And why it wrongly perpetuates a sense of powerlessness & hopelessness over a women’s reproductive health.
Low AMH or AFC is not the end of your fertility journey
The egg timer test, as its commonly touted & even promoted by IVF clinics & Fertility specialists to my dismay is accurately named the Anti-Mullerian Hormone test or AMH. To understand this test further lets understand your ovarian function first. At birth we are born with approximately 1-2 million/oocytes eggs; and by the time of puberty, about 300,000 remain. Of these, only 300 to 400 will be ovulated during our reproductive lifetime. An ovarian follicle is a fluid-filled sac that contains an immature egg, or oocyte. During ovulation a mature egg is released from a follicle. While several follicles begin to develop each cycle, normally only one will ovulate an egg. After ovulation, the follicle turns into the corpus luteum. The follicles that do not release a mature egg disintegrate, a process known as atresia that can happen at any stage of follicular development.
Follicles start off very, very small. All the follicles in the ovary start off as primordial follicles. A primordial follicle is just 25 micrometers—that’s 0.025 millimetres and are impossible to see with the naked eye, let alone on an ultrasound. Every day, primordial follicles are “awakened” by hormonal signals and start to mature. As long as they continue to survive and graduate to the next stage, they grow larger and larger.
One of those stages is the tertiary stage. During this time, the follicle gains a fluid-filled cavity known as the antrum. Follicles with an antrum are referred to as antral follicles. They measure between 2 and 10 mm in diameter. For some perspective, an antrum follicle that is now 5 mm is 200 times bigger than it was as a primordial follicle. Theoretically, if you could know how many follicles are inside your ovaries, you could have an idea of how many eggs you have left. It is impossible to count how many follicles are in the ovaries because they are too small to be visualized. However, once a follicle reaches a certain stage, it can be seen via ultrasound. Antrum follicles are finally visible on the ultrasound. Antral follicles produce higher levels of a hormone known as anti-mullerian hormone (AMH). This hormone circulates in your blood. Measuring AMH levels via blood work considered by IVF specialist & OBGYN’s as a way to evaluate ovarian reserves.
The stages of folliculogenesis:
- 1.Primordial follicle: The stage all follicles are in within the ovaries of a newborn baby girl.
- 2. Primary follicles: The recruitment of a few primordial follicles into the primary follicle stage occurs every day, starting in puberty and continuing until menopause.
- 3. Secondary follicles: Involves the addition of theca cells, which will secrete hormones.
- 4. Tertiary follicles, also known as antral follicles: Follicles that contain a fluid-filled cavity called the antrum, at this stage follicles are visible via transvaginal ultrasound and it is at this point that AMH can be assessed via a blood test.
- 5. Graafian follicle: A follicle large enough to ovulate, only one or two of the tertiary follicles in each cycle will mature to ovulation.
- 6. Corpus luteum: Not technically a follicle anymore, the corpus luteum develops from the broken open follicle that released an egg.
Phew, anatomy & physiology lesson complete.
It comes down to this, the AMH test cannot determine the quality of a woman’s eggs or her total egg count. Why? Because it only assess the AMH that is secreted by the egg sac/follicle that has started the maturation process to become the dominant follicle during that single ovulatory cycle.
This test can only report on the amount of AMH secreted during one particular cycle it does not report on the other 500,000 primordial follicles awaiting recruitment in the primary follicle stage that occurs every day, starting in puberty and continuing until menopause.While there is also research indicating the contraceptive pill can trigger a false low AMH reading. A major 2017 study found (1) women with diminished ovarian reserve and low AMH levels were not associated with infertility.
Women with low AMH levels were no less likely to conceive that women with normal AMH levels, according to the study. “Women should be cautioned against using AMH levels to assess their current fertility,” the study authors concluded.
As previously stated the AMH test can only report on the amount of AMH secreted during one particular cycle, it does not report numbers of primordial follicles awaiting recruitment in the primary follicle stage that occurs every day, starting in puberty and continuing until menopause. Also, unfortunately this test is used too often for the commercial purposes of IVF clinics to incite unnecessary urgency in women of all ages to invest in egg freezing to “protect” her fertility, an enormous revenue-raising venture for IVF clinics. Deep breathe!
Unfortunately in clinic I have many fertility patients come to me feeling depressed & defeated after receiving their “ovarian reserve” AHM test results. This is my response to them, this test is a useful tool for fertility specialists when determining the dosages of fertility drugs or the chances of harvesting eggs for IVF or if it is used in conjunction with other assessments when there are concerns that a woman may be at risk of early menopause.
You make a golden egg every month. Your Antral Follicle Count indicates how well your ovaries are recruiting in that one particular cycle.
It is important to understand that there is no test to measure the ‘primordial follicle pool.’ The actual numbers of eggs in ‘ovarian reserve’ have never been measured. In short, there is no such thing as ‘diminished,’ or ‘low’ ovarian reserve, because they cannot measure it. What they can accurately say is diminished or low Antral Follicle Count.
Assumptions are made about ovarian reserves based on AMC & AFC.
Where to now, as we know AMH begins the life cycle of your eggs. Without sufficient AMH levels, growing good eggs is like trying to grow a plant without sun. It fails to thrive. In clinic I like to highlight some factors that may contribute to a reduced AMH level, these include:
- Vitamin D deficiency
- Ovarian or cyst surgery
- Endometriosis
- Environmental toxins
- Smoking and drinking alcohol regularly
- Overweight (BMI >25)
- Accelerated ageing due to lifestyle
- Low blood circulation to the ovaries
- Poor nutrition & Hormonal imbalances
- Chemotherapy medications
- Autoimmune disorders & Genetic factors
Acupuncture will also support you physically and emotionally in this process, improve and correct hormone functions & help optimal uterine lining increase all while reducing stress response & lowering high levels of cortisol.
Finally PLEASE remember the AMH test only assess the AMH that is secreted by the egg sac/follicle that has started the maturation process to become the dominant follicle during that single ovulatory cycle. These levels determine the effectiveness of potential dosages and effectiveness of IVF drugs to stimulate your ovaries if that is part of your journey. The upper and lower limits of hormone tests define what Modern Medicine can do, not what is possible or “impossible” for you.
(1) Steiner AZ, Pritchard D, Stanczyk FZ, et al. Association Between Biomarkers of Ovarian Reserve and Infertility Among Older Women of Reproductive Age. JAMA. 2017;318(14):1367–1376. doi:10.1001/jama.2017.14588
How Chinese Medicine & Acupuncture supports you from pre-conception to pregnancy, labour preparation & postpartum care.
If you have been trying to conceive for 6 – 12 months without success and you partner’s sperm has been thoroughly assessed and passed with flying colours; which by the way is an increasingly rare occurrence, you maybe starting to wonder why its not happening?
Did you know that it takes four and a half months from the time the follicle in your ovary starts to develop to the moment where the egg it contains is mature enough for ovulation?
There’s a lot you can do during this time that can influence the development of that egg. This is why our approach is to use this time to prepare the soil to receive the seed, this will include the following.
PRE-CONCEPTION:
- Chinese Medicine: Acupuncture and Chinese herbs have a proven record with improving fertility, both in China over many hundreds of years and more recently in the west. Speak to one of our practitioners about an appropriate treatment plan for your circumstances.
- Reducing stress: Increased stress is associated with reduced numbers of follicles and poorer outcomes in IVF cycles. And even minor stressors can cause ovulation failure. Regular acupuncture is effective in reducing stress hormones, relieving anxiety and depression and regulating ovulation.
- Improving sleep: More than 40% of adults get less than 7 hours sleep a night and this has adverse effects on metabolism and weight control. Getting enough sleep is essential to maintain optimal hormonal regulation.
- Diet: Optimal nutrition provides an optimal ovarian environment for the eggs during the critical maturation process. Chinese medicine recommends having a wide variety of tasty fresh foods in season eaten in a relaxed manner, eat plenty of protein, including vegetable protein, and fresh fruit and vegetables – organic where possible.
- Supplements: In keeping with maximising nutrition available to the developing eggs and ensuring you are in good shape for pregnancy, it is advisable to take supplements which include Folic acid and other B vitamins, Vitamins C and D, omega 3 fatty acids, antioxidants such as CoQ10 and minerals such as zinc, iron and iodine.
- Avoiding: High caffeine intake is associated with infertility and increased miscarriage rates. Even moderate coffee drinking (1 – 3 per day) can reduce fertility. Try to limit your intake to no more than 1 tea per day and 1 or 2 coffees per week. Women metabolise alcohol much less efficiently than men and there is evidence to suggest that even moderate drinking (5 or fewer glasses a week) can delay conception.
- Healthy weight: A BMI of 20 – 25 is associated with higher pregnancy and lower miscarriage rates than those above or below this range. If you are overweight losing a few kilos now could make a big difference to your ability to conceive naturally or with IVF. If you are underweight increase your intake of calorie dense protein and low GI carbohydrates.
- Exercise: Doing regular exercise, something you enjoy, is beneficial. It increases energy, lifts mood, helps you sleep and helps to control weight. However exercising too much (4+ hrs/week aerobic exercise) has been shown to reduce IVF success rates. During the first part of pregnancy you need to exercise with care so take the opportunity now to increase your fitness.
So now, you may have had a long journey possibly with plenty of medical intervention to get this far and you’ve just had appositive pregnancy test, CONGRATULATIONS now is the time to relax, let mother nature do her job and enjoy your swelling belly. During this time our approach will continue through out the next 40 plus weeks including.
PREGNANCY:
- Acupuncture: Acupuncture is often used by pregnant women to promote well being and to address pregnancy related symptoms should they occur. We recommend acupuncture weekly for the first 12 weeks, along with a “Holding” Formula to support the pregnancy in this stage, this reduces anxiety and the risk of miscarriage, however will not prevent it if the embryo is abnormal
- Rest: During these first few weeks of pregnancy it is important to pace yourself and not overwork or get overtired. Your body is undergoing enormous changes as it adapts to being pregnant.
- Keep Warm: Successful establishment of pregnancy requires a “warm womb” with a plentiful supply of “blood and qi”. For this reason we advise against swimming, getting chilled around the lower back or abdomen, and the consumption of icy foods and drinks.
- Movement: Exercise Movement is good, but high impact or tiring exercise or strain on the abdomen or lower back is not. Take gentle walks, rather than running and avoid anything that compresses the abdomen or lower back. Try and not stand for extended periods of time. Don’t overheat and don’t lift heavy weights.
- Intercoarse: If you have a history of infertility and/or miscarriage most we caution against sex for the first few weeks. The same applies to vaginal ultrasounds – try to leave off having this investigation until 7 weeks pregnant by which time a heart beat is easy to detect.
- Diet: Nourishing plain foods, choosing fresh foods in season good protein intake. Avoid alcohol and no coffee. If you experience pregnancy nausea, frequent snacks and avoiding rich foods will help, so will acupuncture.
PREPARING FOR LABOUR:
Treatment applied in the 4 weeks before the due date may reduce the rates of medical induction & emergency caesarian. It also has been shown to encourage cervical ripening and may shorten the time of active phase labour. Finally, we are also here for postpartum care to aid in birth recovery, breast feeding, restoring energy & blood and also supporting postpartum anxiety & depression if needed.
Hormone Literacy and PMS
Here’s the down-low on PMS, beautiful ones. PMS is common but its not inevitable, in fact PMS is curable. Just read that again! Before we get into the physiological understanding of PMS, let me just add that I feel the term PMS has been used to trivialise and undermine women’s emotions, generally because they make others uncomfortable. We all have the right to our emotions and the right to feel safe in expressing them, while not having them dismissed as a “hormonal” over reaction.
Don’t you agree ladies?
Now let’s move forward to grasp a better understanding of the big hitters in this game, Estrogen & Progesterone. Here’s a little refresher:
Our cycle occurs in three phases: follicular, ovulatory and luteal. The first half of the cycle is known as the follicular phase, the second half of the cycle is the luteal phase. Midway through the cycle between days 12 and 16 ovulation occurs, known as the ovulatory phase. Your menstrual cycle is the result of a hormonal dance between the pituitary gland in your brain and your ovaries. Every month the female sex hormones prepare the body to support a pregnancy and without fertilization & implantation of an embryo there is a period.
On Day 1 of the menstrual cycle, estrogen and progesterone levels are low. Low levels of estrogen and progesterone signal the pituitary gland to produce Follicle Stimulating Hormone (FSH) as its name suggests FSH begins the process of stimulating & maturing a follicle which is a fluid-filled sac in the ovary containing an egg, then to be released during ovulation.
The follicle produces more estrogen to prepare the uterus for pregnancy by stimulating & building the lining of the uterus in case implantation of an embryo occurs. The more estradiol you have, the thicker your uterine lining at the heavier your period will eventually be.
Estradiol also stimulates your fertile mucus, its main purpose is to help sperm survive & get to the waiting egg. At ovulation, usually around Day 12 – 14, increased estrogen levels trigger a sharp rise in Luteinizing Hormone (LH) from the pituitary gland, causing the release of the egg from the follicle. Once ovulation has occurred the ruptured follicle (corpus luteum) will secrete progesterone, while estrogen continues to prepare the uterus for pregnancy. If the egg is not fertilized, estrogen and progesterone levels drop and then your period will begin.
Here’s an amazing fact… Your corpus luteum is a temporary endocrine organ that forms from the emptied ovarian follicle after ovulation. In fact it’s the only organ you have that will be developed from scratch with its own blood supply every month. Your corpus luteum is the final stage of your follicles 100 day journey to ovulation. The health of which has been affected by the previous 100 days journey until this point. It can be impacted by inflammation, thyroid disease, insulin issues, vitamin deficiencies such as Zinc, Vitamin D, Magnesium, Iodine and B Vitamins. We require all of these to ensure ovulation is supported and that our ovaries are nourished sufficiently to ovulate successfully. This results in the formation of the amazing Corpus Luteum that will then provide our bodies with our precious Progesterone.
Progesterone is considered the Yin to Estrogen’s Yang. In fertility its most important role is to hold & nourish a pregnancy. However it does so much more that is essential regarding our emotional & physical well-being & health. Such as reducing inflammation, building muscle, promoting sleep, protecting against heart disease and calming/soothing your nervous system. So how do these two powerful hormones either contribute to or prevent your premenstrual symptoms? The departure of estrogen at the end of your cycle brings serotonin & dopamine down with it.
The higher your estrogen at this point of your cycle, the further you will fall, causing fatigue, emotional instability, headache and even night sweats. Ideally while this drop in estrogen is occurring, progesterone should be coming to the rescue, that is if you make enough progesterone to balance & contain the instability of its sister hormone estrogen. Progesterone counterbalances estrogen by converting the neurosteroid allopregnanolone, which will in turn calm your brain in the same way the neurotransmitter GABA does.
The brain is highly responsive to progesterone. In fact, progesterone concentrations in the brain have been shown to be 20 times higher than in the blood. Insomnia, anxiety, and migraines are just a few of the conditions linked to an imbalance of progesterone and estrogen. As previously mentioned in the brain as elsewhere in the body, progesterone counterbalances the effects oestrogen. Whereas estrogen has an excitatory effect on the brain, progesterone’s effect is calming.
PROGESTERONE’S MANY FUNCTIONS IN THE BODY INCLUDE:
● maintaining the uterine lining and preventing excess tissue buildup
● inhibiting breast tissue overgrowth
● increasing metabolism and promoting weight loss
● balancing blood sugar levels
● acting as a natural diuretic
● normalizing blood clotting
● stimulating the production of new bone
● enhancing the action of thyroid hormones
● alleviating depression and reducing anxiety
● promoting normal sleep patterns
● preventing cyclical migraines
● restoring proper cell oxygen levels
● improving libido.
Estrogen is considered more “Yang” in nature compared to Progesterone. It stimulates mood, libido, serotonin & dopamine. It’s this fine balance of your body sufficiently producing enough progesterone via the corpus luteum after successful ovulation that provides the conversion of allopregnanolone that ensures a stable transition into your period.
It’s essential to keep in mind that while PMS is common, it certainly does not have to be an inevitable experience of every menstrual cycle. A major contributing factor to the imbalance between estrogen and progesterone is the increased exposure to pesticides, herbicides, plastics, and PCB’s. Estrogen dominance may be caused by normal levels of estrogen and relatively low levels of progesterone, or by low levels of estrogen and extremely low levels of progesterone.
SYMPTOMS OF TOO MUCH ESTROGEN:
● Heavy Bleeding
● Breast Tenderness
● Increased premenstrual symptoms
● Fibrocystic Breasts
● Ovarian Cyst
● Abdominal weight
● Anxiety, Irritability
● Water Retention
● Increased Triglyceride Levels
It’s this fine balance of your body sufficiently producing enough progesterone via the corpus luteum after successful ovulation that provides the conversion of allopregnanolone amongst other mechanisms that ensures a stable transition into your period.
Hormonal literacy enables you to make informed choices regarding what you include in your daily diet, what you expose yourself to regarding endocrine disrupting chemicals, also ensuring adequate essential vitamin & mineral intake are all going aid in reducing your PMS symptoms.
These informed choices support the production of Progesterone through regular ovulation & the corpus lutuem production of progesterone to balance excess estrogen.
By the way, if you take the Oral Contraceptive Pill, then you have no follicular phase, no ovulation, no corpus luteum, no luteal phase & no Progesterone.
But that’s an entirely new blog for another time!
