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By NATURA Magazine.
The days of relying solely on one school of medicine are no longer.
These days, doctors and patients are all too aware of how medical pluralism that considers treatment options from different healthcare systems and cultures can contribute to a fuller understanding of diseases. In particular, achieving the best of both worlds can be increasingly seen in the field of fertility medicine. And it’s not just hopping from medical practitioners on one side of the spectrum to the other. In this gradually emerging model, doctors of Western medicine and physicians of traditional Chinese medicine (TCM) are working hand-in-hand, feeding into each other’s treatments to turn couples into a bigger family.
“I think the main push for TCM treatment is because there is not enough that is known about infertility,” reasons Dr Roland Chieng, Medical Director and obstetrician and gynaecologist at Virtus Fertility Centre at Mount Elizabeth Novena Specialist Centre. Dr Chieng himself has seen the benefits of this dual treatment model in his own patients. He cites the increasing cases of unexplained fertility as the reason why patients and doctors are starting to see TCM as a modality that can be worked with and used to explain unsuccessful patient cases that Western medicine cannot help.
This dual methodology can be used in two areas: first, for treating fertility problems; the other, when the need for in vitro fertilisation enters the picture. But to look at how TCM and Western medicine complement each other, one should first understand how they view infertility.
Although Western medicine uses an anatomical vocabulary that’s different from TCM, which focuses on the zang fu and internal systems of the body, both types of medicine are looking at the same list of problems when trying to identify the causes of infertility. What differs are their treatment methods, as well as TCM’s broader search for and treatment of further underlying issues that contribute to these causes of infertility.
For example, while endometriosis and fibroids are recognised as abnormal tissue growth in and around the uterus, TCM also considers these conditions to be induced by stagnated uterine blood. Instead of surgery, TCM uses acupuncture and herbal remedies to eliminate this stagnation. More than just targeting the uterus, the treatments are also aimed at balancing the endocrine system to bring the bodily functions to an optimal state of health. Subsequently, after recuperation and during preparation for conception, TCM practitioners may nourish the kidney to regulate the menstrual cycle and help to produce better quality eggs. This can also be done for women with no fertility issues and just for the purpose of better preconception health.
Most importantly, treatments are specific to the patient’s constitution and symptoms, and there is no one-size-fits-all protocol.
This collaborative approach can encompass the two types of medicine taking precedence at different stages of the treatment plan, where practitioners from both types of clinics refer patients to the other when necessary, or when patients bring useful information from one doctor to another. For instance, Western screening methods and results can better inform the TCM physician’s treatment plan.
Physician Zhong Xi Ming from the Eu Yan Sang Premier TCM Centre @ Paragon recalls a former patient who had undergone sperm tests and brought his medical records detailing his problem to his consultation with her. “In fact, he came alone, without his wife, and said that she had been given a clean bill of health,” she recounts. After three months of herbal therapy as prescribed by Physician Zhong, the patient was happy to report that his wife managed to conceive.
This example reflects a shift in thinking about fertility treatment among the public. Many husbands no longer mistake fertility for virility, a chauvinistic view that has been prevalent for too long. Today, husbands are more likely to come forth with their worries and queries, and Physician Zhong has met a fair share of husbands who come alone to seek treatment.
While this is a sign of a gradual correction of a damaging misconception that infertility is usually the woman’s fault, Dr Ann Tan, Medical Director and consultant obstetrician and gynaecologist at the Women & Fetal Centre in Paragon, still observes that women usually seek help earlier than their husbands. Yet it takes two hands to clap. Both practitioners agree and advise couples to come in together as both can receive help at the same time. Having both partners present may also make it easier to diagnose and treat fertility problems early.
This East-West approach can flip the other way, where a diagnosis by a TCM physician feeds into the subsequent doctor’s administration of treatment. According to Physician Zhong, TCM tends to use the ‘see-and-touch’ method when it comes to diagnosing infertility. “TCM practitioners will first observe the patient’s physical stature, facial complexion and colour, the expressions in their eyes, and even their smell,” Physician Zhong says. “We also ask them about their medical history, such as whether they have had mumps previously, as it can affect sperm production.”
TCM practitioners will then proceed to a physical examination, for instance, feeling a female patient’s abdomen to check for uterine fibroids or any pain in the stomach area that may signal bigger issues. TCM physicians may then refer patients to Western doctors should they feel that Western treatment might be more targeted or if the problem might be identified much more clearly with Western screening and treatment methods; for instance, when uterine fibroids are too large for herbs to work.
This sharing of consultation notes across practitioners of different modalities is also particularly important and beneficial for male patients. According to Dr Chieng, “males are peculiar in a different way. Unlike the female, males do not exhibit symptoms of infertility.” Although the regularity of menstruation is not a vouchsafe proof of healthy female fertility, inconsistent and abnormal periods can indicate a problem. In comparison, it is difficult to identify males with sperm problems without testing. Yet through the ‘touch-and-see’ method of TCM and its recognition of physical characteristics of male infertility, husbands who visit Physician Zhong can be treated much faster.
The East-West collaboration deepens when IVF enters the picture.
IVF is a form of assisted reproduction technology (ART), where the egg is fertilised by sperm outside of the body. When the patient chooses to go for IVF and takes up the doctor’s recommendation and referral to a TCM physician, both medical practitioners then work in tandem with each other at the same time, sometimes corresponding with each other directly to ensure good quality eggs and sperm, successful implantation and a healthy, full-term pregnancy.
“I am open to recommending my patients to avail themselves to TCM alongside ART,” Dr Tan says. “This is because I have had positive experiences with my patients’ use of TCM, and many couples do it quietly anyway so I prefer to be upfront and ask them about it.” No other patient illustrates the incredible results that can ensue from this collaboration better than Cathy Tan (name changed to protect patient privacy). Both Dr Tan and Physician Zhong refer to her as their ‘miracle patient.’
Cathy first consulted Dr Tan in 2010 and found out about the presence of fibroids, ovarian cysts and polyps in her uterus. She underwent surgery to remove them, along with her right ovary, which decreased her chances of getting pregnant. As she was already 37, Cathy’s age was also a major deterrent for conception to occur.
Age is a dominant factor in infertility, especially when it comes to IVF. “If you look all over the world, IVF has always been classified according to the woman’s age,” says Dr Chieng. He cites the success rate of IVF pregnancies by age: women under 30, 100%; 38 years and below, 80%. “But the moment you’re passed 38 years old, it comes down a lot. If you’re below 40 years, perhaps it’s 20 or 30%. Past 40, it’s 10%. Past 43, 2%. Past 44? Very, very low,” he emphasises.
After surgery, Cathy underwent six months of recuperation and, upon Dr Tan’s recommendation, took on Physician Zhong’s care as well before her first IVF cycle in 2011. Right before the IVF procedure, Cathy received acupuncture from Physician Zhong to complement the IVF treatment. Then, Cathy was also inducing ovulation with hormonal injections. The first IVF cycle eventually led to a miscarriage, and her left fallopian tube had to be removed. In spite of this, Cathy persisted with the second cycle of IVF in the same year. Although she stopped the hormonal injections and relied on the natural ovulation cycle of her body, the combined treatment continued, with regular check-ups with Dr Tan and acupuncture sessions and herbs prescribed by Physician Zhong. Finally, the third time was a charm.
“Acupuncture is mostly used in fertility treatments to complement IVF procedures performed by Western medicine,” explains Physician Zhong. “Herbs and acupuncture can help to improve the womb lining, and enhance follicles so that the patient can have a stable womb lining when the embryo is transferred to it,” she adds. Increasing the yang energy also helps to create a good uterine lining environment and increase the likelihood of successful embryo implantation. Factors such as a calm mind and harmonious flow of qi and blood through the body can also influence the blood circulation in the ovary and uterus, and have a positive effect on the success of IVF.
“After my first failed IVF, I felt sad and thought that I was probably hopeless,” Cathy shares. “For the subsequent IVF cycles, Dr Tan advised me to undergo natural ovulation, and I followed her advice. I trusted her and Physician Zhong. I really felt that they were helping me. Even the lady at the EYS clinic counter helped to schedule me for acupuncture before anyone else as timing is very important for egg retrieval during IVF!”
Even with many factors working against her, Cathy repeated the whole procedure two years later at the age of 39, an age when eggs would be of even poorer quality due to advanced age. Two IVF cycles and regular sessions of acupuncture and herb consumption later, Cathy gave birth to another boy.
“It was a nice combination of work from Physician Zhong and myself to get the eggs out from someone who hardly produced any,” Dr Tan asserts. “And she wanted another and we both got stressed but she did it again!”
Although some might baulk at five IVF cycles and treatment that required daily trips to Dr Tan to check for the most optimum follicle size for retrieval, as well as fortnightly consultations with Physician Zhong to pick up the herbs for targeted treatment, Cathy believes that couples who have problems conceiving should consider this East-West model. “I was open to trying out TCM because I did some research over the Internet myself and read some blogs that talked about this combination of treatment. But even if I eventually didn’t want to go for IVF or ART, those Chinese herbs that I was taking were good for my body, so for those who want to have kids, why not try it?”
Aside from word of mouth, Physician Zhong points out that this collaborative approach owes its popularity and use to a higher number of infertility cases.
She recalls that when she first joined the Eu Yan Sang Reproductive Department more than 10 years ago, she was still hesitant about the need for this department, but was surprised when people started streaming in. “People then were relatively younger and wanted to go for something more natural, therefore, TCM became a good alternative to Western medicine. But now, we can see that the age group of these patients has increased to as old as 45 years old, and they are still trying for the first baby.”
This also means that it isn’t that fertility health is getting poorer. It would seem that way, given that modern life seems a lot more hectic and stressful. But with rising affluence and an increased emphasis on career development in Singapore, couples are deciding to have a child much later. Both Dr Tan and Physician Zhong agree that late marriages and the resultant later age of couples who want to conceive is a dominant factor of infertility. So it isn’t that people nowadays are less fertile; it’s simply that those who want to be parents are much older. In fact, about 90% of Physician Zhong’s patients are above 35.
Although this informal cooperative approach between medical practitioners may give hope to couples struggling to conceive, the road to conception—regardless of method—can be an emotional rollercoaster. Doctors from both modalities have had to face couples in disharmony in the consultation room.
“The most successful treatment is one where both partners are equally in tune to reach the goal of having a baby,” Dr Tan advises. “It’s always very difficult and stressful when one partner wants it more than the other. They must realise that it’s not a blame game; try to make the best out of what you both are as a couple.”
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