Understanding the Cultural and Religious Sensitivities of the Orthodox Jewish Population
RMA of New York specializes in personalized care that is both culturally and religiously informed to meet the needs of individuals and couples seeking treatment.
RMA of New York specializes in personalized care that is both culturally and religiously informed to meet the needs of individuals and couples seeking treatment. Through concierge service, patient-centric care, and open communication, our physicians and clinical team members guide patients through their family-building journeys.
Dr. Robert Setton is a reproductive endocrinologist and fertility specialist who cares for patients at the RMA of New York – Brooklyn office. Dr. Setton grew up in a modern Orthodox Jewish home, studied in yeshiva, and continues to be religiously observant. Additionally, Dr. Setton and his wife are open about their own journey to parenthood in which they utilized fertility treatments to build their family. Because of his personal familiarity and his knowledge of halacha and niddah, Dr. Setton is uniquely positioned to navigate culturally sensitive care for the Orthodox Jewish population. In the first part of this two-part blog, Dr. Setton discusses the steps taken at RMA of New York to ensure adherent treatment for the Orthodox Jewish population.
The Fertility Evaluation
There are several considerations we take into account when performing an initial diagnostic evaluation for the Orthodox Jewish community. The basic fertility evaluation includes: obtaining a complete medical history (including a sexual history, which may be an uncomfortable topic to discuss), evaluating overall health, checking hormones and performing a vaginal ultrasound to assess egg numbers, an X-ray of the of the uterus and fallopian tubes (HSG, or hysterosalpingogram), and a semen analysis.
The HSG may pose an issue as it needs to be performed within a week after menstrual bleeding has finished. An HSG is performed by a radiologist who inserts a small catheter through the cervix to infuse a dye into the uterus. Since performing the HSG may cause spotting, a question that often comes up is whether or not that is considered Niddah. Most commonly, the catheter only enters the cervix and so the spotting does not come from the uterus, but occasionally the catheter may need to go further into the uterus. For that reason, I encourage my patients to have the HSG performed immediately after bleeding has stopped so that if there is an issue of Niddah in their case, it does not push off going to the Mikvah by more than one day, ideally. As always, we defer to the couple’s Rabbi or halachic (religious law) leader for guidance.
Obtaining a sample for a semen analysis can also pose a challenge from a halachic perspective. The ideal method of semen sample collection is via masturbation after 2-5 days of abstinence. However, we understand that masturbation is regarded as not permissible by most religious authorities in the Orthodox community, and so we defer to guidance from an individual couple’s Rabbi. Some religious leaders advise collection of the semen sample after routine intercourse – the female partner will stand up after intercourse and try to capture the ejaculate into a sterile cup and then the couple brings that sample into the office for analysis. Others advise the use of a special collection condom during intercourse (some recommend poking a tiny hole in the condom) and then transferring the ejaculated sample into a sterile cup and bringing that for analysis. Because intercourse is needed for sample production and a certain interval of abstinence (2-5 days) is required for an ideal sample, we typically suggest couples have this test done during the two weeks after ovulation.
Lastly, many couples in the Orthodox Jewish community have had genetic carrier screening performed prior to marriage to confirm there are no overlapping genetic conditions that may risk them having a child with a morbid illness. The genetic carrier screening done prior to marriage through those companies have a panel of roughly ~100 different genetic conditions. We are able to offer a more expanded (link: https://www.rmany.com/treatment-options/pgt-genetics text: genetic carrier screening panel that has ~400 different conditions currently (and that will likely continue to grow in coming years!). And so, couples are offered an opportunity to “up-test” their genetic screening or they can rely on the testing they have already had done, depending on their comfort level and guidance from their religious leader.
The Mikvah
In Judaism, the laws of family purity dictate when a couple is permitted to be sexually intimate and when intimacy is prohibited. When a woman is menstruating she is considered niddah (halachically impure) and couples are prohibited from sexual intimacy and any form of physical contact. After menstruation is complete, a series of “checks” (bedikot) are performed to confirm there is no residual bleeding over the next seven days. Once there have been seven “clean” days, the woman goes to the mikvah (ritual bath), dips into the water several times, and recites blessings. After this practice, she is no longer considered niddah and sexual intimacy may be resumed.
One issue that may come up is that ovulation may occur prior to the time a woman is able to go to the mikvah. There are six days in the menstrual cycle during which sexual intercourse can result in pregnancy – the day of ovulation plus the preceding five days. In a situation where a woman bleeds for many days and so mikvah is delayed or has a short interval in between the start of menstrual cycles, the couple may miss the opportunity to conceive that month. We refer to this as “halachic infertility”. Luckily, RMA does offer low-tech strategies to help with this, such as the use of estrogen or oral ovulation induction agents.
To make an appointment with Dr. Setton, click here.