The birds, the bees and the observant

A recent Jerusalem conference for religious Jews dealt with some delicate reproductive subjects.

Babies are made the same way around the world - whether in bedrooms or in Petri dishes. But in the religious Jewish (modern Orthodox and haredi) community - which produces many more babies than its secular counterparts - there are unique topics related to reproduction and halacha (Jewish law). For example, does a uterine examination using a hysteroscope that may cause bleeding make a woman "impure" so she cannot have any physical contact with her husband before going to a ritual bath? What is a bride to do if she is menstruating while standing under her bridal canopy and thus unable to consummate the marriage after the ceremony? How can a woman get pregnant if she ovulates before she can get to a ritual bath? To what degree may a woman endanger her life to have children? What is a man permitted to do to treat impotence or infertility? Then there are other matters that apply to all women - such as urogynecological problems, menopause and hypercoagulation that causes recurrent miscarriage - but that religious Jews don't hear much about because of their isolation from most sources of information and the self-imposed modesty in their own media and communities. Although many of these issues are dealt with in the Babylonian Talmud and responsa literature, one wouldn't usually hear them discussed in mixed company. Nonetheless, they were discussed frankly and openly at the annual Jerusalem conference of the Puah Institute ( - albeit with the sexes strictly separated. The 12-hour conference, recently convened at Ulamei Nof in Jerusalem's Bayit Vegan quarter, attracted 1,800 religious women and men to hear leading rabbis and (male) physicians discuss such intimate issues. No one blushed - even when men and women mingled in a downstairs hall where refreshments and stands were set up and all the lectures could be heard and seen via closed-circuit video. This conference, as every year, was held a few days before the reading of the Torah portion of Shmot, which deals with Pharoah's decree of death for male babies born to the Israelites. Puah and Shifra, the two Jewish midwives, saved such infants from death. The non-profit institute, headed by Rabbi Menachem Burstein, counsels couples on fertility, gynecology, women's health and marital purity and holds courses for rabbis, bridal counsellors, in-vitro fertilization supervisors and ritual bath personnel. For those unable to attend but interested in the subjects, a thick book of abstracts and background information was available, along with audio tapes and CD-ROMs. When should a mother - or her daughter - begin to get concerned if the girl has passed her bat mitzva and not started menstruating or showing secondary sexual characteristics? Prof. Yoram Beyth, chairman of the Israel Society of Pediatric and Adolescent Gynecology who works at Meir Hospital in Kfar Saba, prefers not to use the word "worry" when dealing with amenorrhea. "I would counsel concern and investigation, but girls should not be made to worry." But he added that if a girl shows secondary sexual characteristics (such as the beginning of breasts and pubic hair), having no period is not worrisome if she is under 16. If she shows no signs of sexual development by 14, then parents should take her to a qualified professional. Not every gynecologist is suitable for dealing with young girls, he said. It is best to go to one who specializes in pediatric and adolescent patients, because the hormonal system at this age is different than in women. In addition, there is no need to perform a gynecological exam, but rather blood tests and perhaps imaging; a physical exam is not necessary, and can cause emotional trauma, Beyth explained. Delayed menstruation can be due to a variety of causes, from physical blockage that prevents menstrual blood from being released to hormonal problems or diseases of the pituitary, thyroid or adrenal glands (which can usually be treated with medications). Since in the embryo the womb develops as a two-chambered organ and normally fuses into one before birth, he said there are even rare cases of girls with two uteri and cervixes, one or both of which may be blocked and prevent menstruation; one in 1,000 to one in 10,000 girls have an imperforate hymen. In all these cases, surgery may be required. A more serious problem is the lack of a uterus and malfunctioning or missing ovaries, which would require surrogacy or ova donations to have a baby. Prof. Drorith Hochner-Celnikier, a senior obstetrician and gynecologist at Hadassah University Medical Center on Jerusalem's Mount Scopus, did not appear before the conference (no women did), but did explain dysmenorrhea in the book of abstracts. This widespread phenomenon of pain before and during menstrual periods affects between 60 and 90% of women at some time. It can be traumatic in young girls, and is responsible for up to half of all absences from school. It is most common in adolescents, she wrote, but also occurs over the age of 30 - usually due to abnormalities such as endometriosis. Hormones called prostaglandins are released at high levels in girls suffering from dysmenorrhea; they can be neutralized with medications that reduce production of these hormones, while non-steroidal anti-inflammatory drugs (not including aspirin) greatly relieve the pain. Dysmenorrhea should not be regarded as something one must live with; the religious community, often not exposed to relevant information, should be educated about treatment options, she wrote. NOW LET'S proceed to the next stage of life: A young woman is engaged to be married and sets the wedding date at the rabbinate after noting when her period is due. But what happens if hormone activity is disrupted by all the stress and she is nidda (menstruating or still ritually impure) at the ceremony? Rabbi Yoel Katan of a halachic institute at Kibbutz Sha'alavim said rabbinical authorities disagree about whether to postpone the wedding, but if the invitations have already been mailed out and the hall rented, the wedding is usually not put off. Katan's wife, gynecologist Dr. Hanna Katan, added in the background material that women who have irregular periods and fear they will be nidda at the wedding can be prescribed progesterone to shift their periods. This is a very sensitive matter, she concludes, and one must make sure that the use of the Pill to regulate menstruation does not violate the prohibition of unnecessarily preventing conception. Suppose the couple have passed this stage, but it turns out they can't get pregnant because the woman has short periods and ovulates before she is permitted to go to the ritual bath? Prof. Ehud Margolioth, head of the fertility department at Shaare Zedek Medical Center, noted that estrogens are most commonly given during the first two or three days of the monthly cycle to reduce the release of FSH and delay ovulation by one to three days. This is usually enough to allow the women to count five days of menstruation and seven clean days before going to the bath. And if there are, God forbid, difficulties in getting pregnant? Women undergo all kinds of tests, and some of them are invasive and can cause bleeding that mimics menstruation, making her wonder if she is ritually impure. Rabbi Gabi Goldman of Kfar Adumim dealt with this complicated issue. After discussing various opinions, he reached the conclusion that the cervix is always open to some extent - about three or four centimeters. If a hysteroscope is very narrow and does not expand the cervix beyond its natural extent, a woman does not become nidda if there is no blood; if there is blood, it apparently results from pressure on the cervix or below, and not from the uterus itself. To obtain a correct halachic ruling, the gynecologist has to be asked about the size of the endoscope and if a tweezer device was used to collect tissue (pinching can cause bleeding that is not menstrual and thus not nidda), Goldman said. ONCE A WOMAN gets pregnant, recurrent miscarriages sometimes occurs. Prof. Michael Kupferminc, head of the maternal and fetal division in the ob-gyn department at the Tel Aviv Sourasky Medical Center's Lis Hospital, discussed this problem. Miscarriage is often due to genetic problems and fetal deformities, as well as pre-eclampsia, the death of the fetus, delayed development in the womb and separation of the placenta. All of these can result from thromboses (clotting). These problems, he said, occur in about 8% of pregnancies, but trigger 75% of fetal deaths. If the woman's blood has a tendency to clot (thrombophilia), it can prevent an embryo from becoming implanted in the uterus, and thus cause its death. One of the most commonly administered and effective drugs for thrombophilia in pregnant women is Clexane, the low-molecular-weight heparin that earned notoriety recently when it was blamed for Prime Minister Ariel Sharon's catastrophic hemorrhagic stroke. But Kupferminc said Clexane should not be feared in young women, who are not at risk of stroke from it. Studies have shown that when pregnant thrombophilic women get Clexane, their babies are much more likely to survive, to be healthy and to be of normal size. After completing their family, numerous women suffer from urinary problems, especially if repeated pregnancies weakened tissues that support the bladder and uterus. Dr. David Gordon, head of the uro-gynecology and pelvic floor unit at Lis Hospital, explained that one in four women suffers at some time from urine leakage when sneezing, coughing or laughing, or feels a constant, urgent need to urinate. In most cases, these problems no longer require major surgery; instead, some medications and pelvic floor exercise can be effective. If not, less-invasive TVT surgery involves the attachment of synthetic strings to hold up the sagging internal organs. These offer a 90% success rate. And finally there is menopause, which most women a century ago never experienced because they died before reaching it. Prof. Bari Kaplan of the Rabin Medical Center-Beilinson Campus and president of the Israel Menopause Society, described the "change of life" to the attentive audience. "Today, a third of life is lived after menopause." Kaplan discussed hormone-replacement therapy, which is now not prescribed automatically to reduce the risk of heart disease and cancer (which it doesn't) but given only to alleviate serious menopausal symptoms and even then for a limited time. Other, non-HRT drugs are available, he said, to reduce the risk of osteoporosis as women age.