The Berkley Center for Reproductive Wellness has scheduled a meet up to discuss how acupuncture and herbs, when combined with A.R.T. can significantly improve pregnancy rates and reduce miscarriage rates.
Click here to find out more information and to register.
http://meetu.ps/s/.0/lHQD8/f
Showing posts with label infertility. Show all posts
Showing posts with label infertility. Show all posts
Tuesday, April 25
Wednesday, April 19
Couples Ideal for Acupuncture Fertility Treatment
Those who have structural infertility caused by tubal blockage and those with premature ovarian failure are unlikely to do well with acupuncture alone and may consider using acupuncture only as an adjunct to ART. Those men with low sperm counts who have a shortage of time (acupuncture and herbs may take three to twelve months, if successful) will also need to consider ART as the primary treatment modality. Good candidates for acupuncture for infertility include:
- Couples who are having difficulty conceiving but are not ready for ART. Some will conceive using acupuncture and others will move on to ART.
- Women who have done IVF and are taking a break and preparing for another cycle and are seeking acupuncture to improve their probabilities.
- Women who have done 3 to 5 cycles of IVF without success and women who have been advised not to undergo IVF by their doctor.
- Couples who prefer natural medicine or have concerns about ART and are young enough to undergo the longer preparation period usually required for acupuncture.
- Women going through IVF cycles. By the time you get to retrieval there will be a good chance that your egg, lining and/or sperm quality will be vastly improved thereby improving your chances for a positive outcome.
Remember this: when trying to conceive you need one good egg, one good sperm and a healthy lining. Acupuncture and herbal medicine have been shown through research to positively affect egg, sperm and lining quality.
For more visit http://www.berkleycenter.com
Tuesday, April 18
After treating infertility cases for twenty-one years I've arrived at some conclusions which I'd like to share.
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
Thursday, May 8
Infertility: FACT vs MYTH
Infertility is a common disease process that affects 10-15% of the couples within the U.S. who are within the childbearing age. It is also very common worldwide. In recent years, tremendous progress has occurred in the diagnosis and treatment of infertility. We can do much more today than we could a few years ago. In spite of this misinformation regarding the subject abounds. These myths create barriers to the timely diagnosis and treatment of infertility.The truth is that most cases can be rapidly diagnosed and effectively treated. Treatment does not have to cost thousands of dollars. Also in spite of the image given in the press, most patients will not have multiple pregnancies.
MYTH #1
Stress causes infertility.
This is usually not the case. In fact infertility and its treatment causes a great deal of stress rather than vice versa. Saying that stress causes infertility is a way of trivializing the problem.
MYTH #2
Infertility treatment is expensive.
In some cases it can be. In many cases, it is simple, brief and inexpensive. The sooner patients are seen and treated the more likely basic treatment will succeed. Timely treatment can also minimize cost.
MYTH #3
Treatment always causes multiples.
Some treatments such as ovulation drugs or in vitro fertilization do predispose to multiples. They do so to a much lesser degree than is commonly thought. For instance use of Clomid or Serophene increase the natural multiple pregnancy rate from 1.5% to 7%.
MYTH #4
Friends, family, newspapers, T.V., and the internet are always accurate sources of information.
Accurate diagnosis and treatment is the way to go! Myths and misinformation are what we need to grow beyond. Many who put forth the effort will succeed.
Article Repost via http://www.cincinnatifertility.com
Tuesday, May 6
Semen Analysis - Why You May Consider It
image via thereallifeadvice.com
Why would you be doing a Semen Analysis (SA)?
Since male factor accounts for about 35% of infertility, a RE’s office will administer a SA as one of the first tests they’ll do to diagnose you as a couple.
A SA measures the following:
Volume (measured in mL)
Liquefaction time
Sperm count (both the overall count and per mL)
Sperm motility (the percentage of sperm that are moving – these are your “swimmers”). Most clinics also measure how many sperm are moving forward, which is called the “forward motility” test.
Morphology (the percentage of sperm that have a normal shape).
The SA also measures the pH balance, number of white blood cells, and amount of fructose in the sample.
A SA measures the following:
Volume (measured in mL)
Liquefaction time
Sperm count (both the overall count and per mL)
Sperm motility (the percentage of sperm that are moving – these are your “swimmers”). Most clinics also measure how many sperm are moving forward, which is called the “forward motility” test.
Morphology (the percentage of sperm that have a normal shape).
The SA also measures the pH balance, number of white blood cells, and amount of fructose in the sample.
image via http://www.cincinnatifertility.com
What you can expect
Giving a sample
Generally, clinics require that you to not ejaculate for 48 hours before the test, BUT also do not abstain for more than 72 hours. In layman’s terms: they want you to ejaculate once between 2 and 3 days before the SA, but then abstain until after the SA.
Obviously, this is not a painful process, but it can be embarrassing. I have heard stories where someone’s husband had to use a bathroom off the waiting area to produce his sample – the poor guy! In most clinics, especially the bigger ones, though, they have a room set up with magazines (and even movies) for you to do his thing. And in most cases they’ll let the wife go in with him if he so desires.
Some clinics also allow for the sample to be produced at home if you live close to your clinic. Once the sample is produced, though, you need to keep it warm and get it to the clinic within 1 hour, or some of the sperm begin to die off.
Generally, clinics require that you to not ejaculate for 48 hours before the test, BUT also do not abstain for more than 72 hours. In layman’s terms: they want you to ejaculate once between 2 and 3 days before the SA, but then abstain until after the SA.
Obviously, this is not a painful process, but it can be embarrassing. I have heard stories where someone’s husband had to use a bathroom off the waiting area to produce his sample – the poor guy! In most clinics, especially the bigger ones, though, they have a room set up with magazines (and even movies) for you to do his thing. And in most cases they’ll let the wife go in with him if he so desires.
Some clinics also allow for the sample to be produced at home if you live close to your clinic. Once the sample is produced, though, you need to keep it warm and get it to the clinic within 1 hour, or some of the sperm begin to die off.
Results
Generally you’ll get the results back within a couple of days of the SA, but it depends on your clinic. We got our SA results the following day.
Generally you’ll get the results back within a couple of days of the SA, but it depends on your clinic. We got our SA results the following day.
Normal parameters of sperm are the following (*Based on World Heath Organization criteria, 1992. Table excerpted from Berger, G.S., Goldstein, M., and Fuerst, M. (1995). The Couple’s Guide to Fertility. New York: Doubleday):
Normal Ranges for a Semen Analysis*
Liquify?: Yes – within one hour
pH: 7.5 to 8.1
% Motility: Greater than or equal to 50%
% of 3-4 + Forward Motile Sperm: Greater than or equal to 50%
Sperm Concentration: 20-200 million per mL
Total Sperm Count: Greater than or equal to 40 million
Total Motile Sperm: Greater than or equal to 20 million per mL
White Blood Cells: Less than or equal to 1 million per mL
% Normal Morphology: Greater than or equal to 30%
Liquify?: Yes – within one hour
pH: 7.5 to 8.1
% Motility: Greater than or equal to 50%
% of 3-4 + Forward Motile Sperm: Greater than or equal to 50%
Sperm Concentration: 20-200 million per mL
Total Sperm Count: Greater than or equal to 40 million
Total Motile Sperm: Greater than or equal to 20 million per mL
White Blood Cells: Less than or equal to 1 million per mL
% Normal Morphology: Greater than or equal to 30%
Problems that might arise
There aren’t many problems that will present themselves in terms of the collection process, unless you miss the cup or can’t ejaculate.
If the results come back abnormal, your RE will suggest that you see a urologist, who can provide a further diagnosis. Additionally, at times, you can bypass sperm issues by trying IUI or even IVF with ICSI to get pregnant. I have also heard from my RE that there are other nifty high-tech sperm extraction procedures that can give you a chance of getting pregnant – even if your husband has a zero sperm count. At the same time, there will be men who will need to use donor insemination if this is your diagnoses.
If the results come back abnormal, your RE will suggest that you see a urologist, who can provide a further diagnosis. Additionally, at times, you can bypass sperm issues by trying IUI or even IVF with ICSI to get pregnant. I have also heard from my RE that there are other nifty high-tech sperm extraction procedures that can give you a chance of getting pregnant – even if your husband has a zero sperm count. At the same time, there will be men who will need to use donor insemination if this is your diagnoses.
Article repost via http://www.stirrup-queens.com
Wednesday, March 26
Treating Infertility with Herbal Medicine
Herbal medicine has been used to treat internal disorders
including infertility for thousands of years.
Practitioners of Chinese herbal medicine rarely use a single
herb in treatment. Chinese herbs are formula based; many herbs are mixed
together to create the perfect ‘concoction’ specifically designed for the
individual patient.
Some formulae contain two herbs and some thirty or more
herbs. Each herb has many functions. Each herb has its own flavor, nature,
temperature and trophism. Prescribing
the right and the safe herbal medicinals requires training and clinical experience. Herbal medicine is an extremely complex form
of medicine which requires many years of arduous study and clinical experience
to master.
Self medicating with herbal medicine presents a dual
dilemma. At best the herbs will be useless, as the key to correct formula
prescription is an accurate differential diagnosis which can only be made by a
licensed, board certified, experienced practitioner. At the worst case, self
prescribing of herbal medicine may prove harmful or fatal.
A good example of this is Ma Huang/Ephedra. Ma Huang is an herb prescribed on a daily
basis by hundreds of TCM practitioners to thousands of patients safely.
That several people have died as a result of taking Ma Huang
has very little to do with the dangerous properties of the herb inasmuch as it
has to do with individuals self-medicating.
Aspirin can prove fatal if taken by a hemophiliac. This is not an indication that Aspirin should
be banned or that it is a dangerous drug.
It is totally safe if used appropriately.
Herbal medicine is totally safe if prescribed by a
knowledgeable expert. Not only is herbal medicine safe, it is highly effective
in treating many pathologies without the concomitant harmful side-effects which
often accompany pharmaceutical drugs.
There are greater than one million hospitalizations per year as a result
of drug induced side-effects; not so with herbal medicine.
photo via youbeauty.com
Infertility
There are many causes of infertility which include but are
not limited to elevated FSH levels, PCOS, endometriosis, luteal phase defect,
hyperprolactinemia; pituitary adenoma, blocked tubes, uterine anomalies, sperm
anomalies, stress, and, infertility which is diagnosed as idiopathic.
Traditional Chinese Medicine has, for more than three
thousand years, successfully treated infertility; and it still does so today.
Nancy is thirty-nine years old and she wants to compete as
an Olympic triathalete; she is five feet in height and weighs three hundred and
thirty pounds. Can she compete? Let’s see.
She asks her best friend, Alice, for a recommendation for a
nutritionist. Alice raves about Teresa J., a fabulous nutritionist who “changed
her life”. So Nancy makes an appointment with TJ and has a consultation. Nancy
listens attentively to TJ, takes notes and leaves TJ’s office full of
enthusiasm, commitment and motivation.
Starting the next day Nancy begins implementing the new
dietary regimen which TJ has prescribed.
Next, Nancy joins a local health club, hires a personal trainer and
works out three to four days per week. Finally,
Nancy joins a meditation group and meditates daily.
What happened? In
twelve months, Nancy lost one hundred and fifty pounds, put on solid muscle,
developed a ‘six-pack’ abdomen and can run twenty-five miles per week. She is
in the best condition of her life! Can
she now compete in the Olympics? Well, I’m afraid not. To be an Olympic athlete
requires a life-time commitment of training and nutritional guidance. Nancy has, however, become healthier,
stronger and happier than ever before!
What if Nancy wanted to get her reproductive system in Olympic
condition?
The proper life-style counseling which includes nutritional
changes and perhaps an exercise routine and acupuncture and herbal medicine can
get a women’s reproductive system in the best possible condition that it can be
in at the present moment. Your TCM
practitioner should be able not only to treat you with acupuncture and the
appropriate herbal formula but should also give you guidance regarding diet,
exercise and life-style changes which will positively impact your health.
Many women undergo three to five unsuccessful IVF
procedures. Often these procedures are unsuccessful for the same reason that
Nancy could not even begin to be athletic – overall poor health and
specifically, poor reproductive health.
Women who are over thirty years old need to get their
reproductive system in the best condition possible to achieve pregnancy either
naturally or via an A.R.T. procedure.
photo via redbookmag.com
As we grow older our circulation becomes less patent. In
addition to the frequent complaint of cold hands and feet, another effect of
inhibited blood flow is that the quantity of blood flow to the uterine lining,
ovarian tubes and ovaries is less.
Acupuncture and herbal medicine have a stimulatory effect on the blood
circulation. An example of impeded blood
circulation is blood clots in the menstruate. Though in and of itself,
menstrual clotting may not be an issue, it does indicate a circulatory
dysfunction which can be both a manifestation of an illness (circulatory
inhibition) and the cause of an illness (blood stagnation [i.e.,
endometriosis], causing infertility).
Acupuncture and herbal medicine can be an important aspect
of one’s healthcare routine, used to assist in achieving the goal of better
health in general and better reproductive health in particular.
Under the care of a licensed and board certified
acupuncturist/herbalist who is experienced in treating the infertile person
there are no negative or dangerous side-effects associated with acupuncture or herbal
medicine; there is only upside potential.
Using acupuncture and herbal medicine as part of the regimen to achieve
a healthy reproductive system is a fertile idea.
Wednesday, July 18
Infertility Increases Risk of Serious Psychiatric Illness
Infertility Increases Risk of Serious Psychiatric Illness
Published: July 16, 2012Multiple small studies have demonstrated a link between infertility and psychological distress, reporting high rates of anxiety and depressive symptoms among women with infertility. These studies have evaluated psychiatric symptoms or psychological distress; however, less is known about the prevalence of more significant psychiatric disorders in this population.
Data from the largest study to date of women with infertility was recently presented at the annual meeting of ESHRE (European Society of Human Reproduction and Embryology) by Dr. Birgitte Baldur-Felskov.
Danish investigators were able to examine the records of 98,737 Danish women evaluated for infertility between 1973 and 2008. They found that women who remained childless after their first investigation for infertility had more hospitalizations for psychiatric illness than women who had at least one child following their investigation. The most common discharge diagnoses were “anxiety, adjustment and obsessive compulsive disorders” followed by “affective disorders including depression.”
In another study (also from Denmark), investigators examine a cohort of 51,221 women with primary or secondary infertility who had been referred to hospitals or private fertility clinics in Denmark between 1973 and 1998. Each woman was followed from the date of her initial fertility evaluation until 2006.
In this study, they discovered that women who did not have a child after initial fertility evaluation had a greater than twofold risk of suicide (HR: 2.43; 95% CI: 1.38-3.71) than women who had at least one child after evaluation. Women with secondary infertility, i.e. women who had a child before a fertility evaluation but did not succeed in having another child after evaluation, also had an increased risk for suicide (HR: 1.68; 95% CI, 0.82-3.41), although this finding was not statistically significant.
These two reports extend our understanding of the impact of infertility and its treatment on risk for serious psychiatric illness. While future studies will help to determine which women are the most vulnerable to illness in this setting, these two large studies highlight the need for adequate screening for psychiatric illness and appropriate interventions in women who are evaluated for infertility.
[Mike Berkley writes: Acupuncture and herbal medicine have been shown to effective treatment modalitites for anxiety and depression.]
Ruta Nonacs, MD PhD
Kjaer TK, Jensen A, Dalton SO, et al. Suicide in Danish women evaluated for fertility problems. Hum Reprod. 2011;26(9):2401-7.
Read more: Childless Women With Fertility Problems at Higher Risk of Hospitalization for Psychiatric Disorders (Science Daily)
Published: July 16, 2012Multiple small studies have demonstrated a link between infertility and psychological distress, reporting high rates of anxiety and depressive symptoms among women with infertility. These studies have evaluated psychiatric symptoms or psychological distress; however, less is known about the prevalence of more significant psychiatric disorders in this population.
Data from the largest study to date of women with infertility was recently presented at the annual meeting of ESHRE (European Society of Human Reproduction and Embryology) by Dr. Birgitte Baldur-Felskov.
Danish investigators were able to examine the records of 98,737 Danish women evaluated for infertility between 1973 and 2008. They found that women who remained childless after their first investigation for infertility had more hospitalizations for psychiatric illness than women who had at least one child following their investigation. The most common discharge diagnoses were “anxiety, adjustment and obsessive compulsive disorders” followed by “affective disorders including depression.”
In another study (also from Denmark), investigators examine a cohort of 51,221 women with primary or secondary infertility who had been referred to hospitals or private fertility clinics in Denmark between 1973 and 1998. Each woman was followed from the date of her initial fertility evaluation until 2006.
In this study, they discovered that women who did not have a child after initial fertility evaluation had a greater than twofold risk of suicide (HR: 2.43; 95% CI: 1.38-3.71) than women who had at least one child after evaluation. Women with secondary infertility, i.e. women who had a child before a fertility evaluation but did not succeed in having another child after evaluation, also had an increased risk for suicide (HR: 1.68; 95% CI, 0.82-3.41), although this finding was not statistically significant.
These two reports extend our understanding of the impact of infertility and its treatment on risk for serious psychiatric illness. While future studies will help to determine which women are the most vulnerable to illness in this setting, these two large studies highlight the need for adequate screening for psychiatric illness and appropriate interventions in women who are evaluated for infertility.
[Mike Berkley writes: Acupuncture and herbal medicine have been shown to effective treatment modalitites for anxiety and depression.]
Ruta Nonacs, MD PhD
Kjaer TK, Jensen A, Dalton SO, et al. Suicide in Danish women evaluated for fertility problems. Hum Reprod. 2011;26(9):2401-7.
Read more: Childless Women With Fertility Problems at Higher Risk of Hospitalization for Psychiatric Disorders (Science Daily)
Labels:
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depression,
distress,
fertility,
hormones,
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stress,
suicide,
women’s mental health
Tuesday, October 18
New Study Finds Sperm Quality Decreases as Males Age
Colorado Researchers Confirm Men, like Women, have a Ticking Biological Clock that Impacts Fertility
DENVER, Oct. 17, 2011 /PRNewswire via COMTEX/ -- A new study conducted by the Colorado Center for Reproductive Medicine (CCRM) in conjunction with the National Foundation for Fertility Research (NFFR) concludes that sperm from middle-aged and older male mice is less likely to lead to a successful pregnancy. The study, the first-of-its-kind, found that sperm quality began to decrease in males at mid-life, 12 months and older (equivalent to forty and older for human males).
"This is not a study observing male factor infertility. Rather, this is a study about once fertile males becoming infertile because of age," said Mandy Katz-Jaffe, PhD, Scientific Director of NFFR. "We were able to document when sperm from older males begins to suffer quality problems, and to understand the impact of older sperm on reproductive outcome."
This is the first longitudinal study following males over a lifetime to directly correlate sperm aging with reproductive success. Ten young male mice with proven fertility were mated every month during their lifetimes as they naturally aged with fertile young females. "This study is unique because we were able to remove infertility related to the female aging from the equation and focus solely on the male," said Katz-Jaffe. "This is something that is impossible to accomplish with human studies."
This study found that when proven fertile male mice reached mid-life (12 months = forties):
Eggs were less likely to be fertilized by aged sperm.
Embryos were less likely to develop in vitro.
Embryos were less likely to implant in the uterus.
Natural conceptions were far fewer. Only 50 percent achieved pregnancy naturally at 12 months (forties) and 10 percent naturally at 15 months (fifties).
Assisted reproductive technologies (ART) improved the chance of clinical pregnancy.
The few successful natural conceptions with aged sperm resulted in significantly smaller fetuses and placental weight.
"There is much focus in society on the 'maternal biological clock.' This study shows us that we also need to be concerned about the 'paternal clock,'" said William Schoolcraft, M.D., Founder and Medical Director of CCRM. "Men in their thirties should consider freezing sperm if they plan to wait to have children. Men in their forties and fifties should consult a reproductive endocrinologist if their partner is unable to conceive after six months of active trying."
About the Colorado Center for Reproductive Medicine
Founded in 1987 by Dr. William Schoolcraft, the Colorado Center for Reproductive Medicine is one of the nation's leading infertility treatment centers, providing a wide spectrum of infertility treatments ranging from basic infertility care to advanced in vitro fertilization (IVF) technology. Today, joined by Drs. Eric Surrey, Debra Minjarez and Robert Gustofson, Dr. Schoolcraft and his staff achieve some of the highest pregnancy rates in the country. CCRM has been ranked "The #1 Fertility Center in the U.S., with the Greatest Chance of Success" by Child.com. For more information, visit www.ColoCRM.com .
About the National Foundation for Fertility Research
The National Foundation for Fertility Research is 501 (c) (3) non-profit collaborative of internationally known researchers dedicated to advancing the field of reproductive medicine. The mission of NFFR is to ensure that all who seek fertility treatment have that joyous moment when they hold their baby for the very first time. Under the direction of Dr. Mandy Katz-Jaffe and her team of senior scientists and embryologists, NFFR research studies will continue to bring hope and new opportunities to couples seeking fertility treatment. For more information, visit www.fertilityresearch.org .
SOURCE Colorado Center for Reproductive Medicine (CCRM)
Copyright (C) 2011 PR Newswire. All rights reserved
DENVER, Oct. 17, 2011 /PRNewswire via COMTEX/ -- A new study conducted by the Colorado Center for Reproductive Medicine (CCRM) in conjunction with the National Foundation for Fertility Research (NFFR) concludes that sperm from middle-aged and older male mice is less likely to lead to a successful pregnancy. The study, the first-of-its-kind, found that sperm quality began to decrease in males at mid-life, 12 months and older (equivalent to forty and older for human males).
"This is not a study observing male factor infertility. Rather, this is a study about once fertile males becoming infertile because of age," said Mandy Katz-Jaffe, PhD, Scientific Director of NFFR. "We were able to document when sperm from older males begins to suffer quality problems, and to understand the impact of older sperm on reproductive outcome."
This is the first longitudinal study following males over a lifetime to directly correlate sperm aging with reproductive success. Ten young male mice with proven fertility were mated every month during their lifetimes as they naturally aged with fertile young females. "This study is unique because we were able to remove infertility related to the female aging from the equation and focus solely on the male," said Katz-Jaffe. "This is something that is impossible to accomplish with human studies."
This study found that when proven fertile male mice reached mid-life (12 months = forties):
Eggs were less likely to be fertilized by aged sperm.
Embryos were less likely to develop in vitro.
Embryos were less likely to implant in the uterus.
Natural conceptions were far fewer. Only 50 percent achieved pregnancy naturally at 12 months (forties) and 10 percent naturally at 15 months (fifties).
Assisted reproductive technologies (ART) improved the chance of clinical pregnancy.
The few successful natural conceptions with aged sperm resulted in significantly smaller fetuses and placental weight.
"There is much focus in society on the 'maternal biological clock.' This study shows us that we also need to be concerned about the 'paternal clock,'" said William Schoolcraft, M.D., Founder and Medical Director of CCRM. "Men in their thirties should consider freezing sperm if they plan to wait to have children. Men in their forties and fifties should consult a reproductive endocrinologist if their partner is unable to conceive after six months of active trying."
About the Colorado Center for Reproductive Medicine
Founded in 1987 by Dr. William Schoolcraft, the Colorado Center for Reproductive Medicine is one of the nation's leading infertility treatment centers, providing a wide spectrum of infertility treatments ranging from basic infertility care to advanced in vitro fertilization (IVF) technology. Today, joined by Drs. Eric Surrey, Debra Minjarez and Robert Gustofson, Dr. Schoolcraft and his staff achieve some of the highest pregnancy rates in the country. CCRM has been ranked "The #1 Fertility Center in the U.S., with the Greatest Chance of Success" by Child.com. For more information, visit www.ColoCRM.com .
About the National Foundation for Fertility Research
The National Foundation for Fertility Research is 501 (c) (3) non-profit collaborative of internationally known researchers dedicated to advancing the field of reproductive medicine. The mission of NFFR is to ensure that all who seek fertility treatment have that joyous moment when they hold their baby for the very first time. Under the direction of Dr. Mandy Katz-Jaffe and her team of senior scientists and embryologists, NFFR research studies will continue to bring hope and new opportunities to couples seeking fertility treatment. For more information, visit www.fertilityresearch.org .
SOURCE Colorado Center for Reproductive Medicine (CCRM)
Copyright (C) 2011 PR Newswire. All rights reserved
Thursday, September 16
Conception is a process - Or...don't microwave your dinner
Process
Conception, pregnancy and parturition are a process. One definition of process is “a series of actions, changes, or functions bringing about a result”. Any natural process is better in every way than an artificial one. A good example is cooking. There is the process of cooking which is a slow, mindful act and there is microwave cooking which is basically a non-participatory act without natural process. There is no relationship between the chef and the outcome of the meal. Which meal tastes better? And, which is healthier to eat?
The process of conception is quite complicated and requires the perfect balance and function of many components all working in a coordinated and harmonious fashion. Sperm must be attracted to egg, it must find the egg, and it must penetrate the egg. The egg has be high quality and so too must be the sperm. The lining must have qualitative integrity. The embryo must find the lining and must be able to penetrate it. The placenta must develop and nourish the developing fetus and rid the fetus of waste matter. The placenta must protect the fetus from immunological attack. The cytokines, proteins, immune function, blood flow, gycoproteins, hormones must all be in balance and not under or over functioning. There must be absence of pathological mitigators which can contribute to infertility or promote miscarriage. Each and every player in the orchestra of conception must be in tune. One sour note and pregnancy will not occur or miscarriage will ensue.
Chinese medicine which consists mainly of acupuncture and herbal medicine does not work by adding to that which is deficient or reducing that which is in excess; Western medicine is good at that. For example, a common practice in treating a deficiency syndrome, i.e., hypothyroidism is to ADD synthroid. Or a common method at reducing excess insulin is by prescribing Metformin. These medicines which add or suppress or reduce have changed the face of civilization. Without the intervention of Western medicine and surgery our life-span would probably not exceed 40 years of age and three million babies would not have been born as a result of IVF. How many couples however, have remained childless even though they have undergone multiple IVFs? I am guessing more than three million.
Here is why: Just as a microwave oven can cook a meal, IVF can create a baby. But, as the microwave does not supplant the relationship between the chef and the food and the process of creating a meal, IVF cannot, in all its glory, in all cases, replace the natural process which is necessary to occur for conception and a take-home-baby to ensue.
The alternative
Acupuncture and herbal medicine are essentially used to create a state as close to homeostasis as possible. Homeostasis is when everything in the body and mind work perfectly. Obviously, this is impossible. But, acupuncture and herbs attempt this and by attempting it a greater state of systemic and psycho-emotional health is achieved. This is why, in many cases, acupuncture and herbs work to help one achieve pregnancy when IVF fails. Because the greater one’s physical and psycho-emotional health is, the more likely that they will be able to conceive.
Based upon fourteen years of clinical experience in the field of infertility it is my professional opinion that the best case scenario for the infertile patient is to utilize Western medicine in conjunction with acupuncture and herbal medicine. The reason for this is quite simple. When the reproductive endocrinologist retrieves eggs and fertilizes them with sperm the resulting embryo is as good as its constituent components, egg and sperm. Most IVFs that fail do so because of poor egg quality and/or poor sperm quality. The reproductive endocrinologist cannot improve egg or sperm quality; acupuncture and herbs frequently can.
Blood
I saw a thirty four year old patient today. She has conceived three times with intercourse only to miscarry each time. She did get pregnant and delivered a baby as a result of insemination. She had one subsequent failed IVF. Now her doctor recommends donor egg with IVF. The patient has cold hands and feet, a pale complexion, low energy and gets dizzy. Obviously she has poor hemodynamics. Blood is what carries FSH and LH from the brain to the ovaries; blood nourishes the endometrial lining; blood carries oxygen, electrolytes and nutrition to the entire reproductive system and removes waste matter from the reproductive environment. When cells die which they constantly do, they are ‘eaten’ up by macrophages. If the immune function is not functioning normally and debris are not removed, the outer layer of the dead cells breach and the internal toxic substance circulates within the ovarian milieu causing degradation in ovarion/egg quality. Acupuncture and herbal medicine increase blood flow and as a result, can, in many instances, improve the target tissue, the ovaries and endometrial lining.
Why are you not using acupuncture and herbs?
It is difficult for me to understand why all infertile patients don’t include acupuncture and herbal medicine in their protocols. Why would they not? There has been so much research elucidating the efficacy of acupuncture in the treatment of infertility that acupuncture is no longer referred to as ‘alternative’ medicine but rather ‘complementary’ medicine. Herbs have a three-thousand year history of positive clinical outcomes.
Herb safety
Regarding the safety profile of herbs I have this to say: there are at least one million hospitalizations per year in America alone which occur as a result of bad reaction to Western medicine. Many of these hospitalizations result in death. This does not happen with herbal medicine.
It is ironic therefore, that many (but no longer all!) doctors don’t want their patients on herbs because “they don’t know what’s in them”. Do you know what’s in Lupron? Or Gonal F? Did you know that ovarian hyper stimulation even from clomid can be fatal?
Don’t misunderstand, I am 100% pro IUI, IVF and donor egg-IVF protocols. But to not partake of a modality with proven results which may change the course from a negative outcome to a positive one especially in the patient who has had multiple IUI/IVF failures is a clinical error.
Mike Berkley, L.Ac.
Conception, pregnancy and parturition are a process. One definition of process is “a series of actions, changes, or functions bringing about a result”. Any natural process is better in every way than an artificial one. A good example is cooking. There is the process of cooking which is a slow, mindful act and there is microwave cooking which is basically a non-participatory act without natural process. There is no relationship between the chef and the outcome of the meal. Which meal tastes better? And, which is healthier to eat?
The process of conception is quite complicated and requires the perfect balance and function of many components all working in a coordinated and harmonious fashion. Sperm must be attracted to egg, it must find the egg, and it must penetrate the egg. The egg has be high quality and so too must be the sperm. The lining must have qualitative integrity. The embryo must find the lining and must be able to penetrate it. The placenta must develop and nourish the developing fetus and rid the fetus of waste matter. The placenta must protect the fetus from immunological attack. The cytokines, proteins, immune function, blood flow, gycoproteins, hormones must all be in balance and not under or over functioning. There must be absence of pathological mitigators which can contribute to infertility or promote miscarriage. Each and every player in the orchestra of conception must be in tune. One sour note and pregnancy will not occur or miscarriage will ensue.
Chinese medicine which consists mainly of acupuncture and herbal medicine does not work by adding to that which is deficient or reducing that which is in excess; Western medicine is good at that. For example, a common practice in treating a deficiency syndrome, i.e., hypothyroidism is to ADD synthroid. Or a common method at reducing excess insulin is by prescribing Metformin. These medicines which add or suppress or reduce have changed the face of civilization. Without the intervention of Western medicine and surgery our life-span would probably not exceed 40 years of age and three million babies would not have been born as a result of IVF. How many couples however, have remained childless even though they have undergone multiple IVFs? I am guessing more than three million.
Here is why: Just as a microwave oven can cook a meal, IVF can create a baby. But, as the microwave does not supplant the relationship between the chef and the food and the process of creating a meal, IVF cannot, in all its glory, in all cases, replace the natural process which is necessary to occur for conception and a take-home-baby to ensue.
The alternative
Acupuncture and herbal medicine are essentially used to create a state as close to homeostasis as possible. Homeostasis is when everything in the body and mind work perfectly. Obviously, this is impossible. But, acupuncture and herbs attempt this and by attempting it a greater state of systemic and psycho-emotional health is achieved. This is why, in many cases, acupuncture and herbs work to help one achieve pregnancy when IVF fails. Because the greater one’s physical and psycho-emotional health is, the more likely that they will be able to conceive.
Based upon fourteen years of clinical experience in the field of infertility it is my professional opinion that the best case scenario for the infertile patient is to utilize Western medicine in conjunction with acupuncture and herbal medicine. The reason for this is quite simple. When the reproductive endocrinologist retrieves eggs and fertilizes them with sperm the resulting embryo is as good as its constituent components, egg and sperm. Most IVFs that fail do so because of poor egg quality and/or poor sperm quality. The reproductive endocrinologist cannot improve egg or sperm quality; acupuncture and herbs frequently can.
Blood
I saw a thirty four year old patient today. She has conceived three times with intercourse only to miscarry each time. She did get pregnant and delivered a baby as a result of insemination. She had one subsequent failed IVF. Now her doctor recommends donor egg with IVF. The patient has cold hands and feet, a pale complexion, low energy and gets dizzy. Obviously she has poor hemodynamics. Blood is what carries FSH and LH from the brain to the ovaries; blood nourishes the endometrial lining; blood carries oxygen, electrolytes and nutrition to the entire reproductive system and removes waste matter from the reproductive environment. When cells die which they constantly do, they are ‘eaten’ up by macrophages. If the immune function is not functioning normally and debris are not removed, the outer layer of the dead cells breach and the internal toxic substance circulates within the ovarian milieu causing degradation in ovarion/egg quality. Acupuncture and herbal medicine increase blood flow and as a result, can, in many instances, improve the target tissue, the ovaries and endometrial lining.
Why are you not using acupuncture and herbs?
It is difficult for me to understand why all infertile patients don’t include acupuncture and herbal medicine in their protocols. Why would they not? There has been so much research elucidating the efficacy of acupuncture in the treatment of infertility that acupuncture is no longer referred to as ‘alternative’ medicine but rather ‘complementary’ medicine. Herbs have a three-thousand year history of positive clinical outcomes.
Herb safety
Regarding the safety profile of herbs I have this to say: there are at least one million hospitalizations per year in America alone which occur as a result of bad reaction to Western medicine. Many of these hospitalizations result in death. This does not happen with herbal medicine.
It is ironic therefore, that many (but no longer all!) doctors don’t want their patients on herbs because “they don’t know what’s in them”. Do you know what’s in Lupron? Or Gonal F? Did you know that ovarian hyper stimulation even from clomid can be fatal?
Don’t misunderstand, I am 100% pro IUI, IVF and donor egg-IVF protocols. But to not partake of a modality with proven results which may change the course from a negative outcome to a positive one especially in the patient who has had multiple IUI/IVF failures is a clinical error.
Mike Berkley, L.Ac.
Wednesday, April 7
Herbs for Fertility
No woman wants to find out that they are going to have problems getting pregnant but every year more and more women find out that this is the case for them. If you are sadly one of those girls you should always remember that there’s hope and because you are having problems doesn’t mean that you can never conceive a kid. There is a lot of female infertility information out there if you just know where to look for it and you may be surprised at what you find out.
There are plenty of ladies who thru using the female infertility information that they find really finish up becoming pregnant later down line. While there are medical treatments available, not many people have any sort of infertility insurance to cover the costs. This implies that a large amount of the money is going to come out of your own pocket which may be anywhere from 5 to 10 thousand greenbacks over the course of a year. For most people, this is a big chunk of money and something that cannot be afforded. If you are one of those people who simply cannot afford the expensive treatments then you could always try your own treatments.
There is a lot of female infertility information out there that shows that you can use some home remedies or herbal mixtures to finally get pregnant. While the medical community hasn’t officially asserted that these work, there are a large amount of folk out there who are converts of it. Start searching the web and you will be surprised at all of the female infertility information that you find. Search blogs and such to see what other ladies in an identical scenario did and how it worked well for them. Something crucial to bear in mind though is that what worked for the girl on the opposite side of the country may not work for you.
There are plenty of ladies who thru using the female infertility information that they find really finish up becoming pregnant later down line. While there are medical treatments available, not many people have any sort of infertility insurance to cover the costs. This implies that a large amount of the money is going to come out of your own pocket which may be anywhere from 5 to 10 thousand greenbacks over the course of a year. For most people, this is a big chunk of money and something that cannot be afforded. If you are one of those people who simply cannot afford the expensive treatments then you could always try your own treatments.
There is a lot of female infertility information out there that shows that you can use some home remedies or herbal mixtures to finally get pregnant. While the medical community hasn’t officially asserted that these work, there are a large amount of folk out there who are converts of it. Start searching the web and you will be surprised at all of the female infertility information that you find. Search blogs and such to see what other ladies in an identical scenario did and how it worked well for them. Something crucial to bear in mind though is that what worked for the girl on the opposite side of the country may not work for you.
Saturday, April 3
Mike Berkley, L.Ac. is in the News!
Many within the field of assisted reproductive technology have embraced this 3,000 year old practice and the trend of East Meets West IVF clinics is becoming popular nationwide. One such integrated practice is Batzofin Fertility Services in New York City. According to Joel Batzofin, M.D. "There is a myriad of ways to travel the road to fertility success, and everyone's situation is unique". The location of Batzofin's practice is adjacent to The Berkley Center for Reproductive Wellness, where TCM and acupuncture are administered to infertility patients.
Monday, March 8
Cigarette Smoking Contributes to Infertility and Miscarriage
Cigarette Smoking linked to Infertility and Miscarriage
Reproductive cells are vulnerable to genetic damage from smoking, but can be repaired.
In ejaculated spermatozoa, repair capacity declines drastically. This means that that repair is necessary at the time sperm is growing and developing in the testicles.
Smoking leads to chromosome errors which affect reproductive outcomes.
Smoking is associated with reduced numbers of eggs leading to early menopause.
Smoking inhibits embryo fragmentation; inhibition may confer survival advantage to embryos genetically altered. This can lead to pregnancy with impending miscarriage, or children born with cancer or born with genetic defects.
Smoking is associated with low sperm quality. Cadmium (a heavy metal), nicotine (a toxic alkaloid), and its metabolite cotinine, are detectable in testicular and ovarian tissue tissues and fluids in association with smoking. Cotinine incorporates into ovarian granulosa–lutein cells, compromising the developmental potential of follicles. Benzo[a]pyrene is a carcinogenic polycyclic aromatic hydrocarbon resulting from cigarette combustion.
Smoking-related cellular products were detectable in ovarian granulosa–lutein cells, eggs, sperm and embryos. Transmission of altered DNA from smoking by sperm was demonstrated in embryos and in association with increased risk of childhood cancer.
We know that cigarette smoking stems in part from anxiety. The satisfaction derived from cigarette smoking is complicated and manifold but nonetheless stems from the need to reduce anxiety.
In 1999, clinical researchers reported that inserting acupuncture needles into specific body points triggers the production of endorphins. In another study, higher levels of endorphins were found in cerebrospinal fluid after patients underwent acupuncture. Endorphins have been shown to reduce anxiety.
Based upon my clinical experience, acupuncture can aid in the cessation of cigarette smoking and thereby serve two purposes: 1) improve the health of the individual and, 2) improve the quality of egg and/or sperm and increase pregnancy outcomes and reduce miscarriage rates as well as aid in the health of the newborn.
If you and your partner are trying to conceive, the cessation of cigarette smoking is of the utmost importance.
At the Berkley Center for Reproductive Wellness, a leading fertility center in New York City, we have devised a protocol which confers an approximate 50% cure to cigarette smoking without drugs, nicotine, or other chemicals.
Reproductive cells are vulnerable to genetic damage from smoking, but can be repaired.
In ejaculated spermatozoa, repair capacity declines drastically. This means that that repair is necessary at the time sperm is growing and developing in the testicles.
Smoking leads to chromosome errors which affect reproductive outcomes.
Smoking is associated with reduced numbers of eggs leading to early menopause.
Smoking inhibits embryo fragmentation; inhibition may confer survival advantage to embryos genetically altered. This can lead to pregnancy with impending miscarriage, or children born with cancer or born with genetic defects.
Smoking is associated with low sperm quality. Cadmium (a heavy metal), nicotine (a toxic alkaloid), and its metabolite cotinine, are detectable in testicular and ovarian tissue tissues and fluids in association with smoking. Cotinine incorporates into ovarian granulosa–lutein cells, compromising the developmental potential of follicles. Benzo[a]pyrene is a carcinogenic polycyclic aromatic hydrocarbon resulting from cigarette combustion.
Smoking-related cellular products were detectable in ovarian granulosa–lutein cells, eggs, sperm and embryos. Transmission of altered DNA from smoking by sperm was demonstrated in embryos and in association with increased risk of childhood cancer.
We know that cigarette smoking stems in part from anxiety. The satisfaction derived from cigarette smoking is complicated and manifold but nonetheless stems from the need to reduce anxiety.
In 1999, clinical researchers reported that inserting acupuncture needles into specific body points triggers the production of endorphins. In another study, higher levels of endorphins were found in cerebrospinal fluid after patients underwent acupuncture. Endorphins have been shown to reduce anxiety.
Based upon my clinical experience, acupuncture can aid in the cessation of cigarette smoking and thereby serve two purposes: 1) improve the health of the individual and, 2) improve the quality of egg and/or sperm and increase pregnancy outcomes and reduce miscarriage rates as well as aid in the health of the newborn.
If you and your partner are trying to conceive, the cessation of cigarette smoking is of the utmost importance.
At the Berkley Center for Reproductive Wellness, a leading fertility center in New York City, we have devised a protocol which confers an approximate 50% cure to cigarette smoking without drugs, nicotine, or other chemicals.
Friday, September 4
Case Report - Ovulation after acupuncture in PCOS patient
EXETER, ENGLAND — A course of acupuncture was followed by ovulation in a 32-year-old woman with oligomenorrhea and primary infertility of 6 years' duration, Dr. Jin Xu said at a health care symposium sponsored by the University of Exeter.
Before undergoing acupuncture, the patient had “very infrequent” menstrual periods, and transvaginal ultrasound revealed polycystic ovaries. The patient's luteinizing hormone to follicle-stimulating hormone ratio exceeded 3:1, as is typical in polycystic ovary syndrome, and her testosterone level was elevated at 3.7 nmol/L.
Five daily sessions of electroacupuncture were performed on acupoints Guanyuan (Ren 4), Zhongji (Ren 3), Zigong (Extra 16), and Sanyinjiao (Sp 6), said Dr. Xu of the University of Oxford (England). Each acupuncture session lasted 25 minutes.
After the course of acupuncture, endometrial thickness increased from 4.5 mm to 8 mm by day 16, and a menstrual bleed was induced, Dr. Xu said.
Treatment was repeated in the next menstrual cycle, and the patient subsequently began to have regular periods. Three months later, she conceived and delivered a healthy baby girl at term, Dr. Xu said.
“It is likely that the hypothalamus-pituitary-ovary axis is involved in acupuncture-driven ovulation induction, but the mechanisms involved remain unclear,” he said.
Limited research has been conducted in this area, and it is unclear whether an actual effect on ovulation exists, Dr. Xu cautioned, adding that a clear need exists for randomized, controlled trials.
For more information on infertility, acupuncture and herbal medicine, visit www.berkleycenter.com
Before undergoing acupuncture, the patient had “very infrequent” menstrual periods, and transvaginal ultrasound revealed polycystic ovaries. The patient's luteinizing hormone to follicle-stimulating hormone ratio exceeded 3:1, as is typical in polycystic ovary syndrome, and her testosterone level was elevated at 3.7 nmol/L.
Five daily sessions of electroacupuncture were performed on acupoints Guanyuan (Ren 4), Zhongji (Ren 3), Zigong (Extra 16), and Sanyinjiao (Sp 6), said Dr. Xu of the University of Oxford (England). Each acupuncture session lasted 25 minutes.
After the course of acupuncture, endometrial thickness increased from 4.5 mm to 8 mm by day 16, and a menstrual bleed was induced, Dr. Xu said.
Treatment was repeated in the next menstrual cycle, and the patient subsequently began to have regular periods. Three months later, she conceived and delivered a healthy baby girl at term, Dr. Xu said.
“It is likely that the hypothalamus-pituitary-ovary axis is involved in acupuncture-driven ovulation induction, but the mechanisms involved remain unclear,” he said.
Limited research has been conducted in this area, and it is unclear whether an actual effect on ovulation exists, Dr. Xu cautioned, adding that a clear need exists for randomized, controlled trials.
For more information on infertility, acupuncture and herbal medicine, visit www.berkleycenter.com
Tuesday, September 1
High FSH
Elevated FSH Women are born with all the eggs that they will ever have, and they lose them constantly throughout life until menopause when few remain.
The term "ovarian reserve" is useful in the field of reproductive medicine. It is an estimate of the reserve of the woman's ovaries, her remaining egg supply. A woman's ovarian reserve is her remaining fertility potential.
There are several ways to attempt to predict egg quantity and quality as well as trying to estimate chances for conception with various forms of fertility treatment. Female age and day 3 FSH levels are two very important variables. The response of the ovaries to ovarian stimulation with injectable gonadotropins (FSH) is another very important variable that affects the overall chance for conception when in vitro fertilization is attempted.
Blood transports hormones from the endocrine system to target cells or organs within the body, including the hypothalamus, anterior pituitary and ovaries, the three essential organs necessary to achieve pregnancy. At The Berkley Center for Reproductive Wellness, acupuncture, herbal medicine, and fertility massage are used specifically to increase blood flow to the ovaries and the uterine lining thereby improving reproductive rates.
If FSH is elevated, the first order of business should be to increase and enhance blood flow to the reproductive organs so that proper hormonal distribution the pelvic bowl is accomplished. At The Berkley Center for Reproductive Wellness, by employing acupuncture and our proprietary herbal formulas, we have successfully increased blood circulation to the ovaries and lowered FSH levels while simultaneously keeping estradiol (E2) between 25 and 65pg/ml. In other words, our treatments don’t falsely suppress FSH levels, but rather, regulate them.
Further, we have repeatedly seen a reduction in the uterine artery pulsatility index after treatment with acupuncture and herbs. The pulsatility index is a method of determining the amount of blood flow to the uterus via the uterine arteries. The pulsatility index should be <>3 rarely achieve conception.
Via the release of beta-endorphins from the brain, the sympathetic nervous system is affected and vascular modulation occurs with dilation of the uterine arteries, thereby reducing uterine artery impedance and increasing blood flow to the reproductive environment.
The term "ovarian reserve" is useful in the field of reproductive medicine. It is an estimate of the reserve of the woman's ovaries, her remaining egg supply. A woman's ovarian reserve is her remaining fertility potential.
There are several ways to attempt to predict egg quantity and quality as well as trying to estimate chances for conception with various forms of fertility treatment. Female age and day 3 FSH levels are two very important variables. The response of the ovaries to ovarian stimulation with injectable gonadotropins (FSH) is another very important variable that affects the overall chance for conception when in vitro fertilization is attempted.
Blood transports hormones from the endocrine system to target cells or organs within the body, including the hypothalamus, anterior pituitary and ovaries, the three essential organs necessary to achieve pregnancy. At The Berkley Center for Reproductive Wellness, acupuncture, herbal medicine, and fertility massage are used specifically to increase blood flow to the ovaries and the uterine lining thereby improving reproductive rates.
If FSH is elevated, the first order of business should be to increase and enhance blood flow to the reproductive organs so that proper hormonal distribution the pelvic bowl is accomplished. At The Berkley Center for Reproductive Wellness, by employing acupuncture and our proprietary herbal formulas, we have successfully increased blood circulation to the ovaries and lowered FSH levels while simultaneously keeping estradiol (E2) between 25 and 65pg/ml. In other words, our treatments don’t falsely suppress FSH levels, but rather, regulate them.
Further, we have repeatedly seen a reduction in the uterine artery pulsatility index after treatment with acupuncture and herbs. The pulsatility index is a method of determining the amount of blood flow to the uterus via the uterine arteries. The pulsatility index should be <>3 rarely achieve conception.
Via the release of beta-endorphins from the brain, the sympathetic nervous system is affected and vascular modulation occurs with dilation of the uterine arteries, thereby reducing uterine artery impedance and increasing blood flow to the reproductive environment.
Sunday, August 30
The Berkley Center for Reproductive Wellness
The Berkley Center is world renowned for treating reproductive disorders with acupuncture, natural fertility medicine, nutrition, and fertility massage. We take a comprehensive approach to increasing your fertile wellness with natural fertility treatment. We even use natural fertility drugs (herbal medicine) which have been shown to be very effective in treating infertility when related to endometriosis, PCOS, high FSH, low sperm count, sperm DNA fragmentation, low ovarian reserve and even advanced maternal age.
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