Female Infertility Assessment

Information Sheet: Female Infertility Assessment

You are not alone.

Infertility is not an uncommon problem; it occurs in 15 - 20% of couples. While it appears that the problem is more widespread today than in the past, according to recent studies the rate of infertility may actually be decreasing. However we are hearing much more about the subject today, partly due to a change in attitude and a greater openness. In addition, there are many more options for treatment available, so the problem is now discussed more, and solutions sought.

Causal and Contributory Factors

There are several factors that have had an impact on fertility rates. As the age of marriage rises, and attempts to have children increases, so too do the incidences of infertility. Greater exposure to chemicals and radiation can have consequences. Smoking and excessive alcohol use can adversely affect both male and female fertility and should be avoided.  Today we live extremely pressured lives, and it has become clear that strain and tension can affect fertility. Research has confirmed what was always suspected: not only does infertility cause stress, but infertility can be a result of stress. When things do not always go quite as planned or expected, people may feel they have lost control of their lives, with doctors and family telling them what they ought to do, and the pressure can be overwhelming. In order to regain control a couple ought to try to focus on their time together. Though difficult, it can prove to be a growth experience, and a meaningful way to strengthen a marriage. Other factors that can cause infertility include abnormalities in uterus and pelvic areas, blocked fallopian tubes, endometriosis, hostile cervical mucus and uterine fibroids.

Irregular Cycles

Irregular menstrual cycles can also affect a couple’s ability to conceive. If, before her marriage, a woman knew she had an erratic cycle, and may even have had some testing, there is no reason to delay treatment. If her cycle becomes irregular only after marriage due to pressure and tension, or a change in lifestyle, or unhealthy habits, the situation can often be remedied with a simple regimen of diet and exercise. Other causes, such as anorexia and other such ailments, are not usually reversible and require medical intervention to regulate the cycle.

Sometimes an irregular cycle is evidence of a hormonal imbalance which can be diagnosed through a simple blood test, and treated by prescription drugs. Natural treatments such as diet and exercise, drinking lemon juice and tea made from blackberry leaves, and taking various herbs may regulate a cycle; all must be done with caution. Pharmacological treatments may be indicated, and various new drug protocols are now being tested, with some showing promising results.

Often irregular cycles are not an indication of any major problem and can be dealt with without the need for medical intervention. If regular methods are unsuccessful, then medical advice should be sought.

Polycystic Ovarian Syndrome

There is also a common condition that causes irregular cycles called Polycystic Ovarian Syndrome (PCO), sometimes referred to also as PCOS, or PCOD (polycystic ovarian disease). This is a condition in which regular ovulation does not take place and a woman may have very erratic cycles as well as other symptoms. While researchers are not certain of the exact cause of PCOS, it is known that an imbalance of the hormonal system is responsible for many of the changes associated with PCOS. However, it is still not known exactly what causes those changes. Hormones are proteins produced by a structure within the body that causes a change within a cell or organ. Of significance to PCOS, the pituitary gland in the brain produces Lutenizing Hormone (LH). LH travels to the ovary where it stimulates the production of hormones such as testosterone. It has been hypothesized that persistently high levels of LH and testosterone causes PCOS. However, this does not explain why many women with PCOS do not have high levels of LH.

Insulin has also been thought to have a role in the development of PCOS. Insulin causes the liver to decrease production of a key molecule known as sex-hormone binding globulin (SHBG). Testosterone is carried in the blood by SHBG when the molecule is present. If a reduced amount of SHBG is available, more free testosterone is available in the blood. It is also believed that high levels of insulin can increase the amount of testosterone the ovary produces. This also does not fully explain PCOS, as many women with PCOS do not have insulin resistance i.e. a change in how body cells react to insulin.

The Need for Assessment and Assessment Technique

A couple having difficulty becoming pregnant needs to undergo a complete medical examination and assessment. All non-invasive tests should be performed on the wife first, to rule out the possibility of female factors, due to the halachic questions related to male testing.

The first stage involves testing the woman to see that she is ovulating regularly and that she ovulates after she goes to the mikveh. This can be tested through a series of blood tests and ultrasounds. These techniques can also be used to test for PCOS. The doctor may also perform a test to look inside the vagina and see the cervix using a speculum.

Such tests do not present any significant halachic questions and therefore she does not need to consult with a Rav to get a specific heter to undergo such tests. However these tests do involve regular medical procedures that raise certain issues concerning niddah.

Halachic Consideration - Niddah

A woman becomes niddah if she feels blood leaving the uterus and exiting through the cervix and the vagina. She then cannot come into contact with her husband until the bleeding stops and she undergoes the appropriate process that concludes with immersion in the mikveh. She can only go to the mikveh after seven clean days have passed during which she checks herself to ensure that there was no bleeding.

Sometimes a woman must be considered niddah even through she did not see any bleeding, for example, if she underwent a medical test that involved widening the cervix, such as an HSG (x-ray of the uterus), a hysteroscopy etc. On the other hand, not all bleeding will determine that she is niddah, as the source of the bleeding may be the cervix or the vagina and not the uterus. Therefore it is imperative to ask a Rav in each case and present to him the relevant medical details and the doctor's opinion.

The use of a speculum does not usually cause uterine bleeding. If there is bleeding, a Rav should be consulted. Sometimes during the test the vagina or cervix is cut or scraped and this causes the bleeding. It is therefore very important to get the exact relevant information form the doctor concerning whether there was any bleeding prior to the test, whether this bleeding is from a cut where the bleeding comes from, and that cervix was clean before the test. This information should be brought to the attention of the Rav in order to get an appropriate halachic decision.

Alternative Ovulation Assessment Methods

There are several other ways to test ovulation, some more effective than others. The most basic is checking basal body temperature (BBT) every morning and charting the results.  On the day of ovulation a woman can see a small rise in temperature. In recent years this method has been replaced by easier, more precise methods.

The home ovulation test consists of chemically-sensitive dip sticks which are placed into the first urine of the morning, and are sensitive to the hormonal changes that control ovulation. This method is useful only for a woman with a regular cycle, and can be expensive. In addition, in certain cases there may be false-positive results; this method, therefore, should not be considered foolproof.

Cervical secretions during ovulation, which differ from those during the rest of the month, are another natural way of testing when a woman is ovulating, though learning to differentiate between them is often difficult.

Other methods, such as testing saliva or using a watch that can detect hormonal changes through the skin, have been tried, with varied results.

Doing a blood test that checks hormone levels, combined with an ultrasound that can see the growth of the follicles in the ovary, is the most accurate way of testing ovulation. However, this treatment requires several doctor visits, an investment of both time and money.

The best method depends on the couple: younger, healthy couples with no obvious problems should be guided initially to one of the low-tech methods. Older couples, those who have been trying to conceive for some time, or those who may have a problem with ovulation, should be advised of the more advanced methods - especially the last.

Halachic Consideration - Shabbat

The halachic question concerning all the different methods is the permissibility of doing them on Shabbat. Basal Body Temperature (BBT) could be problematic, as taking one’s temperature on Shabbat involves the rabbinic prohibition of measuring. However, since this measuring is for the purpose of a mitzvah, it is allowed (Mishnah Shabbat 24:5).  Both Rav Moshe Feinstein (Igrot Moshe O”H 1:128) and Rav Waldenberg (Tzitz Eliezer 11:38 and 12:44 v) allowed measuring temperature on Shabbat for the purpose of determining when ovulation occurs; Rav Waldenberg was especially sensitive to the couple’s psychological distress. One is obviously not allowed to write down the results of the test on Shabbat, and a digital thermometer may not be used. Many poskim allow the Home Ovulation Kit to be used on Shabbat since the coloring is temporary, and minimal (see Tzitz Eliezer 10:25 and Shemirat Shabbat Kehilkhata 33:20 and note 83).

The other methods of monitoring ovulation, such as an ultrasound or blood tests, are forbidden on Shabbat as they involve Torah prohibitions. In each specific case a Rav should be consulted.

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