Low AMH and what it actually means with Alex O'Connor, Fertility Acupuncturist

Dive into what low AMH actually means and what the best things to do are if you have been told you have low AMH. Alex certainly busts a few myths in this episode and gives practical tips and advice how about best to address low AMH. There really is not much about AMH that Alex can't answer!

Alex O'Connor is a Fertility Acupuncturist based in Essex & London, she specialises in complex cases, low AMH, male factor fertility issues and much more. Contact Alex via her website or check our her instagram here. 

Transcript

Unknown: 0:01

Hi, I'm Rachel Sherriff, and welcome to the fertility suite podcast. Our aim is to educate and empower couples who are struggling with all aspects of fertility. By giving you the information to make informed decisions along the way. We've had a little rebrand since series one, we were formerly the fertility method podcast. But in this second series, rest assured, we still have the same high standard of fertility experts coming to share their knowledge and support you. So if you are struggling with fertility, miscarriage or you just want to arm yourself with the facts, then this podcast is for you. Hi, everyone, and welcome back to another episode of our facility podcast. So this week, we have Alex O'Connor joining us, Alex is a fertility, acupuncturist and so much more. And today, we're going to be talking about low Hmh. And exactly what that means and things you can do if you've been told you've got no Hmh and just busting a few myths, really, because I definitely think Hmh is one of those things is very UNMISS. Understood. So Alex, welcome. Would you like to introduce yourself a little bit more and explain to our listeners who you are and what you do and a bit more detail? I will try. Yeah, I'm Alex O'Connor. I am based in Essex and up in the city and I'm a fertility acupuncturist by education. I'm more of a kind of fertility acupuncturist slash fertility mentor guide, general for fertility, Detective II type of person. I work almost exclusively with long term complicated, unexplained infertility. And with clients who've had multiple IVF failures. So I do take on some what I'd call kind of simple cases, but they don't tend to be the norm. You're really helping those women who have struggled with, you know, similar to my own story, I guess, where it's just been really complex and difficult, which is caustic. Yeah. And I'm, I suppose my my kind of reason for working like I do is I think a lot of people who have IVF, and it works, don't need it. I personally had IVF. In hindsight, if I knew now what I do, if I knew then what I know now, that's the way around it goes. I definitely don't think I needed it. I just it I didn't, I just needed to I need to find me. I didn't need IVF. And there is something for me that I think would have been really good for me and empowering for me. Had I known that someone like me could have actually got me through without IVF. So I I'm really interested in trying to I do a lot of stuff out on Instagram. And increasingly on my website, I'm trying to just give people a different perspective on fertility on unexplained infertility, I'm trying to bust that myth that IVF is the obvious answer for unexplained infertility. Or that once IVF has failed that the obvious answer is to try IVF. Again, it isn't the obvious answer is to actually take a deep dive into holistic health and work out a whether IVF can work with a bit of assistance, or in many cases, people come in to me having had IVF before and we ended up with a natural pregnancy. So, you know, even if you've had an unsuccessful IVF cycle, you may still get there without it. Yeah, absolutely. Just repeating IVF when it's not worked previously, you know, doing the same thing over and over. It's like the definition of madness, isn't it? I think Hindsight is a great thing as well, like similar to you, you know, I had IVF and I often say to my patients, you know, I don't I didn't actually need it, you know, it works after the third round, but all that money, emotional, you know, stress strain. I just I didn't need it. I probably could have been pregnant without it. And like you said, I just wish there had been other options presented to me. But fast forward 10 years. In my case, here we are, what an amazing position to be in where we have people that exist that can do this. So let's kind of like talk about, like a couple of myths, like probably similar to you. One of the most common phrases that comes through the door of my clinic is I've been told I've got low Hmh. So therefore I'm having IVF. Like, let's just unpick that that's a massive unpick, but let's just unpick that a little bit. Like why Why are women being told that low H means they need IVs? Yeah, I think when you when you really understand Hmh and the if you really understand the whole low MH thing IVF is the least obvious answer to low MH. It it's almost less obvious that you would want to do IVF with low MH than if you just had Do unexplained infertility? It's like, why would IVF be your answer? With low MH where you know that your egg numbers are likely to be low. And IVF essentially, is kind of geared around wanting big egg numbers, big numbers, big embryo numbers. That's, that's the kind of the pipeline and the funnel that IVF works with. And yet, when you're looking at holistic fertility from a holistic perspective, what you're looking at is quality over quantity, you're not looking at quantities of eggs you're looking at how do you how do you get the best possible egg on a month rather than how do you make 15? Or 20? Or how do you drive those ovaries hard enough to produce more eggs and they're comfortable with IVF is just going to be so low NHI IVF is harder with low MH And when you're looking at like there are there are different categories of women with low MH there are women with low MH who are superduper fertile. If they were with a partner who was superduper fertile. They would be the first ones to fall pregnant. You know, the the friends of yours that you listen to who say Oh, you know, I tried to get pregnant, I would practice within the first couple of months. They probably have low Hmh. You know, the people most likely to conceive quickly have low MH. And so when someone is struggling to conceive with low MH, you have to start thinking about why are they struggling to conceive with low Hmh? Because low MH in itself should be making them more fertile. Unless it is more complicated than that. Can you just explain that a bit? Alex? Like I think you've probably blown a few people's minds. But that that few sentences, they're like, why is having low Hmh going to make you more fertile that goes against the grain of every fertility clinic that out there. I'm not saying does Yeah, I'm not saying does make you more fertile. I'm saying it can do so there are I tend to use a lot of analogies when I'm talking to people in clinic about things. And with Hmh. I have loads of analogies at my fingertips, but the one I will think of at the moment is the tomato plant. So you know, if you're a tomato plant that is a cherry tomato plant, and you produce a cascade of cherries every single day, every single month. So your M H will be really robust, you produce loads of eggs, but you could be a beef tomato plant. And you could produce one or two really good tomatoes in a month, you're never going to produce a massive them, you're going to produce one or two, but they can be fantastic. You equally couldn't be a cherry tomato plant that is designed to produce loads, but you've got an infection or you've got issues with circulation in around your ovaries, or you've got inflammation in your system, or you've got nutrient deficiencies. You've there are so many possible reasons for Hmh to be low when it shouldn't be. And and in those cases, if you're a cherry tomato plant producer and you've got one or two small cherry tomatoes, they're not going to be great, because you should have been producing masses, you've only got one or two because most of them have failed along the way. And in those cases, the low MH is almost like a canary in the coal mine. It's like oh my gosh, we need to take a good look at this. So I kind of think when when someone is struggling with infertility with low MH you either need to take a really good look at her. Or the thing that gets missed all the time with people with low M H is you need to take a really good look at him. Because it could be that you are producing these amazing beefsteak cerita beefsteak tomatoes, you know these fantastic quality perfectly Tip Top eggs but just not very many of them and that's your natural best and there's no point trying to get a MH to be higher because you are comfortably producing great follicles and great eggs with low MH but you've got a partner with male fertility issues so you're not getting pregnant. And then you end up bowling into IVF because that's what they tell you with low MH. And you didn't need to because most male fertility problems can be fixed or improved to the point that you can end up having successful natural conception. Though perhaps key from that sort of that sort of conversation is that you really need to be looking at the male side of things when you're looking at clients that have low Hmh so you know it's not just about the woman having low Hmh and something you mentioned at the beginning of the conversation that I think as fertility experts we know but I think it's really important to again it's like mythbusting Isn't it like low Hmh doesn't mean that your eggs are poor quality? Nope. It it's it's such a flip flop kind of conversation with low MH no it doesn't mean they are poor quality. It could mean they are Meeting quality, but it could mean they are poor quality. Low Hmh doesn't mean anything in low MH doesn't predict your time to menopause and in women under 40 Lohia ah cannot be used at all to predict time to menopause women over 40. They have various kinds of studies where they've kind of looked at time to menopause of women over 40. But the time is far longer in average than then you would think so like a woman in her early 40s. At the point that men ah, can't be measured, it is that low, she would have on average six to eight years until menopause. But people kind of, they just assume that as m h disappears, that they will be in menopause. There's usually years left before you're in menopause, but that people don't get that either. And it's just that that time the ovaries are quiet enough and producing possibly, you know, one follicle a month there's really not very much going on and ah is low. Let's so all the way through. I didn't mean to interrupt you, Alex. Let's do it all the way back to the beginning because I think this is something that's really important to clarify, based on what you've just said like what is a MH like explain to our listeners, what is a MH How is it produced and what things would affect how much ama aid how, how much Hmh is produced. When we grow follicles grow eggs, it takes it takes potentially an awful lot longer. But the the general kind of accepted wisdom is that it takes three to four months to grow follicles from a very simple basic structural state to this kind of complicated, all bells and whistles follicle with an egg in its side and it's going to mature and ovulate. And in those three months, the follicles grow layers of cells around them called granulosa cells. And those cells produce a m h. So h is directly related to the number of granulosa cells you've kind of got and the granulosa cell number will be related to how many follicles you've got. But the granulosa cells three to four months before ovulation, the granulosa cells are they're not really functioning like granulosa cells. They're kind of like a really primitive type of cell and they become more functional granule granulosa cells, they become significantly higher in number. And I haven't got diagrams to hand but you can see the difference between are really kind of you know, three to three to four months before ovulation cell is just really simple. And then at ovulation, you've got this massive granulosa cells. So it's the large antral follicles that pump out the majority of RMH. And it has various different functions and they're not even quite short exactly what it does. It seems to have almost like a protective almost like an umbrella protection on the follicle to stop it from being stimulated by FSH so that those maturing growing follicles can slow down and grow very quietly and gently for three months. And then Hmh kind of switches off and the follicle switches on its receptiveness to FSH and buff it goes. So Hmh is not produced, which I think people get really confused with a MH is not produced by the follicles that you haven't started growing yet. So like your store of follicles, your store of eggs, your egg reserve is what people think of when they think of that they think of the stock of follicles that we were born with that, that we will eke out for our whole kind of menstruating years, mh isn't produced by those MH has been produced by the large developing follicles shortly before they offer late. So that is termed the ovarian reserve because from an IVF perspective, you know, they're they're stimulating this month and they're thinking about, you know, well then we might stimulate next month and we might stimulate the next month. So they're looking at kind of the almost like the the cohort of follicles that are in reserve for the following month. They're not talking about the storecupboard. We can't measure Hmh to measure the storecupboard. In there isn't there is a ama there isn't there is this kind of overarching there's an overarching decline in Hmh from when we shortly after we start period so sort of in our mid 20s MH will be at its peak because we are at our peak and then it will potentially decline. It has a kind of decline all the way to menopause. So it will dig it will get less and less and less. But that is not a steady curve. And you can you know it's a bit like saying I am fitter in my 20s and I will be less fit in my 70s Yeah, that's fairly true, but I could be super duper fit in my late 30s. If I put my mind to it, you know, I could be a marathon runner in my 40s compared to being relatively unfit in my 20 fives if I put my mind to it, so You can do an awful lot for Hmh as you go through Hmh will vary from month to month with your sleep patterns, whether you've been ill or not, whether you've had digestive stuff going on or not your stress levels, all sorts of things will flare Hmh up and down and up and down. I had someone the other day who came to me, I haven't that so many people coming in with low MH. And so she'd come in saying that she'd been told she had low MH for her age. And she's in like, I think it was mid 30s, low MH for her age. And then. And then she mentioned that she had it measured about six months before and it was fine. And then it was low when she re measured it. And so she's now panicking, that her fertility is fallen off a cliff. So you know, a couple of basic questions. And just before she had her secondary MH test, she was ill, and I Okay. I would ignore that then. Because why? You know, it's, it's gonna be lower because you've just had a fever, and you've just been ill and you've just had antibiotics, and therefore it will be lower. Next month, it may be higher. When you fix it when a patient walks in the door of a fertility clinic, and they're Hmh is measured, and they're told your Hmh is low. And they're given this narrative of like you have poor or low fertility. Actually, all that's looking at is sort of the short term health of the for the short term sort of follicle numbers, it's not looking at what you said, like is in the bank. Further beyond what's the next couple of months sort of thing? Is that what you're saying? Ah, in women under 40, there are numerous studies that say you cannot Oh, I can? Can you hear the dog bark? I can't that's fine. For women in their 40s, there's various studies that show that you can't predict time to pregnancy based on EMH. Because some people with MH get pregnant ridiculously quickly. Some people with low MH get pregnant very, very slowly or have real trouble getting pregnant. So Hmh can't predict time to pregnancy. It can't predict fertility. It's really questionable that the IVF clinics still put that message out. They don't all put that message out in that way. There are consultants within IVF clinics who are really upfront about you know, actually, you know, F MH can't predict your fertility. There are websites that offer private blood tests for Hmh. And some of those are really good about actually clearly stating a image cannot be used to predict predict your fertility. Hmh cannot be used to predict your time to pregnancy. But the general message from the IVF industry is that if you've got low MHFA MH is going on the way down that you need to jump up really quickly and go into IVF because your time is running out, which is in the majority of cases baloney. And in the very unusual case where actually someone is sliding towards premature ovarian insufficiency sliding into kind of what we would classically call premature menopause. And yes, there is a possibly an argument that all rushed into IVF and get those eggs out while you're still making eggs. My preferred advice for that would be rushed towards someone who really knows what they're doing from a holistic fertility perspective and put the bloody brakes on, you know, work out what's causing the inflammation so your immune system out sort out your nutrient deficiencies, get your blood supply to your ovaries working better, kind of fix the things that are accelerating your slide into premature ovarian insufficiency or premature menopause, rather than straining your ovaries unnecessarily with IVF in order to get eggs out when they're already struggling because things aren't working very well. What is be like the main thing that you see in clinic that affects Hmh or causes low Hmh? If you can answer that, or is there like a couple of things like if someone comes in the door of your clinic, what would be the first couple of things you would either be advising them to do or you would be looking at like what are the key key factors at play fair. I would be looking for anything that would explain kind of like a higher level of inflammation in the system that seems seems to be quite a big factor in kind of follicle demise. So you're looking at infections, you're looking at digestive inflammation, you're looking at, yeah, the digestive inflammation and infections are quite big depletion. So where where there's just not the nutrients that there need to be to support good follicle growth. So you're looking at iron, you're looking at ferritin you're looking at the beaver, you're looking at sort of that kind of energy reserve. You might be looking at thyroid function, because if the thyroid function is really poor, then that in turn will impact how the Oh risk can respond and behave. I might be looking at whether they've got sort of surgical history, maybe abdominal surgery, appendix out digestive system surgery, whether they've had something going on physically that might be impacting the blood supply to and from the ovaries. The granulosa cells are really susceptible to poor blood supply. I would be looking at male fertility, because that's a huge part of the puzzle with low MH you would like the first thing he would say is have you tested him? You know, is it possible that you are one of the ones that has really great follicles but lo MH? And that what you're really looking at is a male fertility problem. It's male fertility so massively underestimated. I mean, it's the tide is turning, like that being said, there's loads of amazing active runners out there. But yeah, a lot of the time it's not been investigated to the depth that we would like, you know, things like sperm DNA fragmentation, testing is just missed off. And like you said, sometimes not even a basic samples been done, right. So that's good. That's kind of key really, literally have people talking to me, they talked to me about low MH. And in the same breath, they say they haven't run a semen analysis on him yet. It's crazy. Were like, it's two to tango, right? Where How does that even make any sense? It's nuts. Absolutely nuts. I know what I'd like to just delve a little bit deeper into because I find this really fascinating. And I think listeners will find it interesting about links between like digestive system, dysfunction, and the links to low MH And then a little bit deeper about, like, probably a bit more about how you work. But we'll come on to that. So. So in terms of the digestive system, how exactly does that affect low Hmh? What sorts of things are you looking for in clients? I think one of the there was a study that I looked at, which was, I think it was looking at Crohn's, in Crohn's and lo ama or Crohn's and Hmh and the impact of Crohn's on Hmh. And they were looking at the same cohort of people. And they were looking at them when Crohn's was in an active state. And they were looking at them when Crohn's was in remission. And you know, Crohn's kind of has these flares, and then it goes down again, and it will calm down, it can be calm for a while, and then it will flare again. And the difference in MH levels between Crohn's and an active state and Crohn's in remission was massive. Which is I think, for me was a real kind of switch on of oh my goodness, you know, the digestive inflammation angle is really big. For MH, I think partly because of the you know, where the ovaries are, they are in the middle of the digestive system in terms of wrapped around, you've got the colon, you've got the small intestine, you've got a lot of digestive stuff around the ovaries, if that's angry and pumping out kind of inflammation, biochemistry that is going to impact the ovaries. Inflammation has a an impact on microcirculation within the ovary, so it will take down the blood supply that is going into the follicle. So it will affect that the granulosa cells are really sensitive to that granulosa cells produce a MH. So as soon as the inflammation starts to affect the blood supply, and the ovaries MH will drop. Other reasons for the digestive stuff impacting Hmh is if the digestive system isn't working properly, you're not going to be absorbing your nutrients properly, you could be taking everything you need to protect be taking, you could be popping all the supplements that you're popping, but if your digestive system is routinely angry, bloated, disturbed, running too quickly, if your digestive system is not right, you won't be getting a lot of that nutrients into you. And that in turn will impact your follicle growth. And if it impacts your follicle growth, it's going to impact damage. But it comes back to inflammation again, doesn't it like we know that any sort of inflammation is bad for fertility, but when it comes to the digestive system, it is kind of like inflammatory bowel disease, you know, anything where you've got sort of digestive related symptoms could be an indication that there's inflammation there. That could be impacting your fertility generally, but also, you know, animals in low MH. And I don't know about you, Rachel, but I would imagine it's the same. It's ridiculous the amount of people who are struggling with fertility with digestive issues. And when you start to kind of go, oh, we need to look into your digestion a bit more. And they're like, Oh, that's not that's fine. It's been like that for years. It's fertility I'm interested in and you're just like, oh, no, you can't. You can't separate them. I would probably say about 95% of my patients, both in person and online. When it comes to me asking about their digestive system, they say, Oh yeah, I was diagnosed with IBS a few years ago. Like that's the classic like I've got IBS and then wash over, you know, carry on. So it's a common find them. Yeah, yeah, it's to find them linked. The two things I find really cool commonly linked are really poor digestion and really poor sleep. Interesting about the sleep tour. Let's talk more about that then. So, when we sleep as we know, we make melatonin, melatonin is in really high concentration within the ovaries, it's a really big player in the ovary space, where it acts as an antioxidant within the ovaries. They, they actually use a lot of IVF clinics apparently use melatonin in their, in their fluids in the in the IVF clinics in the labs, they add a tiny bit of melatonin in because it is such a good antioxidant for eggs and follicles and ovaries. So when we sleep, we make melatonin when we don't sleep, we don't make melatonin. So when we don't sleep when we're not making a substance that is so good for ovary health, which means that the ovaries are then less healthy, which means less follicles will survive, which means Hmh will be going down. So you can improve someone's Hmh by improving their sleep. I think sleep is probably the most underestimated thing when it comes to fertility in terms of that group of things that a patient can do themselves to take control and support themselves. Sleep is one of those things that people don't understand the importance of and actually there was a really big study done and it showed that actually rather than, than like getting lots of sleep, the most important thing was to have regular sleep hours and actually waking at the same sort of time every day is actually more important than kind of having an early night or going to bed at the same time. The time you wake has a lot to do with regulating your cortisol, which obviously links back to lots of things to do with inflammation, fertility. But yeah, like it's just so important. And like a lot of my patients who do shift work so your classic, you know, please cabin crew, nurses, doctors, like, you know, they're doing night shifts all the time, and there's so much dysregulation going on with the circadian rhythm. And and certainly from a Chinese medicine perspective, we know how that works. But yeah, from a Western medical medicine perspective, you know, it's that link with their hypothalamus pituitary, and that that function of your overall hormones. And again, interesting what you said about melatonin in the ovaries as well. And it's, I mean, as Chinese practitioners, we get the the liver up regulates, in the small hours of the morning, you know, sort of from one o'clock to three o'clock is liver time, isn't it? It's that's the time when the liver is doing its biggest amount of work. From a Western med perspective, I can't remember it was a few years ago, reading a study where they, they'd identified that the metabolism in the liver was at its peak in the small hours of the morning. And I'm like, Yeah, well, we've known that for 1000s of years. But apparently, times it times somewhere between kind of sunset and sunrise. And it sort of sits in that window between sunset and sunrise in terms of natural physiology. So at the time, we are designed to be deeply asleep, because it's somewhere between sunset and sunrise. If we're not deeply asleep, at that point, we lose the benefit of that upregulated liver that then does a big system wide, deep detox. And that in turn is going to impact fertility, it's going to impact egg quality, it's going to impact sperm quality. So the first thing is, you know, when someone says, oh, you know, I have eight hours sleep, but I don't go to bed to one in the morning. It's like, well, actually, that's not good enough. You have to go to bed earlier in order to be asleep at the time that your liver wants you to be asleep. All the good works done in the dark hours of the night, hey. Yeah, very much, very much. So. So what would be a couple of things that you would recommend clients who have low Hmh and signs of inflammation can do themselves to help reduce that inflammation or improve their EMH improve their facility that when you're working with someone, like what would be the practical tools and takeaways that you would give that they can do at home, I know that can be very individualised. But like maybe like the most common things that come up that you're recommending so already is you know, go to bed earlier and get good sleep and have regular sleep. Anything else you would recommend people are doing off their own back or what they can do at home. And when with the sleep thing just before I leave that though, it's also not unusual to find people aren't sleeping poorly in terms of really broken sleep and using caffeine in the day. And, and, and I would that would be if I was having in talking to someone who was having unsettled sleep, the first thing I would suggest would be that they take the caffeine out and see whether that improves the way that they sleep in terms of looking for ways to to dial down inflammation. I mean, the first obvious one would be to have a bit of a sugar detox sugar being just it's just fuel for the fire when it comes to inflammation. So sugar detox, it would be to take the digestive stuff seriously. So sometimes people can find themselves a nutritionist and work through kind of elimination diets workout, if they've got any proper food intolerances or food allergies, if there are things that you know really sort of sought me to flare up your digestive system, avoid them. There are, I'm not a nutritionist, and I don't like to get I don't like to get too far into the nutrition stuff. You'll find lots of people talking about oh, you know, drop gluten drop, get dairy drop sugar, drop this any other sugar? Yes. The others? Personally, I would be doing that under the guidance of a nutritionist because there are there's a sense in some of it and sense not in in some of the other bits of advice. So I I just don't tend to go there too much. Infection is something that we haven't talked about at all yet. That's quite a big thing when you're looking at MH And lo MH is is is there signs of vaginal microbiome infection, which then raises the chances of there being like a low grade kind of pelvic inflammation sort of setup going on. And so I would be able to have my eyes very much open for a history of Sorry, sorry. dog's going, she's lost her bone under the corner. Out. Sorry, she's um, she's my Romanian rescue dog. And she's a bit silly. So yeah, so inflammation. So sorry, infection, I would be looking for any, any sign of a history of vaginal infections, a history of recurrent UTIs. Any unusual discharge itch. A, I would also be looking paying attention to things like if the cervical mucus wasn't very obvious, sometimes that's almost a heads up for infections within the vaginal microbiome, which as I said, can then reach on up into the uterine microbiome and have an impact on the ovaries. In fact, quite often, I would see low MH being linked in with infections, that that comes back to that inflammation again, right? When you've got infection, you've got inflammation, that's not going to be good for the ovaries and therefore affect your MH. Yeah, and anything to do with vaginal infections, it tends to be a two way thing. You also end up in many cases, finding that there's infections within the semen as well. Yeah, again, goes back to that making sure you check both sides of the coin, right, we need to be looking at both partners, we need to be looking at the bigger picture and not fixating on that low ah, you know, it's let's look at step back and look at the context. And this is something I say to clients a lot as I'm sure you do. It's that like, just take a step back and look at the big picture. And don't fixate on that one thing that you've been told is wrong, because that one thing often links into lots of other things you'd like, you know, certainly when we talk about infection, there's that cross contamination, like nothing is in isolation, right. And when I start working with clients, one of the first things I often say is, look, it would be great if we could find one thing that was wrong and fix that one thing and you would fall pregnant straight away, what we often find is that it's a couple of things that need addressing that will cross over and interact and are related in some way, shape or form. And we have to unpick that picture and fix the the bigger picture and not fixate on that one thing that you've been told by whoever is the problem. And again, it's like changing the narrative a little bit and helping people to understand how this how this all works, right. Yeah, so So I suppose if someone if someone walked in my door with low MH I would the the first thing is to get them to understand what Hmh is and what it isn't. To get people to understand that I know the narrative is that Hmh falls from the age of 25 to when you go into menopause EMH goes up and down like the wind it goes up and down from month to month. It goes up and down within the month. There are you know, you'll find people who JMH doubles and halves it within a menstrual month if they were to bother to test it. So it's not a it's not a hormone that you can monitor on a regular basis and make an awful lot of sense of it because it is so variable, but the the general wisdom that people are given is the Hmh only goes down I mean I have people who are told that a MH will not pick up it will not recover it is relatively is related to how many eggs they have left. And that number is on the way down forever. And it's literally not true. So I would first of all get them to understand what Hmh isn't isn't, then I would be my first port of call would be to have a look at a semen analysis, comprehensive semen analysis to try and work out whether it was a low MH, which was causing infertility because of a male factor infertility rather than low MH that I need to investigate for it in itself. From her perspective, my attention would be digestive system, it would be thyroid function, it would be iron and ferritin. And it will be infections. And I would look through all of that, and I would be pretty guaranteed to if his fertility was fine, I will find something in that lot. There's always something isn't that in the clinical picture that's not been investigated enough or, or they've been told, Oh, that's normal. That happens a lot. And a lot of things. Normally they're not. I think when ah, you know, if you're someone who would have a robust DMH level, and it is at a low level, because of infection, inflammation, nutrient deficiencies, poor circulation. So if it was low, because of one of those things, all of those things can impact infertility. So it's your the reason that you're looking for them is not because you're trying to fix a EMH. It's because the sorts of things that will lower MH are the sorts of things that are stopping you from getting pregnant. So you would look for all of those things. And if I didn't find anything in any of those sections, then I would go back to look more closely at male fertility, it would be the DNA frag, you know, because there's a percentage 20 to 30% of men with a normal semen analysis where the semen looks fine under a normal microscope, we'll find that if we look at the DNA fragment there it may be raised. So you would you would just have my investigative hat on because if they if you've got a couple and she has low Hmh and they are not conceiving, there is a problem. Somewhere, you have to find it. And the problem is not low M H, the problem might be whatever is causing the M H to be low, or it might be a slightly more difficult to find male fertility problem. I think it's more likely BOTH Yeah, I think the like something that's really important to mention, as well. And something that I'm I've harped on a lot about lately is that this sort of level of investigation is not something you will get on the NHS, I mean NHS, a wonderful, amazing for so many things. This is an NHS bashing session, however, you want not frozen again, someone that inflammation, infection, sperm DNA fragmentation, those sorts of things just aren't checked, generally on the NHS, that they can be checked at a very basic level, they might want a vaginal swab for a few things. You might already have a diagnosis of inflammatory bowel disease, but you'll be told it's not linked. You know, this is work that is done outside of the remit of the NHS, right? Absolutely. There is there is so much in terms of facility investigations and fertility fixing issues that cause infertility that is done outside of the NHS, you will not find it inside the NHS. Even things like sperm DNA fragmentation tests, you will probably find them within the NHS if you were in a specialist miscarriage clinic, but you wouldn't find them. You won't find them. Generally speaking, there's a lot of the stuff that we do that you won't find. And that's hard, I think because an awful lot of people struggling with infertility are wedded into the mess Western med system. I know I was completely and totally would not have crossed my mind to go out and talk to a witch like me. It would it just wouldn't. It just wouldn't have been it wouldn't have been in my it wouldn't have been in my wheelhouse I just wouldn't have done it wouldn't talk to anyone. Yeah, and I think like I said, I've been harping on a lot about this lately, I think this is like I've realised this is a massive pinch point is that clients and patients don't before they come to you don't necessarily even know you are an option. And that was more help out there. They are being told that the only you know, the only help they can get us within our health care system. And that is so limited resources are so tight, that, you know, sadly, they can only offer so much but that help is out there. Yes, I know. It means you need to pay privately for it. However, you know, I know for a fact that the cost of working with a lot of practitioners is a lot cheaper than a cycle of IVF. So, you know it's I think, you know, if you want to get pregnant, you know, it's definitely worth spending a little bit of money on these things because, you know, quite often this simple fix says, you know, an infection, you know, of course of antibiotics, you know, in reducing inflammation these things aren't complicated really, are they? They sound it when we're talking about them, but they're not really. They're not really and I think I think actually in terms of the who you talk to him and why you took them thing, I also get a fair amount of people who've come to me who said that they've worked with an acupuncturist before and I'm like, That's not me. I mean, I am an acupuncturist, but I'm, I'm a specialist fertility expert in in, in unexplained infertility. I'm, I'm totally different to an acupuncturist. acupuncturist are brilliant for an eye, you know, I was at that point myself, acupuncturists are brilliant for straightforward, I just need to boost my fertility a bit or you know, I'm I just need to, you know, I'd like to conceive in you know, a few months time and I'm just looking to kind of improve my general health with acupuncture, you will improve your sleep, you will improve your digestive system, you will improve your immune system. And for some people, that is enough, just a straightforward acupuncturist. That is enough. And I would say, in my experience, I think I'd got to a point where I reckon about 40% of cases, you could turn around with just straightforward acupuncture. And then there's a whole tranche of people who you need more, you need to know more, you need to know who to refer to where to refer to how to refer. You need to know what your options are, in terms of treatments, you need to know which other experts to pull in, you know, there's more to do, there's more investigations that we can do that a normal acupuncturist wouldn't think twice about doing. I mean, I went before I was working the way I work now. I don't even think I used to run blood tests. You know, I don't I don't remember particularly running blood tests, or particularly needing to see them. I don't I certainly would never have contemplated running a semen analysis wouldn't have crossed my mind, I would have been just focusing on my lady in front of me, you know, now it's like, well, I need to do semen analysis. They're like, Oh, okay, we haven't done one of those. But, you know, so yeah, the way we work, you are the same the way we work is night and day, two, the way in a normal acupuncturist will work. Normal acupuncturist are brilliant at fertility when there isn't really a problem, you know, at improving fertility, when there's nothing standing in the way of it. But if there is an infection, or if there is some kind of systemic issue or there is something more complicated going on, I don't think I it's not that I don't think acupuncture could fix it. I think probably it could, but I think probably the the timescale it would take to do it would be too long. I always refer to the sort of patients where acupuncture on its own can be amazing. It's like the patients were like the tanks just a little bit empty. There's just a little bit of depletion they just need a little bit of nourishing acupuncture can be amazing, but like you said, there's also this massive subset of patients who need more than that and I think I really liked the phrase or the title kind of fertility acupuncturist slash detective because it's doing that detective work that is really what makes the difference and getting to the bottom of the root cause right and then looking at okay, what else can we do to support that? There's so much more than just acupuncture and I know you work with like a visceral osteopath don't need that you have a few other people on your team or who you refer to. So you know, it's like you said it's knowing where to signpost the patient to matching the patient with what they need Yeah, I'm so in house I work alongside of visceral osteopath. So and that makes us it makes us quite a good sort of double act for endometriosis adenomyosis secondary infertility they're kind of things where having that structural and acupuncture worry the head all in the same place is really really helpful for the other thing I was thinking just now though, is is because I kind of think there's when you're looking at low MH most people who are worrying that low MH are eyeing up IVF that that's the norm is as soon as someone mentions low MH the doctors tend to mention low MH IVF IVF right now is tends to be the same breath Yeah. And And yet, for low MH in my opinion, IVF is the last thing you need to rush into it might be necessary, but it would definitely be worth spending a good three to four months prepping for it, which would give you the time that you need to run In the investigations to check for the things that might take the IVF down. And if you're on your money and and everything falls into place, it would mean you don't need the IVF. Anyway. So but but it's, I think there's a lot of people who go into IVF with low MH or without low MH, but they go into IVF. Because they don't know what else to do. It's struggling with infertility, nothing's working. And IVF is this great big kind of, oh, it's like the Emerald Palace isn't it is this great big thing, it's going to be fantastic. It's going to work. And I think for an awful lot of the people that it works for, like me, they didn't need it, but they didn't know what else they could do. And it's going to work. But actually, an awful lot of other stuff would have worked. I think there are some people who IVF won't work for if they just roll straight into it. But it might work for if they prepped with a proper, holistic approach before they went in there. So I think, you know, I think a lot of the people that do their IVF and it works really great. First time, I questioned that they needed it. i One of the things again, I asked often clinic is to patients, why are you having IVF? Do you know why you need IVF? And half the time people don't know why they need IVF. Right? Like there's no diagnosis. It's that like, well, I don't really know. So I'm gonna give it a go. And it's like, hang on a minute, if we can work out why you need IVF you'll probably be able to get pregnant naturally. You know, it's it's all part of the same process, right? So how do people get in touch with you? And there was a study, go and carry on? Cool. I was just as I was studying, there was a study years ago looking at unexplained infertility, and I can't remember, I can't remember. I think it was quite an old study, but they'd they'd sort of taken, I don't know, 100 couples with unexplained infertility, and they did a lot of testing and looking and working out and they worked out. I think about 85 of them. So like 85% of people with unexplained infertility, if you actually look at it, you can work out what's going on, and in most cases, you can fix it. Which is a nuts statistic. Right? Like, that's crazy. I am on in terms of where people can find me. I am on Instagram. I changed my handle quite often. I think at the moment. I'm Alex underscore explained the infertility I think. And then I'm on the web, Essex fertility.co.co.uk. And they're the they're the best places to reach me. I will I'll tag all your details in the podcast episode anyway, so people can get in touch if they if they want to, which I think they will, because I feel like you've just like blown people's minds quite a lot with busted a few big myths there. And I think people will find this episode. Really interesting, and I hope they do anyway. So thank you so much for joining us, Alex. That's been really, really interesting episode. And yeah, I will speak to you soon. Brilliant. Thank you. Thank you for inviting me.