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Archive for the ‘Reproductive Endocrinologist’ tag

Reasons to Consider Annual Fertility Screening

By David Kreiner MD

December 19th, 2014 at 8:01 pm

 

credit: akeeris/ freedigitalphotos.net


What Is Fertility Screening?

Fertility screening starts with a blood test to check the levels of FSH (follicle stimulating hormone), estradiol and AMH (antimullerian hormone). The FSH and estradiol must be measured on the second or third day of your period. The granulosa cells of the ovarian follicles produce estradiol and AMH. The fewer the follicles there are in the ovaries the lower the AMH level. It will also mean that less estradiol is produced as well as a protein called inhibin. Both inhibin and estradiol decrease FSH production. The lower the inhibin and estradiol the higher the FSH as is seen in diminished ovarian reserve. The higher the estradiol or inhibin levels are then the lower the FSH. Estradiol may be elevated especially in the presence of an ovarian cyst even with failing ovaries that are only able to produce minimal inhibin. However, the high estradiol reduces the FSH to deceptively normal appearing levels. If not for the cyst generating excess estradiol, the FSH would be high in failing ovaries due to low inhibin production. This is why it is important to get an estradiol level at the same time as the FSH and early in the cycle when it is likely that the estradiol level is low in order to get an accurate reading of FSH.

The next step is a vaginal ultrasound to count the number of antral follicles in both ovaries. Antral follicles are a good indicator of the reserve of eggs remaining in the ovary. In general, fertility specialists like to see at least a total of eight antral follicles for the two ovaries. Between nine and twelve might be considered a borderline antral follicle count.
As you start to screen annually for your fertility, what you and your doctor are looking for is a dramatic shift in values from one year to the next.

What Does the Screen Indicate?

A positive screen showing evidence of potentially diminishing fertility is an alarm that should produce a call to action. When a woman is aware that she may be running out of time to reproduce she can take the family-planning reins and make informed decisions. The goal of fertility screening is to help you and every woman of childbearing years make the choices that can help protect and optimize your fertility.

Although none of these tests is in and of themselves an absolute predictor of your ability to get pregnant, when one or more come back in the abnormal range, it is highly suggestive of ovarian compromise. It deserves further scrutiny. That’s when it makes sense to have a discussion with your gynecologist or fertility specialist. Bear in mind, the “normal” range is quite broad. But when an “abnormal” flare goes off, you want to check it out. It’s important to remember that fertility is more than your ovaries. If you have risk factors for blocked fallopian tubes such as a history of previous pelvic infection, or if your partner has potentially abnormal sperm, then other tests are in order.

Regardless of the nature or severity of the problems, today, with Assisted Reproductive Technology and the latest Egg-freezing technology, there is a highly effective treatment available for you.

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Have you had a fertility screening yet? Did you find it helpful? Do you have any questions for Dr. Kreiner?

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Long Island IVF Family Reunion 2014 Memories

By Tracey Minella

November 11th, 2014 at 4:26 pm


Long Island IVF just celebrated its 26th Annual Family Reunion event. With schools closed and many people off from work, we were blessed with an exceptionally high turn-out of babies and new parents. And we couldn’t have been happier!

The family reunion is the highlight event of our year because it’s when the doctors and staff get to meet the newest crop of little miracles. The last time some of these babies were held, they were only a few cells in size! It’s such an emotional experience for doctors and patients alike. This year, 99 of the newest babies came out. Maybe we’re biased, but they were all gorgeous! And their parents were bursting with smiles and pride…happiness and gratitude replacing the worry and stress of the past. A photographer was capturing the little dickens in a fall-themed pumpkin patch.

It was remarked that if we’d had all of the babies we helped to create for the past 26 years, we’d have filled the Nassau Coliseum!

We were also so lucky to have the event covered by several media outlets, including CBS, Fox, FIOS, and News 12. Not only did that coverage expose our practice’s success to potential patients who may need our family-building services, but it enabled all of our patients, past and present, to share in the reunion experience. You could feel the happiness in the air.

Please check out some of the videos of that news coverage on our Facebook page or at these links and check back often as we will update them as they are available:

http://longisland.news12.com/news/long-island-ivf-celebrates-26-years-of-helping-families-1.9608352

http://newyork.cbslocal.com/video/10839273-proud-parents-reunite-with-doctors-to-celebrate-birth-of-little-miracles/

 

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Have you been to a LIIVF family reunion? If so, what was the best part? If not yet, what part do you imagine would be the most fulfilling?

 

 

 

 

 

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Infertility Care: Starting with the Basics

By Steven Brenner MD

October 18th, 2014 at 10:52 am

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“Thinking the worst” is a very common reaction for individuals experiencing adversity.

This is especially true for people experiencing infertility. Concerns regarding the question of establishing the family someone has dreamed of since they were young is daunting and can leave a person with significant anxiety and doubt regarding her/his future.

In this context it is important to go back to basics regarding fertility and understand that many people suffering from this disorder will be successfully treated with relatively simple techniques and therapies. For the more severe abnormalities, it is comforting to know current available therapies can address these issues with great success.

Establishing a pregnancy without infertility treatment requires a healthy egg, functioning sperm and an anatomic path that allows sperm to ascend the genital tract and an egg to travel into a fallopian tube where fertilization takes place. The anatomic path needs to allow the fertilized egg to travel into the uterine cavity. A receptive uterine lining is then required for the pregnancy to implant and grow. To make things more challenging, sperm and egg have a very small window of time to find each for fertilization to take place.

Many couples have experienced infertility as a result of improperly timed intercourse.  This often results from the couple not being aware of the timing of ovulation and the short duration of egg viability. The “fix” for something like this is very simple, requiring merely an understanding of the basic physiology.  Sexual dysfunction can plague a relationship, but it is often not until fertility is compromised that couples seek treatment. The simple fix for fertility may involve nothing more than inseminations timed to natural ovulation. Much more in depth therapies may be required to overcome the other, additional concerns associated with sexual dysfunction.

Ovulatory dysfunction, while a very complex issue, is often very easily addressed with simple treatments. Weight loss or gain may be all that is needed to establish regular ovulatory cycles. Correction of hormonal abnormalities leading to problems with ovulation can often be treated with medications that do not require the intense monitoring of injectable fertility medications associated with in vitro fertilization procedures.  Sluggish thyroid activity and elevations in a hormone named prolactin are such issues that readily respond to oral medications.

A receptive uterine lining to allow for implantation of an embryo that formed in the fallopian tube is needed to allow a pregnancy to be established in the uterus. Although a scarred endometrium or one that is distorted from fibroids may require surgical repair, other disorders of the lining can be treated with local hormonal supplementation. The endometrium, the uterine lining, may not develop appropriately after ovulation secondary to hormonal abnormalities. This may reflect an abnormality in egg production and the hormones associated with ovulation.

Therapies directed at improving ovulation or directly supporting the lining of the uterus with vaginal application of the hormone progesterone may be all that is needed to correct this problem.

Anatomic problems such as scarring of the fallopian tubes may require surgical correction. However, blocked tubes may be opened by minimally invasive procedures at the time of a hysterosalpingogram (HSG). In such procedures, a tube blocked where it inserts into the uterus is opened with a catheter in a setting that does not require general anesthesia.

Many patients will be successfully treated with simple techniques and procedures that are not associated with the expense and invasiveness of the therapies that most people think they will require.

For each infertile person a plan of evaluation and therapy needs to be developed, beginning with the basics. It does not necessarily lead to those treatments that are more detailed and invasive.

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Did you put off an infertility evaluation out of fear of needing expensive, invasive fertility treatments?

 

Photo credit: http://www.wpclipart.com/phps.php?q=ostrich

 

 

 

 

 

 

 

 

 

 

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Long Island IVF’s Annual Family Reunion is Coming!

By Tracey Minella

October 17th, 2014 at 7:10 am

 

credit: imagery majestic/ freedigitalphotos.net


With a feeling of thanksgiving in the autumn air, we’re eagerly preparing for LIIVF’s Annual Family Reunion…a celebration of the births of our newest batch of special babies.

I remember waiting a long, long time for my chance to attend this special celebration. I actually aspired to it. It was one of those things on my mental list of perks of getting pregnant. I’d heard talk of it in hushed tones among newly pregnant patients in the waiting room. My turn finally came on the LIIVF 10th Anniversary in 1998.

Back then, it was held outside the Long Island IVF office in Port Jefferson, behind Mather Hospital. And a huge fire truck…the kind with the bucket that soars amazingly high…would arrive to take a group photo of all the parents and their babies. Shortly thereafter, space limitations unfortunately necessitated limiting the attendees to the most recent crop of newborns.

If you haven’t experienced or heard of it, the reunion is a fun-filled, camera-clicking day where proud new parents show off their little miracles and our doctors and staff gets to meet the latest additions to the LIIVF family. (Just ask any “alumni” parents of our older babies if their infants’ reunion party was special.)

We know it may be hard to hear about this event if you’re still on your journey to parenthood. And we’re really sorry for that, and look forward to seeing you at a future reunion. But we want to be sure we haven’t missed any patient who is eligible to attend this year…

So… if your special little bundle was born between January 1, 2013 and today, please email Lindsay Montello at lmontello@liivf.com  so we can put you on the invitation list. (And if your baby’s older and you missed the last reunion…or you just really, really want to come this year, please email Lindsay anyway!)

This year’s event will be held on Tuesday, November 11, 2014 from noon until 2:30 pm, so save the date! More exciting details will come in your invitation.

We’re so looking forward to seeing you again and meeting your new little pumpkins!

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Have you been to a reunion? What’s the best part?

 

LONG ISLAND IVF was nominated BEST IN VITRO FERTILITY PRACTICE in the Long Island Press’s “Best of Long Island 2015” contest. If you’d like to vote to help us win, you can vote once per day from now through Dec 15 here: http://bestof.longislandpress.com/voting-open/

 

Photo credit: freedigitalphotos.net and imagery majestic http://www.freedigitalphotos.net/images/agree-terms.php?id=100116728

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Long Island IVF Doctors Named to “Super Doctors” List

By Tracey Minella

May 23rd, 2014 at 12:52 pm

 

Dr. Pena

Did you catch the big news in Sunday’s New York Times Magazine?

Long Island IVF doctors, Dr. Joseph Pena and Dr. Michael Zinger, have been named as New York “Super Doctors” in the field of Reproductive Endocrinology, securing two of just 6 spots on the elite list for the combined Long Island and Brooklyn area.

What makes this exciting and humbling is that “Super Docs” honorees are chosen by their peers. You can’t buy your way onto the list through paid advertising (at least LIIVF’s doctors didn’t pay for advertising!), or get on it by generating the most “likes” in a social media campaign (but feel free to come over and “like” us on Facebook anyway at http://www.facebook.com/longislandivf! It is doctors recognizing other doctors’ talent and ability.

For a complete list of the SuperDoctors in Reproductive Endocrinology, click here: http://bit.ly/1hglvmu

Dr. Zinger

We know of many other top notch doctors…both on the Long Island IVF team and in other fields who are not included on the Super Doctors list… and are humbled by this recognition. Thanks to all the physicians who voted for Drs. Pena and Zinger for this honor.

And of course, we’d like to thank our wonderful patients, who so often sing the praises of their LIIVF doctors… because it’s possible many of the doctors who nominate our physicians for these honors may have first heard about them from you! You are the reason we all love what we do every day.

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Have you ever told another doctor about your LIIVF experience or recommended your LIIVF doctor?

 

 

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BFN! Negative Pregnancy Test Again! Now What?

By David Kreiner MD

May 16th, 2014 at 11:55 am

 

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Women confronted with a negative result from a pregnancy test are always disappointed, sometimes devastated. Many admit to becoming depressed and finding it hard to associate with people and go places where there are pregnant women or babies, making social situations extremely uncomfortable. A negative test is a reminder of all those feelings of emptiness, sadness and grief over the void infertility creates.

We don’t have control over these feelings and emotions. They affect our whole being and, unchecked, will continue until they have caused a complete state of depression. This article can arm you with a strategy to fight the potentially damaging effects that infertility threatens to do to you and your life.

First, upon seeing or hearing that gut-wrenching news, breathe.
Meditation — by controlling and focusing on your breathing — can help you gain control of your emotions and calm your body, slow down your heart rate and let you focus rationally on the issues. It’s best to have your partner or a special someone by your side that can help you to calm down and regain control.

Second, put this trauma into perspective.
It doesn’t always help to hear that someone else is suffering worse — whether it’s earthquake or cancer victims — but knowledge that fertile couples only conceive 20% of the time every month means that you are in good company with plenty of future moms and dads.

Third, seek help from a specialist, a reproductive endocrinologist (RE).
An RE has seven years of post-graduate training with much of it spent helping patients with the same problem you have. An RE will seek to establish a diagnosis and offer you an option of treatments. He will work with you to develop a plan to support your therapy based on your diagnosis, age, years of infertility, motivation, as well your financial and emotional means. If you are already under an RE’s care, the third step becomes developing a plan with your RE or evaluating your current plan.

Understand your odds of success per cycle are important for your treatment regimen. You want to establish why a past cycle may not have worked. It is the RE’s job to offer recommendations either for continuing the present course of therapy — explaining the odds of success, cost and risks — or for alternative more aggressive and successful treatments (again offering his opinion regarding the success, costs and risks of the other therapies).

Therapies may be surgical, such as laparoscopy or hysteroscopy to remove endometriosis, scar tissue, repair fallopian tubes or remove fibroids. They may be medical, such as using ovulation inducing agents like clomid or gonadotropin injections. They may include intrauterine insemination (IUI) with or without medications. They also may include minimal stimulation IVF or full-stimulated IVF. Age, duration of infertility, your diagnosis, ovarian condition, and financial and emotional means play a large role in determining this plan that the RE must make with your input.

There may be further diagnostic tests that may prove value in ascertaining your diagnosis and facilitate your treatment. These include a hysteroscopy or hydrosonogram to evaluate the uterine cavity, as well as the HSG (hysterosalpingogram) to evaluate the patency of the fallopian tubes as well as the uterine cavity.

Complementary therapies offer additional success potential by improving the health and wellness of an individual and, therefore, her fertility as well. These therapies — acupuncture, massage, nutrition, psychological mind and body programs, hypnotherapy –
have been associated with improved pregnancy rates seen when used as an adjunct to assisted reproductive technologies.

A negative pregnancy test can throw you off balance, out of your routine and depress you. Use my plan here to take control and not just improve your mood and life but increase the likelihood that your next test will be a positive one.

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What have you done…or what tips can you add… to get through the disappointment?

Photo credit: http://www.freedigitalphotos.net/images/Gestures_g185-Depressed_Woman_Sitting_On_Floor__p99322.html

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Femvue: The HSG Alternative Test

By David Kreiner MD

April 9th, 2014 at 5:26 am

 

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Fear can be an awesome motivator. 

Unfortunately, when it leads to avoiding a vital medical test such as investigating the patency of fallopian tubes it can prevent a physician from discovering the cause of a couple’s infertility. 

The hysterosalpingogram (HSG) is an x-ray of the fallopian tubes after radio-opaque contrast is injected transvaginally through the cervix.  Contrast can be visualized filling the fallopian tubes and spilling through patent fallopian tubes into the pelvis.

The HSG is performed using a metal instrument clamped on the lip of the cervix while a tube is placed through the cervix and contrast injected into the uterine cavity under pressure.  Patients have complained that this procedure is too painful for them to endure and either refuse to undergo the procedure or go for a surgical laparoscopy under general anesthesia.

Today, a new procedure, known as the Femvue, is available whereby a physician inserts a catheter similar to that used at insemination into the cervix.  The physician observes by transvaginal ultrasound the flow of air bubbles through the tubes and into the pelvis.  This can be accomplished in the office with typically minimal discomfort to the patient. 

Sometimes, it may be difficult to get reliable results with Femvue in obese patients. In cases where the results of Femvue are abnormal, a traditional HSG may be done to confirm results.

With the Femvue, the fear of pain experienced by some patients from the HSG is no longer an obstacle to the infertility workup.

Femvue is currently being performed at Long Island IVF by Doctors Kreiner, Pena, and Zinger.

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If you have had an HSG, was it painful? If you’ve had Femvue, how did it go?

Have you avoided an HSG because of fear?

 

Photo credit: http://www.freedigitalphotos.net/images/Diseases_and_Other_M_g287-Woman_With_Abdominal_Pain_p76296.html

 

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Infertility and TCM (Part 5) Channels and Points: TCM’s Gross Anatomy Equivalent

By David Kreiner MD

March 31st, 2014 at 2:05 pm

 

image courtesy of stuart miles/freedigital photos.net

 

As a new student in Traditional Chinese Medicine (TCM) and acupuncture one of the first and most important classes we must take is called “Channels and Points”. This to a former medical student is the TCM version of Gross Anatomy. Gross anatomy in medical school was my exciting introduction to the human body, essential to the study of medicine.  I owned the classic Gray’s Anatomy text which today is popularized by the TV show of the same name.  The course requires strict memorization of all the bones, nerves, ligaments, vessels and organs in the body.

Likewise, “Channels and Points” requires the memorization of the precise location of 365 points and the corresponding channels of Qi which course throughout the body and can be utilized in the practice of acupuncture.  How these channels and points relate to each other and to the different organs is important as that will also determine their usefulness in different clinical situations.  

It is believed that the location of the channels of Qi and their surface access points was discovered through centuries of observation of the existence of tender spots on the body during the course of disease.  Furthermore, it was observed that symptoms were alleviated when those points were stimulated by massage or heat.  

When a number of points became known, they were linked into groups with common characteristics and effects and hence a pathway for a channel was identified.  Knowledge accumulated over hundreds of generations documented in several ancient texts.  As information regarding the channels and points accumulated, theories evolved and often resulted in modifications of prior beliefs as more experience clarified more accurate placement and function of these channels and points.  

The first document that unequivocally described the channels and points in an organized system of diagnosis and treatment recognizable as acupuncture is The Yellow Emperor’s Inner Classic, dating from about 100 BCE. The information was presented in the form of questions posed by the Emperor, Huang Ti, and replies from his minister, Ch’i-Pai. The source of the text of his answers was likely a compilation of traditions handed down over centuries, presented in terms of the prevailing Taoist philosophy, and is still cited today in support of particular therapeutic techniques. There is evidence that acupuncture utilizing bronze, gold and silver needles was practiced around this time as well as moxibustion.  

A more contemporary view of the concepts of channels in which Qi flowed that was documented through the precise anatomical locations of acupuncture points developed later.  During the Ming Dynasty (1368–1644), The Great Compendium of Acupuncture and Moxibustion was published, which forms the basis of modern acupuncture. It includes descriptions of the full set of 365 points that represent superficial access to the channels through which needles could be inserted to modify the flow of Qi energy.

Unlike the bones, tendons, nerves and vessels of Gross Anatomy, the channels and points utilized in acupuncture do not have corresponding visible or palpable anatomic structures that may be identified in an effort to memorize.  These channels of Qi are not visible structures nor can they be felt through touching or palpation.  So how does the acupuncturist know where the surface access point is to direct his needle?  

The trained acupuncturist utilizes the surface anatomy such as bones, joints and ligaments to locate these acupoints.  The points typically are found between the ligaments, in bony crevices or between bones. Additionally, the body is divided into units of measure based on an individual’s own bone size.  The most basic unit, cun, is defined as the width of the individual patient’s thumb.  Two cun is the distance from second most distal or middle joint of the forefinger to the tip.  Three cun is the width of the forefinger to the pinky measured at the point of the middle joint of the fingers.  The arms are 9 cun from axilla to the transverse crease of the elbow and 12 cun from the elbow crease to the wrist crease.  The number of cun for every portion of the body is delineated so that the location of the acupoints is based on locating according to the distance by cun units from an identifiable spot on the surface anatomy of the patient and usually are found in between ligaments, bones or in the bony crevices which are palpated by the acupuncturist upon needle placement.  

There are also some points that are identifiable based on particular placement of the fingers and hands of either or both the acupuncturist and patient.  For example, if the acupuncturist places his finger on a patient’s styloid process then has the patient internally rotate his/her hand, the point is located where the acupuncturist’s finger ends up.  This point, currently my favorite, is Small Intestine (SI) 6 with the English name of Support for the Aged because it treats symptoms such as blurry vision, lumbar pain, neck pain and other aches and pains that affect individuals as they get older.  

Another critically important point and therefore given the distinction of being a Command Point for the head and nape of the neck is Large Intestine (LI) 7.  It is located when the acupuncturist places his/her index finger on the dorsal side of the patient’s hand and thumb on the ventral side in between the patient’s thumb and forefinger.  The acupuncturist will locate the point where the tip of his forefinger meets a groove in the anterior portion of the patient’s radius bone.  

How deep to place the needle and in what direction and angle are further issues to be learned another day.

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Are you finding this educational journey into TCM fascinating? Do you have any questions for Dr. Kreiner about this or any other TCM topic he has covered so far?

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Acupuncture: What’s the Point?

By David Kreiner MD

March 12th, 2014 at 3:29 am

 

image courtesy of stuartmiles/freedigitalphotos.net

I have previously mentioned the conundrum facing a Western-trained physician embarking on the study of Traditional Chinese Medicine (TCM).  It is part of our nature after a lifetime of scientific training to explain natural phenomena such as health and illness in ways that have been documented with physical evidence. 

The basic physiology on which TCM is constructed has no corresponding physical support that can be seen or measured…a requirement that scientific thinkers rely on to reassure ourselves about the validity and rationale of a proposed theory or treatment.

Instead, it feels to me as I study TCM that I am memorizing random “facts” with corresponding syndromes and treatments.  For now, I must push myself to continue my studies unconcerned that these basics I am committing to memory are not supported by any physical evidence other than the stories of successful therapies.  It is premature for me to pass judgment for as they say, “the proof is in the pudding”. 

In fact, as a practicing reproductive endocrinologist I have seen patients with poor ovarian function or previous failed pregnancies succeed in their child-building endeavors after acupuncture intervention is added as an adjunct to their fertility treatments. 

For this reason, I persevere to learn as much as possible because despite my own admission that TCM is difficult for me to accept as “scientific truths” I believe that it offers potential advantage to my patients as they go through their Western fertility therapies.

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How important to you is the science…or measurable physical evidence…behind an infertility therapy? Can you take a leap of faith and hope “the proof is in the pudding”?

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Acupuncture: What’s the Point?

By David Kreiner MD

March 11th, 2014 at 8:22 pm

 

image courtesy of stuart miles/free digital photos.net

I have previously mentioned the conundrum facing a Western-trained physician embarking on the study of Traditional Chinese Medicine (TCM).  It is part of our nature after a lifetime of scientific training to explain natural phenomena such as health and illness in ways that have been documented with physical evidence. 

The basic physiology on which TCM is constructed has no corresponding physical support that can be seen or measured…a requirement that scientific thinkers rely on to reassure ourselves about the validity and rationale of a proposed theory or treatment.

Instead, it feels to me as I study TCM that I am memorizing random “facts” with corresponding syndromes and treatments.  For now, I must push myself to continue my studies unconcerned that these basics I am committing to memory are not supported by any physical evidence other than the stories of successful therapies.  It is premature for me to pass judgment for as they say, “the proof is in the pudding”. 

In fact, as a practicing reproductive endocrinologist I have seen patients with poor ovarian function or previous failed pregnancies succeed in their child-building endeavors after acupuncture intervention is added as an adjunct to their fertility treatments. 

For this reason, I persevere to learn as much as possible because despite my own admission that TCM is difficult for me to accept as “scientific truths” I believe that it offers potential advantage to my patients as they go through their Western fertility therapies.

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How important to you is the science…or measurable physical evidence…behind an infertility therapy? Can you take a leap of faith and hope “the proof is in the pudding”?

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