A New Interpretation of Akarah . . . Ein Lah Valad (Gen. 11:30) Based on the Talmud

One of the classic hermeneutic rules of biblical exegesis is that there are no superfluous words in the Pentateuch.¹ When the Torah relates the story of Abram (later Abraham), it indicates that his wife could not have children: Now Sarai was barren [akarah], she had no child [valad] (Gen. 11:30). This standard translation is highly problematic. Rashi, commenting on this verse (TB Yevamot 64b), questions the use of the double term “barren” and “no valad,” and deems this a kera yeterah (superfluous phrase). Based on that, the word valad here cannot mean child. A peshat reading of this verse may understand that, since this is the first time the Bible uses the term akarah, the normally superfluous she had no child (valad) is simply defining akarah. However, the commentaries are baffling: they seem to indicate that Sarai was missing something, rendering her infertile, that she somehow acquired later on. There is the cryptic comment of Genesis Rabbah 38:14, which states that ein lah (“she doesn’t have”) really means that she will have later. Hizkuni writes: “but she had [a valad] afterwards.” Similarly, Radak indicates that in Ur of the Chaldees she had no valad, but did have one in Canaan. If valad does not mean child, then there is something else that she was lacking. Then there is the very strange comment of midrashic sources, such as Yalkut Shimoni and other commentators, indicating that Sarai’s fertility was restored by prayer. Additionally, Radak notes that the form valad is unusual and, in fact, unique in the Bible. Is there thus some other meaning for the word valad? Could the Hebrew akarah refer to its literal meaning, “not attached” or “uprooted”? Is there a logical connection between something “not being attached” and a state of infertility?

The verse Now Abraham and Sarah were old, advanced in years; Sarah had stopped having the periods of women (Gen. 18:11) indicates that, by definition, she did menstruate up to this point — in other words, she had a uterus and functioning ovaries, as opposed to the view in TB Yevamot 64b that Sarai had no uterus. Indeed, the term valad is used in the text rather than beit valad, the term signifying a uterus. Thus, the text is not referring to an anatomical defect (no uterus) but rather a reversible physiological problem. What was this problem?

The Talmud (TB Yevamot 64b) indicates that Sarah was an eilonit, meaning a woman without secondary sexual characteristics: in other words, no pubic hair, deep voice, etc. (see TB Niddah 47b). While the Bible describes Sarah as a beautiful woman (Gen. 12:11), the Talmud indicates that she was not completely developed physically. To a clinician, this scenario is an obvious sign of a common disorder in women (8% prevalence) called Stein-Leventhal syndrome (polycystic ovarian syndrome, PCOS). PCOS is the failure of the ovaries to release an oocyte, a mature egg, due to an excess of androgen (male) hormone; this hormonal imbalance interferes with the ovary’s ability to release eggs during ovulation, thus inducing infertility. Furthermore, the thirteenth-century commentator Ralbag (Levi ben Gershom) stated (on Gen. 16:1) that Sarah was overweight and that was why she could not conceive. Incredibly, 800 years ago, Ralbag found that obesity is linked to female infertility; one of the main causes of polycystic ovarian syndrome is insulin resistance and, quite often, obesity. Ralbag even explains that the reason Sarah had Abraham take a concubine (Gen. 16:1) was to make herself jealous and thus depressed, since the depression would cause her to lose weight.² I therefore suggest that Sarah suffered from PCOS, and that the meaning of valad is not “child” but rather that which enables offspring to be produced — in this case, the “dominant follicle.”

Akarah

But first, a brief excursus on some basic gynecological endocrinology. The follicle is the anatomical structure in which the oocyte develops. Under a follicle-stimulating hormone (FSH) surge, 6-8 follicles develop, one being the dominant follicle with an abundance of FSH receptors; the remaining follicles undergo atresia (a degeneration and subsequent resorption of one or more immature ovarian follicles). The dominant follicle grows and prepares itself for ovulation, and is then called a Graafian follicle, which attaches itself to the uterine wall. A female patient with PCOS has androgen excess (male hormones), oligomenorrhea (very infrequent menstruation), and infertility, because the follicle does not attach — eggs are not released during ovulation. This problem of follicle attachment fits in well with the biblical term used for an infertile woman, akarah, literally, “not being attached” or “uprooted.”

One of the treatment modalities for PCOS, apart from the usual medications for insulin resistance, is relaxation techniques (probably affecting inflammatory cytokines and free radicals, both of which play a role in the etiology of PCOS), and these can include prayer — indeed, there are a number of studies showing the beneficial effects of prayer on PCOS.³ It is intriguing that the first mention of PCOS in the medical literature was in 1935, yet the Bible and Talmud may be providing a description of it, along with a hint at its etiology (unattached follicle: unattached = akarah, follicle = valad).

Isaac (son of Abraham and Sarah) was known for his very passive personality.⁴ Sarah’s androgen excess could also be the key to understanding her son’s very passive behavior. The complex concept is described in detail by Geschwind and Galaburda.⁵