Fertility Treatment Question

March 8, 2009

I'm treating a 34 yo woman for fertility issues with irregular menses, but no

other known problems (ie no tubal blockage etc.) After 3 months weekly

acupuncture and herbs her menses is regular, energy levels are up, sleep is

better, etc. The concern is this. When she first came to me her Day 3 FSH was

17, after a couple months of treatment it was down to 10, now it's up to 27. Her

doctors are telling her she's not a candidate for clomid and she should start

looking for an egg donor. I've heard reports of some TCM doctors treating

infertility with Day 3 FSH as high as 30, but I'm not sure. She wants to know if

there is hope and whether or not we should continue, and I honestly don't know

what to tell her. I don't want to give her false hope. I have two questions:

1. does anyone have experience treating a woman for infertility with Day 3 FSH

levels this high?

2. does anyone know if herbal medicine could be artificially raising her FSH

levels?

I can give more detailed case info if required, but at this point my questions

are pretty general.

Thanks,

Sean Michael Hall, L.Ac.

East Bay Acupuncture & Natural Medicine

Berkeley, CA 94705

http://www.ebacupuncture.com

(510) 457-8886

March 9, 2009

Hi Sean -

The conversation with your patient regarding her elevated FSH levels

is a complicated one, and a simple one at the same time. So, let's

start with the basics:

First - Follicle Stimulating Hormone (FSH) levels primarily correspond

to the number of eggs left in the ovaries, rather than the quality.

There is often a correlation made between rising FSH levels and poor

egg quality, because of the correlation between older women and higher

FSH levels. As a woman ages, and the number of eggs left in her

follicular pool is shrinking, the ovaries become less and less

sensitive to pituitary FSH, and so the pituitary works harder to

stimulate the remaining follicles/eggs - and so the FSH levels rise.

Also, because there is a relationship between the egg and follicle, it

is understood that poor follicular response (i.e. high FSH) can equal

poor egg quality. However, when we look at the epidemiological data

related to clinical pregnancy rates and live birth rates - i.e. the

incidence of women who conceive, and actually give birth to a healthy

baby - the single greatest factor inhibiting live birth rates by far

is age.

If you poll all of the Reproductive Endocrinologists (REI) across the

United States and Europe, and ask them to predict which patient would

have the higher likelihood of live-birth - a 42 year-old patient with

an day-3 FSH of 8.5, or the 34 year-old female with an FSH of 12.5 -

the vast majority would predict that the latter (younger patient)

would have a higher likelihood of live-birth. I keep emphasizing live

birth here because, although the older patient with the lower FSH

might get pregnant more frequently and respond more favorably to

ovulation induction (IVF meds) - she would have a considerably lower

likelihood of live-birth compared to the 34 year old patient, due to

the higher incidence of aneuploid embryos created.

Does this mean that older women with older eggs, and even elevated FSH

cannot conceive and healthy babies? Absolutely not. In fact, lifestyle

changes, , and dietary changes can dramatically

enhance the odds of a successful pregnancy and live birth in older

patients. In fact, if you do a google search for " over 40, high FSH "

you will find page after page of women over 40, with a high FSH, who

were told they were perimenopausal and they would need either donor

ova or adoption, and they go on to conceive and give birth to

beautiful babies. The point of the comparison that I was making, is

that despite your patient's elevated FSH, her chances of delivering a

healthy baby are actually pretty good.

So, when the REI suggests that you patient is not a candidate for

Clomid (one type of ovulation induction), there reasoning is that if

the patient's day-3 FSH is already at 27 mIU/mL (i.e. the ovaries are

not very responsive to endogenous pituitary FSH), then the patient

will probably not respond vigorously to ovulation induction with

Clomiphene Citrate (Clomid), nor with Gonadatropins/Menotropins like

Follistim, Repronex, Menopure, Etc. From there point of view, this

patient most likely has the diagnosis of idiopathic premature ovarian

failure. And there is no western treatment for that other than donor

ova for pregnancy, or hormone replacement to prevent osteopenia if the

patient does not desire pregnancy.

Regarding your treatment, and whether or not it could be related to

her FSH being artificially elevated, I would say that it's possible

but probably not likely. Once a woman has begun the process of

premature ovarian failure/decline, the hypothalamic/pituitary/ovarian

access becomes destabilized, and FSH levels will go up and down. This

is why most REI's will say (and I don't necessarily agree with this)

that the patient is only as good as your highest FSH. From a TCM point

of view, because FSH is a yang hormone, it is essential to try to

clear heat, nourish kidney yin and liver blood, and vitalize blood as

much as possible in order to enhance ovarian sensitivity, and restore

the stability of the H-P-O axis. This means that you should really use

any kidney yang tonics with caution, as this can excite the pituitary.

In the end, when I work with patients who have either diminished

ovarian reserve or premature ovarian failure, I always try to have a

complete discussion with them along the lines of what I outlined

above, so that the decision they make as to which path to pursue, and

when, is theirs. I usually ask them to sit down and look at a calendar

and decide exactly how long they would like to pursue treatment with

TCM before moving on to other steps, i.e. IUI, IVF, or IVF with donor

ova. I tell them that it can take anywhere from 3-12 months to restore

ovarian sensitivity (i.e. get their FSH levels down enough to try IVF

with their own eggs), but that this does not mean they can't try to

conceive naturally in the process.

In fact, at least 50% of the female patients referred to me by the

REI's are sent for exactly this reason: to restore ovarian

sensitivity, reduce their day-3 FSH levels, and make it possible for

them to proceed with IVF. Of course, many of the REI's I work with

understand that probably half of the patients they refer for

diminished ovarian reserve will not come back for another IVF because

they go on to conceive naturally.

I will leave you with one other recommendation: Brandon Horn has a

course on Diminished Ovarian Reserve that is IMHO the most advanced

discussion on the treatment of females with elevated FSH, and/or poor

egg quality, that I have yet encountered. He goes in depth on the

reproductive physiology, anatomy, pathology, genetics, epigenetics,

diagnosis, and treatment of this particular category of female

infertility. It's really profound stuff. If you are interested, you

can purchase the course online from www.prodseminars.com. (Doug -

sorry for the sales pitch here, but it really is the best discussion

on this topic that I know of).

Anyway Sean, sorry to be so long-winded, but I hope this helps

somewhat in you and your patient's decision-making process.

Ray Rubio, DAOM (FABORM)

President ABORM

Chair: Reproductive Medicine Specialty/Yo San University DAOM Program

> I'm treating a 34 yo woman for fertility issues with irregular

> menses, but no other known problems (ie no tubal blockage etc.)

> After 3 months weekly acupuncture and herbs her menses is regular,

> energy levels are up, sleep is better, etc. The concern is this.

> When she first came to me her Day 3 FSH was 17, after a couple

> months of treatment it was down to 10, now it's up to 27. Her

> doctors are telling her she's not a candidate for clomid and she

> should start looking for an egg donor. I've heard reports of some

> TCM doctors treating infertility with Day 3 FSH as high as 30, but

> I'm not sure. She wants to know if there is hope and whether or not

> we should continue, and I honestly don't know what to tell her. I

> don't want to give her false hope. I have two questions:

>

> 1. does anyone have experience treating a woman for infertility with

> Day 3 FSH levels this high?

> 2. does anyone know if herbal medicine could be artificially raising

> her FSH levels?

>

> I can give more detailed case info if required, but at this point my

> questions are pretty general.

>

> Thanks,

> Sean Michael Hall, L.Ac.

>

> East Bay Acupuncture & Natural Medicine

> Berkeley, CA 94705

> http://www.ebacupuncture.com

> (510) 457-8886

>

March 9, 2009

What are her signs / symptoms / tongue / pulse / etc?

As far as prognosis, what's the goal of treatment? Generally, it sounds like

it's not a case where you're going to get her egg quality to a level where she's

going to conceive naturally, but egg donor rates are very good and there's

nothing wrong with doing what you can to help her with ART support.

As far as herbal treatments go, I've had reason to pause recently. I had a

patient who was doing a mock cycle for an egg donor IVF cycle, and when they

tried to suppress ovulation for the mock cycle, she still had a follicle

develop. I don't *think* that the herbs (Wu Chi Bai Feng Wan) would have caused

a follicle to develop while being supressed with hormone therapy, as if using a

formula like this would cause birth control pills to be ineffective - if my

knowledge about hormones and reproductive cycles is correct.

Geoff

, " sean_michael_hall "

<seanmichaelhall wrote:

>

> I'm treating a 34 yo woman for fertility issues with irregular menses, but no

other known problems (ie no tubal blockage etc.) After 3 months weekly

acupuncture and herbs her menses is regular, energy levels are up, sleep is

better, etc. The concern is this. When she first came to me her Day 3 FSH was

17, after a couple months of treatment it was down to 10, now it's up to 27.

March 9, 2009

i never use herbs during a suppression cycle. Suppression is entirely

against what is normal for a woman's body. herbs support what is

normal. there is no way to administer herbs without expecting

something to happen. so during that part of an IVF protocol, i pull

back.

Cara O. Frank, R. OM

Six Fishes

China Herb Company Chinese Herb Department

Tai Sophia Institute

www.carafrank.com

215-772-0770

On Mar 9, 2009, at 2:10 PM, G Hudson wrote:

> What are her signs / symptoms / tongue / pulse / etc?

>

> As far as prognosis, what's the goal of treatment? Generally, it

> sounds like it's not a case where you're going to get her egg

> quality to a level where she's going to conceive naturally, but egg

> donor rates are very good and there's nothing wrong with doing what

> you can to help her with ART support.

>

> As far as herbal treatments go, I've had reason to pause recently. I

> had a patient who was doing a mock cycle for an egg donor IVF cycle,

> and when they tried to suppress ovulation for the mock cycle, she

> still had a follicle develop. I don't *think* that the herbs (Wu Chi

> Bai Feng Wan) would have caused a follicle to develop while being

> supressed with hormone therapy, as if using a formula like this

> would cause birth control pills to be ineffective - if my knowledge

> about hormones and reproductive cycles is correct.

> Geoff

>

> , " sean_michael_hall "

> <seanmichaelhall wrote:

> >

> > I'm treating a 34 yo woman for fertility issues with irregular

> menses, but no other known problems (ie no tubal blockage etc.)

> After 3 months weekly acupuncture and herbs her menses is regular,

> energy levels are up, sleep is better, etc. The concern is this.

> When she first came to me her Day 3 FSH was 17, after a couple

> months of treatment it was down to 10, now it's up to 27.

>

March 9, 2009

Sound advice indeed.

On Mar 9, 2009, at 11:50 AM, cara wrote:

> i never use herbs during a suppression cycle. Suppression is entirely

> against what is normal for a woman's body. herbs support what is

> normal. there is no way to administer herbs without expecting

> something to happen. so during that part of an IVF protocol, i pull

> back.

>

> Cara O. Frank, R. OM

> Six Fishes

> China Herb Company

> Director Chinese Herb Department

> Tai Sophia Institute

> www.carafrank.com

> 215-772-0770

>

> On Mar 9, 2009, at 2:10 PM, G Hudson wrote:

>

>> What are her signs / symptoms / tongue / pulse / etc?

>>

>> As far as prognosis, what's the goal of treatment? Generally, it

>> sounds like it's not a case where you're going to get her egg

>> quality to a level where she's going to conceive naturally, but egg

>> donor rates are very good and there's nothing wrong with doing what

>> you can to help her with ART support.

>>

>> As far as herbal treatments go, I've had reason to pause recently. I

>> had a patient who was doing a mock cycle for an egg donor IVF cycle,

>> and when they tried to suppress ovulation for the mock cycle, she

>> still had a follicle develop. I don't *think* that the herbs (Wu Chi

>> Bai Feng Wan) would have caused a follicle to develop while being

>> supressed with hormone therapy, as if using a formula like this

>> would cause birth control pills to be ineffective - if my knowledge

>> about hormones and reproductive cycles is correct.

>> Geoff

>>

>> , " sean_michael_hall "

>> <seanmichaelhall wrote:

>>>

>>> I'm treating a 34 yo woman for fertility issues with irregular

>> menses, but no other known problems (ie no tubal blockage etc.)

>> After 3 months weekly acupuncture and herbs her menses is regular,

>> energy levels are up, sleep is better, etc. The concern is this.

>> When she first came to me her Day 3 FSH was 17, after a couple

>> months of treatment it was down to 10, now it's up to 27.

>>

>

> ---

>

> Chinese Herbal Medicine offers various professional services,

> including a practitioner's directory and a moderated discussion forum.

>

March 9, 2009

Sean, Ray, et all,

Elevated FSH in a 34 year old women is a concern. As Ray pointed out this could

be a sign of pre mature ovarian failure (POF), in which the woman is heading

towards an earlier menopause. The causes of such are huge, ranging from FSH

receptor problems in the ovary, radiation exposure, environmental toxicity,

pituitary problems, and on and on.

Genetics can be a big factor. It is imperative to ask if any other members of

this woman's family have a history of early menopause. Many women who come from

a culture with a long history of too much inbreading can develop this as a

genetic flaw. For example my wife is of Menonnite background and her

grandmother, mother, and aunt all went through full blown menopause by and

before age 40, most likely because of the small gene pool within the mennonite

community. (My wife is not going through early menopause right now BTW :-))

Other genetic causes include being a carrier for Factor X, where by about 25% of

carriers will experience POF. (Yes Brandon Horn's course on this is excellent

and informative)

So basically this woman can have so many factors that have contributed to her

high FSH. The tx that you gave her Sean most likely did not contribute to the

rise, especially since it was already high before seeing you. (Although it has

been suggested that some herbs may damage FSH receptors). If she were to get

tested again in a few months, it may even show a much lower value again.

When I treat these women I always remind them that the high fsh does not

necessarily mean that their reserve is diminished. That to truly know this one

would have to test their Inhibin B, Anti mullerian hormone, and have an antral

follicle count to have a better idea. But that even then it is still a guess, as

the primordial follicles are microscopic and can only really be seen/ counted if

the ovary is actually removed! As long as this woman is having regular ovulatory

cycles, (and her tubes are clear as you mentioned) then she should be able to

become pregnant, at some point in time. I have seen this in clinic many times.

Now for my pet peeve in modern TCM clinical practice.

Ray, how can you say for sure that FSH is truly a " yang " hormone? I would love

to hear your thinking on this. For me, labelling something yin or yang can only

be done in relation to something else, ie night is yin in relation to the yang

being day. So if FSH is yang then what are you comparing it to? I have heard

others say that inhibin B deficiency is kidney yin deficiency, which seems a far

stretch to me and actually does not make much sense.

All the best,

Trevor