Posts Tagged ‘Acupuncture and Chinese Medicine’

We’ve had multiple losses – what should we be asking about?

Wednesday, October 14th, 2009

“We seem to have no trouble getting pregnant, but we’ve had several first trimester losses.” Or, “We put back good-looking embryos every time, but they just don’t stick.” If this sounds like you, here are a few ideas you might want to discuss with your doctor.

Miscarriages can be caused by any one or more of the following factors:

  • structural
  • hormonal
  • immunological/autoimmune
  • environmental
  • genetic

Let’s start (as the drs often do) with the fairly basic hormonal tests. One of the first that’s included in a fertility workup is testing progesterone in the luteal phase. Most drs order this for CD21 (Day 21 of your cycle), but actually you should really have it done at 7dpo (7 days past ovulation). Of course, 7dpo=CD21 if you ovulate on Day 14 of your cycle, but if you usually ovulate late or early, or if it’s unpredictable, you might want to track your ovulation using BBTs (basal body temperatures) and go at 7dpo. If your progesterone (P4) levels aren’t high enough, you may need progesterone supplements (like utrogestan pessaries) after ovulation (O). Some specialists believe this is a VERY common problem with older women and that if you’re over 40 and ttc naturally you should take P4 after O every cycle.

Another important one to test early, especially if you have any family history or tend to feel tired a lot, is thyroid conditions. Hypothyroid (underactive thyroid) does pop up reasonably often as a cause for conception and sometimes miscarriage problems and is easy to test for. You can ask your GP for this if you’re not seeing a specialist.

If you’re ttc naturally you should also check whether you have a luteal phase defect, i.e. once you ovulate it takes fewer than 12 days for AF (your period) to arrive. You can usually figure this out by charting your basal body temperatures (BBTs) – and a really good site for learning how is Fertility Friend. Again, if your LP is too short, this can be easily fixed with progesterone support after O.

There’s a panel of blood tests you can ask for that are used to diagnose some of the possible causes of “recurrent pregnancy loss” (RPL) or “recurrent implantation failure” (when those embies just don’t stick). Broadly speaking, they cover three categories of issues – autoimmune issues (your body may be rejecting embryos as foreign bodies), clotting issues (not sure the exact mechanism for this, but if your blood clots too much, this makes pregnancy loss more likely – some clotting issues are caused by autoimmune problems) and some genetic issues. Here’s the list that we were sent for, and I think it’s a pretty typical list for New Zealand (some countries like the States seem to test for half a dozen kitchen sinks, several of which aren’t available in NZ):

  • Coagulation screen
  • Thrombophilia screen
  • Autoantibody screen incl.
  • antithyroid antibodies,
  • anti-gliaden antibodies
  • Factor V Leiden
  • Karotype
  • MTHFR mutation
  • Anticardiolipin antibodies
  • Lupus anticoagulant
  • … and a karotype for DH (who gets off easy, as usual).

Probably the next logical step is to get either a saline sono (ultrasound during which they squirt saline solution into your uterus to help them see better) or an HSG (similar, but it’s an X-ray procedure where they shoot iodine dye into your uterus and can also check whether you have blocked tubes). Either of these should tell you whether you have any structural issues in the uterus that might be preventing you from achieving or holding onto a pregnancy. Examples include uterine polyps, fibroids, scar tissue, and an unusual shaped uterus. The most likely issues can often be treated with some fairly minor surgery.

The main environmental causes of miscarriages are not usually tested for, but things you should look around you to check your exposure. Some to keep an eye out for include lead, mercury, organic solvents and ionising radiation. Other more common culprits like cigarettes, alcohol, coffee and other drugs should be cut right out (or, down as much as possible) while ttc. Some naturopaths will do things like send a sample of your hair for analysis for heavy metals, which can highlight things you are exposing yourself to without knowing it. They also advise avoiding those forms of radiation and related exposure that we are not often aware of. These include long-haul flights (which expose the body to as much radiation as a full-body X-ray, or so they say) and keeping a cell phone in your pocket right next to your ovaries – think about it!! Well, who knows which of these various things are real causes, but if you want to make sure you try everything you can to prevent another loss, you’ll probably do what I did and take the ideas pretty seriously.

But what if my specialist won’t run all these tests?

This is quite a common comment from a lot of women/couples dealing with RPL (recurrent pregnancy loss). It may be frustrating, but there is another way to look at this. OK, you may not be able to test for the entire kitchen sink, but maybe you can ask your specialist to consider treating you as if you did have several of these issues going on but they just may well be undiagnosed. That may sound nuts, but there are actually quite a few low-tech options you can ask about that many doctors will agree fall into the “won’t hurt, might help” category. These include:

  • low-dose aspirin (usually 100mg/day) – addresses clotting issues
  • high-dose folic acid (4-5mg/day) – helps prevent neural tube defects
  • progesterone support (usually Utrogestan pessaries) after O on every cycle you are ttc
  • low-dose estrogen support after O too (2mg estradiol valerate, for example)

If you’re doing IVF, each cycle is a bit more high stakes, so you may be able to push for a bit more of a kitchen sink approach. Some other things that people are often allowed to try even if there hasn’t been a definitive diagnosis of a particular cause for repeated losses/failures include:

  • progesterone shots instead of (or as well as) the pessaries – for after egg collection
  • a low-dose steroid such as Dexamethasone – to address any undiagnosed immune issues
  • Heparin shots – Heparin is a blood thinner, so this also addresses clotting factors

Finally, don’t forget that there’s good evidence that acupuncture improves pregnancy and live birth rates for patients undergoing IVF – and good reason to believe this is also true for couples trying to conceive naturally or with IUI. Click on the category Acupuncture and Chinese Medicine in the left-hand column to see more posts on this topic.

Choosing a good acupuncturist

Monday, October 12th, 2009

When I started ttc over the age of 40 and was gearing up for IVF, I decided I should start acupuncture to help maximise my chances. Boy, have I learned a few things since then!

How to tell if your acupuncturist is NOT a good choice:

I initially chose an acupuncturist who was quite close by, whom I eventually decided wasn’t a good choice. To help others choose a good one, maybe it would help to describe what made me think so …

  1. Didn’t ask me what day of my cycle I was on when I went, and didn’t alter acupuncture points according to where I was in my cycle.
  2. Did not have a clear understanding of IUI/IVF, i.e. what happens at different parts of the cycle.
  3. Didn’t seem to have a clear understanding of what happens in a natural cycle, e.g. when implantation occurs (7-10dpo).
  4. Wasn’t able to explain clearly what my Chinese medicine diagnosis was, or the rationale behind the treatment plan. [This wasn’t an ESL issue – the person was a born and bred kiwi.]
  5. In hindsight, seemed to be trying to treat so many things in one acu session (loads of needles; I was a total pincushion) that I started wondering if some of the points used were actually cancelling out the effect of others.
  6. Wasn’t actually formally trained in acupuncture. [I know, I know, what was I thinking?!]

When I switched to another [competent] acu, the difference was just night and day on ALL the above points.

Acupuncture Qualifications and Credentials

The New Zealand Register of Acupuncture has a list of those acupuncturists who are members of the NZRA. If someone is NOT a member of NZRA or another relevant professional association, you should certainly raise an eyebrow. However, the fact that someone is a member of one of these NZ ‘registers’ is NO guarantee of quality. The acupuncturist I mentioned above, who had NO formal qualifications in acupuncture, was (and is) a long-time member of NZRA. Current requirements to join NZRA include a “qualification that meets the NZRA’s criteria” and some form of clinical assessment, but it would appear that several acupuncturists with no formal qualifications appear to have been “grandfathered” into the association early on and not subject to these requirements.

So, who IS a good acupuncturist?

For those of you looking for an acupuncturist, here’s a list of people who come highly recommended by fertility patients around the country (note that I can’t vouch that they really ARE brilliant since I’m not a Chinese medicine dr myself, but am just sharing what others have said). The following interpretation guide should help:

**Absolutely raved about ALL the time by patients (including those who’ve had success!) AND I’ve also heard endorsements from at least one credible expert source
*
At least one or two patients have spoken positively about them AND I’ve also heard endorsements from at least one credible expert source
[no asterisk]
Have been recommended by patients, but I haven’t also heard any expert endorsement about their competence, nor any concerns

Auckland

  • Dr. Vitalis, Mairangi, North Shore, 09 486 5111 **
  • Laura Bradburn, Acudoc, Auckland Central, 09 626 7120 (but she’s apparently on maternity leave in late 2009)
  • Lisa Houghton, Acudoc (above) and the Motherwell Clinic, Mt Eden, 09-630-0067
  • Bessie Lu, Village Acupuncture, Mt Eden, 09 630 3168

Hamilton

Napier

Wellington

Nelson

  • John Black, Nelson Chinese Medical Clinic, 22 Nile Street, Nelson 03 546 8733 *
  • Paddy McBride, Acupuncture Richmond, 40 Oxford Street, Richmond, Nelson 03 544 0411 *

Christchurch

  • Dr. Tracey Bourner (Ph.D. in research), Riverside Acupunture and Chinese herbs, Opawa, 03 981 1683 *
  • Georgia Bryant, Acupuncture for Health, South Brighton, 03 388 7346 *
  • Eleanor Marks in St Albans 03 960 9702
  • Suzy Tapper, Ferrymead Acupuncture, 03 384 8589

What should I ask a prospective acupuncturist before agreeing to work with them?

Whether or not a prospective acupuncturist is on the above list, it’s always a good idea to ask them a few questions before you agree to work with them. Here’s a list of questions to help get you started:

Where did you train? What acupuncture or Chinese Medicine qualifications do you have? Have you done any advanced training or courses since then? Are you a member of the New Zealand Register of Acupuncturists or some other professional association? [The ‘gold standard’ would be a bachelor’s degree in acupuncture from a reputable school in China or elsewhere PLUS some advanced training (master’s degree or other), preferably specifically in acupuncture and Chinese medicine for fertility PLUS some sort of certification that actually evaluates competence. Note that being “registered in New Zealand” simply means being a paid member of a professional association and is no guarantee of competence.]
[Assuming this is at a first/introductory appointment:] What is my Chinese Medicine diagnosis? Please explain (in lay terms) what it means and what your treatment approach would be. [Just my view, but if someone can’t explain what they are doing in understandable terms, that’s a good indicator they don’t REALLY have a good understanding of it themselves.]
How would my treatment differ before vs. after ovulation in my cycle? [Wrong answer: It wouldn’t. A good answer might include explanations like: The follicular (pre-O) phase usually emphasises kidney yin treatment, whereas in the luteal (post-O) phase we typically treat kidney yang. Also, points used after O should be those that would support a pregnancy; some of the ones used before O are good for that phase of the cycle but not safe if you might be pregnant.]
How would my treatment differ during an IVF/IUI cycle vs. during a natural cycle? [Wrong answer: It wouldn’t. A good answer would show some thoughtful logic such as: You’d generally tend to use less aggressive acupuncture treatment while someone’s on stims – you don’t want to make their ovaries blow a gasket!]
What successes have you had with women/couples of a similar age and with a similar Western diagnosis to mine/ours? Please describe one or two recent success cases. [Obviously, more success cases similar to yours are better. But keep your ears tuned too for evidence of the kind of systematic detective work a good practitioner would use to ‘listen’ to how the body responds and tweak the treatment. A fertility-challenged body is like a squeaky old violin that needs to be worked with carefully to make it sing the sweetest tune it possibly can.]
What professional associations are you a member of? Which Chinese Medicine-related conferences and seminars do you regularly attend? How else do you keep up with new developments? [You want to make sure you are working with someone who understands Chinese Medicine as not just an ancient tradition that you get trained for once and that’s it, but as a growing discipline that creates new knowledge all the time. If your acupuncturist isn’t making an effort to keep up with the field, that’s not a good sign.]
What would you say are the two or three most important advances in Chinese Medicine for the treatment of infertility in the past few years. Do you have a copy of a good recent article I could look at? [If your prospective acupuncturist can’t rattle off a few really interesting recent developments that are relevant to your case, that’s a sure sign he/she isn’t keeping up with the play. And beware of someone who doesn’t want to give you an article “because you probably won’t understand it” – first, they may not actually have any relevant articles because they don’t keep up with the field, and second, that’s a hint that they don’t see you as an intelligent and active partner in your own treatment.]

If the choice is not clear cut after asking the above questions, I’d suggest doing a session or two with each possibility and seeing which one seems like a better fit for you. Even the raved about acupuncturists on the list above have some patients who just don’t ‘click’ with their style. So, make sure the person you choose feels right for you.

· Where did you train? What acupuncture or Chinese Medicine qualifications do you have? Have you done any advanced training or courses since then? Are you a New Zealand registered acupuncturist?

[see Qualifications and Credentials, above for how to evaluate answers.]

· [Assuming this is at a first/introductory appointment:] What is my Chinese Medicine diagnosis? Please explain (in lay terms) what it means and what your treatment approach would be.

[Just my view, but if someone can’t explain what they are doing in understandable terms, that’s a good indicator they don’t REALLY have a good understanding of it themselves.]

· How would my treatment differ before vs. after ovulation in my cycle?

[Wrong answer: It wouldn’t. Correct answers would include: The follicular (pre-O) phase usually emphasises kidney yin treatment, whereas in the luteal (post-O) phase we typically treat kidney yang. Also, points used after O should be those that would support a pregnancy; some of the ones used before O are good for that phase of the cycle but not safe if you might be pregnant.]

· How would my treatment differ during an IVF/IUI cycle vs. during a natural cycle?

[Wrong answer: It wouldn’t. Correct answer: You’d generally tend to use less aggressive acupuncture treatment while someone’s on stims – you don’t want to make your ovaries blow a gasket!]

· What successes have you had with women/couples of a similar age and with a similar Western diagnosis to mine/ours? Please describe one or two recent success cases.

[Obviously, more success cases similar to yours are better. But keep your ears tuned too for evidence of the kind of systematic detective work a good practitioner would use to ‘listen’ to how the body responds and tweak the treatment. A fertility-challenged body is like a squeaky old violin that needs to be worked with carefully to make it sing the sweetest tune it possibly can.]

· What professional associations are you a member of? Which Chinese Medicine-related conferences and seminars do you regularly attend? How else do you keep up with new developments?

[You want to make sure you are working with someone who understands Chinese Medicine as not just an ancient tradition that you get trained for once and that’s it, but as a growing discipline that creates new knowledge all the time. If your acupuncturist isn’t making an effort to keep up with the field, that’s not a good sign.]

· What would you say are the two or three most important advances in Chinese Medicine for the treatment of infertility in the past few years. Do you have a copy of a good recent article I could look at?

[If your prospective acupuncturist can’t rattle off a few really interesting recent developments, that’s a sure sign he/she isn’t keeping up with the play. And beware of someone who doesn’t want to give you an article “because you probably won’t understand it” – first, they may not actually have any relevant articles because they don’t keep up with the field, and second, that’s a hint that they don’t see you as an intelligent and active partner in your own treatment.]

What low-tech things can we do to increase our odds?

Saturday, October 3rd, 2009

Maybe IUI and IVF aren’t an option for you and you’d like to try and increase your odds generally while ttc naturally. Or maybe you’re gearing up for – or in the middle of – IUI or IVF treatment. Or on one of those interminable waiting lists!

Is there anything you can do NOW that can help improve your odds?

Yes! There are a number of things you can do to get your bodies readier and more likely to succeed than they currently are for conception and pregnancy. Many of these take several months or more before you see the full benefits, so remember, it’s never too early to start AND it’s never too late to start because every little bit helps! If you’re on a waiting list for IVF (or waiting to get on one!!), this is a fruitful way to make the most use of your time.

Things men can do to improve sperm quality

Let’s start with the guys, for once! Get them out of those briefs and into boxers for starters, and no long spa baths or sweaty bike rides!! Sperm don’t like being overheated. Guys are also supposed to get their BMIs in a healthy range – usually quoted as 19-25, but bear in mind the number can be misleading if you are athletic and carry a lot of muscle. A hilarious recent example is that about 25% of the All Blacks are considered obese and the rest are ALL overweight!

There are also a bunch of supplements that are known to improve sperm quality. Here’s the list that was recommended to us by a naturopath:

  • a multivitamin called V2000
  • CoQ10 100mg (the more bioavailable gel type)
  • Vitamin C 1000mg/day (twice a day if he had a cold)
  • Vitamin E 200mg w/Selenium
  • Flax seed oil 2000mg I think
  • zinc complex (at night)
  • L-carnitine 500mg

I’ve also seen several people also recommend Vitamin B complex and folic acid (800mcg). And most naturopaths would also advise giving up smoking (anything!!), cutting right back on drinking and cutting out coffee (even decaf) if at all possible. Tea is better, green or herb/fruit tea even better.

Does it work? Well, after our IVF#3 failed my DH was so disappointed he went on “vitamin strike” for 3 months. By the time we tried IVF#4 his count had dropped from 90mil/ml to 18mil/ml. After that, no more vitamin strike!!! 😉

What can women do to improve their odds of conception?

The clinics will give you a few basic tips here – cut RIGHT down on coffee and alcohol, stop smoking and other drugs, exercise moderately three times a week, and aim to get your BMI between 19 and 25 to maximise your odds. [However, bear in mind that BMI is a bit overly simplistic for some body types, e.g. very tall women or those who carry a lot of muscle.] Click here to access Fertility Associates’ advice on boosting your fertility.

Acupuncture and Chinese herbs can also be a great way to prepare yourself for IVF. As you can see from this summary of research on acupuncture and fertility, it can be used to treat all sorts of conditions, from endometriosis, PCO/PCOS and sperm counts/quality to advanced maternal age, high FSH and poor eggs. For more information about how and why it works in general and for various conditions, find related blog posts by clicking ‘Acupuncture and Chinese Medicine’ under Topics (in the left column of this page).

What about supplements for women? Well, there is a huge and overwhelming range available depending what diagnoses you are struggling with, so probably the best advice is to see a good fertility naturopath to help you pick out the best mix for you. Having said that, here are a few that seem to be recommended in many/most cases, from what I can tell …

  • a good multivitamin
  • folic acid, at least 800mcg, but if you’re ‘older’ or have had multiple losses or implantation failures, ask your specialist to prescribe you the 5mg dose
  • Vitamin C 1000mg/day, twice a day when you have a cold
  • Vitamin E with Selenium
  • Coenzyme Q-10 (aka CoQ10) 100mg, preferably the more bioavailable gel caps
  • Fish oil or flax seed oil, 2000-4000mg/day
  • zinc complex
  • iron supplement if your levels are a bit low (ask your GP to test)

For an additional truckload of ideas, follow this link to read about low-tech things women can do to increase the chances of conception. And if you fish around that site you will find a lot more info about low-tech methods for couples and some of the basics of conception (most of which you’ll already know, of course). Unfortunately their tips for guys was down when I last checked, but I’ve emailed them about it and will add a link to this blog if it comes back online.

Can acupuncture help?

Wednesday, September 23rd, 2009

There’s a very interesting difference between Western and Chinese medicine on how fertility is viewed. Western doctors tend to focus on the cycle in which your eggs are produced (e.g. the cycle in which you do IVF), whereas Chinese medicine takes a much more long-term view.

To help understand the difference in thinking, here’s a quick (and hopefully not too inaccurate) summary of where eggs come from.

The process starts about a year before you actually ovulate, when a bunch of ‘primordial follicles’ are recruited within the ovary. These are developed very very slowly over the course of several months.

At about three months before ovulation, these primordial follicles start a different phase in their development and are now known as ‘antral follicles’. At the very start of any given cycle, an ultrasound will show several small antral follicles that are ready to go. In fact, this antral follicle count (AFC) is a good rough indicator of your ovarian reserve – check out this guide to how AFC helps predict a patient’s response to IVF stims.

During a natural cycle, just one or two of these antral follicles are recruited and will mature, leading to ovulation of an egg or sometimes two. The remaining antral follicles just fizzle out and undergo ‘atresia’ (basically, they bow out of the race). Here’s a link to a really excellent animation showing what happens in an ovulation induction (e.g. Clomiphene) cycle, which is not that different to what happens in a natural cycle (in a natural cycle you usually only ovulate one egg).

During an IVF cycle, the goal is to try and get more of those antral follicles to mature and fewer of them to undergo atresia.

So, how do the Western and Chinese perspectives on this process differ?

Your Western specialist tends to focus on a particular treatment cycle (i.e. that one month), which is the journey from antral follicles to ovulated eggs, fertilisation and beyond.

A Chinese medicine doctor, in contrast, takes a much more long-term view of the process. The intent is to create the optimal and best balanced environment for the development of your primordial follicles and then their further development once they become antral follicles, and then finally (the last and very short conclusion of the journey), the recruitment of antral follicles to produce an egg, get it fertilised, etc.

This is why the Western view is that there’s nothing you can do to influence egg quality – you are dealt the hand you’ve got; you just have to harvest as many eggs as possible, play the numbers game and hope that one of them is good.

The Chinese medicine perspective is that, although age and heredity are huge determinants of egg quality, eggs and their chromosomes can also be damaged during their development if they are subjected to toxins or have to grow in a sub-optimal environment. So, if you maximise the quality of the ‘soil’ in which they develop, then you will be able to get the best possible eggs that the woman can produce at her age.

This is why acupuncturists (and naturopaths, for that matter, who subscribe to a similar view) will tell you that you should do acupuncture for at least three months before expecting to see real benefits. Here they are talking about optimising the development of your antral follicles prior to a particular cycle. And if you do acupuncture for a year, you are not only helping this part of follicle development, but also the development of the primordial follicles as well.

Is there any actual research that shows acupuncture works?

Yes!! OK, acupuncture is hard to evaluate because treatment is very individualised (you can’t just standardise and expect the same treatment to work on different people). Also, it’s highly dependent on the competence of the practitioner. But there have been some very good studies done that show the benefits of acupuncture on fertility. Dr. Vitalis in Auckland has posted a really excellent summary of the effectiveness research on acupuncture – check it out.

I hope all this makes sense! Please post comments or questions below if not, or if you have something to contribute. Thanks!