Frisch School



The Halakhic and Ethical Issues Regarding Early Ovulation and ConceptionLiat GreenwoodIntroduction to the problemV’el isha b’nidat tumata lo tikrav l’galot ervata.“To a woman in the niddah state of ritual impurity, you may not come near to uncover her nakedness.” (Leviticus 18:19)The sages explain that a woman enters the status of a niddah with the release of uterine blood; as a result, she becomes Temeah, ritually impure, and may not cohabit with her husband. In Torah times, the woman would have been able to change her status to that of Tehorah, ritually pure, by immersing in the Mikveh, a ritual bath, after seven days. She could then resume intimate relations with her spouse.With the arrival of the Israelite nation in their homeland and the rise of the rabbinic leadership, the timing by which a woman achieved the status of Tehorah underwent a significant transformation. The rabbis mandated that a woman would be considered a niddah for the first four to five days of her menstrual cycle (four according to the tradition of the Sephardic Jews–from Arab and Spanish lands– and five according to the Ashkenazic Jews – from the remainder of Europe). But in addition, she would now be considered a niddah for the following “seven blood-free days” as well (at a minimum, a total of eleven days for Sephardic women and twelve days for Ashkenazic women). These laws remain in effect to this day and an observant Jewish woman is bound to adhere to them. Though the extension of the niddah status by several days was ultimately rabbinic in origin, modern Orthodoxy holds that this extension has the same weight and force as the original Torah injunction. How does this work from a practical standpoint in modern times? During the seven blood-free days, a woman must have no physical evidence of uterine bleeding. In the afternoon at the conclusion of her actual bleeding (a minimum of four or five days, as determined by the woman’s origin and family tradition), she performs an internal vaginal check using a white cloth. She then visually inspects the cloth to ensure that there are no traces of red stain. If she determines that the cloth is free of this residue, she may begin counting her seven blood-free days; this initial examination is known as a hefsek tahara. During the successive week, she performs the same internal check, which is now known as a bedikah, on a daily basis to ensure that her status is unchanged from the moment of her hefsek tahara. Under normal circumstances, a rabbi is not consulted in these matters, and the woman relies on her own sense of integrity to declare that she has completed her seven blood-free days. Following her last bedikah, she is permitted to visit the mikveh and is encouraged to resume intimacy with her husband. The connection between these seven blood-free days and fertility may not be apparent to those without an understanding of female physiology. But if a woman generally ovulates during her seven blood-free days, it is likely that she will be unable to conceive during intercourse. This condition is known in the Modern Orthodox and Ultra-Orthodox communities as “early ovulation” and the result is called “Halakhic Infertility,” that is, infertility that is a direct outcome from the practice of halakha, Jewish law. According to a recent study in 2012 by a group of gynecologists in Israel, 21% of women (who observe the laws of niddah) reported that ovulation occurred on average 24 hours or more before their mikveh immersion. This means that they were halakhically infertile since they were prohibited to their husbands at the time they would have been able to conceive. Infertility, resulting from early ovulation combined with adherence to the laws of niddah (i.e., ovulation before immersion in the mikveh and resumption of sexual relations), creates a number of dilemmas, both ethical and halakhic in nature. Physiology of Ovulation and ConceptionThe female reproductive system's primary organs are the ovaries. The two ovaries are located on the lateral walls of the pelvis, and are attached to either side of the uterus or womb by the ovarian ligaments. The ovaries are responsible for creating the ova (the female gametes or eggs). They also release the female hormones estrogens and progesterone, which help regulate the menstrual and fertility cycle, among other functions. An external view of an ovary shows that it is relatively small (about the size of an almond) and spherical. An internal view of an ovary shows many sac-like structures called ovarian follicles, each containing an immature ovum called an oocyte, engulfed in a layer of cells, called follicle cells. Each ovarian follicle goes through stages of growth while the egg is maturing. The follicle expands outwards creating open space between the maturing egg and the cell layer. This space is called the antrum and is filled with liquid. When the ovarian follicle reaches the stage where the antrum is fully developed, it is called the vesicular or Graafian follicle; after this point, the ovum is mature and ready to be sent out from the ovary into the fallopian tubes in the process called ovulation. In the general population of women, ovulation occurs on average every 28 days--towards the end of the proliferative stage--around days 6-14 of a woman's cycle (counted from the first day of menstruation). After ovulation occurs, the mature ovum will live for up to 24 hours before disintegrating. Once it is destroyed, conception cannot occur until the woman ovulates again during her next cycle. If a Jewish woman ovulates regularly during any of the first six blood-free days (i.e., before she has immersed)--equivalent to the proliferative stage of an average woman's cycle--then, she will be unable to conceive during intercourse, as there is no egg present to fertilize. Using advances in modern medicine and technology, and by turning to leniencies in Jewish Law, our sages have devised ways to combat the problem of halakhic infertility.The Niddah Status – Historical OverviewVe'ishah k-tihiyeh zavah dam yihiyeh zavah bivsarah shivat yamim tihiyeh veniddatah vechol-hanogeyah bah yitmah ad-ha’arev“And when a woman has a discharge and the discharge of her flesh is blood, she will be a zavah for seven days, and everyone who touches her will be ritually impure until the evening.” (Leviticus 15:19)The Torah mandates that a woman who has expelled uterine blood is not permitted to engage in sexual relations with her husband for a seven-day period, beginning with the onset of bleeding. The punishment for transgressing this commandment is severe – that of Karet, spiritual excommunication -- as ritual purity is at stake. But the Torah also speaks about another status which is historically relevant, as it relates to the ultimate expansion of the seven-day waiting period to the current minimum of eleven or twelve days. The Torah introduces the concept of a zavah, a woman who encounters uterine bleeding at a time outside of her expected menstrual period. According to the Torah, a zavah must count seven blood-free days following the cessation of her flow before she can become tehorah and is permitted to her husband. In practice, however, women were unable to distinguish between the laws of the zavah and niddah. Therefore, in order to ensure that they were not transgressing a Torah commandment, and were at risk for the punishment of Karet, Jewish women started to observe their own stringencies. The practice became widespread to consider all uterine bleeding as rendering them zavah -- and not niddah -- thus requiring them to count seven blood-free days only after all uterine bleeding had ended. This is known as Takanat Rebbi Zeira, the ordinance of Rabbi Zeira, and is recounted in the Talmud as follows:Amar Rabbi Zeira: B’not yisrael hechmiro al aztman, she’afilo ra’ot tipat dam chardal – yoshevet aleyha shiva neki’imRabbi Zeira said: the daughters of Israel accepted a stringency on themselves, that even if she saw only a drop of blood the size of a mustard seed, she would sit on it for seven blood-free days.In Jewish law, it is customary that a chumra (stringency) created or codified by the sages of previous generations takes on the status of Torah law. It is clear that with Takanat Rebbi Zeira, a woman now needed to wait until the conclusion of her uterine bleeding before performing a hefsek tahara and beginning the count of the seven blood-free days. But how did the rabbis determine that a woman needed to wait at least four of five days before starting the count? What would happen in the case of a woman whose bleeding lasted only three days? The rabbis added an additional day (or two, depending on regional differences) because of the possibility that the woman and her husband had sexual relations just prior to the onset of her niddah status. They feared that her seven days would be tainted by the expulsion of semen, which would cause further impurity forcing her to start a recount.The extension of the counting period by this many days may overlap with ovulation. Hence, a direct result of Takanat Rebbi Zeira is that there are women who will become Halakhically Infertile. That is, they will not be able to conceive naturally during the time that they are permitted to their husbands.Halakhic (Jewish Law) SolutionsIf a women suspects that she ovulates during the period in which she is halakhically prohibited to her husband, she should confirm that this is, in fact, the case by performing a test with an ovulation kit (available over-the-counter at pharmacies). Once confirmed, she should ensure that she is counting her seven blood-free days correctly, before considering any other halakhic or medical interventions. She may only be menstruating for the minimum four or five days (according to her family tradition), but think that she is menstruating for longer, especially if her hefsek tahara is questionable. The woman would need to submit her hefsek tahara cloth to a rabbinic authority to confirm whether or not she has identified her status correctly. If she has misunderstood the colors on the hefsek tahara, then she will be encouraged to consult with a rabbi during the next cycle, so that she can attend mikveh at the earliest possible opportunity and not delay unnecessarily. If she is counting her days properly, then halakhic leniencies can be taken. If an Ashkenazic woman is only menstruating for four actual days, many rabbis will allow her to perform a hefsek tahara at that time (as is the Sephardic custom). She would still wait her seven blood-free days, but they would be pushed forward so she could potentially ovulate after her mikveh visit (or no more than 24 hours beforehand). According to mainstream Orthodox view, if none of the above works, and she wants to have children while still observing Jewish law, she has to proceed with medical intervention.Medical InterventionsClomidThe drug most commonly recommended by doctors for the problem of halakhic infertility is Citamine Citrate (more commonly known by the brand name Clomid). Clomid is a non-steroidal ovulatory stimulant. It interacts with estrogen-receptor-containing tissues (i.e., the hypothalamus, pituitary, ovary, endometrium, vagina, and cervix). The cost for the drug over one cycle appears to run between $10-$100, depending on dosage, with an average cost of approximately $40.Citamine Citrate must be prescribed by a doctor due to its potential side effects, as explained in the Physician’s Drug Reference. 1.5% of women taking Clomid reported blurring and/or other issues with their eyesight. In fact, a woman taking Clomid is advised not to drive or use machinery. For women with careers requiring perfect vision, for example--a surgeon, Clomid may not be an acceptable means to solve Halakhic infertility. 5.5% of women reported having abdominal and/or pelvic pain and distension and bloating. And the risk of multiple pregnancies was 7.98%, higher than with than regular conception (directly due to overstimulation in the ovaries). In addition to these risks, 13.6% of women reported ovarian enlargement, 10.4% reported vasomotor flushes, 2.2% reported nausea and or vomiting, 2.1% reported breast discomfort, 1.3% reported moderate to severe headaches, and 2.1% reported abnormal uterine bleeding (which would defeat the purpose of using this particular drug for the purpose of halakhic infertility).When taking Clomid, a woman is at risk for Ovarian Hyperstimulation Syndrome (OHSS). The risk of OHSS is higher in women under the age of 30. OHSS is a serious medical disorder that can progress very rapidly. OHSS causes a build-up of fluid leading to ovarian enlargement, gastrointestinal symptoms, ascites (fluid in the peritoneal cavity), dyspnea (shortness of breath), oliguria (a low output of urine), and pleural effusion (fluid in the lungs). If used for more than one cycle, taking Clomid may increase the risk of developing an ovarian tumor. According to a study conducted between 1965-1985, Clomiphene Citrate used for one cycle increased the risk of uterine cancer by 1.79%. Finally, there have been no studies to show how Clomid reacts with other drugs. There is also the possibility that a woman will not be allowed to take Clomid due to medical contraindications. A woman cannot take Clomid if she is prone to abnormal ovarian cysts, which occur in 67% of women. Additionally, she may not take Clomid if her estrogen levels are too low, or if she has a history of liver disease, thyroid problems, or adrenal dysfunction. Intrauterine Insemination (IUI)Intrauterine Insemination, known more commonly as?IUI, is a relatively safe medical procedure (it is a type of Artificial Insemination, AI), which takes place while a woman is ovulating. The IUI procedure takes around twenty minutes and costs between $500 and $1,000. Women under 35 years of age have a 10% to 20% chance of getting pregnant after one IUI?cycle. Women between the ages of 35 and 40 have a 10% chance, and women over the age of 40 have only a 5% chance of getting pregnant after one cycle of?IUI. Beforehand, a woman takes Follicle Stimulating Hormone (FSH) or another ovary stimulating drug to ensure that she will produce enough ova for the procedure. Separately (and usually at an earlier date), her husband's sperm is harvested in accordance with halacha and is then cleaned. A rabbi can be present in order to ensure that the husband’s sperm is being used, and not that of another man, thereby preventing issues of adultery and relations with one’s close relative. The sperm are then injected into the uterus so that the ova can be fertilized. The main risks posed by IUI?are multiple pregnancies due to the use of ovary stimulation drugs. Less than 1% of women acquire infections from the procedure.In Vitro Fertilization (IVF)Another option for the halakhically infertile woman is in vitro fertilization, also known as IVF. IVF costs between $1,200-1,500 and has a success rate of 39.6% for women under 35 during one cycle, significantly higher than?that of IUI. Women over the age of 40 have an 11.7% chance of becoming pregnant after a single cycle of IVF, also significantly higher than with?IUI.Because this is a ritual purity issue, a woman cannot have relations with her husband during the seven blood-free days. However, that does not prevent a doctor from harvesting her eggs during the time she normally ovulates for later implantation. Rabbi Eliezer Waldenberg, a former judge on the supreme rabbinical court in Jerusalem, did not allow IVF because he was of the opinion that IVF is an unnatural process. He wrote in his book, Tzitz Eliezer, "the very order of nature has been altered," when conception occurs outside of the woman's body.Before a woman would normally ovulate, she would take drugs such as Gonadotropins (which contain FSH) to stimulate her ovaries so that during this particular cycle, they would produce more than one to two eggs. The eggs are harvested during ovulation. This can be done either laparoscopically or through aspiration guided by ultrasound. Separately, her husband's sperm is collected in a halakhically acceptable manner. A doctor will then fertilize the eggs with the sperm in a petri dish. As an extra precaution in modern times, a rabbi can be hired to oversee the process and make sure the husband's sperm has been correctly mated to the woman's eggs.The fertilized eggs, now called embryos, will go through the stages of early cleavage (a cluster of four cells), morula (expansion to a ball of cells), and the early blastocyst stage. Once the zygotes reach the early blastocyst stage, no more than three or four are implanted into the wall of the uterus--called the uterine lining--into its outermost layer called the endometrium. From there, the pregnancy will most likely continue normally leading to a single birth or multiple births.As with any medical procedure, IVF has its side effects—both on the mother, her husband, and their baby. Although the aspiration procedure is generally considered safe, it can cause damage to the bowel, blood vessels, or bladder. It may also cause some bleeding and or infection. Some babies who are conceived via IVF are born premature with low birth weights, in single as well as multiple births. Research shows that uterine bleeding in the first trimester is more common in women who have conceived via IVF. A major side effect of IVF is its effects on mental health, rather than physical health – namely, the stress that it causes for the woman, for her spouse and on their relationship. One study observed that women undergoing IUI and IVF tended to have higher distress levels, be more fatigued, and have fewer social contacts than their spouses. The same study notes that after failed IVF cycles, 13% of women had suicidal thoughts. Due to the fact that more than one embryo is usually implanted into a mother's uterus, IVF poses a stronger risk of multiple births than does IUI and Citamine Citrate, if more than one embryo is implanted. The risks of multiple births include: premature labor and delivery, low birth weight (under 2500 grams or 5 pounds, 8 ounces), intrauterine growth restriction (also known as IUGR), preeclampsia (the chances of preeclampsia are doubled with multiple births), gestational diabetes, placental abruption, miscarriage, and cesarean section.Women with single pregnancies tend to deliver after 39 weeks of pregnancy, while under 37 weeks is considered premature. With each additional baby in utero, gestation length decreases. On average, twin pregnancies remain 36 weeks, triplets remain 32 weeks, and quadruplets remain 30 weeks in the womb. 60% of twins are delivered preterm, while 90% of triplets are delivered preterm. Babies born prematurely run the risk of both short-term and long-term risks. Short-term risks include: breathing difficulty (due to under-developed lungs), intraventricular hemorrhage (bleeding in the brain), hypotension (low blood pressure), hypothermia (poor temperature regulation), and anemia. Long-term risks include: a higher risk of Cerebral Palsy, impaired cognitive skills and visual, dental, and hearing problems. Ethical Issues regarding Medical InterventionsClomid, IUI and IVF are the mainstays of medical treatment for halakhic infertility, but each has its own costs – both financial and medical. In order to conceive children, a halakhically infertile woman must invest money and significant time into a procedure that may or may not prove successful. In addition, she needs to weigh the benefits of having a child against the unknown health consequences (physiological and psychological). As written in a study researching the effects of fertility treatment on stress, “Infertility treatments are invasive, expensive, time-consuming and emotionally draining. Treatment involves the repetitive raising and dashing of the hope of pregnancy, perhaps resulting in an increase in the saliency of parenthood identity and a heightened sense of distress in the face of the failure to attain parenthood.” Another ethical issue that arises is the allocation of medical resources. Funds, time, and effort, which are directed towards fertility treatments, could instead serve those with significant medical needs. DivorceThe Babylonian Talmud states that a man may divorce his wife if she has failed to produce a child after ten years, so that he may marry another woman and start a family. This begs the question – Can a man divorce his wife if she refuses to undergo any of the aforementioned medical therapies despite struggling with halakhic infertility? Rabbi Dr. Harvey Belovski of the Golders Green Synagogue in London writes that, although this is possible, “in this day and age, we try to do everything possible to make sure that this does not happen, and it rarely does.”Causing HarmSince there are inherent health risks associated with these medical procedures, the question arises -- Can a woman cause potential harm to herself for the sake of having children while maintaining the laws of niddah? The actual positive commandment to “be fruitful and multiply” was given to Jewish men only. Since the wife is not commanded to have children, there is no halakhic reason for her to put herself in any unnecessary danger in order to produce a family. There are several other Torah commandments that are relevant to this issue as they explore the obligation to avoid danger. It is a positive Biblical commandment for the individual to avoid harm. But there are also two relevant negative commandments derived from the Torah; an individual may not harm him/herself (i.e., the flip-side of the positive commandment) and the individual may not harm others. The negative commandment against harming others is derived from a passage in Deuteronomy:Arba'im yakenu lo yosif pen yosif le hakoto alelleh makkah rabah, veniklah achicha le'eineicha.“Forty lashes you may give him; you shall not add, for if you add, and beat him more than these lashes, then your brother will be ashamed before your eyes.” (Deuteronomy 25:3)The rabbis of the Babylonian Talmud learn from this passage that since one cannot add to the punishment (in the form of lashes) of a guilty man, even more so, one should not harm or injure an innocent individual. This commandant seems to present a problem for a Jewish doctor who prescribes any medication or performs surgery that is not absolutely necessary for a woman’s health, and which could cause harm to the woman. As for the commandment to keep oneself healthy (observed as both a positive and a negative commandment), Maimonides wrote:Ho’eel v’heyot haguf bari v’shalem midarchei hashem hu, sheharei ii efshar sheyavin oh yada davar miyediyat haboreh v’hu choleh, lefichach tzarich l’harchik adam atzmo midvarim hama’avadim et ha-guf, v’lihanhig atzmo bidvarim hamavrin v’hamalchimimAs a whole and healthy body are one of the ways of God and it is impossible that one will understand or know the Creator when he is ill, one has to distance oneself from things that destroy the body and engage in practices that are healthful and healing.Rabbi Moses Isserles reiterates this theme in the codification of Jewish law known as the Shulkhan Arukh:V’chen yizhar mikol dvarim hamevi’im lidei sakanah, ki sakanata chamira m’isura, v’yesh lachush yoter l’safek sakanah milisafek issurAnd similarly, he should be careful with those things that lead to danger, and danger is more severe than prohibition, and one has to be more careful about a possible danger than a possible prohibition. These sources elucidate the problem for a woman electing to use a medical solution to halakhic infertility; if there are any medical contraindications, she could be violating both the negative commandment against self-infliction of injury and the positive commandment to keep herself healthy.Upholding Takanat Rebbi ZeiraThe Torah calls for a seven-day waiting period for a woman who is niddah. Ever since the sixth century, rabbis have upheld Takanat Rebbi Zeira, that women should count four to five days following the appearance of uterine blood, before beginning the count of seven blood-free days. No Modern Orthodox rabbi has ever publicly stated that he would allow a woman to count seven days of separation beginning from day one of her menstrual cycle, rather than from day four or five (i.e., adhering to Torah law, but forsaking the rabbinic stringency). In this case, the Orthodox establishment believes that rabbinic law holds greater weight as it is meant to safeguard the correct performance of the Torah decrees. However, there are anecdotal reports, that some rabbis may have allowed this privately on a case-by-case basis. In 2006, Dr. Daniel Roznak, a gynecologist at Hadassah Hospital, in partnership with Rivkah Shimon, an Orthodox Rebbetzin from Pisgat Ze’ev, Jerusalem, caused furor in the religious community after publishing an article in the journal HaTzofeh, calling for a return to the seven-day waiting period mandated in the Torah (i.e., counting from the first day of uterine bleeding). The authors called for the elimination of Takanat Rebbi Zeira. They followed up with the publication of a book and website, on which they write:The “Halakhic” roller-coaster suggested today as a “solution” to the problem of religious sterility by feeding perfectly healthy women hormones they do not need, while risking their health and lives is another facet of the moral and ethical value of this atavistic stringency… It is obvious that the decrees of the rabbis were the best suited for their time and age, but it is also obvious that if they were aware of the medical knowledge we possess today, they would be the first to cancel this specific Chumra… it is obvious that we are dealing with a non-moral solution…”Reactions to the writings of Dr Roznak have been virulent. Rabbi Bornshtein, director of Puah (the Institute for Halakhic Infertility in Israel), is highly critical of the way in which Roznak publicizes his ideas. Rabbi Bornshtein argues that rather than approaching this issue from the bottom-up (i.e., bringing it to the masses to advance change), it should have been approached from the top-down (i.e., discussing it with the rabbinic authorities) in order to actuate change.It is unfortunate that my request [for Roznak to refrain from publishing] was not accepted and that we arrived at an article such as this. Publications such as these cause suffering to people with urgent need who would have benefitted from the provision of a personal psak (Halakhic ruling), but today we encounter a greater fear -- lest the exception becomes the rule.Though Rabbi Bornshtein’s language is vague, he alludes to the fact that he may allow for leniencies on a private, case-by-case basis (though those leniencies are never defined). He is deeply disturbed, however, that Dr. Roznak has brought attention to the matter and carried it from the personal realm into the public realm. Rabbi Bornshtein also addresses major gaps in Dr. Roznak's understanding of Jewish Law. He strongly disagrees with Dr. Roznak’s assertion that our sages did not fully understand fertility and the concept of ovulation. He writes:Even if medical technology during the time of the sages was not at the level it is today, there is no need to underestimate their intelligence or mental sensibilities. Even then, the sages also knew the period for conception, as they discussed in Niddah (a section of the Babylonian Talmud), "No woman conceives, unless she has just completed her immersion." Any intelligent individual understood that there were those who missed this time period (for conception). It is possible they solved this through vaginal insemination because there was no need for the medical wisdom of the 21st century to conduct this treatment.Furthermore, Rav Bornshtein brings in the professional medical opinion of Dr. Chana Katan, a gynecologist, who disagrees with Dr. Roznak’s statistics--from the potential dangers of possible medical intervention to the percent risk of breast cancer from the use of hormones such as Clomaphine Citrate. Dr Katan minimizes the risks of short-term hormone use (claiming that they may even be protective against some cancers), and accuses Roznak of leaning towards extremes when evaluating medical data. I want to say unequivocally, and I repeat it at almost every medical conference--there is not a single posek (halakhic authority) in the world that would shorten the seven blood-free days.Rabbi Yuval Cherlow, a well-known rabbinic leader and Yeshiva educator in Israel, reinforces this notion:The severity of Rabbi Zeira already ceased to be a severity in the time of the Babylonian Talmud and was accepted by Israel in its entirety. All authorities without exception have understood this severity as law.However, he also writes that avoidance of medication for treatment is preferable and that the issue of Takanat Rebbi Zeira is a discussion for a later time and place. It is clear that Roznak’s ideas are rejected by all mainstream halakhic authorities, at this time, however, he continues to be an outspoken advocate on behalf of the halakhically infertile woman and has succeeded in raising awareness to the questions that rabbis must consider when they provide rulings.ConclusionThe psychological effects of infertility were evident even in biblical times. We learn in the Torah about Sarah, Rachel, and Chana who went through trying times before they were finally able to conceive. Sarah was distressed to the point that she begged her husband, Abraham, to take her maidservant as a concubine in order to have children. Rachel also pleaded with her husband, Jacob, to do the same. In addition, Rachel relinquished a night with Jacob to her sister, Leah, as part of a deal to acquire mandrakes, which she believed would help her to become pregnant. Chana’s anguish can be understood in her very emotional prayer to God at the Tent of Meeting; she was so involved and physically demonstrative that the High Priest thought she was a drunkard.Modern medical innovations have made it possible for women who are Halakhically infertile to join the ranks of these Biblical heroines, and bear children. But at what cost? These women may face tremendous stresses – stresses that are psychological, physical and financial in nature. At this point, these stresses are still the subject of discussion and debate, as there is no agreement in the medical community about the effects of the cited medical interventions on women’s health. It is encouraging to note that Nishmat, a prominent women’s learning institute that runs the website (to assist women in answering queries about niddah), is currently enrolling women in a study to gather more information on halakhic Infertility; hopefully, this study will also make observations on the psychological impact of this condition. Ultimately, each couple needs to weigh the potential risks against the possible reward/s, and the rabbis who lead them need to consider the ethical boundaries when guiding them. ................
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