Category Archives: Fertility

To Induce or not to Induce? Let’s look at the evidence

Elective induction of labour (EIOL) is a hotly debated topic in the birthing community made even more controversial recently with the publication of the ARRIVE Trial (2018).  It’s not that often that a study will divide the community as much as this one has simply due to it’s large scale. The results can not be ignored, but can also not be misapplied.

The biggest thing to come out of the trial was that the results showed elective induction of labour at 39 weeks for first-time mothers had a decreased c-section rate. This took the birthing world by storm and begs the question: Should we induce ALL first time mothers at 39 weeks?

The answer is NO.

These results can not be generalized to the whole population because they are not representative of the whole population. Keep in mind that the study participants had to agree to be induced which means that it aligned with their values and beliefs. A large number of women qualified to participate in the study, but the majority of them declined because they did not want to be induced without a medical indication. It did not align with their values and beliefs.

Although the results of this study concluded that EIOL at 39 weeks for first time mothers decreased the cesarean rate, it did not acknowledge that there are many other effective and less-invasive approaches to lower the risk of c-section (1. continuous labour support (i.e Doula) 2. Intermittent auscultation (Hands on fetal monitoring) 3. Walking during labour and water births).

While the results of the ARRIVE Trial should not be applied to every birthing mother, the information can be used on an individualized basis and can be a viable option if: 1. It is inline with the mother’s values 2. the staff and facility are available to assist in longer labour (need to allow for a longer first phase of labour) 3. the protocol for “failed” inductions avoids a c-section. It is important to note that the outcomes for neonatal death or complications were the same for the induction group and the group that waited for spontaneous labour, so safety is not a concern. Also important to note is that not all women in the control group had a spontaneous vaginal delivery (some ended up being induced and some had c-sections, but this occurred after 39 weeks). This also skews the results.

PROS:

  • avoid potential complications associated with longer gestational periods (preeclampsia, hypertension, macrosomia)
  • Lower c-section rate with first time mothers under best-practice of ‘failed’ inductions
  • Theoretically may prevent future stillbirth
  • Convenience, ending an uncomfortable pregnancy

CONS

  • Failed inductions can lead to a preventable c-section
  • Longer time for labour
  • Medicalization of birth (more interventions such as electronic fetal monitoring)
  • medically induced contractions are much more painful and this leads to a higher epidural rate
  • Potential uterine tachysystole, infection
  • Unknown impact on labour and delivery costs/resources

I would like to specially thank Rebecca Dekker of Evidence Based Birth for dissecting the information and presenting it during her webinar. For more information on all things birth related visit: https://evidencebasedbirth.com/

 

Turns out the “stress” from labour is beneficial for the baby because it helps with lung maturation, improved sense of smell (important for breastfeeding), decreased obesity and higher cognitive function. Contractions are good for the baby!

Stress Deprivation in the Perinatal Period

Fertility Hormones and Their Reference Ranges

You know the drill when it comes to hormonal blood work; it’s a lot of poking and prodding on multiple days of your menstrual cycle. In my experience, my patients have had all the right testing done (mostly), but no one has taken the time to sit down with them and explain what the results truly mean.

The biggest pitfall of serum (blood) hormone testing is that the reference ranges are MASSIVE. Which means it is highly unlikely that your results will be deemed “abnormal” even though you know something is wrong. So that’s what this blog is for; I’m going to break it all down for you and discuss what the results mean and the REAL range you’re looking for. Note: the following reference ranges are for women and are Canadian units. 

1) Estradiol 
What it isEstradiol, along with LH and FSH, stimulate follicle (egg) maturation. It’s also responsible for female sex characteristics, thickening of the endometrial lining, and bone protection. Estrogen can also be converted from fat, in both males and females, by an enzyme called aromatase.
What it meansLow estradiol is present in peri-menopause and menopause. Elevated estrogen is present in early premature ovarian insufficiency (followed by low levels), and in estrogen dominant conditions like: PMS, endometriosis, PCOS, and obesity.
Reference Range:
Follicular 77-921 pmol/L
Luteal 77-1145 pmol/L
The “real” range: The width of the above ranges is ridiculous! Estradiol should be tested on day 3 and should be lower than 200 pmol/L and higher than 80 pmol/L. A level higher than this is a sign that the body is trying too hard to stimulate egg development, and the ovaries are not responding. In this case, you will likely see elevated FSH too.

2) FSH (follicle-stimulating hormone)
What it isThe name says it all. FSH is in charge of the development and maturation of follicles.
What it meansHigh levels are diagnostic of menopause, ranging from 27-133 IU/L. When your body is pumping out more FSH than normal, it’s a sign that the ovaries are not responding (just like estrogen). Low levels of FSH are typically present in PCOS.
Reference Range:
Follicular 3-8 IU/L
Mid-cycle 3-22 IU/L
Luteal 1.5-5.5 IU/L
The “real” range: Higher than 8 IU/L on day 3 (that’s the 3rd day of your period) is too high and the value is only going up from there. 6 IU/L is as good as it gets on day 3.

3) LH (Luteinizing hormone)
What it isAh, the hormone everyone knows and loves! The LH surge triggers ovulation and is measured by urine strips. LH also contributes to the maturation of eggs. You may not know that estrogen surges right before LH, which can also be used to detect ovulation.
What it meansOn day 3, an LH to FSH ratio greater than 2:1 is indicative of PCOS. LH is elevated in PCOS for so many reasons I’ll need to dedicate another blog to it. Elevated LH also stimulates elevated testosterone production, and in turn estrogen production. Contrary to what you may think, high LH actually inhibits ovulation instead of stimulating it.
Reference Range:
Follicular 2-12 IU/L
Mid-cycle 8-90 IU/L
Luteal 1-14 IU/L
The “real” range: LH should be almost equivalent to FSH on day 3.  6-8 IU/L is ideal.

4) Progesterone
What it isMost of the body’s progesterone is produced by the outer coating of the egg, called the corpus luteum. After you ovulate, progesterone levels increase to maintain the endometrial lining and prepare for embryo implantation. Progesterone also stimulates the production of a thick mucous that covers the cervix so no sperm can enter the uterus (FYI this is the basis of hormonal birth control).
What it meansA low level of mid-luteal progesterone indicates anovulation and luteal phase defect (short luteal phase) and predicts implantation failure/ early miscarriage.
Reference Range:
Luteal 4-50 nmol/L
The “real” range: On day 21 the minimum value is 10 nmol/L to have ovulated and 20 nmol/L to carry a pregnancy. Day 21 is arbitrary if you don’t ovulate on day 14. Progesterone is best-tested 7 days after you ovulate.

5) Prolactin 
What it isThe main function of prolactin is to stimulate breast milk production. However, elevation can also occur due to the following: benign pituitary tumor, periods of high stress, hypothyroidism, PCOS, and certain medications.
What it meansElevated prolactin inhibits the release of GnRH, which then inhibits the release of LH and FSH. Without LH and FSH, follicles will not develop.
Reference Range:
5-30 ug/L
The “real” range: Prolactin levels as high as 50 ug/L can inhibit ovulation, but small increases by a few points are relatively harmless. One-time elevation should be followed by repeat testing. As mentioned, stress is a major influence on this hormone.

6) DHEA 
What it isA precursor hormone to both estrogen and testosterone.
What it meansDHEA is often evaluated in PCOS, as elevations in this hormone increase androgen levels. It may be prescribed to improve ovarian reserve (but not without fun side-effects).
Reference Range: <9.8 umol/L

7) Androstenodione 
What it isProduced from DHEA, this hormone is the precursor to testosterone.
What it meansElevated androstenedione is found in PCOS and adrenal hyperplasia. Both conditions inhibit ovulation. It may be elevated in isolation, or with testosterone.
Reference Range:
Follicular 1.2-8.7 nmol/L
Luteal 1.1-8.2 nmol/L

8) Testosterone 
What it isYou know this hormone for its role as the primary male sex hormone, but it’s important for women too! In the ovaries, testosterone is produced by the stromal cells and converted to estrogen. It participates in follicle growth and development, not to mention male and female libido.
What it meansToo much is present in PCOS which is far from ideal, but too little can inhibit ovulation and egg development.
Reference Range:
Total testosterone 0.3- 1.8 nmol/L (some labs up to 4 nmol/L)
The “real” range: Testosterone is extremely tricky to test accurately. Free testosterone is a better measurement than total and the reference ranges (depending on the lab) have huge variability. In order to test free testosterone you need to test total testosterone and sex hormone binding globulin.

9) AMH (Anti-Mullerian Hormone) 
What it is: It’s a hormone that can depict the female egg reserve because it is secreted by the eggs in the ovaries. The more eggs you have, the higher the value will be. Not surprisingly, AMH decreases with age. This is the only hormone test we have for predicting ovarian reserve.
What it meansA lower value for your age means you have a lower number of eggs than the average female. A much higher value for your age is indicative of PCOS, as the cystic ovaries in PCOS secrete excess AMH.
Reference Range: The numbers are averages based on age:
< 33 = 2.1 ng/mL
33-37 = 1.7 ng/mL
38-40 = 1.1 ng/mL
> 41 = 0.5 ng/mL
The “real” range: At any age, a value > 3.15 – 4.45 ng/mL warrants further testing for PCOS. A value of 6.8-10 ng/mL is diagnostic.

10) TSH (thyroid stimulating hormone) & Antibodies (anti-TPO, anti-TG, anti-TSH) 
What it isTSH is released by the anterior pituitary, which then stimulates the release of thyroid hormones (T3, T4) from the thyroid gland. TSH above the reference range with symptoms present is diagnostic of hypothyroidism, and below is hyperthyroidism. TPO and TG antibodies cause the thyroid condition known as Hashimoto’s, anti-TSH is more commonly present in Graves’.
What it meansDeficient thyroid function affects egg quality, embryo quality, and implantation rates. Combine that with thyroid antibodies, and there’s an increased risk of miscarriage.
Reference Range:
TSH 0.32-4.0 mIU/L
Antibodies should all be negative
The “real” range: TSH should be < 2.5 to prevent miscarriage. A full thyroid lab panel (with individual thyroid hormones) is certainly necessary in cases of recurrent miscarriage.

Have more questions? Meet with me!
Wondering about your own lab results? Need a little help wading through the information and finding the useful parts? I offer a free 30 min consultation to all new patients. Click below to book yours today. I look forward to seeing you soon!

About the Author

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​Dr Caleigh Sumner is a Naturopathic Doctor
at the Toronto Reproductive Acupuncture Clinic.

http://www.toronto-fertility.com/blog/the-top-10-hormones-worth-testing-for-fertility-the-exact-results-you-want-to-see-dr-caleigh-sumner-nd

Markham-Stouffville Hospital Opened The First Midwife Unit located IN Canadian Hospital

First hospital midwifery unit in Canada opens in July

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Integrative Fertility Symposium 2018 #IFS2018

It was an absolute honor, pleasure and privilege to spend the past five days in Vancouver at the Integrative Fertility Symposium learning for world-renowned leaders in the field of reproductive medicine. Speakers from Canada, the United States, the U.K, Australia and Europe traveled to Vancouver to share their research and knowledge on all aspects of fertility from both a Western Medicine and Chinese Medicine point of view. It was amazing to see different practitioners with different areas of expertise convene in one place to share one common goal – creating babies.

One of the great things about this symposium is that it promotes INTEGRATION of different styles of medicine. It’s not an “us vs them” mentality like so many other fields. Medical Doctors and Reproductive Endocrinologists have seen first how acupuncture and Chinese Medicine have benefited their patients and are fully supportive of this field. Most Fertility Clinics work closely with acupuncturists and Naturopathic doctors because it improves IVF and IUI results.  It is satisfying and empowering to receive the respect and support of these doctors and be able to learn from them.

I am home now and back at the clinic. I am so excited to implement everything I have learned and help more patients achieve their fertility goals!

If you are interested in fertility acupuncture or have questions about how acupuncture can help you conceive feel free to call me directly for a free 15 minute phone consultation: 647.299.4631. Reception: 905.553.9255 or book online: www.besthealtacupuncture.com 

Scroll down to see pictures from the Symposium and scenic views of beautiful B.C

Vancouver, British Columbia, Canada

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Fresh or Frozen IVF Embryo Transfer – Which is better?

The main take away points for this article (below) is that whatever protocol is used should be specific and individualized to you. As this article states, there is no difference in pregnancy or live birth rates between a fresh or frozen IVF embryo transfer. The problem arises when certain clinics decide to run their practices by exclusively doing one or the other. There are pros and cons to both and it is important for the Reproductive Endocrinologists to take the time to review your case and figure out what is best for YOU! This is where alternative medicines, such as acupuncture and traditional Chinese Medicine (TCM) has it’s strength. We take the time to sit down with our patients and get to know them and their unique bodies. We ask questions about their menstrual cycle and any hormonal issues, but we also take into consideration their bodily function as a whole (sleep, stress, digestion, bowel movements, appetite, emotional state, etc). This is important because sometimes the answers lie outside the reproductive system and by creating an acupuncture treatment that is tailored to their specific body constitution patients are more likely to respond to treatment with their fertility clinic (IUI, IVF or other ART).

For more information or to book an appointment:

Call: 905.553.9255

Email: amanda@besthealthacupuncture.com

Book online: www.besthealthacupuncture.com

Check out the full article on frozen vs fresh transfers here:

http://www.huffingtonpost.ca/dr-caitlin-dunne/you-now-have-more-reasons-to-freeze-embryos-for-infertility-treatment_a_23330442/?utm_content=65707768&utm_medium=social&utm_source=twitter

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Acupuncture & Pregnancy Health – Natural support for women during pregnancy, labour and delivery

Pregnancy is an amazing time in a woman’s life. Many women report feeling healthier than they have ever felt before; however, the physical growth of the baby and changes in hormone levels can bring about pain, discomfort and a variety of health problems.
Acupuncture and Traditional Chinese Medicine (TCM) can provide a safe, effective alternative for many of the health complications that may arise before, during and after pregnancy. A growing number of women are choosing acupuncture to use throughout their pregnancy and as an optional treatment for an overdue or difficult labor.
Planning for a Healthy Baby
Healthy parents produce healthy babies. With acupuncture and TCM, parents can improve their health to create the most optimal environment for their unborn child. In addition to their ability to strengthen, support, and balance overall health and well-being, acupuncture and TCM are an effective treatment for regulating menstruation and hormone levels, reducing stress and addressing any pre-existing medical conditions or concerns that a woman may have.
Acupuncture during Pregnancy
Acupuncture and TCM can play a vital role in the comfort of a pregnant woman. There is strong evidence to support that acupuncture is highly effective at treating some of the most common problems experienced during pregnancy including morning sickness, heartburn, insomnia, water retention and sciatica.
Here is a list of some of the problems that an acupuncturist often treats during pregnancy:

  • Nausea and Vomiting
  • Heartburn
  • Constipation
  • Hemorrhoids
  • Edema and Swelling
  • Urinary Tract Infection
  • Pelvic Pain
  • Neck and Back Pain
  • Sciatica
  • Carpal Tunnel Syndrome
  • Leg Cramps
  • Fatigue and Exhaustion
  • Insomnia
  • Anxiety and Depression
Acupuncture For Malpostion of The Fetus
Study: Acupuncture Point, UB 67, for Turning a Breech Baby
An acupuncture point on the small toe of the foot (Urinary Bladder 67) has been found to effectively revolve fetuses in breech presentation.
In an Italian study, 240 women at 33-35 weeks of gestation carrying a fetus in breech presentation were randomized to receive acupuncture plus moxibustion (an herb used to apply heat to an acupuncture point) or to be assigned to the observation group. At delivery, the proportion of babies that had turned from breech position to vertex (head-down) position was 53.6 % in the group treated with acupuncture while the proportion of babies that had turned from breech position to vertex position in the observation group was 36.7%.
(Source: J Matern Fetal Neonatal Med. 2004 Apr;15(4):247-52)
 

Acupuncture for Childbirth
There are many acupuncture points that can provide natural pain relief during labor, however, if you do not have the luxury of having an acupuncturist at your beside you can obtain significant relief from acupressure. Using your fingers and hands to produce strong stimulation at certain acupuncture points can be just as effective as needles. This works best if your support person learns these acupoints beforehand and massages them for you during labour. 

Acupuncture is also commonly used to induce labor. There are several points that stimulate contractions and influence cervical ripening. It is best to wait until after your due date or as a natural alternative to a medical induction as there are many benefits to your baby by waiting until 40 weeks gestation. 
Acupuncture Postpartum
Many women feel depleted after the birth experience. Acupuncture can help the transition of those first few months after birth to ensure a quick recovery. Postpartum care focuses on the physical, emotional and psychological recovery of the mother from the effects of pregnancy and labor, as well as encouraging breast feeding.
Here are some of the postpartum disorders that can be treated with acupuncture:

  • Fatigue
  • Postpartum Depression
  • Mastitis
  • Insufficient or Excessive Lactation
  • Post Operative Healing
  • Night Sweats

Safety of Acupuncture During Pregnancy
Acupuncture is safe to use while you are pregnant; however, there are some points that can cause contractions and should NOT be needled during pregnancy or should be used with extreme caution. ****It is important to see an acupuncturist that has specific training in pregnancy wellness**** Both Amanda Barone and Kim Tran are trained to safely and effectively treat pregnant women

 

For more information or to schedule an appointment please call: 905.553.9255 or email: amanda@besthealthacupuncture.com or book online: www.besthealthacupuncture.com

Why Do Women Have Miscarriages?

Acupuncture can help prepare a woman’s body for pregnancy – especially by creating a healthy uterine lining (an essential component to implantation and miscarriage prevention). Contact us to learn more about our ‪#‎fertility‬treatments and ‪#‎pregnancywellness‬ 647.299.4631 or amanda@besthealthacupuncture.com

http://www.fitpregnancy.com/pregnancy/getting-pregnant/science-finally-knows-why-women-have-more-one-miscarriage

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Acupuncture for Fertility

“The body will not conceive if a woman is not in a healthy enough state to support a pregnancy” – Justisse Healthworks for Women

From an evolutionary perspective, your body’s main priority is survival. This means its basic needs must be met and the body must be functioning optimally before it considers reproducing. This sounds like common knowledge, but how many people have actually looked at the correlation between their sleep, appetite, bowel movements, digestion etc and their reproductive health? Many women are diagnosed by Western doctors with “unexplained” infertility. The truth is, there IS an explanation with Chinese Medicine and the source of the problem usually lies outside of the reproductive system. Acupuncture can increase your chances of conceiving by correcting any dysfunction in other systems (respiratory, circulatory, digestive, urinary, etc.) that are distracting your body from focusing 100% of its resources on reproduction.

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IVF Funding In Ontario – Coming December 2015

IVF Will Soon Be Publicly Funded In Ontario Through OHIPBaby