Body and Soul in Fertility, Halacha and Science

birth-control-pillOn January 16, 2011, I attended the conference on fertility, halacha and women’s health, sponsored by the Orthodox women’s organization Kolech, the Bar-Ilan department of Gender studies, and the-Woman-to-Woman health center in Haifa.

Knesset Member Gila Gamliel introduced the panel on Fertility, Gender and Halacha: Critical Viewpoints, and I’ve already written about her proposal to raise the marriage age.

Dr. Uri Levi, a faculty member of the British Royal College of Obstetricians and Gynecologists (RCOG), spoke about the influence of nefesh on women’s bodies in science and halacha (Jewish law).  Nefesh is usually translated as soul, but it also refers to mental or emotional state—mental illness is known as machalat nefesh. , Like the majority of the speakers Dr. Levi provided no slides or handouts, so I am quoting from my notes. I hope that sources will go up on the Kolech website, as promised.

Dr. Levi started off with an important message, saying how important it is to avoid close pregnancies, quoting the gemara (Niddah 9b): A woman doesn’t return to herself until 24 months [after birth].  He quoted studies showing a high rate of depression among women with close pregnancies.  A study in Utah showed that less than 15 months between pregnancies led to birth defects and learning disabilities. The European Journal Contraception published an article that found risks to mothers and babies when pregnancies were closer than 24 months.

He also quoted from a Jewish text about how husband are not only responsible for supporting their wives economically–they are also responsible for their health. This must be a consideration when planning children.

Levi gave several examples showing the connection between fertility and emotional health. A woman who had been infertile for 14 years once called him to make an appointment. They made the appointment for a few weeks later, and the woman asked Dr. Levi if she could tell him her story on the phone. A few days before the appointment the woman called to tell him that she was pregnant. —œYou listened to me,— she explained to Dr. Levi.

[Update: A reader thought that Dr. Levi was discounting physical causes of infertility–not at all! Much of the conference was about treatment for infertility. His talk was about emotional connections. He also gave examples of women who got their periods during exams, before their weddings or other stressful times.]

Dr. Levi recommended the books How Doctors Think and Trick or Treatment, a book about alternative medicine. He implied that many alternative treatments are successfully simply because the practitioner listens to the patient and relieves tension. He acknowledged that doctors today have much less time, but one can still give encouragement and be friendly even if they  have only a few minutes.

He recommended the non-hormonal IUD as an effective and safe birth control method. While the combination birth control pills contain lower doses of hormones than earlier ones, they still increase cancer risk significantly. New studies show that the IUD  decreases the rate of ectopic pregnancy ten-fold, and does not lead to infection. The Mirena (hormonal IUD) and hormone replacement therapy after menopause also increase cancer risk.

The diaphragm is also a safe and reliable method rarely used in Israel. Because doctors did not take the time to fit them properly, they frequently failed. Dr. Levi is teaching a nurse in the south how to fit them. Women need the largest size that is still comfortable, and my have to try it overnight before making a decision. It’s 95% effective up to age 35, and 98% effective afterward.

I found links to articles by Dr. Levi (Hebrew) on birth control methods at Naomi Sela’s blog.

You may also enjoy:

Fertility and Halacha for Couples

Breastfeeding, Babies and Hormonal Birth Control

Are Mature Religious Women Leaving the Fold?

Breastfeeding:An Optimal Way to Space Babies

Photo credit: Nateone

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Comments

  1. I can’t believe Dr. Levy is trying to pass off infertility as an emotional problem…

    This is just… sad.

  2. Sorry, as someone who’s been very close to a few women going through infertility, I know that there’s entirely too much of the layman saying “just relax and it’ll happen” or suggesting vacations as a cure, and it often sounds like the person is saying “it’s all in your head” which is more than a little insulting, especially when medical tests show that there is a real medical issue like endometriosis or PCOS.

    Saying that there is a lot of emotion involved and that the emotional stress can prevent resolving the underlying problem is a different ball game.

    • Leah, this was one physician’s topic talk at a professional conference. Would you rather that this aspect of infertility, shown in many studies, be ignored? Acknowledging that emotional states are sometimes tied to infertility isn’t the same as telling a woman it’s all in her head (which I agree is judgmental and counter-productive).

  3. From my understanding (unless they’ve improved it), the nonhormonal copper IUD can cause both heavy, longer periods and breakthrough bleeding. Both of these would make it unappealing to the religious crowd, right? (The Mirena, on the other hand, lightens and shortens periods. I know people who are at increased cancer risk who won’t use it, but for the average population I think it’s more popular.)

    • Kate, if you follow the links at Sela’s site, his article on IUDs (hetken) explains that the heavier bleeding is temporary, although some women may continue to bleed for an extra day or two each cycle. He also says that the bleeding in between periods when using a non-hormonal IUD generally does not count as menstrual bleeding for halachic purposes. Bleeding in between periods while using the Mirena is more of an issue because it’s caused by hormonal changes.

    • Just from a completely non scientific survey of my friends, iud seems to be the most popular method. So I guess they must have improved.

    • Who is at increased risk for cancer from the Mirena? Just curious.

  4. fascinating, the idea that a woman doesn’t “return to herself until 24 months after birth.” What does that mean? Why is sex OK after 40 days, but somehow we’re supposed to avoid having close pregnancies? How did the ancients handle it, if this is really a religious as well as physical issue?
    My period came back 1 month after each of my babies were born. So I have to say, I’m a little more than careful about the birth control; though I didn’t realize there were potential physical problems related to close pregnancies. Hope this makes sense.

    • For 24 months you have the status of a nursing mother (I assume even if you’re not?) and this has halachic ramifications.

    • Abigail, the Talmud talks about women who were permitted to insert some type of cloth(moch) to prevent pregnancy. How effective it was, I have no idea. Nursing mothers were included, the idea being that another pregnancy could lower milk supply and threaten the existing baby. The Talmud considered a woman a nursing mother for 24 months, even if she is not nursing. How much that applies today is disputed. There are a small number of rabbis who automatically permit certain types of birth control for 24 months after birth. I know of a rabbi who insists that his students space pregnancies in this way.

      • Hannah, do you think that in pre-modern times that breastfeeding was done in such a way that it was much closer to the “ecological breastfeeding” of today (no pacifiers or bottles, nursing on demand, cosleeping, etc)? If so it was probably a more effective birth control method for longer into the baby’s life.

        • Kate, I’m sure it was. But the rabbis still discuss the use of a moch for nursing mothers.

        • Even in our own day when I know many women who practice this type of breastfeeding (cosleeping, no other nipples, nursing on demand, etc.) – it is no guarantee against getting pregnant. I was tandem nursing, etc. and got preg 5 mo post-partum – no guarantees of anything even in the mythical “good ole days”.

          • Both exclusive, on-demand nursing and close pregnancies run in my family, so even though I’m nursing, I don’t want to take any chances. It really does not work for everyone.
            BC is a touchy issue. I hate being on hormones and dislike messing with the diaphragm, but husband hates condoms. Someday maybe I’ll try the copper, but I’m scared of the stories such as the punctured uteruses, prolonged bleeding, and wild mood swings…

          • Abigail, you can rely on nursing if you are willing to research and watch for the signs that your fertility is returning. For me, the signs were obvious once I knew to look out for them.

      • My understanding was that the moch was treated with some sort of medicinal mixture. Rabbi Haim Vital lists a couple of interesting mixtures in his “Sefer Peulot.” Rabbi Hiam Vital, brings in the name of the Ari(in several places) that it is very important that the baby nurse for a full 24mos.

    • There was a time when I was suffering from undiagnosed giardia – it kept going around the family but everyone else was asymptomatic. So I weaned our 16 month old because it was enough to deal with the unexplained illness. When I called the Rav to ask for a heter to skip a minor fast, he immediately said but you have a young child – and since she was under 2 years it didn’t matter that I wasn’t actually nursing her.

      (Eventually we all took a concurrent course of humatin.)

      • Hi Miriam (there are several Miriams who post here so you may want to choose a different user name).
        Rabbanim seem to be much more lenient about fasting than about birth control.

  5. Thanks for the review. I was also a little shaken by Dr. Levy’s harsh words against the pill (he basically said that it causes cancer and that it is just a crime to give it to women) but later when I told this to a friend of mine who is a Yoetzet Halacha and is involved in the field, she told me that he is involved in importing the new IUD to Israel, so…

    • “she told me that he is involved in importing the new IUD to Israel,”
      I’m not sure that’s enough of a reason to discount what he said. People should do their own research.

      • absolutely, but in my eyes, it definitly puts a different light on what he said in the lecture. people should also be upfront about their interests in the matter. (I would have had more respect for him if he had mentioned this while he was strongly recommending this method)

  6. From my understanding, using a diaphragm is halachically problematic in many cases (as are condoms, or anything that acts as a barrier method), and that is why the hormonal methods are more often suggested. Also doctors will often avoid giving an IUD to any woman with Anemia- a very common ailment in pregnant age and nursing women. Hormones make me a little nutty, so an alternative (other than exclusive breastfeeding for 24 months!) would be nice.

  7. http://www.yoatzot.org/article.php?id=76

    There are reliable halachic opinions going both ways on the diaphragm. I’ve been using it for years after a bad experience with the pill.I will never use hormonal bc again.

  8. Nurse Yachne says:

    The IUD was extremely effective in preventing pregnancy in my case, largely because I was constantly in nidda. And not for just the “first few months”. In my experience, there is NO way to distinguish between period bleding and IUD-related bleeding and no heter either.

    What a nightmare that was. It nearly broke up our marriage.

    The whole bc/taharat hamishpacha issue is complicated and varies from woman to woman, and as you stated, “just getting pregnant” is no solution either, especially if you don’t have the financial, social and family resources of Ethel Kennedy.

  9. I asked my OB in Israel about a diaphragm (I needed a new one since the birth of my baby), and this otherwise very competent doctor was completely befuddled. She asked me if I had one already, I said yes, she said, What’s the number, I’ll just write you a rx for that. *I* had to explain to *her* that since I gave birth, I needed to be refitted. She had no means of fitting me for one. I ended up with an rx for the pill. (This after a disasterous Mirena experience in which 2 days after it was put in, I was in the hospital bc it had perforated my uterus and needed to be surgically extracted. Good times.)

    • Don’t know where you are, but Dr. Nili Yanai in J-m has the fitting rings for diaphragms. So does Dr. Hillel Factor in Kfar Saba. There is a list on the Nishmat Yoatzot site of other gyns that can fit them.

  10. “It’s 95% effective up to age 35”

    not impressive

  11. Ms. Krieger says:

    Dr. Uri Levi’s focus on nefesh is fascinating. I would like to offer a slightly different translation – spirit. There are multiple words for soul in Hebrew, right? But nefesh is closely related to the root for breath or spirit, which then leads to the thought of speech, which is impossible without breath. Speech and so discourse between doctor and woman is critical. The consideration of spirit/state of mind and emotion in women is oft neglected by physicians today. (This is one of the reasons why I get ob/gyn care from midwives whenever I can – at least in the US, they are much more concerned with health spirit/mind/soul in addition to body.)

    I also second the gemara’s notion that a woman does not return to herself until 24 months after a birth. I certainly noticed that right when my child was approaching two years old, my relationship with my husband, family and friends “renormalized”. I felt more like myself, was sleeping more as I used to, could think and function at the level I did pre-child.

    The status of ‘nursing mother’ has more to it than just considerations of family purity and protection of the mother/child nursing relationship. It is a mental status as well.

    • Breathe is nishima and does not share a root with nefesh. The two ideas are, of course, closely related and the roots do share two letters. If you like exploring Hebrew roots, I recommend R. Matityahu Clark’s book based on R. S.R. Hirsh’s research. The book is written in English with all roots given in Hebrew letters. The arrangement is mainly in list form with the relationships between roots extensively explored.

  12. I have encountered very few Orthodox rabbis who recommend the diaphragm or IUD over the pill. According to the link, an article in a medical journal claims that Rav Orbach permits the diaphragm when the IUD is permitted. That doesn’t sound like a wholehearted endorsement. This issue makes me want to cry. I take the pill, am I 100% comfortable, no! Do I worry about strokes, cancer etc, of course, but my Rav said take the pill, as do most rabbeim. We need doctors to do more research and come up with better answers!

    • A heter is a heter. If you feel you’re a better Jew for suffering, than go for it. If you’d rather not suffer, than find a rabbi who is more understanding of your situation.

    • There are many orthodox Rabbis (here in Israel at least) who do in fact permit the use of IUD.

      There are not a few women who cannot use pills, including those suffering from problems with blood clotting, those who the pills cause soaring of the values of cholestrol, those whom the pill causes bleeding to an extent which they are often nidda and the many who cannot stand the side effects. (migranes and more).

      However, I quite agree that Doctors should do more research, as there are many disdvantages for women of all the types of bc that are halachically permitted.

  13. having a doctor listen to you while suffering with infertility is a HUGE factor, been there and done that ladies – i struggled and was a lab rat for a long time. it helps to have someone who makes choices with you and encouragement and difficult times. obviously the end result is in Hashems hands.

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  1. […] Posted on Feb 7, 2011 in Fertility | 0 comments The Orthodox website Kipa.co.il billed the Kolech conference on fertility as an “anti-Puah” event. Puah is an institute that helps couples with issues related to […]

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  5. […] society where artificial birth control is discouraged, breastfeeding serves as a natural means of spacing children. Even if you don’t believe that it is a reliable method for an individual mother, there is no […]

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