Female Infertility

feamle infertility

“So, you would like to fall pregnant and have a healthy baby?”

Fertility Health is our experienced Chinese medicine (CM) team dedicated to supporting your ability to conceive and give birth to a healthy child. We provide CM treatment for: male and female infertility, gynaecological conditions, miscarriage prevention, pregnancy support, labour induction, and preparation and support for natural pregnancies and assisted reproductive technology (ART) cycles.

The Service We Provide

Our Sydney based team has a great deal of clinical experience and knowledge in treating infertility, chronic disease, gynaecology, and male urology. We have worked together for many years and we provide well over 9,000 treatments a year (see also Our Practitioners).

The Director, Jann Mehmet, has worked in Chinese medicine (CM) for nearly 3 decades and, in 2006, conducted the only CM clinical trial in Australia on sub fertile men.

The results were clinically and statistically significant in the semen parameters of count, motility, and morphology.

The RACM Sydney team have a research background and are passionate about providing you with best evidence CM treatment (see Clinical Trials).

Today, the team continues to aim for high pregnancy rates through best evidence clinical research.

We are currently collating data on unexplained infertility, miscarriage prevention, egg donor cycles, IVF stimulated and frozen cycles, pregnancy over 40, PCOS (polycystic ovary disease), natural killer (NK) cell therapy, and the impact of the MTHFR (folate) gene mutation on conception and health.

ASSESSMENT AND TREATMENT

We offer an in-depth assessment of your health and fertility potential by integrating our clinical knowledge and experience with the unique traditional Chinese medicine skills of tongue, pulse, and Hara diagnosis (see Chinese Medicine).

We incorporate this assessment with a naturopathic style consultation that reviews blood tests and scans, and offer a supportive role in discussing all issues related to falling pregnant naturally, and ART (assisted reproductive technology) cycles.

Using our research background, we follow systematic reviews, meta-analysis and the latest research. We empower you with information on world's best practice in: ART cycles, natural fertility, blood tests, semen analysis, ultrasounds, and surgical intervention in gynaecology and male urology.

We listen to your requests and take into consideration your needs and desires and, after our thorough assessment, we advise on: Chinese herbal medicine, preconception education, lifestyle, and nutrient and diet supplementation.

Once a treatment plan is developed, we allow you to relax with a gentle acupuncture treatment (see Acupuncture).

If essential, we recommend further blood tests and scans. Throughout the following sessions, the team monitors your progress and offer full support six days a week, throughout your natural or ART cycles; during pregnancy; labor and after delivery.

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PREPARING FOR PREGNANCY

Many women wish to get really healthy before they fall pregnant in an effort to maximise their chances of having a safe pregnancy and a robust baby.

We believe this is an excellent investment in your child's future, and suggest preparing for at least 2 months before trying to conceive depending on whether: you are reasonably healthy, have been on the pill for many years, have a chronic gynaecological condition, or have a chronic health disorder.

The Fertility Health team supports pre-conception health in several ways.

We provide education and instruction on:

  • Pre natal diet and lifestyle choices,
  • Pre natal detoxification,
  • Pre natal vitamins and herbs,
  • Weight loss,
  • Weight gain.

We review your risk for infertility and miscarriage. We assess all chronic conditions that might make falling pregnant a challenge, whether naturally or with IVF.

We offer CM treatment support for:

  • Chronic health conditions that can undermine fertility,
  • Gynaecological and hormonal imbalances,
  • Implantation issues,
  • Poor egg and embryo quality,
  • Anxiety, insomnia and depression,
  • Miscarriage risk,
  • Endometriosis,
  • PCOS,
  • Irregular cycles,
  • Luteal phase weakness and low progesterone,
  • All gynaecological issues (see the Fertility Health menu at top).

We train you to know when you are most fertile each month.

We teach:

  • Fertile mucus detection,
  • Basal temperature interpretation,
  • Daily hormonal monitoring,
  • Ovulation prediction,
  • Conception timing.

We continue our support throughout your pregnancy.

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UNEXPLAINED INFERTILITY

Jann Mehmet

by Jann Mehmet

Approximately 45% of infertile couples are given a medical diagnosis of ‘unknown cause’. This may be the result of all the medical tests and scans that a couple undergo coming up with negative results, and perhaps providing no answers. The Fertility Health team has found Chinese medicine’s unique diagnostic theories and insight into health and gynaecology can play a key role in finding answers and solutions.

What does Chinese medicine say about ‘unknown cause'?

In CM theory, the age of the woman and man, and their gynaecological, urological and hormonal status, are not the only factors that influence egg, sperm and embryo quality, and the ability to fall pregnant.

CM theory dictates that general health and wellbeing also influence hormonal, gynaecological, and urological health and the ability to produce healthy eggs, sperm, and embryos, regardless of age.

As infertility is medically considered for the most part a gynaecological or endocrinological problem, chronic disease or seemingly minor health issues may not be considered important in a medical assessment. Chinese medicine shows there is usually a cause for infertility - and age may not always be the main factor.

CM theory suggests that there are ‘patterns of disharmony’ that put you at greater risk of developing compromised fertility, whether a disease is identified or not.

For example, both the immune system and the digestive systems may play a huge role in your ability to conceive or not, or produce healthy eggs and sperm. However, these systems and their impact on fertility are not investigated in the usual endocrinological or gynaecological assessment.

We find Chinese medicine assessment sucessfully complements a medical diagnosis to provide insights into potential 'unknown causes’.

Patterns of disharmony may provide good guidance for further tests and medical examinations for both men and women that assists in better diagnosis and treatment outcomes.

After supporting thousands of cycles, we have concluded that the following issues are commonly overlooked in a diagnosis of ‘unknown cause':

  • Progesterone weakness,
  • Fallopian tube infection,
  • MTHFR gene mutation,
  • Sperm mucus intolerance,
  • Natural killer cells,
  • A male factor that is overlooked.

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PROGESTERONE WEAKNESS or LUTEAL PHASE DEFECT

What is it?

The hormone progesterone is essential for the regulation of normal female reproductive function. Progesterone supports libido, ovulation, implantation, and pregnancy. Low progesterone levels can lead to:

  • Problems with ovulation,
  • Premenstrual tension,
  • Spotting,
  • Unexplained infertility,
  • Miscarriage.

What causes progesterone or luteal phase weakness?

There is no single cause for progesterone weakness in Western medicine, and there is very little information as to why it happens.

Medically, this is said to be a result of either:

  • An endocrine disorder (for example, endometriosis), or
  • idiopathic (unknown) causes.

In Chinese medicine progesterone weakness is diagnosed as a kidney Yang deficiency, however there are multiple reasons in Chinese medicine for kidney Yang deficiency to occur.

For example, progesterone weakness or kidney Yang deficiency may potentially be caused by numerous factors: including constitutional, environmental, general health, diet, and lifestyle. Exactly what factors are at play is the role of the Chinese medicine practitioner to determine on assessment.

What are some of the possible symptoms?

  • Late ovulation or irregular menstrual cycles,
  • Infertility,
  • Unexplained infertility,
  • Spotting before the period starts,
  • Spotting mid cycle,
  • Low libido,
  • History of endometriosis or pelvic infection,
  • Miscarriage,
  • Lower back ache,
  • Weak knees,
  • Fluid retention,
  • Fatigue,
  • Underactive thyroid,
  • History of long cycles (more than 32 days),
  • Low basal temperatures,
  • Sensitive to cold weather,
  • Urinary frequency during the day,
  • Regular loose stools,
  • Chronic constipation.

Why is luteal phase defect overlooked in blood tests?

In a nutshell, the blood tests provided are not always sufficient to give an accurate assessment of either the luteal phase or progesterone levels. The luteal phase commences once ovulation occurs, and it can be monitored from the time you ovulate to the time menstruation starts. In order to be adequate to support conception and pregnancy, the luteal phase needs to last at least 12 days and the progesterone levels need to be stable for that whole period of time.

However, progesterone blood tests are typically evaluated on day 21. A ‘normal’ reading for progesterone on day 21 may be misleading because progesterone levels can change from one day to the next, and while they might be good on day 21, there is no guarantee that the levels are good or stable for the rest of the luteal phase or until menstruation.

Further, as this blood test relies upon a 28 day cycle, if the woman does not generally have a 28 day cycle, the blood test on day 21 may not be reliable. Ultimately, this results in less women being diagnosed with progesterone weakness than those who actually suffer from this weakness.

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How do we diagnose progesterone weakness in Chinese medicine?

The Fertility health team has been treating and monitoring luteal phase defect for nearly three decades.

Our preliminary findings offer better guidance on:

  • How to best monitor progesterone levels,
  • Optimum progesterone levels to reduce risk of infertility,
  • Optimum levels to reduce ectopic pregnancies,
  • Optimum levels to avoid miscarriage,
  • Optimum levels to support implantation rates and reduce failed IVF cycles.

We have observed some very consistent patterns and our evidence suggests progesterone weakness is frequently under-diagnosed in approximately 90% of the women we see diagnosed with ‘unknown cause’.

Our practitioners use traditional Chinese medicine diagnostic tools in complement with medical tests to assess low progesterone risk which is a Chinese medicine disorder called ‘Kidney Yang Xu'.

This includes monitoring:

  • Pulse,
  • Tongue,
  • General physical and emotional wellbeing,
  • Menstrual history,
  • Basal temperature.

Together, these markers are able to confirm an individualised diagnosis while determining the likely cause of ‘Kidney Yang Xu’.

How is progesterone weakness treated medically?

For women trying to conceive, and diagnosed with unexplained infertility or suffering recurrent or idiopathic miscarriages, assisted reproductive techniques may be recommended. Our observational study at RACM has concluded that there are similar outcomes for this group compared to studies done world wide. These studies conclude that a higher percentage of failed cycles, ectopic pregnancies, and miscarriage rates are experienced during IVF (in-vitro fertilisation) cycles, compared to the general population.

Women who are already pregnant but are at risk of miscarriage or 'threatened miscarriage' are often prescribed progesterone pessaries.

However, a review conducted by the Cochrane Collaboration determined that there is no statistical significance in reducing miscarriage rates using pessaries versus placebo.

How does Chinese medicine treat poor luteal phase and progesterone weakness?

During the initial consultation we assess risk for progesterone weakness, miscarriage, and being a poor responder to IVF cycles. We prefer to address the underling cause of progesterone weakness before the woman conceives naturally or attempts an IVF cycle.

Treatment to support progesterone levels at RACM may consist of:

  • Acupuncture,
  • Chinese herbal medicine,
  • Western herbal medicine,
  • Naturopathic and/or nutritional supplements,
  • Chinese diet therapy,
  • Hormonal monitoring through basal temperature charting,
  • EMPATHY.

Summary

  • Progesterone is important for menstrual and reproductive health,
  • Progesterone weakness is often overlooked,
  • Progesterone weakness is commonly the main cause of 'unexplained infertility',
  • Signs of progesterone weakness include; menstrual abnormalities, unexplained infertility, recurrent miscarriage, and poor implantation rates with IVF cycles,
  • Current medical treatment involves assisted reproductive technology such as IVF and this group experiences high rates of failed cycles, miscarriage, and ectopic pregnancies,
  • Chinese medicine has a rich history of treating gynaecological and hormonal disorders that focuses on an individualised diagnosis and treatment plan.

At RACM, we are here to help prevent infertility and miscarriage with a holistic diagnosis and treatment support plan.

REFERENCES

  1. Oates-Whitehead, R.M., Haas, D.M. and Carrier, J.A.K. (2007). Progesten for preventing miscarriage (Review).
  2. Ried, K. and Smart, K. (2011). Efficacy of Traditional Chinese Herbal Medicine in the management of female infertility: A systematic review. Complementary Therapies in Medicine, I9: 319-331.

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SPERM MUCUS HOSTILITY

When sperm mucus hostility exists it is an effective contraceptive that normally goes undetected and is not tested because it will not interfere with an IVF cycle. It will, however, impact natural fertility rates and should therefore be excluded.

What is it?

Sperm mucus hostility is a term used to describe a hostile response to sperm during the fertile or pre-ovulatory period.

If the woman's mucus is hostile, it may render the sperm immobile and the sperm may not live very long or have a chance to fertilise an egg.

What causes it?

The causes can be broken down into male and female factors.

Male factors that cause a hostile response:

  • pH of seminal fluid not healthy or within normal ranges (7.2-7.8),
  • Elevated seminal sperm lgA or lgG antibodies will tend to provoke a hostile response,
  • Vaginal lubricants,
  • Low grade testicular infection,
  • Scrotal fungal infections and the use of fungicides on the groin area.

Female factors that cause a hostile response:

  • Vaginal infection including thrush, fungal or candidiasis,
  • Vaginal lubricants may be hostile to sperm,
  • Pelvic inflammatory disease or endometriosis may put a woman at a higher risk,
  • Unhealthy vaginal pH,
  • Poor production of fertile mucus,
  • Irregular cycles that lead to poor timing around ovulation,
  • Poor production of fertile mucus after colposcopy or LEEP biopsies of the cervix.

What are the symptoms?

The symptoms of sperm mucus hostility are often very mild and not noticeable by either partner, and therefore go undetected by the couple and are generally undiagnosed. In most cases it is ‘asymptomatic’ (shows no symptoms).

How is it diagnosed?

Diagnosis is made by two methods: pH and sperm antibody testing during a semen analysis; and a post coital test.

During a routine semen analysis, seminal pH levels can be observed. Sperm antibodies can also be tested during a semen analysis and both lgG and lgA antibodies are observed.

The post coital test is the most useful assessment however currently, the post coital test is rarely recommended in Sydney for reasons unknown, while in the USA and Europe it is a standard non-invasive early intervention, and an inexpensive test given to couples finding conception difficult.

Chinese medicine (CM) diagnosis of sperm mucus hostility

It is important to note that:

  • Further specialised training is required for a practitioner to understand how to assess risk for sperm mucus hostility using CM.
  • An in-depth understanding of the interpretation of seminal pH, sperm antibodies, ‘debris’, white blood cells, viscosity and clumping is essential.
  • Specific questions also need to be asked on a medical history form that give greater insight into risk of sperm mucus hostility and its cause. These further questions are not often covered in general fertility assessment, however the Fertility Health team has the experience and training required for this assessment.

What is the medical treatment of sperm mucus hostility?

  1. IVF (in-vitro fertilisation) or ICSI (intra cellular sperm injection) are effective procedures to bypass sperm pH or antibody issues. Poor pregnancy rates may occur because related factors may not be resolved. For example, low grade infection in the fallopian tubes (that may lead to sperm mucus hostility and infertility) may inhibit embryo implantation,
  2. Antibiotics are often incorporated in treatments conducted in other countries - but not those in Sydney,
  3. Steroids may also be prescribed when sperm antibodies are found however, due to bad side effects (such as hip fractures), only short courses of these steroids are prescribed,
  4. Currently, in Sydney antibiotics and steroids are rarely prescribed, especially if a male factor is diagnosed,
  5. In many clinics in the USA, it is routine to combine IVF and ICSI cycles with a short course of antibiotic use for both the man and woman, before and during a cycle. Due to the difficulty in diagnosing infections it is considered more cost effective to simply treat both partners. Short term use of specific antibiotics during IVF OR ICSI cycles appears to have no long term side-effects on the baby while encouraging higher pregnancy rates compared to those from ART alone. This combination of treatment is currently not widely available in Sydney,
  6. IUI or intra-uterine insemination. This is not often recommended in Sydney despite being very inexpensive compared to IVF,
  7. In the US and Europe IUI (inter uterine insemination), is frequently offered as a first treatment option, especially for women over 40, as many clinics have claimed the same pregnancy rates for women over 40 as with IVF, and therefore the less invasive and cost effective option is promoted.

Chinese medicine treatment of sperm mucus hostility

Long term training, including mentoring in male infertility in Chinese medicine, is preferable in order to develop the skill set required to adequately interpret the semen analysis and be able to investigate the risk factors for sperm mucus hostility and determine a male or female factor.

As multiple causes can lead to sperm mucus hostility, a thorough Chinese medicine diagnosis is required for an individualised treatment plan to be devised to support a couple through natural conception.

Guidance in appropriate diet therapy is also paramount. Chinese medicine diet therapy can be of great assistance while complementing this knowledge with the latest, best practice evidence.

Acupuncture and Chinese herbal medicine may be used to offer treatment support for all male and female factors related to sperm mucus hostility.

Miscarriage rates are seen to be 50% higher when antibodies are present, so it may be important to address underlying causes - whether a couple want to conceive naturally or use IVF/ICSI.

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FALLOPIAN TUBE INFECTION

Low grade fallopian tube infection is commonly one of the most overlooked pathologies to impact implantation rates during natural and ART cycles.

This infection has a long history of misdiagnosis because it cannot be detected in normal blood tests and scans and the woman appears apparently asymptomatic in ever other way. The Fertility Health team is aware of all the risk factors that might suggest low grade tubal infection.

Mostly this condition is overlooked in the ART and Chinese medicine community, despite discussion and research on this subject being presented at fertility conferences (Johnson et al., 2003).

The Fertility Health team has developed a screening program to assess risk for fallopian tube infection. RACM has also developed a treatment strategy to improve implantation rates, both naturally and during ART cycles.

In Chinese medicine the fallopian tubes are said to be the ‘orifices of the heart’, and as such, problems with fallopian tubes may be considered related to the function of the heart and there are very specific treatments and herbal remedies that are designed to keep the fallopian tubes in peak condition so that the sperm and egg can meet without obstacle.

NATURAL KILLER CELLS (NK cells)

uring pregnancy, the body's immune system is suppressed in order to allow an embryo to implant and grow. This is required because the embryo contains ‘foreign matter’, namely the DNA from the male partner's sperm. According to Dr Alan Beer, a pioneer in the field of reproductive medicine, up to 80% of problems with infertility are caused by immune system or autoimmune problems. His comments are not limited to but include elevated levels of Natural Killer Cells (NK Cells). However, despite much debate and anecdotal evidence, the role of NK cells in repeated embryo implantation failure and miscarriage is still a controversial issue amongst many Western medical fertility specialists.

NK Cells are a type of lymphocyte that is involved in the body's immune response. NK cells are produced in the bone marrow and circulate in the blood and are also produced in the uterine lining. Normally they work in conjunction with hormones to assist in reproduction and pregnancy however, in some women, it is argued that the over-production of these hormones negatively affects embryo implantation and growth, leading to repeated embryo implantation failure and miscarriage.

Over the last 10 years our team at the Rozelle Acupuncture and Chinese Medicine Centre (RACM) has recognised the role of NK cells in pregnancy and has worked with many women on western medicine protocols to treat elevated NK cells. This has resulted in many successful live births that we believe may not have been possible without this intervention.

Of particular interest, our team at RACM has developed a Chinese medicine 'pattern of differentiation' that enables us to identify and predict patients at risk of NK Cells, which can then be verified by blood tests. We then go on to support our clients with acupuncture through the Western medical NK immune regulating protocols such as Dr Gavin Sack's "Bondi Protocol".

So whilst there is limited evidence through randomised clinical trials for the role of elevated NK Cells in early miscarriage, our team has strong anecdotal evidence that suggests when all other risk factors are accounted for, and when NK cells are diagnosed and treated, we observe better pregnancy outcomes.

Importantly, our team recommends a period of preparation before a NK cell cycle commences. During this period of preparation our team helps regulate the immune system and supports optimal liver function to reduce side effects because predisone is prescribed, which can significantly affect the liver and also cause problems with sleep and anxiety. Acupuncture both prior and during an NK treatment cycle helps calm the body and support the liver, thus reducing the side effects of these medications, and optimally leading to a healthier pregnancy and baby.

References

  1. Alan, E.Beer (2006) Is your Body Baby Friendly, AJR Publishing.

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MTHFR GENE MUTATION

Approximately 30-50% of the population have a mutation in the MTHFR gene that has been passed down from their parents. Most people with the mutation remain unaffected by it, however it is becoming increasingly recognised that for some people it is associated with an increased risk of miscarriage, birth and neural tube defects, cardiovascular disease (CVD), high blood pressure (HBP), glaucoma, stroke, mood disorders, and autoimmune disease.

The MTHFR gene produces the enzyme that is required for the complex multi-step process that converts Folate (B9) into a form that can be absorbed by the body. Folate (B9) is an important nutrient because it is required for the creation of every cell in the body, for DNA repair, and for methylation. Methylation is the process whereby folate and folic acid are converted into an active form that the body can use for these important functions. Proper methylation enables the body to detoxify toxic metals, toxins, and other waste products effectively.

The two most problematic mutations of the MTHFR gene are C677T and A1298C. Depending on whether there is a homozygous mutation (two copies of the mutation, one from each parent) or a heterozygous mutation (one copy of the mutation from one parent and one normal one from the other parent), determines the significance of these mutations.

Those with a defective MTHFR have a reduced ability to produce the MTHFR enzyme, the enzyme that allows the body to properly utilise folate vitamins in the complex chemical process described above. It is estimated that those with a homozygous mutation are only 40% effective in breaking down folate and folic acid into the components required for proper methylation and cellular function while those with a heterozygous mutation are functioning at around 70% capacity.

For the last 10 years our team at the Rozelle Acupuncture and Chinese Medicine Centre (RACM) has been monitoring research on the MTHFR gene mutation and developing strategies that allows us to identify and treat those affected by the mutation. For instance, high levels of folate and B12 in blood serum testing may be an indication of gene mutation, affecting absorption of these nutrients that build up in the blood stream.

Our team recognises that when treating those with the MTHFR gene mutation a gentle approach works best to avoid over-methylation and detoxification that can result in headaches, fatigue, insomnia, irritability, or anxiety. Our aim is to safely assist the body to detoxify without putting further stress on what is commonly an already over stressed system.

We use acupuncture and Chinese medicine diet therapy to support this process and to improve the health outcomes of those with a significant MTHFR gene mutation. We often also recommend supplements, such as glutathione and folinic acid, to gently support the methylation process, allowing the body to detoxify, after what is, for some people, many years of toxins.

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POLYCYSTIC OVARIAN SYNDROME (PCOS)

A recent Cochrane review on the treatment of PCOS, found that Chinese medicine treatments provide good results compared to conventional medical treatments, with much fewer side effects (Lim et al., 2011).

At the Rozelle Acupuncture and Chinese Medicine Centre we listen to your concerns about PCOS; your fertility, irregular cycles, fatigue, acne, weight gain, and hormonal imbalance. We understand that everyone experiences PCOS differently and we bring to the consultation: support, insight, explanations, and an individualised treatment plan.

We obtain good results using acupuncture and Chinese herbal medicine to treat all symptoms related to PCOS. Chinese medicine theories on ‘patterns of disease’ provides a unique understanding of conditions that lead to PCOS and how to address all of the associated symptoms (see Acupuncture, and Chinese Medicine).

We teach you how to understand why PCOS develops and what measures you can take to reduce its reoccurrence.

Chinese medicine theory dictates that there are reasons related to constitution, diet, and lifestyle that predisposes a woman to PCOS.

What is PCOS?

Polycystic Ovary Syndrome (PCOS) is one of the most common endocrine disorders of women of reproductive age and is a leading cause of female infertility.

It affects between 4% and 12% of women worldwide and its clinical features include menstrual disorders, secondary amenorrhoea, blood hormone abnormalities, excessive hair growth, acne, obesity, and infertility.

What causes PCOS?

PCOS is regarded as a chronic systemic disease whose precise pathogenesis has not been well defined by Western Medicine.

It is however, frequently associated with insulin resistance, elevated androgen levels, chronic inflammation, and oxidative stress.

What causes PCOS in Chinese medicine?

Traditional Chinese medical (CM) theory provides an excellent framework with which to diagnose the cause of PCOS in patients, as its exact cause varies from patient to patient.

Clinically, CM suggests PCOS is often a combination of both excess and deficient conditions and the most involved organ systems include the spleen, liver, and kidneys. From a CM perspective the most common patterns of PCOS are phlegm and damp accumulation (fluid filled cysts) and Kidney Yang Deficiency (poor metabolism). The team at the Rozelle Acupuncture and Chinese Medicine Centre is able to explain these theories in a practical every day application during the consultation.

What are the symptoms?

There is a wide spectrum of symptoms of PCOS and they can vary from patient to patient. Some of the most common symptoms include:

  • Irregular, heavy, or infrequent periods, or an absence of periods altogether (ammenhorea) - 90% of women with PCOS experience irregular menstruation,
  • Obesity - 50% of women with PCOS are overweight,
  • Acne and or excessive hair growth - 83% of women with PCOS have heavy hair growth and/or acne,
  • Insulin resistance - 50-70% of women with PCOS have insulin resistance,
  • Infertility and recurrent miscarriage - up to 70% of women with PCOS experience infertility.

How is it diagnosed?

The diagnostic criteria for PCOS were established by the European Society for Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) in 2003 and are known as the Rotterdam Consensus Criteria.

    According to the Rotterdam Consensus Criteria a diagnosis of PCOS can be made when at least two out of three of the following criteria are met:
  1. The ovaries are ‘polycystic’ because there are 12 or more follicles visible on one ovary or the size of one or both ovaries are increased,
  2. There are high levels of ‘male hormones’ (androgens) in the blood (hyperandrogegism) or there are symptoms suggestive of an excess of androgens such as excess hair growth or acne,
  3. There is menstrual dysfunction such as a lack of periods, menstrual irregularity or lack of ovulation. It is important to note that with these criteria a woman can be diagnosed with PCOS even if she has regular periods or normal androgen levels.

What is the medical treatment for PCOS?

The common treatment response of Western medical specialists, for those not wanting to conceive, is to prescribe the oral contraceptive pill (OCP). PCOS sufferers with irregular cycles who wish to conceive are often prescribed ovulation-inducing medications such as clomifene citrate.

If ovulation cannot be induced using clomifene then injectable gonatrophins such as gonal f may be given in small doses as part of an artificial insemination (AI) cycle. Alternatively, IVF may be recommended.

There are also various surgical methods including wedge resection, ovarian drilling, and ovarian diathermy that are recommended in some more severe cases of PCOS.

How does Chinese medicine treat PCOS?

Chinese medicine (CM) utilises treatments that are aimed at primarily re-establishing the healthy function of the ovaries and treating the underlying causes.

Acupuncture has been shown in several studies to be particularly useful in this regard. It is also important to note that lifestyle modification is an essential component of treatment.

At Rozelle Acupuncture and Chinese Medicine Centre the Fertility Health team uses CM theory to comprehensively diagnose the factors contributing to the development of PCOS and treats these using acupuncture, Chinese herbal medicine, nutritional supplements, and lifestyle modification. A Cochrane study in 2011 found that the current western medical treatments for women with PCOS had increased risk of multiple pregnancies, undesirable side effects, and inconsistency in their effectiveness, while various studies of acupuncture in PCOS had suggested low rates of adverse events and no increased risk of multiple pregnancy.

Summary

  • PCOS is the leading cause of female infertility,
  • Conventional western medical treatment focuses on symptomatic treatment rather than curing the condition,
  • TCM provides an excellent framework with which to diagnose the underlying causes of PCOS,
  • TCM and lifestyle modification provide effective means of treating PCOS.

References

  1. Zhao, L. (2012). Comprehensive Treatment of Polycystic Ovary Syndrome and Related Infertility. Journal of the Association of Traditional Chinese Medicine and Acupuncture UK, 19 (1): 12-16.
  2. Lim DCE, Chen W, Cheng LNC, Xue CChangli, Wong FWS, O’Sullivan AJ, Liu Jp. Acupuncture for polycystic ovary syndrome. Cochrane Database of Systemic Reviews 2011, Issue 8. Art No: CD007689.
  3. Jiang D, Zhang y, Wu X, Wu S. (2015). Infertility in polycystic ovary syndrome treated with acupuncture and clomiphene: a randomized controlled trial.
  4. Zhongguo Zhen Jiu, 35 (2): 114-118 4. Zuo T, Zhu M, Xu W. (2016) Roles of Oxidative Stress in Polycystic Ovary Syndrome and Cancers. The Journal of Oxidative Medicine and Cellular Longevity: Article ID 8589318.
  5. Joham AE, Teede HJ, Ranasinha S, Zoungas S Boyle J, (2015) Prevalence of infertility and use of fertility treatment in woman with polycystic ovary syndrome. Journal of Women’s Health 24(4): 299-307.

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ENDOMETRIOSIS

The Fertility Health team listens to your concerns about endometriosis, fertility, pain and your future. With nearly 30 years' experience, and access to the latest research, we offer insight, assessment, and treatment using ancient Chinese medicine theories of ‘patterns of disharmony’ (see Acupuncture, and Chinese Medicine).

We aim to alleviate your symptoms, teach you how to understand why endometriosis develops, and plan with you a strategy to help avoid its reoccurrence.

Encouragingly, we have seen very good clinical evidence for the treatment of endometriosis with Chinese herbal medicine and acupuncture (Ding and Lian, 2015; Flower et al., 2012; Brown and Farquhar, 2014).

What is it?

Endometriosis is defined as the presence of endometrial tissue outside the normal uterine cavity. In endometriosis, the kind of tissue that is normally found inside of the uterus grows outside of it. It is a common gynaecological disease that affects 10% of women and 40% of women with infertility.

What causes endometriosis?

There are various theories about what causes endometriosis and it is recognised that several factors probably play a role. According to a theory known as the ‘transplantation theory’, cells from the lining of the uterus migrate to other parts of the body and multiply there, these are referred to as endometrial implants. It is thought that the cells either travel through the bloodstream or move through the fallopian tubes to the abdomen in menstrual blood.

Every month during the menstrual cycle, endometrial implants outside of the uterus build up and shed in response to hormonal fluctuations. Since the blood and shed tissue cannot leave the women’s body through the vagina they stay near the endometrial area. Here they cause inflammation, which in turn can lead to the development of scar tissue and adhesions.

In biomedicine it is not clearly understood why the endometrial cells grow outside the uterus in some women and not others. It is believed that other factors play a role in its development, including a problem with the interaction between hormones and the immune system, as typically the immune system ensures that the tissue from a particular organ does not grow elsewhere in the body.

What does Chinese medicine say about the cause?

According to Chinese medicine (CM) theory endometriosis results from the slow down and stagnation of blood flow in the pelvis. CM recognises several causes of this as well of many contributing risk factors that accompany this pathology that need to be addressed in order to effectively treat the disease. The liver, spleen, and kidney meridians travel through the pelvis and as such any issues within these meridians can affect blood flow in the pelvis.

What are the symptoms?

The symptoms of endometriosis vary from woman to woman but dysmenorrhea (painful periods), dyspareunia (painful intercourse), and dysuria (painful urination) are the most frequently reported symptoms. Around 70% of women with endometriosis experience severe pelvic pain and/or painful periods, whereas others are asymptomatic. In many women the recurring pain can impact their general physical, mental, and social wellbeing.

In the early stages of the disease one or two mild symptoms may be felt for the first day or two of the menstrual period but as the condition continues to develop, symptoms may get worse for more days of the month. The type of symptoms and their severity tend to be related to the location of the misplaced endometrial tissue rather than how much misplaced tissue there is.

This helps explain why some women experience no symptoms. In fact around 30% of women with endometriosis only discover they have it because they have not been able to fall pregnant, or because endometriosis is found during an operation for another reason.

How is it diagnosed?

There are several tests that may indicate and assist in the diagnosis of endometriosis:

  • Clinical examination - a pelvic examination by a specialist can reveal localised tenderness or nodules in the vagina that are suggestive of endometriosis,
  • Blood test - an elevated protein CA-125 can be helpful in diagnosing the disease, however, it is less reliable as an indicator in the early stages,
  • Ultrasound - the ability to diagnose deep infiltrating endometriosis with trans-vaginal ultrasound has improved dramatically in the last 5 years. Ultrasound can now detect deep infiltrating endometriosis with a high degree of accuracy. It is a useful pre-operative diagnostic tool,
  • Laparoscopy - laparoscopy is the definitive method of diagnosing all forms of endometriosis. It is during this surgery that a biopsy of tissue that is thought to contain endometriosis is removed and sent to a pathologist to confirm the diagnosis.

What is the treatment in biomedicine?

In western medicine there is currently no cure for endometriosis. Conventional medical and surgical treatments for endometriosis aim to remove or decrease the deposits of endometrial implants and to manage the pain associated with endometriosis.

The medication options include painkillers and hormone therapy. Painkillers only relieve the symptoms, whereas hormone-based treatments aim to slow down the growth of endometrial implants. These hormone therapy treatments include progestins, oral contraceptives and gonadatroprin releasing hormone agonists. Meanwhile surgical interventions aim to remove visible areas of endometriosis via laparoscopic surgery.

Laparoscopic surgery can often relieve the terrible pain and heavy bleeding many women experience, however, the endometrial cells soon return and the process begins again.

What is the treatment in Chinese medicine?

In China, the treatment of endometriosis using Chinese herbal medicine (CHM) is routine, and considerable research into the role of CHM in alleviating pain, preventing relapses, and promoting fertility has taken place. Our team uses acupuncture, CHM, nutritional supplements, and diet therapy to treat the symptoms of endometriosis and reduce the growth of endometrial lesions.

We reduce fatigue, emotional distress and anxiety, endometrial lesions, pain, heavy bleeding, and irregular bleeding associated with endometriosis and hormonal imbalance.

We assess your general health and wellbeing using the insights of Traditional Chinese Medicine theories on ‘patterns of disharmony’, to prevent the reoccurrence of the disease. There is good evidence to support the use of acupuncture to treat endometriosis.

A 2012 Cochrane Review found that post surgical administration of CHM may have comparable or better overall treatment effect than hormone therapy alone, but with fewer side effects.

Summary

  • Endometriosis is a common gynaecological disease that can cause considerable pain to some sufferers and can negatively impact a women’s fertility,
  • Laparoscopic surgery is the ‘gold standard’ of western medicine diagnosis,
  • Chinese Medicine has a long history of treating endometriosis with fewer side effects than conventional treatments.

References

  1. Hsu. A, Khachikyan. I, Stratton. P, (2010) Invasive and non-invasive methods for the diagnosis of endometriosis. Clinical Obstetric Gynecology 52(2): 413-419.
  2. Vercellini. P, Vigano. P, Somigliana. E, Fedele. L, (2014) Endometriosis: pathogenesis and treatment. Nature Reviews Endocrinology 10(5): 261-75.
  3. Ding. Z, Lian. F, (2015) Traditional Chinese Medical herbs staged therapy in infertile women with endometriosis: a clinical study. International Journal of Clinical and Experimental Medicine 8(8) 14085-14089.
  4. Flower. A, Liu. JP, Lewith. G, Little. P, Li. Q, (2012) Chinese herbal medicine for endometriosis. Cochrane Database System Review, 2012 May 16(5).
  5. Brown. J, Farquhar. C, Endometriosis: an overview of Cochrane Reviews. Cochrane Database System Review 2014 March 10(3).

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POOR OVARIAN RESERVE and AMH (Anti-Mullerian Hormone)

by Sally Gole

What is AMH?

Anti-Mullerian Hormone (AMH) is a hormone secreted by cells in developing egg follicles. Women are born with a finite number of eggs, around one to two million at birth. By puberty this has reduced to around 200,000, declining further through a women’s reproductive years to less than 1,000 at menopause. Each egg is surrounded by cells, called granulose cells, and these cells produce AMH.

What is the AMH blood test?

The AMH test is an inexpensive blood test that has, in the last decade, become popular as a means of estimating a women’s ovarian reserve. The blood test measures the level of AMH in the blood stream and through that level, determines approximately how many eggs a women has remaining. The test correlates that the higher the level of AMH, the higher the ovarian reserve. The test was developed by Adelaide clinic Repromed in 2004 and is commonly referred to as the “egg timer test” however, increasingly there is evidence to show that this test is not as reliable as we are led to believe.

What are the issues with the test?

One of the biggest issues with the AMH test is that while it does provide us with some insight into the ovarian reserve of a women, it doesn’t give us any information as to the quality of these eggs. At the Rozelle Acupuncture and Chinese Medicine Centre (RACM) we commonly see women who have been given low AMH readings but who are still able to fall pregnant and carry to term. Conversely we also see many women with good AMH levels who are struggling to fall pregnant as the quality of these eggs are poor.

This is supported by a European study that found that low levels of AMH does not mean that a women cannot fall pregnant. In that study 88 women between the ages of 25 to 40 were diagnosed with very low ovarian reserves but within 5 years 57 of them had fallen pregnant.

Another critical issue with AMH testing is that there is currently no international standardisation of AMH testing and this can affect a test's validity and accuracy. The first published study in 2012 on the effectiveness of AMH testing found that there were significant variations in the results, in some cases up to 60 per cent. One woman did the test three times and in one six week period her egg reserve, based on the AMH test, had increased by 30%.

Head researcher Dr Oybek Rustamov said that the study, which looked at the results of 5,000 women between 2008 and 2011, found “current commercial AMH tests provide erroneous results”.

These erroneous results can be the result of poor quality lab testing, particularly if the blood had not been stored correctly or not analysed immediately.

Studies have also shown that there can be a lot of variability in test results as different labs have different methods and don’t calibrate their results to the same clinical outcomes. The absence of an international standard for AMH testing is a key issue affecting its validity.

As such, it is important to bear in mind that, while the AMH test can be a useful component of fertility testing, it should however be a part of a more thorough and complete fertility assessment. When low ovarian reserve is diagnosed it is important to read these results in conjunction with the antral follicle count observed on an ovarian ultrasound, and with other relevant hormone blood levels.

How is low AMH treated?

Conventional medicine encourages women who are diagnosed with low AMH levels to not delay trying to fall pregnant or undergo IVF procedures to give them the highest chance of conceiving. Egg freezing is also recommended if the woman is not yet ready to try and fall pregnant.

How does Chinese medicine consider low AMH levels?

In Chinese Medicine (CM) a women’s ovarian reserve and egg quality are related to their constitution and overall general health. Interestingly, in CM our ‘kidneys’ represent our fertility potential and our ‘kidney Jing’ is our essence, a bit like our DNA, and this ‘Jing’ determines our basic constitution, our growth and development and our reproductive potential. The ‘Jing essence’ is made up of ‘prenatal Jing’ and ‘postnatal Jing’. When we observe low ovarian reserve, in CM, we consider supplementing the ‘Jing essence’ for example with Chinese herbal medicine and strengthening acupuncture treatments.

At conception we gain our ‘prenatal Jing’ from our parents and as such this is of a fixed quantity and cannot be added to, only conserved. From a CM perspective this is conserved by maintaining balance in diet, work, rest and sexual activity. Our ‘postnatal Jing’ is derived from the air we breathe and the food we eat and can therefore be replenished to some degree by utilising certain breathing techniques and improving our eating practices.

What is the CM strategy to support healthy eggs?

Acupuncture and Chinese herbal medicine are used to support the body to make the most of the eggs that are left. This is achieved through using herbs and acupuncture that increase the blood flow to the ovaries to nourish the eggs. Acupuncture and Chinese medicine are also given to decrease toxins in the body that may damage egg quality. Other herbs and treatment aim to balance hormone levels and nourish the uterine lining in order to effectively support a pregnancy.

At RACM, the Fertility Health team works with our clients to supplement their ‘Jing essence’, to improve their overall health and to decrease their toxic load using diet and lifestyle changes, acupuncture, Chinese herbal medicine, and nutritional supplements. Our approach is holistic and comprehensive by supporting the system as a whole rather than treating ‘low AMH’ as an exclusive condition of the ovaries. In this way we support women to be able to fall pregnant naturally or through IVF.

Summary

  • The AMH blood test has become a common fertility test to gauge a women’s ovarian reserve,
  • There is increasing research to suggest that this test is not always reliable and that results can vary. There is currently no international standard for this test,
  • It is important to note that this test is only a gauge of a woman’s ovarian reserve and it does not indicate the quality of the eggs,
  • The Fertility Health team at the Rozelle Acupuncture and Chinese Medicine Centre works with our patients to support the body to make the most of the eggs that are left by improving blood flow and circulation to the ovaries, detoxing the body, improving hormone levels, and using diet and lifestyle changes to supplement their ‘post natal Jing’.

References

  1. Nelson, S.M., (2013) Biomarkers of ovarian response: current and future applications. Fertility and Sterility 99: 963-969.
  2. Rustamov, O., Smith, A., Robrts, S.A., Yates, A.P., Fitzgerald, C., Krishnan, M., Nardo, L.G., Pemberton, P.W., (2012) Anti-Mullerian hormone: poor assay preproducibility in a large cohort of subjects suggests sample instability. Journal of Human Reproduction, Vol 27, 10: 3085-3091.
  3. Grynnerup, A.G., Lindhard, A., Sorensen, S., The role of antimullerian hormone in female fertility and infertility - an overview. Acta Obstet Gynecol Scand, 2012 Nov: 91(11): 1252-60.
  4. LaMarca, A., Sighinolfi, G., Radi.D., Argento.C., Baraldi.E., Artenisio, A.C., Stabile.G., Volpa. A.,(2010) Anti-Mullerian hormone (AMH) as a predictive marker in assisted reproductive technology (ART). Human Reproduction Update 2010 Mar-Apr: 16(2):113-30.
  5. Gleicher, N., Kim, A., Kushnir, V., Weghofer, A., Shohat-Tal, A., Lazzaroni, E., Lee, H.J., Barad, D.H., (2013) Clinical Relevance of combined FSH and AMH observations in infertile women. Journal of Clinical Endocrinol Metab. 2013 May: 98(5):2136-45.
  6. Dewailly, D., Andersen, C.Y., Balen, A., Broekmans, F., Dilaver, N., Fanchin, R., Griesinger, G., Kelsey, T.W, LaMarca, A., Lambalk, C., Mason, H., Nelson, S.M., Visser, J.A., Wallace, W.H., Anderson, R.A., (2014) The physiology and clinical utility of Anti-Mullerian hormone in women. Human Reproduction Update. 2014 May-Jun: 20(3):370-85.

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HEAVY BLEEDING and IRREGULAR CYCLES

(See Gynaecology - Heavy bleeding and irregular cycles)

IVF CYCLE Support

There is now some good evidence to suggest that acupuncture improves implantation and pregnancy rates during IVF and ICSI cycles compared to IVF or ICSI alone (Balk J et al., 2009; Benson et al., 2006; Cheong et al., 2008; Dalton- Brewer et al., 2010; Dieterle et al., 2006; Horn et al., 2007; Magarelli et al., 2004; Meagrely et al., 2009; Manheimer et al., 2008; Paulus et al., 2002; Quintero et al, 2004; Siterman et al., 1997; Siterman et al., 2000; Smith et al., 2008; Smith al., 2006; Song et al., 2008; Teshima et al., 2007; Udoff et al., 2007; Westergaard et al., 2006; Yang et al., 2005; Youran D et al., 2008; Zhang et al., 2003).

The Fertility Health team is dedicated to supporting good pregnancy outcomes when a couple undergo ART cycles and are thrilled to have an opportunity to support women through this journey.

The clinical research provides good guidelines for acupuncture treatment before and after embryo transfer, however the evidence also suggests preparation before ART will increase pregnancy outcomes further.

CM theory suggests there are many causes for poor implantation and pregnancy rates during ART. Our team recommends assessment and preparation before ART cycles begin (see Preparing for Pregnancy).

Here is a list of commonly seen factors we observe that reduce implantation rates, both naturally and during IVF cycles:

  • Poor luteal phase and progesterone instability,
  • Low grade fallopian tube infection,
  • Poor lining of the uterus,
  • Polyps and fibroids,
  • Low libido,
  • NK cells,
  • Poor sperm quality,
  • Sperm antibodies,
  • Poor egg and embryo quality.

Other factors that compound these problems include:

  • Poor sleep,
  • Anxiety and depression,
  • Fatigue and exhaustion,
  • Overwork,
  • Having a small child that doesn't sleep well,
  • Compromised immune system,
  • Chronic infections and disease,
  • History of significant gut parasite or bacteria.

Chinese medicine theory dictates that all the conditions listed that reduce implantation rates have multiple causes that are related to the constitution, general health, diet, lifestyle, and the woman’s environment (work stresses, chemicals, and stress at home) (see Assessment and Treatment).

Further, while most couples feel under pressure to push ahead and ignore many of these known factors, more valuable time tends to be wasted with continuing to have failed cycles. This is heart breaking even to watch! Our team recommends pre-conception care preparation.

POOR EMBRYO AND EGG QUALITY

(See Poor Ovarian Reserve - AMH)

POST NATAL Recovery

We provide acupuncture throughout pregnancy to our clients to support the health of both mother and baby, as well as to monitor risk factors in conditions that might arise after delivery. We have had nearly three decades experience supporting women during pregnancy and have learned to monitor large and small signs and symptoms so we might prevent problems down the track.

We find being progressively preventative is in the best interest of our clients. In addition, Chinese Medicine (CM) has highly developed theories and ‘patterns of disharmony’ that alert and guide our practitioners to better serve our clients.

If a woman has never had acupuncture prior to the delivery of her baby, she can still benefit from acupuncture treatment and receive support so that she might recover better after childbirth.

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