Halacha and IVF

Fertility treatment comes with many questions and decisions. For those who care to follow Jewish law, there's the added element of making sure everything about the treatment follows halacha. In general, my husband and I feel confident enough in our education to make informed decisions with regard to halacha. There are times, however, that either we don't agree on an outcome or we've reached a point where we recognize that it's beyond our knowledge. At that point we ask the Rabbi for some halachic guidance.

 

In this particular case, we had two questions related to IVF that we couldn't agree on* and wanted the Rabbi's input. The two questions were: 

1. Do we need to have supervision for the embryos as is suggested by some?
2. Are we allowed to violate Shabbat for IVF treatment, specifically for the egg retrieval surgery and for shots and monitoring? 

The idea behind having a certified supervisor (aka mashgiach), according to some, is that in order to establish lineage without any doubt, some claim there needs to be a third party supervisor to watch over the eggs/embryos from the time of the egg retrieval until they are put back in at the transfer to ensure that there was no mixing up of the sperm, eggs, or embryos at any point. I was very uncomfortable with the idea of having a "supervisor" having access to the embryos. The clinic we use not only has a professional lab with trained embryologists, but they also have so many checks and balances specifically to avoid this very issue. Forget Jewish lineage issues, they are scared of malpractice lawsuits! It's in their best interests to keep everyone's reproductive material clearly labeled and not mixed up.

 

Before sharing what the Rabbi told us, let me clarify each of our positions. I didn't think there was even a question. I don't see the need for halachic supervision - I trust the clinic and mistakes can happen even with an added random person there watching (would they even know if a mistake was made?). I didn't think it was necessary. Not only is it an added cost but in my opinion it's entirely superfluous and possibly hazardous. With regard to Shabbat, I didn't think there was a question there either. Everything about the treatment is time sensitive so if the egg retrieval needs to happen on Shabbat it's not ideal but it's still going to happen. I'm not going to bust a cycle because of timing, there's just too much at stake! To make things interesting, my husband did not entirely agree with me. He found conflicting texts regarding the halachic supervision and didn't know who believe. In addition, it didn't sit right with him to violate the laws of Shabbat for something that is not technically life threatening.

 

For the sake of shalom bayit, we agreed to look into it. Specifically, I agreed to bend just enough to hear more information. I was vehemently against having a halachic supervisor or postponing for Shabbat. While I was confident in my position, I didn't want to have issues in the future (someone second guessing my child's heritage?) and I was willing to admit that there's a very small chance I was wrong and didn't want to deal with the repercussions for our future kids if that was the case. Mainly because we had the time (this conversation was sparked shortly after our last failed cycle so there was plenty of time to wait for the new year and new insurance to kick in), we agreed to look into it so we can have more information. I contacted an organization in New York to ask questions about the halachic supervision. They were unable to answer any of my questions. In fact, they were surprised I even had questions - they were ready to take my credit card. I was very unhappy with the conversations I had with multiple people there. This organization inspired zero confidence and I was completely turned off by them. Then I took a step back and made an appointment with the Rabbi - let's see if this was even necessary.

 

The meeting with the Rabbi was brief. I shared our questions and the Rabbi asked two follow up questions: where our treatment will be taking place and whether we already have children. His answer to our first question was that no halachic supervision is necessary. The reasoning he gave was that it was a trusted clinic with advanced technology which makes an added person unnecessary. He said that halachic supervision is something that is done in Israel but many poskim have ruled that it is not necessary in the USA.

As for the second question about Shabbat, the answer was simply that if it was possible to work it out that the retrieval will be on any other day then that is preferable. If it absolutely has to be on Shabbat, then it's preferable to stay nearby and walk to the clinic or have a non-Jew drive us there/back so that we ourselves are not violating any of the Shabbat prohibitions. Long story short, it is permissible to have treatment on Shabbat. When I asked the part about it not being pikuach nefesh, the Rabbi said that there is leniency with regard to laws that are derabanan vs those that are d'orita, especially since we don't have children yet and this is to fulfill the mitzvah of p'ru u'rvu. In other words, we can have things done on our behalf as long as we're not violating Shabbat ourselves. With regard to shots and monitoring, it was the same idea: preferable to work around Shabbat if possible, and if it needs to be on Shabbat that it's preferable to have someone else do it for you.

 

Both my husband and I are satisfied with these answers. I'm also happy with the outcome - not only did we look into it but basically nothing is different. Actually, one thing was different: the Rabbi gave us a blessing that the treatment should be successful :)

 

*For the record, our first two cycles did not have supervision and luckily the ERs did not end up on Shabbat. Once we got the second negative beta we did more research and came across the supervision issue which is what sparked the conversations.

Updates

It's only been ten days since the last post but I'm happy to report that there are a few new things that have happened since (progress!): 

• Timeline - I started my CD1 and reported it to my nurse who was able to  give me a timeline for our treatment.  It looks like my baseline is scheduled for 2/9 with an estimated ER on 2/26. It would have worked out a lot better schedule-wise if the ER was during President's Day weekend, but I'm happy to get a date and get started. 
• Insurance - My new benefits have been verified at the clinic - yay!  Finally. It took 3 weeks for that info to come in. Now that it's in, they can submit for authorization for an IVF cycle which may take another two weeks. Still... progress!  
• Medication - Since my benefits were verified I was able to go ahead and schedule a delivery for the fertility medication. We had to work around the epic Blizzard 2016 and the delivery came today.
• Halachic all-clear - We were able to schedule an appointment with the Rabbi which I will elaborate more on in another post. We had specific questions which we needed answered before a cycle started and today we got our answers. This was an ongoing conversation my husband and I have discussed almost daily and finally having a resolution puts the issue to rest and gives peace of mind. 

Even though the current schedule puts a transfer later than I wanted, I'm still glad we're moving forward. I'm praying for a successful cycle with embryos to transfer and not a repeat of disastrous IVF #2 where none of the embryos were viable. Late is still better than nothing, so I'll take it, and if it works the extra 6 weeks won't matter in the long run. 

Waiting

My insurance changed on January 1 and we are still waiting for them to approve the IVF cycle. While I'm waiting for that I'm waiting to hear back from the pharmacy regarding the medication. The wait is part of the package of fertility treatment.

There's waiting in every part of it. Wait for your period, then wait for several weeks on BC pills, then go through stims and wait every day for the nurse to call with the results -- is the number high enough? Am I responding well? Is there progress?  Then there's a flurry of activity where you go through the trigger shot and egg retrieval, but then there's the wait every day to find out which eggs fertilized, which ones made it to day 3, then day 5.  For us there's an added wait to hear back the results of the PGD testing and that adds another ten days of waiting.

Because of the PGD we can't do immediate transfers so we have to wait two weeks for the next period to come and then start another few weeks on BC pills for an FET. The worst is the official two week wait (aka 2WW) after the transfer. You know there's nothing you can do. After the whirlwind of activity it's truly a hellish wait and the hormones really don't help things. The last two times the 2WW resulted in the dreaded negative betas. As hard as the 2WW was, it was also frustrating to know that the entire cycle needed to be repeated and I was as far away from starting the process as possible.

A positive beta, as exciting as it seems, doesn't guarantee a baby. There's still 9 months to get through starting with a second beta, ultrasound at 6 weeks, and lots and lots of PIO shots besides for the regular OB/Gyn visits. I assume... I haven't gotten to that point yet.

By my estimates we can't get started until February. Two weeks of stims puts the ER around President's Day weekend and the transfer the end of March.  It seems like so long. I have to learn to see it as a time investment instead of a waste of time. I also have to remind myself to not hold myself back from doing other things in the meantime. I have to do other things with the time other than wait, so I am working on the following:

• Home projects: redecorate the living room, basement, or bedroom (still need to pick one)
• Eat better: reduce take out, be mindful of portions, add veg and fruit to daily menu
• Move more: exercise is important and I have a hard time getting motivated in the cold 
• Plan a trip: my birthday is coming up and we're planning a short getaway 
• Learn a new skill: currently attempting to learn Spanish

Not only will these projects make the time more meaningful but it will hopefully make it go by faster. 

There are so many times you have to wait for your body to get to where it needs to be that it's frustrating to have to wait for insurance. I know I am lucky that insurance covers a part of it, but at the same time I want to move on... I want a big family - so let's get this started!!!!

Leaning In

I agree with Sheryl Sandberg's message in her book, Lean In, where she encourages women to make their voices heard in the workplace. Having women in leadership roles is good for everyone, including the bottom line. I easily give advice to coworkers and friends about career choices when it comes to work-life balance. When it comes to making decisions for my own path, I hesitate, overthink, and freeze in place.

When I graduated with my MBA I had not much else than a degree and good grades.  My work experiences in the field were slim and I took the first job offered. After a while, and through various poor company choices, that job ended when the company folded and I was unemployed for a short time before landing my current gig at entry level. I developed the position and with it came yearly salary increases, but I've stalled and started considering my options.

There are so many good things about my job and I am grateful to be employed. There is schedule flexibility, copious time off, great supervisor and coworkers, predictable schedule, short commute... the list goes on. The issue is that I am bored. BORED. It doesn't seem like a reason to leave, and on its own it may not be. The daily downtime gets to me. I am severely overqualified for my job that honestly any competent college grad can accomplish. I know I can get a new job elsewhere, but here are my issues. 

Paid Time Off

My current schedule flexibility is a big deal and so is the excess time off for legal and Jewish holidays.  I have been at my current position for several years and they know me so I don't have to prove anything, whereas if I go to a new job I need to start from scratch and work extra hard to prove myself.  I know I'm not at my best when I'm hopped up on hormones, let alone adding hours to make point. 

Salary

The current salary is ok, not amazing. It's good enough and I'm ok with that, but I know there is a lot of earning potential if I switch jobs.  For instance, I am on track to receive 2-3% raises yearly, unless something spectacular and surprising happens. If I switch to a new job, I can request a 20% hike or more as a starting negotiation.  The thing is there are some perks that money can't buy. 

FMLA

If I switch jobs and then get pregnant, I will not be eligible for the Family Medical Leave Act because you have to have been at your job for a year before that kicks in. That means that when I go on maternity leave they don't have to save my job for me and I may lose the job before I even get a chance to prove myself. The other part of my brain says that there's no baby yet, and even if I start interviewing tomorrow there's still 9 months before a baby is even an issue.  

Timing

On one hand, now may be the perfect time to make a transition -- before we get into treatment again for the 2016 year (waiting for insurance), before there's maternity leave, before there's an infant at home to care for.  On the other hand, I don't want to add any extra stress to an already stressful situation of fertility care. 

I have this conversation with myself (and lucky family members) every few months and the answer is always the same: better to stay put. First, we maxed out fertility benefits on my husband's insurance and recently switched over to mine. I want to use that benefit to its max before moving on, keeping in mind that some time in the future either he or I will have to get new insurance depending on how many cycles we do and how many succeed. Second, as much as I think I would want a stimulating job, I know if I'm honest with myself I don't want to deal with new responsibilities as I'm trying to get pregnant. If I need the distraction I can start a new hobby or add hours to Netflix, but trying to mix a new job and treatment just seems like such a terrible idea.  

I don't want to look back with regrets. Hindsight is 20/20 but at this point I can only decide based on the facts in front of me. I may regret not making a career move, but I will never regret giving treatment the best shot possible. With that in mind, the choice to stay put becomes clear. I can, and probably will, revisit this conversation again in a few months.

Best case scenario

It's hard to explain to someone what it feels like when a transfer doesn't work. An embryo isn't a baby, and yet you put all your hopes and dreams into a tiny basket and wish for the best. The doctors tell you to act pregnant and cut down on alcohol and deli, "because you might be!"  So when the beta comes back at zero or a number close to it, it's not like you were pregnant and you lost it -- you were never pregnant.  How can you be sad for losing something you never had?

I believe the two week wait has a lot to do with it. After the transfer they cut you loose with many thoughts to keep you company for the next two weeks. Those weeks are maddening!  A person can go nuts grinding those what if's over and over again in their mind. Staying positive means being hopeful and it's impossible not to imagine and day dream the best case scenario.

I compare it to playing the lottery. You know the odds and yet just playing is enough to let your wildest dreams run free -- pay off debt, live a life of luxury, help the family, fund a charity, travel the world -- the options are endless! Your dreams will come true if only this works.

Here's to many dreams coming true in 2016.

Circle of friends

In an earlier post I started talking about the importance of a strong support system. Sometimes I struggle with who I want to be surrounded by. I've categorized three groups of people in my support network: Cheerleaders, Clueless, and Knowers.

The Cheerleaders are the small group of family and select friends who know we are going through fertility treatment. They listen to our struggle and offer comfort and encouragement. While they share our sadness at the disappointments and our hopes for the future, they aren't fully aware of exactly what happens with each cycle. They mean well when making suggestions which are sometimes unrealistic or irrelevant. They are a necessary backbone of the support network.

The Clueless are people who have no idea we are going through fertility treatment. As far as they know we just decided not to have kids. These are the random acquaintances, neighbors, shul goers, coworkers, etc. While fertility treatment is all-encompassing, sometimes it's nice to remember your life includes more than that so occasionally it's refreshing to hang out around them and be just normal adults. Often, some thoughtless remark come up such as, "You're so lucky you don't have to deal with homework or bedtime, grr what a nightmare!" but considering they don't know it can't really be held against them.

Then there are the Knowers.  These are the people who know the daily struggle of fertility treatment. They are the ones who understand the heart-crushing feeling of a negative beta, they know the disappointment of a failed cycle. They get it because they've been through it. Our current support circle doesn't include anyone like that in real life, only the connections I've made online. I hesitate to reach out to anyone because of how sensitive this is. I'm certainly not going to go up to someone in the clinic waiting room and ask if they want to be fertility besties, so for now I'm finding comfort in
the vast online group of people who share their stories.  For the record, anyone who wishes to connect, whether fertility related or otherwise, is free to email me at jewishivf@gmail.com.

So back to my struggle about who to be around... Sometimes I feel like people around me can be so insensitive.  They complain about the hard transition it took from one baby to two. They say how tired they are from staying up with a barfing kid. They share their struggle to pay the tuition bills. I understand that these are all real struggles for them. I get that they have their own issues. But sometimes I wish they didn't complain so much about their kids who came seemingly so easily. The friend who complains about her accidental third pregnancy when her other two are still under 5 years old is facing a real challenge - that's a lot of babies!  But it's a challenge millions of infertile women would give anything to face.

Then I consider spending time with members of the Cheerleaders group and sometimes it helps that they know but other times I just want to be regular. I don't want to feel pitied. I don't want to be excluded from things out of an abundance of sensitivity. I had really close friends that I didn't see often wait until second or third trimesters to tell me they're expecting, and it was more hurtful that they waited -- I hated being the last to know. I know the Cheerleaders mean well but sometimes it's exhausting being around them too.

I consider what it would be like to hang out with Knowers. It would be so easy to speak the lingo and not have to explain the terminology like what monitoring means or that the ultrasounds they do aren't on your belly. Instead of a horrified look, Knowers would nod knowingly at the ridiculous size of the PIO needles. But what happens if I find a Knower bestie and then either she or I get pregnant and leaves the other behind? What if we both get pregnant and one miscarries? How could a relationship sustain that? It's bad enough when it happens to you; it's almost as bad watching a friend go through it also and the heartache seems so overwhelming.

It's hard to explain to people how I want them to act when I myself don't have the answer. Yes, I want you to be sensitive but also don't leave me out. I want you to feel comfortable talking about what regular friends talk about but also don't mention anything that has to do with 98% of your life. People who have gone through fertility treatment know the triggers and know when to be sensitive but it's unrealistic to expect that same level of treatment from the general public.

We have a hard time letting people in as it is and this isolates us even more. It feels safer to just be alone and carefully protect an already sore heart.

Starting out

When I first started treatment I was sure that it would work. I had so much confidence in the science and technology and felt lucky to be able to afford the care. I started out not telling anyone, not keeping a journal, not spending any time building a support system because I was sure I wouldn't be in the pre-parenthood stage for long. It was just my husband, me, and our clinic.

Two IVF cycles and two FETs later, I am not so sure anymore. Medically they say everything looks fine. According to the docs, it's about a numbers game and the more often we try the more likely it will happen. Not only has my confidence in the medicine wavered, but it also reaffirms that no matter how technologically advanced we have become there is still a point where nature has to take over, and that is entirely up to Him.

As we prepare to start a third IVF cycle, mentally and financially, I realize how important it is to have a strong support system. We told our parents after the first negative beta when the sadness was so overwhelming and I couldn't even begin to pretend to act normal. The rest of the family found out before we started the second cycle. They were there for us when we got our second negative beta, possibly even more devastating than the first.

I also came across several IVF blogs online and found comfort in the knowledge that there are others who understand the daily struggle. There were a few blogs from frum families who stopped blogging as soon as they were blessed with children, but their words are still published and helpful. While there are many different blogs, I didn't find many authored by Orthodox Jewish couples. I decided to share my experiences in the hopes that it may help someone else going down a similar path, and possibly connect with other couples going through similar challenges.