New Frontiers in Reproductive Medicine: Halakhic Perspectives

1. New Frontiers in Reproductive Medicine: Halakhic Perspectives Rabbi Edward Reichman, M.D.Professor, Emergency MedicineProfessor, Education and Bioethics Albert Einstein College of Medicine Yeshiva University

2. Jewish Fertility Organizations

5. Lecture Outline History of the Understanding of Reproduction Male Infertility Female Infertility Prenatal Testing and Genetics

6. Rabbinic Conception of Conception Creation of the First Man Creation of the Rest of Mankind תלמוד בבלי מסכת נדה דף לא עמוד א תנו רבנן: שלשה שותפין יש באדם, הקב"ה ואביו ואמו. אביו מזריע הלובן, שממנו עצמות וגידים וצפרנים, ומוח שבראשו, ולובן שבעין. אמו מזרעת אודם, שממנו עור ובשר ושערות, ושחור שבעין. והקב"ה נותן בו רוח ונשמה וקלסתר פנים, וראיית העין, ושמיעת האוזן, ודבור פה, והלוך רגלים, ובינה והשכל. וכיון שהגיע זמנו להפטר מן העולם - הקב"ה נוטל חלקו, וחלק אביו ואמו מניח לפניהם. Mark Richard Bosworth

7. Rabbinic Conception of Conception ויקרא פרק יב א( וידבר יקוק אל משה לאמר: ב( דבר אל בני ישראל לאמר אשה כי תזריע וילדה זכר וטמאה שבעת ימים כימי נדת דותה תטמא: ג( וביום השמיני ימול בשר ערלתו: רמב"ן ויקרא פרק יב ואין כוונתם שיעשה הולד מזרע האשה, כי האשה אע"פ שיש לה ביצים כביצי זכר, או שלא יעשה בהן זרע כלל, או שאין הזרע ההוא נקפא ולא עושה דבר בעובר, אבל אמרם "מזרעת", על דם הרחם שיתאסף באם ומתאחז בזרע הזכר, כי לדעתם הולד נוצר מדם הנקבה ומלובן האיש, ולשניהם יקראו זרע. וכך אמרו שלשה שותפין יש בו באדם, איש מזריע בו לובן שממנו גידים ועצמות ולובן שבעין, אשה מזרעת אודם שממנו עור ובשר ודם ושער ושחור שבעין. וגם דעת הרופאים ביצירה כך היא:

8. History ofArtificial Insemination

9. 1677 Anton von Leeuwenhoek (1632-1723) observed "animalcules" under a microscope

10. Epigenesis and Preformation

11. First Case of Artificial Insemination John Hunter -1785 John Hunter consulted on a patient who suffered from hypospadias and who was unable to impregnate his wife in the natural fashion. He suggested that the man collect his seed in a vial and inject it into his wife with a syringe, which Hunter provided. The women reportedly became pregnant a short time thereafter. John Hunter

12. 1827 Karl Ernst von Baer (1792-1876) identified the mammalian ovum; like many of his predecessors, he regarded sperm cells as parasites; named them "spermatozoa."

13. Cause of Infertility In 1873, Edward H. Clarke, an esteemed Harvard physician, claimed to have discovered the reason for 'female sterility’. The cause was the education of women, which diverted energy from the reproductive machinery to the brain. Previous to the age of eighteen or twenty, opportunity must be periodically allowed for the development of the reproductive system. If the reproductive machinery is not manufactured then, it will not be later. If it is imperfectly made then, it can only be patched up, not made perfect, afterwards. … The brain cannot take more than its share without injury to other organs.” If woman pursue higher education: “The results are monstrous brains and punybodies; abnormally active cerebration, and abnormally weak digestion; lofty aspirations and neuralgic sensations;” This leads to infertility…

14. Treatment of Infertility in the21st Century

15. Halakhic Issues in the Use of ART Does use of assisted reproductive technologies constitute a violation of the divine order? Obligation to use ART Seed procurement Paternity in Artificial Insemination Fulfillment of “be fruitful and multiply” Permissibility of donor gametes Maternity with egg donation and surrogacy

16. Male Infertility Artificial Insemination Halakhic Issues Seed Procurement Fulfillment of Pru Urvu Inheritance Paternity

17. Is supervision of the process required?

18. The Stuarts, a Dutch couple, had been trying to conceive for years. They decided to try IVF, a process in which Willem Stuart's sperm would be inserted into his wife Wilma. While the specifics are not clear, the belief is that a piece of lab equipment called a pipette had been used twice, causing another man's sperm to be mixed with Willem's. This other man was from the Dutch Antilles, it is assumed he was at the clinic the same day undergoing insemination with his partner. After some time, the Stuarts found out Wilma Stuart was pregnant with twins. In 1999, a New York woman was implanted with two embryos, one belonging to her and the other from an African American couple. Donna Fasano gave birth to twins, and subsequently the African American baby was given to his biological parents, after DNA tests were conducted

19. Black Baby Born to White Pair March 22, 2007 By T. Venezia New York Post A Park Avenue fertility clinic's blunder has left a family devastated - after a black baby was born to a Hispanic woman and her white husband, the couple charges in a lawsuit. The mistake, made during in-vitro conception, wasn't discovered until Jessica Andrews was born - and it became clear she didn't look anything like her mom, Nancy, or dad, Thomas, the suit says. The baby's complexion was much darker than that of her mom - a light-skinned native of the Dominican Republic - or dad.

20. Hashgachah Doesn’t Always HelpA Rare Case of Superfetation What Is Superfetation? California Surrogate Mother Unknowingly Gives Birth To Biological Son October 28, 2017 A surrogate in California, who gave birth to twin boys for a Chinese couple in December 2016, later learned from a DNA test that one of the twins was her biological child. In February, she was reunited with him, but not after a harrowing ordeal.

21. AID and Possible Consanguinity Igrot Moshe E.H. 1:71 Since the concern is that a child may possibly marry a paternal sibling, in theory artificial insemination with the seed of a non-Jew would be permitted. In this case, the child would be legally Jewish and would have no legal relationship to the father. As the child has no legal father it would be impossible to marry a paternal sibling, as none exists. Rabbi Moshe Feinstein 1895-1986

22. Assisted Reproduction One Sperm Donor, 150 Offspring September 5, 2011 NYT Cynthia Daily and her partner used a sperm donor to conceive a baby seven years ago, and they hoped that one day their son would get to know some of his half siblings — an extended family of sorts for modern times. So Ms. Daily searched a Web-based registry for other children fathered by the same donor and helped to create an online group to track them. Today there are 150 children, all conceived with sperm from one donor, in this group of half siblings, and more are on the way. It’s wild when we see them all together — they all look alike, said Ms. Daily, 48. Some experts are even calling attention to the increased odds of accidental incest between half sisters and half brothers, who often live close to one another. Without limits, the same donor could theoretically produce hundreds of related children. And it is even possible that accidental incest could occur among hundreds of half siblings.

24. AID and Mamzerus שו"ת אגרות משה חלק אה"ע א' סימן י באשה שזרק הרופא במעיה זרע של איש אחר אם נאסרה לבעלה, ואם יש איזה חשש בהולד א' דר"ח אדר תשכ"א. מע"כ ידידי הר' ברוך גראס שליט"א. . הנה ברור שבלא ביאת איש לא נאסרה אשה לבעלה ואיסור סוטה לבעלה הוא רק מצד איסור הביאה ולא מצד הזרע של איש אחר שיש במעיה נאם עבדיה בכמהר"ש הדאיה פרק ז' מה דין הולד הנולד מזרע אחר, אם יש בו חשש ממזרות? א( לפי מה שהעלינו בפרק הקודם, דכיון שהוא בכוונה וברצון נאסרת לבעלה, הרי מזה ימשך שגם הולד הרי הוא בבחי' ממזר, דתי' "ממזר" משמעה הפשוט הוא מום זר, ז"א דהוא נולד מזרע זר, שאינו מבעלה, ולכן כלשהאשה נטמאת ממנו, מסיבת שהוא זרע זר, הרי חל על הולד יחס מום זר

25. AI and Single Motherhood Haredi Hospital Sued for Refusing Fertility Treatments to Unmarried Woman 7 Heshvan 5778 October 26, 2017 The Lod District Court will hear a $17 million class action suit against Laniado Hospital in Netanya, on behalf of a woman who asked to receive fertility treatments and was refused on the grounds that she was not married. This is the first time an Israeli court has approved a class action against a hospital. The ruling was contrary to the position presented by the Health Ministry that Laniado is a private hospital, - it is owned by Sanz Hasidism - which provides public service, and that since the complainant had alternative options for fertility treatments in other hospitals she was not discriminated against.

26. Israeli Religious Court Declares Woman Conceived From Sperm Bank Eligible for Marriage 28 Heshvan 5778 November 16, 2017 In a revolutionary ruling, a religious court in Tzfat (Safed) has given full permission to a Jewish woman who was conceived via a donation from a sperm bank to marry without limitations. According to Jewish law, a child born to a Jewish mother is Jewish, but when the identity of the father is unknown, that throws new variables into whom that person may or may not marry. The rabbi was concerned of potential problems that could arise, such as a child whose father was a "mamzer", or incest. In this new ruling, he said his restriction was for before-the-fact (lechatchila), but if the woman already conceived through the bank, there’s room to permit. It appears the primary problem is "shetuki", when the identity of the father is unknown, which could lead to a close relative getting married. Presumably due to DNA testing, and the fact that the hospital knows the identity of the father, the court decided that wouldn't be an issue.

27. Challenges to Paternity Posthumous Paternity The Case Shaked Meiri was a 27-year old Israeli reserve soldier when he was killed in an army training accident in the Golan Heights. Meiri was a newlywed, married just three months before/ the fatal accident, and had no children with his wife, Shela. Immediately after the accident, Meiri’s widow accepted an offer by the IDF to extract sperm samples from Meiri and to preserve them for later use. Ownership of the 19 preserved samples became a point of contention between Meiri’s parents – Hadarat and Roni - and his widow. While Meiri’s widow has since remarried and had two children, the fallen soldier’s parents wished to use the samples to produce a grandchild with a surrogate mother. But Meiri’s widow refused to use them herself prior to getting remarried, and has since insisted that no one else make use of the samples.

28. Testicular Transplantation

29. Artificial Reproductive Seed

30. Reproductive Organ Transplant Wounded US veteran receives among world’s first penile transplant April 23, 2018 The Johns Hopkins reconstructive surgery team performed the world’s first extensive transplant of a penis and scrotum on a wounded soldier. “It is our hope that such a life-changing transplant will allow him to regain urinary and sexual function and lead a normal life,” said Dr. Richard Redett, an associate professor of plastic and reconstructive surgery at Johns Hopkins University School of Medicine. Potential Halakhic Issues • Requirement for milah • Risk of surgery to fulfill pru urvu • Permissibility of donation if not for pikuach nefesh • Does a transplant reverse the status of sirus?

31. Female Infertility - Maternity

32. Maternity – Legal Issues • Mitzvot • Pru urvu • Honor your mother • Pidyon haben • Personal status • Nationality • Marriagability (e.g., mamzer) • Prohibited marriages • Yibum • Family lineage (yichus) • Civil Law • Inheritance (including first born status and inheritance) • Child financial support

33. Who gets a card on Mother’s Day?

34. Jewish Personals I was Reform as an embryo, Conservative as a fetus and Orthodox from birth, seeking same

35. Rabbinic Sources Midrash of Leah and Rachel בראשית פרק ל יט(ותהר עוד לאה ותלד בן ששי ליעקב: כ( ותאמר לאה זבדני אלהים אתי זבד טוב הפעם יזבלני אישי כי ילדתי לו ששה בנים ותקרא את שמו זבלון: כא(ואחר ילדה בת ותקרא את שמה דינה: כב( ויזכר אלהים את רחל וישמע אליה אלהים ויפתח את רחמה: כג( ותהר ותלד בן ותאמר אסף אלהים את חרפתי: כד( ותקרא את שמו יוסף לאמר יסף יקוק לי בן אחר:

36. Agricultural Source – Birth Mother Talmud Bavli Sotah 43b If a young branch is grafted onto an old branch, the young one becomes subsumed into the old one and the laws of orla do not apply. תלמוד בבלי מסכת סוטה דף מג עמוד ב ילדה שסיבכה בזקינה - בטלה ילדה בזקינה ואין בה דין ערלה

37. Agricultural Sources הבאר וע"ד השאלה הביולוגית משפטית לענין ההמצאה החדשה לפקוד העקרות באופן שחותכים השלל ביצים מאשה בעלת בנים ומחברים אותו בחדרי בטן העקרה וכו' נראה לי להעיר מש"ס ב"מ ד"ק. שטף נהר זיתיו ונכנס לתוך שדה חבירו זה אומר זיתי גדלו וזה אומר ארצי גדלו יחלוקו, וא"כ ה"נ בנ"ד הוא הדין דהמשנה הנ"ל ואם כן יש לומר דיש גם להאם הראשונה טענה וחלק להילד ועל פי זה יתעורר החששית שחששו האחרונים לזה. חנוך העניך בהרב דוד זצללה"ה טשארנאטשפקי רב בק' גאלין

38. Conversion of Twins תלמוד בבלי מסכת יבמות דף צז עמוד ב ת"ש: שני אחים תאומים גרים, וכן משוחררים - לא חולצין ולא מייבמין, ואין חייבין משום אשת אח; היתה הורתן שלא בקדושה ולידתן בקדושה - לא חולצין ולא מייבמין, אבל חייבין משום אשת אח; היתה הורתן ולידתן בקדושה - הרי הן כישראל לכל דבריהן; קתני מיהת: אין חייבין משום אשת אח, חיובא ליכא,

39. Genetics is the Determinant ויקרא פרק יב א( וַיְדַבֵּר יְקֹוָק אֶל מֹשֶׁה לֵּאמֹר: ב( דַּבֵּר אֶל בְּנֵי יִשְׂרָאֵל לֵאמֹר אִשָּׁה כִּי תַזְרִיעַ וְיָלְדָה זָכָר וְטָמְאָה שִׁבְעַת יָמִים כִּימֵי נִדַּת דְּוֹתָהּ תִּטְמָא: Niddah 31a “There are three partners involved in creating a human being; G-d, the father, and the mother. The father sows the “white” seed whence are derived the bones, sinews (nerves), finger-and toe-nails, the brain inside the head, and the white of the eye. The mother sows the “red” whence are derived the skin, the flesh, the hair, and the black of the eye. G-d provides the רוח, נשמה, פנים קלסתר, the ability of the eye to see, the ability of the ear to hear, the ability of the mouth to speak, the ability of the legs to walk, understanding, and know-how.”

40. Approaches to the Definition of Maternity • No halakhic mother • Genetic mother • Birth mother • Both mothers

41. Challenges to the Definition of Maternity

42. Challenges to Genetic Position • Mitochondrial DNA transfer • Artificial reproductive Seed

44. Challenges to Gestational MotherAnimal Gestation of Human Embryos We had trouble finding a surrogate mother.

45. Ectogenesis Potential Halakhic Issues : definition of a human being, definition of maternity, prohibition of murder/abortion, pidyon haben, milah on Shabbos, epigenetics, Shabbat violation, men producing children without women, impact of multgestational pregnancies and fetal reduction, Spacing of children, nursing, ownership rights or liability in case of harm

46. Uterus Transplant Woman With Transplanted Uterus Gives Birth, the First in the U.S. DEC. 2, 2017 For the first time in the United States, a woman who had a uterus transplant has given birth. The transplants are meant to be temporary, left in place just long enough for a woman to have one or two children, and then removed so she can stop taking the immune-suppressing drugs needed to prevent organ rejection. Photo in the delivery room of first successful birth after uterus transplant (courtesy of Rabbi Dr. Avi Oppenheimer)

47. Transgender women "will soon get womb transplants" so they can have babies 2 Jul 2017 Womb transplants for transgender women who want to be mothers could be available in just a decade's time, a leading NHS doctor has said.

48. Male Breastfeeding Transgender Woman Breast-Feeds Baby After Hospital Induces Lactation FEB. 15, 2018 When a transgender woman told doctors at a hospital in New York that she wanted to breast-feed her pregnant partner’s baby, they put her on a regimen of drugs that included an anti-nausea medication licensed in Britain and Canada but banned in the United States. Within a month, according to the journal Transgender Health, the woman, 30, who was born male, was producing droplets of milk. Within three months — two weeks before the baby’s due date — she had increased her production to eight ounces of milk a day. In the end, the study showed, "she was able to achieve sufficient breast milk volume to be the sole source of nourishment for her child for six weeks," according to the journal. תלמוד בבלי מסכת שבת דף נג עמוד ב תנו רבנן: מעשה באחד שמתה אשתו והניחה בן לינק, ולא היה לו שכר מניקה ליתן, ונעשה לו נס ונפתחו לו דדין כשני דדי אשה והניק את בנו. אמר רב יוסף: בא וראה כמה גדול אדם זה, שנעשה לו נס כזה! אמר לו אביי: אדרבה, כמה גרוע אדם זה שנשתנו לו סדרי בראשית!

49. Egg Freezing

50. Indications for Egg Freezing • Egg Donation- Egg Banks • Fertility Preservation in Cancer • At Risk for Premature Menopause • If Undergoing Prophylactic Ovary Removal for BRCA Gene