What do patients say about us?
Susan came to us when she was 42 with low AMH and high FSH. She had a retest of her FSH after a few months of treatment.
Here is what she told us:
‘My FSH result was 25 before. When I receive the test result after a few months of treatment, I was so nervous that I was too frightened to look at first. When I did, I was so pleased. It is now 13.9!’
Subsequently, she went for a cycle of IVF with the Clinic we work with. It was not successful but she told us:
‘When the eggs were collected, the IVF Clinic was surprised to find that all my eggs are of excellent quality. They say this is very rare in a woman of my age’.
Lucy is 38, has low AMH (3.2; Normal range: 5.5 – 37.4) and high FSH (14.9; Normal range: 3.5 – 12.5), high prolactin (609; Normal range: 102 – 496) and low oestrogen (90; Normal range: 98 – 571). She wants to go for egg freezing and know that her hormones are not good enough and would unlikely to be able to preserve good quality eggs. After 3 months of treatment, her AMH has risen to 6.3, FSH dropped to 7.5, prolactin dropped to 438 and oestrogen increased to 210. In short, all hormones are now in normal range. Please check our pages on AMH and FSH, her initials are L.R.
Lucy said to us:
‘I am very pleased with the improvements to my hormones. Can you help me arrange to see the egg freezing specialist please?’
Why is egg quality important in fertility ?
For successful pregnancy – natural or through IVF:
Egg quality is vitally important in fertility. Research has shown that poor egg quality is strongly associated with chromosome abnormalities which in turn impacts on embryo quality, Poor egg quality is the main cause for increased risk for miscarriage in “older” women. It is also the main cause for embryo arrest and the failure of implanting in IVF.
Egg quality is therefore a vital factor in determining success in natural pregnancy or IVF.
For successful egg freezing:
Last but not least, more and more women are considering egg freezing. An egg freezing clinic will wish to determine the likely quality of one’s eggs by looking at age, AMH, results from antral follicle scan etc. prior to egg freezing. This will form the basis on which the clinic will provide guidance for patients whether/how to proceed. Needless to say, regardless of procedural protocol, one would wish to freeze the highest quality eggs possible.
What determines egg quality?
One important factor is age. We know that egg quantity and quality decline in the mid to late 30s and fall faster in the late thirties and early 40s.
However, it is important to note that egg quantity and quality in an individual woman can be average for her age, better than average, or worse than average. We will have more to say on this later.
Another vitally important factor which tends to be ignored at times, is hormones. The immediate manifestation of how well your hormones are working is your periods. Each menstrual cycle is governed by the growth of a single egg.
This is how it works: over the course of 10-14 days the egg will grow from immaturity within an antral follicle, and turn into a large, hopefully-soon-to-be-fertilized, mature egg in its dominant follicle. Both the egg and the follicle have to be functioning properly for the cycle to go well.
The dominant follicle makes estrogen, and once you ovulate, progesterone. Estrogen and progesterone together govern the activity of your uterus, which you experience as your menstrual cycle.
When your menstrual cycle is going well, it is highly likely that you are making healthy, high quality eggs. When your menstrual cycle is not going well, the chances are you are unlikely to be making strong healthy eggs.
Here are the factors that you may wish to look at when deciding if a given menstrual cycle is going well:
Menstrual Cycle History
Day of ovulation
Ideally ovulation will occur on days 11 or 12. Delayed ovulation – day 13 or later may not be a problem but early ovulation – days 8,9, or 10 of the cycle – implies lower quality eggs.
Once the egg is released, the leftover follicle (now called a corpus luteal cyst) makes progesterone. Progesterone stabilizes the lining of the uterus. A low-quality follicle is less likely to be associated with enough progesterone, and therefore the woman may notice a shorter luteal phase and/or premenstrual spotting.
Long cycles are ok, but short cycles are not. If previously-28-day-cycles are now 26 days, it suggests egg quality is failing. Cycles are shorter because of the early ovulation and shortened luteal phases described above.
In short, when your hormones are in balance, it is highly likely that your menstrual cycle will go well and you will end up with a good quality egg in your cycle. When your hormones are out of sync, your menstrual cycle is likely to be irregular and you will end up with poor quality egg or no egg at all.
Are there tests for egg quality?
The most direct way to check egg quality is to see it under laboratory conditions. This however is only feasible when a woman goes through IVF where her eggs are collected.
Nonetheless, a number of tests are available to tackle this issue:
– AMH (Anti-Mullerian hormone)
– FSH (Follicle stimulating hormone)
– antral follicle scan
Collectively, their test results will help us go someway to determine egg quality.
What is AMH (Anti-Mullerian hormone)?
In short, AMH is a hormone that is associated with ovarian reserve, the lower the AMH, the lower amount of egg reserve. However, an exceptionally high reading is not good news either as it may indicate you have PCOS.
What is FSH (Follicle stimulating hormone)?
Follicle stimulating hormone kicks in every cycle when your ovaries need to be stimulated for producing eggs. A high FSH means that your ovaries are less responsive as they require more stimulating to get going.
What is Antral Follicle scan?
Antral follicles are small follicles (about 2-9 mm in diameter) that we can see – and measure and count – with ultrasound. Antral follicles are also referred to as resting follicles.
Vaginal ultrasound is the best way to accurately assess and count these small structures.
Antral follicle counts (along with female age) are by far the best tool that we currently have for estimating ovarian reserve, the expected response to ovarian stimulating drugs, and the chance for successful pregnancy with in vitro fertilization.
The number of antral follicles visible on ultrasound is indicative of the number of microscopic (and sound asleep) primordial follicles remaining in the ovary. Each primordial follicle contains an immature egg that can potentially develop and ovulate in the future.
The number of visible antral follicles is an indication of the number of eggs remaining – the fewer antral follicles seen, the fewer eggs remaining (primordial follicles) in a woman.
To conclude, AMH, FSH and Antral Follicle scan combined will give us a good indication of your egg quality. In addition, if your period is too short or it is irregular, your egg quality is likely to be poor.
If you wish to check your egg quality, the best thing to do is therefore to carry out the following:
– AMH test
– FSH test
– Antral follicle scan
Can egg quality be improved?
Gynaecologists and IVF clinics tend to think of egg quality as part of an irreversible ageing process which means that egg quality will be in decline and cannot be improved.
The standard view on egg quality vis-a-vis age
If you are a woman in your late thirties and forties, you may be turned away by egg freezing or IVF clinic. The IVF clinic may say that your age and poor state of your ovaries are unlikely to respond well to stimulating hormones. You may produce fewer eggs, making fertilisations much more difficult. Eggs that do become fertilised may have more inclusions (waste products put out by the mitochondria) during early embryologic development. Fewer fertilised eggs may make it to the blastocyst (five day) stage, even fewer are capable of implantation, fewer still make it through full embryonic development. This is why a woman over forty is statistically less likely to give birth and is encouraged to find alternative ways to becoming a mother. You may be strongly advised to use donor eggs. While using donor eggs may increase your chances of having a baby. Even with donor eggs, older women still have a less of a chance of conceiving. The problem is not just the quality of eggs that older women produce. The real problem is that the IVF process focuses only on the last few weeks of the egg’s journey from initial follicle to the egg being released.
An egg’s journey to life – A story seldom told
The most important story about an egg’s journey from birth to maturity is often not fully told. In truth, for an egg to grow from a follicle in its resting state into a fully blown egg ready to be released takes up to a full year. In particular, follicles are selected form the pool of resting follicles almost a year before ovulation. About 5 months before ovulation, a follicle is chosen from the pool to become a primary follicle. Approximately 120 days before ovulation, it reaches its secondary stage. In approximately 65 days before ovulation, the follicle then cycles through the pre-antral and antral phase. Over the course of five months, the follicle will quadruple in size and has gone through many stages of proliferation.
During this period, (before the follicle is signaled FSH from the pituitary), key hormones that influence ovarian health include insulin like growth factor, interleukin, tumor necrosis factor, inhibin, vascular endothelial growth factor and activin to name but a few. These ovarian growth factors help determine the eventual fertility potential of the egg. During the time in which a follicle is developing its residing egg, these regulator proteins prepare it to be healthy and responsive.
Only during the last two to three weeks of its cycle through the ovary does the follicle become dominant. During the selection phase, which lasts approximately ten days, the follicle activates mechanisms to make itself responsive to FSH. Now the follicle grows to twice its previous size, rises to the surface of the ovary and becomes an estrogen-producing follicle. Then it fulfills its major purpose and releases its egg, which leaves the ovary and travels down the fallopian tube, seeking its chance to become fertilized. The follicle ends its life cycle by becoming its own endocrine gland, called the corpus luteum, which secrets the progesterone needed to maintain a pregnancy should the egg e fertilized.
The intricate hormonal map that an egg has to navigate from beginning to end would strongly suggest that where there is hormonal imbalance, the chances of a good quality egg maturing would likely to be compromised. Age is only one factor among many that may be the primary cause of hormonal imbalance.
What are the likely causes for poor follicle development?
Poor general health
This is almost a given. If a woman has poor general physical and/or mental health, no reproductive therapy will make up for her poor health.
Blood flow to ovary
As a woman ages, the blood flow to the ovaries begins to decline precipitously. As she approaches menopause, the ovarian blood flow is around five times less than when she was in her reproductive prime.
A woman’s hormones levels fluctuate more as she ages, the lack of communication between the brain, the pituitary gland, and the ovaries makes the follicles resistant, they stop paying attention to FSH, perhaps not surprising, since the poor ovaries are undernourished by lack of blood flow.
It goes without saying that although older woman tend to have poorer health, poorer blood flow to the ovaries, and is more likely to have hormonal imbalance, if we can help women to improve general health, to improve blood flow to ovaries and to improve the balance of hormones, follicle development and egg quality will thereby improve as a result.
At TCM HealthCare, this is precisely what we aim to do.
Although the ageing process does impact on egg quality, our scientific data and clinical experience demonstrate that egg quality can be improved over a period of time to increase the chances of natural pregnancy, and success rate for IVF or egg freezing. This applies to younger as well as older women.
While AMH is not a direct reading of egg quality, the scientific literature suggests that combined with antral follicle scan, it could be a good predictor of egg quality. High FSH is often associated with low AMH. Given that we are able to increase AMH and reduce FSH, it is likely that we are also able to improve egg quality. The best way to find out about egg quality is of course when the eggs are collected. Our clinical experience, as testified by patients and consultants, confirms that we can indeed improve egg quality for older women.
How do we improve egg quality?
Our approach is to focus on using natural herbal remedy and acupuncture to strengthen the reproductive system to improve general health, treat blood statis, and bring about hormonal imbalance which will ensure the period is regular. Once the hormones are balance and the period is regulated, ovulation is likely to occur and egg quality will improve where natural pregnancy will be the result.
The most common treatment mode is through tailor-made Chinese herbal remedy. We sometimes use acupuncture when the circumstances are appropriate.
Patients come to us with their most recent hormone test result and other results such as scan (hormone test results are considered up to date if they are less than 3 months old). The first consultation will last for an hour where detailed but non-invasive and pain-free Chinese medical diagnostic procedures will be carried out. This will ensure we understand your particular condition and circumstances thoroughly. This in-depth understanding will allow our specialist to prescribe an unique herbal formula which usually consists of around 20 kinds of herbs tailored made for you only. You will be asked to make drinks out of them and consume them twice a day for 18 days in a month.
A month after the first consultation, you would have finished the herbal remedy. You come back again for a second consultation which will last for 30 minutes. Again, a diagnostic procedure will be carried out to see how well you respond to the treatment. Another unique herbal prescription will be formulated for your improved condition. This monthly cycle will repeat 3 to 4 times before you are asked to have another hormone test carried out. Most patients see significant improvements.
Where patients would like to combine us with IVF, a regular period will increase the chances of IVF e.g. higher dosage of stimulating hormone can be used. In some cases, patients reported that IVF specialists found through scan that their PCOS have now disappeared.
How do we know we are successful in improving egg quality?
We know we can improve egg quality for the following reasons:
– We have an excellent track record of increasing AMH over time. See AMH results here.
– High FSH is associated with poor egg quality. We have a track record in decreasing FSH over time. See FSH results here.
– We have an excellent track record in regulating period using natural herbs. Most patients see their periods becoming regular within a few months. Regular periods are a clear indication of better egg quality for reasons given above.
– Some of our patients who are under the care of IVF specialists at the same time report that the IVF specialists tell them that their PCOS has disappeared. See testimonials for our patients’ experience.
– Some of our older patients who went through IVFs and their specialists reported the eggs collected are of excellent grades. See testimonials for our patients’ experience.
How much are the fees?
The all inclusive fees are in the region of £350 per month.
How often do I need to come?
Once a month. Most patients come to us for 3 months to 9 months. Just over half of our patients combine our treatment with IVF.