The Isolation of Infertility- CJN’s top pick for favourite cover stories

FEATURE: HALACHAH CAN COMPLICATE INFERTILITY TREATMENT

Religious and medical experts get creative in an attempt to find a happy medium between science and Jewish law.

For Orthodox Jews, keeping the laws of niddah (the menstrual period) is a sacred, holy practice between married couples that prohibits them from touching during menstruation and the days after, until she dunks in a mikvah, a ritual bath.

For a woman who has regular menstrual cycles, in the days following niddah, she is at her peak of fertility. But for women who don’t have regular cycles, who may ovulate earlier in their cycle, the practice of niddah – which keeps couples apart for the five days during menstruation, and an additional seven days until they visit a mikvah – can render them “halachically infertile.”

Dr. Clifford Librach, director of Toronto’s Create Fertility Centre, said he has had hundreds of Orthodox Jewish clients over the years who have come to him with this issue and others.

“There is a lot of pressure on Jewish couples. They want, especially the Orthodox, to fulfil the mitzvah of having children, so in our culture, just like many other cultures, having children is critically important to people when they get married and have families,” he said.



“But in the Orthodox group, going to the mikvah can have its pros and cons. If a woman… has short cycles, and during her fertile time, she’s not able to be with her husband… sometimes they have to try to manipulate the cycle using hormonal medication so that when she is fertile, that’s the time they can be together.”

Rabbi Yoseph Oziel, spiritual leader of Toronto’s Petah Tikva Anshe Castilla Congregation, offers moral support and guidance to couples struggling with infertility. He said he doesn’t think halachic infertility is as much of an issue today.

“We live in a time and a day when Halachah and science can work very much in harmony,” Rabbi Oziel said. “I’ve never yet encountered a situation where, because of a couple’s adherence to Halachah, they were sentenced to not being able to have children. It’s never happened.”

At Small Wonders, a Toronto-based non-profit organization that helps Jewish couples cope with infertility through financial, emotional, medical and halachic support, clients have access to rabbis who work with the organization to guide Orthodox couples.

“The couple will always consult with a doctor, and the doctor will tell the rabbi what the issue is. They will work together to see how it could possibly work. It doesn’t always work, but there is a lot of medicine that can tweak, let’s say, ovulation for a different day or something like that,” said Denise Levin, the couples director at Small Wonders.

She said the rabbis will not advise a client to forgo the rules of niddah, but will work around it instead.

“No one is making any kind of [decision] that if it doesn’t work, you can try [to conceive] five days earlier – we don’t do that… and we don’t want people to get the wrong impression,” Levin said.

Beyond the timing of a woman’s ovulation, another challenge posed by Jewish law is the process of testing a man’s semen.

“What the rabbis say is that having relations has to be an act that could result in pregnancy. Masturbation is not allowed,” Librach explained. “With sperm testing, we can do one of two things. We can look at sperm in the mucous of the cervix to see if [the sperm is] moving. The other thing we can do, when it is allowed, is to get a special condom we have that isn’t latex, because latex kills the sperm.

“So what they do is that they poke a pinhole in the condom so one or two sperm could get through and then we can collect the condom and get the sample.”

Librach said many rabbis will recommend testing the female for reproductive abnormalities first, but not the male.

“This goes against the medical advice. Just because there is a problem with the female, it doesn’t mean there isn’t also a problem with the male,” he said.

“There are a lot of things that get in the way. Some rabbis are strict about, if you have kids already, whether you can carry on with more advanced treatments, because they feel like you’ve already had children. If you have no children, they may be more liberal versus if you already have children.”

Librach, who said he is open to talking to clients’ rabbis about their medical issues, said many rabbis are “quite knowledgeable,” but suggested couples do their research about a rabbi who deals with infertility “because apparently, once you get advice, you can’t really go rabbi shopping” for another opinion.

But once a couple is ready to undergo treatment, Librach said there are many techniques to help a couple conceive.

The clinic has a new type of incubator, called an embryo scope.

“It’s a technology from Denmark where you can take a picture of the embryo over a period of time… every 20 minutes. It makes a time-lapse video movie of the embryo.”

Using that technology, doctors can better identify which of the embryos are likely to implant and produce a baby.

“An embryo should normally go one cell, two cells, four cells, eight cells and so on, but if an embryo goes from one cell to three cells, that is not a good sign. If that happens in the middle of the night, no one is there to see that. But this technology allows us to see it the entire time,” Librach explained.

He said in the year since his clinic began using that technology, the success rate has jumped by 25 to 30 per cent.

Another technique they use is called pre-implantation genetic screening.

“We can now test an embryo before it goes in the uterus to see if it is normal or abnormal… This is a way of preventing miscarriage or a child with handicap,” he said, adding that Create is the only clinic that does the testing in-house.

Medical treatments and moral support aside, Rabbi Oziel said when couples go through infertility, it is important to have faith.

“From a religious perspective, philosophically speaking, I find that sometimes… when a couple is going through infertility challenges, they have to know that most of the time there is a light at the end of the tunnel and that when the child finally comes, it sort of erases the past and the difficulties,” he said. “One needs to be positive.

“The second thing is we believe that things like the miracle of creating life are not entirely in the hands of daddy and mommy. God plays a role… Couples have to be prepared to care for the child when they have the child – there is a reason why some couples aren’t able to conceive right away… Timing is very important in life.”

Librach recommended an organization based in New York and Israel for couples seeking rabbinical support.

He said the Puah Institute is “one of the most knowledgeable groups that specializes in fertility and helping couples who are Orthodox with Halachah issues with fertility.

“I recommend that if you have a rabbi you want to confer with, any help is amazing. Because it is very stressful and anything that can keep your stress level down, rabbinical help or counsellors, friends and family – they can be really supportive.”

http://health.gov.on.ca/en/public/programs/ivf/

Ontario’s Fertility Program

Ontario’s new Fertility Program provides funding to help eligible Ontarians build their families at 50 fertility clinics across the province.

Who can join the program

If you are trying to start or expand a family, you may be eligible to receive government-funded fertility treatments. The program is available to eligible Ontarians of any sex, gender, sexual orientation or family status.

What is infertility?

A common definition of infertility is not being able to become pregnant through intercourse after 12 months of trying, or experiencing repeated miscarriages after becoming pregnant.

While single people or people in same-sex partnerships may not be medically infertile, they may use fertility treatments in order to build their families.

Age is the single most important factor affecting infertility. Female fertility starts to decline at age 30, and starts to rapidly decline at age 35. Male fertility begins to decline around age 40 and the risk of birth defects doubles.

Eligibility for fertility treatments

  • You must be an Ontario resident with a valid OHIP card to be eligible for any of the fertility treatments under the program.
  • For the one-time cycle per lifetime for in vitro fertilization, women under the age 43, after speaking to their health care provider to determine if IVF is the most appropriate family-building option for them, are eligible.
  • To be eligible for government-funded fertility preservation (i.e. freezing of eggs), you must also have a medical reason.
    • For example, patients undergoing cancer treatment may be at risk of infertility in connection with their treatments.

Types of fertility treatments

The program offers the following fertility treatments:

  1. Artificial insemination (AI) is a medical procedure used to transfer sperm into the vagina or cervix.
  2. Intra-uterine insemination (IUI) is a type of AI where sperm is directly injected into the uterus with a catheter. The egg is fertilized inside the body.
  3. In vitro fertilization (IVF) is a complex medical procedure where an egg is retrieved and then fertilized by sperm outside the body.  The resulting embryo is then transferred to the uterus for implantation.
  4. Fertility preservation (FP) involves the freezing of sperm or egg samples to be used later in either AI or IVF for patients, who are preparing to undergo treatment that may lead to infertility.

What the program covers

The Fertility Program covers:

  • Artificial insemination (AI), including intra-uterine insemination (IUI)
  • One in vitro fertilization (IVF) cycle per eligible patient per lifetime, including:
    • The one-at-a-time transfer of all viable embryos to allow for the possibility of multiple chances for pregnancy
    • One additional funded IVF cycle, if acting as a surrogate. This can occur either before or after receiving a funded IVF cycle for the purpose of building your own family
  • One fertility preservation (FP) cycle, including sperm and egg freezing for medical reasons, per eligible patient per lifetime.

The program provides over 10,000 patients with AI and IUI services every year.
It also provides over 5,000 patients annually with IVF and FP services.

Ontario is removing IVF as an insured service under OHIP, and is instead funding it through contracts with 50 fertility clinicsin the province.

How to take part in this program

You can directly contact one of the 50 fertility clinics in the province offering funded services.  However, you are encouraged to speak with your health care provider first to determine if the Fertility Program is an appropriate family-building option for you.

What is not covered under this program

Ontario pays for the costs of AI, including IUI, IVF and FP treatments, but does not cover the cost of fertility drugs. You would still need to cover these drug costs yourself.

The approximate drug costs are:

  • $1,000 per cycle of AI
  • $5,000 per cycle of IVF

Some private health plans may cover some of these drug costs.

You would also have to pay for the cost of any other associated services, such as genetic testing, and the storing of sperm, eggs, and embryos.

Wait lists

Fertility clinics are responsible for managing wait times, as they already do, using the physician’s best clinical judgement.

The Ontario government will be monitoring the wait lists across the 50 eligible clinics. Clinics will be required to report regularly to the government on the success of the program, including wait list volumes.

Safety and oversight

To establish a stronger quality and safety framework for the fertility services sector, the government is working with the College of Physicians and Surgeons of Ontario (CPSO) to ensure the highest-quality fertility services.

Quality assurance in hospital-based fertility clinics will continue to be managed through the Public Hospitals Act.

Recommended for you

Read the Advisory Process for Infertility Services – Key Recommendations Report

For more information about pregnancy, birth and childhood in the province of Ontario, check out bornontario.ca

http://news.recombine.com/2015/12/15/infertile-womans-guide-holidays/

Change the XMAS holiday to any of ours- say Rosh Hashana, Sukkot, Chanukah, Purim, and Passover.

 

Every holiday season for the last five years my heart has told my head that this time next year everything would be different. An extra person would be added to our Christmas card photo. An extra stocking hung by the fireplace. An extra reason to smile and give thanks. But as “this time next year” rolls around and nothing is different, and everything remains the same, my heart hurts more. My empty womb aches deeper. Because for the last five years my Christmas list has only consisted of one wish: A baby.

Thanksgiving and Christmas are some of the hardest holidays for those who long to grow their family but can’t. And it’s not because they are bitter or angry, but because it reminds them of loss. The loss of the family they once hoped to have by now. The loss of the child they thought would be in their arms. The loss of a million dreams they had been dreaming since they were little. And all of these losses hurt. They cause hopelessness and fear.

If you are feeling the painful emotions that often come with infertility during this holiday season, I want you to keep allowing your heart to tell your head that “this time next year “ things can be different. Allow yourself to keep believing that at a moment’s notice your circumstances can change. Doors can open. And the sorrow you feel now, will be replaced with joy later. But until then–until you are hanging an extra Christmas stocking on the fireplace mantle–here are a few tips I hope will help you not only survive the holidays, but thrive in them.

 Just Say No

Make it a habit to just say no this holiday season to those triggers that will destroy your joy, steal your peace and ultimately drag you down into a pit of bitterness and despair. This might mean saying no to certain social engagements, or going to the mall. It might mean saying no to logging into your Facebook or Instagram account. It might mean saying no to holding your sister’s baby or attending the children’s Christmas program at church. And those holiday cards with the cute family’s decked out in their color coordinated outfits that make you smile, yet at the same time cause your soul to cave? It’s okay to set them aside and look at them later when you are ready. Even if “later” means waiting until January…or even Easter…

Don’t go into hiding—at least not completely.

I know what some of you might be thinking…if you can just close the curtains and hide underneath the covers until after the holidays are over, then all will be okay. But trust me, it won’t work. Isolating yourself completelyfrom those you love and who have loved you since you were in diapers will only cause you to dwell on what you are missing and focus on what you don’t have. But with that being said, know that it is okay to revert back to #1 and just say no to those holiday invitations. Because there will be days when you will not be able to handle seeing babies, children and pregnant women. Or be able to deal with the well intention inquiries about when you are going to start your own family. Or cope with the loss you might have just experienced. However, if by some chance you can’t decline the invitation, set boundaries and have an exit plan in place before arriving. For instance, possibly go to the family gathering late if you know children will be opening their presents first. Or maybe make arrangements to leave early before you get too overwhelmed with your emotions.

Be prepared

Be prepared for nosey questions. Be prepared for unsolicited advice. And be prepared for the surprise pregnancy announcements. Because THEY. WILL. HAPPEN. Aunt Judy will ask you when you are going to have a baby and Uncle Matt will yell from the living room that you are not getting any younger. And before you know it, your extremely fertile cousin will start telling you to “just relax” while your sister will jump up from her seat to“make an announcement.” And if you are not prepared, things could get ugly. And fast.

Therefore before you attend your next social gathering, prepare a short and simple answer to their nosey questions…“when we have news to share we will let you know.” Or my personal favorite, “We are trying and having lots of fun doing it (then end it with a wink)”And just in case your cousin does give you advice you have heard a million times over, go ahead and smile and try to keep in mind how it was offered. Chances are they just want to help. And for the surprise bun in the oven? Don’t forget to handle yourself with grace as you quietly use your emergency exit plan to the bathroom. Because while you are happy for them, sometimes you just can’t hold back the tears. And it’s okay. It doesn’t make you a horrible person. It just makes you human.

Don’t wait to start your holiday bucket list

We all have it. It’s a bucket list of everything we will do when we have children, am I right? We may even say,“Someday, when I have children…” and then rattle off all the fun holiday traditions we hope to one day fulfill… Elf on the Shelf, baking Christmas cookies to take to the neighbors, or putting out carrots for the reindeer… but don’t! Nothing kills joy faster than wishing for something other than what you have. Instead, invent traditions you can enjoy with your spouse now. Because whether you believe it or not, you two are already a family. Besides, who says you need to wait until you have children before you can do Elf on the Shelf? I don’t see it in the rule book anywhere. So go ahead! Buy the Elf and take turns moving it around the house with your husband. I did this a couple of years ago with mine and the laughs we both had are now some of my favorite memories with him.

Sock someone with kindness

Anytime I want to get out of my Grinch-like mood, I do something to bless someone else. Why? Because it works. One of my new favorite traditions with my husband is to buy Christmas stockings and place candy and $5 gift cards inside with a note pinned to the top that says, “You’ve been socked!” It’s so much fun trying to tie one to a friend or family member’s front door before getting caught. And sometimes, if I am feeling really brave, I’ll tie one to the door handle of a car parked at Target or the mall. Talk about an adrenaline rush! (You can read more about this idea here.) But if this isn’t your thing, perhaps you can do one (or more) of the following:

  • Bless an unfortunate child placed in foster care
  • Visit a nursing home (holidays are lonely and heartbreaking for them also)
  • Invite your friends over for pizza and a board game (If they have kids, pay for their babysitter)
  • Have a gingerbread-making contest with your nieces and nephews while their parents go Christmas shopping
  • Bring gifts to a children’s hospital and read Christmas stories to them

Write it out

Over the course of my journey through infertility, I have found writing to be a surprising outlet. It helps me process my thoughts, vent my frustrations, and express my emotions. And sometimes it has even helped me work through and solve my problems. So go grab a pen and a cute notebook and when a particular event causes your heart to ache or your blood pressure to rise, write about it. It’s so good for the soul.

I realize that no matter if you follow one or all five of these tips, there will come a day when the tears will flow, your womb will ache, and all you can do is say “Bah humbug.” Know that this is not only okay, but normal. Coping with infertility is difficult. So give yourself the gift of grace. You are not a bad person if you need to cry in the bathroom at a social gathering or pass on holding your cousin’s baby. You are not weak if you spend an entire day on the couch in your pajamas, eating a pint of ice cream, and a large pizza. You are human, with real emotions. But with that being said, don’t get stuck in your emotions. Don’t camp out on the couch of despair, or you might miss the moments of beauty…the moments of laughter…and the moments of love this holiday season can bring you.

 

When a picture is worth a million words- Sher Clinic

A single photo has captured the truth behind fertility struggles, alongside the beauty of what is possible with in vitro fertilization.
Sher Institutes, a network of fertility clinics, posted a photo on Facebook of a baby surrounded by syringes in the shape of a heart on Oct. 5. “Wow, what a photo. Thank you to Sher Fertility St. Louis and Dr. Dayal patient Angela, who shows the true definition of love that went into making this gorgeous new baby girl,” the caption read.

http://haveababy.com/fertility-information/ivf-authority/when-a-picture-is-worth-2-million-words

Ontario Approves New Pregnancy Loss Support and Awareness Bill

Ontario’s new pregnancy loss awareness bill is considered the first of its kind in North America.

Bill 141, also known as “The Pregnancy and Infant Loss Awareness, Research, and Care Act, 2015,” received all party support at Queen’s Park on Tuesday.

From now on, October 15th will be known as ‘Pregnancy and Infant Loss Awareness Day’ in the province of Ontario.

The law will also increase funding for research into the causes of stillbirths and pregnancy loss, improve access to counselling, and expand programs for high-risk pregnancies.

Some hospitals in the province have perinatal programs to help women cope with pregnancy loss, but in many cases they aren’t referred until they’ve lost three pregnancies. That creates gaps in treatment, testing, research and mental health support.

Eglinton-Lawrence MPP Mike Colle tells AM980 why he introduced the private member’s bill.

“It came as a result of my daughter losing three babies, and that’s when I got to meet some of her friends that were going through the same trauma of infant loss and they basically wanted something done about this huge gap in our healthcare system so that’s where it got started,” said Colle.

About 37,000 soon-to-be parents lose their baby along the way each year in Ontario, and roughly one in four women will lose a pregnancy in her lifetime. Many of them struggle with a system that often lacks support and training, as well as families, friends and even health care providers who are unsure of how to assist them. Their grief can be worsened by a lack of answers.

Colle wants to eliminate the ‘veil of silence’ surrounding pregnancy loss.

“It’s something that really hurts the healing process,” he said. “These Moms have nobody to talk to, I mean even their families sometimes won’t even talk to them, and everyone is supposed to essentially be quiet about it, meanwhile you’re going through that serious grief, talk about postpartum depression and all these issues and your health is affected, so we have to start talking about it.”

During the debate at Queen’s Park on Tuesday, MPPs said they were overwhelmed by the number of women and men who wrote them, urging the bill’s passage.

“As Ontario’s leading organization for pregnancy and infant loss for the past 25 years, we believe that this is precedent-setting legislation that we hope will spark other provinces across the country to quickly follow, this is a healthcare issue affecting hundreds of thousands of families and healthcare professionals across Canada,” said Michelle La Fontaine, bereaved mother and president, board of directors for the Pregnancy and Infant Loss (PAIL) Network.

The bill creates new duties for the health ministry to increase support for research and care, but the final version of the bill is far less explicit than the original. The first version called for comprehensive analysis of the issue, in-depth research, new programs and a comparison of best practices with other jurisdictions.

Ontario Announces 50 Clinics Offering Government-Funded Fertility Treatments

December 21, 2015 11:00 A.M.Ministry of Health and Long-Term Care
50 clinics across the province will now be offering government-funded fertility treatments.

Starting today, Ontario is making fertility treatments more accessible by contributing to the cost of one in vitro fertilization (IVF) cycle per eligible patient per lifetime. This funding will help support over 5,000 Ontarians per year who are trying to start or expand a family.

It is estimated that one in six Ontario couples is affected by infertility at some point in their lives.

The province is also working with the College of Physicians and Surgeons of Ontario to ensure that patients receive the highest quality fertility services, whether services are received in a hospital or in a non-hospital fertility clinic.

Who is Eligible

Patients with medical issues causing infertility as well as patients with non-medical forms of infertility, such as single people or same-sex couples, are eligible under the new Fertility Program.

Women under the age of 43, after speaking to their health care provider to determine if IVF is the most appropriate family-building option for them, will be eligible for IVF funding.

What is Covered

Ontario will fund one cycle of IVF and unlimited rounds of artificial insemination for eligible people at fertility clinics across the province.

One cycle of IVF includes one egg retrieval, which may yield multiple eggs and result in multiple embryos. The program will also cover the cost of the one-at-a-time transfer of all viable embryos to allow for the possibility of multiple chances for pregnancy and to reduce the occurrence of higher-risk multiple births.

Patients or their private health plans will be required to pay for some supporting services such as fertility-related drugs and storage of embryos.

The government will continue to work with the fertility implementation advisory working group to monitor the success of the new Fertility Program. The province will be in regular contact with participating clinics to examine wait lists and other issues related to implementation. Further details on eligibility and coverage are available on the Fertility Program website.

Expanding access to fertility services is part of the government’s plan to build a better Ontario through its Patients First: Action Plan for Health Care, which is providing patients with faster access to the right care, better home and community care, the information they need to stay healthy and a health care system that’s sustainable for generations to come.

Quick Facts
IVF is a complex medical procedure where an egg is retrieved and then fertilized by sperm outside the body, and the resulting embryo is then transferred to the uterus for implantation.
In October 2015, Ontario announced it is investing $50 million a year to expand access to IVF treatments, in addition to the $20 million per year currently spent on IVF and other assisted reproduction services under OHIP.
Ontario worked together with an implementation advisory working group of physicians and clinic owners to effectively and thoughtfully implement Ontario’s new Fertility Program.
Age is the single most important factor affecting fertility Female fertility starts to decline at age 30, and starts to rapidly decline at age 35. Male fertility begins to decline around age 40, and the risk of birth defects doubles.
Ontario is also helping to grow families by strengthening the adoption system to help more children and youth find forever homes, and to help more families care for their adopted children and youth.
Additional Resources
Ontario’s Fertility Program
Frequently asked questions about Ontario’s Fertility Program