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Acupuncture for IVF and Assisted Reproduction - E-Book

Acupuncture for IVF and Assisted Reproduction - E-Book

Irina Szmelskyj | Lianne Aquilina | Alan Szmelskyj

(2014)

Additional Information

Book Details

Abstract

The management of infertility using acupuncture is an expanding area of practice and one which is frequently rewarding for TCM acupuncture practitioners.

Acupuncture for IVF and Assisted Reproduction has been specially prepared to meet the growing demand for information in this area and draws upon 20 years combined experience of the authors together with the latest evidence from both orthodox medicine and TCM.

Richly illustrated and clearly written throughout, the book takes the reader through the anatomy and physiology of reproductive medicine (from both an orthodox and TCM perspective) and explains the underlying basis of orthodox medical fertility tests and investigations. The volume then explores the pathology and aetiology of TCM syndromes and shows how common fertility-related conditions, such as endometriosis and male factor infertility, affect Assisted Reproductive Technology (ART) success rates. It explains in great detail how to take a reproductive medical history and successfully diagnose TCM syndromes. Acupuncture for IVF and Assisted Reproduction also provides guidelines on how to regulate the menstrual cycle in preparation for IVF treatment and shows how lifestyle can affect fertility and ART success rates.

Placing a strong emphasis on the practical aspects of patient care, Acupuncture for IVF and Assisted Reproduction contains an abundance of case history templates, algorithmic acupuncture treatment pathways and patient fact sheets and will be ideal for all acupuncture practitioners working in this field.

"A must have for the bookshelf of any acupuncturist who is ever called upon to treat fertility issues - if you have room for one book this surely must be it." Reviewed by The Acupuncture Fertility Centre March 2015

"Practitioners of all levels of experience and TCM students should find it compelling reading and an invaluable companion to their learning." Reviewed by Stephen Clarke, Journal of the Australian Traditional Medicine Society May 2015

"This book is extremely well re-searched and referenced." Reviewed by Danny Maxwell on behalf of Journal of Chinese Medicine, February 2015


Table of Contents

Section Title Page Action Price
Front Cover Cover
Dedication ii
Acupuncture for IVF and Assisted Reproduction: An Integrated Approach to Treatment and Management iii
Copyright iv
Contents v
Biographies ix
IRINA SZMELSKYJ ix
LIANNE AQUILINA ix
ALAN SZMELSKYJ x
Foreword xi
Preface xv
Acknowledgements xvii
Chapter 1: Subfertility overview 1
Introduction 1
Definition of Infertility Disorder 2
Definition of pregnancy 2
Definition of regular intercourse 2
Length of time to achieve pregnancy 2
Implications 2
Prevalence of Infertility 3
Infertility trends 3
Infertility treatment seeking 3
Major Causes of Subfertility from an Orthodox Medical Point of View 3
Common medical causes of subfertility presenting in acupuncture practice 4
Importance of treating both male and female partners 4
Contributory Subfertility Factors: The Orthodox Medical Perspective 5
Socioeconomic factors 5
Delayed parenthood 5
Education and financial status 6
Political policies 6
Healthcare spending 6
Traditions, culture, and family values 6
Environmental factors 6
Occupational factors 6
Overview of other factors 7
Increased stress levels 7
Nutrition, weight, and exercise 7
Early puberty 7
Sexual intercourse 7
Reproductive tract infections 7
Negative lifestyle habits 7
Causes of Subfertility from the TCM Point of View 7
Internal causes of disease/injury through emotion 7
Anger 8
Contemplation or worry 8
Anxiety 8
Fear 8
Sadness and grief 8
Guilt 8
Interrelationship between the emotions, the body, and the Spirit 9
External causes of disease 9
Cold EPF 10
Heat/Fire EPF 10
Damp EPF 10
Miscellaneous causes of disease 10
Constitution 10
Inappropriate diet 11
Surgery 11
Social, recreational, and physical overexertion 11
Work and rest 11
Previous fertility treatment 11
Miscarriages 11
Coitus and family planning 12
Contraception 12
Summary of the causes of diseases in subfertility 12
Reproductive History and Development from an Orthodox Medical Perspective 12
Reproductive History and Development from a TCM Perspective 13
View and worship of fertility 13
Works of classical Chinese medicine physicians 13
Recognition by Chinese medicine of some of the fundamental concepts of fertility 16
Fertile window and intercourse timing 16
The effect of age on fertility 16
Importance of optimizing natural fertility 17
Integrated approach 17
Summary 17
References 17
Chapter 2: Anatomy and physiology of the reproductive system: Prerequirements for conception 23
Functional Anatomy of the Reproductive System from an Orthodox Medical Perspective 23
Female reproductive anatomy 23
The ovaries and follicles 23
The fallopian tubes 23
Uterus 25
Vagina 25
Abnormalities of the female reproductive anatomy 25
Ovarian factors 25
Tubal factors 25
Uterine factors 25
Male reproductive anatomy 27
Testes 27
Epididymides 27
Vas deferens 28
Seminal vesicles 28
Ejaculatory ducts, prostate gland, and prostatic urethra 28
Urethra 28
Penis 28
Abnormalities of the male reproductive anatomy 28
Sperm and Egg Production 28
Spermatogenesis and spermiogenesis 28
Structure of sperm 28
Oogenesis 30
Structure of the egg 30
Folliculogenesis 32
Initial recruitment and development of primordial follicles up to class 5 antral follicles 32
Cyclical recruitment (selection) and development of antral into preovulatory follicles 32
TCM integrated perspective on follicular and egg development 33
Influence of acupuncture on primordial, primary, and early secondary follicles (approximately 360 and 190 days before ovula... 33
Influence of acupuncture on late secondary to preovulatory follicles (approximately 190-0 days before ovulation) 33
Reproductive Physiology from an Orthodox Medical Perspective 33
The Hypothalamic-Pituitary-Gonadal Axis 33
Key reproductive hormones 34
Gonadotrophin-Releasing Hormone 34
Follicle-Stimulating Hormone 34
Luteinizing Hormone 34
Oestrogens 35
Progesterone 35
Human Chorionic Gonadotrophin 35
Testosterone 35
Inhibin 35
Relaxin 35
Other hormones 35
Menstrual cycle 35
Follicular phase 36
Ovulation 36
Luteal phase 36
Reproductive Physiology from a TCM Perspective 37
TCM and Orthodox medical paradigms 37
TCM view of the human body 37
The reproductive lifespan in TCM: The yearly cycles 37
Qi, Blood, and Jing (Essence) 38
Qi 38
Blood 39
Jing (Essence) 39
Egg 41
Sperm 41
The menstrual cycle 42
Menarche 42
Menstrual discharge 42
Menstrual cycle 42
The four phases of the menstrual cycle and Yin Yang 43
Key Zangfu organs in fertility and early pregnancy 45
The Kidney 45
The Liver 47
The Heart 48
The Stomach 49
The Spleen 49
The Lung 49
The Uterus 50
Zangfu organ interactions and IVF 50
The key Extraordinary Vessels in reproduction 50
The Chong Mai (Penetrating Vessel) 51
The Du Mai (Governing Vessel) 51
The Ren Mai (Conception Vessel) 51
The Dai Mai (Girdling Vessel) 52
Summary 52
Reproductive anatomy and physiology 52
Reproductive ageing 52
Egg maturation 53
Reproductive system physiology 53
References 53
Chapter 3: The magic of conception 59
Sexual Intercourse 59
Sperm Transportation up the Female Reproductive Tract 60
Prefertilization Sperm Changes 60
Egg Maturation and Ovulation 61
Egg Fertilization 61
Transportation of the Embryo Down the Female Reproductive Tract 62
Comparison of Natural Fertilization (In Vivo) with ART Fertilization (In Vitro) 62
Embryogenesis 62
Implantation: The First Communication Between the Mother and Her Embryo 66
Implantation window 66
Process of implantation 66
Embryo-maternal interaction 66
Factors affecting implantation 66
Conception from the TCM Point of View 67
Natural conception 67
Classical Chinese literature 67
Traditional Chinese Medicine 68
Conception in IVF or by ICSI from the TCM point of view 68
The embryo's energy (Pre-Natal Qi) 68
Yuan (Original) Qi 68
Pre-Natal Jing (Essence) 69
Zhen (True) Qi 69
Shen (Spirit) 69
Summary 69
Acknowledgement 69
References 69
Chapter 4: Orthodox medical tests and investigations: Optimizing patient care 73
The Initial Consultation 73
Medical history 73
Initial physical examination 74
Tests and Investigations Overview 75
Tests and Investigations: Female 76
Ovulation assessment 76
Ovarian reserve screen 78
FSH, E2 (and LH) 78
AMH 78
AFC 80
CCCT 80
Inhibin B 80
Other blood tests 80
Cervical assessment 80
Uterine anomalies, tubal patency, and other peritoneal factors 80
Ultrasound 80
Hysterosalpingography 81
Hysterosalpingo-contrast-ultrasonography 81
Sonohysterography (saline infusion sonography (SIS)) 81
Laparoscopy 81
Fluoroscopic/hysteroscopic selective tubal cannulation 82
Hysteroscopy 82
MRI 82
Endometrial biopsy 82
Chlamydia Antibody Test 82
Genetic screening 82
Thrombophilia investigations 83
Overview 83
Types of thrombophilia 83
Diagnostic tests for acquired or secondary thrombophilia 83
Diagnostic tests for genetic or inherited thrombophilia 84
Treatment 84
TCM associations 85
Infection screening 85
Immunological investigations 85
Tests and Investigations: Male 85
Semen analysis 86
Endocrine investigations 87
Postejaculatory urinalysis 88
Ultrasound scan 88
Test of leukocytes in semen 88
Antisperm antibodies tests 89
MSOME 89
Sperm DNA fragmentation tests 89
Genetic screening 90
Cystic fibrosis gene mutation 90
Karyotyping 90
Y-chromosome analysis 90
Infection screening 91
Other tests 91
Sperm Penetration Assay/Hamster Egg Penetration Test 91
Hemizona Assay 91
Acrosome Reaction assay 92
Hyposmotic Swelling test 92
Summary 92
References 92
Chapter 5: Investigations from a TCM perspective 97
Medical and Fertility History Taking 97
Personal information 97
Presenting complaint 97
General health 98
Menstrual cycle 98
Past medical history 99
Medical tests and investigations 99
Family medical history 99
Previous pregnancies and obstetric history 99
Modifiable lifestyle factors 100
Assisted Reproductive Technology treatment (ART) history 100
Previous ART treatment cycles: Basic information 100
Preparation phase 100
Acupuncture treatment (if it was done) 100
Orthodox medical treatment (if relevant) 100
Lifestyle factors 100
RIF prevention steps 100
Pretreatment stage (usually downregulation stage) 101
Chapter 6: The fundamentals of ART 143
Introduction 143
Types of ART Treatment 143
Ovulation induction 143
IUI 144
Overview 144
IVF 144
Frozen Embryo Transfer 146
IVM 147
GIFT 148
ZIFT 148
Third-party ART 148
Donor ART 148
Surrogacy/gestational carrier 148
Pharmacological Drugs Used in ART 149
Ovulation induction medication 149
CC therapy 149
Aromatase inhibitors 149
Insulin-sensitizing drugs (commonly used in patients with PCOS) 149
Gonadotrophins 149
hCG 149
Dopamine agonists 149
GnRH 149
GnRH analogues (agonists and antagonists) 149
Luteal/endometrial support medication 150
Other medications 150
Embryo Grading 150
Importance of embryo grading 150
Embryo-grading principles 150
Cleavage-stage embryo scoring systems 150
Blastocyst scoring systems 151
Implications for acupuncturists 151
Advanced ART Techniques 151
Assisted hatching 153
Specialist sperm retrieval methods 153
ICSI 153
IMSI 153
The Role of Acupuncture in ART 154
Physiological effects of acupuncture in reproductive medicine and fertility 154
Role of acupuncture at key stages of ART 155
Preparation phase (3-6 months before the ART/IVF treatment cycle begins) 155
Pretreatment phase (up to 3 weeks before the ART/IVF treatment cycle) 155
The ART/IVF treatment cycle: Ovarian stimulation phase 155
The ART/IVF treatment cycle: Ovulation trigger and final egg maturation 155
The ART/IVF treatment cycle: Egg retrieval 155
The ART/IVF treatment cycle: Embryo transfer 155
The ART/IVF treatment cycle: Luteal phase and early pregnancy 155
The role of fertility acupuncturists 155
Advisory role 155
Emotional support 155
Referral 156
Prevention 156
Future Advances in ART: A Potential Role for Acupuncture? 156
Reproductive ageing and fertility preservation 156
Mitochondria replacement techniques 156
Summary 157
References 157
Chapter 7: Preconception care in preparation for ART 161
Weight 161
Maternal weight 161
Maternal weight and infertility 161
Maternal weight and comorbidities 161
Maternal weight and ART 161
Maternal weight and miscarriages 162
Paternal weight 162
Paternal weight and infertility 162
Paternal weight and ART 162
Paternal weight and miscarriages 162
Recommendation 162
Smoking 162
The effects of smoking on reproductive health 162
The TCM view of smoking 163
Recommendation 163
Alcohol 163
The effects of alcohol on reproductive health 163
Effects of alcohol on IVF outcome 163
The effect of alcohol on the risk of miscarriages 163
The TCM view of alcohol 163
Recommendations 164
Caffeine 164
Effect on female fertility 164
Effect on male fertility 164
Recreational Drugs 164
Orthodox medicine 164
TCM 164
Recommendation 164
Medication 164
Female fertility 164
Male fertility 164
Recommendation 165
Environmental and Occupational Factors 165
Environmental factors 165
Occupational factors 165
Recommendation 166
Nutrition and Supplementation 166
Micronutrients and female fertility 166
Folic acid and vitamin B 166
Vitamin D 166
Iodine 167
Vitamin A 167
Vitamin E 167
Omega 3 167
Selenium 167
Iron 167
Micronutrients and male fertility 168
Antioxidants that help with DNA sperm damage (vitamin C, vitamin E, vitamin A, omega 3) 168
Omega 3 168
Zinc 168
Vitamin D 168
Vitamin B12 168
Other 168
Diet 168
Female fertility 168
Male fertility 168
TCM 169
General dietary advice 169
Foods beneficial in Qi Deficiency syndromes 169
Foods beneficial in Blood Deficiency syndromes 169
Foods beneficial in Yin Deficiency syndromes 169
Foods beneficial in Yang Deficiency syndromes 169
Foods beneficial in Jing (Essence) Deficiency syndromes 169
Foods beneficial in Qi Stagnation syndromes 170
Foods beneficial in Blood Stasis syndromes 170
Foods beneficial in Heat/Fire syndromes 170
Foods beneficial in Phlegm-Dampness syndromes 170
Foods beneficial in Cold syndromes 170
Exercise and Rest 170
Orthodox medical perspective 170
Exercise and female fertility 170
Exercise and male fertility 170
Activity levels after the embryo transfer 170
Sleep and fertility 170
TCM perspective 171
Exercise 171
Rest 171
Sleep 171
Recommendation 171
Stress 171
Stress as a cause of infertility 171
Effects of stress on the reproductive system 172
Prevalence of stress in ART patients 172
Practical tips to reduce stress 172
The TCM view of stress, mind, and emotion 172
Research on acupuncture and stress and/or anxiety in fertility patients 173
Relationship and Sexual Issues 173
Sexual intercourse 173
Fertile window and timing of intercourse 173
Frequency of intercourse 173
Coital practices 174
Ovulation detection methods 175
Cervical mucus 176
Ovulation predictor kits 176
Basal body temperature (BBT) charting 176
Other methods 177
The TCM view of sexual intercourse 177
Recommendation 177
Summary 177
References 178
Chapter 8: Identification and management of conditions detrimental to IVF outcome 185
Tubal Pathology 185
Overview 185
Prevalence 185
Aetiology 185
Diagnosis 185
Orthodox medical treatment 185
Impact on ART treatment 186
Blocked fallopian tubes 186
Hydrosalpinges 186
The role of the acupuncturist 186
Acupuncture treatment 186
Referral for hydrosalpinges surgery 186
Referral for IVF 187
Ovulatory Disorders 188
Overview 188
WHO grade I ovulation disorders 188
WHO grade II ovulation disorders and clomiphene citrate treatment 188
WHO grade III ovulation disorder 189
Polycystic Ovary Syndrome 190
Overview and diagnosis 190
Prevalence 191
Pathology 191
Effect on reproduction 191
Ovarian reserve 191
Miscarriages 191
Pregnancy 191
Mental-emotional health 191
Orthodox medical management of PCOS 191
Lifestyle and dietary modifications 192
Ovulation induction 192
Metformin 192
Surgery 192
IVF 192
In Vitro Maturation 192
Vitamin D supplementation 193
Acupuncture treatment of PCOS 193
Research on acupuncture and PCOS 193
Acupuncture treatment 193
Thyroid Disease 196
Overview 196
Aetiology 196
Orthodox medical management of thyroid disease 197
Indications for biochemical tests 197
Thyroid function tests 197
Management of patients with hypothyroidism 197
Management of patients with hyperthyroidism 198
Effect of thyroid disease on fertility and pregnancy 198
Effect on ovarian reserve 198
Effect on the menstrual cycle 198
Effect on ART 199
Effect on pregnancy and the foetus 199
Effect on male fertility and reproductive health 199
Lifestyle factors 200
The role of acupuncture 200
Referral for investigations 200
Treatment with acupuncture 200
Management during pregnancy 202
Endometriosis 203
Overview 203
Risk factors 204
Signs and symptoms 204
Diagnosis and staging 204
Effect on fertility and reproductive health 204
Orthodox medical treatment 205
Expectant management 205
Medical treatment 205
Surgical treatment 205
ART treatment 206
The role of acupuncture 206
Referral 206
Treatment with acupuncture 206
Unexplained Subfertility 207
Chapter 9: Acupuncture during ART 237
Treatment During IVF 237
Pretreatment phase (suppression or downregulation) 237
Orthodox medical protocol 237
GnRH agonist 237
GnRH antagonist 237
Baseline evaluation 238
TCM protocol 238
Ovarian stimulation phase 239
Orthodox medical protocol 239
Patient monitoring 241
Follicular growth 241
Oestrogen levels 241
Endometrial development 241
TCM protocol 242
Final egg maturation and ovulation induction 244
Chapter 10: Clinical issues during ART 275
Poor Follicular Development 275
Orthodox medical therapeutic options in the affected cycle 276
Longer gonadotrophin stimulation 276
Increasing the dose of stimulation medication 276
Conversion to Intrauterine Insemination 276
Orthodox medical preventative options 276
Androgen pretreatment (DHEA or testosterone) 276
Treatment protocol 276
Higher stimulation dose 277
Minimal stimulation dose or natural IVF 277
Weight loss 277
Acupuncture: Rescue treatment 277
Follicles develop too quickly 277
Follicles develop too slowly 277
Combination of very large and small follicles 277
Acupuncture: Preventative treatment 277
Immature or No Eggs 277
Overview 277
Empty follicle syndrome 277
Follicular flushing 278
Higher dose or different `trigger medication 278
Timing of hCG trigger 278
> 36 h between the trigger injection and egg retrieval 279
Rescue hCG 279
Donor eggs 279
Immature eggs 279
The role of the acupuncturist 279
Suboptimal Endometrial Lining 279
Overview 279
Causes and therapeutic options 280
Lifestyle advice 280
Role of the acupuncturist 280
No Sperm 281
The role of the acupuncturist 281
Fertilization Failure 281
Fertilization failure incidence and implications 281
Fertilization failure in IVF 282
Fertilization failure in ICSI 282
Other causes of fertilization failure 282
The role of the acupuncturist 282
Poor Embryo Growth or Growth Arrest 283
Causes of poor embryo development 283
Maternal influences 283
Paternal influences 284
Other factors 284
Role of the acupuncturist 284
Difficult Embryo Transfer 284
What can go wrong and the consequences 284
Therapeutic options 284
The role of the acupuncturist 285
Summary 285
References 285
Chapter 11: ART complications 291
Ovarian Hyper-Stimulation Syndrome 291
Introduction 291
Orthodox medical management of OHSS 291
Acupuncture management of OHSS 294
TCM view of OHSS 294
OHSS patient management 294
Multiple Gestation 296
Introduction 296
Risks associated with multiple pregnancy following ART 296
How to minimize the risks of ART while maximizing the chances of pregnancy 296
Implications for fertility acupuncturists 297
Summary 299
References 299
Chapter 12: Managing the patient with a complex medical history 301
Repeated Implantation Failure 301
Overview 301
Definition 301
Implantation failure versus preclinical pregnancy failure 301
Causes of RIF 301
Uterine and maternal factors 302
Anatomical abnormalities and hysteroscopy 302
Endometrial injury (biopsy or `scratch) 302
Interval (sequential) embryo transfer 302
Frozen Embryo Transfer 303
`Embryo glue 303
Endometriosis 304
Hydrosalpinges 304
Endometrial thickness 304
Infections 304
Immune disease 304
Thrombophilia 304
Maternal age 304
Male factor 305
Embryo factors 305
Zona hardening and assisted hatching 305
Inadequate culture conditions 305
Blastocysts versus day 2 versus day 3 transfer 305
Zygote Intra Fallopian Transfer 305
Number of embryos transferred 305
Genetic causes: Parental 305
Genetic abnormalities: Embryo 306
Non-invasive embryo assessment (morphokinetic analysis) 306
Other causes 306
Treatment protocol 306
Poor embryo transfer techniques 307
Lifestyle factors 307
Psychological 307
Clinical perspective 307
RIF from a TCM point of view 307
Introduction 307
Common syndromes causing RIF 307
TCM pathophysiology of RIF 307
Kidney pathology 307
Liver pathology 308
Heart pathology 308
Spleen pathology 308
Blood Stasis 308
Cold 308
Phlegm-Damp 308
Blood-Heat 310
The acupuncturists role in the management of RIF 310
Miscarriages and Pregnancy Loss 310
Background and terminology 310
Causes of miscarriages 312
Embryo genetic abnormalities and parental age 312
Parental genetic abnormalities 312
Anatomical factors 312
Infections 313
Acquired and inherited thrombophilia 314
Endocrine factors 314
Polycystic Ovary Syndrome 314
Hypothyroidism and thyroid autoimmunity 314
Luteal phase insufficiency 314
Immunological factors 315
Male factor 315
Environmental, lifestyle, and nutritional factors 315
Unexplained miscarriages 315
Orthodox conventional medical management of patients presenting with suspected miscarriage 315
Presenting signs and symptoms 315
Pregnancy viability assessment 315
TCM management of patients presenting with threatened miscarriage 316
Pathophysiology of miscarriages 316
TCM management of inevitable or missed miscarriages 317
TCM management of patients with a history of RMs 317
When to refer for miscarriage investigations 317
TCM lifestyle advice in prevention of miscarriages 321
Physical activity 321
Intercourse 321
Emotions 321
Diet 321
When to start trying for a baby again 321
Management of patients experiencing anxiety about miscarrying 322
Ectopic pregnancy 322
Preterm birth and cervical insufficiency 323
Reproductive Immunology 325
Introduction 325
Reproductive immune pathology and tests 325
CD56+ natural killer 325
Reproductive immunophenotype 325
Th1:Th2 assay 325
Leukocyte Antibody Detection test 326
Human leukocyte antigen HLA-DQ alpha test 326
Immunotherapy 326
Intravenous Immune Globulin 326
Intralipid therapy 326
Glucocorticoids 327
Lymphocyte Immunization Therapy 327
TNF-alpha inhibitors (Th1:Th2) 327
Peripheral blood mononuclear cells 327
Granulocyte colony stimulating factor 327
Reproductive Immunology from a TCM Point of View 327
Research on the effect of acupuncture on the immune system 327
Acupuncture and Th1:Th2 (TNF-alpha) cells 327
Acupuncture and NK cells 328
Acupuncture points that modulate the immune system 328
Associations of reproductive immunology and TCM 328
Implications for Acupuncturists: To Refer or not to Refer? 328
Summary 331
References 331
Chapter 13: The therapeutic relationship in acupuncture practice 339
Mutuality 339
Trust 340
Care 340
Challenge and Performance 341
Return to Mutuality 341
Measuring the Success of Acupuncture Treatment 342
The Effect of Subfertility on Patients 342
Legal and Ethical Considerations 342
Assisted reproduction ethics 342
Is fertility treatment ethical? 342
Health of babies born as a result of ART 342
Treatment of much older patients 343
Third-party reproduction 343
Regulation of ART treatments 343
Ethical fertility acupuncture practice 343
Fees structure 343
Professional boundaries 344
Continuity of care 344
Confidentiality 344
Limit of competence 344
Treating patients when the prognosis is very poor or futile 344
Refusing to treat a patient 345
Summary 345
References 345
Chapter 14: Aftercare 347
Negative Outcome 347
Immediate aftermath of a negative test 347
Guiding patients in their possible future steps 347
When is the right time to stop the treatment? 347
Positive Outcome: Healthy Transition from Subfertility to Pregnancy 348
Pregnancy following ART and the risk of complications 348
Transition from subfertility to pregnancy 349
Acupuncture treatment during early pregnancy 349
When to discharge pregnant patients 351
Acupuncturists Self-Care: Saying Goodbye to Patients 351
Summary 352
References 352
Appendix I: Templates 355
Appendix II: Basal body temperature (BBT) chart template and instructions 379
Basal Body Temperature (BBT) Template 379
Basal Body Temperature (BBT) Charting Instructions 379
Taking the Temperature 379
Recording the Temperature 379
Intercourse 379
Cervical Fluid 379
Ovulation Test Results 379
Other Notes 379
Appendix III: Investigation reference ranges at a glance 383
References 392
Appendix IV: Fertility factsheets 395
Optimizing Female Fertility 395
Patients factsheet 395
Weight 395
Smoking 395
Alcohol 395
Caffeine 395
Recreational drugs 395
Prescription or over-the-counter medication 395
Environmental toxins 396
Nutrition 396
Supplements 396
Exercise 397
Stress 397
Sexual intercourse 397
Optimizing Male Fertility 397
Patients factsheet 397
Weight 397
Smoking 397
Alcohol 397
Caffeine 397
Recreational drugs 397
Prescription or over-the-counter medication 397
Environmental toxins 397
Nutrition 398
Supplements 398
Exercise 398
Stress 398
Sexual intercourse 398
Appendix V: Commonly used medications in ART 401
Appendix VI: Medications known to adversely affect fertility 405
Index 415