The business of having babies - lots of them - belongs increasingly to observant couples who take God's first commandment - Be Fruitful and Multiply - seriously. Even when everything is normal, there are many halachic rules that affect pregnancy and delivery, including which prenatal tests to undergo and even how to get to the hospital if labor begins on a Shabbat. Infertility or defects in the fetus complicate the situation, and rabbis are consulted along with physicians. The Puah Institute for Fertility According to Halacha - established in 1990 and run in Jerusalem by Rabbi Menachem Burstein - is aimed at meeting the needs of this population, with experts in fertility medicine and Jewish law working in tandem. The one in six couples who have some difficulty conceiving need help from fertility experts and consultation with halachic experts on what interventions are permitted. In the vast majority of cases, these problems can be overcome through counseling and treatment. The non-profit organization (www.puahonline.org) long ago expanded its reach to provide counselling and referral on pregnancy in general. Its educational efforts among health professionals on the unique needs of religious Jews, seminars for rabbis on women's health and reproductive medicine; and enrichment courses for rabbinical students, marriage counselors and teachers of brides and bridegrooms are carried out quietly on an ongoing basis; a phone line receives an average of 165 calls a day. But its main public event is the annual conference. The ninth, held in a Jerusalem location best known as a wedding hall, recently attracted over 1,000 people (half women and half men, completely separated by screens for reasons of modesty), and went on for 12 hours. The event is always held in the winter, before the Shabbat whose Torah reading is the first chapter of Exodus. This biblical portion cites the bravery of the Hebrew midwives Shifra and Puah (after whom the institute is named), who defied Pharoah's order to kill all Israelite males; if they had followed his edict, Moses would have been killed at birth. PUAH CONSULTANT Rabbi Eliahu Ha'eitan began by saying that while pregnancies are naturally hidden, perhaps reflecting God's will that the fetus's condition remain unknown, it is not a violation for women to undergo prenatal tests despite their fears that medical personnel might "force" them to abort if the fetus is defective. They approve non-invasive ultrasound scans and tests because "knowledge of doctors comes from God, and can even be used to save the life of the fetus." As rabbinical arbiters put the woman's wellbeing at the fore, they note that knowing more from scans generally makes a woman more relaxed. Prof. Yisrael Meisner, head of the ultrasound unit at the Rabin Medical Center-Beilinson Campus, told the audience that ultrasound scans are not dangerous, but he did not recommend them for uses such as in the US, where any pregnant woman who wants to "see" her baby out of curiosity can have it done. "It is the ultimate test for pregnant women, but having one doesn't have to lead to an abortion, as ultimately parents decide if they want to continue the pregnancy of a defective fetus." In fact, surveys of a fetus's bodily systems (srikat ma'arachot) were an Israeli invention, said Meisner, because the vaginal and abdominal ultrasound technology was invented by Israeli companies and put to use after women here insisted they wanted to see the images and make sure everything was OK. THERE ARE times when ultrasounds can save lives. Meisner said some serious and even potentially fatal defects can be corrected in utero if the ultrasound specialists find them in time. He recalled that he detected fluid that was putting pressure on the internal organs of a three-month-old fetus. He and colleagues introduced a syringe into the chest and removed the fluid. "Today that child is healthy and living on a kibbutz. We removed 8cc of fluid in 20 minutes." Another pregnant patient was found to have a fetus with a liquid-filled cyst putting pressure on the heart at 20 weeks of pregnancy. When doctors tried to remove the liquid by syringe, the cyst filled up again. Desperate, they introduced a shunt through the woman's abdomen into the amniotic sac. The shunt harmlessly drained the fluid out of the baby's chest and into the amniotic fluid in which he was floating. When the doctors detected a hemorrhage unintentionally caused in the heart, they inserted a needle that halted the bleeding. "To my knowledge, it was the first intrauterine resuscitation," he recalled, adding that the fetus was born healthy a year ago. An asthma patient who was pregnant with twins got medication for her condition which caused a growth in the fetus's neck that could cause retardation. "We saw this on the ultrasound and injected thyroxine, which solved the problem," Meisner recalled. THREE-DIMENSIONAL ultrasound is not only "nice to have" because the fetus looks like a real baby, but it can help doctors make a more exact diagnosis, said Prof. Ronnie Tepper, head of the ultrasound unit at Meir Medical Center in Kfar Saba. "When we ultrasound specialists see a two-dimensional ultrasound, we automatically imagine a 3D image. Yet a 3-D scan can be combined with computer processing and examined from all angles after the woman goes home. When a couple are shown a defect in the fetus, it also helps them decide what to do. Yet behind a fetus's beautiful face there can be a hemorrhaging brain, he continued, so it works both ways. In conclusion, said Tepper, 3-D is not required for most cases, but it's absolutely not a gimmick, and there are cases in which it offers clear benefits. If a pregnant woman's waters break on Shabbat or a festival, how is she permitted to get to the hospital? Holon's chief rabbi Avraham Yosef (son of Shas spiritual leader Rabbi Ovadia Yosef) delivered a long lecture on the subject. "In the past, women gave birth at home and didn't have to get to delivery rooms, but today all do, and they can't go there alone." A woman may prefer to give birth in a hospital some distance from where she is if she prefers more rigorous kashrut standards. She is allowed to be driven to the more distant facility on Shabbat or festivals, Yosef said, because this gives her peace of mind. An ambulance is best, because it regularly deals with emergencies and there is no problem about the driver - even a Jew - turning off the engine on Shabbat, because he always has to be ready for the next call. A taxi is preferred if an ambulance is not used, said Yosef, "but make sure to prepare a wallet with taxi fare in advance. Let him take the money out; don't come without cash due to Shabbat and promise he will get it later, as he will be suspicious and reluctant to take the woman to the hospital." Halachically, the least preferable is for the husband to drive his wife to the hospital. Even a doula (childbirth support adviser) can be picked up on the way to the hospital on Shabbat, Yosef said, because having her there will help the mother. EVEN BEFORE Tel Aviv Ashkenazi chief rabbi Yisrael Meir Lau was Israel's chief rabbi, he was told about in-vitro fertilization (IVF) and asked for rabbinical approval, which he gave. "Becoming fertile is like having a lost object returned," said Lau. "There are tens of thousands of couples with a fertility problem," he said. But if even advanced medicine cannot make a woman into a mother, she is still a woman - equal to a man. Despite the cries of barren women in the Bible, "it is not true that women who have no children are better off dead." Many women with fertility problems prefer not to receive hormones to ripen their ova before removal, followed by IVF, fearing it will harm their health. Prof. Yehoshua Dor, head of the IVF unit at Sheba Medical Center at Tel Hashomer, reported on the use of IVM (in-vitro maturation), in which eggs are removed and "ripened" in a lab instead of the woman being injected with hormones. "Daily injections are difficult, and can affect a woman's moods and concentration. We at Sheba try to do 'friendly IVF,' in which the amount of injected hormones is reduced. A decade ago, we were the first to show that IVF can be performed on some women without giving hormones at all, often without significantly reducing success rates," he said. "Some people think hormones can cause cancer, but it's not true." THE RATE OF cesarean section is unnecessarily high, said Dr. Benny Chen, director of the delivery rooms at Bnei Brak's Ma'ayanei Hayeshua hospital. The average rate in Israeli hospitals is 19 percent, with some hospitals' as high as 25%. But his own medical center as well as Shaare Zedek Medical Center and Bikur Holim Hospital in Jerusalem perform cesareans only 12% to 15% of the time. "It's a big operation, said Chen, "and we try to avoid it. Abroad, women who have two or three cesarean deliveries are advised to have their Fallopian tubes cut so they won't get pregnant again, since there's a fear that the scar in the thin uterine tissue will tear or uterine tissue will adhere to internal organs, which is very dangerous." At the Bnei Brak hospital, where women have six, eight or more children, every case has to be discussed. "There is not one uniform rule, but if a woman has had one cesarean, we do try to do a vaginal birth the next time; in 80% of such cases, one can have a vaginal birth after a cesarean." RAMAT GAN chief rabbi Yaacov Ariel discussed the difficult halachic question about whether religious girls should be offered the vaccine that prevents cervical cancer. Holding a very graphic leaflet distributed in secular schools discussing how infection occurs through sexual relations, Ariel said such material - or even mentioning the subject - is inappropriate for this group. Although some girls raised in religious homes will have premarital sex, the vast majority will not, and should not be told about the vaccine until they are engaged, as the option would "harm their souls." PROF. CHAIM YAFFE, the non-religious director of the Orthodox Bikur Holim hospital, had to start from scratch when preparing his lecture on rapport between a secular doctor and a rabbi for the patient's benefit. Noting the wide variety of differences within haredi and modern Orthodox sectors, Yaffe said secular doctors have to earn the confidence of their patients, and that some rabbis have more difficulty reaching agreement with observant doctors than with secular ones. "A haredi woman will send her husband to their rabbi, while a secular woman will go to the Internet," he joked. "Some things - like modesty during an examination and ritual purity - are easy for secular doctors to respect. But other things," such as the waste of money spent on fertility treatments for too-old women or refusing to have a cesarean section for a first delivery because it cancels the need for a redemption-of-the-firstborn ceremony, are difficult to agree to, Yaffe declared. He recalled the case of a pregnant woman who had an epileptic fit but didn't tell her doctor or even her husband that she suffers from such a chronic condition. Yaffe prefers to speak to rabbis directly rather than have the wife tell her husband, who tells the rabbi's assistant, who speaks to the rabbi. The Puah Institute's facilitation of contact makes things easier, Yaffe said.