Navigating Infertility in a Pandemic
As if infertility wasn’t hard enough, now we’ve got to learn how to navigate the confusing world of infertility in a global pandemic? Trying to survive yet another round of IUI or IVF is difficult enough with telemedicine, being wholly responsible for monitoring your own vitals, the isolation of quarantine, making the difficult decision whether to vaccinate or not vaccinate, etc. Let’s face it, reproductive endocrinology is just DIFFERENT today, and your experience is going to be different than your friend’s who went through it all 2 years ago due to Covid and the multiple obstacles stemming from the pandemic. But take heart mama. Even if you’re just trying to manage your situation at home without a professional, there are still things you can do at home to optimize your fertility.
We talked with Anne Kinchen, owner of Cleveland Acupuncture and a practitioner of Traditional Chinese Medicine for over 22 years. Anne was one of the first Ohio Medical Board licensed acupuncturists, and she holds a National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) Diplomate in both Chinese Herbology and Acupuncture. Anne holds a Master’s degree in Acupuncture and Traditional Herbal Medicine from Pacific College of Health Sciences, class of 1999. Anne is a lifelong learner, passionate about holistic fertility, and continues to expand her knowledge base in an ever-changing industry that is informed through science; yet also reflects the basic tenets of Traditional Chinese Medicine. She is closely affiliated with Dr Robert Gustofoson, a Reproductive Endocrinologist at CCRM, Denver, with whom she often co treats fertility patients.
Anne, thanks for speaking with us today. Tell us, what’s the biggest difference for people going through infertility treatment during the pandemic?
The biggest difference is that there is less monitoring of medicalized doctor driven treatments than ever. This can make finding out if you are responding to what they have suggested that much more difficult than in the past. Unfortunately, even in a normal public health situation, the proper initial approach to fertility issues is typically bypassed in favor of methodical "one size fits all fertility treatment” utilizing prescription fertility drugs like Clomid or Femara /Letrozole, sometimes with the addition of IUI. In my professional opinion these drugs and procedures should not be used until all the parameters for normal reproduction have been investigated thoroughly. It seems reproductive specialists who will always favor interventions over investigation and correction, which is to some extent what insurance companies have dictated as the “standard of care.” This situation remains unchanged since the pandemic’s arrival.
Without proper monitoring (ultrasound), the effects of those prescribed treatment’s (clomid/femara/Letrozole) benefits are undetermined. The undesired side effects of repeated rounds of fertility drug usage will eventually outpace any potential fertility benefit. It would be good to know what effect, if any, these drugs are having while taking them. Since Covid, patients are discouraged more than ever from monitoring, which may be good since medical environments can unnecessarily expose patients to the virus, but also not good because how can you know what effect the medications are having without an ultrasound? In addition to this, some of these fertility drugs have long lasting side effects that, when used over time, actually CREATE more problems than they solve, so you want to minimize your exposure to them.
I believe that the correct approach for the fertility patient is to identify and CORRECT any underlying conditions, whether hormonal or otherwise, BEFORE utilizing fertility drugs. It just makes more sense and ensures that the patient will be able to respond favorably to the drugs, or if they are so lucky as to get pregnant, that their pregnancy will advance without ending in miscarriage or complications.
For example, a weak thyroid is often responsible for infertility and/or early miscarriage, so doesn’t it make sense to check this out before taking fertility drugs? I have encountered this very situation numerous times with patients who, after several unsuccessful rounds of fertility drugs (even with monitored IUI cycles, and perhaps a few miscarriages, too) discover they have Hashimoto’s hypothyroid antibodies! Hashimoto’s thyroiditis is an unpredictable thyroid condition that requires specific testing to detect, which should be piggybacked with regular thyroid testing. If antibodies are high, monitoring while attempting to achieve pregnancy AND throughout the first trimester is necessary. While a patient’s TSH test may be normal, unless antibody testing is ALSO done, you would not know if you had it.
It is a more common condition than you would think it to be, and very frequently the patient has NOT been tested for it specifically. A lot of this can be discovered by the woman trying to conceive naturally at home, especially with the new testing kits on the market.
The approach of a fertility-based acupuncturist (or other provider claiming to be a fertility-based practice) should begin with investigation of the obvious: disparities of the cycle length, ovulation factors, how many days of bleeding, clotting in the menstruate, presence of cervical mucus, pain during period or during intercourse, etc. While patients CAN order blood tests and hormonal panels on their own, fertility professionals are trained to interpret the tests and offer remedies for tests that are out of range.
Many signs and symptoms related to general health can impact fertility as well, these include allergies, digestive issues, food intolerances, skin issues, or any condition which inspires a histamine or inflammatory response from the body.
Super interesting! What other factors should patients be looking to for impact to fertility?
Hormonal testing that is specific to fertility generally does not include testing for stress related hormones such as cortisol, or homocysteine. Stress response can have a significant impact on overall health including fertility. Mental health is important when facing fertility challenges, and tele-med therapy is more popular than ever. There are also various types of approaches to support the stress of fertility such as nutraceuticals, herbal medicine, and guided imagery.
The bottom line is that emotional stress has a very real impact on blood flow, nutritional choices, and the way we react and respond to our significant other. Since fertility journeys tend to be rather long; burnout is a factor. Watching your friends or relatives conceive effortlessly while you struggle with expensive and often unproductive and invasive procedures will test your mental health and marriage. There are providers that specialize in offering guidance and support for this and the effect of fertility frustrations on hormones and psyche should not be underestimated. Be certain to volunteer information regarding general emotional stress to your provider if it is a significant problem in your day-to-day health. Markers of mental health struggles may manifest as feelings of depression, easy crying, and disrupted sleep. All of that can impact fertility and should be made known and treated as part of a wholistic approach.
Surprisingly, the diagnostic approach is often saved for after the drugs and IUIs by doctors, and even then, labs are often incomplete, leading patients to increasingly expensive and futile interventions that do not yield the desired results (i.e., pregnancy). Interpretation of the labs, and selecting which ones are to be done varies greatly from provider to provider. You may have been told you have had “all the tests”, and everything is “normal.” So, you are designated as “unexplained infertility.” In my opinion there is no unexplained infertility. There IS “subfertility,” and there can be undiscovered factors because the right tests were not done, or the tests results were not interpreted correctly, or you, the patient, were not specifically informed by your doctor.
A good example of this is a current patient, who at age 34, was told labs were all normal by their doctor, who suggested fertility drugs as a first effort. She did a couple rounds of Clomid and IUI. She hated the side effects and came to me to see what insights I might provide. I decided to begin our efforts by doing comprehensive testing for her, which she thought she had already had. Sure enough, elevated levels of the hormone prolactin were detected at twice the normal lab range. This result then led to an MRI to look for a possible pituitary tumor that is a known cause of elevated prolactin, and yep, there it was. The condition is now managed with medication that corrects prolactin levels and would allow her to conceive naturally. It also explained her recurrent headaches, which are now cured. That month, I found elevated prolactin in another patient, as well!
With pandemic considerations, patients want to stay out of doctor’s offices as much as possible. There is actually a lot they can do from home, including basal body temperature graphing. Structural concerns, such as testing for open fallopian tubes/hystosalpinigram can only be done in the office, obviously. But the most important hormonal tests can be ordered from your computer without ever seeing a doctor. Likewise, there are phlebotomists that will collect your blood at your home or workplace for your convenience or during increased pandemic threat. There are apps to help track basal body temperatures, and ovulation predictor kits (like Clear Blue Easy), and Proov (which backs up the OPK/Ovulation predictor kit, by measuring an electrolyte in the urine). Patients now have the ability to confirm these important markers in their cycle and compare them to what the ideal cycle looks like when striving for fertility optimization.
Knowing what your weak points in your cycle are, late ovulation (after cycle day 15), early ovulation (before cycle day 12), overall low temperatures, clotty periods, etc., is important information for your provider and valuable when formulating a diagnostic pattern. For instance, a patient with severe menstrual cramps who is trying to conceive, might emphasize this to her provider in order to push for an investigation for the possibility of endometriosis. Doctors are all too ready to dismiss symptoms especially like this in favor of pushing drugs and IUI, first. But in the presence of endometriosis, these kinds of treatments rarely succeed!
Patients need to demand from their doctors that attention be paid to the symptoms they report, menstrual or otherwise. If a doctor is not willing to do comprehensive hormone testing, the patient can order their own tests.
Companies like Modern Fertility, Rupa Health, Anylabtestnow.com and Requestatest.com all utilize local labs for the blood draw. The interpretation can be done via tele-med with whatever fertility provider you choose. Some of these companies offer lab interpretation with the package, but this is not always reliable information. (Editor’s note: see Resources below for more info).
A few of these tests are time sensitive, i.e., they need to be taken on specific days of the cycle, so patients should investigate this before appearing at the lab for the blood draw. Some testing companies allow for HSA payment as an option. Overall, these tests will typically cost around $200.
What are some of the foundational markers patients and doctors should be looking at before designing a treatment plan?
I suggest fertility evaluation for BOTH men and women. Since men’s sperm will take 75 to 90 days to fully respond to interventions if any are needed (typically dietary and lifestyle changes do help), it’s good to know where they fall in the spectrum of sperm health. For women, follicular/egg quality improvement is three full cycles (that’s 3 months, so be patient). Many of the supplements that help egg quality will be continued throughout pregnancy, such as Omega Fatty acids and vitamin d3. For the women, tracking menstrual cycles, investigating thyroid health, checking ovarian reserve, would be top on the list. For men, a Krueger sperm analysis.
Regarding Covid and vaccination, personally I do not accept patients at my clinic if you’re unvaccinated. There is a tremendous amount of research that says vaccination is best for anyone hoping to conceive. It also protects your provider and the patient coming to use the room after you. Particulate matter related to covid can waft on the air for hours after an infected person leaves, which is why I use BOTH humidifiers and air filters in my treatment rooms, in addition to standard cleaning procedures. I also open windows and run a fan if temperatures permit.
One thing I see a lot is male factor infertility being missed, simply because so much time and focus is on the female. For the man who doesn’t want to go to a medical office, there are also opportunities to utilize men’s sperm analysis tests where the specimen is collected at home, and then mailed in for lab analysis. While this is another great, convenient at home assessment tool, what it won’t tell you is if there is a presence of varicocele. Varicocele is a structural abnormality that affects sperm development, and the test for this requires a manual exam and or ultrasound. Varicocele literally means a varicose vein, which is an inflamed vein in the scrotum. It is more common than you think and can affect normal sperm development. This in turn, can affect the ability of sperm to fertilize an egg. Diagnosis of varicocele is ultimately by ultrasound, and this must be performed by a doctor in a medical setting. There are additional tests beyond the Krueger morphology test, and the need for these secondary tests will often be precipitated by scores that are off in the Krueger analysis. Many men are hesitant about being evaluated at all, but it is crucial to the fertility effort that everything be assessed. For women undergoing months and sometimes years of fertility treatments, only to find out her partner has issues as well, it can be maddening.
The most efficient at home approach to discovering fertility issues is monitoring the cycle by observing basal body temperatures. Using the temperatures to make a graph will inform you if your cycle is consistent with fertility. It can also inspire specific lab testing for diagnostic purposes. It is an easy and inexpensive way to see if your cycle is improving.
A trained fertility specialist, whether acupuncturist, naturopath, or chiropractor, should be able to suggest appropriate testing, evaluate the labs, and suggest corrections. General lab values are not necessarily indicators of optimal fertility. Often with a fertility patient, we are looking to see a specific bandwidth on the lab test spectrum that is more specific than for the general population, such as with thyroid testing.
And what would you consider to be some of the more foundational tests patients should have & have baselines for?
Important tests and markers to understand for everyone include:
AMH- Anti Mullerian Hormone test; this indicates ovarian reserve, not egg quality. How many eggs are still in the basket? Ideally, between 2.0 to 3.0. Lower than 2.0 needs to be retested every 6 months to see if it is falling, and AMH greater than 4.0 ought to consider treatment for poor egg quality using PCOS supplements, regardless of whether there are visible cysts on the ovaries or not.
SH/E2/LH- Taken on cycle day 3 only! How hard are the ovaries working to produce an egg? The closer the level is to 10, the less likely for “easy response” to fertility treatment, over 10, you are going to work for it!
Thyroid Panel: Thyroid Stimulating Hormone, TGAB or TPO
A thyroid panel SHOULD ALLOWS INCLUDE TGAB or TPO (the tests for Hashimoto’s thyroid antibodies):
Test to diagnose Hashimoto's thyroiditis, an autoimmune disease that causes hypothyroidism, TGAB or TPO
TSH “normal” values are 0.5 to 5.0 mIU/L. However, for the fertility patient, TSH levels at 2.0 or LESS are ideal. Higher levels require Synthroid supplementation and SHOULD be managed by an endocrinologist, not your fertility provider!!! Low functioning thyroid hormone is indicated by TSH levels over 2.0. It is one of THE most common reasons for miscarriage, late ovulation, and low basal temperatures (remember, you must become a human incubator after ovulation).
T3, Free T3, T4, and others
Male Factor- Krueger Strict Morphology
Motility- how well the sperm moves, at least 50% should ‘swim’ in a straight line
Morphology- How the head, midpiece, and tail of the sperm look. At least 16% of sperm should have normal shape & structure
Sperm Count- Counts should be above 20M in a milliliter of sperm. A complete semen sample should have at least 40 million sperm.
Testosterone
What are the most important things patients can do at home to optimize fertility?
There’s an old tenet in Traditional Chinese Medicine, “a seed only sprouts in fertile soil.” I use that one a lot with my patients…look to nature! If you till the soil now, fill it with nutrients and THEN plant your seed, you’ve got a lot better chances for a strong, healthy seedling.
Plant the seed in the correct climatic conditions/season: internal body temperatures are within a specific bandwidth to “nourish life”. Optimizing your diet and supplementation are the easiest contributions you can do to boost your fertility at home.
BBT: Monitor your cycle and basal body temperature (BBT), it will give a lot of important information: cycle length, day of ovulation, whether your temperature spikes at ovulation, as it should, and whether temperatures decline rapidly when your period begins, as it should. A professional can read the hormonal activity on the chart easily, I often teach this to my own patients. You can also find this information on the internet. The best app I found for tracking your cycle is FertilityFriend.com. Its uber simple, and free for three months. A good basal body temperature thermometer costs around $20.
Note: You DO, however, need to remember to take the temperature every morning at the exact same time, at very least within a 15 min leeway, and do it after 2 hours of solid sleep (no getting up to the bathroom). Otherwise, the temperatures you record to make a graph are meaningless.
By the way, I have NOT found the tracking devices like the bracelets and other gimmicks on the market to be particularly accurate. There IS a temperature converting app you can use if you cannot be consistent with taking your temperature, but I can’t attest for its accuracy (at least its free).
Diet- This is another area where diagnostics are important. The patient diagnosed with PCOS is not eating the same diet as the patient with endometriosis. If you have both it gets a little tricky!
There are special gluten free dietary recommendations for the patient with Hashimoto’s thyroid disease, and overall, high OR low body mass will affect fertility potential. Added hormones in milk, meat, and other animal derived foods may compete with your own hormones, so pay the extra for the hormone free, its lots cheaper than IVF! Processed food, non-organic fruits and vegetables sprayed with pesticides, personal care products from nail polish, to sunscreen to deodorant can all be sources of endocrine disrupting chemicals. www.EWG .org is an excellent source to discover if your choices are healthy ones or not, and what the alternatives might be.
Evaluate your diet; are you eating things that cause inflammation? Most of my clients are on elimination diets to remove gluten & dairy, as well as all trans fats. Most people don’t have celiac disease, but many people in the Western world DO have a gluten sensitivity due to the environmental factors of how our wheat is grown and processed. Our soil is selenium deficient, which is a co-factor for the absorption of iodine, both iodine and selenium are vital for thyroid health. Selenium deficiency coupled with the fluoride in our city water (can’t be avoided even if you drink bottled water, it is in the water coming out of the tap) is a recipe for disaster regarding thyroid health, so it’s no wonder it is an all-too-common issue in the treatment of fertility.
What are some basic supplements that pretty much everyone should be taking at home to boost fertility?
Omega 3’s (vegan capsules)- Everyone can benefit from 1500-200mg of Omega 3 fatty acids. The reason I’m recommending the vegan form is that the likelihood for heavy metal contamination in the one from fish is unpredictable.
Vitamin D- Daily dosage for Vitamin D is dependent on your bodyweight.
Folate, cracked cell chlorella, or a greens powder (600-100mcg)
In my clinic, I require a Vitamin D baseline test to determine your baseline level. If you test low, taking the daily dosage isn’t going to correct your deficiency. A corrective dose would be recommended over a period of time, time and dose depending on initial D baseline testing, with a repeat test at 6 to 8 weeks.
Vitamin D requires cofactors of K2 and magnesium. The dry version must be taken with some sort of fat at a meal for absorption (oil or butter).
Others that I typically test that are important for fertility:
Iron & Ferritin: Normal range for Ferritin is 50-100. For fertility you’ll need to be 70 or above. Test for baseline before supplementing
B12: levels between 700 and 900 are ideal. Test for baseline before supplementing
What should I do if my doctor won’t test me for some of this stuff? Are there any independent options without paying an arm and a leg?
Usually by the time a patient walks through my doors, they think they have had all the important tests. This is seldom the case. The testing is decided by two factors, insurance companies, and the whim of the doctor. The doctor’s incentive is to apply treatments that cost money and make revenue for the hospital. The insurance company’s goal is to pay for as little as possible, so it’s no wonder that testing is minimal. YOUR goal should be to discover what needs fixing, get yourself straight so you can conceive on your own, or if you do decide to do fertility treatments with a doctor, you can respond well to the treatment.
Doctors of all kinds discount the value of basal body temperature monitoring, which actually unfortunate because it a great way to keep track of your cycle and determine if you are off when comparing to a fertile cycle. The cycle length should conform to 28 to 30 days long. No spotting.
OPK positive is ideally cycle day 12 through 15, and temperature rising .4-.6 within three days of the positive opk, above the average follicular phase temperature (follicular phase is cycle day 1 to opk positive).
Menses: three days of red bleeding, no cramping, BBT temperatures back to low level, no headaches, pimples, PMS, etc.
Basal temperature data can also assist in diagnosing a low functioning thyroid.
When ordering a sperm analysis test, ask specifically for the Krueger strict morphology test. The other type of test, which is cheaper, WHO, offers comparatively little useful information.
It’s useful to know that high dosage of specific antioxidant vitamins are often prescribed for men, along with minerals, for sperm issues. I do think giving men some supplements is useful, even if they are testing ok on the Krueger. Beyond the Krueger there are other tests as well- ROS, DNA fragmentation, etc., but these are more difficult to get with at home kits.
Baseline testing and correction should be the first line of defense in fertility treatment, a large part of this can be done from home but is better in combination with supervision via tele-med with an informed practitioner.
In summary, there is still a lot patients can do to optimize fertility, even at home. If nothing else, be sure to:
Get your covid vaccines and booster.
Investigate baseline testing for both you and your partner.
Monitor your cycle with basal body temperature tracking, compare it with fertility optimal cycles.
Eat as healthily as possible, avoid chemical laden processed foods, hormones in your food, cleaning products, and personal care items (www.ewg.org)
Find cooperative and trustworthy medical professionals who aren’t just in it for the money
Check out some of the other resources on our site, including our book “Navigating the Weeds of Infertility 101” and check out more resources below. Good luck mama; you got this!
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