Halakhic Advisor Portal

Suggestions for how to use this guide:

It may be helpful to emphasize to the people you are guiding that although you will do your best to assist at any time that questions arise, calling you as soon as possible before each procedure is the best way to plan ahead and avoid potential halakhic issues.

For each procedure, you may wish to review the list of “questions you might have” with the patient and discuss which ones might be relevant at this point.    It may be helpful to you to have the patient obtain the medical information you will need from the “ask the doctor” list for each question.  You might have some additional questions of your own for the patient to ask the doctor.   For accuracy, it is highly recommended to obtain this information directly from the doctor, as opposed to the support staff (nurses, medical assistants, receptionists, etc.)  At times it might be easier for you to have direct contact with the doctor, with the patient’s consent.  Additionally, to assist you in providing halakhic answers, which may require further research and consulting with Poskim (halakhic authorities),  we provide a list of  “notes for the Halakhic Advisor.”

While this guide is meant to be as useful as possible, keep in mind that this is NOT an exhaustive list of every possible procedure.  Please be in touch if you need guidance for anything not on this list.  In addition, although we have tried to be as thorough as possible, we cannot claim exhaustive inclusion of every possible halakhic question and opinion.  

 

 

Female Diagnostic Workup

  1. If I find blood after the procedure, must I assume I am niddah?

Notes for the halakhic advisor:

  • Might the blood be permitted based on attribution to a wound?  [This depends on whether the procedure is expected to cause bleeding, what the source of the bleeding is, how long it is expected to last, and whether the woman has a veset (expected period) now.  Other evidence that the blood is from a wound may be relevant as well, such as irritation or presentation on bedika cloth. ]  Is it possible that there was a wound to the endometrium, and if so could the blood be permitted based on attribution to an endometrial wound (makkah b’mekor)?
  • If not, might the blood be permitted for any other reason (such as location, size, color, etc.)?  Keep in mind that with an HSG, the color of the discharge might be affected by the dye used in the procedure.   

Ask the Doctor:

  • Is the procedure expected to cause bleeding?
  • If so, where is the bleeding coming from?  
  • How long is the bleeding expected to last?

 

  1. What should I do if I have this procedure during the Seven Clean Days?

Notes for the halakhic advisor:

  •  Is it possible/advisable to eliminate any bedikot in the day(s) following the procedure- just in case there is bleeding? If the procedure is performed on the seventh clean day, is it sufficient to do one bedika before the procedure, and none afterwards? If the procedure is done earlier in the week, should a bedika be done on the seventh day? Is it necessary to prolong the seven clean days and delay mikva immersion?
  •  Is it possible/advisable to modify the practice of wearing white undergarments by wearing colored undergarments and/or liners in the day(s) following the procedure – just in case there is bleeding? 
  • What if blood  is found following the procedure- whether on a bedika, white undergarment, or elsewhere?  See Question 1.  

 

  1.  If I need to use contraception before the procedure, what are my options?

Notes for the halakhic advisor:

  • This procedure is not performed if there is any chance the woman could be pregnant.  Usually it is timed accordingly with the cycle, but what if that is not possible? What are the contraceptive options?

Ask the doctor:

  • If abstinence is halakhically preferred over contraception, when would be the time frame to abstain?

 

  1. Does the procedure make me a niddah [or interrupt seven clean days] due to a concern of petikhat ha-rekhem (“opening the uterus”), even without bleeding?

Notes for the halakhic advisor:

  • Is there enough cervical dilation to raise a concern of petikhat ha-rechem?*

*petikhat ha-rechem literally means “opening the uterus,” i.e. cervical dilation. In theory, if an instrument penetrates the uterus, there is the concern that uterine bleeding has occurred, even if not observed. In reality, most poskim (halakhic authorities) limit this concept to dilation that is large enough to require general anesthesia, and thus its application is limited.  (If a procedure requires anesthesia, that does not automatically mean the dilation was wide enough to meet the criteria of petikhat ha-rechem.)  Opinions differ.   Note that due to the use of dilators in some procedures  the cervix may theoretically be dilated beyond the width of the instrument.  Dilators may be used in advance of the actual procedure to prepare the cervix, so this concern might arise before the actual procedure.

Ask the doctor:

  • Was the cervix dilated, and if so, to what degree? (see above note)
  1. If I find blood after the procedure, must I assume I am niddah?

Notes for the halakhic advisor:

  • Might the blood be permitted based on attribution to a wound?  [This depends on whether the procedure is expected to cause bleeding, what the source of the bleeding is, how long it is expected to last, and whether the woman has a veset (expected period) now.  Other evidence that the blood is from a wound may be relevant as well, such as irritation or presentation on bedika cloth. ]  Is it possible that there was a wound to the endometrium, and if so could the blood be permitted based on attribution to an endometrial wound (makkah b’mekor)?
  • If not, might the blood be permitted for any other reason (such as location, size, color, etc.)?  

Ask the Doctor:

  • Is the procedure expected to cause bleeding?
  • If so, where is the bleeding coming from?  
  • How long is the bleeding expected to last?

 

  1. What should I do if I have this procedure during the Seven Clean Days?

Notes for the halakhic advisor:

  • Is it possible/advisable to eliminate any bedikot in the day(s) following the procedure- just in case there is bleeding? If the procedure is performed on the seventh clean day, is it sufficient to do one bedika before the procedure, and none afterwards? If the procedure is done earlier in the week, should a bedika be done on the seventh day?
  • Is it possible/advisable to modify the practice of wearing white undergarments by wearing colored undergarments and/or liners in the day(s) following the procedure – just in case there is bleeding?
  • What if blood  is found following the procedure- whether on a bedika, white undergarment, or elsewhere?  See Question 1.  

 

  1. Does the procedure make me a niddah [or interrupt seven clean days] due to a concern of petikhat ha-rekhem (“opening the uterus”), even without bleeding?

Notes for the halakhic advisor:

  • Is there enough cervical  dilation to raise a concern of petikhat ha-rechem?

*petikhat ha-rechem literally means “opening the uterus,” i.e. cervical dilation. In theory, if an instrument penetrates the uterus, there is the concern that uterine bleeding has occurred, even if not observed. In reality, most poskim (halakhic authorities) limit this concept to dilation that is large enough to require general anesthesia, and thus its application is limited.  (If a procedure requires anesthesia, that does not automatically mean the dilation was wide enough to meet the criteria of petikhat ha-rechem.)  Opinions differ.   Note that due to the use of dilators in some procedures  the cervix may theoretically be dilated beyond the width of the instrument.  Dilators may be used in advance of the actual procedure to prepare the cervix, so this concern might arise before the actual procedure.   

Ask the doctor:

  • Was the cervix dilated, and if so, to what degree? (see above note)

 

  1. If I need to use contraception before the procedure, what are my options?

Notes for the halakhic advisor:                   

  • This procedure might not be performed if there is any chance the woman could be pregnant.  Usually it is timed accordingly with the cycle, but what if that is not possible? What are the contraceptive options?

Ask the doctor:

  • If abstinence is halakhically preferred over contraception, when would be the time frame to abstain?
  1. If I find blood after the procedure, must I assume I am niddah?

Notes for the halakhic advisor:

  • Might the blood be permitted based on attribution to a wound?  [This depends on whether the procedure is expected to cause bleeding, what the source of the bleeding is, how long it is expected to last, and whether the woman has a veset (expected period) now. Other evidence that the blood is from a wound may be relevant as well, such as irritation or presentation on bedika cloth]  Is it possible that there was a wound to the endometrium, and if so could the blood be permitted based on attribution to an endometrial wound (makkah b’mekor)?
  • If not, might the blood be permitted for any other reason (such as location, size, color, etc.)?  

Ask the Doctor:

  • Is the procedure expected to cause bleeding?
  • If so, where is the bleeding coming from?  
  • How long is the bleeding expected to last?

 

  1. What should I do if I have this procedure during the Seven Clean Days?

Notes for the halakhic advisor:

  • Is it possible/advisable to eliminate any bedikot in the day(s) following the procedure- just in case there is bleeding? If the procedure is performed on the seventh clean day, is it sufficient to do one bedika before the procedure, and none afterwards? If the procedure is done earlier in the week, should a bedika be done on the seventh day?
  • Is it possible/advisable to modify the practice of wearing white undergarments by wearing colored undergarments and/or liners in the day(s) following the procedure – just in case there is bleeding?
  • What if blood  is found following the procedure- whether on a bedika, white undergarment, or elsewhere?  See Question 1.  

 

  1. If I need to use contraception before the procedure, what are my options?

Notes for the halakhic advisor:                   

  • This procedure is not performed if there is any chance the woman could be pregnant.  Usually it is timed accordingly with the cycle, but what if that is not possible? What are the contraceptive options?

Ask the doctor:

  • If abstinence is halakhically preferred over contraception, when would be the time frame to abstain?

 

  1. Does the procedure make me a niddah [or interrupt seven clean days] due to a concern of petikhat ha-rekhem (“opening the uterus”), even without bleeding?

Notes for the halakhic advisor:

  • Is there enough cervical dilation to raise a concern of petikhat ha-rechem?

*petikhat ha-rechem literally means “opening the uterus,” i.e. cervical dilation. In theory, if an instrument penetrates the uterus, there is the concern that uterine bleeding has occurred, even if not observed. In reality, most poskim (halakhic authorities) limit this concept to dilation that is large enough to require general anesthesia, and thus its application is limited.  (If a procedure requires anesthesia, that does not automatically mean the dilation was wide enough to meet the criteria of petikhat ha-rechem.)  Opinions differ.   Note that due to the use of dilators in some procedures  the cervix may theoretically be dilated beyond the width of the instrument.  Dilators may be used in advance of the actual procedure to prepare the cervix, so this concern might arise before the actual procedure.   

Ask the doctor:

Was the cervix dilated, and if so, to what degree? (see above note)

  1. The test is done in the office soon after having sexual relations.   If we as a couple are normally strict not to have sexual relations during the daytime, may we do so for the purposes of this test?
  1. If I bleed after the procedure, does that mean I’m niddah?

Notes for the halakhic advisor:

  • Might the blood be permitted based on attribution to a wound?  [This depends on whether the procedure is expected to cause bleeding, what the source of the bleeding is, how long it is expected to last, and whether the woman has a veset (expected period) now.  Other evidence that the blood is from a wound may be relevant as well, such as irritation or presentation on bedika cloth.]  Is it possible that there was a wound to the endometrium, and if so could the blood be permitted based on attribution to an endometrial wound (makkah b’mekor)?
  • If not, might the blood be permitted for any other reason (such as location, size, color, etc.)?  

Ask the doctor:

  • Is the procedure expected to cause bleeding?
  • If so, where is the bleeding coming from?  
  • How long is the bleeding expected to last?

 

  1. What should I do if I have this procedure during the Seven Clean Days?

(Note: If possible, it is generally preferable to schedule a pap smear for AFTER the mikva.)

Notes for the halakhic advisor:

  • Is it possible/advisable to eliminate any bedikot in the day(s) following the procedure- just in case there is bleeding? If the procedure is performed on the seventh clean day, is it sufficient to do one bedika before the procedure, and none afterwards? If the procedure is done earlier in the week, should a bedika be done on the seventh day?
  • Is it possible/advisable to modify the practice of wearing white undergarments by wearing colored undergarments and/or liners in the day(s) following the procedure – just in case there is bleeding?
  • What if blood  is found following the procedure- whether on a bedika, white undergarment, or elsewhere?  See Question 1.  
  1. If I bleed after the procedure, does that mean I’m niddah?

Notes for the halakhic advisor:

  • Might the blood be permitted based on attribution to a wound?  [This depends on whether the procedure is expected to cause bleeding, what the source of the bleeding is, how long it is expected to last, and whether the woman has a veset (expected period) now.  Other evidence that the blood is from a wound may be relevant as well, such as irritation or presentation on bedika cloth.]  
  • If not, might the blood be permitted for any other reason (such as location, size, color, etc.)?  

Ask the doctor:

  • Is the procedure expected to cause bleeding?
  • If so, where is the bleeding coming from?  
  • How long is the bleeding expected to last?
  1. If I find blood after the procedure, must I assume I am niddah?

Notes for the halakhic advisor:

  • Might the blood be permitted based on attribution to a wound?  [This depends on whether the procedure is expected to cause bleeding, what the source of the bleeding is, how long it is expected to last, and whether the woman has a veset (expected period) now. Other evidence that the blood is from a wound may be relevant as well, such as irritation or presentation on bedika cloth]  Is it possible that there was a wound to the endometrium, and if so could the blood be permitted based on attribution to an endometrial wound (makkah b’mekor)?
  • If not, might the blood be permitted for any other reason (such as location, size, color, etc.)?  
  • Sometimes  a dye is placed into the fallopian tubes by way of the uterus in this procedure, which could affect the color of any discharge.  

Ask the Doctor:

  • Did the procedure involve entering the uterus at all?
  • Is the procedure expected to cause bleeding?
  • If so, where is the bleeding coming from?  
  • How long is the bleeding expected to last?
  • Was a dye used in the procedure?

 

  1. What should I do if I have this procedure during the Seven Clean Days?

Notes for the halakhic advisor:

  • Is it possible/advisable to eliminate any bedikot in the day(s) following the procedure- just in case there is bleeding? If the procedure is performed on the seventh clean day, is it sufficient to do one bedika before the procedure, and none afterwards? If the procedure is done earlier in the week, should a bedika be done on the seventh day? 
  • Is it possible/advisable to modify the practice of wearing white undergarments by wearing colored undergarments and/or liners in the day(s) following the procedure – just in case there is bleeding?
  • What if blood  is found following the procedure- whether on a bedika, white undergarment, or elsewhere?  See Question 1.  

 

  1. Does the procedure make me a niddah [or interrupt seven clean days] due to a concern of petikhat ha-rekhem (“opening the uterus”), even without bleeding? (Laparoscopy may or may not involve entering the cervix at all.)

Notes for the halakhic advisor:

  • Is there enough cervical dilation to raise a concern of petikhat ha-rechem?

*petikhat ha-rechem literally means “opening the uterus,” i.e. cervical dilation. In theory, if an instrument penetrates the uterus, there is the concern that uterine bleeding has occurred, even if not observed. In reality, most poskim limit this concept to dilation that is large enough to require general anesthesia, and thus its application is limited.  (If a procedure requires anesthesia, that does not automatically mean the dilation was wide enough to meet the criteria of petikhat ha-rechem.)  Opinions differ.   Note that due to the use of dilators in some procedures  the cervix may theoretically be dilated beyond the width of the instrument.  

Ask the doctor:

  • Was the cervix dilated, and if so, to what degree? (see above note)

 

  1. If I need to use contraception before the procedure, what are my options?

Notes for the halakhic advisor:                   

  • This procedure is not performed if there is any chance the woman could be pregnant.  Usually it is timed accordingly with the cycle, but what if that is not possible? What are the contraceptive options?

Ask the doctor:

  • If abstinence is halakhically preferred over contraception, when would be the time frame to abstain?
  1. If I find blood after the procedure, must I assume I am niddah?

Notes for the halakhic advisor:

  • Might the blood be permitted based on attribution to a wound?  [This depends on whether the procedure is expected to cause bleeding, what the source of the bleeding is, how long it is expected to last, and whether the woman has a veset (expected period) now. Other evidence that the blood is from a wound may be relevant as well, such as irritation or presentation on bedika cloth].   
  • What if the wound is to the ENDOMETRIUM- is a woman rendered niddah by a wound to the uterus (makkah b’mekor) or not? In this procedure in particular, there most certainly has been a wound to the endometrium.  
  • In certain situations the physician may perform “endometrial scratching” during the biopsy.  Does that make it more or less possible to attribute any bleeding to a wound?
  • If it is not possible to be lenient by attributing the blood to a wound, might the blood be permitted for any other reason (such as location, size, color, etc.)?  

Ask the Doctor:

  • Is the procedure expected to cause bleeding?
  • If so, where is the bleeding coming from?  
  • How long is the bleeding expected to last?
  • Was “endometrial scratching” performed?

 

  1. What should I do if I have this procedure during the Seven Clean Days?

Notes for the halakhic advisor:

  • Is it possible/advisable to eliminate any bedikot in the day(s) following the procedure- just in case there is bleeding? If the procedure is performed on the seventh clean day, is it sufficient to do one bedika before the procedure, and none afterwards? If the procedure is done earlier in the week, should a bedika be done on the seventh day?
  • Is it possible/advisable to modify the practice of wearing white undergarments by wearing colored undergarments and/or liners in the day(s) following the procedure – just in case there is bleeding?
  • What if blood  is found following the procedure- whether on a bedika, white undergarment, or elsewhere?  See Question 1.  

 

  1. Does the procedure make me a niddah [or interrupt seven clean days] due to a concern of petikhat ha-rekhem (“opening the uterus”), even without bleeding?

Notes for the halakhic advisor:

  • Is there enough cervical dilation to raise a concern of petikhat ha-rechem?

*petikhat ha-rechem literally means “opening the uterus,” i.e. cervical dilation. In theory, if an instrument penetrates the uterus, there is the concern that uterine bleeding has occurred, even if not observed. In reality, most poskim limit this concept to dilation that is large enough to require general anesthesia, and thus its application is limited.  (If a procedure requires anesthesia, that does not automatically mean the dilation was wide enough to meet the criteria of petikhat ha-rechem.)  Opinions differ.   Note that due to the use of dilators in some procedures  the cervix may theoretically be dilated beyond the width of the instrument.  

Ask the doctor:

  • Was the cervix dilated, and if so, to what degree? (see above note)

 

  1. If I need to use contraception before the procedure, what are my options?

Notes for the halakhic advisor:                   

  • This procedure is not performed if there is any chance the woman could be pregnant.  Usually it is timed accordingly with the cycle, but what if that is not possible? What are the contraceptive options?

Ask the doctor:

  • If abstinence is halakhically preferred over contraception, when would be the time frame to abstain?
  1. If I find blood after the procedure, must I assume I am niddah?

Notes for the halakhic advisor:

  • Might the blood be permitted based on attribution to a wound?  [This depends on whether the procedure is expected to cause bleeding, what the source of the bleeding is, how long it is expected to last, and whether the woman has a veset (expected period) now. Other evidence that the blood is from a wound may be relevant as well, such as irritation or presentation on bedika cloth].   
  • What if the wound is to the ENDOMETRIUM- is a woman rendered niddah by a wound to the uterus (makkah b’mekor) or not?
  • If it is not possible to be lenient by attributing the blood to a wound, might the blood be permitted for any other reason (such as location, size, color, etc.)?  

Ask the Doctor:

  • Is the procedure expected to cause bleeding?
  • If so, where is the bleeding coming from?  
  • How long is the bleeding expected to last?

 

  1. What should I do if I have this procedure during the Seven Clean Days?

Notes for the halakhic advisor:

  • Is it possible/advisable to eliminate any bedikot in the day(s) following the procedure- just in case there is bleeding? If the procedure is performed on the seventh clean day, is it sufficient to do one bedika before the procedure, and none afterwards? If the procedure is done earlier in the week, should a bedika be done on the seventh day?
  • Is it possible/advisable to modify the practice of wearing white undergarments by wearing colored undergarments and/or liners in the day(s) following the procedure – just in case there is bleeding?
  • What if blood  is found following the procedure- whether on a bedika, white undergarment, or elsewhere?  See Question 1.  

 

  1. Does the procedure make me a niddah [or interrupt seven clean days] due to a concern of petikhat ha-rekhem (“opening the uterus”), even without bleeding?

Notes for the halakhic advisor:

  • Is there enough cervical dilation to raise a concern of petikhat ha-rechem?

*petikhat ha-rechem literally means “opening the uterus,” i.e. cervical dilation. In theory, if an instrument penetrates the uterus, there is the concern that uterine bleeding has occurred, even if not observed. In reality, most poskim limit this concept to dilation that is large enough to require general anesthesia, and thus its application is limited.  (If a procedure requires anesthesia, that does not automatically mean the dilation was wide enough to meet the criteria of petikhat ha-rechem.)  Opinions differ.   Note that due to the use of dilators in some procedures  the cervix may theoretically be dilated beyond the width of the instrument.  

Ask the doctor:

  • Was the cervix dilated, and if so, to what degree? (see above note)

 

  1. If I need to use contraception before the procedure, what are my options?

Notes for the halakhic advisor:                   

  • Sometimes a D&C is part of the process of medically terminating a pregnancy or treating a woman following a miscarriage.  Otherwise, this  procedure is not performed if there is any chance the woman could be pregnant.      Usually it is timed accordingly with the cycle, but what if that is not possible? What are the contraceptive options?

(note: it is beyond the scope of this guide to address the permissibility of medical termination.)

Ask the doctor:

  • If abstinence is halakhically preferred over contraception, when would be the time frame to abstain?

Male Diagnostics and Procedures

Note: This is not an exhaustive list of diagnostic and therapeutic male procedures.

  1. Is it permitted for me to undergo semen analysis at this time? If not, at what point in the diagnostic process may it be done?

Ask the doctor:

  • Is it medically recommended for the husband to undergo semen analysis at this time?
  • Regarding the particulars of this couple’s situation and history, does it make sense for the wife to undergo any testing and/or treatment before a semen analysis is performed?  What treatments could be undergone without semen data?
  • Based on the husband’s history, is there reason for concern about severe male factor (yielding a  poor semen analysis)  that could possibly be progressive? If so, would it be recommended to do a semen analysis as soon as possible in order to diagnose the problem and save sperm before the condition worsens?

Notes for the Halakhic Advisor:

  • The question of when to do a semen analysis is a matter of debate in halakha, in which the concern of shikhvat zera l’vatala (spilling seed in vain) is considered alongside the degree of medical imperative.  Some authorities do not see this concern as being relevant at all (although the METHOD of collection may be relevant- see q. 3 below), since the semen is not ejaculated in vain but for the ultimate purpose of procreation.  Many authorities do see this concern as relevant but only up until a certain point in the diagnostic or treatment process; where exactly that point lies is a matter of widely divergent opinions. The couple’s history, any known or suspected cause(s) of infertility, what tests (if any) have already been performed, and what interventions (if any) have already been attempted may all be significant factors in the halakhic decision-making process.  The potential emotional and logistical impact on the couple of delaying the analysis in terms of the ramifications on the treatment process should also be explored.   

Communication between physician and halakhic advisor are highly recommended. Here are some suggested points to guide discussions with the doctor:

  • Are there any treatments that could or should be performed, including the prescribing of hormonal medications, without the collection of male data? Would that be recommended in this situation, and if so, for how long?  Is there medical risk involved in these treatments?  If they prove to be ineffective, how much of a time delay would that cause, and how emotionally strenuous would that be for the couple? Are there any reasons that delay would be problematic for the couple, such as the wife’s age?  In many instances, infertility is caused by a combination of female and male factors, thus even if a female factor is diagnosed, the physician may not wish to proceed with treating the female partner before testing the male as well; treatment without the male data may very well be in vain if there is an undiagnosed male factor.  
  • In terms of female diagnostic testing: How much of a workup (if any) is halakhically necessary before male testing? Again, even if a further diagnostic workup would reveal a female factor, how much could be done medically without male data?  (For example, does it make sense to have a woman undergo an HSG [hysterosalpinogram] to diagnose problems in the fallopian tubes, when if a severe male factor is found requiring IVF, the state of the fallopian tubes is irrelevant anyway [since IVF bypasses the tubes].  Even in the absence of a male factor, IVF is often the recommended treatment for a fallopian tube problem, and cannot be undergone without semen analysis anyway.  This example highlights the importance of the halakhic advisor and physician understanding each other’s processes and concerns.)  How would possible delay caused by further female testing affect the couple medically and emotionally?
  • Important note: If the halakhic decision is to delay semen analysis, be sure to ask the doctor the following:  Based on the husband’s history, is there reason for concern about severe male factor (yielding a  poor semen analysis)  that could possibly be progressive? If so, would it be recommended to do a semen analysis as soon as possible in order to diagnose the problem and save sperm before the condition worsens?

In conclusion, this is a highly sensitive topic that requires close communication and mutual understanding between the physician, halakhic advisor, and patient in order to appropriately weigh the halakhic, medical, psychological, emotional, and financial concerns involved in the timing of semen analysis.

 

2. After the semen analysis, is it necessary to save the sample for intrauterine                        insemination (IUI)?

Ask the doctor:

  • Is the sample of high enough quality to be useful in IUI?

Notes for the Halakhic Advisor:

  • According to some authorities, saving the sample after analysis for an IUI (either immediate use or frozen for future IUI) makes it permissible to perform a semen analysis earlier than it would be otherwise.  

 

3. What is the best method to procure a semen sample for analysis? (See notes on               “Postcoital test” in Part I if that method is being used.)

Ask the doctor:

  • What method(s)  is/are medically preferable, if any? Why?
  • If there is a known or suspected male factor, is there a method that will better preserve the sample in case it needs to be saved after analysis?

Notes for the Halakhic Advisor:

  • Of the following possible methods, which one should be used?
  • Collection through intercourse with a condom
  • Collection through intercourse with a medically perforated condom
  • Collection through coitus interruptus with a collection cup
  • Collection through manual masturbation with wife’s presence
  • Collecting through manual masturbation without wife’s presence
  • Halakhic, medical, and logistical factors may need to be considered together to make this determination.  Is the woman niddah or not right now (and if she is niddah, is it required to wait until she is tehorah in order to perform the analysis in a way that involves her?) Is the couple comfortable with condom use and/or coitus interruptus? Is there enough time to transport the sample from home after intercourse to the physician’s office before the sample becomes inviable?
  • Are relations permitted during the daytime for purposes of collecting sperm for this procedure, if a couple is usually strict to abstain during the day?
  1. Is it permitted for me to undergo this procedure?

Notes for the Halakhic Advisor:

  • Although there is a potential halakhic concern of mutilation to the genitalia that comes along with this procedure,  many authorities do permit it.  Guidance from halakhic authority (posek) should be sought.  

Assisted Reproductive Technologies (ART)

  1. If I find blood while using the hormones, must I assume I am niddah?

Notes for the halakhic advisor:

  • Might the blood be permitted for any other reason besides attribution to a wound (such as amount, location, size, color, etc.)?  
  • If not, might the blood be permitted based on attribution to a wound?  [This depends on whether the hormones expected to cause abnormal bleeding from dryness, irritation, etc, what the source of the bleeding is, how long it is expected to last, and whether the woman has a veset (expected period) now.  Other evidence that the blood is from a wound may be relevant as well, such as irritation or presentation on bedika cloth. ]  
  • What measures can be taken to assist a woman from becoming niddah from abnormal /breakthrough bleeding and staining? If a woman is in seven clean days, what measures may be taken to assist her in getting to the mikva despite breakthrough bleeding and staining?

Ask the Doctor:

  • Is the procedure expected to cause any bleeding from dryness,  irritation, etc?

 

  1. What should I do if I’m in the Seven Clean Days while using the hormones?

Notes for the Halakhic Advisor:

  • If breakthrough bleeding/staining is occurring, is it possible/advisable to eliminate any bedikot? Is it possible/advisable to modify the practice of wearing white undergarments by wearing liners and/or colored undergarments?
  • If blood (of a problematic color) is found on a bedika, etc  is it possible to attribute it to a wound (see q. 1)?

 

  1. What if I’m taking hormones via injections while I’m niddah, can my husband help me?

Notes for the Halakhic Advisor:

  • Is it permissible for the husband to administer an injection to his wife while she is niddah, if touching is necessary for the administration?  If so, should he avoid directly touching the woman’s skin by wearing gloves? Is it preferable or required to arrange for someone other than the husband to perform the injection?  Note that some women are comfortable self-injecting and other are not.  
  • Is this injection subcutaneous or intramuscular? The former may be easier to self-inject, and if done by another person may not require im/her to touch the skin at all (it can possibly be pinched by the patient herself.) The latter may be more difficult to self-inject due to the longer needle and is generally not possible to perform without the administrator touching the skin him/herself to gain leverage.
  • Is it problematic for the husband to see a part of his wife’s body while she is niddah that would otherwise be covered, and if so does this preclude him from helping with injections performed on private parts of the body?

Ask the doctor:

  • What is the best place on the body to perform the injection?  Are there other possible spots?

 

  1. What about Shabbat and Yom Tov?

Note to patient: it is absolutely crucial to raise this question as far in advance as possible with your halakhic advisor and doctor.  Solving halakhic problems in ADVANCE eliminates the chance of needing to cancel treatment mid-cycle because of Shabbat or Yom Tov.  

Ask the doctor:

  • Is there anything that can be done medically, such as the timing of medication, to eliminate or minimize the chance of procedures and/or monitoring being scheduled for Shabbat/Yom Tov?

Shabbat and Yom Tov

See “hormone treatments” if hormonal treatments are used in conjunction with IUI.

(Note: see Part III if donor sperm is being used.)

 

  1. Birth Control/Estrogen Patch use (sometimes used prior to treatment in order to regulate the cycle)

 

     1a.  If I find blood while using the birth control/ patch, must I assume I am a niddah?

Notes for the halakhic advisor:

  • Might the blood be permitted for any other reason besides attribution to a wound (such as amount, location, size, color, etc.)?  
  • If not, might the blood be permitted based on attribution to a wound?  [This depends on whether the hormones expected to cause abnormal bleeding from dryness, irritation, etc, what the source of the bleeding is, how long it is expected to last, and whether the woman has a veset (expected period) now.  Other evidence that the blood is from a wound may be relevant as well, such as irritation or presentation on bedika cloth. ]  
  • What measures can be taken to assist a woman from becoming niddah from abnormal /breakthrough bleeding and staining? If a woman is in seven clean days, what measures may be taken to assist her in getting to the mikva despite breakthrough bleeding and staining?

Ask the Doctor:

  • Is the procedure expected to cause any bleeding from dryness,  irritation, etc?

 

1b. What should I do if I’m in the Seven Clean Days while using the hormones?

Notes for the Halakhic Advisor:

  • If breakthrough bleeding/staining is occurring, is it possible/advisable to eliminate any bedikot? Is it possible/advisable to modify the practice of wearing white undergarments by wearing liners and/or colored undergarments?
  • If blood (of a problematic color) is found on a bedika, etc  is it possible to attribute it to a wound (see q. 1a: “ If I find blood while using the birth control/ patch, must I assume I am niddah?” )?

1c. If I am using an estrogen patch, how should I proceed during mikva immersion?

Notes for the Halakhic Advisor:

  • Is the patch considered a barrier to immersion (chatzitzah)?

Ask the Doctor:

  • May the patch be removed for the duration of immersion?

 

  1. May I undergo IUI while niddah (note that this includes being in the seven clean days prior to mikva immersion), if I don’t have a sperm sample frozen?

Notes for the halakhic advisor:

  • What if the woman is niddah when the sperm is needed for the procedure, and no backup frozen sample is available, or the physician wishes to save it? Is manual masturbation allowed, if that was not the preferred method otherwise?

 

  1.  What is the best method to procure sperm sample ( if husband’s sperm, as opposed to donor sperm)  is being used?

Notes for the Halakhic Advisor:

  • Of the following possible methods, which one should be used?
  • Collection through intercourse with a condom
  • Collection through intercourse with a medically perforated condom
  • Collection through coitus interruptus with a collection cup
  • Collection through manual masturbation

Halakhic, medical, and logistical factors may need to be considered together to make this determination.  

If the wife is not niddah, which of the possible methods is preferable? Is the couple comfortable with condom use and/or coitus interruptus? Is there enough time to transport the sample from home after intercourse to the physician’s office before the sample becomes inviable?

  • Is it permitted/advisable/mandatory to freeze a sample when the woman is still tehorah (not niddah), in case she is still niddah at the point the sperm is needed?
  • What if the woman is niddah when the sperm is needed for the procedure, and no backup frozen sample is available? Is manual masturbation allowed, if that was not the preferred method otherwise?
  • Are relations permitted during the daytime for purposes of collecting sperm for this procedure, if a couple is usually strict to abstain during the day?

 

  1. If the IUI is performed during the Shiva Nekiim (Seven Clean Days), can I go to the mikvah on time?

Notes for the Halakhic Advisor:

  • According to some poskim, there is a concern of any expelled semen (poletet shikhvat zera) interrupting the Shiva Nekiim following an IUI. Opinions differ.  Some disregard this concern entirely since the semen is not in its natural form (ie it has been concentrated) when inserted into the uterus .  Some are only concerned if the woman actually feels the semen being expelled, but do not require the assumption a priori that it will be expelled.  
  • If poletet shikhvat zera is a concern, does that necessitate restarting the shiva nekiim entirely after the procedure or just extended? If the latter, need the shiva nekiim be extended by more than one day?

Ask the doctor:

  • Is it expected for semen to be expelled from the woman’s body following the procedure, or is it inserted too deeply?
  • If there will be a halakhic issue with IUI in the seven clean days, is it possible to delay the procedure until after mikva?

 

  1.  If I have bleeding from the procedure, must I assume I am niddah?

Notes for the halakhic advisor:

  • Might the blood be permitted based on attribution to a wound?  [This depends on whether the procedure is expected to cause bleeding, what the source of the bleeding is, how long it is expected to last, and whether the woman has a veset (expected period) now. Other evidence that the blood is from a wound may be relevant as well, such as irritation or presentation on bedika cloth]  Is it possible that there was a wound to the endometrium, and if so could the blood be permitted based on attribution to an endometrial wound (makkah b’mekor)?
  • If not, might the blood be permitted for any other reason (such as location, size, color, etc.)?  

Ask the Doctor:

  • Is the procedure expected to cause bleeding?
  • If so, where is the bleeding coming from?  
  • How long is the bleeding expected to last?

 

  1. What should  I do if I have this procedure during the Seven Clean Days?

Notes for the halakhic advisor:

  • Is it possible/advisable to eliminate any bedikot in the day(s) following the procedure- just in case there is bleeding? If the procedure is performed on the seventh clean day, is it sufficient to do one bedika before the procedure, and none afterwards? If the procedure is done earlier in the week, should a bedika be done on the seventh day?
  • Is it possible/advisable to modify the practice of wearing white undergarments by wearing colored undergarments and/or liners in the day(s) following the procedure – just in case there is bleeding?
  • What if blood  is found following the procedure- whether on a bedika, white undergarment, or elsewhere?  See Question 4 above: “If I have bleeding from the procedure, must I assume I am niddah?”  

 

  1. Does the procedure make me a niddah [or interrupt seven clean days] due to a concern of petikhat ha-rekhem (“opening the uterus”), even without bleeding?

Notes for the halakhic advisor:

  • Is there enough cervical dilation to raise a concern of petikhat ha-rechem?

*petikhat ha-rechem literally means “opening the uterus,” i.e. cervical dilation. In theory, if an instrument penetrates the uterus, there is the concern that uterine bleeding has occurred, even if not observed. In reality, most poskim limit this concept to dilation that is large enough to require general anesthesia, and thus its application is limited.  (If a procedure requires anesthesia, that does not automatically mean the dilation was wide enough to meet the criteria of petikhat ha-rechem.)  Opinions differ.   Note that due to the use of dilators in some procedures  the cervix may theoretically be dilated beyond the width of the instrument.  

Ask the doctor:

  • Was the cervix dilated, and if so, to what degree?  (see above note)

 

  1. What about Shabbat and Yom Tov?

Note to patient: it is absolutely crucial to raise this question as far in advance as possible with your halakhic advisor and doctor.  Solving halakhic problems in ADVANCE eliminates the chance of needing to cancel treatment mid-cycle because of Shabbat or Yom Tov.  

Ask the doctor:

  • Is there anything that can be done medically, such as the timing of medication, to eliminate or minimize the chance of procedures and/or monitoring being scheduled for Shabbat/Yom Tov?

Shabbat and Yom Tov

 

  1. Do I need hashgakha (supervision of the staff in the laboratory facility) during IUI? If so, at which points?

Notes for the Halakhic Advisor:

  • The necessity of hashgakha — supervision of the staff in the laboratory facility when handling the patients’ specimens– during fertility treatments is an area of controversy amongst halakhic authorities. For those who hold that it is not strictly necessary under halakha, there is debate as to whether it still has value.  Some feel that it adds an extra layer of security in the laboratory to prevent mix-ups beyond government requirements, while others feel that this is not the case.   Some couples are comforted by the presence of women from  a halakhic organization during their procedures; other couples feel burdened by the extra expense.  
Note: for IVF involving donor eggs and/or sperm, see Part III on donor materials.

  1. What about Shabbat and Yom Tov?

Note to patient: it is absolutely crucial to raise this question as far in advance as possible with your halakhic advisor and doctor.  Solving halakhic problems in ADVANCE eliminates the chance of needing to cancel treatment mid-cycle because of Shabbat or Yom Tov.  

Ask the doctor:

  • Is there anything that can be done medically, such as the timing of medication, to eliminate or minimize the chance of procedures and/or monitoring being scheduled for Shabbat/Yom Tov?

 Shabbat and Yom Tov

 

  1. What is the best method to procure sperm sample ( if husband’s sperm, as opposed to donor sperm)  is being used?

Notes for the Halakhic Advisor:

  • Of the following possible methods, which one should be used?
  • Collection through intercourse with a condom
  • Collection through intercourse with a medically perforated condom
  • Collection through coitus interruptus with a collection cup
  • Collection through manual masturbation

Halakhic, medical, and logistical factors may need to be considered together to make this determination.  Is the woman niddah or not right now? Is the couple comfortable with condom use and/or coitus interruptus? Is there enough time to transport the sample from home after intercourse to the physician’s office before the sample becomes inviable?

  • Is it permissible/ possible/advisable to freeze a sample when the woman is still tehorah (not niddah), in case she is still niddah at the point the sperm is needed?
  • What if the woman is niddah when the sperm is needed for fertilization, and no backup frozen sample is available? Is manual masturbation allowed, if that was not the preferred method otherwise?
  • Are relations permitted during the daytime for purposes of collecting sperm for this procedure, if a couple is usually strict to abstain during the day?

 

     3.Birth Control/Estrogen Patch use (sometimes used prior to treatment in order to              regulate the cycle)

 

3a.  If I find blood while using the birth control/ patch, must I assume I am niddah?

Notes for the halakhic advisor:

  • Might the blood be permitted for any other reason besides attribution to a wound (such as amount, location, size, color, etc.)?  
  • If not, might the blood be permitted based on attribution to a wound?  [This depends on whether the