Family Planning - Choosing a Method


Family Planning - Choosing a Method

Overview

Once a couple have halachic permission to use contraception, they should work together with their rabbi and physician to choose the most appropriate method. A couple cannot simply learn from the experience of others, or even from their own experience at a different stage of life. Both medical and halachic factors need to be considered to answer the following questions:

Is the method halachically permissible? Some methods are halachically preferable to others, and some are not permitted. The permissibility of a given method may depend on the couple's individual circumstances, and on the rabbi's halachic approach.

Is the method safe? Safety is an important halachic concern. A woman should discuss with her physician which methods are safe for her to use.

Is the method effective? If it is essential to avoid pregnancy, a very reliable method should be chosen. If pregnancy would not be disastrous, a couple may opt for a more convenient method that is somewhat less dependable.

Are there halachically significant side effects? Some contraceptive methods may cause bleeding or spotting. Physicians should be aware of the problems this can present for couples. Couples using such methods should be prepared for a difficult beginning (spotting often subsides after a few cycles), and should be familiar with the laws of stains.

General Halachic Principles

 

Hotza'at Zera L'vatalah

Purposeful emission of semen without the ability to enter a woman's body is prohibited as hotza'at zera l'vatalah, generally translated as wasting of seed. The condom is therefore prohibited by all authorities, as the semen is completely blocked from entering the wife's body. While in certain circumstances, a condom may be used for semen collection as part of an attempt to allow the couple to fulfill the commandment to procreate, it is not an acceptable method of contraception except in very extenuating circumstances. Other barrier methods (e.g., the diaphragm and sponge) that allow entry of the semen into the wife's body but not progression through the cervix, are a matter of debate. Some authorities also consider this a prohibited form of emission, but others permit it because the semen does enter the vaginal canal. Allowing marital relations to take place as "naturally" as possible is also a consideration; thus, some weight is placed on whether the husband is physically aware of the barrier device or not.

Sterilization

Another halachic concern with contraception is the prohibition against sterilization. Leviticus 22:24 prohibits the sacrifice of an animal whose genitalia have been damaged, and goes on to prohibit inflicting such damage. The Shuchan Aruch Even HaEzer 5:11 explicitly prohibits the sterilization of men and animals. According to most opinions, sterilization (sirus) is a Torah prohibition for men and a rabbinic prohibition for women.

This prohibition applies, according most opinions, to a permanent and stable condition and not to a temporary state. Vasectomy and tubal ligation are permanent forms of birth control and thus raise serious problems of sirus. Vasectomy is not a halachically accepted form of birth control and tubal ligation ("tying the tubes") is permitted only under very extenuating circumstances. (Now that these procedures can sometimes be reversed, although with variable success, there are those who are somewhat more lenient.)

References on Sterilization

Weinreb Shaul. Tubal Ligation and the Prohibition of Sirus. Journal of Halacha & Contemporary Society - XL; Fall 2000, Sukkot 5761.

Ozarowski JS, Tubal Ligation and Jewish Law: an Overview. Journal of Halacha and Contemporary Society (1984) 7.

Malach Daniel. Ikkur Chatzotzrot. Sefer Assia 8, 1995. 121-149.

 

Choosing a Contraceptive Method

 

Hormonal Contraception

When medicinal methods of contraception are used, hormonal regulation is usually the halachic first choice, as it is temporary and presents no physical barriers to intercourse. However, some rabbis hesitate to recommend this method due to health concerns. With the modern low-dose estrogen preparations available, the risks for most women are negligible. Some women, however, have medical conditions (liver disease, high blood pressure, clotting problems) that preclude using hormones. All women should be seen by a physician and undergo an appropriate history and physical exam before beginning hormonal contraception.

There are two categories of hormonal contraception. Combinations of estrogen and progesterone are given for a fixed time and then interrupted to allow for shedding of the uterine lining to take place. These are currently available in pill, patch and ring form. Progesterone-only formulations are available in oral form ("the mini pill," taken daily) or as injections (Depo provera, administered every three months). Progesterone-only formulations are favored by some physicians for use while breastfeeding, as they are reported to have less effect on milk production.

It should be noted that hormonal contraception can cause spotting for some women. Therefore, it is not appropriate for all couples. 10 - 30% of women will have spotting the first month of taking combination pills - the lower the estrogen concentration the greater the chance of such spotting. With the progesterone preparations, 40 - 70% of women will have some spotting the first month of use. For many women, spotting improves by the second or third cycle of use. Couples using either of these methods need to be prepared for a difficult beginning and should be fully familiar with the laws of stains (ketamim). Caution should be used in deciding to use long term methods such as Depo provera because if there is a spotting problem, it can not be reversed for a prolonged period of time.

Intrauterine Device

The intrauterine device (IUD) is a small, plastic device, sometimes coated with copper, that is inserted deep into the uterus in order to prevent pregnancy. Because it allows for completely natural relations, it is generally considered the halachic second choice method of birth control.

It is not entirely clear how the IUD prevents pregnancy. Because there is a possibility that it prevents the fertilized egg from implanting in the uterus, some rabbis prohibit its use. Many rabbis, however, permit the IUD because it may interfere with fertilization rather than implantation, and because even abortion at such an early stage is less halachically problematic. (For continued debate, see: Katan Yoel and Katan Chana, Chashash Hapalah B'Ikvot Hetken Toch Rachmi v'Shimush Biglulot Etzel Nashim Mevugarot. Assia 65-66, Elul 5759.)

There are two classes of IUD - those that are copper only and those that secrete progesterone. The first class is quite likely to cause spotting, at least for the first few months of use. It also tends to lead to longer menses. The progesterone IUD (Mirena) can cause extensive spotting for up to about half a year and then often leads to amenorrhea (lack of menses). Couples using either of these methods need to be prepared for a difficult beginning and should be fully familiar with the laws of stains (ketamim).

There were cases of death associated with the use of one brand of IUD (the Dalkon Shield) in the United States during the 1970s. This has not been reported with currently available devices, but the IUD remains less popular in North America than in Europe and Israel. The main concern with this method is a fear of increasing pelvic inflammatory disease, which can lead to sterility. Thus, some physicians will only use it in women who already have their desired number of children. For monogamous women the danger from this method is slight. Nevertheless, since preserving health is a serious concern in Jewish law, some rabbis do not recommend this method.

Barrier Methods

Barrier methods raise the issue of hotzaat zera l'vatalah. Condoms, which are used by men, are seen as a clear example of this prohibition and thus they are not permitted except in very dire circumstances. The female condom is also quite problematic as it clearly prevents progress of the sperm into any part of the vaginal canal.

Barriers that are inserted more deeply, such as the diaphragm or cervical cap, allow more room for leniency. Some authorities permit these methods only when other methods are not possible and when there is a clear medical need for contraception. Other authorities consider the diaphragm or cervical cap to be preferable to hormonal methods that are likely to cause staining (e.g., the Progesterone-only pill, Mirena).

Spermicides

Spermicides, although they kill sperm, are not considered "wasting sperm" and do not interfere with natural relations. Therefore, most halachic authorities permit the use of spermicides where contraception is permitted. However, their use alone without a diaphragm is not a very effective method of birth control (about 85%) and thus not helpful in cases where pregnancy must be avoided. They are sometimes useful as backup method for women who are otherwise unlikely to get pregnant (e.g., breastfeeding women) or for whom a pregnancy would not be catastrophic.

Lactational Amenorrhea Method

One method of birth control that presents no halachic problems at all is the lactational amenorrhea method (LAM). This method takes advantage of the fact that breastfeeding women generally do not ovulate for some time after giving birth. It works for women who are within six months postpartum, have not resumed menses, and are exclusively or almost exclusively breastfeeding. If all three conditions are met, LAM can be over 99% effective. LAM has been proven effective in multiple clinical trials worldwide including in developed countries, and has the added health benefits that are accrued to mother and infant by breastfeeding. Halacha encourages breastfeeding for at least two years, without concern about the potential reduction in fecundity at this time. As lack of ovulation is a natural process postpartum, no specific permission is needed to use this method.

Natural Family Planning

LAM is not to be confused with natural family planning (NFP) in which marital relations are limited to times of reduced fertility. As purposeful abstinence is a form of contraception, rabbinic approval is required for this method. It is often hard for the mikveh observant couple to implement as it requires even further minimization of the days in which relations are permitted.

Emergency Contraception

Post-coital contraceptives ("the morning after pill") are high dose hormones taken within three days after relations when another birth control method failed or was not used. This method is not medically recommended for routine contraception.

The hormones work by disrupting the menstrual cycle. Depending when in the cycle they are taken, they may prevent ovulation, fertilization, or implantation. These mechanisms have different halachic implications: preventing ovulation is the least problematic, preventing implantation of a fertilized embryo is the most problematic. The insertion of an IUD, which may also prevent implantation, is an alternative form of emergency contraception.

In practice, emergency contraception is generally required in extenuating circumstances and will be permitted in most such cases.

Most rabbis permit use of emergency contraception after a case of sexual assault. Questions about emergency contraception should be asked quickly, since this method is most effective when used within 72 hours of relations.

Other Methods

Since the obligation to be fruitful and multiply is incumbent by Torah law on the man, methods that involve the husband are more problematic. An oral contraceptive used by men (not yet on the market, but currently undergoing clinical testing) would thus be more problematic than an oral contraceptive used by women (Rav Aviner. Sefer Assia Vol 4 p 171 1983).

 

Users of Internet filtering services: This site discusses sensitive subjects that some services filter without visual indication. A page that appears 100% complete might actually be missing critical Jewish-law or medical information. To ensure that you view the pages accurately, ask the filtering service to whitelist all pages under yoatzot.org.

All health and health-related information contained within Nishmat's Women's Health & Halacha Web site is intended to be general in nature and should not be used as a substitute for consulting with your health care professional. The advice is intended to offer a basis for individuals to discuss their medical condition with their health care provider but not individual advice. Although every effort is made to ensure that the material within Nishmat's Women's Health & Halacha Web site is accurate and timely, it is provided for the convenience of the Web site user but should not be considered official. Advice for actual medical practice should be obtained from a licensed health care professional.