Israel has the highest per capita rate of fertility clinics in the world. It has greater socialized medical coverage of new reproductive technologies than any Western country. In addition to the natural desire to reproduce, this is due in part to the murder of six million Jews in the Holocaust, in part to the Jewish male’s obligation to procreate, and for some segments of the population, competition with and the felt need to counter Arab population growth. The pronatalist society has increased the sense of failure in infertile couples, pushing them to find a variety of solutions for infertility.

The Pu’ah Institute (an acronym for the Hebrew “fertility and medicine according to halakhah”) in Jerusalem gives halakhic counseling to infertile couples, informs them of reproductive technological opportunities, advises them concerning halakhic issues, and directs them to appropriate centers, staffed by doctors willing to relate to halakhic concerns. Many women, particularly in the ultra-Orthodox and Orthodox communities where a very high premium is placed on fertility, are uncritical consumers of new reproductive technology. Unfortunately, the poskim (decisors) are willing to exploit this natural desire and societal pressure by subjecting them to unnecessary techniques in order to maintain halakhic stringencies for the men involved. Although any woman can refuse to undergo any reproductive technological procedure, her infertility puts her at a social disadvantage and may be used as grounds for divorce. As a result, women are often pressured into repeated fertility treatments. Male impotence and infertility can be grounds for divorce if the woman claims that she wants children to lean on in her old age and to bury her (BT Yevamot 65b). The rabbinic courts from Talmudic times have considered impotence and infertility claims to be very delicate and fraught with shame, making such claims unlikely on the part of women. Moreover infertility, unless intentionally used as a divine punishment biblically (e.g. Pharaoh and Avimelekh concerning Sarah), was attributed to women, particularly if the man was not impotent.

Almost none of the Halakhic decisions written by rabbinic authories in response to questions posed to them.responsa relate to the health or safety of the woman undergoing fertility treatments. A few note that the woman is not obligated to undergo any fertility treatment but at the same time do not relate to her vulnerable position in that her husband may divorce her because of her infertility. At least one acknowledged rabbinic authority suggested that the obligation to procreate has been suspended in the post-destruction of the Temple era. Nonetheless a couple may choose to undergo fertility treatment, especially if infertility is painful for the woman.

From the middle of the Lit. (Aramaic) "spokesman." Scholars active during the period from the completion of the Mishnah (c. 200 C.E.) until the completion of the Jerusalem and Babylonian Talmuds (end of the fourth and fifth centuries respectively), who were active primarily in the interpretation of the Mishnah. In the chain of tradition they follow the tanna'im and precede the savora'im.amoraic period, Jewish menstrual laws (Menstruation; the menstruant woman; ritual status of the menstruant woman.niddah) took all women out of the category of normal menstruants (seven days) and put them into the category of women with abnormal uterine bleeding (zavah). This stringency has been one cause of infertility due to halakhic observance (akarut hilkhatit). The necessity of waiting seven clean days after the cessation of menstruation (a minimum of twelve days) had the result that women with short cycles would be in a post-ovulatory stage before resuming sexual relations in a state of ritual purity. In the past this destined women to infertility, with the possibility of divorce as a result of the infertility. Some modern attempts to chemically adjust the cycle have been successful. Some halakhic authorities even allowed artificial insemination with the husband’s semen to occur before the completion of the seven clean days in order to allow conception without transgression of the rabbinic norms (Rabbis Ovadiah Yosef and Moses Feinstein). Some require immersion after the seven days of niddah in accordance with biblical and early rabbinic law before artificial insemination (Minhat Yizhak), while others forbid immersion lest the couple come to believe that intercourse itself is permitted prior to the seven clean days in accordance with the rabbinic decree. Maintaining the structure of the stringent niddah laws has been paramount in determining reproductive technology.

If after a year of unprotected regular intercourse the woman has not conceived, the diagnosis of infertility is made. In a normal fertility work-up the man is asked for a semen sample because it is the cheapest and least invasive fertility test and the one with the fastest results determining whether the root cause of the infertility is primarily due to the man. Many poskim forbid masturbation to obtain the semen sample as this is considered needless spilling of his seed (hashhatat zera), preferring instead post-coital semen collection from the woman (e.g. Rabbis Abraham Kook, Moses Feinstein, and Eliezer Waldenberg). Ignoring modesty issues for the woman who must be in the doctor’s office within one to two hours after coitus for a pelvic procedure, usually performed by a male doctor, is less bothersome for most poskim than allowing the man to masturbate to produce the semen for the fertility test. Some poskim allow use of a medical condom or coitus interruptus or non-coital sexual relations by the couple in which the ejaculate is collected. Rabbi Ben-Zion Ouziel interpreted BT Yevamot 76a, the same source used by the other poskim to forbid masturbation, to allow masturbation in case of need. His statements, made concerning a man with damaged genitalia who could ejaculate properly and thereby marry a Jewish woman, could easily be applied for semen testing. Semen analysis often determines whether surgical intervention is necessary; for example there is a high correlation between varicoceles (which can easily be repaired surgically) and male infertility.

Fertility work-up on the woman is much more complicated and expensive than for man because a woman’s reproductive organs are internal; thus some of the tests are invasive, with the risk of injury or infection. Hence in secular society male fertility is always examined before checking for female related causes for infertility. The percentages of infertility are roughly the same for both sexes: forty percent attributed to male causes, forty percent attributed to female causes and twenty percent with unknown causes or a combination of sub-fertility in both.

Disease and malformation of the fallopian tubes are factors in a significant percentage of female-related infertility. The two standard tests to evaluate the tubal factor, hysterosalpingography (HSG) and laparoscopy, require anesthesia. HSG requires the insertion of a cannula through the cervix into the uterus through which radiopaque contrast medium is injected and followed by radiographs or fluoroscopy in order to determine that the fallopian tubes are open. Use of oil-based contrast mediums have sometimes resulted in lipid embolization (fats clotting together) and the penetration of the clot into the venous or lymphatic system. This procedure may be considered dangerous as it carries some risks; a small number of deaths and a large number of injuries and illnesses have resulted. Laparoscopy with lavage is a similar process with the insertion of a dye through a cannula and a camera inserted through an abdominal opening to visualize the movement of the dye through the fallopian tubes. The insertion of the cannula itself is considered to cause a state of niddah impurity because the concept “The grave [= uterus] cannot be opened without blood” goes into effect even in the absence of overt uterine bleeding.

Ovarian factors are generally tested by taking the basal temperature each day for a number of cycles, following follicular development by ultrasound, or a series of blood tests to determine hormonal levels. Endometrial biopsies give indirect evidence for ovulation. Despite the added cost factors and invasive methods, most poskim require a fertility work-up on the woman before allowing semen testing but generally do not require HSG prior to male testing because of the pain and danger to the woman involved in that procedure.

After a diagnosis is made, there are several possible treatments. Artificial insemination (AI) is the oldest method, widely used since the mid-twentieth century. Halakhic questions associated with AI include the legitimacy of non-coital ejaculation even for the purpose of procreation; the status of a child conceived by AI both in regard to illegitimacy (mamzerut) and family status (Priests; descendants of Aaron, brother of Moses, who were given the right and obligation to perform the Temple services.Kohen, Levi, or Israel); status of the mother in reference to adultery and Mandated ceremony (Deut. 25:9halizah; status of the child as heir to the husband of the mother; fulfillment of the biblical commandment to procreate incumbent on the man and the rabbinic commandments to inhabit the land and not to cease procreating; future potential for incest in the case of an anonymous donor; permissibility if the man has already produced children; genealogical issues; the unnaturalness of technology denigrating normative sexuality; the potential for resentment on the part of the husband when donor semen is used; stress on the marriage due to the rigors of fertility treatments, and other health issues.

Semen collected for insemination sometimes undergoes treatment prior to insemination. Sperm are sometimes washed in such a way as to separate them from the seminal fluid to increase their motility when this is suspected or diagnosed as a problem for fertility. Alternatively, a swim-up technique is applied to fresh semen by which only the most motile sperm are collected. A culture medium is placed over the semen allowing healthy motile sperm to swim up to it. Sperm may also be frozen and stored for future procedures. Careful identification on the containers and the use of new or newly sterilized laboratory equipment are absolute requirements lest mislabeled semen samples get mixed up with each other. Some fertility clinics have specially appointed overseers (mashgihot) to see that only the designated semen and ova are combined in vitro fertilization and only new or sterilized equipment is used for semen collection and transfer.

Most poskim allow artificial insemination with the husband’s semen (AIH), tending towards leniency in reference to non-coital ejaculation for this purpose. Most poskim consider the husband to have fulfilled at least the A biblical or rabbinic commandment; also, a good deed.mitzvah to inhabit (lashevet) if not the mitzvah of procreation (R. Eliyahu Bakshi Doron permits semen collection only for this mitzvah). For others the issue is undecided (R. Shlomo Zalman Auerbach). Some poskim consider that AIH exempts the woman from the need for halizah upon her husband’s demise should he have no other children and have a paternal brother. Transferal of his family status to the child without natural conception is questioned by some poskim and some have suggested transferring the status of the mother’s father to the child. Most consider the child as legitimate heir. Some, however, require the physical act of intercourse to establish halakhically recognized paternity.

AIH solves a relatively low percentage of fertility problems, for example if the husband is impotent but has sufficient quantities of normal motile sperm; if the number is low but can be concentrated by combining extracts of his different ejaculates; if he has retrograde ejaculation into the bladder; if he has hypospadias where the opening to the urethra is not at the tip of the penis, preventing the semen from being ejaculated into the vagina; or if the vaginal chemistry is too hostile to the husband’s sperm. During AIH, semen is generally injected directly into the uterus. The greatest halakhic concern in this technique is that the husband’s semen could inadvertently be confused with someone else’s semen in the laboratory of the fertility clinic, thereby confusing the genealogy and according to some poskim creating a Lit. "bastard." Offspring of a relationship forbidden in the Torah, e.g., between a married woman and a man other than her husband or by incest.mamzer. In general, seed wastage for semen testing is a primary concern in the diagnostic stage but not in the insemination stage.

Artificial insemination using semen from a donor (AID) is far more halakhically controversial. Some poskim, including R. Joel Teitelbaum, interpret Lev. 18:20—“Do not give your lying (shekhovtekha) for seed (zera) to the wife of your fellow”—to include not only actual physical sexual intercourse but also semen from a donor. For these poskim AID constitutes adultery and results in the illegitimacy of the offspring. Those who permit AID interpret this verse to mean that only sexual intercourse (“your lying”) yields adultery and bastardy. Even those poskim who permit AID, for example R. Moshe Feinstein, do so only because of extreme distress of the childless woman married to an infertile man. R. Feinstein requires the consent of the husband for AID. The absence of consent on his part can be used as grounds for divorce. Other poskim agree that AID is not adultery but consider it an abomination. Those who allow AID require non-Jewish donors. The most significant halakhic issue is that a Jewish donor (who by civil law remains anonymous) could be a donor for several different women, creating a sibling relationship among such offspring. Because of the anonymity, these siblings may inadvertently marry each other, transgressing the biblical incest laws and resulting in offspring who are bastards. Only if the donor were identified, causing potential social and legal disruption, could such a situation be avoided. AID is not problematic in terms of the Jewishness of the child because Jewishness is universally accepted when transmitted through the mother. The husband, however, does not fulfill his obligation to procreate through AID, and if he dies without naturally conceived children and has paternal brothers, halizah must still be performed before his wife can remarry, despite the fact that she has had children. Children produced through AID are not considered legitimate heirs, but the husband could make a will in which he gives them (or others) all his property, so that they are not guilty of robbing the biblically established heirs of a childless man.

In addition to the halakhic issues concerning AIH/AID, new issues arise for in vitro fertilization (IVF). A few poskim forbid IVF (e.g. Rabbis Eliezer Waldenberg, Yehuda Gershuni, and Moshe Sternbuch). R. Waldenberg justifies his position on the basis of seed wastage, that no procreation can take place outside of the uterus, and that there are no paternal/maternal relationships established by IVF. The majority of poskim, however, permit IVF and accept the child born of the Jewish mother as a Term used for ritually untainted food according to the laws of Kashrut (Jewish dietary laws).kosher Jewish child with both maternal and paternal relationships.

Halakhically, IVF is more complicated than AI but avoids some of its problems and creates leniencies with reference to genetic screening and disposal of defective pre-embryos and unneeded fertilized ova. The procedure is generally used for women with damaged fallopian tubes, unexplained infertility, or male infertility. Certain rabbis have used this method to get around the halakhic difficulties mentioned above connected with AID because in IVF male seed is not inserted into the woman’s uterus but rather fertilized ova, thereby removing issues of bastardy. Unfortunately, IVF involves treating the woman with injections to halt ovarian function, followed by about ten days of fertility drug injections to induce superovulation. There are sometimes very severe side effects, such as fluid retention, swelling of the ovaries, and abdominal pain. More rarely there is formation of blood clots, kidney failure, fluid buildup in the lungs, and shock, which very rarely create a life-threatening situation. The ova are generally harvested through a needle in a probe inserted vaginally and guided by ultrasound. A mild sedative is required. Some or all of the ova are combined with the husband’s or donor’s semen in a petri dish.

A variation of IVF, called gamete intrafallopian transfer (GIFT) consists of the immediate injection of the ova into the fallopian tube after combination with semen without determining whether they have been successfully fertilized. Laparoscopy is employed in this procedure, usually requiring anesthesia. Another variation of IVF is the zygote intrafallopian transfer (ZIFT), in which the ova are checked to determine that they have been fertilized before implantation in the fallopian tube. Blastocyst transfer involves allowing the fertilized ova to develop for five days as opposed to the 48–72 hour fertilized ova normally transferred in IVF. There may be stimulation of the fertilized ova to initiate cell division before transfer to the woman’s fallopian tubes or uterus. Any procedure that involves genetic material remaining in the laboratory is susceptible to confusion of samples. Halakhic overseers are employed to prevent such potential confusion.

Sometimes the husband produces only a few viable sperm instead of the normal twenty million or so per ejaculation. Some poskim permit testicular sperm extraction through which a small amount of testicular tissue is surgically removed to harvest sperm found in it. If a man has undergone a vasectomy, surgery to attempt reversal of the procedure may be performed. If such surgery is unsuccessful, the following techniques, which are less controversial because no testicular tissue is damaged or removed, may be utilized: percutaneous, microepididymal, or vasal sperm aspiration. Through the use of micro-techniques, a single sperm can actually be inserted into the ovum in a process called intracytoplasmic sperm injection (ICSI). The fertilized ovum is then injected in the fallopian tube or uterus. There has been some critique concerning ICSI usage because of the potential transmission of diseases, including the tendency to infertility. Nonetheless this has become a commonplace procedure in Israel because it avoids the halakhic problems associated with AID and male infertility is on the rise. It should be noted that success rates for IVF procedures are less than thirty percent and decrease as maternal age increases.

Sperm banking in anticipation of radiation or surgically or chemically induced infertility has been forbidden by some poskim because it is considered by them to be seed wastage and the potential exists for confusion of samples in the laboratory. Surprisingly, some poskim have prohibited the practice even though it doomed a man who had not yet procreated to infertility. It should be noted that the mitzvah to procreate for the man does not obligate him to make use of new reproductive technology. His physical inability to procreate may have repercussions on his marriage but he is not therefore considered a sinner.

For some poskim, two new halakhic issues arise with the various IVF techniques. 1) Genetic screening of the fertilized ova before insertion into the uterus, aimed at preventing chromosomally or congenitally malformed pre-embryos from developing, is potentially problematic. Nearly all poskim, however, even those who forbid genetic testing via amniocentesis or chorionic villi testing, lest the parents opt to abort a congenitally malformed fetus, allow pre-embryo screening. It is well before there is even a “suspicion” of pregnancy (Codification of basic Jewish Oral Law; edited and arranged by R. Judah ha-Nasi c. 200 C.E.Mishnah Niddah 3:7). More importantly, as long as the pre-embryo is outside the woman’s body it has no fetal status. Several poskim even allow sex selection if it is done in order to avoid a sex-linked disease such as hemophilia (R. Auerbach). At least one rabbi has permitted sex selection to avoid the production of sons to a kohen so that the couple’s use of IVF, which may not confer family status, would not become public knowledge. This is a major reason IVF has become so popular in Israel: it avoids all questions of bastardy because no semen is transferred and it allows genetic testing without dealing with the problem of abortion.

2) Generally three or more fertilized ova are inserted into the uterus. As even triplet pregnancies complicate the health/welfare of the developing fetuses and the mother, multifetal pregnancy reduction (MPR) is often employed in IVF multiple pregnancies. MPR, the removal of one or more of the embryos, maximizes the potential development of the remaining embryos and increases the protection of the woman from the risks of a multiple pregnancy. This procedure has generated a great deal of halakhic discussion as to its permissibility, since—according to some authorities—the procedure falls into the category of abortion. There are those who permit such a procedure when done at a very early stage of pregnancy using transvaginal aspiration, sometimes before there is a halakhic “suspicion” of pregnancy. To some extent this circumvents halakhically prohibited abortion issues. Medically, very early MPR does not allow time for the “vanishing twin” phenomenon in which one or more of the fetuses in a multiple pregnancy ceases to develop. As a result, all the fetuses may be lost. Some poskim redefine MPR to involve a fetal lifesaving process rather than a fetal reduction process. As all of the fetuses are considered pursuers (rodfim) of one another, no one has a preferred status halakhically and cannot be chosen to be saved. Based on the possibility that all the fetuses may be lost without MPR, some poskim allow the procedure. Others concentrate on the lifesaving aspects to the remaining fetuses without the assumption that all would be lost. Those who allow MPR leave the decision to the doctors as to which fetuses to remove. Physicians’ decisions are generally based on implantation locations and the relative size and development of the fetuses. If the mother is endangered, for example by gestational diabetes, premature delivery, or eclampsia, all poskim allow MPR.

Because the woman’s task in pregnancy is two-fold, conception and gestation/birth, halakhic issues can arise at each stage. If the Jewish woman receives an ovum donation from a non-Jewish woman, does the gestation and birth convert the genetically non-Jewish fetus into a Jewish child? One Israeli rabbi suggested ignoring scientific knowledge and assumed that the Sages did not have an idea of female seed but rather held the Aristotelian position that women contributed the uterine environment only. As a result, non-Jewish ova donations would not be halakhically problematic because the Jewish uterine environment and parturition by a Jewish woman would confer Jewishness. (It should be noted that certain rabbinic sources provide strong evidence for a belief in female seed, as also seems to be the case in Leviticus 12:2, making this position questionable.) Some infertile couples prefer their children to be both genetically and gestationally Jewish. To that end, they advertise for Jewish women to donate ova, even specifying family characteristics such as height, build, coloring, and IQ from the potential donor. Large sums are offered and the advertisements in America can be found in Ivy League and other East Coast university student newspapers. Most poskim have accepted gestation as sufficient to determine the Jewishness of the child. R. David Bleich and others suggested that halakhically there may be two mothers, the genetic mother and the gestational mother. This necessitates the conversion of the genetically Jewish child gestated and birthed by a non-Jewish woman. Moreover, if the surrogate mother were Jewish, incest prohibitions would go into effect with the relatives of both mothers.

Alternatively, if a Jewish woman donates her ova to a gentile woman, does her Jewishness inhere to her genetic material or are the gentile gestation and birth definitive? If Jewishness inheres to the genetic material, a Jewish ova donor to a gentile may be guilty of turning a Jewish child over to non-Jews. This, however, is a fairly uncommon scenario because of the complicated procedure and potential danger in ova donation. Sometimes ova, even fertilized ova, are preserved by freezing. A woman who has undergone successful IVF treatment and who has leftover ova or a woman who has decided not to carry on with IVF after ova harvest may donate or sell the ova to other infertile women or to the clinic for experimentation. Thus this scenario is more likely than it may initially appear. Civil law in Israel requires the consent of both of the parents on the disposition of fertilized ova. In the event of a disagreement, a court decision for “custody” of the ova is made. Some poskim require destruction of unused fertilized ova to prevent inadvertent incest. Others do not relate to ova as female seed, and as a result, no maternity inheres in ova. While this use of contradictory sources concerning female seed alleviates potential problems, it ignores women’s proven genetic contribution to procreation.

There is significant halakhic concern for the fate of unused fertilized ova (and, of course, semen) lest there be seed wastage. Passive treatment of such material, which allows it to “die” by itself as opposed to its active destruction, is required. Ova that have not been transferred into the uterus after twelve to fourteen days from fertilization are no longer physically capable of implantation. Since these ova are already considered to be nonviable, halakhah is more lenient concerning their use in embryonic experimentation.

Halakhic authorities must decide whether to treat women as donors of Jewish genetic material (hence upholding a concept of female seed) or whether to determine Jewishness by gestation. Thus far, gestation has won the day.

Surrogacy is another new reproductive technology replete with halakhic problems. This is an area where all the problems in all the other technologies can come into play. Surrogacy is employed when the wife is unable or unwilling to carry a pregnancy. She may be able to donate ova fertilized through IVF by her husband to the surrogate mother, in which case she and her husband are the genetic parents. Alternatively, she may not have ova to donate, and the surrogate is impregnated through artificial insemination by the adoptive husband. In this case, the surrogate mother is the genetic and gestational mother, thereby having a larger “claim” on the child. The most complicated and least likely situation would be one where the ova were donated by another party, creating two adoptive parents (who have no genetic connection with the child), the surrogate who is the gestational but not the genetic mother and the ovum and sperm donors. Even in civil law it is obvious how complicated the situation can become. The main additional halakhic objections concern the obligation of the Jewish father to the child even if the surrogate changes her mind and demands custody. His legal rights to the child could be countered by the surrogate mother’s rights, particularly if she were also the genetic mother. It is particularly difficult if the gestational mother is not Jewish and decides to renege on the contract. Since 1996 surrogacy arrangements are legal in Israel. Great care is taken in drawing up surrogacy contracts, but the claim of the surrogate mother, especially if she is also the genetic mother, is very strong halakhically and civilly.

Cloning remains illegal from a civil point of view, but the halakhic problems of the procedure have already been discussed. Cloning is a process whereby the nucleus of an ovum is removed and replaced with a full complement of a single person’s DNA. It is then stimulated artificially to initiate cell duplication and transferred to the uterus. Some rabbis have welcomed this technique both for the chronically infertile and for its potential to produce organs, tissue, and stem cells for therapeutic purposes. Among the halakhic problems involved in cloning are: determining genealogy; determining whether the mitochondrial DNA of the ovum have any influence on the character or development of the clone, thereby creating more than one mother; determining whether cloning constitutes procreation as opposed to replication of an existing individual; determining whether such a technique is permitted halakhically; determining the status of a clonee in terms of Jewishness, family status, inheritance, and the possibility of exempting the “mother” from halizah.

New reproductive technology has solved the problem of infertility for many people. Nevertheless, there remains a great deal of halakhic dispute on many of the topics. Many of the halakhic decisions were made to maintain the most stringent practices of avoiding ejaculation in vain. As a result, unnecessary medical procedures are routinely performed on women, sometimes endangering them. These procedures (such as IVF) are constantly being reinforced because they avoid other controversial procedures such as genetic screening and abortion.