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Reproductive concepts and practices among observant Orthodox Jews may Lead to Halachic subfertility in a significant portion of couples. According to Halachah [the Jewish code of law) sexual activity may not take place during the time a woman menstruates (Niddah) as well as for a full week thereafter (7 days of cleanliness). Coitus is allowed to resume after the woman has immersed herself in a ritual bath (mikvah). In the case of unexpected spotting or bleeding (Zavah), the woman should consult a rabbi and a doctor to determine the origin of the blood. Uterine bleeding entails that intercourse is forbidden for a minimum of 5 initial days plus 7 days thereafter. In practice, any minute bleeding or spotting, regardless of timing during the menstrual cycle, renders the woman ritually impure and invokes the stringencies of Niddah rulings. Even a physiologic occurrence such as midcycle ovulatory bleeding or spotting renders the woman Zavah and prohibits sexual intercourse at the optimal time for conception. The inability to conceive in this halachically mandated time period is not due to a biologic fault but rather to social, cultural and religious norms as defined by the rabbinate. Medically lengthening the pre-ovulatory phase is a common practice, as shortening the count of days of ritual impurity is often seen as nonnegotiable. Ethical issues concerning the role of the physician and the safety of such treatments are discussed.

Due to temporary social trends, many women elect to postpone their first pregnancy to a later stage in life. Pregnancy and labor later in life entail major risks to both the mother and the neonate. Furthermore, a large part of this population will be infertile by the time they opt to conceive, mainly because of decreasing ovarian reserve and low oocyte quality. Assessment of the fertility potential of the elderly nullipara includes clinical measurements of early follicular FSH and estradiol, clomiphene citrate test and ultrasonographic evaluation of the ovaries. A fast track step-by-step fertility evaluation is the procedure for women above 35 years of age. Only empirical treatment modalities may be offered to the elderly infertile patient, with the exception of ovum donation.

Many epidemiological studies have demonstrated an association between low birth weight and the subsequent development of hypertension, insulin resistance, type 2 diabetes and cardiovascular disease. This association appears to be independent of classic lifestyle risk factors such as smoking, overweight, social class, alcohol consumption and lack of exercise, which are additive to the effect. The association holds for the full range of birth weights, including those within the normal range. In addition, it was suggested that faster postnatal catch-up growth may also predict later risk of cardiovascular disease. 'Fetal programming' has been proposed as a mechanism underlying the link related to low birth weight, rapid neonatal growth and adult disease. The fetal programming hypothesis suggests that the intrauterine environment during critical periods of organogenesis and tissue growth may permanently alter organ structure and function in an epigenetic manner. Indeed, evidence from both human and animal studies suggests that diseases of adult life are induced by the fetal environment. This review describes epidemiological and physiological evidence that the programming phenomenon is a major factor in determining later life diseases. Better management of pregnancy in the present will have long term wide-scale effects on the health of our society.

Breast cancer is the most common malignancy in women and constitutes 18% of all cancers in women. Female gender, age and country of birth are the strongest determinants of disease risk. Family history and mutations in tumor suppressor genes BRCA1 and BRCA2 are important correlates of lifetime risk. Genetic polymorphisms associated with estrogen synthesis and metabolism are viewed as major factors in breast cancer prevalence in specific populations. Atypical hyperplasia and ductal/lobular carcinoma in situ although uncommon, are considered as pre-malignant conditions as well as markers for invasive breast cancer. Lately, increased bone density and high breast tissue density on mammogram in postmenopausal women have been reported in association with increased risk of breast carcinoma, probably attributable to increased levels of endogenous estrogen. Serum estrogen levels are higher in breast cancer cases as compared with controls. Current use of oral contraceptives and prolonged, current or recent use of postmenopausal hormonal replacement therapy are also considered as risk factors for breast cancer. Tamoxifen and raloxifene, selective estrogen receptor modulators, were shown to reduce breast cancer risk among high-risk women. Various nutrients were evaluated for their possible effect on breast cancer risk but further studies are needed. High socioeconomic status is found to be associated with increased risk of breast malignancy for as yet unestablished reasons. Studying breast cancer risk factors and further research into the molecular etiology of the disease will enable early diagnosis and detection of high-risk women and ultimately improve prognosis.