Partners in Creation: Fertility, Modern Medicine, and Jewish Law
October 14, 2007
When I met Dovid Fuld a few months ago, I realized I was in the presence of a true ba’al tzedakah, literally translated as a master of philanthropy and charitable acts- not only generous in his support but he also has a very generous heart- their gift is allowing us to present today’s important information to 3 other cities across north America along with Israel- we are recording and producing today’s conference proceeding to allow vital info to enlighten, enrich and and guide ____ for future.
Aaron Kogut and Chani Schonbrun- Presidents- dedicated countless hours and time and making it possible in order to learn- making it possible for people to learn from today’s event- welcome Aaron and Chani.
Aaron and Chani: Hello and welcome to the 2nd annual YU Medical Ethics conference- today’s conference is the result of many months of planning and work and hope that each of us will be able to work- appropriate to hold today’s conference following parshat noach- avraham and sarah- avraham and sarah were very first couple who struggled with fertility and ultimately rewarded with birth of son Yitzchak- with those who struggle with this may seem like long and difficult journey- critical to learn lesson from them- they showed us the power of prayer and faith- the chachamim teach that God wanted tefillot of sarah, rivkah and Rachel- we must remember source of all life- must ultimately rely on creator for everything- today have tremendous tools to help against battle of fertiliy- many different types of fertility issues and many different remedies- we have knowledge and power but only true scope of overwise torah that we must view these technologies- goal of today’s conference to not only present many of today’s technologies but also to show how they interact with halakha
Founded only 2 short years ago, YU Medethics saw a need in Jewsih society for greater understanding of medical ethics and halakha- rapidly enhancing technology- as torah committed jews we accept privilege of “v’yrapeh y’rapei” but only within guidelines of halakha- YU Medethics Society goes to greater local communities as well- programming, all of which are recorded and available on website. This year will certainly be no different and we’ll see many new lectures on the latest technology
Additional- biblical commandment to achieve matrimony (misheard?) conference for layperson is clear, today’s speakers, many of whom are YU alumni- all here- special thank you to each of them for taking from their busy schedules to be here- interact and Pose questions to our speakers, both in between and at end of sessions- nine simultaneous breakout sessions- hope people will gain.
Acknowledge help provided by Pres Joel and CJF- without continued support, dedication and interest in continued efforts in- Rabbi Kenneth brander, cantor, shalom silbermintz, jordana schoor- aliza berenholz- who has gone above and beyond and worked tirelessly to ensure success of today’s event- continued relationship
Grant Grasdorf- director of department of communications- deepest gratitude to rabbi dr. Edward reichman- mentor and friend who has guided us thru process of planning and running today’s event- without you
Presence of our parents, Mr. and Mrs. Schonbrun, Kogut, Bardos and Lowengrub
Thank officers and board members of society worked tirelessly to ensure success of today’s event- long hours of event are inspirational
Special thanks to Avi Anselom, Miriam, Yonah Bardos
Student moderators at today’s breakout sessions- (lists them all)
Great honor to call upon Dr. Ed Burns- executive Dean of Albert Einstein to introduce first session and esteemed guest speaker
***
Good Morning.
Before actually begin our formal intro of our guest speaker, like to send greetings to Dovid Fuld and wife in Yerushalayim- greetings to all the pre-meds in the audience and wish them good luck on their journey this year- debt of gratitude to Aaron Kogut, Yonah BArdos and Choni Schonbrun, especially Yonah who got me here on eve of my daughter’s wedding-
Chief Rabbi Sir Jonathan Sacks has been Chief Rabbi of United Cong… etc since September 1931. Sixth incumbent. Prior to that principal of Jews College London, oldest Rabbinical cemetery- seminary- very much alive- as well as Rabbi in Marble- semikah from Jews College as well as Eitz Chaim- educated at Cambridge- first class honors in philosophy- post graduate studies at Oxford and Kings College London. Each year before Rosh Hashana Chief Rabbi delivers message to Great Britain on television- this honor accorded only to Chief Rabbi, Queen and Archbishop of Canterbury (in that honor.) The Chief Rabbi is a true scholar- author of some 17 books-
Born in 1948 in London, married to lovely Elaine for 37 years- three children, Joshua Gila and Rena- baruch hashem two grandchildren- great- kol hakavod- ken yirbeh
Ralph Waldo Emerson once said “The House praises the carpenter” modification of German proverb of “work praises the workers” rather than going on and on about the honors of the Chief Rabbi- think it’ll be more instructive to quote some of his thoughts on the subject of tikun olam- orthodoxy’s responsibility to
Remarks made some 10 years ago to address to OU which have always impressed me-
Chief Rabbi asked why is it that if you read shulchan aruch in gemara find very little on tikkun olam- answer is that for 2000 years we were dispersed, scattered, exiled- we were powerless- who in the world would think of learning from us- then in 19th century under impact of emancipation and enlightenment- became clear that by being particularist, jewish, orthodox- we have universal consequences- WE help change the world- the maskilim wanted to give up the particularism and change the world through universalism- the orthodox worried about universalism and began to suspect the phrasing associated with tikkun olam- “light unto world” became code words for assimilation- whole concept became suspet- what a tragedy that was- today for first time in 2000 years we can put into practice- state of Israel first chance to create macro society run on jewish principles- able to speak and be hold, able to teach and be heeded, able to sanctify gods’ name in public
ladies and gentlement, this entire conference is a manifestation of the philosophy espoused by rabbi jonathan sacks- privilege and honor to introduce to you man who has articulated most powerfully philosophy of tikkun olam- which is sublime extension of our own philsohpy at YU- Rabbi Sir Jonathan Sacks
OPENING PLENARY: SPECIAL INTRODUCTORY ADDRESS BY CHIEF RABBI SIR JONATHAN SACKS
Rabbi Sir Jonathan Sacks: b’chvod harabbanim, beloved children- dr. Edward burns thank you so much for those very kind words- slight exaggeration on your part to call Jews College Rabbinic Cemetery- since as you said 6 chief rabbis since 1985 so being a chief rabbi is a particular segulah for long life- in fact one of my distinguished predecessors- late JH Hertz- may know of Hertz Chumash- was once asked by somebody how long do Chief Rabbis serve and gave the following reply-
“Chief Rabbis never retire and only very rarely die” (Laughter)
So we will settle, especially on a day like this and a theme like this to “uvacharta l’chaim” let me add my congratulations to aaron, chani, organizers- forgive me I’ve been giving a lot of lectures and voice is hoarse but can you hear me roughly? yeah- you’re okay- baruch hashem-I did once give a lecture when someone in the back said “speak up I can’t hear you” and someone in the front said “I can hear you, would you like to change places with me”
before I begin the specific topic you’ve asked me to address- it does seem to me given the particular atmosphere of intellectual world in new york and London for that matter- might just say some general remarks- as hakdama and preface in general to relationship between science and religion- this was or so we thought the oldest of the old and I believed that anything that could be said on the subject HAD been said on the subject- however we are currently living through a new chapter in this rather old story- we recall the very first chapter- confrontation that began in the very beginning- great confrontation between Vatican and Galileo. Second chapter took place in Victorian England- famous debate between Bishop and Thomas Huxley on Darwinism- apparent contradiction between natural selection and argument from design- currently living through third chapter of this confrontation because I do follow the bestseller lists on Barnes and Noble- I always like to know what Americans are reading because whatever you read we’re going to read a year from now (laughter) and I’ve noticed a whole list on ____, atheism, Sam Harris’ “The End of Faith” and his “Letter to a Christian Nation”, “Breaking the Spell”- Richard Dawkin’s wonderfully apoplectic book “The God Delusion” – I do recommend it if you wish to experience indigestion (laughter) – in France “The Atheist Manifesto”- and from the other side is the argument from what tends to be called nowadays Intelligent Design- specifically associated with Michael Beady- argument that random genetic mutation cannot give rise to irreducibly complex systems- from Jewish view this argument simply should never have happened in the first place- for simplest of reasons- we believe that God of Revleation is also the God of Creation- and therefore they cannot be in principle a contradiction between them. And when you apply revelation to creation the result is redemption- tikkun olam. And therefore in Judaism, science and religion and that very much includes medical science- two distinctive domains between the world- everything reflects that duality- two names for Hakadosh Baruch Hu refer to God that way- name Elokim as encounter him in Creation- name Hashem name of God as we encounter him in Revelation- two corresponding epistemologies, two ways of coming to come to know things- 1. knowledge of creation- chochma 2. knowledge of revelation- torah
Chochma is the truth we discover. Torah is the truth we inherit. Torah tziva lanu moshe MORASHA tzivanu moshe. Chochma, which includes science, tells up about the world that is. Torah tells us about the world that ought to be. Our task as Jews in the world is to bring the world that is closer to the world that ought to be- Chochma I define as everything that leads us to understand the universe of the work of God and therefore the image of God- therefore includes all the natural sciences and humanities- and what is really remarkable of Judaism and has been true before sciences ever rexisted- extoardinary autonomous dignity grants to chochma-
Bracha you make on sciences- “Shenatan meichachmato l’vasar l’dam”- made that bracha several times, every time I meet a Nobel Prize winner- had the great privilege of making it over the person who famous honor and- James- codiscoverers of Watson Crick of DNA
Gemara in Pesachim, Daf Tzaddi-Daled- just absolutely extraordinary in its respect for science- Gemara is asking where does the sun go in night? Chachmei Yisrael belive in day goes beneath rakia and during night above the heavens- Greeks say that during day sun is above the earth and the night is beneath….- so then chachamim say it seems the Greeks got it right and we didn’t! Can you imagine if Vatican had been able to say tha? How was it Chachamim were able to say that- as you know, happens to be Greeks got it wrong as well, but even so- the answer is that where the sun goes at night- that’s chachma, that’s not Torah- and when it comes to chochma we apply the rule most famously stated by Ramban in Hakdama to Shmoneh Prakim- “Kabel ha’emet mimi sheamrah” we don’t care who said it as long as it’s true! In Torah it’s the opposite- in Torah it’s important who said it “kabel torah mimi she’amro”- because in Torah we inherit it- so we need to do that
We can go further- famous philosopher of sicnece- Karl R. Popper- always thought he was one of the family we recite in Siyum on Shas---R’ Papa, Karl Popper (laughter) – he revolutionized science by saying you can never conclusively confirm a natural law but can refute a natural law- delivered this in famous theory “Conjectures and Refutations’- chazal beat him by 2000 years- remarkable scientific statements comes from Rabbi Akiva’s teacher, R’ Shimon, had a particular exegetical principle and came to pasuk “and you shall fear the lord your god” and word et was supposed to indicate something else as well as god- had one counterexample to his law of interpretation and he stood up and retreacted his whole life’s challenge- “k’sheim shekabalti sechar al ha’derisha kach kibaliti sechar al ha_____” true spirit of Karl R. Popper- conjectures and refutations
Now in Judaism we do not believe you can improve the existence of God by science- so argument of Dawkins, etc is irrelevant- why not? Because God transcends the universe- Hebrew word of universe is Olam which comes from verb Ne’elam which means Hidden- very existence of universe is place where God’s presence is hidden- so scientist only looking at things that are not hidden can never actually encounter God- that’s why we need the twin belief that God is the God of creation and revelation
What is the relationship between science and religion? Not a relationship of proof- quite different- hilchos yesodei hatorah, perek beis, halacha beis per rambam- when we understand extraordinary of universe, vast ___, our temporal insgificance- filled with love for god and at same time filled with awe because we’re so small and universe is so great- science doesn’t teach the existence of god- what it does teach is the fear nad love of god- dawkins’ book, ____’s book become totally irrelevant
there was a time when science seemed to disconfirm religion- I don’t need God to explain the universe- then came Spinoza to argue that all human behavior is result of causation and therefore free will is an illusion- in those days science seemed to disconfirm religion- today precisely the opposite is the case- first game discovery in 1965 of background radiation which universe into being- finally proved 800 years after rambam insisted on it- universe did have an origin in time and therefore torah was right that matter is not eternal – once gave lecture in Cambridge on history of science along with history of science professor- person came up to me after, thought I wouldn’t have heard of him- Sir Martin Reese, not jewish, wrote a book called ‘Just Six Numbers’ – shows structure of Universe based on just six numbers and if any of those had varied to the degree of one in a billion the universe would not have come into existence- and this man, a non-Jewish agnostic says that the finetuning of universe is just too improbable to be simply chance
and of course through discovery of DNA we now know that every single thing that lives, from plant life to human life derives from one single origin- eukaryotic cell- so we have proved fundamental truth of monotheism- that unity promotes diversity- read Matt’s book The Human Genome.
Human genome itself- that every human body contains a hundred trillion cells- within every cell a nucleus, within every nucleus a double copy of human genome, ____ enough if transcribed to fill a library of over 5000 books- and what all of this is doing in our lifetime is to show that science immeasurably enhances the verse we said yesterday- barchi nafshi- at no time in civilization have we been better able to understand “mah rabu ma’asecha hashem kulam b’chachma asisa”- how great and how many are your works, og god- today science is making people religious- today one of your great scientists who has just written a book on this, Francis Collins- not jewish but just wrote a book- The Language in God- work on genome product that brought him to believe in god- remarkable
now you want me to say a few words on ethical issues of beginning of work- listen, I’m not sure I can add anything to this- you’ve read the books- I’m also Chief Rabbi of Hong Kong, went there for a few days and asked me to stay on as Chief Rabbi I don’t know if that de facto makes me Chief Rabbi of China-
story of Chief Rabbi who went there to give lecture on philoshpy- can’t speak Mandarin- gets up in front of philosphers, begins lecture- complicated lecture and stops after first sentence- waits for translator- speaks for fifteen minutes and then the translator says four words in Chinese- after half an hour and again after forty five minutes and after the hour of the lecture the interpreter got up and said three words to audience and filed out of room
said it was amazing- given whole complicated lecture on philosophy- how could I do this!
after fifteen minutes I said “so far he hasn’t said anything new” and afterwards “still hasn’t said anything new” and afterwards said “I don’t think he’s going to say anything new” and then “I was right, he didn’t” (laughter)
Chevra, can’t really say anything new but let’s remind ourselves of the old- human genome is really the most scientific/ religious- Clinton said “we have learned to read the book of life” – now where science is going to lead us I don’t know- I can tell you that over next few years there will be scientists working in feritily who will make revolutionary discoveries- who will show genes are not the only factors in shaping the biology of human life- ___ reserved hasn’t yet appeared- pursued right now in cutting edge laboratories in Hammersmith in London and in New Zealand- reason I know about this is because Britain’s leading genetic expert in whole field of fertility and far and away the best known medical expert because has done series of documentaries is a gentleman called Lord Robert Winston- Lord Winston, Britain’s leading geneticist- is an Orthodox Jew who is absolutely never ashamed to say so in public and on television.
first award winning series on human body- fifth episode was called The Brain and after the end of that program said “So far I’ve spoken as a scientist and I am a scientist and that’s what I believe but there’s something about the human mind that I cannot explain as scientist- and that is consciousness- and that is the soul, neshama” and cuts from Robert Winston wearing laboraty coat to wearing yarmulke and lening in shul- thought that was a huge Kiddush hashem
No question that this research will help ….bring new ways of treating infertility- may in addition allow us to address organ failure- especially stem cells without need for …surgery- genetic switches if we learn how to turn them off that could seriously reduce the aging process and increase human longevity- we are almost in a position as of now to rewrite the genetic script- with power come responsibilities- with every advance in technology come new ethical challenges and therefore we need to ask wher e we are going because otherwise will never arise (arrive?) so starting point needs to be the idea that fertility is a blessing- somebody just mentioned that avraham and sarah’s infertility is a cry of pain from torah itself-it’s more than that
does anyone know abraham’s first words to god? we know god’s first word to Abraham- “Hashem Elokin mah titein li va’ani holech…” What can you give me if I go without a child?! First words after Tower of Babel, cry of pain and childlessness- Abraham, Sarah, Rivkah, Rachel, Chana…I wont’ accept this in context- what is Rosh Hashana? Rosh Hashana is the anniversary of creation- hayom haras olam- therefore if you never opened a machzor in your life what would you expect the krias hatorah to be? Beriesihsis bara elokim- genesis 1- you would espect haftorah to be something from Isaiah about creation- instead what do we read on Rosh Hashana day 1- the birth of Isaac and as haftorah, Chana’s prayer for child and birth of Shmuel- go figure we are celebrating birth of universe and we talk about birth of two children- answer very simple “im nefesh achas haolam” if one life is like creation of universe then understand the birth of one jewish child
that is why I wanted to write to Stephen Hawking- if you’ve read A Brief History of Time- more people have started and failed to finish that book than any other
- famous closing words …” then we would know the mind of God” – I wanted to write to him, in fact wrote this to him in open letter in The Times- you want to know the name of God? You don’t need to pursue theoretical physics- all you need to know is how to be a parent- or as one American Jewish mother put it after her first child- now that I’m a parent I can relate to Hsahem much better- “Now I know what it is to create something you can’t control” (laughter)
So there is an obvious question- does Judaism have something to say about it? Certainly yes- treatment of infertility is being hashem’s partner in creation- nearest human equivalent to creation of universe- now we have had an enormous debate- within Christinaity and others as to where exactly- basically been an enormous debate about how we answer these ethical issues raised by science- there was one theory which is associated with Jeremy Benfman- consequences, does it create the greatest happiness for greatest number? Utilitarianism- enormous, enormous weakness of this theory- must regard this theory as simply inadequate- because according to utilitarianism, most secular ethicist judge an act by its consequences- one thing we know is The Law of Unintended Consequences- every single new development in human civilization has consequences no one could have foreseen- Gutenberg’s invention of printing- who could have foreseen this would lead to Re…, birth of free economy, birth of revolution- every new invention is unpredictable and therefore utilitarianism fails utterly and totally- we cannot talk about maximizing consequences we can only talk about doing right or wrong-religious- however another consequences that has entered discourse in West- that is, forget about consequences and look in terms of personal choice- what medical ethics calls reproductive autonomy-
Important idea, valuable idea but utterly inadequate to actual issues at start of life- each of us certainly has rights and with each right comes human responsibility- no greater right than those we bring into being- therefore parenthood is part of responsibility- one of those responsibilities is the right of every child to have the space to be themselves. And that must inhibit any such approach as reproductive cloning or design embryos and so on and so forth… as the great Professor of Philosophy of Harvard, Hilary Kutman put it “Every child has a right to be a surprise to its parents.” (laughter)
Chazal tell us of the first ever act of cloning- you remember what the first act of cloning was- beginning of Toldos? Rashi and Chazal want to know why the apparent repletion- scoffers of generation saw that sarah all this time was infertile and taken into harem of avimelech and all of a sudden she’s pregnant- so they said that she was pregnant by avimelech- but God brought about a miracle and made Isaac a clone of Avraham- what was the result? Do you know the result? Beginning of Bereishit, chapter 24- Avraham “zakein”- he is first person to become old- nobody was mentioned as old behavior. Chazal explained that Avraham, who was initially thrilled to have child who was clone of hiself- realized no one could tell difference between the generations- so prayed, let there be a difference, God make me look old.
So first experiement in cloning ahd to be undone because failed to demarcate sufficiently between parent and child- secondly I’m going to say something b’kitzur nimras because I have been speaking for quite long- I have a theory that Akeidat Yitzchak- (take another hour to explain) I think the story of Akeidat Yitzchak is Torah’s protest against a principle universal in ancient world (I have a writing on this principle) this was called patria potestas- that a parent has total rights over a child, even the right of life and death- that a parent owns a child- that’s how it was in non-Jewish law- that’s why child sacrifice was widespread in ancient world- so can offer up animal, can offer up child- Akeidat Yitzchak had nothing to do with asking Avraham to sacrifice Isaac and rather it is Avraham renouncing ownership of Yitzchak- are you willing ot give Isaac to me? Once Avraham was willing to do that God said stop- your children are not your possessions- there is no patria potestas-
Is there any child called a possession of a parent? Answer is yes and it was the first ever human child- Eve became pregnant and said “Kaniti ish et elokim”- I have acquired a person from God! And therefore she called his name Cain- my possession, a kinyan. IF parents believe they own their children, the result is pain- the result ain’t good. So the Torah is a protest against the idea that parents own their children and that must be a protest against eugenic cloning, designer genes- we must allow a child to allow the space to be itself and not what we decide but what Hakahdosh Baruch Hu decides- therapeutic cloning, yes. Eugenic cloning, no. And that is I believe important.
We must place a limit on genetic technology- if we are clever enough to create genetic technology, we may also limit it- generation measured by what it is chosen not to do- God created world in six days and rested on the seventh- there are limits to creation- we must remember these limits- if we forget those limits, the result is a disaster
Friends, there is indeed a principle here- the principle Rabbi Soloveitchik spoke about in Lonely Man of Faith- in Bereishis we speak about powers of human being, we are told Adam 2 “l’avda l’shamru”- to serve it and to conserve it- shemira is in Judaism- in Judaism it is a very specific halakhic ethical category- you don’t own it and it is your task to look after it and if possible to improve it a little but it’s not yours
Famous Yiddish translation of Shakespeare- your job to translate, maybe improve but it doesn’t belong to you
That means we have an obligation not only to natural environment but also to human environment, genetic heritage to make sure we hand it on undamaged and undiminished
Major ethical issue of germline genetic interventions vs somatic cell interventions- effect between person to whom it is done versus those that have an effect on all future generations- any genetic procedure that has potentially lasting consequences for genetic gene pool- that consideration alone mediates against any large scale gene pool interventions-
don’t forget there is a fundamental question- why did God create zachar u’nekavah- for sexual reproduction? extremely complicated and messy way to reproduce- as anyone trying to find shidduchim for children/ reproduction can attest- why not progenesis- answer is that zachar u’nekavah constantly renew then we help genetic gene pool- so if we use cloning then this is wrong
we are willing to contemplate the possibility of human cloning if that is the only way infertile husband and wife can have a children- but for parents who can have children naturally, we say no to it
I think finally- I actually think that’s actually enough to be getting on with for I’ve been talking for far too long- so let me say simply this-
we have to- we remember the message the torah gives us at the very beginning in its very opening words- torah begins with a “beis” not an aleph- bereishit bara elokim- you know the answer of Chazal that god saved the aleph for first word of aseret hadibrot, anochi hashem elokecha- message of that to medical science of today is absolutely clear- creation takes second place to revelation- what we engage in the medical world, especially in reproductive technology- is measured not by what we can do but by what we may do- the beis in creation is secondary and always to be regulated by the aleph of hashem’s anochi,
And now if you let me sum up very briefly, even though I’ve only given you as Artscroll call a summary
God has given us these extraordinarily great powers- how do we use them? Must use them with three R’s-
Reverence
Responsibility
Restraint
To allow for an infertile couple to have a child is a mitzvah beyond all mitzvahs- reproductive technology is a massive blessing- but hedged around with ethical constraints- May we use our god given powers to honor our God given powers- may we use those powers to engage in tikkun olam, to perfect the world under the sovereignty of God. Amen.
INFERTILITY: A LONG-STANDING CHALLENGE
BY RABBI DR. EDWARD REICHMAN
Good Morning Everybody. I think we will all concur that the Chief Rabbi’s remarks provocative, profound, already made your journey here very worthwhile- to introduce myself my name is Eddie Reichman- had great privilege and zechus of working with students who organized this conference- b’rshus the chief rabbi and b’rshus rosehis yeshiva- would like to begin with story with which I began last year’s conference and look forward to beginning many other conferences-
Scientist came to God and said “We have accomplished extraordinary feats- end of life, beginning of life, cloning- God, we don’t need you anymore- we can do just about anything you can do- we can create man.”
God said, “Is that so? How do you do such a thing?”
Scientists says we take some dirt, get some enzymes, put in testubes, create man-
So scientist begins to bend down and take dirt from ground and God says “No, no, no. You take your OWN dirt.”
(laughter)
Despite what scientists say- we as Torah observant Jews know that there is a higher authority- God has created- it behooves us here at YU to addresss these issues, extraordinary technology that literally changes every day in halls of Yeshiva, in context of Torah. Obligation of peru u’revu- be fruitful and multiply- classic form to bear children is today’s conference. Marriage of CJF with Medical Ethics Society has also bore fruit- this only happened/ started two years ago! I’ve had the pleasure of working with a number of the students including Yonah, Aaron and Chani- don’t’ have high enough praise for these devoted, intelligent people and legion of volunteers that have made this day possible- bringing together world class faculty to address these issues- fulfillment of Torah u’Madda- may this union continue to bear fruit- Michael, can I trouble you for the presentation-
[power point]
I begin our presentation of the specifics of infertility this morning with following case- case of young girly Jasey Luzenka- who cries out for mother and father- question mark, not exclamation point-
Number of years ago John and ___ Luzenka wished to conceive a child, couldn’t do so in conventional way, approachred reproduction specialist, tried to use his reproductive seed and her reproductive egg- unsucessfull- so purchased designer embryo (donor egg and sperm together= embryo) and Pamela Smell was surrogate mother. Shortly before Pamela gave birth to this child John and Luanne Luzenka divorced. Year later Luanne petitioned for money to help support the child. John and his lawyers argued what constitutes paternity- said that he is not genetically related to child/ didn’t conceive child- so Judge turned to John and said “You are indeed not the legal father of this child!’ Then said to Luanne “You are not genetic mother of this child- you did not bear this child- you are not the legal mother of this child”
So in essence what the Judge said is that this child is a parentless child- but one of many extraordinary cases- world that has arisen due to infertility- question is how to address the issues within religious context- is it appropriate to undergo work for infertility- what are halakhic bounds? Designer embryos, surrogate motherhood, - what constitutes the halakhic mother/ father of the child? What I would like to do this morning is to give us a historical context of today’s conference
We are in 21st century- no appreciation oftimes of where we are come from- Chief Rabbi gave extraordinary overview- gave thoughtful works of 20th century- history of infertility in Jewish law- history of understanding of reproductive anatomy and physiology in eyes of rabbinic sources- then discuss a little of what you will be hearing today and then will share with you a few thoughts on what future may hold
RABBINIC CONCEPTION OF CONCEPTION
Passage in Gemara Niddah Daf 31a
This is the source for titles of this conference.
Three partners in creation- father, mother, God. Father gives forth white substance for bones, etc- mother gives forth red substance that gives forth hair, skin, etc- God gives forth the inanimate substance that allow for power of life- gives legs ability to move, etc- when time comes for man to leave this earth, God takes his part and the lifeless corpse is left.
This is the extraordinary process of procreation. We now know today and this is part of discussion in creation- not only 3 partners in process of creation today- now we have potential egg donors, sperm donors, cytoplasmic donors, surrogate mothers- now substance of our conference.
Move beyond Talmud to medieval times.
Vayikra, Perek Yud-Beis- Pasuk alef- beis
Here’s an interpretation from the Ramban- Ramban was a physician and wrote medical works- we may not realize he was also a physician- we do have references in literature of Ramban’s students that he practiced medicine- teshuvot harashba, Rashba mentions that his teacher practiced medicine- actually in field of infertility- Ramban treated women who suffered from infertility.
So what does he say? He says “Don’t think that the fetus is formed from the seed of the woman. Even though the woman has reproductive organs analogous to those of the male- either they don’t produce any substantive seed or this seed that is produced does not assist in reproduction at all.”
From times of antiqiutiy intense debates about contributions male/ female made to process of conception. Female contribution always made because female produced child- male produced seed so understood. But what was not understood was female’s contribution? Some said female emitted seed- some said woman’s menstrual blood (because there were no more menses) – so they assumed all nine months’ blood went to form the child- some scientists actually weighed nine month’s blood and it rougly equaled weight of fetus.
Though they knew male emitted some fluid, exact nature of that fluid-
Here in middle ages- Doctrine of the Chamber Uterus- Da’as Zekeinim from the Ba’alei HaTosfos- state the following: We have learned in books of scientists that reproductive organ of woman has seven chambers- three on right, three on left and one in center. If conceives from right, male. If conceives from left, female. And if from the center, then a hermaphrodite or a child of ambiguous genatalia- these are illustrations from the middle ages of the seven-chambered uterus. An idea you will not find in Talmudic literature of Talmudic times because idea not extant at that time- such a prevelant idea that even in paintings of Leonarda Da Vinci.
Maharal used this to explain the women giving birth in Egypt- women gave birth to six babies at a time (per Rashi) so Maharal says thank God they only gave birth to six because only capable of giving birth to six- the seventh would not have been a bracha- it would have been hermaphordie/ child of ambiguous genitalia
Here- Anton von Leeuwenhoek (1677)- visualized male seed under microscope- notion of understanding of female seed but wouldn’t be visualized till 200 years later- so then evolved subsequently theories of how child formed- one is that male and female seed together, child grows organ by organ- Epigenesis- debate about whether brain, kidney, liver or heart produced first. The other theory was the theory of Preformation – said tha entire human being in miniscule form was found within human seed of human being. Even there a machlokes- in which seed (male or female) do we find this entire human being? Some said male side and some said within the female egg.
We find this idea mentioned in Rabbinic Literature- accepted science at that time- in Aruch HaShulchan, Even HaEzer, 23- he mentions this theory that scientists have seen this miniscule human being in male reproductive seed- so masturbation not okay because destroying miniscule human beings!
I apologize to half the audience for this comment- in 1800s believed women were responsible for infertility.
In 1873 Edward H. Clarke, an esteemed Harvard physician, claimed to have discovered the reason for female sterility. The cause was the education of women, which diverted energy from the reproductive machinery to the brain.
Nature has reserved the catamenial week for the process of ovulation and for the development of the reproductive system…
If women pursue higher education:
“The results are monstrous brains and puny bodies…” and this leads to infertility.
Another fascinating chapter in early 20th century, last chapter which I have attempted to resurrect- passage from Hungarian journal in 1907- question posed to symposium “Vayelaket Yosef” by Rabbi Yaakov Gordin- Shana Yud, Siman Chaf Beis
Says like so: I would like to present a question to you- scientists today have developed a new technology that allows them to transplant reproductive organs from one woman to another woman (we’re talking about 1907 now) so they asked appropriate halakhic questions- can you take mother’s reproductive organs and transplant to daughter- question of who is halakhic mother of child? Many have read this and assumed this was simply a hypothetical- no way this could have occurred- but fact is not true
In 1906 one article in journal called Medical Record by a man named Robert T. Morris (who was experimenting in field of transplanting human ovaries)- he himself and removed two ovaries from a woman, removed sliver of ovary from another woman- transplanted sliver of ovary to the other woman- a year and a half later recipient of this transplantation gave birth to living, healthy child
case in point- halakhic article in 1907 is a response clearly to this research- spawned, if you will, a very fertile subsequent debate- lasted for many decades and even used to this day for discussions of surrogate motherhood and assisted reproduction
so that brings us to the present- what are we going to discuss today- we’ve discussed some interesting ideas now- we’ve discussed seven-chambered uterus- so what are we going to discuss in today’s conference?
we have for you a wonderful away of topics and a wonderful away of speakers- first session will be workup on infertility- when couple approaches a physician, what are the scientific issues/ halakhic issues involved- in classic format, we have scientific issues discussed and then halakhic issues discussed- being abreast of current up to date science is absolutely integral part of achieving the appropriate psak
breakout sessions: One is on PGD (preimplanation genetic diagnosis)- this is becoming ubiquitous in field of assisted reproduction- actually used for those who wish to prevent the birth of a child with genetic diseases- had privilege of consulting for institute of genetics of public policy in Washington- multi-disciplinary group spent about six months on ramification of PGD- you’ll hear about technology of PGD in one of the breakout sessions- we are only just beginning to explore ramifications of this- im yirtzeh hashem not just in breakout session but also discussed
To give you idea of the relevance:
This is from this week in British journal BMJ 2007 (6 October)
Italian Court Upholds Couple’s Demand for Preimplantation Genetic Diagnosis (Fabio Turone Milan)
Court reversed decision to forbid PGD in order to help couple have child without rare blood disease.
We have people here from Machon Puah- ongoing pleasure to have them here to have presentation
Male infertility- is supervision of the process required? (cartoon-Frozen Sperm/ Serve at Womb Temperature)- relevance “Black Baby Born to White Pair” from March 22, 2007
“A Park Avenue fertility clinic’s blunder has left couple devastated-“ black child born to white parents
With respect to donations when husband not able to provide reproductive seed- becoming fewer and fewer cases with introcytoplasmic injection (known as ICSY) – can take one single sperm to reduce ICSY- to reflect on complexity of these issues- this is this week from The Mirror in UK- a dad of 72 is to become a sperm donor for his own grandchild- asked to step in by his son and daughter-in-law after they failed to succeed.
One of the sessions on Egg Donation- rabbinic and scientific authority on egg donation- distinction between surrogate motherhood and gestational host.
Fascinating case – from April 20, 2007- Montreal woman has frozen her eggs so they can be used by her seven year old daughter who cannot have them due to genetic condition- mother has donated her eggs so that her daughter can have them- what are the halakhic issues that relate to this kind of arrangement?
Issues of surrogate motherhood- including of course who gets a card on mother’s day- possibility of two mother’s-in-law
We’ve reached the point where you can find the following in the Jewish Personals:
I was reform as an embryo, conservative as a a fetus and orthodox from birth, seeking same. (laughter)
Halakhic (Religious) Infertility- in medical literature- to understand definition of problem – (something about niddah and laws of family purity because of this? couldn’t hear)
Psychological Aspects of Infertility- say this has not radically changed since biblical times- “Bring me a child for if not, it is as if I am dead”- advances have progressed in terms of scientific aspects but in emotional aspects, there is a lot of work that needs to be done and again we have the privilege of having a session that will be done because of this
Also treatment of Cancer and Infertility (extraordinary developments over next)- Multi Fetal Reduction (as result of technology, women conceiving multiple births- challenges of positions to try to address that- to reduce that, is that halakhically permissible- does that overlap with issues of abortion/ something halakha countenances or mandates?) Breakout sessions- final one is Avoiding Miscarriage- extremely important aspect of infertility- many unable to carry child to term.
This brings us to what the future holds (picture by Patrician Piccinini entitled “The Young Family”) It is an artist’s rendition of what the future may hold especially with respect of interrelationship between man and animal-
Animal Gestation of Human Embryos- Theoretical discussion for world of halakha- if an animal could carry a human embryo. What if we transplanted them into an animal? What would halakhic status be if cow actually carried a human fetus? Would that resultant being who was born be considered an animal form or a human form? These are some of the fascinating, exciting areas that will challenge future generations.
Scientists in experimental stage to splice DNA from animals and insert into human beings- Animal- Human Chimeras- this appeared in England “Scientists create a sheep that’s 15% human” March 24, 2007 by Claudia Joseph- the sheep have 15 percent human cells and 85 percent sheep cells. Can you halakhically shecht this sheep and eat it? One of the challenges of the future will be identity of redefining what constitutes a human being- some can be mechanical, animal, donor- at what stage is this person still considered a human being?
Fascinating Yerushalmi- quoted by Rabbi Levi Yitzchak Halpern- quotes this Yerushalmi “she’hakol tolei b’tzuras hapanim” –definition of individual relates to facial features- if entire being is human but the facial features are that of an animal, even if he is reading from the Torah you say come and let us schecht you! And the converse is also true- if his face were humanoid like in bottom left (picture on the powerpoint slide) but the rest of the being is like a behama- and it’s plowing the fields- you can say come and perform the chalitza for your brother’s wife!
Obviously the application of this to today’s circumstance would need to be addressed by a posek.
Finally for last entry which I believe will be addressed to some extent in last session- Gametes from Stem Cells New Challenges to the Definition of Maternity and Paternity- can harvest gametes from stem cells- context in secular world- one of the areas where this is being entertained in world around us is for same-sex couples. Possible through stem cells and harvesting of gametes couple of the same sex can have a child of his own genetic material- man through his stem cells can provide egg cells- new question if woman can provide sperm cell and father can produce egg cell- shake very foundation of paternity and what constitutes mother and father.
So ends my discussion- I encourage you to interact with all the participants here today- for those who are interested Rabbi Brander and I ran a course on infertility and put together a very lengthy list of sources which is available on the internet- feel free to contact me and I can direct you to those sources- thank you so much and I look forward to a very exciting and productive and reproductive day.
Miriam: Dr. Reichman just went over the breakout sessions- look at insert, please choose which session you’re going to which also affects which lunch you’re going to- please go to lunch in building where your session is located
Good Morning. I am Harry Lee, Medical Director of Einstein and Montefiore’s Fertility Program- I must admit that when I was a student at MTA back in the late 70s, early 80s and at Yeshiva College, I never envisioned myself returning the podium in this auditorium- and especially discussing the issues and topics we’re discussing today. In my days Lamport Auditorium was the equivalent of multipurpose room you see here- SATS, Driver’s Ed, Rosh Chodesh Davening- not sure my emotions when walking into this building today- because I haven’t been here in 21 years.
Honored to be part of this program, thrilled to be moderating first session today. I think if you speak to any of the doctors who are joining us today who are practicing in infertility/ fertility world/ you’ll get similar answers- day’s exciting- surgeon, internist working on endocrine system, infectious diseases- sometimes you’re a geneticist as you’ll see in some of the topics you’ll cover today- sometimes you’re the psychologist for the couple- and also you’re a scientist. There are so few fields in medicine that the work going on in labs so quickly get to the clinical arena- place like Einstein where I work is that you’re also a teacher- teachers for obstetricians in gynecology and also in ….YU has a phenomenal endocrinology/ fertility program. We have approximately 70-80 applicants a year, interview 30, only 2 get the opportunity to make it on our site. Fortunate to be part of the program, challenged by patients and by young men and women working in the lab- making rapid discoveries in the field- sometimes they’re too rapid- why today is special. We’re in a public forum to educate/ communicate/ learn from each other to see what techniques are available today to help men and women grow their families and what can halakhically be used- what we’re working on in lab today-
Introduce Dr. Richard Grazi and Rabbi Kenneth Brander- consider both of them visionaries and going to start first with Dr. Grazi- when I was a fellow he had first come out with “Be Fruitful and Multiply: Fertility Therapy in the Jewish Tradition.” Text- couldn’t put it down because these were the same issues I was dealing with on regular basis with these patients- compiled a lot of resources in response literature- Director at Maimonides Medical Center- undergrad from Cornell, medical degree from SUNY, internship and residency at NYU, postdoc at University of Medicine in New Jersey- he and I have another thing in common- we have the common denominator- both taught by Dr. Gersman Weiss- UNJ.
Dr. Grazi has written extensively- numerous awards by fertility advocacy groups- as you saw with Dr. Reichman’s recent presentation- recently came out with another text- has an extensive resume and definitely person who should be opening up our scientific sessions.
Rabbi Brander- he and I crossed paths many many years ago- I was a student in YC- today at Pesach Table use YU Haggadah he edited- received Semikha from RIETS, special ordination from Machon Puah, then moved on and went to Boca Raton. He’s another man who has a lot of vision, a lot of drive, a lot of impact. Boca Raton- from 60 families to 600. He developed schools, synagogues, numerous awards from Florida institutions for all his work- nationally and internationally- vision and impact that the YU President Richard Joel named him the Dean for CJF. CJF focuses on using YU’s vast academic, rabbinic policies to help shape….
I think you’ll find their talk very interesting- you’ll need some of the basics to benefit from sessions later today. Thanks very much.
FERTILITY WORKUP: THE ABC’S OF TREATING INFERTILITY
SPECIAL ADDRESS: DR. RICHARD GRAZI AND RABBI KENNETH BRANDER
Rabbi Brander: Dr. Grazi is going to formally begin our presentation however I wanted to take a moment of personal privilege and do some thank-yous- to really thank them. To thank a group of students who this was their vision, they marched with this, they took the whole summer to prepare it- they choreographed it- they actualized their own dream- to truly celebrate what YU is all about- allowing students to take their vision and finding ways to give them the opportunity to not only help themselves but to help- like to thank Aaron Kogut, Chani Schonbrun, Yonah Bardos- entire board of MedEthics society- also like to think Dr. Eddie Reichman to Aliza Berenholz and Jordana Schoor who worked from CJF with them.
Remiss if didn’t acknowledge two particular personalities- first of all Dr. Adrienne Asch- Dean of University’s Center for Ethics.
(Dr. Asch: Don’t promote me- I’m only a Direcotr!)
And a teacher of mine, Dr. Burshtein- dean of Mechon Puah. Now, it is my privilege and honor to ask Dr. Grazi to begin this session.
Dr. Grazi: Thank you Rabbi Brander. Story told of young Jewish man who is freshman at local college- befriends roommate and tries to explain to him what it’s like to grow up Jewish in New York- so he brings him to shul for Shabbat- they get there a little late, chazarat ha’shatz. So roommate sees all men and women bouncing up and down on toes three times and uttering this strange incantation so friend explains pesukim from Navi, Kadosh-Kadosh-Kadosh and how we pray with feet together and the non-Jewish friend is quite intrigued. So then when Chazzan brings out sefer Torah- all the men kissing sefer Torah and women blowing kisses out to the front- so friend asks “What is the meaning of this?” so friend explains 5 books of Moses- how we go through cycle of reading it every year- reading is finished and roommate sees congregation sitting down in silence and Rabbi gets up at his lectern- takes off watch and puts it down in front of him and roommate says “What is the meaning of this?” and roommate says “Absolutely nothing.”
(laughter)
On a tight schedule- rather late. And Rabbi Brander and I have an ambitious talk ahead- A, B, C and D. I’m going to present for a few minutes and we’re going to switch off several times so that Rabbi Brander can freely comment.
How remarkable this crowd is- not only for size but also for the youth- looked around in hallway and realized that most of the people in this room were not consciously alive when the terms assisted reproduction and in-vitro fertilization were not part of the human vocabulary. I remember that day almost 30 days ago when birth of first human being conceived in-vitro- and having connection of problem of infertility and the problems that causes- this struck me like a thunderclap- I realized if this were possible and could be achieved reliably, this could solve almost every cause of infertility- I say that because historically what happened in my life is trying to bring home all the issues that I knew would be difficult for the Jewish community. Important to know that so understand how a nice Jewish boy grows up to be a gynecologist- although that’s part of it- also so that you understand how thrilling it is to see such a large crowd and that YU has chosen to make such a significant day of this.
[powerpoint slides]
I want to start off by dispelling myths. And there are many of them. It seems somehow that every man or woman who has ever had a child can think of themselves as a fertility specialist- that’s not what this is about- this is about giving you accurate information. Infertility is a couple’s problem- not a woman’s problem. Also, it’s not because “not doing it right.” And not about stress- relax and let it happen-
MYTHS ABOUT INFERTILITY
Infertility is a woman’s problem
Infertility because of sex
Infertility is about stress
Only 10-20% of couples with infertility need in-vitro fertilization.
THREE COMMON MISCONCEPTIONS
(slide switches too quickly)
Pelvic Exam= Niddah – Source of great frustration. They are always asking whether pelvic exam will make her niddah- Rabbi told them about this- it is impossible for pelvic exam to render a woman niddah. Examining instruments placed in vaginal canal- in order for niddah to happen there needs to be bleeding from inner cavity- uterus itself- not touched ever in routine exam.
Egg- egg grows inside little cyst called egg follicle- ruptures out- formation of corpus lutem- corpus luteum goes away over fourteen days, hormone levels fall and uterine lining comes out. It is the growth of the uterine lining that happens in response to the growth of the egg follicle which is sensitive to hormonal changes involved in menstrual bleeding- has nothing to do with the passage of the egg. People often ask “If my tubes are blocked- how can I be having periods?” One has nothing to do with the other.
Getting to the basics:
1 in 6 couples is infertile involuntarily (very, very common problem- defined as absence of pregnancy after trying for at least 1 year. as practical manner, when women get older reproductively speaking, beyond age of 35 like to
male factor 40%
female factor 40%
combined 20 %
important to look at couple together
FEMALE INFERTILITY
Ovulatory disturbances 40%
Anatomical distortion (tubal blockage, adhesions/ scarring, endometriosis) 40%
Unexplained 20%
Do not yet have technology to diagnose source of every couple’s infertility.
MALE INFERTILITY
Men with Sperm (Used to be if you had a low sperm count- that’s a problem for infertility)
Men without Sperm (but today even men with 0 sperm can father biological children)
RABBINICAL ROLES
Counseling
Spiritual support
Halakhic instruction
Physician-patient liaison (Many halakhic minefields that couples need to negotiate on their way to treatment success. What I see as a matter of fact in my practice and more of certain communities than others is that rabbis are very into herbs and potions- even prescribe medications –medical referral is an interesting thing- very important for Rabbis to be aware of expert doctors in each field so they can do appropriate referral- if couple happens to be going to another doctor, not a reason to send them to your specialist- open lines of communication are productive)
Physician referral
DIAGNOSTIC TESTING
Endocrine Testing
Pelvic Exam
Semen Analysis
Postcoital testing
Endometrial
(more- slide switched too fast)
In terms of diagnostic testing, if half of fertility problems are due to the male- semen analysis is the first thing that is done. So need to know what is going on side of the male. Semen analysis is painless, cheap test- why not do that first? Chronology has to be changed a little for Torah observant couple. But in terms of normal procedure, semen analysis is first thing we do- shapes of sperm are very important and do correlate very closely with sperm’s ability to fertilize the egg.
With observant couples, semen is harder to do-
Postcoital test instead (insert a speculum in order to see the cervix and aspirate a little bit of fluid from the cervical canal in order to look under microscope on a slide to look for presence or absence of sperm- also movement of the sperm- are they alive once in women’s body)
Differs from semen analysis because it does not tell you anything about the count- whether there is a large percentage of sperm moving- because you’ve singled out the ones that have survived the journey- also important to know that postcoital test can sometimes cause bleeding but not niddah (irritation of cervix but not uterine bleeding)
Hysterosalpingogram (HSG) basically means x-ray of cervix: little x-ray placed in cervical canal, some contrast material put in uterine- then fallopian tubes are filled (because of blockage)
One of the other things that HSG gives us is picture of the Uterine Cavity themselves. Many women are born – have been identified as having congenital abnormalities of uterus itself- possible to do procedure of Hysteroscopy- very minor procedure (requires dilation of cervix and passage of telescope into cervix- did he say uterus?) does cause uterine bleeding- whether or not niddah leave up to Rabbi to decide
Endometrial biopsy- now abandoned and no longer seen as being useful for fertility evaluation
Laparoscopy: This is a surgical procedure that isn’t done as much today as in past- look at pelvic organs through very small incision made through belly-button- telescope attached to camera so magnifies pictures of pelvis- can look at these pictures and quite complex operations through small incision
Transvaginal Ultrasound: Small vaginal probe as replacement for doctor’s finger- but this one sees- this is a very, very common part of not only diagnostic evaluation but also the treatment of fertility- allows us to see what is happening to the woman during cycle of fertility- not uncommon to have three or four of these ultrasounds in one week - that probe does not go into uterus (way too wide to fit through cervical canal) and bleeding from this will never render a woman niddah
Rabbi Kenneth Brander: Famous story of a Rabbi traveling on an airplane who is sitting next to an individual and has a conversation with individual and says “Listen Rabbi, I’m Jewish- I understand that all your study that you had in Israel, college, rabbinical school can be summed up in one statement- love thy neighbor as you love yourself and that’s what it means to be a Rabbi.” Rabbi was a little distressed- that is indeed a very important idea- but taking so many bechinot- didn’t sit right with him that his entire rabbinic studies should be summed up like that. So turns to person next to him, and says “What do you do?” “I have two PhDs- one from Harvard, one from MIT, Astrophysicist and you have no clue what you do.” Rabbi says, “That’s true- but all of that can be summed up in one statement- Twinkle Twinkle Little Star.”
After hearing what Dr. Grazi has said, we should really call this the Twinkle Twinkle Little Star version of this- everything he’s said he could spend hours on- halachot we could spend hours on.
In the first slide that I’ve prepared for you- very famous Gemara in Baba Batra 10a- Dr. Twersky discusses in an article in “Tradition.” It’s a Gemara of a dialogue between Turnus Rufus and Rabbi Akiva where Turnus Rufus says “I want to explain to you why the Jewish people are condemned to hell. You know why? Because you help the poor and the indigent!” And he explains, “Suppose an earthly king incarcerated one of his subjects and said that no one is to give them any food or drink and somebody snuck food to them, would not the king be upset at the individual who didn’t follow his decree-and you the Jewish people are considered the servants of God- and therefore when you help poor, that’s why you’re condemned to hell!” So Rabbi Akiva responds in following way- Rabbi Akiva who went through worst of humanity- martyr- suppose earthly king incarcerates his child and somebody finds a way to give food to child of the king- would not the king be happy that someone saved his child? And while we the Jews are called the servants of God, we are also called the Children of God.
On that, Dr. Twersky commented- “This conversation between Rabbi Akiva and Turnus Rufus is an important philosophical conversation- it is not our responsibility as a Jew to wear the eyeglasses of God- not our responsibility to say God willed it this way so don’t try to change the status quo. It is our responsibility to be proactive and to finish the creative process which he began.” The entire issue of infertility- of reaching out to world community- responsibility of being messengers of God and deeds celebrating our responsibility within this world- so halakha celebrate the opportunities to use medical science to actualize the couples’ interest in having a family.
In 1200s, great Rishon named the Meiri- writes the following in a comment to Tractate of Sanhedrin- Sanhedrin 67. What’s the difference between witchcraft, which Torah forbids people to benefit from, as opposed to medical science? He said anything achieved through science is not considered magic- he says “there will come a time when science will know how to create human beings of nature and is not an impossibility. It is permitted to be involved in such procedures for they are considered within the order of nature and not in the category of forbidden magic. This is similar to the statement that anything achieved through the science of medicine is not considered darkei amori (idolatrous practices.)
Halakha- if a couple wishes to use the gifts of science, they can.
Dealing with halakhic issues Dr. Grazi mentioned- two categories. Article in Contemporary Jounral of Halakha where I go through this in greater depth.
What procedure would put a woman in situation to be a niddah- horror stories and tragedy of Rabbis who do not understand women’s physiology and body- people missed chance to have child-
Two basic issues.
1. Blood needs to come from uterus/ endometrine lining- but if blood came there through not a natural flow but through an injury (dam makah) that does not create the status of niddah. Situation in which a women has a flow from the endometrial lining but since it is dam from that location- this idea is further defined and categorized by Rabbi Shlomo Zalman Auerbach in Nishmat Abraham 187:2- the Talmudic definition of blood from an injury includes blood from the uterus or the cervix- in such a case, the woman would not be considered a niddah. What is of critical importance is what caused the blood to flow from the lining- if what caused the blood to flow is injury different.
2. Petichat Kever- dilation of the uterus. You have in the Shulchan Aruch and in Masechet Niddah, daf chaf alef, lamed bet- impossible to dilate the uterus without blood (even if it is not visible.) Shailah amongst the achronim- when Gemara speaks about dilating the universe, means from an internal stimuli. What about when we dilate the universe externally? Several teshuvot- Chazon Ish, Nodah B’Yehudah- we pasken that if there is dilation, even externally, that creates a status of niddah. How much dilation does there need to be? Argument amongst poskim- need to speak to local orthodox rabbi. Normative approach amongst Ashkenaz Jewry- if dilated less than three quarters of an each (can’t happen unless woman goes through some process of anastheisa)- Teshuva from R’ Moshe Feinstein Igrot Moshe Orakh Hayim 3:100. Many of the Sephardi poskim disagree with that- they say it’s even less than that. Speak to LOR about what his definition is of petichat kever.
Blood created based on some type of test- blood created for injury- is not a niddah challenge. And only dilate cervix to extent of ¾ of an inch- based on fact that Shiltos in Tazria tells us that embryo that is 40 days old is essentially that size- that is halakhic milemarker for issue of taharat ha’mischpacha.
Now turn back over to Dr. Grazi- I will discuss a little more in depth semen analysis- halakha does not permit for semen analysis to be first thing done when dealing with infertility challenges.
Dr. Grazi: After the evaluation of the couple is complete, we turn to treatment. And treatment in world of reproductive technology can be either surgical (very few halakhic issues with having surgery but as practical matter- besides for removal of cysts that get in the way- very few reasons to do surgery for infertility) or medical treatment (the manipulation of the endocrine ovulatory cycle.) Four compartments- compartments I and II (hypothalamus and pituitary glands) – control uterine cycle- all necessary for normal cyclicity.
Ovulation induction changes woman from woman who does not ovulate to woman who does ovulate. Moreover, these medications can be given to women to ovulate more or better (cannot go into details of what exactly that means.)
Ovulation induction: halakhic pitfalls
Midcycle Bleeding
Accelerated ovulation
Multifollicular response (this is subject of one of the breakout sessions- woman ovulates too many eggs)
Goal is to show uterus that looks like this to uterus that looks like this- one baby at a time.
[shows picture of woman on magazine cover with six kids] she’s smiling for cover because they pay her to smile…I assure you not all smiles at home.
When this type of thing happens (woman with six children at once) gigantic likelihood that babies will be handicapped.
Sperm- watching- Insemination procedure is very simple and can be done by a nurse. Done by a very fine catheter only 2 mm in diameter- slip sperm into cervical canal and very high in cervical cavity- so putting very concentrated quantity of sperm near opening of fallopian tubes-
Insemination:
Cervical factor (poor postcotial test)
mild male factor
(slide switched too quickly)
Ovulation induction/ IUI
Male factor
Unexplained infertility
Advanced age
Idea is to get lots of sperm to meet perhaps more than one egg with one proviso- we don’t want to end up in a situation where we have a multifetal pregnancy- halakhic questions that come up in this approach- include if insemination needs to be done because woman is ready to ovulate- also problem of hashgacha- before sperm can be inseminated need to be separated from seminal fluid- lab procedure that takes an hour- goes into laboratory- hasgacha procedure is to make sure what they’re getting back is their own- of course every licensed clinic exists/ makes sure that does not happen. I particularly reference Tzitz Eliezer who wrote his teshuva on IVF- his real concern was about doctors intentionally using somebody else’s sperm to boost up pregnancy-
While in secular world look at hashgacha as weird and unordinary, this is basis of allowing this procedure for many couples.
We use IVF judiciously to prevent the problem of multifetal pregnancy (shows a graph)- this one slide is to try to eliminate to the extent that it is possible triplet pregnancies and certainly more than that- proud to say at Genesis we only had a 1% triplet rate- and 0 triplets in the entire IVF program this year so far. Green bars- mean that we still have a problem- 35% of people walk away with twins. But twins, even twins- come with additional risk to mother and to each other- chance to having cerebral palsy and other diseases- 7 times higher than in singleton pregnancies and 20 times higher with triplets mostly because of premature birth ( so still have work to do to ensure patients getting pregnant safely.)
Rabbi Brander:
Doing certain procedures while check the man’s sperm- while in medical community one of the first tests, from halakhic perspective, one of last tests done if not the last- this is because of prohibition of expressing sperm for naught and how Shulchan Aruch speaks about this prohibition (Shulchan Arukh Even Ha’Ezer 23: 1, 2)
“Forbidden to express sperm – enter and then withdraw from woman before completing the act- worst sin in the Torah- if sinning with one’s hands (masturbation) – it is as if he has killed an individual because he has wasted the fluid that allows us to achieve the great gift that allows us to bring a child into this world.”
I could easily spend the rest of the day showing you sources against expression of sperm in this way- check the sperm after normal sexual relations and not sufficient and you need to do an appropriate semen analysis- in order to make sure that couple can actualize having a child.
Great poskim have discussed this- two approaches:
1. Rav Moshe Feinstein Igrot Moshe E.H. 2:16- When the doctor needs to do a test on the husband in order to check how he can heal the couple- notice his first comment- all the tests have been done on the woman and now the only thing left is some type of semen analysis then he permits one to do this. He suggests it can be done in the following way: Either it can be done to begin the sexual activity and at moment that is appropriate, he removes himself and expresses sperm in testube of some sort. But notice he makes a comment here on the bottom- you should wait five years before you do any type of test of this nature. Most poskim of more contemporary times disagree with that and allow one to do this test much earlier.
2. Tzitz Eliezer- Rav Waldenburg- 9:51 end of chapter 1: This is what Tzitz Eliezer says is for man to wear condom (unique condoms- not with spermicide)- have normal sexual relation with his spouse and then the sperm is within the condom, condom brought to doctor- doctor. Some say a prick in condom itself (size of a needle) so potential for some sperm to ooze out and enter into the woman. Bottom line is that most poskim permit it as long as it is understood that this is the final step in the process, not the first step in the process. First, if you look at aleph the Tzitz Eliezer says that only after the woman has gone through her test can the man do his test in the way that has been suggested and secondly, best is after man and woman have had sexual encounter to then remove the sperm (but that is often compromised, etc) and then gimmel, he quotes the teshuva of R’ Moshe Feinstein (he has this teshuva as well as Minchas Yitzchak) – at moment at which man is about to express his sperm, he removes himself and puts sperm on some type of appropriate sperm (but if that is difficult as it can be)- this is challenging at best- and therefore daled, the more preferred way- you can wear a condom (again, without spermicide) and that condom is brought to the doctor and they do what they need to do in order to make sure all those texts are taken. Tzitz Elizer goes further- look at chet- if you cannot find sperm through these activities, then if necessary one is permitted to do a type of procedure where you remove sperm from testicle itself (based on Tosfos) and suggests you start with left testicle (not necessarily required)- if husband has no sperm but possibly has sperm within testicle. Most important piece I want to point out is that you do not need to wait five years but rather, everything is based on the issues- if a doctor feels the sperm test is necessary after other tests- even if within a year or so, based on the age of the couple, then that would be permitted.
Dr. Grazi:
We’re going to turn now to IVF with specifics of how it’s done though the proviso is that you don’t go home and try it on your neighbor-
The pioneers of in vitro fertilization- Patrick Steptoe and Robert Edwards (picture on Powerpoint) Their accomplishment, by the way, not treated with such joy by most of the world- opened up Pandora’s box of ethical problems.
Moved egg (for woman who had blocked tubes) how to move egg from this stage to this stage (pointing with laser) in order for it to reach human fallopian tubes. Trying to replicate conditions of human fallopian tubes in IVF laboratory.
One cell with two pro-nuclei (one from the sperm, one from the egg)- this is what a two-cell, four-cell and eight-cell embryo would look like (shows more pictures.) Now of course, the goal of all IVF procedures is to move an embryo from how it looks originally to implantation in the uterus. I can’t give you all the specifics of how that happens since some of it is still a miracle even to us who do it every day.
give you ABCs so you know who *gets* IVF.
Anatomical Disease (endometriosis, adhesions, tubal blockage)
Unexplained Infertility (failure to conceive with other treatments)
Severe male factor (since the advent of ICSY)
IN VITRO FERTILIZATION
Ovulation induction (never like to work with just one egg- has to be more)
Egg retrieval
Sperm procurement
In vitro culture of eggs and sperm
Embryo transfer
+/- Cryopreservation
I should add that the advent of many highly effective methods of embryo preservation has opened up more ethical problems- how to dispose of them/ use them/ whether or not it is ethical to use them, specifically for stem cell research.
(Graphic picture of IVF cycle- based on medications) shows FSH Injections/ Lupron Injections
Tracking of egg follicles as they develop- then we give a final dose of the medication called HCG- either three or five days later we’ll take eggs out and put fertilized eggs back into universe.
Remove eggs, fertilize in dish, put eggs back in low. Success rates vary with age.
This slide is an important slide, particularly because of the niddah issue- using ultrasound to view the ovary, the physician inserts the needle through the wall of the vagina into the ovary and removes the egg for use in IVF or GIFT. This ultrasound picture shows you the tip of the needle in the egg follicle depicting how the microscopic egg is removed from the ovary –usually necessary to put that needle through just twice- even though always bleeding from this procedure, usually never niddah bleeding.
We then put the eggs and sperm together and hope that the sperm are confident enough to traverse the zone of shell around the egg and decondense and form the fertilized pro-nuclei.
This is somehow how it looks in the laboratory- we want to make sure there are only two pronuclei and not three or four (evidence of pre---sperm)
this is ICSI- picture- completely turned around world of fertility therapy. ICSI makes it possible to conceive even if man has very few sperm- even only needs one- used to be needed 20 sperm per ml to be considered fertile but then went down further- with advent of ICSI just need one sperm.
This is another picture of how the ICSI procedure is done- the sperm is trapped inside of a very thinly drawn out pipette- this is the edge held in place by holding pipette- discrepancy between size of egg (largest cell in human body) and sperm (smallest.) Pipette used to insert single sperm into the egg. From thereon, embryo development proceeds in normal fashion.
There are some men who have 0 sperm in the semen- that happens based on two problems- sperm production is normal but can’t egress into outside world. Or problem with sperm producing machinery in the testicle.
(Skip over next couple of slides)
This is a picture of MESA- microsurgical epididymal sperm aspiration- men born without vas deferens- common condition for men with cystic fibrosis- tissue opened up, urologist expert in this technique can basically harvest normal sperm even though none of them can be used in the normal way- same procedure used more simply but less successfully through the skin (testicular through skin)- experienced urologist extract tissue through skin itself- sometimes it can take literally all day to find just a few sperm to use for the ICSI procedure-
If you can get even just 3 or 4 moving sperm from the testicle, can go on to do the IVF procedure through ICSI.
Rabbi Brander:
Time is short and we have a lot yet to discuss- so I will take my presentation and collapse it in the Twinkle Twinkle Star Way we discussed earlier. Here we have an issue where the sperm comes from the husband and the egg and the host mother is the wife and it’s pretty clear the husband’s donating the sperm, wife donating the genetics- carrying the fetus, we know who the mother is and who the father is. what happens if the father has no sperm? what happens if mother has no womb? what if mother has eggs but no womb?
then situation where you can have a sperm donor but have two women involved in the process- one who is the genetic donor of the egg and one who is the donor with fertilized egg
famous gemara in chagiga 15a
We know that a Kohen Gadol is forbidden to marry a woman who has already had sexual relations with another man. Ben Zoma asks- can a high priest marry a virgin who has become pregnant? A woman who has become pregnant without having relations- bifurcation between sexual act and the idea of the woman becoming pregnant. The Gemara concludes: We do consider the possibility that she may have conceived in a bath- could have entered cervix and to fallopian tube- becoming pregnant without any form of intimacy.
So a) one can be a sperm donor without the sexual act. R’ Samuel Fivish Even Ha’Ezer 1:11- woman who becomes pregnant in the bath- if the sperm donor is the father, is this his son? And therefore he quotes the Hagot Smag- not the Sefer Mitzvos Katan here- it’s actually the Hagaos Smag- Sefer Mitzvot Gadol- based on a few issues, namely the prohibition of ____ there this is this notion that the sperm donor is the father even though there has been no sexual act. With this in mind, R’ Yaakov Weiss, the Minchas Yitzchak, who is not known for his left-wing tendencies (Minchat Yitzchak 1:3) explains that this child was not born by himself but by activity done between husband and wife- therefore husband still considered father (even without intimate act.) We need to make sure there is appropriate hashgacha- appropriate watching of the process- since the owner of the sperm is the father, we want to make sure that the right sperm is implanted within the woman. What happens if the husband has no sperm and the couple wishes to have a child- even ICSI IVF isn’t working- in this case, when you have exhausted all other ways- since the sperm donor is considered the father, we want to make sure the sperm donor is not Jewish- and therefore R’ Feinstein in two versions suggests that the child will be a Yisrael not a Kohen if the husband of the wife whose carrying the child- doesn’t make a difference; it’s the sperm donor who defines paternity- so you can use a donation of sperm from a non-Jew. I believe that R’ Moshe’s house was firebombed because of this.
R’ Shlomo Zalman Auerbach had same Teshuvah (Noam Volume Aleph) but in much more obscure place- therefore issue important to mention- other thing important to mention- discuss in breakout session- true case- let’s say there’s a couple who lives in a more right-wing community. The husband’s a Kohen, has no sperm, do IVF- now have many fertilized eggs from donor sperm of a non-Jew- husband says I don’t want male children. 13 years they’ll see he doesn’t get Kohen aliyah- they’ll see he gets Yisrael aliyah- I want to do PGD- only want to return fertilized female eggs to womb of my wife- and I wont’ have that challenge with the aliyah situation. Is it permitted to do that? Discuss in breakout session.
Another interesting thing- unbelievable teshuva from 1700s- person goes off to war- R’ Yechezkel Landau Nodeh B’ Yehudah Even Ha’Ezer 1:69- before he does that he expresses some sperm (frozen properly)
Husband dies at war. Wife wants to be inseminated with frozen sperm and then posthumously- conceived posthumously because husband is not alive- is this child- does this child have a relationship with the father who never knew the child and wasn’t even alive from the moment of conception? The Nodah B’Yehudah says the following- he asks, why do we only wait 90 days when a woman loses her husband- you wait 90 days before she marries somebody else or do yibum/ chalitzah- the Nodah b’Yehudah says wait 93 days because sometimes takes 3 days to travel to Fallopian tube. The Nodah b’Yehudah says the following- if the woman has not conceived at the moment of death even though there is sperm within her and even though she won’t become pregnant from her dead husband still has to go through yibum/ chalitzah. So you can have a pregnant woman who goes through yibum/ chalitzah. Nevertheless this child who is born- conceived posthumously- it’s HIS child. So Nodah B’Yehudah suggesting that even posthumously there can be a relationship between sperm donor and child.
We will not have time to discuss maternity other than to suggest that it is a slippery slope- is it host mother, genetic donor. For the most part the approach has been- Yonah is telling me I’ve got to end, so give me one minute- the student telling the teacher and he is 100% correct- for most part it is the surrogate concerned mother (not host mother.) But tables starting to turn- R’ Elyashiv said it was the host mother but changed his opinion and now suggests that it is the genetic donor. Try to recognize host mother and genetic donor are Jewish- don’t create situation where perhaps the child would not be considered Jewish. One thing- when we have different kashrut standards- it would be tragic if when it came to genetic/ surrogate mothers, pasken one way and not the other and weren’t concerned about both approaches- that someone in 20 years from now, someone might say this child is considered Jewish only according to one school of thought/ another school of thought.
Deal with issue of definitions of mother clearly a challenge at the present of time- significant poskim on both sides of the aisle when it comes to this issue.
Thank you.
Miriam: Thank you so much for all communities which have joined us during these sessions though videoconferencing. Breakout sessions- lunch in 2 different locations- lunch in Belfer and in Furst in Room 501. Breakout sessions starting at ten to 2.
BREAKOUT SESSIONS
Multi Fetal Reduction by Rabbi r. Zalman Levine (Furst Hall 313)
Powerpoint entitled “An Excess of Success: The Problem of Multiple Pregnancy” by Rabbi Zalman Levine, M.D. (Assistant Professor of New York Medical College, Division of Reproductive Endocrinology and Infertility, Fertility Institute of New Jersey and New York- Westwood, NJ)
Doni Waintraub: We’re going to start now. Hi, my name is Doni Waintraub. I’m a Bio major at YU and a member of the MedEthics society. I’d like to welcome you all to Multi-Fetal Reduction with Rabbi Dr. Zalman Levine. Received semicha in 1991, MD from Albert Einstein in 1995, obstetrics and gynecology at Albert Einstein, then spent time at Harvard University. Albert Einstein & Harvard in IVF, etc. Today he will be discussing a very sensitive matter- high risk of multi-fetal pregnancies- selectively aborting one or more of the fetuses. As I’ve heard from my father (colleague of Rabbi Dr. Levine) if there’s anyone who has served as…outstanding physician/ Talmud Chacham- present to you Rabbi Dr. Zalman Levine.
The field of reproductive biology has advanced enormously- now in year 2007 many couples can be helped enormously through techniques of reproduction- extensively examined in light of halakha/ hashkafa. In addition to this, assisted reproductive techniques and status of children, also have to concern ourselves with the risks of reproductive treatments- how halakha will handle the risky outcomes. Because poskim are often consulted by people in terms of this- poskim really need to be informed of all this. So need to give you overview of the problem of multiple pregnancy and outline what can be done to prevent the conception of a multiple pregnancy and what can be done medically/ halachikally.
Multiple pregnancy- larger and larger problem over past 25 years. Twin births have increased by about 55% from 1980 to year 2000. Approsimately 1.9 out of every 100 births were twins, rose to 2.9 by year 2000. These data even more dramatic for triplets or greater. Live births- was 3.7 of them out of 10,000- by the year 2000, accounts for almost 18 of every 10,000 live births.
TOTAL HOM BIRTHS 1980 2000
1337 7325
triplets 6742
quadruplets 506
quintuplets 77
This is actually understated (because pregnancy losses are not reported.) So the number is actually significantly higher- so why is this? What is the reason for this trend?
Twofold:
1. Older age at childbearing- physiologically, older woman more likely than younger woman to ovulate more than one egg during menstrual cycle- trend toward older childbearing responsible for part of the increase- responsible for about 20% of this increase
20% contribution
predominantly twins
(so this factor accounts for very very little)
2. Fertility Treatment
80% contribution
Overwhelming majority of all HOM births
(So this is the far more significant factor)
Two forms of assisted reproductive technology implicated in multiple birth:
IVF
Superovulation with or without insemination
Generally both of these techniques require the administration of hormone injections- FSH (for instance) – these are normal hormones produced by women to help ovaries help produce/ prepare an egg- in reproductive therapy, much larger doses of this- this is known as Controlled Ovarian Hyperstimulation (in controlled and carefully monitored fashion)
Unfortunately it’s not yet successful enough with a single egg- therefore in order to help many couples achieve a pregnancy or a reasonable chance at a pregnancy- carefully monitor progress of egg development (picture on powerpoint) 8-10 eggs maturing and preparing for hopeful pregnancy
These eggs can now be used either for IVF or for insemination. For IVF, the eggs are removed from the ovaries through a surgical procedure called the Egg Retrieval (a bit of a misnomer.) The woman’s eggs are removed from her ovaries and introduced to her husband’s sperm cells in laboratory (grown and observed in laboratory) then a couple days later placed in woman’s uterus in procedure known as _____ Transfer.
Alternatively, these eggs can be allowed to ovulate inside woman’s reproductive tract (as they normally do) and can find their way into Fallopian tubes (hopefully will be fertilized by sperm.) Only difference here is the number of eggs waiting by the Fallopian Tubes to be fertilized (as opposed to normal cycle, where only one egg ovulates.) The chances of such a meeting can be increased by intrauterine insemination to place husband’s sperm cells higher up near entrance to fallopian tubes.
It’s clear why multiple pregnancy can result from either type of reproductive therapy- just as putting in more embryos increase likelihood of pregnancy, also increase likelihood of a multiple pregnancy- so will it also increase the chances of more than one egg fertilizing.
(figure)
As of 1994, the relative contributions of IVF and superovulation have been approximately equivalent (slightly skewed toward superovulation side.) Overall, approximately 60% from superovulation- the remainder is from IVF. Superovulation is the worst offender because it’s the least controlled- (pie charts) overall approximately 20-30% of all pregnancies achieved with superovulation are multiple pregnancies. About 5-10% of all pregnancies are high order multiple pregnancies. IVF in contrast is much more controlled- couple decide how many embryos to place in woman (with rare exception of monzygotic splitting, if no more than one embryo is transferred, no more than one pregnancy will result.)
Although IVF is more interventional (considered the most aggressive reproductive treatment) it is a safer tactic (in terms of multiple pregnancy.) But tactic has lagged behind the theory- multiple embryos continue to be transferred and continues to put couples at risk for multiple pregnancies.
Worldwide there has been a big push to try to keep the number of embryos transferred to the minimum (recently published from 1991-2004) for Sweden compared to the US. Multiple birth rate in US has fallen pretty nicely over the past 10 years but has plummeted dramatically in Sweden. Reason for this is clear- when look at mean number of embryos transferred- pretty good job at decreasing the number of embryos- mean of about 4 to a mean of about 2.8 embryos today.
1.3 embryos per IVF cycles (in Sweden) that’s the mean.
In June 2006, the ASRM published recommended limits of number of embryos that should be transferred (physicians trying to regulate themselves rather than having government come in to do it for them.) Want it to be only one embryo transferred for women under age of 35 who have favorable prognosis.
Even so, certain times multiple pregnancies can occur.
What do we need to worry about if we have a twin pregnancy? What about a triplet pregnancy? Quadruplet pregnancy? Or God forbid, a higher order pregnancy- sextuplet pregnancy?
Multiple Pregnancy poses many risks-
Fetal
Maternal
Economic
Psychosocial
FETAL
Preterm Birth with attendant consequences of immaturity. This is a very serious issue. The usual duration is 40 weeks from last menstrual period. Approximately 50% of twin pregnancies deliver early (about 90% of triplet pregnancies deliver early)- not only early but some very early. 41% of triplets and almost all quadruplets deliver at lest than 32 weeks gestational age (less than 7 months.)
Complications of Multiple Pregnancy- Prematurity:
Intraventricular hemorrhage
Respiratory distress syndrome (immature lungs)
Sepsis
Nerotizing entercolitis (life threatening failure of the intestines)
Premature babies can develop blindness/ cerebral palsy as well.
PREMATURITY (MORBIDITY)
Percentage with a Major Handicap:
Triplets: 20%
Quadruplets: 50%
PREMATURITY (MORTALITY)
A total of almost 200 out of every 1000 babies born from a triplet or greater pregnancy will die within one year in age (almost 20 fold increase over singleton pregnancies.)
(graph)
Infant death- increase geometrically.
Maternal Point of View
Eclampisa/ Preterm Labor/ Gestational Diabetes/ Anemia/ Polyhydramnios/ Hemorrhage/ Caesearian delivery/ Thromboembolic Disease
Women need to be hospitalized for all of these (give statistics) much more as opposed to
Economic
Costs extremely high- can cripple a couple.
Psychosocial
Psychological Costs: Depression
Preexisting Psychopathology
Language Development (problems for children)
Reading difficulties
Behavioral problems
Social Costs- lack of sleep/ lack of space/ need for extra help/ isolation/ overburden
Multiple Pregnancy is a problem and we need to do everything we can to prevent the onset of such a pregnancy- I tell this to couples all the time- I would much rather their fertility attempt fail rather than it leading to a triplet or quadruplet pregnancy. This includes Rabbanim as well- Rabbanim are often a little bit reluctant- takes longer for a couple to get a psak that it’s okay to perceive with IVF- really if you look at this data it might be safer to go through IVF- risk of multiple pregnancy will be significantly less.
Now what do we do if despite best –
1. Close monitoring of the pregnancy, with interventions as warranted
2. Multi-Fetal Pregnancy reduction
Technique where bring about demise of one or more fetuses in a multiple pregnancy, with the intent to….consequently lower risks of mortality or morbidity
MPR- Multifetal Pregnancy Reduction
Ultrasound Guidance
Intracardiac or Intrathoraci Injection of Potassium Chloride
Transabdominal or Transvaginal
So inserts potassium chloride to child’s heart- it stops the child’s heart.
The decision of which fetuses should be reduced is made according to preevaluation- nuchal translucency measurement, limited anatomical survey, mapping of fetal location. They try to see if any have any abnormalities or malformations. If all of the fetuses seem to be normal then becomes question of position in uterus- what will interfere least with the others-
Timing- can be risky –
Usually done between 10-15 weeks from last menstrual period (which is 8-13 weeks from conception)
Multifetal Reduction includes certain risks:
1. Bleeding
2. Infection
3. Pregnancy Loss
The risk of losing the entire pregnancy correlates with number of fetuses reduced.
3-5% from 3 babies to 2
5-10% from 4 to 2
10-25% from 5 to 2
BENEFITS
Increases duration of pregnancy
Reduces incidence of prematurity
Increases birthweight
Reduces neonatal mortality
Reduces maternal risks
RISKS
Guilt
Regret
Patients might feel guilty afterwards and might regret having underwent the procedure- small number of women 1/3 of those women reported feeling persistent guilt. Although there have been studies to look at women that see no serious psychological problems/ issues- one large study of 91 women where 93% said they would make the same decision again.
Unique situation- here we have husband and wife desperately hoping for pregnancy, actively pursuing medical treatment for this- now have achieved that pregnancy but it’s in excess of success. Striven so long for fertility and now problems.
Especially for Jewish couple-
Fertility is considered a bracha- blessing. Pesukim in parshat Eikev- Devarim 7:14. “You shall be blessed from all the nations/ We will not have among us any infertility”
Very first words of God to Adam is “Peru u’Revu”- be fruitful and multiply. Not “Hello and welcome to the world” or “Hi, I’m your creator” but Peru u’Revu.
The mishna in Edyot 1:13 says that “The world was created for procreation.” Only by reproducing can man live within this world and therefore live within it it
Genesis 1: 28- it says “And God blessed them, and God said to them: Be fruitful and multiply and fill the world and conquer it.”
They should be very fertile and fill up the whole world- their first two pregnancies per Genesis Rabbah 22- says they had one twin and one triplet. The Medrish says that Cain was born together with a twin sister and Hevel was born as a triplet pregnancy (together with two pregnancies.)
Many people in Tanakh products of multiple pregnancies
Cain/ Hevel
Rachel/ Leah (Midrash says they were twins- based on calculations of their ages- Seder Olam, perek 2)
Yaakov/ Eisav (They might have been identical twins suffered from twin-twin transfusion syndrome.)
Sons of Jacob (Shevatim) – this is quoted by Rashi on 37: 35 in Genesis
Dinah (had a twin sister)
Benjamin (a triplet with two sisters)
Peretz and Zerach
Midrash brought down by Rashi highlights high fertility of Jewish couples while we were slaves in Egypt (conceived six children simultaneously)
We assume that these pregnancies in Egypt had good outcomes- seems sextuplets were almost physiologic. But now, though, we see that high order multiple pregnancies carry significant risks of morbidity/ mortality. So we have technique of multifetal pregnancy reduction.
How does halakha approach this?
We must begin with overall issue of feticide.
Abortion in Halakha- its own extensive topic. But in brief, Genesis 9: 6. “Whoever sheds the blood of a person within a person, his blood shall be shed; for God made man in His image.”
This verse teaches us that it is prohibited for a non-Jewish person to kill a fetus in utero.
For a Yisrael/ Jew, this rests in a Gemara in Sanhedrin 59a.
The Gemara sets forth a principle that any mitzvah given to benei noach and repeated to us by Har Sinai- if a mitzvah is restated at Har Sinai- the Gemara says that we know our principle from the prohibition of not worshipping idols. One of the 7 mitzvot benei noach. Clearly mitzvah repeated by Har Sinai was meant for everyone.
And any mitzvah said to Benei Noach and not repeated by Har Sinai is meant just for us and not non-Jewish people. We might think the opposite- we would assume it is meant only for Children of Noah. But no, answers the Gemara. We cannot entertain the notion of something being commanded to non-Jewish people (Benei Noah) and not to Jewish people.
For any specific situation, if a non-Jewish person is held responsible for a particular action, there can be nothing that is prohibited for a non-Jew that is permitted for a Jew.
Tosfos explains that although a Jew who kills a fetus is not prohibited- does not get capital punishment- still important.
The concept of Rodef plays a very large role in MFR. Rodef refers to role of Pursuer. The source for this concept is a verse in Exodus 22: 1. “If a thief shall be found breaking in to someone’s house and shall be attacked and killed, there shall be no liability for his account.”
If someone comes after you to kill you, you have right to kill him. (Sanhedrin 72a)
Rambam in “Hilchos Rotzeach” 1:9
…Therefore, if a pregnant woman’s life is threatened during childbirth, it is permitted to kill the fetus in her womb…because the fetus is considered to be pursuing her to kill her.
The Rambam says because one is allowed and even obligated to kill a pursuer one can kill a fetus to save the life of a woman. Now, the concept of a Rodef can be applied to high-order multiple pregnancy. It can be considered Rodef vis-à-vis the mother or vis-à-vis its siblings. If we’re talking about Fetus as Rodef with regard to mother, there would be no question at all where we could perform the reduction. But this is rarely such a clear-cut issue. But for all women- pregnancy is a state of higher risk than non-pregnancy but no one would argue pregnancy is not a normal part of the human condition. Perhaps twins aren’t also part of normal human condition- where do we draw the line- not an easy question- when does fetus become a Rodef? This question probably needs to be individualized (for some woman, with preexisting problems- cardiovascular, etc) might be enough to define fetus as Rodef (pursuer) and allow its life to be terminated.
More complicated than the question of the fetus’s status of Rodef with regard to the mother is the question of whether each fetus can be considered a Rodef with regard to its siblings. Multiple nature of pregnancy- presence of other fetuses in uterus- same halakha in Hilchos Rotzeach- while okay to kill a fetus during childbirth, once the fetal head has delivered, it is no longer permissible to do so.
…But once the fetal head emerges, we cannot harm the fetus, because we do not discard one life for another, and this is the natural order of the world.
1:9
This is a natural process- unlike thief breaking into house to kill you- this is not within the umbrella of Rodef. This is based on a Gemara in Sanhedrin- Sanhedrin 72b.
“Once the fetal head emerges, we cannot harm the fetus- but why isn’t he still a rodef? Because Heaven is the pursuer.”
R’ Chaim Brisker addresses obvious question- why is fetus who is not yet born allowed to be killed? If Heaven is the pursuer…if that’s a natural phenomenon, why don’t we say the same thing for a fetus in utero? His conclusion: R’ Chaim invokes a principle from the mishna in Ohalos- the mishna says “If a pregnant woman’s life is threatened during childbirth, it is permitted to kill the fetus in her womb because her life takes precedence over the fetus’s” (Ohalos 7: 6)
This, R’ Chaim feels, is the cornerstone of Rambam’s reasoning.
Yerushalmi brings a different point of view. Bavli says that since Heaven is the pursuer, fetus is not the Rodef. The Yerushalmi gives a different reason- the mother and the fetus are simultaneously endangering one another- so one is pursuer and pursed (simultaneously!)
Bavli: Natural phenomenon (pursuit from Heaven)
Yerushalmi: Mother and baby are simultaneously Rodef and Nirdaf (pursuer and pursued)
It would seem to leave very little room to allow for point of view to engage in MFR for benefit of other fetuses.
Put that aside for now- another crucial set of halakhot that comes into play for MFR is the permissibility of sacrificing one life to save another- concept of handing over someone to save other people’s lives-
Rambam-
If a group of Jewish (women) were informed by idolaters that one of them must be handed over to be defiled or otherwise they will all be defiled, they must all submit rather than hand over a single Jew
(similarly)
Similarly, if idolaters said to a group of Jews that they will kill everyone unless one is handed over to be killed, all must submit to death rather than hand over a single Jew.
However, continues the Rambam- “If the idolaters specify the person hwo must be handed over to be killed, that person can be handed over only if he is already deserving of headth. If he is nodeserving of death, all must submit rather than hand over a single Jew.”
(example of Sheva ben Bichri) Story of Sheva ben Bichri is brought down in Samuel II, Chapter 20. Sheva rebelled against David. Joab surrounded to kill everyone in city unless Sheva was handed over. Wise woman (identified by midrash as Serach) convinced city to kill Sheva and therefore to save the city. So the wise woman and the people in the town were halakhically correct in handing him over.
The Kesef Mishna on this Rambam quotes the following question from the Ramach- “The teaching that one should submit himself to be killed rather than kill another is rooted in logic- no person’s blood is redder than another’s.” (Pesachim 25b)
Therefore, asks the Ramach- in the case where idolaters are asking for someone to be handed over or else everyone will be killed- we should use logic- he’ll be killed regardless! So the sevara- logic of no one’s blood being redder than another’s- shouldn’t apply here! But Kesef Mishna answers that the logic here “no blood redder than another person’s” still applies. Because idolaters are not specifying any particular person- becomes “Why are you choosing me? Go choose him!” So we can’t choose anybody to hand over to save entire time.
Then Kesef Mishna asks the opposite question- the Rambam had said that when a specific person is named, can only be handed over if condemned already to death- why not? because that person cannot protest- he was named by the gang of marauders- so because he will be killed anyway should be handed over! The logic of no one’s blood being redder than anyone else’s is not the real basis for the principle of “yehareg v’al ya’avor.” Really this principle is an inherited one- halakhic principle still applies because of tradition from Har Sinai. Person cannot murder someone to save himself from death.
This issue might be basis of machlokes between two views-
Yerushalmi says- brigands name a specific individual to be handed over to die (he’s not on death row- he’s not worthy of death) R’ Yochanan says we can hand it over. Reish Lakish says no. According to Reish Lakish, can only be when a person is named AND he is on death row. I would suggest that this machlokes can be understood based on basis of “yehareig v’al ya’avor.” Is this idea based on logic or on kabala- that is, tradition?
Maybe Rabbi Yochanan says it is completely based on Sevara/ Logic. That’s why the person can be handed over even if not on death row. Maybe Reish Lakesh’s position is that it is based on Kabala/ Tradition. In that case, if specified person is not on death row, can’t be handed over, no matter what. According to Reish Lakesh, only time is when the person is a dead man walking- he is on death row for a capital crime- maybe that is when “yehareig v’al yaavor” doesn’t’ apply.
Lechem Mishna 5:5 disagrees with Kesef Mishna. He says it’s based on logic. The reason you can’t kill another person to save yourself is because of logic that everybody’s blood is equally red- in case where desperados specify the victim for death, he can be handed over because he can’t say why not someone else? He was specifically named. (missed something here) The Lechem Mishna says refers only to specific situation where person has a chance at escape (when gangsters come in to kill everyone else)- in that case the logic that nobody’s blood is redder than anyone else’s.
According to Lechem Mishna’s understanding of this machlokes, can only arise when possibility exists that the specified person might be able to escape. Because if no escape for this indivudal, no matter what, even Reish Lakeish would agree he can be handed over- because according to Lechem Mishna everything is based on Sevara. When possibility exists where person CAN escape, that’s when R’ Yochanan says he can still be handed over. Raish Lakish says no.
Chazon Ish suggests that the underlying question here might actually be about the concept of Rodef.
Perhaps the reason why Rabbi Yochanan says that specified person is handed over is because of Rodef- because lives of everyone else in town is in danger because of this person- he has become a Rodef and therefore he can be given over. According to Reish Lakesh, he cannot possibly be considered a Rodef- poor innocent person.
Fundamental machlokes about Rodef. Is a Rodef someone who pursues with nefarious intent- or is a Rodef someone where his actions, no matter how purely meant, puts another person’s life in danger?
Contextual/ Intentional- Is Rodef defined by intent (degraded morality, trying to cause harm) or is it simply that a Rodef hurts someone else?
R’ Yochanan- Maybe he thinks it’s simply contextual. This specified person, through no fault of his own, is threatening lives of everyone in town simply through his existence.
Reish Lakeish- To him, pursuit is based on iniquity. Here you have to look at the intent of the pursuer- that’s why the person can’t be defined as a Rodef. Even though his name was specified by bandits, he is guilty of no intentional desire to harm someone else.
This understanding of the machlokes might actually be related to a machlokes we saw earlier as to why a fetus that is partially born- heavens doing pursuing and not the fetus. Yerushalmi said mother and fetus threaten each others’ lives simultaneously.
Bavli: Intentional (morality of pursuer- therefore Heaven is Rodef) That is why a fetus is not a Rodef- fetus is not a criminal- does not desire to harm his mother
Yerushalmi: Contextual (It’s the context that defines a Rodef without any regard to intent.) Even though fetus has no desire to harm his mother, this is not what would make him rodef or not redof- the fact is that here they are both rodefs.
That’s why Yerushalmi had to give a different explanation at this point.
So Intent= Bavli, Reish Lakesh, Rambam
Context= Yerushalmi, Rabbi Yochanan
From a practical point of view, both of these concepts (of Rodef and mesibah ofYehareig v’al Yaavor.) Whether MFR should be permitted likely depends on machlokes between Lechem Mishna and Kesef Mishna.
According to Lechem Mishna-
1. Yehareigh v’al Yaavor is based on Sevara/ Logic
2. If logic doesn’t apply (as it doesn’t in this case) then we can save someone to save ourselves- because person won’t survive anyway
3. MFR should be okay
If all the fetuses will die without reducing a particular fetus, then MFR should be okay. However, if there is a chance/ probability of survival (that is, escape, in halakhic terms) does that prevent us from reducing? It would seem that MFR is not okay in that situation.
If in the other hand we hold like the Kesef Mishna that:
1. Yehareig v’al Yaavor is based on Kabala
2. Even if all would die- cannot deliver fetus to its death
3. Unless fetus has gross abnormality, because maybe then can be argued that abnormal fetus who is doomed to die is in same category of being “on death row” and then MFR is permissible
Even according to Kesef Mishna there might be room for leniency with regard to killing a normal fetus- Minchas Chinuch suggests that “Yehareig v’al Yaavor” might not apply to a fetus.
The Minchas Chinuch suggests that because there is no capital punishment for killing a fetus by a Jew, killing a fetus is less severe than killing a born baby.
A fetus’s blood- a postnatal’s life’s blood is indeed redder than blood of the fetus. Fetus carries with it monetary punishment for being killed whereas born person carries with it capital punishment for killing him.
In that case, “yaharaig v’al yaavor” only applies to situation where capital punishment is the punishment. But this is not the case with a fetus!
Clearly fetal life, however important, has less value than the life of someone who is born already- and if there’s never the logic of “damah didach”- that it’s equally red to anyone else who is born- then the kabbalah of “yaharaig v’al yaavor”-
MFR IN HALAKHA (MODERN POSKIM)
Rav Eliezer Waldenburg in 20th volume in Tzitz Eliezer and quotes R’ Elyashiv- dealing with reduction for quadruplet pregnancy- he allows reduction of one fetus to reduce from quadruplet to triplet because each fetus considered a Rodef with regard to the others.
I myself had personal communication with R’ Elyashiv with 21 year old frum woman- treated her with injectable gonadotropins- she ovulated 3 eggs- had triplet pregnancy plus one split so there was a total of 4 fetuses. Identical twins are risky in and of themselves. So the question posed to R’ Elyashiv is whether it is permissible to reduce quadruplet pregnancy to a twin pregnancy by reducing the identical twins. He said it’s okay to reduce the identical twins if and only if the chances of survival without the reduction was less than 50%. Mortality only thing he was taking into consideration- in this case parentologists were uniformly in agreement that infant death were at least that hi- so we actually did terminate this.
End of story with this particular couple- they underwent their multifetal reduction at 12 month-somewhere around ___ semester, intrauterine growth restriction of female, preeclampsia at 29 weeks, unstoppable preterm labor at 30 weeks, c-section, girl died in NICU, boy alive and well ad is now 8 months old.
R’ Shlomo Zalman Auerbach permits the reduction of either 1 or 2 fetuses in a quadruplet pregnancy where mother had a small pelvis
Rav Yitzchak Zilberstein allows muti-fetal reduction. Says that since fetuses are noviable without MFR, should be called “preservation” rather than “reduction.” MD can decide how many to reduce- use indirect technique. (Should be called Multi-Fetal Production vs Multi-Fetal Reduction) This heter is predicated upon reality that none of the fetuses would survive if reduction were not done. They want indirect technique (potassium chloride satisfised this)
Rav Chaim Dovid Halevi wrote that although abortion is murder, we can be lenient here if otherwise very low survival rate for others
Rav Mordechai Eliyahu considers each fetus to be a Rodef vis-à-vis the others- therefore MFR is permitted, MD can decide how many to reduce, can be done by either a Jew or non-Jew- can be done anytime but before 40 days gestation if possible
Ravi Tzvi Kushelevesky recently wrote that while multi fetal pregnancy reduction- MFR is certainly fine when reducing a fetus with a known abnormality
R’ Aharon Soloveitchik quoted by R’ Yitzchak Mehlman- says abortion varies during time being done. From bulk of pregnancy, not considered homicide (rather based on Chullin- it is considered a limb of it’s mother) – considered Chavala to the mother- injuring the mother. Person can sacrifice one limb to save the other- so can abort one fetus to save the other.
We’ve discussed epidemiology of multiple pregnancy, causes of multiple pregnancy, risks of multiple pregnancy, prevention and management of multiple pregnancy, multiple pregnancy in Chumash and Hazal, the issur of feticide, concept of Rodef, concepts of mesirah and yaharog v’al yaavor and summarized opinions of well known modern poskim.
Rabbi Brander: Ladies and gentlemen, if I could have your attention please. I want to first begin by thanking the entire Medical Ethics society, the students who made this possible and many of the staff from the CJF and the staff from the whole University who made this event possible and made it a very special event. We’re about to begin the final session-we’re blessed with having major experts here to share words of Torah with us- we thought it would be appropriate to dedicate this session in loving memory of Rebbetzin Tendler. Rabbi Tendler has been a true pioneer in Medical Ethics- Rebbetzin Tendler, who was always his full partner- Rabbi Tendler is in the midst of sitting shiva for his wife- thought it would be appropriate to dedicate this to her.
New Frontiers in Fertility Technology-
Introductions and Scientific Moderator: Dr. Susan Lobel
Special Address: Rav Menachem Burshtein and Rav Herschel Schachter
Dr. Lobel: Several years ago a woman called me and identified herself as graduate student at NYU- of course very lovely, surprised to see that she was obviously not Jewish. I asked her what had prompted her to write an article about Jewish law and infertility treatment. She had said she was originally going to write an article about comparative religion fertility treatments. Catholic doctrine severely limits this- Islam has significant conflicts- Judaism is the one religion where this is not only not limited but it actually embraced. As technology gets more complicated, so too do the halakhic issues that are raised. 30 years ago IVF ___ currently 1% of all babies born are conceived through assisted reproductive technologies. Equally if not more impressive moving forward in field of molecular genetics- prevention of disease- use of embryos created through IVF and stem cell technology, hopefully treating diseases that are very common like diabetes and Alzheimer’s and treating patients with problems like spinal cord injuries.
Explore these halakhic issues through a series of case presentations- very lucky to have with us today Rabbi Herschel Schachter, Rabbi Mordechai Burshtein, Rabbi Gideon
_____ etc. Even if you understand Hebrew, suggest working off of headphones b/c of technical terms.
_____ can affect even before undergo puberty- autoimmune, genetic, chemotherapy. Up until 30 years ago only treatment was IVF. Several years ago transplantation was done moving ovaries from one identical twin to another- also have been a few recent cases using non-genetically identical sister where one sister has already donated bone marrow to the other- while right now this technique is limited to identical twins/ closely compatible siblings, it’s not too much to hope that in the same way that kidney donation started off with identical twins, moving on to ____ for ovarian failure.
Recently a patient presented to me has premature ovarian failure. She has a sister who is happily married and who does not have premature ovarian failure. Can this patient do ovarian transplantation with her sister? Does it matter that her sister is married or not? Can she do Donor A,
Rabbi Burshtein: Rabbi Brander and the wonderful audience know- we are working on message- in contact with the luminaries of the age- we are standing on the shoulders of giants- we don’t come up with the answers- we have the great Rabbi Schechter sitting here and doing the same things- not just me being modest, but Rabbi Schachter is the great person who gives the teshuvot- I’m not saying that I am _____ but he is a giant- there is a very important point to be aware of in terms of this subject. In terms of ovarian transplanatation, whenever I asked in the past- researching for so many years, why do you have to speak of questions of getting eggs- it’s so much simpler with the ovary- there was a matter- the writer of Even Yekarah said that if you are actually it doesn’t happen- if you were in fact to implant an ovary then it would be, then it’s not the egg itself- part of the same system.
Now we should know that there is a big controversy among the people who do decide of who is the mother when you have an egg donation- like R’ Elyashiv and Yosef- in last few years they changed their opinion as opposed to what they said in the past- there is no final decision they said in the past. All the more so it is certain when you implant an entire ovary- even though medically it might be better- let’s not start with family itself in order not to get involved in this halakhic controversy- we have Evan Yekarah (precious stone) and many others, Rabbi Shapira, Rabbi Elyashiv- once spoke with _____ and he apparently did not want to reply to this point. He wouldn’t say.
He says “If we were to succeed!” So he says “ Tell me when that happens.”
So I wouldn’t want it to come from same family- so that’s…
Rabbi Gideon: He spoke about question of mother. Question of _____- question of taking from donor and question of taking from sister
Rabbi Schachter: Isn’t there a question of Chovel? Cutting off finger- Is it possible to take the ovary from the ______?
Rabbi Burshtein: There is a problem, then, in donating an ovary.
Dr. Lobel: The technology is actually just giving part of an ovary- so between two sisters, is there an issue with that?
Rabbi Schachter: That’s not a problem- teshuva from Evan Yekarah- once take an organ from another body and sit it on my body so then it’s part of my body! So there’s no question of mamzerus or anything like that- I still say that there’s a problem of chavalah- will it be possible for it to take- like heart transplants- list of 5000 people who need a heart.
Dr. Lobel: Issue here is with autoimmune system and rejection- new technique and actually in Israel they’re working on techniques- lots of technical issues to work out, both with surgery itself and because ovarian tissue so fragile so if there is a decrease in the blood supply, ovaries die quickly- biggest factor is the rejection factor. Now this was worked out with kidney transplantation- if someone needs dialysis versus a kidney transplant- it’s so much better to have a kidney transplant. To have her go on- vs just do IVF and pregnancy is like any other pregnancy. Depends on working out immunotherapy but in theory organs could be taken just like any other organs are taken, take us a while to take
Rabbi Schachter: The day will come when women will be donating their ovaries and there will be a list of people who want to receive it- so there will be a list like any other kind!
Dr. Lobel: I was in Israel, talking to shopkeeper, asked me what my job was, said that I did IVF. Asked if he knew what that was- he took out a picture of two adorable twins and said “This is Invitrofertilization.” So he goes on about story between husband and wife, wife now has frozen embryos and I told my wife “Here are these frozen embryos- now you don’t need me anymore.” Thank God they are doing well. But what would happen if God forbid he weren’t there? Situation will become more and more common- husband dies and widow, can she have the embryos transplanted- should she have them done or should they be discarded? Related but somewhat different is where embryos have not been created but husband has left frozen sperm- or when husband has been killed- to retrieve sperm from recently deceased husband, freeze it, go ahead and do it-
Rabbi Burshtein: This answer has come up in a very severe manner in Israel- couple came to us after Holocaust- only one who survived was child who was killed who had frozen his own sperm- clarified problem before great luminaries. What is the end of life? Now we have to- we joke of it- that should be our consolation- that you will never suffer this again- I hope that you froze the sperm for the continuation of your progeny. The journal opinion of most of the response is NOT to do so, not from halakhic basis is it prohibited, but so that things will be clear from the point of view of….because death is, in Israel for example, there was a war widow who took sperm and then sued the IDF because her son is an orphan- he was born after the father died! The court did not accept that after the father died. Although court allows freezing of semen, if a will has been left by the father according to this- most responsa said not to do that- several poskim I was told that we should deal with every case by a case by case basis- I will have Rabbi Schachter answer.
Rabbi Gideon: Less of a halakhic question and more of a psychological question- Rabbi Menachem mentioned that there was a soldier killed with frozen sperm- do we bury it with him or should they keep it- and then there was another question- can we remove zerah from the meit- nivul ha’met- is that something that should be done? Maybe the Rav can answer.
Rabbi Schachter: I thought it was generally assumed that you don’t give artificial insemination to single women because it will just encourage promiscuity- every girl is going to become pregnant and say that she has had artificial insemination. Not to encourage for this for people who are not married- for women-
Rabbi Gideon: And to remove zera- someone will use it, a married couple will use it?
Rabbi Schachter: (Mamzerus?)
Dr. Lobel: These are cases that we are facing right now- now moving a little bit more to the future, I’d like to focus on genetics. Genetics- there are two forms. Defects inherited by single gene mutation resulting in abnormal enzyme or other factor that causes genetic defect- Trisomy 21 resulting in Down Syndrome- with the advances in molecular genetics, there are now over 100 diseases that have been identified on a genetic basis- both doing blood tests and in the actual embryo. When IVF moved conception into the laboratory, it enabled the field of genetics to be combined with the field of reproductive technology. …commonly referred to as PGD. To briefly review, with PGD couple undergoes ____ in standard way. General two or three days after fertilization, remove two or three cells from the embryo. Then, in the laboratory, these cells can be analyzed in one of two ways- if you’re looking for single-cell mutation (technique called ______) for another diseases where looking at chromosomes, there’s a technique called FISH (Flourescent ISH.) Abnormal vs. Normal Embryos/ embryos that do not have the specific defect that we are checking for can be transferred back on day five. Extremely powerful technique but has error rater of up to 10%. Right now the technique is not widely used, primarily because it’s very labor intensive and therefore very expensive. Scientists working on technique so that it can be done in a way which is much less expensive- we can assume in future it will be used much more widely.
Have a couple who are both carriers for a disease- say two people who are carriers for Tay-Sachs. So you can take away embryos that have two copies of the abnormal gene. You can also do this to select for embryos that are either male or female. This was done not for elective sex election but in case of hemophilia where girls generally are unaffected and boys are- it was done to select for female embryos- but it can now be done electively if a couple wishes to have a child of the certain sex. PGD also looked at in reproductive medicine to enhance success rates of IVF. So scientists are looking at if PGD is done before embryos are put back, so abnormal embryos can be weeded out- given the current cost of doing PGD as well as the increased time, this is not being done widely and people generally are just putting back more embryos. The expectation is that with time PGD might be a standard time of IVF.
Currently there are 16 inherited diseases that are more common amongst Ashkenazim- 11 of these can be tested for. In 1975, American College of OBGYN said that all Ashkenazim should be offered genetic testing- Sephardim do have diseases, but Ashkenazi diseases more lethal.
Case Study- Couple who has been married for number of years. Back then, only tested for 2 or 3 diseases. Now gone to gynecologist- found that they are both carriers for a disease. Use the example of Caravan’s Disease- where child generally dies by age 4. Now couple is faced with situation where they want to have more children- what can they do? From medical point of view-
1. Only do IVF with PGD
2. Conceive naturally (75% chance of having a child who is either totally normal or a carrier for the disease and only 25% chance of having that child)
3. Not to have any more children
Another situation that is presenting more and more is a gene for the disease that manifests itself later in life- 2% of all Ashkenazim are carriers for what are known as defects in DIBCA 1 and 2. Two defects that occur in Ashkenazi Jews- particularly women who have this are more likely to develop breast/ ovarian cancer. Women with relatives- breast/ovarian. Risk of developing cancer-
If a woman tests positive for having BRCA (BICA) mutation, medical community recommends her removing or replacing her breast tissue and removing her ovaries. Could be recommended relatively early or by age 40.
Also possibility if a woman knows she is a carrier and hasn’t completed her childbearing, should she do IVF to select for ovaries who don’t carry this gene? Should she do that/ can she do that if she doesn’t have a fertility program?
Sex-Election: Doing PGD for sex election- was designed for medical reasons. The medical community in their ethics discussion has strongly come out supporting that PGD not be done for sex election. But if a couple has five boys and they want to have a girl, halakhically- and they have no infertility issues- halakhically, can they do IVF with PGD to select for a girl. Or if they have five children but husband has sperm problem so only way they can conceive is with IVF, since doing IVF anyway are they allowed to select for a girl.
Rabbi Burshtein: Rabbi Schachter, I hope you received booklets- handouts- answers- at the moment we hear about conference something new- for example Rabbi Weissman- international fertility- and we work with the institute- the new things, the novelty- we raise this inseminators- question of choosing the sex of the embryo rose in Israel, most promptly with a couple of ours- after many years we went to a responsa Rabbi who did not want a son because he would say that son is not a Kohen, because father is a Kohen and they would see son is not a Kohen. They suggested that I threaten them with appeal to Supreme Court- and they ultimately made examination, instituted certain ethics committee (page 11 in this handout)- whoever wants to turn to address this committee- mostly this is a problem of hereditary- for example, when you have four of the same sex and the mother is elderly, it’s possible to request to do PGD to choose the sex of the embryo. The committee and I convinced them that it’s fine, all right- really tremendous psychological strain on couple- I have not convinced community to do PGD for a Levite- a Levite don’t have to go in front of Ark- so no one needs to know child is not a duchaning. So look at page 3- that’s the answer, the responsa- we have 3 methods.
1. One is based on what at the time one spoke of- our sages- who is the one who fertilizes first? The male sperms die sooner- while the female eggs are slower but ultimately do reach the goal in real life. So this method- one tried to work based on this method. This works with diets and the like- but to say it succeeds? not so much. But more than 30% success rate.
2. They are separating the sperm but there’s some success- you see through the sperm and you separate through them- the doctor told me, 62%- 50% I can do without any treatment- for another 12% you want to get the sperm? It’s not possible. Out of 21 cases, all of them were successful. The 22nd case did not succeed- wonderful child but not the sex the couple wanted for the child. Separation of the sperms is a difficult halakhic process.
3. Look at page 3 again- R’ Schneur Zalman- says not to use PGD. Rabbi Silverstein is even more severe in this method- he is a well known person. He is son-in-law of Rabbi Elyashiv. On page four, there is something very interesting- he writes in a very strenuous manner issue of throwing out sperm needlessly- page four, right side- seems peculiar to to allow someone to ______- questionably his, questionably a Kohen, just so he’s male. Not worth to get into this technology unless there is really a need- look at page 6, Rabbi Hofsky- he too writes that only in a case to prevent diseases but to keep the sex of the embryo in and of itself- Rabbi Ariel page 7 says that one should- whoever who has only daughters, there’s someone else in the world who has only sons! and it’s fine! They can marry each other- everything will work out perfectly in the world- Rabbi, when he spoke- the whole subject of diets and the like are fine but to get into technology- and this subject is very complicated. Rabbi Lior, on other hand, on page 8, writes in responsa- that there’s no way for the Torah to let the person be overly clever and beat nature. All the laws of Torah are based on nature and if nature allows for child of one sex, one should not choose methods to contravene this. Rabbi _____ said I am very sorry that you are dealing with such matters- your purpose is to deal with fertilization, matters of marriage- leave this matter for the Almighty. Another place- Rabbi Levental writes us that he prefers all the methods but NOT the PGD method. Rabbi Mazuz who is a very great learned man found a gematria for- all of these have same letters that come to the same numbers- he says that- it’s preferable not to deal with these methods- instead go to _____ from United States who has a lot of contact with us- entire subject of treatment that’s barely permissible now- now we’re coming to a slippery slope. One day, they’ll ask for color of eyes! What?! If my son will not have blue eyes, then he won’t be able to manage in society?! So what we see here- Rabbis not a fan of doing PGD to choose sex of the embryo. Most couples who have four or five children of the same sex- naturally they want to fulfill to fulfill the obligation- that’s the question- Rabbi Mordechai Eliyahu in these matters is very different from most of the responsa- he says whoever wants someone, send to me and convince him- then maybe there is a mitzvah involved here that sometimes the emotional difficulty is so severe that some people who reached us are literally- I am amazed! they have so many children- someone who had 14 children and the 15th was a daughter. Only one daughter, which was the main thing- he didn’t want to be so many years without children- had so many boys so he won’t be sorry so wife doesn’t have a daughter- so I just want you to see how this things- where the responsa is on the matter.
I would also like to address myself to genetic testing but first want to hear Rabbi Schachter.
Rabbi Gideon: They can have children and just want to have children of a different sex (elective sex)- Rabbi Burshtein disagrees with this strongly. I’m very glad this wasn’t around when I was born because my family only had boys- and so I wouldn’t be here!
Second permutation is a couple who need to do IVF anyway and then would like to do sex selection anyway.
Third permutation is to do PGD in a case where it’s not fatal- carrier- carrier where it has some ramifications but it’s not life-threatening. Dr. Lobel said that PGD doesn’t damage the embryo- PGD apparently does cause some damage to the embryo. Dr. Lobel made another point that it’s becoming more common to do PGD across the board- put back embryos, some have genetic abnormalities- do PGD and remove those embryos- had you not removed them- certain ____ within the cell that has the ability to redress those minor genetic abnormalities- something to bear in mind when you give a psak- PGD is not something that has no ramifications for this treatment- may in fact remove embryos that are indeed healthy.
So three questions are:
1. Couple who wants to choose sex of child
2. Couple who need to do IVF anyway and want to choose sex of child
3. PGD for abnormality where not fatal?
Rabbi Schechter: I don’t think even the diet and the other gimmicks…I don’t think that one is obligated to stand on his head to see to it that he has a son and a daughter. If one can only have children through IVF, then I would think that strictly speaking it would be permissible to- and not concerned about any sicknesses- could possibly damage the embryo, so why should you damage the embryo? But if you’re checking already for diseases and have to do this PGD anyway for diseases so what should be so bad as a matter of policy- slippery slope- should never do that- should never do the PGD if the only purpose is to determine whether boy or girl- as far as mitzvah as pirya u’rivya I don’t think it’s necessary. It’ll lead to ridiculous…
Rabbi Gideon: In the case of the Kohen, we should expand a little bit on that- I think Rabbi Brander raised it before- case where couple had been through tremendous amount of treatment- wife had come from quite unstable background- theoretically could even be lifethreatnening and really needed to have treatment- Chassidim of particular rebbe who usually wouldn’t allow sperm donation. Rabbi Menachem and myself went to go see the Rebbe and he said teshuva of Rabbi Moshe, R’ Shlomo Zalman- so he allowed it. But under no circumstances would he be willing to do the treatment- if every single day that boy would know he was not a kohen- and everyone in the shul would know- would be incredible embarrassment- not to do the treatment, worry about wife’s health. To do the treatment, worry about husband’s health (if male ensued.) The only possible way to navigate through this very hard situation- is to make sure to have PGD and to have a daughter- the doctor was so taken with this case so he went to the newspaper and said “Look what we can do!” and the Health Ministry did a whole thing on it- elective sex, elective sex election- in order to ensure that it was a girl, they needed to have an elective IVF and elective PGD- such a social question and the whole commission- because of this case- and in fact Israel is one of the few places in the world that does allow sex election. It’s because of this case…can you allow sex election because of sex election?
Rabbi Schachter: You think by mamzerim also? Mamzerim also has to fulfill pirya u’reviya but children will be mamzerim! So Rabbi Feinstein has tremendous chiddush- says that child who is a product of artificial insemination is not a mamzer- in such a case also should recommend b’dafka to have artificial insemination.
Rabbi Gideon: In a case where there is a genetic abnormality, then PGD would be recommended?
Rabbi Schachter: Recommended, sure…
Rabbi Gideon: And if it’s….?
Rabbi Schachter: B’dafka recommended- don’t have to be a tzaddik at your children’s expense- couple came to me and the wife had some kind of psychological problem- one of the children who they had had a ___disability, one wedding, another wedding- woman had nervous breakdown- so they couldn’t have children unless they ____- want to know is it okay if they have another child? So I said- It’s not fair for me to tell you- I have nine healthy children- if I would be you, I would call it quits- you have two healthy daughters, I wouldn’t look for trouble- then he came back to me and asked whether it was a psak- I said it wasn’t a psak, just daughters- so woman became pregnant and almost jumped off of the roof- was going to commit suicide- then became depressed- so he reconsidered. First time I and my wife walked into Machon Puah- wife said in Hebrew, “He has nine babies- now wants more babies!” Should practice birth control afterwards- who needs to bring ba’alei mumim into the world?
(exchange between Rabbi Gideon and Rabbi Schechter)
Rabbi Burshtein: Blue bill and pink pill at pharmacy- now technology is different now- I want to talk about something else on page 5- various illnesses that we see- have to improve more than others so God gave us more diseases than others- each community has- there is Dor Yesharim today and we can check most of the things. We encountered a question of a couple who went through Dor Yesharim and both were told they were carriers for a disease that there was 25% to give birth to this- they didn’t know what to do- all my life I’ve been looking for my bashert- and now I can marry if I can do with PGD- I asked a few Rabbis- Rav said she’s an agunah- how can she be agunah if she hasn’t been married yet? 34 year old woman who has not married- considered agunah, similar agunah- so this woman should be married and she can do it through IVF/ PGD.
Rabbi Schachter: Boy 23 and girl 20- marry each other despite the fact that they are both carriers- that’s ridiculous! They have a whole lifetime to find someone else.
Rabbi Burshtein: Chemotherapy/ man with cancer- to take it out under anesthesia- maybe poskim allow it- not so much freezing of eggs by women- it’s been said that 150 children have been born by frozen eggs. Today they freeze parts of ovaries- they take part of an ovary and freeze it- in Israel a girl was already born from a part of a retrieved ovary. But you have to know that after chemotherapy, depending on amount of chemotherapy the woman is not fertile anymore- today we recommend to women who goes to chemotherapy and who won’t be fertile anymore to freeze a part of the ovary although it’s not sure- so if the Rabbi allows it, we also make a suggestion here that the woman who undergoes chemotherapy should freeze parts of the ovary because it’s only parts of the ovary-
Rabbi Schachter: Even for a single woman/ single boy who is undergoing chemotherapy? Also permit him?
Rabbi Burshtein: Yes. Not everybody, but even singles we do it- depends on the poskim- there are methods. Some allow men to retrieve- R’ Elyashiv says that when man is under anesthesia-
Rabbi Gideon: In that case, single boy going through chemotherapy- especially if not 12- if he is 16, 17, 18- part of the therapeutic process is to know he is frozen sperm- so that if it should happen that he is infertile, then he should know that he still has possibility to have children-
Rabbi Schachter: So you mean psychologically….?
Rabbi Gideon: Yes
Rabbi Burshtein: And not only psychologically- you cannot compare chances of marriage with people who froze it and the people who didn’t. A very high percentage- over 70% of people who found and got married (who had frozen sperm/ ovaries) besides the psychology- it has been found in family- I want to ask the Rabbi about here in America about freezing part of the ovary-
Dr. Lobel: Yes, this is becoming more and more of an issue as the treatment for cancer gets better and better- we’re seeing more and more of this- so it is important for us to know.
Rabbi Gideon: In Brazil (or did he say BRACA), have ____ team (gene?) which may lead LATER to certain types of cancer- is that something that can be tested/ may be tested- to do PGD to find carriers of particular genes?
Rabbi Schachter: To avoid…why not?
Rabbi Gideon: Getting back to question of ____
Rabbi Schachter: How high is the percentage of finding this particular gene?
Woman: Can be as high as 80%.
Rabbi Schachter: That’s terrible! Of course we should do it.
Rabbi Burshtein: The trend in general is among the poskim that I’ve asked that if ____ is discovered- one should during the period when one is fertile the woman should look to see whether she has cancer- there is a possibility of removing ovaries (after woman is finished with her birth-giving)- say it in English! here, say it in English- it’s preferable
Rabbi Gideon: We did a genetic test and the woman has such a gene- should we electively in order to prevent it, not wait for her to get cancer but do a breast removal now- not to wait to get cancer- because often by time you get cancer, it’s spread so quickly-
Rabbi Schachter: It’s not elective! It’s 80%- even 5% I would think! It’s a safek sakanah- safek pikuach nefesh- doesn’t need to be 80%- only 2%- if its’ a safek people are nervous about-
Rabbi Burshtein: But we should not tell her to remove the ovary before she gave birth because there is the risk of giving birth before she has cancer- the risk of discovering that it’s already disease- it’s not like breast cancer where you can discover it early- not tell 20 year old woman to have an exam and remove the ovaries because she’s supposed to give birth still!
Woman: In this country there’s been somewhat of a more ____ on stem cell research- issues on using embryos that are created for IVF and then not used- if you could briefly address embryos not being used for IVF to donate them for research to be used for stem cells-
Rabbi Burshtein: To be able to discover- to learn with various poskim in Israel- if there is a care taken that there is no use to return it to another woman- if really and truly will be used for research only- the only question is using/ wasting sperm- but since there is a possibility that through this they will save others- there is the possibility of using it- on condition that there will be control over this in a proper manner- that at least in hasghacha over this- that a gift could be given to another woman so this case will not be done! but in case where that embryo could be given to another woman- but if no longer useful to woman, then can use them…
Rabbi Schachter: If it’s in a freezer…not abortion- not in woman’s body-
Rabbi Gideon: If they are leftover- can we discard them?
Rabbi Schachter: I would think certainly yes.
Rabbi Gideon: What you have just seen is the kind of discussion we have daily at Machon Puah- we’re going to take- if anybody in the audience would like to ask a specific question- couple of mikes up- if you come up, you can ask!
QUESTION: R’ Schachter mentioned in the case of ovary donation from one sister to another- problem of chavala, but in BRACA case- not in BRACA case, in cancer case where the woman would be having chemotherapy- would that be a problem of chavala as well? You seem to say you would be able to freeze it for the future
R’ Schachter: If a person does chavala for tikkun haguf, to improve his own body- that’s what we call a surgery in America- even in cosmetic purposes (plastic surgery)- so women used to pierce their ears (per Mishna)- so want to take out part of the organ to help her out- I think that would be permissible
QUESTION: Seeing more and more in the papers- couples who have a sick child- they can have another child to specifically combat the problem of the first child- can you have another child specifically as a donor to the first child to help the first child?
Dr. Lobel: Specific cases where this has been done where you have a couple where child has a type of anemia/ cancer, where need a bone marrow transplant- and not another sibling who is compatible- so now couple who did not have infertility problem before- they check for embryos that are HIV compatible with sick child- so they have a child to be a bone marrow transplant for them-
R’ Burshtein: Poskim I asked say that people have a million different reasons for having a child- how often will people know that child was born for that purpose? Not good for whole world to speak about it- for then child will feel bad- but quietly it can be done.
Rabbi Schachter: Under age of 18, when 2 or 3 years old, the parent can decide to give blood?
Dr. Lobel: it’s not such a big deal…legal, permissible, little to no risk to newborn.
Rabbi Schachter: I’ll have to digest that (laughter)
QUESTION: In breast cancer gene- is the woman obligated to do so (have the mastectomy, etc) if she can get cancer later?
Rabbi Schachter: Yes, she is obligated to do so- her life is in danger- 80% chance- as soon as doctors say so
Men: What if not lethal or just a gene causing blindness in the family?
Rabbi Schachter: What age would it cause blindness? At age of 95?
Men: No, early.
Rabbi Schachter: Do people who have sight live longer? If so, then it’s a safek sakanah- in that case, then yes, safek sakanah
Rabbi Burshtein: Like to point out cases- difference between breast- question of ovary- already spread beyond question of ovary- more serious matter than halakha-
Rabbi Gideon: One last question-
QUESTION: The Rav has been somewhat enthusiastic about putting on the emphasis on life- on life- if there’s a safek sakanah, so then we’ll be sure to select out that embryo with that life-threatening gene- the BRACA 1 gene, going back to this breast cancer gene- doctor previously stated up to 80% possibly- that’s definitely on the higher end, for the most part it could be between 10-15% as a risk factor (correct me if I’m wrong)- the previous speaker asked about blindness- but what about for example Down’s Syndrome-is that grounds for aborting that embryo as well? How do we stand on quality of life versus life itself?
Rabbi Schachter: Both couples carriers of Down Syndrome gene…
Dr. Lobel: That’s not a real situation- down’s syndrome is a mutation- sometimes-
Rabbi Burshstein: There’s also a gene for Down that has a tendency to provide it- but in most
Dr. Lobel: Most cases- it’s a mutation- it’s a rare situation where someone would be normal and would be “a carrier” for Down’s Syndrome. What we’ve learned from doing PGD for different reasons is that even in a situation where we have a young egg donor- healthy young woman- in generally 30% of the embryos created are abnormal- which in part probably explains why if you have a totally fertile couple, have relations at right time of the month- having normal embryos- most of the time, the embryos just don’t implant- and if they do implant, pregnancy usually results in a miscarriage for chromosomal abnormalities- so when we do PGD, done IVF, almost certainly several of them are going to be abnormal- discarding them is very similar to what happens in nature- some will be boys, some girls, some will have other characteristics- how are we guided selected in them.
Rabbi Burshtein: I would like to say that thank God we have 165 people a day- we love the public here in the USA- and we would love to come and aid in all languages- in English, French, Spanish, Yiddish, Ivrit- doesn’t cost anything- there’s a lady- there’s a person here in charge of ____need hashgacha in terms of fertility- secondly, like to thank the staff- feel as if I’m in the next world- all these questions with my Rabbi- here it’s like, I hear on my left, I hear this- on my right, Rabbi Schachter telling me what I can do- it’s realy like Utopia, it’s like Utopia!
Rabbi Gideon: Not only R’ Schachter’s great knowledge but R’ Schachter’s great sensitivity to these matters- thank you for encouragement and advice for the Machon.
Rabbi Dr. Edward Reichman:
To give you a small glimpse- the planning for this final session probably took more man-hours and more power than the rest of the entire conference. Efforts of the student body here and the MedEthics society with extraordinary support of CJF- and YU has really born an extraordinary support- dialogue we will all continue- comments of one of the participants here- Rabbi Brander commented also- this is the very hall the Rav lectured in for many years- he knows the Rav is looking down on Lamport Auditorium and saying “You got it right! This is exactly what I meant by Torah u’Maddah!” I hope this shidduch between CJF and MedEthics continues on-
Benjamin Franklin quote: “Progress of human knowledge will be rapid and discoveries made of which we at present have no conception”- no pun intended- im yirtzeh hashem more discoveries, people of caliber of those sitting on this stage will continue to address these issues- thank you so much for joining us today!
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I'm always sorry, out here in the hinterland, missing such gatherings and presentations. Your amazing notes have compensated me! Thank you!
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Rabbi Gideon is, I believe, Rabbi Gideon Weizman, who works at Puah in Israel and is a Rav in Modiin.
As far as I am aware R' Jackovitz Zt"l is on longer alive. Was it a video or descendent/
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Kol haKavod! I am a new fan (from uptown). Did you actually type this "in action"? Gosh, I wish I could take notes as efficiently as you do. Kochekh LaTora!
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