Religious Considerations While Pursuing Fertility Treatments
Dr. Michelle Goldsammler is a board-certified reproductive endocrinologist and infertility specialist and obstetrician and gynecologist. She has clinical expertise in both reproductive endocrinology as well as all aspects of fertility treatment such as IUI, IVF. Dr. Goldsammler educates her patients to empower them to be active participants on their reproductive journey.
Dr. Goldsammler holds the distinction of being the only female, orthodox reproductive endocrinologist on Long Island. Here she discusses how religious observances can be adhered to while pursuing assisted reproductive technology to build a family.
Are there many considerations that are specific to people in the Orthodox community when planning to use ART for pregnancy?
In the Orthodox Jewish population, there are definitely some considerations that are taken when discussing fertility and planning a patient or couple’s treatment plan. I have a lot of background in what is commonly referred to as family ritual purity, a set of laws that guides couples about appropriate times for sexually intimate activity. This includes rules about the mikva, the ritual bath. As REIs, we find that the timeline of when a woman is fertile sometimes conflicts with when she is allowed to be intimate with her partner based on religious law. And so, there are some women that actually have what I refer to as religious infertility and that ovulate too early to be religiously appropriate timing to be sexually intimate with their partner. And so that's one of the first things that is unique to this kind of orthodox community – that there are people that ordinarily wouldn't have had an issue getting pregnant, but because they follow these orthodox guidelines about the mikva or ritual purity, they now are unable to get pregnant because they're ovulating too early.
As a physician, what are actions you take to engage in a religious or culturally sensitive relationship with your patients?
Because I am an observant religious person in general, I found, even in the populations that I served before that aren't primarily orthodox and aren't primarily Jewish even, that I just have a sense of cultural sensitivity towards the potential religious or cultural conflicts that may show up during this process. Or that there's questions to ask, you know, with regard to people's private practice and religious or cultural practice at home that, how that may be affecting their desire to seek treatment or different types of treatment, things like that. But specifically for the Jewish population.
Tell us more about the mikva. There's a specific time when you have to go but it may coincide with an ovulation window?
Yes. There is a minimum timeline between when someone can get to the mikvah, assuming even the shortest menstrual cycle. And so, for some women that have shorter cycles that are 21, 22, 23, 24, 25 day cycles, they're going to ovulate early. They may ovulate before they can get to mikva. And so for that particular population, being sensitive and aware of that kind of concept, some people are even too afraid to mention it to their doc. They don't understand the nuances that when you're undergoing an ovulation induction cycle, taking Clomid, taking Letrozole, and your doc says, Hey, you're ready to ovulate, these couples sometimes don't even know that they should have mentioned, Hey wait, I'm not ready to go to mikvah for another two days. This isn't going to work out. I have some tricks and tips up my sleeve to delay ovulation or to kind of try to time things differently. In the past, I’ve worked with rabbinic people to figure out how we can make it so that they're fertile at the time when it's appropriate for them.
And how do you advise someone on that? You acknowledge that this is important to the patient and then determine if there are protocols that allow a patient to observe their traditions, but then also, hopefully, help them get pregnant?
The field of reproductive endocrinology and infertility is about manipulation of hormones, manipulation of cycles. And so, having that background expertise, can I manipulate your cycle a little bit? Sure. Sometimes I can delay ovulation. I can give you estrogen in the beginning of your cycle so you don't start growing an egg until a couple of days later than you ordinarily would so your ovulation is pushed off. Can I start medication like Clomid or Letrozole a little bit later to try to, again, push off ovulation time? And for other patients, I may need to prevent natural ovulation from happening and then trigger ovulation when we need it to happen. There are ways to work within the law and ways to work within medicine and make them cohesive with each other.The overarching message is that it's so important to speak up regardless of your religion. You don't have to lose yourself or your values or your religious observations in this process. And it really is collaborative and it's about sharing with your doctor. I like that idea of collaboration because you don't want to have medicine and religion at odds with each other. Even on a peer-to-peer level, I reach out to religious providers or religious figures to see where we can have that compromise or meet in the middle to make it work for both sides. Whether that's Judaism and I'm happy to do it or a different religion as well.
Do you communicate with religious leaders or do the patients normally go back and forth between their physician and religious leader?
It’s very individualized. Some patients like to be their own go-between, between the doctor and their spiritual figure. I'm always more than happy when a patient says, Hey, can you call so-and-so and explain what's going on. I actually had a case where the rabbinic figure thought one thing was happening based on the patient's report, but when I spoke with them, I was able to resolve the potential issue and make the patient’s cycle go much smoother. I am not a rabbinic authority, I'm not any spiritual authority for anybody, but I'm happy to at least explain my side of it. There are different levels of observance regardless of religion, regardless of what group you're affiliated with, so I leave the judgment to the spiritual side, but at least give them that knowledge.
How did you learn to handle more sensitive cases, whether religious or culturally based?
In my medical education, we had cultural competency, but no education on practices for a specific religion? I've learned a lot from my colleagues about other religions. I've learned a lot from my patients. If I haven’t heard of a particular practice, I always ask them to tell me more about it, tell me what they are comfortable with, religious holidays they observe, and any restrictions they may observe on religious holidays. I've learned how to manage a patient who, for example, may need to fast all day for Ramadan and shouldn't necessarily get blood draws every other day because they might be dehydrated. Or shouldn't take their meds in the morning because they need to take meds in the evening to be appropriate religiously. I’ve learned these lessons over time, but I do wish we had something more formal in our medical education.
What are some resources patients can use as support while going through their fertility journey?
I am not as familiar with resources available for other religious groups, but in the Jewish community, there are actually a lot of external organizations geared towards helping patients or families that struggle with fertility issues. PUAH, for example, is a rich source of educational material and can be referenced as religious concerns come up. They can also assist with rabbinic supervision or other supervision of treatment as well. But there are programs like Bonei Olam, for example, and support organizations that help for a variety of different things. There's even ones that cater to more specific needs within a community. For example, not just fertility, but fertility preservation for cancer patients.
How can patients take charge of their health and reproductive journey?
I wish all patients felt comfortable advocating for themselves and for their individualized needs, but I know it's hard for some, especially when you're already overwhelmed by the world of REI. And so I think having a provider who at least is able to open the door to the conversation is helpful. Sometimes, all the patient needs is a window to share a little bit more. My biggest piece of advice is to talk to your doctor. Share your concerns. They're not there to make life more difficult for you. They're there to make your life and treatment go as smoothly as possible. If we don't know what's going on, we can't guide you and help you. And so I think that's the biggest message I can send is that we're there to help you. We're there to try to be as culturally sensitive as possible, but sometimes we just don't know. Share with us and we'll work with you to kind of make it all be a nice cohesive treatment plan.
Dr. Goldsammler cares for patients at both the Melville and Lake Success locations of RMA New York - Long Island. If you are interested in scheduling an appointment with her, click here.
Note: This blog has been condensed from an interview with Dr. Goldsammler on the Fertility Forward podcast.