Apr 14
Written by Diana Palmentiero
Many women think of their infertility issues as a struggle. Having lived through the “struggle” twice and survived, I have come to realize that I was on an incredible journey. I just didn’t realize it at the time.
My journey began in the spring of 2004 when I was 37, married for 6 months and trying to conceive for the first time in my life. The first month we tried, I became pregnant. Wow, that was easy! Then at 5 weeks pregnant, I began bleeding. I was shocked, confused, disappointed and every other emotion you can be when you miscarry, especially the first time you are pregnant.
After the first miscarriage my husband and I tried again for several months but we were once again disappointed when I miscarried the second time I became pregnant. Now my feelings included “what did I do to cause this to happen?” I was a healthy woman with no medical issues and now I had had 2 miscarriages in less than a year each time I had been pregnant. Somehow this must be my fault. Miscarriage is not a topic that many people discuss so I had no one to talk to about it. I was becoming increasingly despondent. If I wanted to feel better, I knew that I needed to take action.
Being 38, I realized that my eggs were not getting any younger so my husband and I decided to visit our local fertility doctor. The next thing I knew he was telling me that I had a little problem called high FSH and that I had a less than 1% chance of having a “take home baby.” I was going to need his help and quickly. So we started fertility treatments. I was put on the highest dosage of fertility drugs that anyone could possibly take and then felt like I had PMS for 24 hrs. a day, 7 days a week.
Between the high dosage of fertility drugs and the emotional roller coaster that I was on, I became depressed. If someone looked at me the wrong way, I would start to cry. Holidays didn’t help either. The worst was having to go to the hospital to wait for someone else to give birth. I spent most of the time in the bathroom crying until the baby was wheeled up to the nursery glass window.
After 6 months of roller coaster emotions and only being able to go through 2 IUIs, we did not get pregnant. Although I desperately wanted to have a child, I hated all the medications that I was on so I began to explore other options.
And where do you turn to when you need alternate solutions? The Internet, of course! That’s where I started to read about acupuncture and traditional Chinese medicine. The idea behind it is that “infertility” happens when a woman’s body is not in balance. I never realized that so many things in our bodies need to happen perfectly for conception to occur. When a woman’s body is not in balance and it’s trying to have a baby, then either (a) conception won’t happen, or (b) as in my case, it will happen, but a woman won’t stay pregnant. I then discovered a book called “The Infertility Cure.” What a great title! Who wouldn’t want a “cure” for their infertility, as if it is a disease? I quickly ordered one. Here’s a link to find out more about her at The Fertile Soul. Dr. Lewis also holds retreats so I found out where her next retreat was being held and headed out to Austin, Texas. By this time it was January 2006.
What a life altering experience the retreat was. It lasted for 5 days. Along with Dr. Lewis, there were dynamic speakers, classes, spa treatments, and group healings. Dr. Lewis herself claimed in her literature that I “would enter a lifestyle path that [I] won’t ever want to leave.” One of my favorite sessions of the retreat was on nutrition. She stressed the importance of eating whole, natural and organic foods and especially not eating foods that are processed. She also stressed eating gluten-free and dairy-free. Before I knew it, I had lost 7 lbs.
When I came home from the retreat, I felt like a changed person. Although I had a back-up plan to start IVF a few months later, I believed that I was going to get pregnant without medical intervention. Dr. Lewis referred me to an acupuncturist, Dr. Michael Berkley of The Berkley Center, who performed acupuncture and prescribed herbal teas from a pharmacy in Chinatown called Kamwo. And sure enough, one month after I came home from the retreat, I was pregnant! As I continued on my pregnancy journey, I realized that Dr. Lewis was right and that I wanted to continue on the path that had helped me to have a child. I made some changes in my life that I had learned at the retreat which would also be beneficial for my unborn child. My husband and I continued to eat more natural and organic foods.
When my daughter April was born in 2006, we decided that she would be breast-feed for 1 year and eat organic baby foods when she began to eat solids. Later, as I was cleaning the house and April started to crawl around, I realized that I did not want her to breathe in the fumes from the cleaning products that I was using. This made me change my cleaning products to more eco-friendly ones. My fertility issues and experience at the retreat made me aware how important it is to know exactly what is going into your body, no matter how it goes in.
When we tried to have a sibling for April, we again went through the same struggles. April was nine months old when I had my third miscarriage after 5 weeks. We again decided to try acupuncture and herbal teas. Dr. Berkley referred me to Dr. Yaron Seidman of Hunyuan Fertility. He made some further, individualized dietary suggestions such as eating more liver. (That wasn’t much fun.)
The next time we had a miscarriage, I had not been using acupuncture long enough. That’s when I knew it was time to give my body a rest. We took three months off from acupuncture and trying to conceive. When we began again, I started going to acupuncture and brewing and drinking herbal teas. This time it worked and my son Cody was born in July of 2009.
And now, almost 6 years and 2 kids later, I am doing things that I never thought I would do. For the past 2 years, I have joined Sport Hill Farm’s Cash Crop program, so that my family can enjoy farm fresh vegetables. We now eat mostly organic foods from meats to breads to cookies and jellies. We recycle as much as we can and use healthier cleaning solutions. My fertility struggles led me on a journey to where I eventually became a part of the “green revolution.” Who knew that would happen but I think it is incredible!
Wednesday, April 18
Wednesday, April 11
Recognize that because you are not familiar with something and that it has not been rigorously tested by Western scientific standards does not negate its efficaciousness.
Dear Esteemed Colleagues:
Many of you have recommended that your patients do not take herbal medicine when TTC.
Recognize that because you are not familiar with something and that it has not been rigorously tested by Western scientific standards does not negate its efficaciousness.
I implore you to maintain an open mind and to realize that Western medicine and Western reproductive medicine is not the ‘only’ medicine that works.
Science per se, is about seeking the truth. The truth is that Chinese herbs have been used safely to treat fertility cases for thousands of years without iatrogenic effect, unlike many pharma products.
I beg you to be more flexible in your standards (not lower them!), which may be based on dogma as opposed to rejection after investigation; not very scientific indeed. Why not study the effects of herbs on infertile patients instead of outright rejection – that indeed seems like a more rigorous approach than outright denial of efficacy and the bold statement that ‘herbs can be harmful’.
I would be happy of course, to participate in the study. Let’s move forward in medicine - not Western medicine – but medicine. Medicine is something that positively affects a patient’s outcome - this is true whether the medicine comes from Ferring, Organon, or the mountains of China. It’s about time that minds start to open instead of remaining hermetically sealed.
Let me know if you are brave enough, or inquisitive enough to seek the truth about herbs in the milieu of the infertile patient. Let’s break new ground together; let’s think out of the box together; let’s be pioneers together!
Respectfully,
Mike Berkley, Licensed Acupuncturist/Board Certified Herbalist; FABORM
http://www.berkleycenter.com
Many of you have recommended that your patients do not take herbal medicine when TTC.
Recognize that because you are not familiar with something and that it has not been rigorously tested by Western scientific standards does not negate its efficaciousness.
I implore you to maintain an open mind and to realize that Western medicine and Western reproductive medicine is not the ‘only’ medicine that works.
Science per se, is about seeking the truth. The truth is that Chinese herbs have been used safely to treat fertility cases for thousands of years without iatrogenic effect, unlike many pharma products.
I beg you to be more flexible in your standards (not lower them!), which may be based on dogma as opposed to rejection after investigation; not very scientific indeed. Why not study the effects of herbs on infertile patients instead of outright rejection – that indeed seems like a more rigorous approach than outright denial of efficacy and the bold statement that ‘herbs can be harmful’.
I would be happy of course, to participate in the study. Let’s move forward in medicine - not Western medicine – but medicine. Medicine is something that positively affects a patient’s outcome - this is true whether the medicine comes from Ferring, Organon, or the mountains of China. It’s about time that minds start to open instead of remaining hermetically sealed.
Let me know if you are brave enough, or inquisitive enough to seek the truth about herbs in the milieu of the infertile patient. Let’s break new ground together; let’s think out of the box together; let’s be pioneers together!
Respectfully,
Mike Berkley, Licensed Acupuncturist/Board Certified Herbalist; FABORM
http://www.berkleycenter.com
Monday, March 19
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.
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.
Friday, March 2
Acupuncturists - What Would You Do?
If a 38 year old female patient had 4 donor egg cycles where there were no pregnancies during the first two and one pregnancy each in each subsequent cycle ending in miscarriage at the third week?
There is no male factor and no pelvic distortion in the reproductive organs. The patient has elevated fsh and diminishes AMH – hence – donor egg.
She is symptomatic for endometriosis, has hypothyroidism as too does her mother and maternal grandmother. There is h/o infertility or miscarriage in the family.
Patient is normomorphic.
Her reproductive endocrinologist recommends another donor-egg cycle. I advised her against this.
What would you advise this patient to do from a Western medical perspective?
There is no male factor and no pelvic distortion in the reproductive organs. The patient has elevated fsh and diminishes AMH – hence – donor egg.
She is symptomatic for endometriosis, has hypothyroidism as too does her mother and maternal grandmother. There is h/o infertility or miscarriage in the family.
Patient is normomorphic.
Her reproductive endocrinologist recommends another donor-egg cycle. I advised her against this.
What would you advise this patient to do from a Western medical perspective?
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