Vatomer Devorah

In the Torah, information is a form of love. It is called Da’as.

Along this secondary fertility journey, I remember talking to someone from one of the organizations. During the conversation, he said, “I’m sure you know you have to advocate for yourself”. I recall thinking, “please fill me in on what I should advocate for, because I don’t know what to ask”. I went online on a forum where people spoke about their fertility process. How much they had been through, how much money they had spent. Often times 10’s of thousands of dollars and years in they learned to ask for an additional test, or something additional to be added to an intervention.

I eventually learned that there are conditions for which testing seems to be sidelined. Often having to do with the womb, and immune factors. (The womb is an immune organ). One is endometritis, as I discovered in my experience. However, after looking into this further, it seems the doctor was kind enough to offer testing to us “early”, considering that many people go many years while investing into invasive interventions without considering common uterine infections, even though they are common, treatable and affect fertility outcomes.

We became aware that the office we were using was based around interventions, from “least to most” invasive. It seems right to start with the least invasive- like coming in for rounds of monitoring- bloodwork, and ultrasounds, ovulatory medications. However, moving people along with the least information and understanding of underlying issues often leads to more interventions and financial, emotional and physical investments, in a series of expensive procedures, or trial and error.

Do we have a gambling problem?

It felt that way, and our bank account reflected that.

Years in, I took the Receptiva dx, and I found out that I had inflammation in my uterine lining. Something that couldn’t be picked up by blood tests or ultrasounds that I routinely came in for. It is associated with excess estrogen and progesterone resistance. It’s something that up to half the women at a fertility clinic have as an underlying issue, and higher than 65% of “unexplained” cases. Even without the test, there are ways to connect the dots. Things like systemic inflammation, digestive issues, chronic fatigue- and walking into a fertility clinic, all point to the fact that inflammation and receptivity of the uterine lining should be considered.

When I looked up the statistics on elevated bcl6, the inflammatory marker I tested for, and how prevalent it is, I wondered why most doctors weren’t so interested in those statistics. When I went through a miscarriage, the doctor sat us down to show us a graph of statistics. And that was basically it for the meeting. I was thinking at the time, “I do have google”. I felt that, as a specialist, he could have told us something more helpful, but at the time, I didn’t know what. It’s confusing when you are sharing a lot of data, but you did not gather the data about me.

Fast forward to half a year later, and the doctor went over the results of the Receptiva dx. He was telling me that we needed to suppress estrogen and I realized that everything we did up until then was blind.

Something my husband told me about life – חיים – Hashems name is in it, surrounded by מח, the mind- consciousness, understanding, and חם, warmth- emotional investment.

According to the Tanya, conscious awareness with emotional investment is called Da’as. Da’as is the awareness that bonds the mind and the heart, bringing abstract wisdom and understanding into embodied knowledge that’s personally applicable. When you have da’as, you are empowered with clarity and guidance. Da’as is also relational, it builds relationships and trust. Without da’as, information remains abstract and disempowering.

Leah was scheduled to have a procedure on the day of ovulation. She went in for monitoring with increasing frequency for about two weeks. One day the nurse called her afterward to tell her that she had already ovulated. Then the nurse told her that the doctor said she could come in the next day for the procedure if she wanted to. The words “if you want to ” stuck out in her mind. She asked to speak to the doctor who admitted that she would not actually recommend that Leah pay $1500 and come in for that procedure the next day but she wanted to give her the option. After that Leah and her husband switched to another doctor at the clinic.

At one point we again sought advice from someone from an organization. He was kind and helpful. However, he mentioned that he generally is an “in the box” kind of person. I thought at the time, “maybe he is ok being in the box from his vantage point because he is not actually in the box”. All I wanted to do was get out of this “box”. The box of “infertility”, general assumptions about age and demographics that you are told you fit into. Expensive investments into procedures done really in desperation. I felt very limited and confined.

In some ways I felt that I must be “unexplained”, because I didn’t know that so much could be explained, it’s just that the explanations offered were very limited. Going through this felt like a very narrow and constricted way of operating In Hebrew, Egypt is called “Mitzrayim”, which is from the word ‘Meitzar”, narrow or constricted. All of the Israelites were slaves in Mitzrayim except those from the tribe of Levi. The tribe of Levi corresponds to da’as, something they always maintained, and therefore, they operated with clarity.

Without information people can’ ‘t really make sound decisions while financially, emotionally, physically and spiritually investing themselves in treatments. Even though G-d can make any effort successful, we are told to make aligned efforts and not to rely on miracles. Before we got to Dr David we looked into endometrial specialists, and realized that we really did not have the budget for that because we had spent so much money (and time) doing interventions, which were in retrospect unjustified. But it feels kind of like a right of passage as you are going through the system. Of course, Hashem has a plan all along and there is always an answer.

Chochma–Bina–Da’as Wisdom–Differentiation–Embodied Knowledge

When you arrive at da’as, you are no longer “in the box”. Then you have personal context, which gives you the clarity to make choices.

After many treatments, Sarah was offered testing to look into immune factors, and she was positive for an inflammatory marker called bcl6. She was offered the option of months of estrogen suppression. At that point, Sarah realized that her fertility issues had to do with her immune system. (The womb is an immune organ and “inflammation” means that there is elevated immune activity). With this information, Sarah went to an RE who incorporated immunology into his fertility practice. Her offered her testing and immune regulators. Soon after, Sarah became pregnant naturally.

A couple spoke to their doctor after coming to the realization that they were investing iui’s even though the sperm count was actually below the recommended threshold. When they questioned further, the doctor told them they can go to a specialist for further diagnostics and treatment of the underlying issue. The couple seemed surprised that they weren’t told of this before being told to go ahead with the procedures. The doctor explained that she didn’t think it was necessary because they were going to do ivf next, and for that you only need a few healthy sperm. After looking into this, they realized that this was not great advice, nor was it a recipe for success. The couple went to another specialist who treated the underlying issue. They did do an egg retrieval, but shortly after, they were able to conceive naturally.

Today, I was listening to a class on Likkutei Moharan where Rabbi Nachman spoke about mishpat. We translate that as judgement, but he says it means to make an accounting of one’s deeds. This is best done during hisbodedus- personal prayer in your own words. Talking to G-d. This is important, he says, because it will cause the fire in your heart to burn strong, and you will not be influenced by the residual evil of people who you are bringing closer (mekarev) to G-d.

This was interesting, because I’ve been thinking about bina/ discernment. Bina is the womb, and it is also a midda/trait. The word “bina” starts with the letter ב/beis, which also means “home” or container- like the womb. In some ways, I feel that Hashem has gifted me with Bina for the first time in my life. Partly in the ability to allow the sparks of truth that I feel to develop and gestate into something productive instead of corroding my nervous system.

In sefer Shoftim, Devorah is called Eishes Lapidos. This can be translated as the wife of Lapidos, “torches”. She speaks to Barak, telling him that Hashem said to go to war to defeat Sisra. Barak means lightning. Devorah seems to be surrounded by people whose names mean fire. Some commentaries say that this is a description of Devorah herself. Eishes Lapidos means she was a woman of flames. The Yalkut Shimoni explains, Devorah and her husband made wicks for the Mishkan. She would make sure they were thick wicks so that they would have much light. Hashem said to her: “Devorah, you intend to increase My light. I will also increase your light”.

In theory, fire is a source of illumination and light. But during this journey, we did not feel illuminated much, more gaslit and in the dark. I also felt consumed, inflamed and burned out. My body felt more inflamed with each intervention, and I wondered if this was conducive toward fertility and life. I asked Hashem if He could give me the anesthesia some people seem to be on, that numbs them so that they don’t ask many questions.

I started to talk to G-d more, and I asked Him to restore my fertility. Numerous times I had tried to tell myself to let go of the desire for fertility, however, I did not feel that was possible. I realized it’s because I’m not the one who planted it. That was G-d. What helped was eventually recognizing that my feelings, insights, goals and dreams were actually not just my own. I am not separate from G-d so I didn’t need to convince Him of anything. He wants my palm tree to thrive, after all He planted it.

The Tanya teaches that the conscious awareness of recognizing that we are part of G-d and there is nothing apart from Him brings inner stillness or awe and opens the mind. Then insight can enter. That is Yiras Hashem which preceeds chochma, insight. But chochma itself is not enough. You need bina, which is the vessel to contain and develop a process that you can’t see all at once.

I began to take a little more of an observer’s stance, slightly less reactive to things that were draining us physically, emotionally, psychologically and financially. I started writing. It was like taking the sparks that could have developed into an electrical fire and giving them a space to glow, where they could shed some light. Instead of trying to suppress the flames that were consuming me, I tried to gather them into a torch of light. As I wrote, I felt less consumed and more illuminated. This must be the fire of the heart that Rabbi Nachman is talking about. The kind that protects you from the residual evil when you bring people closer to G-d.

בינה אקרי אמא עלאה (Zohar)

So, after a certain amount of procedures and interventions a woman may be informed of diagnostics that look at the environment of the womb. Is the uterine lining receptive to progesterone, is it inflamed? Up until then it is assumed that you can proceed with interventions without this knowledge, even though uterine inflammation is highly prevalent as an underlying cause of infertility.

So many doctors proceed without bina- without discernment and without knowledge of the womb. Additionally, women are often told they have no issue with the hormones being administered during treatments, when many women actually do.

Chana* was ready to have an egg retrieval. Her doctor explained that these are hormones just like the ones in her body that she has no issue with. Her doctor prescribed estrogen priming (something not included in every protocol). She was put on medication to stimulate the ovaries. At one point the doctor raised the estrogen to a higher dose, but then lowered it back to the original recommendation, when her estrogen spiked. In the days during and after the egg retrieval , Chana had some intense stomach pain and she did not feel well at all. She spoke to her friend, the nurse who was helping her administer the meds, who told her this was not normal. Chana contemplated going to the hospital because of how much pain she was in.

Some time after this she did the receptivadx and it was positive for the bcl6 inflammatory marker. The doctor explained that her body had an issue with excess estrogen. He recommended months of Lupron shots -estrogen suppression.

I discovered that there are some doctors who take endometriosis/uterine inflammation into account and gather this information early on. It doesn’t even need to be through the Receptiva test. There are doctors who have something like a checklist or questionnaire, simply by being familiar with signs of inflammation, they assess whether this may be an issue to consider with their patient. There are also other tests available that look at the uterine environment. But why is the health of the uterus simply ignored by most doctors for as long as possible?

The Standard of Care

I don’t know the answer to this question, but I know that most doctors often are following the “standard of care”. Most fertility offices are protocol driven and looking into these underlying factors is not seen as a basis for care, but as a last resort, even though that means many people go through months or years of treatments that have much lower success rates when the womb is not receptive.

After seeing and experiencing this standard of care, I wanted to see it upgraded. I wanted people to have access to information and early diagnostics that consider the environment of the womb, before they go through many months or years of interventions which can be upwards of tens of thousands of dollars or much more, and take a large physical and emotional toll.

I began thinking about Tomar Devorah, Devorah’s date palm and all it represents, life, truth, fertility.

I remember going to a general naturopathic office and another couple sitting next to me. At this point I had started to contemplate writing down my thoughts. The husband randomly turned to me and asked what I think of this doctor. Then, surprisingly, he shared that they are going through fertility challenges and coming here for help. I remember looking over at his wife and recognizing myself in her face. I saw a kind of repressed anger, a silent feeling of helplessness behind her smile.

The next day I was still contemplating writing down my thoughts. I went shopping to buy a dress. On the way there I thought, G-d, I need a sign, maybe I will find a dress with palm trees on it.

I got to the store and there were no dresses with palm trees. It was the end of August, and the summer stock was already out, and the new fall collection was on the shelves. I went to the check-out counter to pay. In front of me was a women wearing a very unusual dress. It was a brown dress with green palm trees printed all over it. Later that day I started to write.

One way to describe the trait of Bina is receptivity- receiving information, processing it and absorbing it using discernment and gaining understanding before taking outward action.

After being on this journey for some time, I was offered to take the Receptiva dx test. It is known to test for “silent endometriosis”. It actually measures BCL6, a marker associated with inflammatory signaling and progesterone resistance, most commonly correlated with endometriosis but also seen in other inflammatory uterine conditions. We decided to do it, thinking it was pretty unlikely since it’s brought up as an afterthought. About a week later the results came in and I was positive for a marker that indicates inflammation in the endometrium. The doctor recommended months of hormonal suppression of estrogen and mentioned that surgery is the gold standard for actually diagnosing endometriosis and removing it.

I was kind of shocked. I had been coming in all the time for testing and ultrasounds, and I was told everything looked fine. And I didn’t have the classic symptoms of endometriosis. But inflammation, I was familiar with. Digestive inflammation, chronic fatigue and some other symptoms that now I was starting to put together.

I looked up statistics. Apparently, endometriosis (known or “silent”) is one of the most common underlying factors in women who go in for fertility treatments. Especially, in “unexplained” cases (>50%!). I asked the doctor why this test is offered as an option after much time and expensive interventions if the results are considered highly clinically significant and actionable. There wasn’t really an answer. I also wondered why doctors often treat estrogen as a non-issue until a woman is tested and then recommend suppression. I wondered if they would adjust medications or the recommendation of rounds of clomid if they know there is an elevated inflammatory marker. Endometriosis is fed by estrogen. Elevated bcl6 is often associated with excess estrogen and progesterone resistance, the hormone necessary for pregnancy.

Oh.

Until then, I was encouraged (but confused) by the constant testing indicating that everything appeared normal. I was encouraged to take estrogenic drugs like clomid and to do interventions that were quite expensive and draining. I felt like it was all without basic context.

I learned that there are other tests that indicate uterine inflammation from chronic infections in the uterine lining or endometritis, which is also very common. According to the NIH, when the inflammation in the uterine lining is addressed, pregnancy rates significantly increase.

Shira* went to a fertility specialist and did some preliminary testing in which it was found that she had a uterine polyp. She was advised to have it removed, as the doctor explained that it could be an obstruction. About a year later, she went to another doctor. At that point Shira* and her husband went through months and months of interventions which included many blood tests and ultrasounds, iuis, egg retreival. At that point, she was offered the Receptiva dx test and found that her uterine lining was inflamed- she had elevated bcl6 marker. She was advised to take lupron or do excision surgery before transfer.

Shira remembered the polyp. It had been a while, but she realized after looking some things up, that uterine polyps are associated with excess estrogen and inflammation. So, years ago and since then, she was not advised to look into that given that,

1. She was struggling with fertility
2. She had a sign of excess estrogen and inflammation in her uterus

She and her husband were pointed elsewhere until they came back around after a process of many interventions, to what would seem obvious unless you are not really looking for context.

According to the National Institute of Health, among women with endometrial polyps, 51.35% have chronic endometritis- that means they have chronic infection and inflammation affecting the uterine lining. The prevalence of CD-138 positivity among those women was 70.73%. CD-138 is a marker for chronic endometritis.

https://pmc.ncbi.nlm.nih.gov/articles/PMC870053

Recently, I was reading the morning blessings and these words jumped out at me:

אשר נתן לשכוי בינה

Hashem gave the rooster bina- understanding, intuition, discernment, to differentiate between day and night.

The rooster is clearly a male bird. Bina is a feminine trait that women are especially endowed with. Why did Hashem give the rooster (a male bird), bina?

The rooster crows and heralds the coming of the dawn because it is able to discern the subtle naunces between day and night before anyone else can. It takes action only after using the trait of bina, discernment. The dawn refers to new life, just as the day begins anew. In fertility care, by advancing with interventions without discerning the signs of life from the signs of inflammation a doctor is like a rooster without bina: crowing at all hours of the night, a time that is not receptive to life. He may get it right some of the time (or eventually after many interventions). But acting without bina/discernment, makes the process long and difficult, draining people physically, emotionally and financially. And-exacerbating underlying issues in the process.

Proceeding with interventions without environmental context means proceeding in the dark, without knowing if it is actually dawn. That is why the rooster is bestowed with the gift of bina. His outward actions-heralding of the dawn is dependent upon (the feminine root of) receptivity and discernment. The rooster takes in the environmental cues so he can understand when it is dawn. The womb is the environment in which new life begins. It is where new life dawns. That is why רחם (womb) is the same letters as מחר (tomorrow).

“And she would sit under the date palm of Devorah…” (Shoftim 4:5)

The commentaries say that Devorah sat under a date palm to judge the people because it was a place of openness and transparency. The palm tree is straight and rises higher than other trees, its overarching height and unbranched trunk represent uprightness, truth and unity.

In the torah, the date palm is a symbol of blessing and fertility.

The date palm is evergreen, enduring drought and heat, it’s roots reaching deep to find water. It produces sweet, nourishing fruit even in desert conditions.

The date palm teaches patience. It grows slowly, taking many years to bear fruit, but once it does, it continues for generations.

According to Bamidbar Rabbah 3:1, The date palm is entirely beneficial. It provides dates to eat, branches for schach ,trunk for wood, fibers for ropes.

My intention in sharing this website- vatomardevorah.org, is to share all the date palm has to offer with you. A fertility journey can feel like wandering through a desolate and barren desert, making stop after stop, trying to find answers. That is where this date palm grew. In sharing my thoughts along this journey, I hope they can provide some much-needed resources, and to remind you of the promise written by David Hamelech/ King David: “The righteous shall flourish like the date palm” ( tehilim 92:12).

צדיק כתמר יפרח

My name is Devorah, and in recent years I read a book written by the Ramak, R’ Moshe Chaim Cordovaero, a page every day. The book is called Tomer Devorah. It is about the 13 attributes of Rachamim/mercy and how we can emulate the ways of Hashem. I had stopped reading it a while ago but picked up again after I started writing this blog that I called Vatomer Devorah. It reminded me of the book.

Rachamim is almost the same as the word Rechem (womb). In Hebrew when two words share the same root, they are intrinsically connected.

In Chassidic teachings, Rachamim (compassion) is the merging of judgement with kindness. The womb is the most tangible form of rachamim. It is enclosed and boundried, protecting the life inside it, while nurturing it with overflowing kindness. The intent of vatomerdevorah.org is to help restore this life- giving balance. It’s an accounting for the purpose of restoring sweetness and renewed life into a field where that is the stated goal: fertility care.

Restoring balance means putting both the Rechem (the womb) and rachamim (compassion) at the center of fertility care, so that it is patient centered- compassionate, curious, and progressive, rather than mechanistic.

In fertility care today, the womb is often overlooked, as people go through expensive and draining procedures, without accounting for underlying factors, like endometriosis and other uterine inflammation, even though they are common. They often come around to this after spending much money, time and energy. Getting back to a womb centered approach means applying the principles of rachamim, which is not only compassion, but also the merging of kindness with justice. It’s where underlying and root causes are used clinically as a basis for care.

It also means restoring the feminine principle of bina/discernment, where people can benefit from a full circle of professional knowledge and experience rather than assembly line thinking. In the torah, bina is also a reference to the womb. All of these concepts are found in the torah, and my experiences have led me to reconnect my roots to its living waters and fertile soil. Rabbi Nachman of Breslov teaches that we find G-d in the obstacles that we encounter. That is where this date palm blossomed. And it is not just any date palm, it is a tree of life.