Dear Tahareinu friends,
Shvat is here!
It’s a time of renewal. Blossoming. Hope.
Those are the feelings of this month, and those are the feelings we hope to offer every hopeful caller to Tahareinu.
We know you share those sentiments – as evidenced by your enthusiastic participation in our recent campaign.
Thank you. For your enthusiastic support, and for sharing our vision for Building Families, Fulfilling Dreams.
This month, we are pleased to present a comprehensive outline that should be in the arsenal of every young couple, as well as anyone associated with them.
It includes all the basic information regarding achieving Tahara and pregnancy.
Read it and empower yourself and others with this vital knowledge.
Thank you,
Rabbi Yitzchok Melber
THE ESSENTIAL GUIDE FOR EVERY COUPLE:
ACHIEVING TAHARA AND PREGNANCY
By Rabbi Yitzchok Melber, founder of Tahareinu
Welcome to our guide for all future parents – in Shana Rishona and beyond.
After their wedding, many young couples find themselves wondering: When is the right time to begin investigating possible infertility? The question is divided into several parts:
- Do we always need to wait a full year before starting?
- Are there any signs to look out for of issues that can prevent pregnancy that we can take care of before a year?
- Is there a Halachic or Hashkafic problem to be aware of when visiting the doctor?
- What type of examinations will the doctor recommend? Are any of them subject to Halacha/Hashkafa questions?
- Is the area of Taharas Hamishpacha a cause of infertility?
With that introduction, we present practical advice for future parents – sharing your goal of holding a beautiful baby in the near future, with the least medical stress and the optimum adherence to Halacha.
NOW OR NEXT YEAR? A PRIMER
The Mitzvah of Pru U’revu is the first in the Torah – and the deepest held Jewish value. B’Chasdei Hashem, we are Zoche to live in a time when we can help couples to be Zoche to Zera Shel Kayama despite medical obstacles.
To answer a couple’s primary question, when is the right time to check things out medically, some history is important. In previous generations, the general rabbinical consensus was to wait a year or two in the absence of any known problem. From a medical perspective as well, there seemed to be no reason for a young couple to worry or investigate any potential issues, because in the case of no issues, many couples will not get pregnant for that first year.
We now know however, that there are some times that certain issues present, such as an irregular cycle or Taharas Hamishpacha problems, that should compel a couple to consult with a Posek and medical experts.
The reason for this decision is that it is certainly okay and recommended for a woman to regulate her period in order to help her get pregnant (even in Shana Rishona), especially as generally this only entails light medications and not infertility treatments.
In fact, it’s better to take care of any potential challenges as soon as possible so as not to be caught in a high-pressure situation a couple years later which will impel them to seek more aggressive infertility treatments.
We will discuss these issues at length later in this guide.
PRACTICALITY PAYS: HOW AND WHEN
In order to endeavor to prevent an irregular cycle, we first need to know: What is a regular cycle? When would a woman need to be concerned?
Monthly cycles spaced between 27 and 36 days apart are considered within normal range.
If a woman’s cycles are 24 or 25 days apart, she must reach out for help because she will not be able to get pregnant that way. (See more on this later.)
Conversely, if her cycles are 40 days apart, in many cases it will be difficult to get pregnant.
And even if she has regular cycles of 27 or 28 days, if she has a hard time performing a Hefsek Tahara before day 8 or 9, she should seek medical solutions in order to regulate her period – for the sake of both Tahara and pregnancy.
A woman who has a regular cycle every month, about 30 days apart, will have her day of ovulation 14 days before her next period. At that time, the egg is growing to the right size and emerging from the ovary into the fallopian tube, where it will remain for 24 hours.
If sperm reaches that tube in those hours, the sperm can fertilize the egg and develop a pregnancy. This is known as the window of opportunity for pregnancy.
MAXIMIZING THE NATURAL WINDOW
Realistically, there are women that don’t have an opportunity to get pregnant at all because they don’t ovulate. The main sign of this problem is an irregular cycle. If she gets her period every 2-3 months, she generally will not ovulate, making it impossible to get pregnant. According to medical research, if the cycle is more than 38 days after the previous one it is also unlikely that she is ovulating every month. If her cycle is 60 days there is almost definitely no ovulation.
Similarly, if her periods are irregular, even if she does ovulate it won’t be predictable and it will be hard to pinpoint the window of opportunity.
The chief reason women struggle with irregular cycles, skipping periods, or not ovulating is the medical condition called PCOS (polycystic ovarian syndrome). This means there is an unbalanced level of hormones in the body, which causes irregular ovulation and therefore cycle.
There are several types of PCOS. Some can be taken care of naturally, and as per the official guidelines of medical associations from 2018, any woman who is overweight should increase her exercise and incorporate lifestyle changes to lose 5% of their weight as a first-line solution.
In certain cases they will also be prescribed a medication Metformin, intended for insulin resistance, that will help them lose weight. If this is not effective, there are other medications to help those women lose weight, mainly via injections.
As of now, there is no widely-accepted medication to cure PCOS. It is currently in the research stage.
There are medical options that can help us create ovulation. The first is a medication Letrozole, the second another medication Clomid, and the third – injections. Obviously, every patient is going to need a different dosage and will need blood work and follow-up while taking medications. No one should take them without a clear medical directive and prescription from a doctor. These medications can help tremendously.
In general, before a woman takes medication she should do a hormonal profile: a blood test on day 3 of her period. This blood test includes a full panel of hormones, mainly LH, FSH, TSH, AMH, estrogen, progesterone, testosterone, prolactin. The most accurate profiles are taken only in the beginning of the month between day 2-5, day 3 being ideal.
If someone is married for a year or two and wants to know what their first step should be – this is it. Hormones need to be balanced; if they are not, there are medications available.
How to take Letrozole/Clomid:
The general protocol is to start at day 5 for 5 days and if possible 4 days later (the day after Tevila) an ultrasound should be performed to see if the body responded to the medication, how big the egg grew, and when ovulation is expected. If that is not possible, she should at least use ovulation stick tests to track ovulation.
The rule: Follow-up is always necessary with medication.
WHICH DOCTOR?
If a woman is seeking basic medication, for example to push up ovulation, she can visit any doctor.
For the hormonal profile, the blood work can be done with any family doctor.
However, treatment with medications Letrozole or Clomid should ideally be done with infertility specialists and not even her OB/GYN. This is because when the protocol is done in an infertility framework, they can do proper follow-up with an ultrasound.
However, at times when it is difficult, either financially or physically (due to travel times), people can consider treatment with their gynecologist.
SHORT CYCLES
Women who struggle with short cycles, every 21-24 days, don’t have a natural way to get pregnant because their window of opportunity will come out when she is still a Niddah.
Since the egg is not going to remain in the body more than 24 hours in general, she will miss the opportunity without intervention.
Someone who has a 28 day cycle but doesn’t make Hefsek Tahara before day 10 will also ovulate before Tevilah and can’t get pregnant.
Sometimes, the reason a woman has a short cycle is because she doesn’t ovulate because of PCOS, but sometimes it’s due to POI (Primary Ovarian Insufficiency) which needs special treatment.
In general, the solution for a short cycle is to push up ovulation by a few days. Usually a doctor will start with a low dose of estrogen for the first few days of the cycle, and in the vast majority of cases this simple medication will be enough.
The name of the medication is Esterase in the U.S. or Progynova or Estrofem in Europe. There are different protocols; the basic one published by many medical institutions is to take 4 mg for the first 3 days of the period – 2 in morning and 2 in evening. If this doesn’t work, she should try other protocols. In Tahareinu’s experience this is the most effective.
If this doesn’t work, we can add other options including Letrozole/Clomid/injections.
It is also prudent to use Vitamins for cycle regulation.
Though the success rate has not been published, Agnus cactus/Vitex have been proven to be very effective. The dosage for non-overweight women is 700 mg, 1000 mg for overweight women this is taken for a few months every day of cycle.
If a woman has tried this vitamin and it didn’t work or she’s uninterested in the natural route, she can go directly to the medical route with medications.
If someone has suspected POI, they should measure their AMH levels via blood test. Tahareinu recommends for anyone with a short cycle to do this test to rule out POI, because POI needs immediate attention and sometimes dealing with this a year or two later might be too late.
If they receive this diagnosis, they should reach out to their Posek and doctor about fertility preservation options.
In cases that women have difficulty making Hefsek on the fifth day, especially if it’s only on days 8-10, they can reach out for help and in most cases we can shorten the bleeding days – especially if there’s only light bleeding or staining on the latter days.
Sometimes, long bleeding can be because of a medical condition called endometriosis, especially if it involves terrible pain in the beginning of the period or very heavy bleeding. There are different treatments and medications for this.
Anyone who has terrible pain the day before or the first couple days of their period to the point that they cannot function normally even with painkillers, that might be a sign of endometriosis – and they must consult with an expert for treatment options.
This is not normal and no one should suffer with this.
In most cases, surgery should be avoided but she should start with light infertility treatments to help her get pregnant. She will not experience pain during pregnancy and in some cases the irritation will get lighter after having a baby.
How to solve the issue of long bleeding:
- Take bioflavonoids: 3000 mg a day from day 1 of her period until after Mikvah
- Take Advil 3 times a day for five days
- Take Lysteda for 5 days 3 times a day
In previous years, problems of ovulation before Tevila were serious because there were no medications to push up ovulation. In those days, all the Gedolei Hador and Poskim published Teshuvos on how to be Meikel. Today B”H we don’t need to use those kulos; we can be machmir to be Yotzei according to all opinions by simply taking care of the problem.
We would like to highlight that even today many doctors are aware of the need for observant women to push up ovulation but because by the non-Jews this is not a common need, the doctors are not always so forthcoming – they will recommend more aggressive infertility treatments. Of course, there’s no reason to go there if we can take care of the root of the problem as explained.
If a woman has a regular cycle and is not getting pregnant for a few months, she should be aware of the following key points:
- There is a window of opportunity for ovulation that occurs for 24 hours. Below are 3 ways to check.
- Subtract 14 days from her expected period.
- Use ovulation sticks. There are several types; some of them just check for LH hormone, 36 hours before ovulation while the newer versions also check for additional hormone, so they give an additional day or two’s notice before ovulation.
- Monitor ovulation through blood work or ultrasound.
- How to maximize the window of opportunity:
- The sperm will be active for approximately 3 days after entry; therefore, there is no need to have relations every single night during the window; every second night is recommended
- Once the ovulation sticks show that ovulation will happen in 1.5 days, it is best to have relations that night, skip one, and then another night, then skip a night, then have the next night, for a total of 3 times in 5 days.
- With blood work and ultrasound, it is a little different but they should follow the same pattern for relations.
Common question: Isn’t it better to have it every night? Although this is a debate in medicine, the research shows that there is no benefit, and some doctors say the chances are lower because the quantity and quality of sperm go down.
The success rate has been proven to increase 25% by using this method.
NORMAL OR ABNORMAL?
It is important to focus on emotional wellbeing when a woman gets her period. Over 80% of women have PMS (premenstrual syndrome) which is the catch-all name for changes in wellbeing during menstruation. These can be emotional, such as crying easily or mood swings, and also physical: headaches, cramping, and tiredness. This is a natural, normal process; however, PMS can also become more severe and reach a level that affects her and her family very strongly. This condition is called PMDD (premenstrual dysphoric disorder). PMDD sufferers can be abnormally emotional, have difficulty focusing, and find it challenging to function normally.
About 15% of women experience this, and there are natural and medical solutions. It’s important to reach out to experts and doctors who can improve her quality of life.
SUCCESS! THANK YOU.
We have no words to thank each one of you for making our Building Families, Fulfilling Dreams campaign a resounding success. Each one of you made a difference, and enable us to impact the lives of thousands. On behalf of every grateful Tahareinu caller and every desperate couple, we thank and salute you. Didn’t get a chance to donate yet? It’s not too late!
SHOVAVIM REMINDER: We are here to help
This time of year is dedicated to focusing on Taharas Hamishpacha, and many rabbis and
Kallah teachers are delivering Shiurim and refresher courses on the topic. We would like to remind you to direct anyone with questions or concerns to reach out to our hotline – because that’s why we’re here!
Call the Tahareinu Hotline!
Got a question about relieving tahara problems, infertility, reproductive health, pain or other related issues?
call the Tahareinu hotline
For ongoing infertility, recurrent pregnancy loss, or reproductive genetic issues,
you and your spouse are warmly invited to schedule an in-person, phone or Zoom consultation with our founder and president, Rabbi Yitzchok Melber.
Please send an email to rabbimelber@tahareinu.com Include your first name and location, and briefly describe your issue.
Personal consultations are for more involved reproductive issues. Note the Israel
office has reopened for in-person consultations, in line with the country’s coronavirus status.
IMPORTANT
Most Tahareinu issues are addressed by our hotline advisors, 13 hours a day, 5 days a week. If you are unsure whether to schedule a consultation, call the hotline first.