A 38-year-old cisgender female calls you asking

A 38-year-old cisgender female calls you asking about fertility services. She has just had a failed IVF cycle (this was her first one) and, when she debriefed with her fertility doctor, they mentioned that ‘acupuncture might help’ She reports that she is just starting her period, and plans to get started with another IVF cycle in a few weeks. She tells you that she has been diagnosed with diminished ovarian reserve (CD 3 FSH = 12, AMH = 0.75), and has been trying to conceive for 2 years, saying that she met her cisgender male partner later in life. All other screening labs/imaging have been “normal”. However, during her FET cycle, the uterine lining development was “borderline”, and while they went ahead with the embryo transfer, it was only after she took an additional weeks’ worth of Estradiol to get the lining to the minimum thickness the doctor wanted to see. She is pleasant on the phone and seems earnest when she tells you that she wishes someone had told her about acupuncture before, but she didn’t know it could help. She has a demanding job as a marketing manager at a local well-known company, and has a typical full-time work schedule. She can only come see you on weekends or after work. She does have very good acupuncture benefits from her corporate job. You find a time to see her that same week by squeezing her in on your schedule. However, it is not as much time as you usually spend with a new patient – you just want to get her in ASAP. The basic details during the initial intake: She has been pregnant once in the past, at age 24, and chose to terminate the pregnancy without complication. She has regular menstrual cycles every 29 days, that are mildly crampy on cycle day one only – pain is better with heat and movement. The periods have been getting slightly shorter in the past year, shifting from lasting x3 days to 2 days. Periods have always been somewhat on the lighter side, and blood is fresh red and slightly thin without clots. PMS has gotten worse in the past year. Is more irritable, but it’s hard for her to know if that’s because of the fertility process. Also – she now has night sweating, insomnia, and heart palpitations for 2 nights before her period starts, which is new in the past few months. She started taking low-dose Prozac about 6 months ago. Her grandmother is also ill and her overall stress is very high. Her fertility doctor told her she has to reduce her exercise level and she reports that this is challenging for her mental health. She runs 3-4 times per week for about 40-45 minutes. It’s been several years since she ran a marathon due to her work schedule, but enjoyed doing that in the past. MD told her to walk every day instead, but “it’s not the same.” She had an eating disorder for 2 years in high school that involved moderate caloric restriction and over-exercising. She was never hospitalized and her menses never stopped. She reports that she felt she got “back to normal” after doing some counseling in her late teens and in her 20s. She states, however, that she tends to avoid any diets or programs that involve food restriction, due to the potential to trigger a disordered eating pattern for her. Her digestion is fine. She has had IBS symptoms in the past, and has diarrhea when she has to give presentations at work. She tells you that she had a mild dairy allergy as a child that she grew out of. She eats salads for lunch “to be healthier”. She often eats at her desk. Breakfast includes a smoothie she gets from a Starbucks near her office. She eats white meat or fish only about 3 times per week, and when you ask her where the majority of her protein comes from, she is not sure. She has moderate seasonal allergies with rhinitis, eye itching, and sneezing every Spring. Allergies were bad in California where she grew up, but are worse since she moved to Portland 5 years ago. Takes Claritin in the Springtime. She did an egg retrieval cycle about 3 months ago – she made 8 eggs, 4 fertilized and 1 was genetically tested to be normal and the others were abnormal. As above, her labs showed DOR and she had difficulty making an adequate endometrial lining for her FET cycle last month. You see her initially on CD 6. She plans to start over with an egg retrieval cycle, since she only made the one viable embryo last time and “it didn’t take.” She will start with Estrogen priming during the last week of this cycle, and the will start ovarian stimulation (COH) after her next menses. She states that her temperature has been mostly neutral, but would rather be too cold than be too hot. Tongue: thin, paler pink with red tip and sides, moderate white coat, slightly scalloped. On exam, you observe that her skin is dry and there is tenderness at Ren 12 and the abdomen overall is tight and warm but not hot. She has a lean body type. 1. Make your best diagnosis for this person? 2. How would you handle the possible conversation of explaining to her how Acupuncture or TCM works, and asking her to wait 1-3 months to do her next IVF cycle? Keep in mind that Biomedicine believes that each month you wait after 40 is like falling off a cliff fertility-wise, and that her MD might feel that waiting is reckless. Can you cite any sources to support this perspective to wait to try again, if her MD were to you? 3. What possible lifestyle recommendations might you suggest for this patient, that, again, could have the most impact in a short time? How would you go about presenting them to a person who is already feeling depleted and emotionally taxed by her life? How do you give a person with Liver Qi Stagnation and high stress a “To-do list” without worsening their condition? 4. Similarly, she could use a better nutrition plan. What would that be for her? How do you frame that to this person with this particular history? What plan do you give them to set them up for success and not distress? 5. When she starts taking the Estrogen for the priming part of her IVF prep, she gets overwhelmingly depressed and irritable. What can you do to support her, given that herbs are not allowed by her IVF clinic? Be specific with points and therapies, explaining what you are doing form a TCM perspective.

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