After treating infertility cases for twenty-one years I've arrived at some conclusions which I'd like to share.

1. A reproductive endocrinologist cannot determine when an embryo is "good".  Embryo grading means nothing unless it's a bad embryo.  Yes, one can visualize a 'bad' embryo, but even with PGD, a 'good' embryo is undeterminable. How many times have you heard about an embryo (blast) which is 'normal' based upon PGD and the cycle fails?  Here's why: embryo grading is only as good as current diagnostic procedures. Perhaps in time, embryo testing will be viable. Yes, PGD can rule out various chromosomal anomalies but that is determining a 'bad' embryo. My point is - if an embryo looks bad, it probably is. If an embryo looks good, it may not be.  This why including acupuncture and herbal -medicine in your reproductive medicine protocol makes sense. Acupuncture and herbal medicine can improve egg quality and embryo quality. There are many studies on the web that are revealing.
2. Endometriosis can still contribute to infertility even after laparoscopy. Why? Because it may not be possible to eradicate all endometriosis due to several reasons.
a. Some endometriotic tissue looks exactly like normal tissue and therefore, the surgeon will not be able to observe this tissue as diseased tissue.
b. Some endometriotic tissue may be on structures which are difficult or dangerous to reach and the surgeon will opt not to try and excise this tissue.
Endometriosis does more than cause tubal pathology; it changes the uterine environment by causing an inflammatory state in the uterus. This is not amenable to facilitating an ongoing implantation. This is why acupuncture and herbal medicine should be included in the reproductive medicine protocol of those trying-to-conceive who have been diagnosed with endometriosis as acupuncture and herbal medicine can reduce inflammation and make the uterus more hospitable to an implanting embryo.
3. PCOS We all think of PCOS as a metabolic-endocrinological disorder whose main deterrent to conception is lack of ovulation. All of this is correct but myopic. Clomid or gonadotropins can cause one to develop mature eggs and other meds are used to actually facilitate ovulation - but that's not enough. Why do many PCOS patients not conceive after several IUI's or even IVF's? Because women with PCOS have excess androgen within the follicular fluid. Androgen is an anti-estrogen and as such causes or can contribute to poor egg quality. This is why PCOS patients have a difficult time conceiving or frequently miscarry. In fact, those with PCOS are twice as likely to miscarry as those in the non-pcos population. Acupuncture and herbal medicine should be included in your reproductive medicine protocol is you have PCOS since we know that these Chinese medicine protocols help clear the ovary and its contents of 'debris' and other pathological substances, i.e. androgen excess.

For more information on how acupuncture and herbal medicine may be of help to you visit our site: http://berkleycenter.com

NYC Community Event for Endometriosis and Infertility

Community Presentation on Endometriosis

 Thursday, April 17, 2014

 7:00pm-8:00pm

 The Berkley Center 

16 E 40th Street, 2nd Floor

New York, NY 10016

This is an open event to the community to join us for an intimiate Q&A with Director and Founder of the Berkley Center, Mike Berkley about the topic of Endometriosis.

CLICK TO RSVP

March is Endometriosis Awareness Month

                       

Acupuncture has been shown to help idiopathic couples, women with PCOS, endometriosis and poor egg quality due to advanced maternal age. 


Let's start with PCOS. These patients typically have double the miscarriage rate of patients in the non pcos population and are often infertile; the etiology of both of these dynamics occurs as a result of poor egg quality as a result of ovarian hyperandrogenism.

Acupuncture improves hemodynamics to the uterus and to the ovaries there by facilitating an improved excretion of androgen from the ovaries leaving the ovaries with a less challenged estrogenic milieu. This can, in some case, improve egg quality and therefore help to improve pregnancy outcomes while simultaneously reducing miscarriage due to aneuploides.

Furthermore, acupuncture, along with exercise and life-style counseling can often improve weight loss, which, in and of itself, lowers the androgen profile of these patients.

Acupuncture has also been shown to facilitate ovulation in some of these patients but I believe that an east meets west approach to care is best as clomiphine citrate (clomid) or injectables can almost guarantee ovulation - but not improved egg quality. The utilization of both modalities therefore potentiates the effect of both with a concomitant advantage to the patient.





On to endometriosis: this is an autoimmune, inflammatory disorder that is mostly (though not always) diagnosed via laparoscopic intervention. When laparoscopy is performed fertility quotients often improve even in cases where there is no tubal pathology. Why is this? It is because when endometriotic implants are resected, the origin of pro-inflammatory cytokines is eliminated and the uterine milieu is improved and perhaps (I don't know for sure) pinopode behavior and manifestation is improved.

It is a fact that even though endometriosis in inherently a disease that is not of the uterus, uterine linings in woman with endometriosis are often clinically or sub-clinically affected. So not only are there uterine inflammatory processes occurring but implantation failure may also be a contributing factor. None of this has anything to do with the tubes. When a laparoscopy is executed it is probable that not all of the endometriosis is resected because 1)some endometriosis has the same color as normal tissue and 2) some endometriosis is located in areas that are either unavailable to the surgeon or are hidden behind various pelvic structures. As a result, some pro inflammatory cytokine activity may sill be manifest even after laparoscopic intervention. Since acupuncture improves hemodynamics, once again the utilization of acupuncture may serve to help excrete these unwanted cytokines improving uterine receptivity and environment creating a more hospitable environment for an embryo.

Some woman status-post resection still have severe pelvic pain and remain infertile (and I am taking age and other confounding pathologies out of the equation). Why is this? Probably because there remain ectopic endometrium with concomitant pathology at the level of the uterus. Acupuncture often helps these patients for the reason(s) I stated above.

In the case of the idiopathic patient, the acupuncturist, through his or her diagnostic evaluation will often uncover factors that are not taken into consideration during the Western medical evaluation. These issues (clots in the menstruate, severe pelvic pain with menses, night sweats, cold pelvis, severe stress and more) lead the practitioner of traditional Chinese medicine to arrive at what is known as a 'pattern of disharmony' and that pattern is then treated. Often, pregnancy results. Though the language and paradigm of traditional Chinese medicine are different from this of Western medicine there must be some biological, metabolic, endocrinological, neurologic effect occurring in response to the acupuncture which often, though certainly not always results in pregnancy.

                       

Stranger stories have been told. For example: take the patient who has undergone 6 IUI's and 6 IVF's (even with PGD or CGH) and have never conceived and the couple gives up. Four years later, she conceives with intercourse and has a live birth of a healthy baby.

The point is, as you can imagine, Western diagnostic capabilities are excellent but not complete nor all encompassing. Certainly fertility evaluations will be different 50 years from now. There are reasons for infertility that none of us are aware of and only a few that we are.

The use of acupuncture may be touching upon areas that Western medicine is not looking at or paying attention to. This is not a criticism but a scientific fact. We know what we know, we don't know what we don't know, but we must know that we don't know; in time, we will know more but never all.



I hope this helped to elucidate the use and mechanism-of-action of acupuncture in the setting of the infertile patient. 


Best wishes. 
Mike Berkley, L.Ac.

                        

Endometriosis – or is it? And...a diagnostic dilemma

Endometriosis can present with mild adhesions or deep infiltrative lesions whereupon the endometriosis has penetrated deep into organs and adnexa.

There is no medical cure for endometriosis. Surgery is the gold standard for amelioration. Ablative therapy cauterizes the endometriosis on the surface and can penetrate deeper and deeper but without precision and therefore can be dangerous to underlying tissue and surrounding structures. Excision is precise and safer.

There are four stages of endometriosis of endometriosis from stage one to stage four with stage four being the most severe.
This staging is in fact, inadequate, as there are cases of endometriosis that are far more severe than that which is shown in the above photo. There should probably be six stages to facilitate greater accuracy in determining and tracking disease.

Endometriosis is an autoimmune disease with a genetic predisposition.

There are several theories as to the etiology of endometriosis including Sampson's theory which postulates that retrograde menstruation carries blood through the fallopian tubes out and onto surrounding organs and tissue depositing epithelial remnants that attach and proliferate and act in response to hormones in the same way that eutopic endometrium does.; displaced coelimic epithelium; the lymphatic route; and surgery whereupon there is deposition of endometrial epithelial cells in other parts of the body (C-section).

Stem cells may also play a role in endometriosis. This is evident from the fact that total hysterectomy is not a cure for endometriosis and endometriosis can form in the absence of the uterus and ovaries. As stem cells are totipotent, they may, especially with dysregulation of the KRAS gene (Molecular Human Reproduction Vol.12, No.11 pp. 671–676, 2006) contribute to the development of endometriosis.

The gold standard for detection of endometriosis is via laparoscopic exploration, followed by therapeutic excision if endometriosis is found.

If a patient has an endometrioma it can typically be seen via TVU. But the absence of an endometrioma should in way be construed as an absence of endometriosis.

A woman with endometriosis may present with these symptoms – and she may be asymptommatic

1. Doubling over in pain

2. Missing school or work due to menstrual pain

3. Pain with defecation

4. Requirements of narcotics to reduce menstrual pain

5. The use of birth control pills or GnRH agonisits for pain reduction - which are not effective

6. Pelvic pain during adolescence

7. Infertility

8. A family history of severe menstrual pain

9. Endometriosis at stage 4 can be asymptomatic

10. Endometriosis at stage 1 can present with severe pain

When is laparoscopy appropriate?

I would certainly recommend laparoscopic review in an infertile patient who is under thirty-four years old and has a diagnosis of idiopathic infertility where there is also an absence of male factor, where there are at least three of the above sypmtoms manifest. Of course one problem with this algorhythmic approach is that endometriosis can be prevalent in the absence of symptomatology.

Even with negative hysterosalpingographic findings and negative TVU findings, endometriosis many be extant.

Infertility

Endometriosis is causative of infertility via several pathways including tubal damage, endometrial abnormality, inflammation in the uterine cavity, and low libido as a result of painful intercourse.

The endometrium is dysregulated in the patient with endometriosis: this can cause implantation failure. There is extra macrophage proliferation emitting proinflammatory cytokines within the uterine cavity: this may cause an inflammatory uterine environment that can be destructive to the embryo. There is also an inappropriate presence of MMP’s in the endometrium of the endometriosis patient during the window of implantation causing inappropriate and excessive tissue destruction and possibly preventing implantation (Ann N Y Acad Sci. 2002 Mar; 955:37-47; discussion 86-8, 396-406.)

Pregnancy

Some patients get pregnant even though they have endometriosis some do not. Some conceive after a laparoscopy and some do not. These variances exist perhaps because of varying degrees of disease; this of course, presupposes an absence of other pathologic states that may be contributory factors to inability to conceive. Another possibility is that not all of the endometriosis was excised and therefore there is still a hostile uterine environment as a result of continued prevalence of an inflammatory environment.

Chronic pelvic pain

Interstitial cystitis can mimic some symptoms of endometriosis.

IC is a chronic inflammation of the bladder wall.

Symptoms

1. Painful intercourse

2. Pelvic pain

3. Painful urination

4. Frequent urination (up to 60 times a day in severe cases)

5. Urgency to urinate

Treatment is symptomatic

Diagnosis is made by ruling out other causes. Tests include:

1. Bladder biopsy

2. Cystoscopy (endoscopy of bladder)

3. Urine analysis

4. Urine culture

5. Urine cytology

6. Video urodynamics (shows how much urine must be in the bladder before you feel the need to urinate)

Data about IC was obtained from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001508/


Traditional Chinese medicine

The dilemma of differential diagnosis

When a patient reports to the clinic for care and presents with chronic pelvic pain and dyspareunia one may immediately think of endometriosis.

If the pain is dull and aching one will undoubtedly state that stagnation of liver qi is the diagnostic foundation. If the pain is sharp and stabbing one will conclude that stasis of blood is the culprit. Of course in the chronic presentation both qi and blood will be stuck.

Typically the diagnosis which is commonly arrived at in the patient who reports a history of endometriosis is stagnation of liver qi and stasis of liver blood.

But we know that endometriosis is an inflammatory disorder and we also know that endometriosis is only manifest where there is ectopic endometrial epithelial cells.

This then renders the diagnosis of qi stagnation and stasis of blood incorrect. If there is ectopic deposition of cells and tissue – those cells could only have arrived in ectopic locations via rebellion. So rebellious qi and blood must be part of the differential diagnosis. If endometriosis is an inflammatory disease where inflammatory cytokines end up in the uterine cavity then we must include heat as part of the diagnosis. So, rather than qi stagnation and stasis of blood, I would diagnose this patient as being afflicted with rebellious qi and blood with heat trapped in the uterus. Frequently the endometriosis patient will not present with heat signs and then I diagnose the case as rebellious qi and blood with hidden heat trapped in the uterus.

Then there is another diagnostic dilemma: when the patients reports to you status post laparoscopy and complains of still having chronic pelvic pain, do we consider that her diagnosis of endometriosis is of value in helping us to formulate a TCM differential diagnosis? No – because the endometriotic implants have been excised and therefore the endometriosis, at least for the time being is no longer extant.

Then we can safely state that the diagnosis is stagnation of liver qi and stasis of liver blood based strictly on the patients symptoms. So: what once was – no longer is – and therefore, the diagnosis must change.

If the patient presents in clinic with a chief complaint of chronic pelvic pain and a Western medical diagnosis of IC, the TCM diagnosis is damp-heat in the bladder. This is a very different diagnosis than that of the endometriosis patient – with or without active endometriosis.

The patient with IC may not present with signs of damp-heat. Her only symptoms may be dyspareunia and CPP. Therefore, without the Western diagnosis available to us we may in fact miss a diagnostic pearl.

Based on the above it is my contention that having knowledge of the Western medical diagnosis can be very helpful in leading us to a more precise TCM differential diagnosis.

The fact is, in China today, most hospitals that have a Western wing and a TCM wing share data on cases and work together; so, the TCM doctor typically does know the Western medical diagnosis before he or she starts treating the patient.

We are not living in ancient China and we must remember that all knowledge which can help us to help our patients should be actively sought after, obtained and used. To not do this indicates a romantic belief that TCM is all our patients need and that the four examinations are all we need. This is ignorant and dangerous thinking based on dogma. This does not bode well for optimal patient care.

Endometriosis and Herbs

I do use herbs to clear heat in endometriosis patients because endometriosis is an inflammatory disease. So even in the absence of heat signs/symptoms the patient still has ‘heat’. My most frequent dx in endo cases is derangement of qi and blood, qi and blood stagnation and stasis and hidden heat trapped in the interior. I don’t have a cookie-cutter formula for said cases as each case is different. But heat clearing is always part of my treatment principle and clinical goal in endometriosis patients. Also, IVIG/intralipid is not typically used to prevent miscarriage due to endometriosis or remnants of,  but rather to suppress activated natural killer cells which are often, though not always evident in the endo pt.  A pt w/ endo should be screened for activated nk cells, ata, apa, lac, and have a reproductive immunophenotype panel done to rule out other potential autoimmune etiologies of chronic recurrent miscarriage. It is often these OTHER causes that are the culprit rather than the endo itself which, is generally no longer extant as the dx of endo is done via lap and ablation is done at the time of discovery.  This may seem contradictory in that earlier I said I always use heat clearing herbs in the endo pt. and here I am saying that after a lap the endo is no longer extant. The reason I use heat clearing herbs even after a lap is because it is virtually impossible to ablate or resect ALL endo lesions. Some lesions are the SAME COLOR as normal tissue. So even after a lap, there is STILL ENDO though much less.

Embryo Grading

I never understood the presumed science behind embryo grading. In fact the 'science of embryo grading' may be an oxymoron. Embryo grading is theoretical but not scientific. It is my experience that embryo grading gives patients fall hopes and also lowers hopes of patients inappropriately.  There have been many 4 cell embryos transferred on day two back in the 1980's in the U.S., which resulted in live births. There are many 6 cell embryos with up to 25% fragmentation which yield live births. There are countless grade A blastocysts which do not yeild a pregnancy or do, but with resultant miscarriage.  Yes, if an embryo has > 45 or 50% fragmentation it can be safely assumed that won't result in a pregnancy or live birth. But without such an extreme presentation, it is really not possible to predict an outcome.

I would rather the 'line' that reproductive endocrinologists offer their patients be "we have transferred 3 embryos successfully into your uterus. In 2 weeks we will know if you are pregnant. Let's keep our fingers crossed and hope for the best."  This way the patient has no expectation other than the fact that she will or will not become pregnant.  This is an issue of 'patient management' and one, which in my opinion, should be adhered to.

It is possible to determine a poor embryo. For example a 3 cell embryo with 40% fragmentation probably won't yeild a pregnancy or a live birth. However, it is impossible to determine a good quality embryo if by good quality it means that a reasonable expectation of pregnancy can be expected.  The underpinnings of what makes a good embryo good have yet to be parsed out scientifically.  This is equivalent to an acupuncturist feeling a pulse and telling the patient that they are pregnant. The acuracy of this endeavor is rarely experienced. However, a very experience acupuncturist probably can tell by pulse palpation whether a patient is pregnant before a reproductive endocrinologist can prognosticate the outcome of an IFV ET based upon visual inspection of an embryo.

The take-home message is this: do not be excited when you have an IVF-ET and your doctor raves about the beauty of your embryos just transferred, nor be dismayed when you are told that they are a grade C. You must clear your mind of expectation and 'be' and wait. It is very difficult to go through the day without an expected outcome. Expected outcomes are derived from your output which typically yeilds a result. This is an example of 'control' which we all thrive on and feel so lost without.  In the case of IVF-ET your output nor that of your doctor has any prognostic value. You must 'be' and wait and have no expectation. You can hope; and that's it.

This is also the case of the endometrium. Your doctor will tell you that you have a "beautiful 10 millimeter lining." You are 30 years old and so is your husband. His sperm is healthy, you are hormonally within-normal-limts and both you and your husband are anatomically normal. You have tried to conceive for two years with intercourse, you have done 4 intrauterine inseminations and two invitro-fertilization-embryo-transfers and you have never gotten pregnant. There is a good possibility that your endometrium is defective and can only be properly diagnosed via an endometrial biopsy.  Remember the things needed for a successful pregnancy and a live-birth are good egg, good sperm, good lining, anatomic normalcy and absence of pathology which can mitigate conception. Pathology which can mitigate conception is often under-diagnosed.  A perfect example of this is endometriosis. The mean-time to diagnosis for endometriosis in 10.3 years. Imagine this: a couple is idiopathic meaning that there is no known casue for their inability to conceive. After multiple attemps via assisted-reproductive-technology-interventions the reproductive endocrinologist states "it's time for you to consider using a donor egg" You are devastated, but you MUST HAVE THAT BABY! So you proceed and the transfer is negative. Then, after six years of trying, a doctor recommends a diagnostic laparoscopy to rule out endometriosis and you are found to have stage four endometriosis which is why, all along, you have not been able to conceive. But now you're forty-years old. So even though the endometriosis has been resceted, you have 40 year old eggs and your chances of conceiving with your own eggs are about 8-10%.  You were robbed of your opportunity to conceive becasue of the ultra-conservitism, ignorance or ego of your doctor.  I am not suggesting that at the drop of a hat a diagnostic laparscopy should be scheduled. What I am suggesting is that many reproductive endocrinologists (just as is the case with acupuncturists and every other type of health-care-provider) are too conservative and think-out-of-the-box when it's too late.

I had a doctor tell me recently that mild endometriosis doesn't interfere with conception. This is not true; it does. "Endometriosis is likely the most the common cause of endometrial receptivity defects, especially in cases of minimal or mild disease for which mechanical reasons do not explain the loss of fertility." This is from the September, 2011 issue of Fertility & Sterility, Vol 96, No 3, page 524.  When I brought this to the attention of the doctor, he replied with "Fertility & Sterility is a lousy journal." It is not. In fact, most American reproductive endocrinologists read it and respect it.

It is very difficult to find a good doctor in any field.  I know most of them, especially in New York City. If you would like guidance in finding one with an open mind, an agressive outlook and that has you in mind rather than protecting his or her ego I wouuld be happy to offer it to you.

Mike Berkley, L.Ac., FABORM
http://www.berkleycenter.com/
212-685-0985

Infertility, Endometriosis, Pain Management

Changes in my Acupuncture Protocol


After 13 years of study and clinical experience in treating infertility I have refined my approach to treating patients with acupuncture.
Previously I had always treated patients lying on their backs facing upwards.

Now I treat with three successive protocols: 1)Patient is on back facing upwards; 2) Next visit the patient is on his/her side and I needle the front and back simultaneously; 3) 3rd visit, I treat the patient face down and use acupuncture points on the back only.

This multi-faceted approach allows me to access many important acupuncture points on the body and potentially improve efficacy.

For those of you who are acupuncturists, I am using front mu points, back shu points and points of the 8 extra meridians as well as points which are appropriate for the pattern of disharmony being addressed.

I am starting to see good results with this new appropach.

Endometriosis

Recently, I have added endometriosis as a disease which I am treating.

Treatment is geared towards ameliorating pain AFTER a laparoscopy is performed; potentially slowing down it's re-growth after a laparoscopy by potentially regulating and stabilizing the immune function of the endometrium (for REI's: reduction of MMP's and aromatase IN THE uterine cavity. This is obviously experimental, but if success is manifest then many will be helped - if not, then I will strictly deal with pain management).

So, endometriosis patients are welcome!

Meditation & Pain Management

Lastly, we just completed our second Joanne Verkuilen, Fertility Meditation and everyone loved it! Thanks Joanne for a great job! Joanne is the Co-Founder of Circle+Bloom an incredible organization.

Oh...one more thing, I have hired two excellent acupuncturists whose expertise is in pain management. So, if you, a friend, or a loved one suffers with headache, back-pain, neck-pain, arthritis, etc., have them call Abbey Fromkin, L.Ac. or Jeff Wolf at The Berkley Center they will receive excellent care.

Ciao for now!

Endometriosis

Endometriosis and pain


Pain in the endometriosis patient is caused by several factors which may function individually or concurrently.

1. Inflammation

2. Increased prostaglandins (pain substance)

3. Adhesions which cause distortion of the pelvic organs

4. Endometriotic adhesions on nerves (the woman with endometriosis who suffers with sciatica for example, as a result of endometriotic adhesions on the sciatic nerve)

Acupuncture and herbal medicine often facilitate the following effects.

1. A reduction of inflammation

2. An interruption of the prostaglandin cascade

3. Increase blood flow to areas with adhesions delivering appropriate biochemical products which increase healing; macrohphages for example, which serve to ‘eat’ foreign objects in the body of which an adhesion is but one. Acupuncture nor herbs can eradicate adhesions or endometriotic implants but may, as a result of increased delivery of mitigating biochemical substances, help reduce pain.

If you have pain pre and during menses, pain with deep penetration during intercourse, pain with ovulation, pain at mid cycle, and bowel changes with menses this is suggestive of endometriosis.

Before you get your laparoscopy (for example, if there is a 3 month waiting period because of your surgeons busy schedule), then use acupuncture and herbs to help reduce the pain.

In many cases pain is completely ameliorated after laparoscopy. There are occasions however, when pain persists. It is at this juncture that the use of acupuncture and herbs are very appropriate. Your ONLY alternatives are strong pain medication or medication which will prevent you from menstruating such as aromatase inhibitors or Lupron.

Though these medications will reduce pain, and prevent endometriosis re-growth you will not be able to get pregnant while on them. Even though these drugs can help reduce pain, they will also reduce your estrogen levels which, over time, can negatively affect your heart, brain function, and bone density. Acupuncture and herbs do not have these side-effects and permit pregnancy to occur.

The Berkley Center for Reproductive Wellness is pleased to announce that we are now treating endometriosis patients in addition to treating those couples who are trying to start or grow their families.


Endometriosis and infertility

Endometriosis causes infertility for several reasons.

1. Tubal damage which prevent egg fertilization.

2. Inflammatory proteins in the uterine cavity which prevent implantation

3. Implantation deficit as a result of endometrial pathology associated with endometriosis

4. Possible additional contributing autoimmune disorders which can contribute to infertility; activated natural killer cells, for example.

For the individual wishing to achieve pregnancy who has tubal damage, in-vitro-fertilization after laparoscopic excision surgery is the quickest means to a successful outcome in general. However, the endometrial lining itself is often pathologic and even after a laparoscopy, implantation failure is common. Even the best laparascopic surgeon cannot always excise all endometrial implants.

If, after a laparoscopy, if any endometriosis is still manifest, so too will be the inflammatory proteins associated with endometriosis which contribute to a hostile uterine environment preventing embryo implantation. One may think of this state as having a fever in the uterus. In essence, the uterus is sick. Acupuncture and specifically customized herbal medicine can, in some cases, as mentioned above, reduce these proteins, improve the uterine environment, and help increase pregnancy and live birth rates.

A new perspective on infertility treatment

How many failed IUI's and IVF's have you had? Four? Five? Seven? Have you heard this "you are producing beautiful embryos, your lining looks great and your husbands sperm is off the charts"?  How many failed donor egg cycles have you had?

You may be a victim of poor diagnosis.  For example, how many of you have had a fluid ultra sound? If you have not, raise your hand.  Did you know...one polyp residing in the uterine cavity can prevent implantation? Did you know that frequently a transvaginal ultra sound cannot detect a polyp but a fluid ultra sound always can?

Let's look at a common scenario together. You are thirty-nine years old and you have an fsh of 17 and you have endometriosis. Your doctor thinks that you are not getting pregnant because you have an inflammatory disorder (endometriosis), and that you have poor egg quality, and low ovarian reserve indicated by your age and fsh levels respectively. But, if you have a regular period, the odds are that you still have some good eggs and may have a chance to conceive, else why would your doctor be willing to proceed with an IVF embryo transfer.

The fact that you have been diagnosed with endometriosis indicates that you have had it surgically addressed and so now its clinical relevance is diminished. Now its down to egg quality and ovarian reserve. If you still menstruate regularly, you still have some good eggs even if your fsh is 17. 

So why are you not conceiving? Perhaps because of a physical obstruction, i.e., a polyp or worse, multiple polyps. Polyps are easilly, painlessly and quickly removed via a hysteroscopy.  So, instead of continuing to have ivf after ivf and failure after failure why not rule out possible hidden causes of your problem with simple procedures?  I am not trying to insinuate that all infertility stems from improper diagnosis; sometimes woman can't conceive for reasons which are beyond the scope of current diagnostic tools. I am, however, suggesting that many cases of infertility can be successfully treated where heretofore, they have not.

Did you know that day 3 embryos with less than 6 cells and more than 10 cells are often indicative of poor sperm quality?  Yes I know: your husband had a normal semen analysis. But, has he had a sperm dna fragmentation assay? This test can reveal a  hidden sperm pathology that may be contributing to your inability to conceive?

If his sperm tests normal from the perspectives of volume, count, motility, and volume and you are producing day 3 embryos with less than 6 cells or more than 10 cells, he should have this test. Frequently this test is not performed because your doctor doesn't believe in this test and wouldn't know what to do with the results anyway.  Doctors will tell you that the only challenge that sperm with fragmented dna poses is their inability to penetrate an egg, so the answer is simple: do icsi. ICSI is a process whereupon the sperm is injected into the egg enabling forced fertilization. So your egg is being fertilized with a sperm that couldn't, on it's own, have done this. Essentially, by default, you are ending up with a less than optimal embryo which may yeild a pregnancy which may either result in miscarriage or produce a male child with the same problem as his dad with his future familiy planning requiring IVF with ICSI.

So, are we not, through these 'band-aid' procedures facilitating a nation of weakened children and actually contributing to a generation of infertile couples?

You're wondering what the solution is.  Well that begets a question. If you had type 2 diabetes and were very overweight and had insulin resistance you could do two things to get better: 1) take Metformin and possible other medications or you could change your diet, lose weight, exercise and cure your-self.

One approach is a 'band-aid' approach and one approach is to address the problem at its root.  The solution lies ahead.

Back to sperm dna fragmentation. Before we can hope to address a 'root' treatment we first need to know what causes the problem. Reactive oxidative species or 'ROS' causes fragmentation of the dna in the sperm. ROS is caused by environmental assault such as exposure to certain chemicals, toxins, etc., which can come from smoking marijuana or cigarettes, testicular injury or testicluar surgery allowing antibodies to enter the testicular environment and cause damage.

The severity of DNA fragmentation is determinied by the amount of sperm that is affected. 0 to 15% is indicative of good outcomes in IVF procedures; 15% to 29% means that chances are fair to good; numbers above 29% usually do not result in live births.

In the idiopathic (no known cause) infertile couple, a full diagnosis has not been rendered without a sperm dna fragmentation test. What is the cure? The eradication of free radicals which manifest as a result of ROS.

How? acupuncture ( stimulates blood to the testis helping to send more oxygen and nutrients and dispel dead cells), herbs which have anti oxidant properties, vitamins C and E which have strong anti oxidant properties and daily intake of wheatgrass juice. There is no traditional Western medical approach to the successful treatment of sperm dna fragmentation.

Is medical ego perhaps a contributing factor to the paucity of testing done for this significant pathology?  In other words: if the doctor doesn't 'believe' in the test then it won't be done.  Can you see air? Can you see microorganisms? Can you see God? Can you see energy? No, no, no and no. Do you believe in their existance?  Is your day to day behavior not based upon your belief in these entities even though you have never seen even one of them? 

There are some people that do not believe in the existance of God or microorganisms. Does their lack of belief indicate the lack of existance of these things? It is the wise person who, though belief may not be held, understands that there is a  possibility of existance nonetheless.

Did you know that endometriosis is an autoimmune disease than can cause infertility even in the absence of damaged fallopian tubes? Another interesting thing that you should be aware of is that when one has an automimmune disease such as endometriosis there are often other autoimmune factors which can contribute to infertility which have not been diagnosed; but they should have been. I always recommend a full autoimmune evaluation when one of my patients presents with a known automimune disease to rule out the posibility of other, asymptomatic autoimmune disorders which can cause infertility.

The reason for the paucity of testing for autoimmune disorders which are known to contribute to infertility is that many doctors don't believe that autoimmune disorders can contribute to infertility. The terms yin and yang according to traditional Chinese medicine, means, among other things balance. Balance, according to the traditions of Chinese medicine is required for health, and imbalance is what leads to sickness. Would you agree that an immune system which acts innapropriately against it's host represents an imbalance? And, does it make clinical sense to try to rebalance the behavior of organ/endocrine systems to re-institute health?

Let me tell you an interesting story: when the surgeon general first advised the nation  that there was a direct link between lung cancer and other cancers with cigarette smoking, most doctors who smoked (many, many did) continued to do so becasue they didn't believe what the surgeon general said. Now, years later, most physicians don't smoke because they became convinced of the validity of the surgeon general's report. So, perhaps, years from now, many reproductive endocrinologists will finally understand the clinical significance of certain autoimmune disorders in so far as their role in infertility is concerned.

An example of an autoimmune disorder which can cause infertility is activated natural killer cells. These cells are meant to kill cancer in the uterus. They do so by spraying something called TNF-alpha or tumor necrosis factor on tumors, killing them, and in the best case scenario, saving the patient from endometrial cancer. 

However, in one with an autoimmune mitigated hyperactivity of activated NK cells, these cells spray TNF-alpha on the embryos, instantly killing them causing infertility.  This again is a hidden pathology as it presents with no signs or symptoms. 

The appropriate treatment is intralipid therapy or intravenous immunoglobulin therapy, both of which have been shown to positiviely effect pregnancy outcomes in patients presenting with highly activated NK cells. 

Again, this is the band-aid approach and, in many cases a band-aid approach is not a bad thing; if it works, it works and at the end of the day that's all we want.

To include a modality of medicine which can regulate immune function so that the body can behave normally again also makes sense. Acupuncture and herbal medicine can frequently manifest in this regulation of the immune system.  This is how acupuncture and herbal medicine helps patients who are HIV+ or in full blown AIDS to feel better and stronger - by immune function regulation to whatever extent possible.

Infertility treatment is still in its infancy stage. There have been more than three million babies born as a result of IVF. But this is similar to the concept that many people with cancer have been saved by medical intervention. Both are true, yet the fact remains many more people die from cancer than who are saved and many  more IVF's have been done without the production of a baby.

As time goes on, more and more research will yield better treatment approaches and perhaps one day  infertility will not exist.  In the mean time however it is my contention that all testing, even testing that may present a greater insight into the cause of a couples infertility should be rendered and, the root cause of the problem should simultaneously be treated with natural medicine such as acupuncture and herbs.

Western medicine is superior to Chinese medicine in treating the manifestation of an underlying disregulation or lack of harmony in the functioning of the body but traditional Chinese medicine is, in my opinion (based on clinical experience and three thousand years of data) superior in treating the human body and spirit at the deepest levels.  Therefore, the best approach to treatment of the infertile couple is to employ both modalitities of intervention.  This is the solution!

Acupuncture and Herbal Medicine and How it Helps in the Treatment of Endometriosis

Endometriosis is a very painful condition that affects women; the condition can lead to multiple health related issues. Instead of using traditional forms of medicine some women prefer treating the condition with acupuncture and herbal medicine. The treatments offered vary upon the level of severity as well as a woman’s future plans to have children.

Typically women between the ages of 25 to 35 are diagnosed with endometriosis, but it can occur at different stages of a women’s life. Once a month the ovaries produce hormones that cause the cells of the uterine lining to increase in number and plan for a fertilized egg. The specific cells that cause this are called endometrial cells. They should only grow inside the uterus, when they begin to grow outside of the uterus the condition is referred to as endometriosis.

This condition causes a woman a great deal of pain and can also produce scars on the ovaries, tubes, and area surrounding the pelvis. It can also lead to chronic pelvic pain, development of large cysts in the pelvis, and infertility. A doctor may provide many options for treatment such as: surgery, hysterectomy, and medication. Not all women wish to take drugs or have an invasive operation such as a surgical procedure. For women that wish to have children at some point a hysterectomy is not an option, so they search for possible alternatives such as herbal medicine and acupuncture.

Herbal medicines and acupuncture are often used collectively to not only treat the physical conditions but the mental, emotional, and spiritual conditions as well. Acupuncture has been practiced in China for thousands of years, its use in America started around the 1970s. One of the most common uses for acupuncture in America is for pain treatment.

An acupuncturist inserts small sterile needles into specific points of the body based on the purpose for the treatment. Common locations where the needles are inserted for the treatment of endometriosis are the back, legs, feet, ears, wrists, and abdomen. The amount of time that the needles will be inserted vary on the severity of the condition, typically they remain in place for 20 to 40 minutes. It is believed that acupuncture treats endometriosis by balancing hormone levels, increasing circulation, and reducing pain by boosting the amount of endorphins produced by the body.

Herbal medicine is one of the premier forms of medicine. Typically medicinal plants are used internally and externally to treat a patient and restore their health. Herbalists base their methods on the traditional use of a specific plant as well breakthroughs in modern science. There are many different plants that may be used for the treatment of endometriosis such as: horsetail, cramp bark, burdock, wild yam, motherwort, and dandelion. These plants as well as others are used to help rebalance hormones and increase the strength of the immune system so the body can naturally fight endometriosis.

Like most medicines and treatments the use of acupuncture and herbs may take some time to produce results. When a woman chooses acupuncture or herbal medicine they should only be performed under the careful watch of an acupuncturist or herbalist. For women that suffer from endometriosis, acupuncture and herbal medicine offer an alternative to surgical procedures and drugs produced in a lab.

The best of the best in complementary reproductive medicine

I was invited to speak on the Chinese medcial approach to the treatment of endometriosis in New Mexico by the American Association of Acupuncture and Oriental Medicine.

I had an opportunity to mingle with the best-of-the-best in modern day practitioners of traditional Chinese medicine experts-in-reproductive disorders.

These elite group included: Ray Rubio, Stuart Zoll, Sadhna Singh, Dagmar Ehling, Diane Cridenda, Gerald Williams, Kirstin Karchmer and Caylie See. Paul Magarelli, M.D., Reproductive Endocrinologist was also very much there and participating in educating, supporting and facilitating. I also met Sabine Wilms, scholar and translator of Classical Chinese medicine works. Her most recent contribution is a translation of 3 volumes of gynecological writings the famous doctor by Sun Si Miao. I have already purchased this tome. It is available from CM-DB.Com.

Being with this group of wonderful 'Fellows' is always inspiring; this is the crem-de-la-crem of TCM reproductive medicine practitioners currently practicing in the U.S.

It was an honor for me to be counted among them.

If you want more information on any of these brilliant practitioners, please visit www.aborm.org

Warmest wishes and love to all my ABORM colleagues and thank you all for your amazing and never-ending contribution to this field.

PS: If I left out any names above, please forgive me; you know how I drink!

Love and best wishes.
Mike Berkley, L.Ac.
Founder and Director, The Berkley Center for Reproductive Wellness
212-685-0985
berkleycenter.com

Acupuncture, massage, and herbal therapy have all been linked with success in treating the symptoms of endometriosis including pain reduction and improved fertility outcomes

An estimated five to seven million American women currently suffer from this endometriosis, according to the Journal of the American Medical Association. Endometriosis is derived from the word "endometrium," which is the lining of a woman's uterus.

In this condition, organs like the ovaries, fallopian tubes, ligaments surrounding the uterus, and possibly the lungs, head, and other locations, can have endometrial cells as well as the uterus. However, unlike the uterus, these cells are not expelled from the body during menstruation, but rather linger and are slowly absorbed into the body. This can cause symptoms ranging from pain during intercourse, painful menstruation, low back pain, nausea, fatigue, and infertility.

Diagnosis is performed via laparoscopy. A laparoscopic procedure requires that a lighted optical tube be inserted through a small incision in the navel.

The causes of endometriosis are still unclear, although many theories have been made with attention to, genetic predispositions, and autoimmune causes.

Acupuncture, massage, and herbal therapy have all been linked with success in treating the symptoms of endometriosis including pain reduction and improved fertility outcomes.

Traditional Chinese medicine considers endometriosis as a condition of qi and blood stagnation and heat, which means that the woman’s blood circulation is not occurring properly and that heat (read autoimimmune attack is built up in the pelvic region.

The TCM treatment for endometriosis attempts to increase circulation and clear internal pathogenic heat.

When acupuncture needles are applied to points influencing the nervous system, organ functions, and endocrine system, balance can be restored and blood stasis improved and heat cleared.

Oriental medicine, in conjunction with Western medical approaches often show improvement in symptoms and conception rates greater than those seen when using one of these modalities alone.

Sources:

1. http://tcm.health-info.org/Acupunture/treatment/endometriosis.htm

2. http://www.endo-resolved.com/index.html

3. Du, Li, Endometriosis Through the Eyes of Tradition Chinese Medicine, New Life Journal, 2003

Western Reproductive Medicine and Traditional Chinese Medicine – Things You Should Know

Western reproductive medicine can do the following things: promote follicular development with certain medications, promote ovulation with other medications, perform intra-uterine-insemination, and in-vitro-fertilization. Western reproductive surgeons can also perform often necessary surgeries to create a fertile environment where polyps, fibroids, uterine anomalies and cervical anomalies are present. Without these types of interventions many infertile women would never have children.

Traditional Chinese medicine can often regulate systemic dysfunction naturally. That means that TCM can contribute to helping the PCOS patient ovulate without Clomid or perhaps with a lesser amount of Clomid. In the morbidly obese PCOS patient, weight loss is of paramount importance in increasing the ability to conceive because excess fat stores androgens and converts androgens to estrogen thereby creating a hormonal imbalance that is unlikely to enable conception. Acupuncture and herbal medicine along with exercise and life-style changes can make weight loss and its attendant health benefits possible.

Endometriois

In the endometriosis patient, acupuncture and herbal medicine cannot eradicate endometriosis but it can reduce the inflammatory environment associated with this disease. An interesting example of this is the patient with stage 1 endometriosis who does not present with pelvic distortion but cannot get pregnant. Why not? Her husband’s sperm is fine and other than the endometriosis there are no contributing factors that are contributing to the state of infertility. Even other autoimmune disorders have been ruled out as possible contributing factors. The infertility stems from an inflammatory intrauterine environment that either destroys the embryos or makes the uterine lining inhospitable to an embryo which is trying to implant. Acupuncture and herbal medicine can often regulate this environment by reducing this inflammatory process.


Male factor

Many men have low sperm count as a result of a minor vericocele. Surgeons do not operate on minor vericoceles because the benefit does not exceed this risk. The cause of a vericocele is pooling and stagnating and over-heating of blood in the pampiniform plexus. The pampiniform plexus is the veins in the testicles. The sperm- killing-heat is caused by the pooling and stagnating of blood. Acupuncture and herbs can strongly move qi (energy, metabolism, circulation) and blood in the testicles. As a result of this, the blood is less congealed, the blood flow is more functional and the heat is diminished, contributing to increased sperm count. Even in the face of a major vericocele, the surgical outcomes are successful 50% of the time. This means that even with surgery there is a 50% possibility that the count will remain low. One of the reasons for this is that long term blood stagnation and heat in the testicles causes tissue necrosis (death) and sperm cannot be adequately produced. The determination of success can only be made after the surgery. The recovery time after the surgery is six months.

The reason that this is the case is because the inflammation which is caused by the surgery takes that much time to be reduced. Utilizing acupuncture and herbal medicine after a vericocelectomy shortens recovery time by two months making the total recovery time four months instead of six. Men with any sperm anomaly should refrain from taking hot baths, saunas or riding a bicycle for long periods of time as all of these activities facilitate increased testicular temperature.

What about the patient who wants to do an IVF with her own eggs but her FSH is 18 and her doctor states that donor-egg is the only option? The doctor, essentially, is correct. He or she views this patient as one who either will not respond to gonadal stimulation and therefore produce either no eggs or produce too few to justify the continuation of the IVF cycle. So the reproductive endocrinologist offers the donor egg option with full integrity and with the patient’s best interest in mind. But, here is what I have witnessed on more than a few occasions: I will treat the patient with acupuncture and herbal medicine and her numbers will regulate. Not necessarily to a ‘perfect’ level, but to levels which will facilitate having the reproductive endocrinologist have a ‘second-look’. Subsequently many IVF cycles have been completed with a great many successful outcomes and many failures too. But I choose not to focus too much importance on the failures. It is the successes that would have never occurred had acupuncture and herbal medicine not been utilized on the patient who was told that donor-egg was the only option. In other words, inclusion of TCM has only an upside potential.

Implantation failure

Accounts for a substantial amount of infertility. Almost every patient that I have reports that her lining is “beautiful” according to her reproductive endocrinologist. The scientific truth however is that the morphology of the lining is not analogous to intraendometrial vascularization. This means that even though your lining may be thick it does not mean that there is enough blood flow getting to the lining. This is why sometimes even in the absence of any observable or diagnosable pathology, infertility manifests. Acupuncture and herbal medicine have been shown to increase endometrial vascularization and thereby increasing implantation potential.

The idiopathic patient

Idiopathy means ‘no known cause’. What ‘no known cause’ means is that the limited Western medical diagnostic capabilities available today are only able to diagnose what they can, not what they cannot. In other words, there are many subclinical causes of infertility that have yet to be discovered and which, to date, have no remedies. Over time, this will change. This is by no means meant to be a derisive comment of Western reproductive medicine. IVF has brought thousands of children into the world and created thousands of happy families. These successes would not have been possible in the ‘infertile population’ prior to the advent of this incredible technological breakthrough.

Traditional Chinese medicine, based upon its method of diagnosis does not, as part of its medical vocabulary have a word that is analogous to ‘idiopathic.’ In other words, all cases of infertility can be diagnosed and treated. There are no mysteries or impossible cases.

Each and every case can be, analyzed, differentiated, diagnosed and treated.

TCM can often establish a treatment protocol where Western medicine has none to offer other than donor-egg. TCM uses specific herbal formulas prescribed for a particular patient for a particular disorder, taking into consideration the whole patient as well as their pathology. The whole person is treated, not just their disease. What really does the “whole person” mean? It means that if the patient has a bad marriage, has low libido, chronic headaches, arthritis, depression, anxiety, frustration, a history of surgeries, a history of psycho-emotional trauma, a job she hates, a dying mother, low self-esteem, a smoker, a drinker, a stress eater, etc., etc., these things can contribute to her infertility.

How? Because the mind, spirit and body are inextricably connected. Not convinced? Ok, the why when you are very stressed do you get a headache or a stomach-ache. Why is it that when you are very depressed you have no energy? Why is it that when you pray you feel more empowered? Why is it that when you look better, you feel better and when you feel better you have more energy and when you have more energy you are less likely to get sick and when you are not frequently sick you are not chronically depressed?

Because the mind, spirit and body are inextricably connected. This is why TCM doctors treat the whole person; only treating the disease is like treating a cancer patient with aspirin for their pain.
This is why the best case scenario in the treatment of reproductive disorders (as well as all disorders) is to integrate both methods of medical expertise. The TCM application will help the Western reproductive medical protocol succeed in a shorter period of time. Or TCM may be the difference between success and failure in the Western medical setting; remember, IVF has a 30% success rate which means conversely that it has a 70% failure rate.

Herbs

Many doctors tell their patients not to take herbs. Can you imagine why? Go ahead, let your mind swirl around and try and latch on to one word that sticks. How about ‘dangerous’? DID YOU KNOW: there are more than one million hospitalizations per years as a result of dangerous side-effects caused by pharmaceutical products. But pharma is big business and it has the money and power to squelch the media. When is the last time you heard about someone dying or even being hospitalized as a result of taking herbs? I’ll tell when: NEVER. When is the last time you heard about someone getting sick, or being hospitalized or dying from herbal medicine? I’ll leave that answer to you.

My view is that most Western medicine when prescribed by an expert in his or her field is safe and effective and usually there are no harmful side-effects. Why is it so difficult for Western physicians to say the same thing about herbal medicine? Is it perhaps because if a patient conceives as a result of herbs that a $10,000.00 to $15,000.00 IVF cycle would be cancelled?

Again, I’ll let you answer that question.

Herbal medicine, when prescribed by a Board Certified herbalist is not only safe, but safer than Western drugs. Can herbs “interfere” with Western medicine in an IVF cycle? No. I have been giving herbs to patients while they have been taking Western medicine for ten years. All that’s happened is the production of babies. Can the Western medical establishment be threatened by herbs or acupuncture? I’ll leave that for you to answer.

Here is a medical quiz. If you had a choice of doing something that could improve your chances of conception, would it be:

1. Meditating

2. Praying

3. Yoga

4. Acupuncture

5. Herbal medicine

6. Changing your diet

7. Reducing stress

You’re correct; all of these will help. But can you identify the two things above that have a three-thousand-year-old history of successfully treating infertility? There are only two in the list and only two in the world.

What I find amazing is that every infertile couple is not including acupuncture and herbal medicine as part of their protocol to conceive. Some individuals say they “don’t believe in it.” How can you not believe in something that has been scientifically proven to be effective in countless Western scientific studies?

Non-Believers

I’ve had my share of non believers; they were believers nine months later when they sent me tear-stained letters of gratitude for helping them become parents. Come to my office and see the photos on the walls, the photos of families, the photos of joyous moms and dads, the photos of their smiling cherubs; all sent from non-believers. I can assure that they are all converts now. In fact, a large referral source for me is from former ‘non-believer’ patients.

I am a staunch supporter and firm believer in Western reproductive medicine. But, TCM has been successfully treating infertility for 2930 years longer than Western medicine. And I want parity. Not for my ego or for the validation of the medicine that I so proudly practice but because parity will enable real patient care; better patient care than we presently have; more successful outcomes, more families granted to those who should but cannot have them.

Based upon the information I have provided herewith, it is my conclusion that to not use Traditional Chinese Medicine as part of an assisted-reproductive-medical-protocol is very short-sighted indeed.

Your world is a garden from which you can remove weeds of doubt and replace them with seeds of hope.


mike berkley, L.Ac., FABORM

Doctor of Acupuncture (RI)

Founder and Director, The Berkley Center for Reproductive Wellness

The Berkley Method - Acupuncture

The Berkley Method of Reproductive Wellness(TM) merges Western and complementary medical data enabling the creation of a complete and well rounded treatment protocol. All Berkley Method Certified Practitioners engage in on-going specialized training in Western reproductive science and complementary medicine for the treatment of those faced with fertility challenges.

The Berkley Method, in addition to its philosophy, includes a clinical aspect too. For example, I have started to compile specific acupuncture point protocols for specific pathologies. These point-prescriptions are effective. I have used them to achieve pregnancies for many years.

So far, I have written down my protocols for high fsh, vericoceles, low sperm count, pcos and endometriosis. More will follow.

These acupuncture point combinations must be used as guidelines, changed when necessary to fit the needs of the specific patient in treatment.

Thanks for reading!

Dr. Mike Berkley
mikeberkley@berkleycenter.com