
However, an embryo is not capable of growing past a certain point outside the body. The poskim ruled that early pregnancy cannot be terminated since it will eventually become life if left alone, but unused embryos may be destroyed since they will not.
Doesn’t PGD involve interference with nature? Is that permissible?
One might express the worry about interference with nature. However, we do not believe that once someone has a medical condition we are prohibited in intervening in a Divine plan and should therefore leave them to suffer. Rather, the Gemara interprets the verse ‘and he will heal him’ to mean that the doctor is given permission, and even obliged, to heal the sick. Thus we are commanded to heal others, even if as a result we “interfere” with nature.
We do distinguish between life-threatening conditions and elective procedures. This applies in this case as well. A fertility challenged couple is considered to be sick with a non life-threatening illness. Furthermore, people dealing with the prevention of genetic illnesses would also be classified as ill. As such, we are certainly permitted to act in a manner that would heal their illness.
The matter becomes a bit less clear when we are talking about adding additional criteria to an existing PGD. There is a clear difference between a couple who are undergoing PGD for a genetic disorder and want to utilize the analysis which is already being done to perform gender selection or some other elective selection and a couple for whom there is no medical indication for PGD or even IVF.
How far does this extend? Are we obligated to use PGD?
This question only arises when we are talking about life-threatening genetic disorders. All other cases are considered to be elective and we cannot obligate someone to undergo an elective treatment.
The real question is not simply the use of PGD, but in forcing a couple who might have children with genetic disorders to use ONLY PGD to have children. They must practice birth control against natural conception (excluding the IVF procedure) and perform PGD any time they wish to have a child.
At the heart of the issue is the obligation one has to save another person’s life. Using PGD to prevent the birth of a child with a genetic disorder falls into this category. Therefore, the question being raised involves how far this obligation extends?
Some rabbinic authorities maintain that our obligation to save others extends even to a person who is not yet alive and thus obligates the use of PGD to prevent potential life threatening illness. Others maintain that our obligation to save a life does not extend to a person who is not alive.
That does not mean that they recommend against it – quite the contrary. Yet they cannot require it.
Each couple considering PGD should consult with their Rabbi and their PUAH counselor to determine their best course of action as well as the halachic obligations of their particular case.
Examples of permitted elective PGD
Most poskim recommend against the performance of elective PGD. However, there can be instances where elective PGD is beneficial and thus has been allowed. In order to understand the depth of halacha and using halacha to solve problems and benefit people, we will present two sample cases where elective PGD was recommended. The cases being discussed are anecdotal in nature and not an indication that a procedure is halachically permitted. In each case, the couple’s Rabbi and PUAH counselor reviewed the particular circumstances involved and the couples were given an answer appropriate to their circumstances. Any couple with similar issues must consult with their Rabbi and PUAH counselor for a halachic decision for their particular circumstances.
The Kohein
A Kohein (member of the priestly class; descendent of Aaron) who could not produce sperm and his wife had gotten a halachic ruling that they were allowed to use a sperm donor to become pregnant. However, the husband did not want to explain why his son could not be called to the Torah as a Kohein nor why his son does not perform the Birkat Kohanim. They were permitted to use PGD to select only female eggs and today have two wonderful daughters.
The Depressed Father
A family with 5 children of one gender consulted PUAH. The father was under psychological care because of severe depression at having single gendered offspring. The depression was so severe that it prevented him from interacting with his children and functioning as a parent to them and husband to his wife. While extended psychological treatment was a viable option, the psychologist also felt that having a gender selected child could also treat the problem. After consulting with the psychologist and PUAH counselor, their Rabbi determined that the incapacity in this case was so severe that it permitted gender selection for their 6th pregnancy. The treatment was successful and the father is fully participant as a parent for ALL his children and no longer requires psychological care.
Supervision
The IVF parts of PGD certainly require halachic supervision. However, since the PGD cells will not be reintroduced to the body, there is no need for special supervision in the PGD lab. However, supervision will be required for the removal of the cells, in order to maintain the integrity of the IVF supervision of the egg.
Summary
PGD technologies have been given to us as a tool to provide unbelievable benefits to couples whose options for having children used to be extremely limited.
  • PGD is performed as part of IVF
  • Among other applications, PGD technology is being used to eradicate the occurrence of genetic disorders
  • PGD is not only permissible in such instances, it is seen by some as an obligation to perform
  • Elective uses of PGD require analysis and specific Rabbinical guidance
  • PGD can sometimes even help avoid complex halachic issues
In Vitro Fertilization (IVF)

In Vitro Fertilization (IVF)

A number of medical techniques exist that help infertile couples have a child. One of these techniques is In Vitro Fertilization (IVF). What is this technique, what does it involve and what are the halachic issues that need to be considered?
Defining In Vitro Fertilization (IVF)
If IUI has been performed several times without success, or in cases where IUI is not an option, either due to age, quality of sperm, or blocked fallopian tubes, the best treatment is in vitro fertilization (IVF). In IVF, the meeting between sperm and egg takes place outside of the body, in the fertility laboratory (“vitro” means glass in Latin, referring to the material of a test tube).

The woman receives hormonal stimulation using shots, and she is monitored the optimum time for her egg retrieval. She then receives a final injection and 36 hours later comes to the clinic for the retrieval. At this time the sperm is also brought to the lab. The sperm sample is obtained through the method already described using the condom. The eggs are then extracted from the woman’s ovary using a long needle inserted through the vagina.

The eggs and sperm are then either left together a Petri dish to fertilize together, or sperm cells are injected into the egg in a process called intracytoplasmic sperm injection (ICSI). The following day the eggs are monitored to see whether they have fertilized; the next day a number of fertilized eggs are implanted in the uterus. Usually, the treatment also includes drugs for the woman to increase the likelihood of successful implantation.

Sometimes the eggs will be left until the fifth day, until a stage of development called the blastocyst and will then be implanted. Two weeks later a pregnancy test is performed to see whether a pregnancy has been achieved.

The entire process requires outside supervision. The outside supervisor is present throughout.

Halachic Considerations: Niddah
The actual egg retrieval does not usually render a woman a niddah as the bleeding comes form the vagina, not the uterus. If there was abnormal bleeding a Rav should be consulted. Implantation should also not make a woman niddah, as the bleeding is usually cervical and not uterine. Again, when in doubt a Rav should be consulted.

Whenever possible, all efforts should be made to administer the hormone treatment prior to the IVF in such a way that the woman will not ovulate before her immersion in the mikveh. If despite all these efforts the ovulation occurs before the mikveh, then there is nevertheless no halachic problem with taking out the eggs; the sperm sample can be retrieved using the same method referred to above.

If the implantation falls before the mikveh, then it is better to delay this treatment and only afterwards to implant the fertilized eggs, as there are opinions that implanting the eggs before the mikveh will make the child a ben niddah. However, many poskim disagree and rule that where it is essential, the eggs can be implanted before the mikveh.

Halachic Considerations: Be fruitful
While the commandment of being “fruitful and multiply” is of foremost importance the question arises as to whether this requirement is fulfilled by having children or by fathering them only in the regular “natural” way, in which case having children born through insemination or in vitro fertilization would not be a fulfilment of this halachic requirement. This question of whether one fulfils their obligation to “be fruitful and multiply” through IUI or IVF has been debated widely by different poskim.

While many poskim do accept that any child born through IUI or IVF fulfils the obligation of having children, Rabbi Yaakov Breisch1ruled that not only does the couple not fulfill their obligation to have children, but the wife is considered childless and even if she were to have several children through IUI or IVF, were the husband to die she would be have to undergo yibbum (levirate marriage) or, more likely, chalitzah2, like any widow of a childless man.

It is clear, though, that most couples do not have children simply to fulfill their halachic obligation, but as they have an existential need to have children, and as previously stated, this is of supreme importance when counselling couples in this area.

Summary
The methods used in IVF are halachically acceptable;  any questions that arise during the process should be directed to a competent Rav. While some poskim question the halachic status of a child thus conceived, most rule that the parents do fulfill the commandment to be fruitful and multiply through IVF.
1. Responsa Chelkat Yaakov Even HaEzer 12.
2. See Deuteronomy 25:5-10.
Fertility Guidance, Intrauterine Insemination (IUI)

Intrauterine Insemination (IUI)

What is IUI? What does it involve? What are the halachic considerations?
After a full examination and elimination of external factors that would make fertility difficult the doctor may suggest IUI (intra uterine insemination). Generally IUI is only indicated in one or more of the following cases:
  • Mild male factor
  • An unsuccessful course of ovulation induction
  • Advanced maternal age

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Genetics Awareness, Medical Conditions and Fertility, Recurrent Pregnancy Loss, Recurrent Pregnancy Loss and PGD

How Preimplantation Genetic Testing Has Revolutionized the Treatment of Patients with Recurrent Pregnancy Loss

Of the known causes of recurrent pregnancy loss, chromosomal abnormalities account for the majority of miscarriages. Biopsying an embryo for preimplantation genetic testing has revolutionized the treatment of recurrent pregnancy loss, by improving the embryologist’s ability to choose the healthiest and most chromosomally normal embryo for transfer.
Miscarriages can be emotionally and physically challenging for both women and couples. Recurrent pregnancy loss, which is defined by the American Society of Reproductive Medicine as two or more failed clinical pregnancies, can be devastating. Estimates vary, but at least 5% of women will suffer more than one miscarriage, and it is important that their evaluation be thorough, and their treatment be precise.
Recommendations vary regarding the evaluation and treatment of women with recurrent pregnancy loss, and debate exists about which treatments are most effective. Evaluation of a woman with multiple miscarriages includes a search for structural, hormonal, infectious, immunological, and genetic causes. Frustratingly, in up to 50% of women with recurrent pregnancy loss, a clear cause will not be identified. Of the known causes, chromosomal abnormalities account for the majority of miscarriages.
When a woman has a fibroid or abnormally shaped uterus (such as a uterine septum), surgical correction is usually indicated. When a woman suffers from recurrent miscarriages due to chromosomally abnormal eggs and embryos, we usually recommend that she undergo in vitro fertilization (IVF) so that we can analyze her embryos prior to implantation. Preimplantation genetic testing of embryos has revolutionized the treatment of recurrent pregnancy loss. Biopsying and sequencing an embryo allows us to choose the best embryo for transfer and to minimize the likelihood of miscarriage. More than half of embryos are chromosomally abnormal, and the percentage of abnormal eggs increases each year with maternal age. This is significant because up to 90% of chromosomally abnormal pregnancies abort spontaneously, compared to only 7% of chromosomally normal pregnancies. As such, selection of the healthiest embryo is integral to improving outcome in patients at risk for miscarriage.
As women age, natural fertility declines, and it becomes more difficult to find a normal embryo. In some women, it may even take more than one egg retrieval to find a healthy embryo for transfer. The good news is that available literature has found IVF with preimplantation genetic testing of embryos to be a safe and effective way of helping patients conceive and deliver a healthy baby.
We are fortunate to live in an era in which technology can be used to help prevent human disease and suffering. Preimplantation genetic screening using next-generation testing of embryos allows for selection of the healthiest embryos for transfer. Data continues to accumulating that by using the right technology, healthy outcomes are common, even in patients who previously suffered from recurrent pregnancy loss.
Dr. Alan B. Copperman
Medical Director of the Division of Reproductive Endocrinology and Infertility, RMA of NY

 

IVF Failure: Is Sperm Quality to Blame?, Men's Health

IVF Failure: Is Sperm Quality to Blame?

 

In-Vitro Fertilization (IVF) with Intracytoplasmic Sperm Injection (ICSI), the process whereby a single sperm is injected into an egg in order to fertilize it, has been a world-wide breakthrough in conception over the past few decades. This technology has lowered the requirement for the amount of viable sperm needed to conceive from millions to only a few, and has become the cornerstone of fertility treatment at the hundreds of clinics offering it around the globe.

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