EAGO Newsletter

INFERTILITY EVALUATION AND TREATMENT ACCORDING TO JEWISH LAW
By Joseph G Schenker, MD

Introduction
Religion and science have been interrelated since the beginning of human history. The most striking change in the last two decades has been the secularisation of bioethics. The identifiable religious influence on bioethics subsequently seemed to decline. The field of bioethics has moved from one dominated by religion and medical tradition to one now increasingly shaped by philosophical, social and legal concepts.

Religious groups still exert influence on the civil authorities in the field of reproduction, such as prevention or procreation, and in issues such as abortion and infertility therapy. Recent developments in the science and technology of reproduction raise new religious questions which do not always have clear answers. The role of theology in bioethics is to clarify for the different religious communities their attitude to the new developments in the new field of reproduction.

Since religious groups have been active in pressing their bioethical concepts on the public in different parts of the world, it is of importance that those who practise assisted reproduction learn about the religious attitudes related to the problem of infertility and its therapeutic approach.
Jewish law
The Jewish religion is characterised by a strict association between faith and practical religious rulings. In principle, the Jewish law is a compound of two divisions: a written law and the oral law. The foundation of the written law is the Torah - the first five books of the scripture, which are the origin of authority. It is an expression of God's revelation, teaching and guidance of man. The Torah unites the whole of divine text, which includes moral values as well as practical laws. The oral laws interpret and elucidate the written Torah and regulate new rules and customs. Its authority is derived from the "Written Torah".
The dominant parts of the oral law are:

a) Mishnah:

An early textbook of the Jewish oral law, which was compiled systematically by numerous scholars over a period of a few centuries. Its final form was established early in the third century. The Mishnah includes early traditional interpretation of the Written Torah, original interpretation of the Written Torah, ancient regulations that are not written in the Torah and post Bible regulations.

b) Talmud:

During approximately three centuries after the final compilation of the Mishnah, the great interpreters studied the six orders of the Mishnah and wrote a monumental composition called Talmud. The great interpreters (Amoraim) included in the Talmud commentaries and interpretative studies of Mishnah and Midrashim, and established regulations and new customs.

c) Post-Talmudic Codes:

After the compilation of the Talmud, an enormous amount of Talmudic knowledge was essential for efficient ruling. These Post-Talmudic codes came to the world with the intention of assisting access to the laws, regulations and customs of the Talmudic Halakha. Different scholars until the 16th century have summarised and reviewed the Halakhic conclusions of the Talmud in the Post-Talmudic Codes. Among the scholars were Rashi (1040-1105), Rabbi Moshe Ben Nachman (1195-1270), Rabbi Manachem Ben Shlomo Hameiri (1249-1316).
The most prominent Post-Talmudic Codes are:

She'ltot - Rav Akhai Ga'on, Babylonia
680 - 752 A.D.
Halakhot - Rabbi Ytzhak Alfasi, North Africa - Spain
1013 - 1103 A.D.
Maimonides - Rabbi Moshe Ben-Maimon, Spain - Egypt
1138 - 1205 A.D.
Piskey Harosh - Rabbi Asher Ashkenazi, Germany - Spain
1250 - 1300 A.D.
Shulkhan Arukh - Rabbi Yosef Karo, Israel
1488 - 1575 A.D.
d) Responsa:
The various attitudes of Rabbinical scholars, to the way religion should be applied in the changing world, is analysed and discussed with regard to the legal codes and written opinion given by qualified authorities to questions or aspects of Jewish law. Responsa is the term usually confined to written replies given to questions on all aspects of Jewish law by qualified authorities from the time of the later Geonim to the present day. About one thousand volumes, containing more than half a million separate Responsa have appeared in print. Rabbinical scholars in recent times have dealt with new problems that have risen with the investigation and treatment of infertility. Thus, as new a technique as artificial insemination and in vitro fertilisation in human beings is already the subject of numerous Responsa. Moreover, the Responsa of later Rabbinical authorities are often short monographs in which every text remotely relevant to the point at issue is quoted and discussed.

The Jewish attitude to infertility is based on the fact that the first Commandment from God to Adam which was "Be fruitful and multiply". This is expressed in a Talmudic saying from the second century which says: "Any man who has no children is considered a dead man". This attitude arises from the Bible itself and refers to the words of Rachel, who was barren "Give me children or else I die".
Procreation
A Rabbinic disagreement in the Mishnah deals with the problem of how many children are required for the divine command of procreation to be fulfilled. The School of Shammai claimed that two sons are acceptable as an accomplishment of the command, while the School of Hillel insisted that one son and one daughter are essential for accomplishment of the command. The School of Shammai cited Moses with his two sons as a proper model, while the School of Hillel turned to God's creation of the world, with Adam and Eve as the proper model.

As in most cases, the Talmudic preference is for the School of Hillel.

A person who accomplishes the basic commandment of procreation, though he is not committed by the Torah to continue procreating, is still obligated to be married and not live in celibacy.

The Mishnah brings another interesting controversy: does the commandment of procreation rest equally upon males and females, or is it an exclusive obligation of males, whilst the female, who bears all the medical risks of childbearing, is not committed?
Marriage
In Judaism marriage is a combination of a religious and a legal act between a man and his chosen mate. By this act the couple commit themselves to their mutual duties and create between them a religious binding relationship in marriage which also affects others.

To get married is a Mitzvah (religious duty) affirmed by all Codes of Jewish Law. Marriage is considered to be one of the most useful means of preventing sexual sins, as well as the proper way to fulfil God's commandment "Be fruitful and multiply". The duty to marry and procreate is independent of social status or religious position. Moses and other Biblical heroes got married and had children. At the Temple, the High Priest was not allowed to serve on the Day of Atonement unless he was married.
Marital sex
Sex is part of human life. The Jewish law, intending to cover all aspects of human life, contains discussions and regulations dealing with normal and abnormal sexual life. The Jewish approach to sex was always free, healthy and lacking frustration. The Jewish law recognises the sexual desire. Therefore, the complete abstinence of a married couple is against the attitude of the Jewish law. Each of the married partners has conjugal duties toward the other. The husband has a duty to please his wife. Her conjugal rights are based on Mitzvat Onah, which is one of the three elementary duties of the husband: supporting his wife with food, clothing and conjugation. The desired frequency depends on the man's occupation and his style of life.
Evaluation of the infertile couple
According to Jewish law, the infertile couple should be diagnosed and treated as a single unit. The medical treatment is different for men and women. When evaluating an infertile couple, one should first evaluate the female partner. If pathology is not found, one may proceed to investigate the male. The male factors that should be evaluated are inadequate or abnormal sperm production, ejaculation or deposition of spermatozoa.

According to the Jewish law, the preferred method of seminal fluid analysis should be the post-coital test, which is based on examination of motile sperm in a mucus sample collected several hours after coitus. If the results are inconclusive or abnormal (repeated several times), ejaculate should be collected following coitus interruptus, using a special condom. Examination of the semen for infertility investigations is not included in the prohibition "spilling one's seed" and if all the methods mentioned above are not possible because of mechanical or emotional problems, some rabbis permit the collection of an ejaculate by masturbation.

The halakhot (religious laws) surrounding a woman's menstrual cycle are important to our discussion as they govern the normal sexual life of a religiously committed Jewish couple. An understanding of these basic concepts is indispensable to the professional managing fertility therapy for a devout couple.
The laws of Niddah
A menstruating woman is called Niddah in the Bible, and in the Talmudic and post Talmudic literature. As long as a woman is within the status of Niddah, sexual contact with her is forbidden.

The Bible distinguishes between Niddah - menorrhea (the uterine bleeding occurring at the regular intervals of menstruation) and Zavah - metrorrhagia (the uterine bleeding occurring completely irregularly). In the case of Niddah, the duration of menstrual prohibition is seven days (even if the bleeding is of much shorter duration), and a ritual bath - Mikveh is required to change her status back to the regular permissible status. In the case of Zavah, the ritual bath - Mikveh is required only after a period of seven entirely "clean" days (Shivaah Nekiyim).

The laws concerning Niddah comprise some of the most fundamental principles of the Halakhic system, and the historical development of the relevant tracts through the centuries is likewise extremely complicated. A concise summary of the contemporary Halakhic rules concerning the Niddah is given below:

Practically, there is no distinction between Niddah and Zavah.
Cohabitation is forbidden from the beginning of uterine bleeding until after seven clean days, followed by a ritual bath (Mikveh immersing).
A brief uterine bleeding requires a minimum of five days after which the seven "clean" days begin.
Postpartum bleeding is subjected to the same rules.

This substantial family law is discussed in the Mishnah, the Talmud, the post Talmudic codes and extensively in the Responsa literature.

A unique Halakhic issue is the "virginal blood". Principally, virginal blood is ritually pure and should not generate any prohibition, in distinction from menstrual blood. Yet, the early Talmudic literature regulates that the couple has to keep apart from each other, in a way similar but not identical, to the laws of Niddah.

In practice, any minute amount of bleeding - with or without any associated sensation and regardless of the timing of such bleeding - invokes the stringencies of both Niddah and Zavah. In addition, all bleeding must cease before observing a required interval of seven clean days. The woman goes to the Mikveh on the evening of the seventh clean day (days begin and end at sunset, not sunrise) and is then permitted to have intimate relations with her husband. This halakha applies to spotting as well. Furthermore, any amount of bleeding or spotting during the seven clean days cancels this sequence retroactively, thus requiring a new seven-day series.

The Talmud and Shulhan Arukh rule that bleeding from a wound or lesion does not render the woman Niddah, even if the wound is in the uterine lining itself.

While traumatic bleeding may not create a state of Niddah, it is still significant for a woman beginning the sequence of seven clean days. All bleeding must cease prior to seven days to enable the woman to realistically and accurately perform internal examinations.

Mid-cycle bleeding and continuous bleeding are related to the problem of Niddah, which can be solved by using different agents for induction of ovulation.
Artificial homologous insemination (AIH)
There is near unanimity of opinion that the use of semen from the husband is permissible if no other method is possible for the wife to become pregnant. However, certain qualifications exist. There must have been a reasonable period of waiting since marriage (two, five, or ten years or until medical proof of the absolute necessity for AIH), and, according to many authorities, the insemination may not be performed during the wife's period of ritual impurity.

It is allowed by most rabbis to obtain sperm from the husband both for analysis and for insemination, but difference of opinion exists as to the method to be used in its procurement. Masturbation should be avoided if at all possible, and coitus interruptus or the use of a condom seem to be preferred methods.

Since many important legal and moral considerations which cannot be enunciated in the presentation of general principles may weigh heavily upon the verdict in any given situation, it seems advisable to submit each individual case to rabbinic judgements, which, in turn, will be based upon expert medical advice and other prevailing circumstances.
Sperm donation
The practice of artificial donor insemination (AID) is not morally accepted by all infertile couples or their physician, and it is not accepted by most rabbinical authorities. For many centuries rabbis have been discussing the principles involved in artificial insemination from a donor. The discussions are based on ancient sources in the Talmud and the Codes of Jewish Law. From the fifth century Talmudic passages show that procreation without intercourse had been recognised as possible by the sages of old - for example the Midrashic legend of Ben-Sira's birth.

The legend is that the prophet Jermiah went to the bath house where his semen entered the bath water, soon after, Jermiah's daughter came and had a bath and became pregnant by her father - resulting in the birth of Ben Sira, recognised as a legitimate child. The legend has since been quoted many times in medical literature and in rabbinical Responsa dealing with AID. Some rabbinical scholars deny the legend of Ben Sira's birth as having followed a conception sine concubito.

Another ancient source indicating the possibility of conception without sexual intercourse is mentioned by Rabbi Elishah of Corbell in his work Hagahot Semak in the thirteenth century: "A woman may lie on her husband's sheets but should be careful not to lie on a sheet upon which another man has slept lest she becomes impregnated by his semen".

In the modern era, rabbinical authorities have focused on two issues: is it permissible, according to Jewish law, to perform AID, or is the very act a transgression to adultery? What is the status of the AID offspring?

All Jewish legal experts agree that AID using the semen of a Jewish donor is forbidden. It is the severity of the prohibition that is debatable. The question is whether AID constitutes adultery, which is strictly forbidden by the Torah, or whether the injunction stems from other sources - mainly the legal complications of the birth of an AID offspring - as most of the experts hold. Some rabbinical authorities permit AID when the donor is a non-Jew. This eliminates some of the legal complications related to the personal status of the offspring. If the semen donor is a gentile, the child is pagan (blemished); if the child is a female, she is forbidden to marry a cohen (priest).

AID, according to the Jewish law, is prohibited for a variety of reasons: incest, lack of genealogy, and the problem of inheritance. Semen donors for AID, as well as the physicians who use the semen, are violating the severe prohibition against masturbation.

Some Halakhic authorities prohibited a married woman who underwent the procedure of AID to continue to live with her husband. However, most rabbis state that without intercourse being involved, the woman is not guilty of adultery and is not prohibited to cohabit with her husband. If the woman undergoes AID without her husband's knowledge and consent, she must accept a divorce and forfeit any rights to financial support, including her Ketubah and alimony. AID may not be used to fulfil the requirement of levirate (the obligation a man has to marry his deceased brother's wife). The child conceived through AID is considered by many rabbinical scholars as having the status of Mamzer - bastard. The mark of bastardy severely limits the offspring's prospects of marriage in keeping with Jewish law, and this implies a severe functional handicap from a social point of view. Some rabbis consider the offspring to be legitimate, as Ben Sira was considered, while others consider it as safek mamzer.

There are various views regarding the legal relationship that exists between the semen donor and the child born as a result of AID. Some rule that no relationship exists; others that the child is considered the donor's child with all the legal complications like incest, inheritance, levirate marriage, custody etc. The majority opinion is that the donor has not fulfilled the Mitzvah (obligation) of procreation by fathering an AID child. The practice of AID is accepted by part of the Jewish population in Israel, and according to the regulations of the Ministry of Health, this procedure is allowed under special regulations.

Although it is difficult to see fertilisation with donor sperm as an act of adultery, there may still be a legal prohibition against IVF of an oocyte with donor sperm. This prohibition does not affect an unmarried woman as long as the possibility of bastardy is excluded. Those scholars who oppose the IVF procedure, claiming that there is no parental relationship in IVF and embryo transfer (ET) procedures, may give an advantage to the offspring resulting from the use of donor sperm and the IVF technology. If there is no kinship, the offspring cannot be regarded as the product of an unacceptable genetic union, and is thus at least as good for society as the offspring of a non-Jew and can marry a Jewess. In this case, the paternity of the non-Jewish genetic father is not recognised, while the status of the offspring is that of an ordinary Jew almost without exception.
In vitro Fertilisation (IVF)
The practice of IVF and ET, and especially its future potential applications, creates legal and religious problems which have special problems with regard to implementation of this procedure in different societies, and especially in Israel, a country where jurisdiction in matters of personal status is governed by the religious, as well as the civil authorities.

The various aspects of the "test tube baby" are of considerable interest in the rabbinical literature - Responsa. The basic fact which allows IVF and ET to be considered in the rabbinical literature at all is that the oocyte and the sperm originate from the wife and husband, respectively. The attitude favoured by the Jewish religious authorities with regard to IVF and ET is based on the commandment of procreation in the Bible.

What are some of the delineating factors which would nevertheless withhold Jewish law from proceeding with IVF/ET? Some of the rabbis take a strict position and suggest that the legal and biological ties are severed with the removal of the egg. Since the host environment is sustained by medical intervention, using different culture media, this might change the biological and legal status of the child. From the Jewish religious point of view, the Chief Rabbis of Israel, one of the Ashkenazi sector (European origin) and one of the Sepharadic sector (Oriental origin), support IVF and ET procedures. Jews living outside Israel are generally subjected to the laws of the country in which they live, except in cases where they wish or are required to obey the Jewish traditional personal regulations. In such cases, the rules applicable in the State of Israel will also be applied by local rabbinical authorities, when such exist and are recognised.

In Israel, special juridical problems have arisen from the powers vested in rabbinical courts in matters of personal status. Although general laws in Israel are secularly legislated by the Knesset (Israeli parliament), matters concerning marriage, divorce, paternity, legitimacy and bastardy are adjudicated according to Jewish law as determined by the rabbinical courts, which follow the orthodox interpretation of Halakhah. Since the rabbinical courts in Israel must recognise the legitimacy of the child's birth, the legal status of a child born through IVF and ET must be determined by them.

Jewish law places limits on semen collection, management of menstrual problems, and homologous and heterologous insemination. These factors are considered when IVF and ET are undertaken.

The collection of semen can present problems because of the prohibition against masturbation and "seed wasting". Masturbation is strictly condemned by the rabbinical sources: "Thou should not commit adultery, neither by hand, nor by foot". Coitus interruptus, or withdrawal, and the use of condoms are generally prohibited on the basis of the Biblical injunction against "spilling of the seed needlessly". However, for fertility analysis, many rabbinical authorities permit the collection of semen either by coitus interruptus or in a perforated condom. If a condom is used to obtain semen for IVF, it must be of the type that will not damage sperm vitality. On the other hand, intercourse before oocyte aspiration or immediately afterwards could affect the success rate of embryo transfer.

In some cases, using the natural cycles or the induced cycles for preparing the patient for aspiration of the preovulatory oocyte may interfere with the Niddah state.

Up to now some thousands of Jewish children have been born as a result of IVF procedures in Israel, many of them to very religious couples.
Oocyte donation
In the case of egg donation or embryo donation, the problem arises: who should be considered the mother, the donor of the oocyte or the one in whose uterus the embryo develops, the one that gives birth? In a case where one of the women is Jewish and the other is not, the religious status of the child is determined by its mother. This interesting subject has an apparent precedent in the literature. According to ancient tradition found in the Talmud and Midrashim, Dinah, the daughter of Leah and Jacob, was first conceived in Rachel's womb. But in the end they were exchanged so that the male embryo which was in Leah's womb was removed and implanted in that of Rachel and the female embryo was removed from Rachel's womb and implanted in Leah's. The result was that Leah gave birth to a daughter called Dinah and Rachel gave birth to a son called Joseph. This description is based on a Talmudic writing. Through the Bible, Dinah is considered the daughter of Leah and Joseph the son of Rachel.

Contrary to the Talmudic interpretation, in Jewish law the father of a child resulting from AID is the sperm donor. With regard to motherhood in the case of ovum donation or embryo donation, there is a divisible partnership - ownership of the egg and the environment in which the embryo is conceived. Jewish law states that the child is related to the one who finished its formation - the one who gave birth. A judgement is found in the Mishnah that a person who starts an action but does not complete it and another person comes along and completes it, the one who completed the action is considered to have done all of it. Nevertheless, in spite of the sources mentioned above, it is difficult to rely on them in giving a final determination as to the maternity and Jewishness of the child.

A solution can be found elsewhere. The religious law decrees that only the offspring of a Jewish mother may be regarded as a Jew. But who is the mother in a situation where woman A is implanted with an ovum retrieved from woman B and then carries the pregnancy to term and gives birth to a child? If one adopts the position that, for purposes of lineage, the gestational-carrier woman rather than the ovum donor is the mother (although the latter is certainly the genetic parent), a position not without religious foundation, then the solution becomes obvious. The child of the (Jewish) gestational mother would be Jewish.
Cryopreservation
Cryopreservation of pre-embryos is at present frequently practised in IVF programs.

The freezing of the pre-embryo raises the basic question whether cryopreservation, which stops the development and growth of the embryo, cancels all rights of the pre-embryo's father. With regard to the mother, the problem is simplified, since the embryo is transferred into her uterus later and will renew the mother-embryo relationship. The relationship between the father, whose main function is to fertilise the oocyte in order to form the pre-embryo, and the child may be severed by the period of freezing. Freezing of sperm and pre-embryo is permitted in Judaism only when all other measures have been taken to ensure that the father's identity will not be lost.
Surrogate motherhood

Complete surrogacy
In cases of infertility due to uterine factors, when the woman is unable to carry the embryo, the ovum is fertilised with the sperm of her husband, after which it is implanted in the uterus of another woman, who gives birth as a "surrogate mother".
Partial surrogacy
Partial surrogacy is when the surrogate mother is inseminated with another woman's husband's sperm and, therefore, donates her oocyte and leases her uterus. Following birth the child is given to the infertile couple for adoption.

The Jewish religion does not forbid the practice of surrogacy. According to Jewish law, if partial surrogacy is practised - a strange woman is inseminated with the sperm of a man and she completes the pregnancy on agreement - the child born should be handed over to the owner of the sperm. In case of full surrogacy, when the embryo is transplanted into another woman, the question is not resolved, as discussed in the case of ovum donation. From the religious point of view, the child will belong to the father who gave the sperm and to the mother who gave birth.
The legal status of the pre-embryo
The legal status of the pre-embryo is difficult to establish. If one suggests it is a person, or even a potential person, it has no legal status according to the law in most countries. There is a suggestion that the embryo is property, and by this definition it offends ethical principles. The above suggestions leave open the legal question of the right to use, to dispose, to sell and to purchase an embryo. A pre-embryo or embryo seems not to be a human being for the purpose of criminal law. Deliberate destruction of a pre-embryo is not a criminal act.

Juridical protection for a pre-embryo may be difficult to achieve, except through specific legislation.

The legal status of the pre-embryo is broadly discussed in the history of our civilisation when the question of compensation for causing miscarriage is discussed. According to the Babylonic code, compensation for destruction of an embryo or fetus was paid according to the social status of the pregnant woman. According to the Old Hebrew law, the compensation was paid according to the severity of the damage. The Hites Code states that compensation should be paid according to the state of gestation.
Research on pre-embryos
The modern assisted reproductive technologies, including pre-embryo research, are presently practised by one of the following systems:

Religious regulations.
Governmental regulations.
Regulations prepared by professional bodies.
Local Helsinki committees.
Own standards.
According to our survey, research on pre-embryos is practised in only 13 countries. According to legislation in some countries like in Germany, Norway, Switzerland, Ireland and Israel, research on embryos is forbidden. The most important reports are from the following committees: The Walter Committee in Australia, The European Human Reproduction Society (ESHRE), American Fertility Society, and the European Parliament.
Clinical indications for human pre-embryo research
Benefits from human pre-embryo research can be achieved in the four major medical areas:

Infertility research - in order to improve clinical results.
Diagnosis of genetic aberrations and possible therapy.
Contraceptive research.
Therapeutic use of embryonal tissue for transplantation in life-threatening conditions.

The potential sources of pre-embryo for research are:

Existing surplus pre-embryos from IVF.
Defective IVF pre-embryos.
Aborted pre-embryos or embryos obtained by flushing methods (in induced or spontaneous abortions).
Creating pre-embryos for research.

There are differences of opinion among the various ethical committees concerning embryo research, but all of them agree that the following procedures should be forbidden:

Cloning.
Inter-species fertilisation.
Genetic manipulations.
Transfer of a human embryo into another species.
Jewish attitude to pre-embryo research
It should be permitted to create a pre-implantation embryo for fertility research if there is a real chance that the sperm owner may benefit and have a child as a result of this research. Jewish law forbids destruction and use of a pre-embryo as long as it has a potential for implantation. An in vitro blastocyst that has hatched from its zona pellucida and lost its implantation potential may be kept for research. It is prohibited to use a post-implantation pre-embryo for research, unless the research is essential to save the embryo's life. The arbitrary period of 14 days limit approved for research on pre-embryos by some ethical committees is not recognised by Jewish law.
Genetic screening
The new DNA amplification technology for IVF provides a new problem for consideration. It is now possible to identify the X or Y gene in an embryo soon after it has been fertilised in vitro and to detect early genetic anomalies.

Some genetic disorders are X- or Y- linked. Because the sex of the embryo can now be detected prior to implantation, it is possible to choose only embryos of a certain sex for implantation, guaranteeing that the embryo which develops is free of a specific sex-linked genetic disorder. Using specific gene probes, it is already possible to diagnose specific genetic disorders (as opposed to simply the sex) at an early stage.

While Halakha generally takes a conservative approach regarding abortions, many contemporary Poskim (rabbinic decisions) maintain that untransplanted embryos have no standing and may be discarded. Therefore, screening for genetic diseases is permitted.
Jewish law and abortion
An unborn fetus in Jewish law is not considered a person (Heb. Nefesh, lit. "soul") until it has been born. The fetus is regarded as a part of the mother's body and not a separate being until it begins to emerge from the womb during parturition. In fact, until forty days after conception, the fertilised egg is considered as "mere fluid". These concepts form the basis for the Jewish legal view on abortion.

Intentional abortion is not mentioned directly in the Bible, but a case of accidental abortion is discussed in Exodus 21:22-23, where Scripture states: "When men fight and one of them pushes a pregnant woman and a miscarriage results, but no other misfortune ensues, the one responsible shall be fined as the woman's husband may exact from him, the payment to be based on judges' reckoning. But if other misfortune ensues, the penalty shall be life for life".

Prior to forty days after conception, the fertilised egg is considered by some rabbinic authorities as "mere fluid". Such an early zygote has no status at all; is not a person or nefesh; is regarded as part of the mother's flesh, and aborting it is not considered legal murder.

Abortion on demand is contrary to the ethics of the Halakha; however, within Jewish law, there are many situations in which a pregnancy may be terminated. If the mother's life is in danger, each fetus is a Rodef, an aggressor who may (or must) be killed to save the individual in danger.

Most rabbis permit and even mandate abortion where the health or life of the mother is threatened. Some authorities are strict and require the mother's life to be in danger, however remote that danger, whereas others permit abortion for a serious threat to the mother's health. Abortion is prohibited for fetal or social indications.
Fetal reduction
Reduction on demand is unacceptable according to the ethics of the Halakha. If the danger is to various fetuses as in the case of multiple pregnancy, and not to the mother, each fetus is an aggressor and victim with equal status; it therefore might not be permissible to put aside one soul for the sake of another. If, however, it is absolutely certain that all fetuses would be lost unless one is forfeited, some authorities would allow fetal reduction. Some fetuses being sacrificed in an attempt to save the others.
Non-Orthodox Jews' views
Reform

Reform Judaism was introduced by German Jews in the 1830's and 1840's. Early reform Judaism was radical: it totally rejected the Orthodox view that the Bible was divinely inspired and therefore also rejected traditional practices, including the laws of Kashrut (the dietary laws) and the laws of Shabbat. All ritual incompatible with a modern way of life was abandoned and Reform's new prayer introduced a logical, humanistic type of Judaism. By the 1870's and 1880's Reform Judaism was almost synonymous with American Judaism. Immigration between 1881 and 1924 brought to America over two million Jews escaping from economic pressures and pogroms in Eastern and Central Europe. They came from countries in which Jews lived in ghettos, and this new inpouring either clung to the certainties of Orthodoxy or, at the other extreme, were idealistic socialists rejecting religion altogether. Reform once more gained ground with the children and grandchildren of these immigrants and, in the 1930's, with the refugees from Nazi Europe. By the mid 1960's it has been sensitive to a growing desire among non-Orthodox Jews for some traditional practices and, responding to this, has re-introduced ritual into the synagogue services and into home observances.

Many of the seminal changes in Reform Judaism are to do with women's participation in public worship and in religious affairs. Firstly, women are permitted to become rabbis (and half the current enrolment for rabbinic training within the Progressive movement is female). Secondly, Reform synagogues have mixed seating, as distinct from the segregation of Orthodoxy where in united synagogues women are in a gallery and in ultra-Orthodox congregations they are behind a Mechitzah (curtain). Thirdly, women in Reform Judaism can be honoured in the synagogue and called up to read from the Torah scroll. Girls have Bat-mitzvah and Batchayil ceremonies, women may wear the Tallit (prayer shawl) and be included on synagogue boards of management.

The Reform movement first considered questions of the new treatments for infertility in 1952. Its early leadership agreed that all efforts should be made to help infertile couples, in part to meet the individual's need to challenge a declining population. All of its authorities in 1952 approved of AIH, but they split over AID, although all agreed that it did not involve adultery. By the 1970's, Reform opinion had definitely accepted AID and it therefore was not troubled by the aspect of IVF or of surrogate motherhood. Also, Reform opinion had concluded that the fetuses below the age of forty days were not in any way persons and could be used for experimentation, so there should be no problems with disposing of unimplanted zygotes in IVF.

Conservative Judaism

The conservative synagogue began in 1887 as a reaction not to Orthodoxy but to Reform, which was increasingly felt to be abandoning too many of the tenets of traditional Judaism. The time of its greatest expansion was during and after the horrors of World War II, which led to many Jews wanting to re-identify with some form of religion.

From its earliest days, the conservative movement showed a willingness to respond to contemporary issues, and this attracted increasing numbers of followers, the majority of whom were not committed to the rigid observance of Halakha. They felt easier with the conservative ideology of "Tradition and change".

Committed to a more egalitarian form of worship, it gradually introduced mixed seating, mixed choirs and Bat-mitzvah ceremonies for girls.

Conservative Jewish opinion has evolved over a period of time. The Committee on Law and Standards in 1967 opposed AID for essentially the same reasons found in the Orthodox view. However, even then, leading Conservative figures were far from unanimous in that opposition. In more recent years, most Conservative leaders have come to accept the legitimacy of AID with the consent of the husband, as a final alternative when nothing else has helped. This seems to be emerging as the attitude toward IVF as well. Finally, with similar reservations, the Law Committee approved in 1985 the practice of surrogate motherhood.

At present, because of political circumstances, rigid Orthodoxy is the only form of Judaism officially recognised in Israel, for example, in solemnising marriages and in military chaplaincy. But a large part of the population is remote from formal religion, and the modernist versions have difficulty in making their message heard. On the other hand, there has been a remarkable resurgence of Orthodoxy after a long period of decline, and modernist groups are placing greater emphasis on tradition and ceremony.

Jews living outside of Israel are generally subjected to the laws of the country in which they reside, except in cases where they wish or are required to obey the Jewish traditional personal status regulations. In such cases, the rules applicable in the State of Israel will also be applied by local rabbinical authorities, when such exist and are recognised.

Since in Jewish communities, and especially in the State of Israel, religious groups have been active in pressing their bioethical concepts on public life, it is of importance to those who practise assisted reproduction to learn about the religious attitudes related to the problem of infertility and its therapeutic approach.

Joseph Schenker is the Professor and Chairman of the Department Of Obstetrics and Gynaecology, Hadassah, University Medical Centre, Jerusalem, Israel.

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