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Orthodox Jewish women may follow an ancient tradition that requires sexual abstention during her menses and for the seven days that follow. Once the woman has completed the period of sexual abstention she immerses in a ritual bath to purify her soul and then is encouraged to have intercourse with her husband but when your patient experiences infertility, how do you treat the infertility while maintaining respect for her religious traditions?
Orthodox Jewish women may adhere to religious laws that require sexual abstention during her menses and for the seven days that follow. Once the woman has completed the period of sexual abstention (called niddah), she must immerse herself in a ritual bath (mikvah) for purification before she may have intercourse with her husband. Archaeological digs have unearthed the ruins of a mikvah in every Jewish community dating back over 2,000 years. There has been a recent resurgence of this ritual, and orthodox Jewish couples almost universally follow the practice.
Since the fertile window begins prior to ovulation and extends up to 24 hours (or less) past ovulation, infertility can result if couples are only permitted to have intercourse in an interval outside the fertile window.
As a physician, it is improper to impose one’s personal value on a patient's religious belief. It is, therefore, not proper to advise the patient to adopt more lenient practices. Our responsibility is to work within the system.
There are several endocrinological manipulations that the reproductive specialist can try to help the patient overcome this “religious” rather than “medical” cause of infertility. Treating with progesterone may lengthen the luteal phase, but does nothing to help the problem of ovulating prior to mikvah. The goal is to either shorten the duration of bleeding, if the bleeding lasts more than five days, or to delay ovulation if it occurs before the mikvah. One important consideration when a patient bleeds for more than five days is to rule out an anatomic source of bleeding such as a fibroid or polyp. Although many diagnostic tools are available, a hysterosonogram is the least intrusive way to examine the endometrial cavity. Furthermore, the myometrium can also be examined with this methodology.
Once anatomic abnormalities have been eliminated, endocrinologic manipulation is appropriate. My first line of treatment is estrogen for seven days beginning on the third day of menses. I like to follow patients with a sonogram on the day they go to the mikvah to be sure that the goal of delaying ovulation has been achieved. A more aggressive tactic is clomiphene on days three through seven with similar sonographic monitoring. Clomiphene carries a higher risk of multiple pregnancies and the risk of an antiestrogen effect on the mucous and endometrium. Some physicians are using letrozole instead of clomiphene, but you should be aware that this is an off label usage that is not supported by the manufacturer. A theoretical advantage of letrozole is that it does not bind the estrogen receptor and therefore may have less of an antagonist effect.
In all cases where a woman with normal ovulations undergoes hormonal manipulation of her cycle, it is important to be sure that the intervention is not adversely affecting the cycle. I like to start with blood work on day three, a sonogram on the day of mikvah, and to check the luteal phase progesterone. If several attempts of this treatment are unsuccessful a more thorough search for male factor and anatomic disease is warranted.