Acupuncture & IVF Research with Dr. Lee Hullender Rubin

A new Lancet study on IVF add-ons made headlines, and acupuncture was one of the treatments under review.  Dr. Lee Hullender Rubin joins Dr. Susan Fox to discuss what the study actually found, what it got right, and what it missed.  Dr. Lee explains that 

• studies using one or two sessions on transfer day was an insufficient dose.
• research was done on fresh embryo transfers, but almost nobody does fresh anymore.
• “sham acupuncture” isn't placebo..

This episode is for you if:

• you saw the headlines and want the full picture
• you’re planning IVF and considering acupuncture 
• you’re thinking acupuncture on embryo transfer day will help
• you want to understand what "sham" acupuncture is and why it matters

Support your fertility journey with Preconception Plan at Health Youniversity. Learn more here: https://healthyouniversity.co/programs 

Want to know more about the latest IVF acupuncture study? Read the full article here: https://www.rosefinchhealth.com/blog/acupuncture-ivf-major-new-study-fuller-story 

Website: https://www.rosefinchhealth.com/ 

💻 About Susan Fox: https://www.healthyouniversity.co/about

Take your 5-Element Fertility Quiz:  http://yourfertilityquiz.com/

Detox to De-Stress:  View the FREE Masterclass on the importance of detoxification to prepare for a healthy pregnancy:  https://susanfox1.easywebinar.live/gentle-detox

Learn about our program entitled Your Fertile Health: https://www.healthyouniversity.co/programs

Schedule a Fertile Health Assessment: https://www.healthyouniversity.co/your-fertile-health-call

Let us journey with you as you navigate your fertile health. Connect with me:

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Transcript

SPEAKER_02 1:25

Hello and welcome to today's episode of Health University, where we talk all things fertility, pregnancy and postpartum, and what we refer to as the pre-perimenopausal time frame, just little steps across the bridge of a woman's reproductive health. And today we're going to talk about something that we don't often cover but should be covered more frequently, and that is the importance of rigorous, reliable research that backs up a lot of our claims as to why Chinese medicine and acupuncture in this conversation is particularly useful. A renowned researcher and fertility specialist and a doctor of acupuncture in East Asian medicine, Dr. Lee Hollander-Rubin. She is an internationally recognized award-winning doctor of acupuncture and a leader in the field of integrative reproductive medicine. As founder of Rosefin Health, Dr. Lee blends compassionate care with over two decades of clinical experience. Dr. Lee is also an accomplished teacher and researcher of acupuncture and integrative East Asian medicine. Having authored more than 30 publications, I can personally attest that you are my teacher and I rely on your research. So today we're talking about a particular study that has recently come out, and it is in the Landsat, and it's entitled Safety and Effectiveness of 10 Common In vitro fertilization add-ons, a systematic review and meta-analysis, in which it concluded that acupuncture, among others, showed no significant effect in live birth outcomes for people undergoing IVF. Thankfully, Dr. Lee is going to help us really look into that research, see what they did well, and see what they missed. First of all, welcome, Dr. Lee, and thank you so, so, so very much for joining me.

SPEAKER_01 3:14

First, thank you so much for that very kind and thoughtful intro. You're you're such a dear colleague and friend of mine. I I really appreciate the opportunity to talk about this. One, and I was so happy to say yes to you when you reached out. Um I'm I'm very excited, I'm not excited about the study so much as I am. I think this is a great opportunity for us to continue talking about this. Because I've been writing about this, this particular issue, the research, um, how we're concluding how acupuncture may or may not help since 2018. Um, but you know, in this, I'll just start with your first question is like, what do we think was great about the study? And then I'll move into what we think could be a little more of a nuanced interpretation of the acupuncture results. So what's really wonderful about this team from Australia is that they essentially did 10 different studies and reported them in one paper. So they reviewed 10 common IVF add-ons and they did this very high-quality analysis that included measures that aren't typically included in meta-analyses. And this is really good. We need these kinds of very rigorous studies. So they looked at trustworthiness of studies, risk of bias assessments, grading for certainty that is very often skipped, especially the trustworthiness and the certainty are often skipped in a lot of meta-analyses. And what they found was, you know, endometrial scratching showed some possible increase in live births. They had moderate confidence in that. Um, Pixie was appeared to reduce miscarriage rates. They had moderate certainty in that. Embryo glue showed a possible benefit for pregnancy rates, though they did find that the live birth effect was not consistent across all their models, all of their research um questions. And then the remaining add-ons that they that included acupuncture, they they either said that the evidence was unclear or showed no effect. So I'm a formally trained clinical researcher, in addition to being a clinician. And um I found I've been looking at how acupuncture and whole systems, traditional Chinese medicine influence IVF outcomes since about my first study started in 2004.

unknown 5:21

Wow.

SPEAKER_01 5:22

So I've been doing this for a while.

SPEAKER_00 5:23

Yeah.

SPEAKER_01 5:24

Um, and I've been writing about the research, as I said, and about the conclusions from meta-analyses since about 2018. We'll include the papers. Um, I'll give those to Susan so she can put them on the the in the show notes, yes.

SPEAKER_02 5:36

So be sure to end of this conversation to go to go take a peek at the show notes so you can actually link to a lot of these articles and blogs and so forth to really get a deeper understanding and to share.

SPEAKER_01 5:47

Yes. And the issues that I've been talking about in 2018 continue forward in 2026. So things haven't really shifted that much. But so when we say that acupuncture may or may not help, or it's unclear if it helps, I think that what we need to understand is that the research that we've been looking at isn't really reflective of clinical practice. So let's let's break it down into a couple of different pieces. First, on the day of embryo transfer, you're often said, oh, do acupuncture on that day. It's one to two sessions, it might help your help you become pregnant. And you know, from a perspective as a provider, uh, and their conclusion that one to two sessions doesn't appear to improve improve birth outcomes, this actually does make sense to me. I don't agree. I absolutely agree.

SPEAKER_02 6:39

And you have research that also backs some of that up.

SPEAKER_01 6:42

Yes. So I don't think this is an appropriate dose of acupuncture. It's like asking one to two shots of ganadotropins to be enough to take you to egg retrieval or one or two doses of progesterone to be enough to support you in the luteal phase after transfer. That's not a sufficient dose. You need to have uh, and the research has actually been able to confirm that you need more of the dosage. We, however, don't have that. But in as you just mentioned, my own research, we had observational research, we found 12 to 15 sessions that included day of embryo transfer acupuncture was associated with more lead births and fewer biochemical pregnancies with fresh embryo transfer. And so then this brings me to my second point. Yes. The evidence we've been looking at and we continue to use in meta-analyses was largely generated in a clinical context that no longer reflects how we practice now. So when you go to get a transfer, you're likely having a frozen embryo transfer. And the majority of the studies are not on frozen embryo transfers. In the Lenson study, they had about they had three studies that had at least some frozen embryos in them, but not all of them. And so, how can we conclude that we can't, we can't conclude that it's going to be the same outcome for frozen as it is for fresh?

SPEAKER_02 8:09

And can I ask a quick question? Yes. So as the studies included both fresh and that they reviewed fresh and a very few frozen, would it not lend itself to say then therefore, you know, and we don't do fresh hardly. I mean, I can't remember the last time a patient did a fresh embryo transfer. Can we conclude that that those studies are, you know, sort of like they don't belong in the analysis, the ones that that really depends on your research question.

SPEAKER_01 8:38

Yes. You have to say at the at the front end, before you even start looking for studies, we're only going to look for frozen embryo transfer trials that added acupuncture on as an as an add-on. And then you would see that there are an insufficient number of studies to actually do an analysis. Right. Because you would have less than five. And to do a meta-analysis in that case is is not you won't have any certainty. It's just not, it's insufficient numbers, there's an insufficient number of trials. There's all these things that would go into the calculation of certainty. So the the other thing I would say is that the piece that is not included in their study, in the Linson study about IVF add-ons, is that you know, while one to two sessions may not improve live birth rates and should actually be part of a larger um dose of acupuncture, it could offer you some modest improvements on the emotional burden of the day. So it is providing something. It's just it may not be enough to actually improve your chances of becoming pregnant.

SPEAKER_02 9:42

So it's so so the the day of transfer is actually a different question that we should be asking. Does it improve the patient experience, the the you know, the the level of anxiety that they may be feeling and all of that, as opposed to does it improve live birth outcomes? And it and correct me if I'm wrong, but that whole on the day of transfer always seems, in my opinion, to refer back to the 2002, I think it was, or maybe even earlier Paulist study, like one of the first that came out. And because it was one of the first that came out, it it became almost this, I don't know, like like Hollywood version of research.

SPEAKER_01 10:22

Well, it hasn't been reproduced, to be really frank with you. The the the study design that was published in 2002 has never been replicated that I'm aware of. And I've been looking at the data for a long time. Um, and there's a lot of stuff that comes out of China, but it's very difficult to get all of the details about the study itself, the studies themselves. And so that's a large reason why a lot of the studies that you'll see in other meta-analyses were not included in this particular analysis. And that's coming back to that quote, trustworthiness measure, um, as well as uh the ability to contact the authors to get more information.

SPEAKER_02 11:00

Right. I don't want to get too far too far, you know, sort of either in the weeds or off topic, but yeah, a lot of the um uh research seems to include sham acupuncture. So let's talk about what is sham acupuncture and why is it or isn't it uh a criteria, a variable that that should be um included in in research.

SPEAKER_01 11:23

Well, you you when you do a randomized control trial, your ideal situation, if you're looking for efficacy, if you're trying to prove that your intervention is superior to nothing or to an inert uh intervention, um, you have to use some type of sham or placebo. Um the problem is that we don't have a good uh sham or placebo that is truly inert. So I the I wrote about this a lot in the 2018 paper and the 2022 paper about um some of the challenges with IVF acupuncture uh research. And essentially a sham needle or placebo needle looks like a stage dagger. It it looks like acupuncture, it feels like acupuncture, so when it strikes the skin, the needle sort of retracts up into a handle. Um, and it it it creates a little bit of a effect in the local place where you are doing the treatment. So if you're using the same points as you are in the in the treatment group, so you're not to get too far in the weeds here, treatment group got the real acupuncture, correct. Control group got the placebo acupuncture, sham needling, and if they're doing it on exactly the same points, you're still engaging the effects, the physiological effects in on those points. And in the chronic pain research, we know that the sham controls have a much more robust effect size than other sham controls like placebo pills or um whatever else you could be using in a in a study. So uh there's also been recent research showing that people who got real acupuncture compared to a sham had a much longer duration of effects. That was a recent study from Judas Schlager on vulvadinia, which is an excellent paper. Um, highly recommend saying that. But anyway, um, so sham is not ideal for us to be looking at efficacy right now. We have to figure out what is the best control for uh acupuncture research. And we haven't quite figured that out yet.

SPEAKER_02 13:31

So I is it safe to say that there is no sham when it's acupuncture?

SPEAKER_01 13:37

Uh I don't think we can actually safely say that. I think people are gonna still keep trying it um in all the different ways. But I think what we have to understand is that you need a really large study because the effect size of the placebos or shams that we're using are so robust that they mask any detectable difference between a treatment group and a control group uh that that makes it very difficult to run these trials because they're first of all very expensive.

SPEAKER_00 14:05

Yes.

SPEAKER_01 14:06

Um it require you need roughly 400 people per arm uh to do a study. And that's who's funding acupuncture research right now? Bingo, yes. Yeah, not not especially in IVF. Nobody is double bingo, yes.

SPEAKER_02 14:21

Yes. Please connect with us for a fertility assessment call at the link below. We'd love to learn a bit about you and share our resources. And make sure you subscribe to our YouTube channel so that you never miss an episode. All right, well, I uh forgive me if I'm hopping all over the place and pull me back. But you you mentioned that, you know, that that the study that had just the day the day of transfer before and after was not enough dosage, and you made a recommendation for in your research, you know, what is a proper dosage, but let's talk about that dosage over time, right? So what what is the ideal dosage over time for someone who is you know planning on undergoing IVF so that that that person can have the right dosage and frequency to have the effect?

SPEAKER_01 15:11

Well, I think we don't actually have a research-backed answer to that question. So I want to be very clear about that at the outset. What we do know is from our clinical experience and from multiple observational studies that frequency of treatment should be at least weekly, sometimes twice weekly, depending on the um whatever the goals are of the of your treatment plan. In my own research, we did once a week for up to um 15 sessions on the average, and that included again day of embryo transfer acupuncture. Other studies have done four to five, sometimes six sessions, including day of embryo transfer acupuncture. I think that the challenge right now is that the more it's not the challenge, the challenge that we have is we've got to determine what is the perfect number of sessions. But because in Chinese medicine we we practice individualized care, I think it'll be very difficult to generalize all IVF patients are the same. They are not. Of course, the reasons for going to IVF might be because of, you know, the sperm is not so great, or maybe it's because um there's diminished ovarian reserve, or maybe it's because there's endometriosis or recurrent pregnancy loss. Those are all different reasons that need different support mechanisms. And we don't treat them all the same on the IVF side, and neither do we on the Chinese medicine side. So um it's very difficult. I know I'm not really answering your question because this is worth no right now.

SPEAKER_02 16:37

Actually, you are answering the question because the that there isn't a singular answer. There is no singular answer. Yeah, and that is that is the the the beauty of our medicine as well, is that we aren't we aren't doing protocols per se. We will implement protocols that have been shown to be um you know successful, and then we we modify them because we are having this person-to-person interaction, you know, uh provider-to-to-patient interaction, where we can modify it and and should modify it based upon our our you know knowledge and education. Two two questions come up for me. Day of embryo transfer. Um, I recall one of your studies, I believe it was, that was that that uh had shown that if the post-transfer treatment was not done immediately after acupuncture, but that patient you know got in the car, drove across town, maybe ran some errands, and then went for the acupuncture treatment, that that was less effective than not doing it at all. Am I remembering that correctly?

SPEAKER_01 17:41

You're remembering that exactly correctly, yes. Um, that was the first randomized control trial I ever participated in in 2004. That we were, and there was we had three different sites that people could come to our uh acupuncture clinic uh who were going through fresh embryo transfers with day three and day five embryos. Um and they one particular clinic had a two-hour period of time where they made them lie down. So it was a rest period. Now we know based on research that that's no longer considered something that actually, as an IVF add-on, improves outcomes. Um, but for that particular clinic, they still implemented that practice of you will have bed rest for two hours after the transfer and then they would come back to us. Um I think that, and these were all acupuncture naive people. They'd never had acupuncture before, they'd never been to our clinic before. As you as I noted earlier, there is a significant mental health burden on the day or emotional burden on the day of embryo transfer for many people, not everyone. Um, and so I our our question is was the stress of going to a place they'd never been to before for a treatment twice on a day that was already emotionally charged, did did the challenge of getting to these places, the um the delay in in implementing the second treatment, was that enough to um basically erase any benefits of acupuncture on the day of embryo transfer? And it was a very that was a that really got my fire lit to better understand how to do acupuncture on the day of embryo transfer when we did have these outcomes because I was like, oh my gosh, this isn't helping at all. And we thought it was the protocol.

SPEAKER_00 19:22

Right.

SPEAKER_01 19:22

It wasn't the protocol. I looked at the same protocol in a in another setting. It did not harm, in fact, it actually helped the donor cycles um and over the the autologous cycles, you know, the embryos, your own embryos for a fresh embryo transfer. I it's there's so much that we still don't know. And it's again coming back to it is very expensive to run trials, which is why many of us who have high volume um clinics could potentially contribute to the evidence by doing observational research, uh, which is one of the things that I did because I could.

SPEAKER_02 19:57

Yeah, yeah, yeah. Well, I I I thank you for that because still people are being encouraged to run back and forth to their acupuncturist before and after treatment. And and I whenever I can, I try to just kind of, you know, raise my hand and say, before yes, after no. You know, you know, do all the work prior so that this person is really primed for a successful embryo transfer, and including that, you know, just before will kind of calm some of the of the nerves. But the the real work in terms of blood flow and and you know supporting a nice fluffy endometrial lining, that's already been done up until that day of transfer. So excellent. It's the cumulative effect of a larger dose of acupuncture.

SPEAKER_00 20:46

Yeah.

SPEAKER_02 20:47

And then another question that came up with because this this study, this meta-analysis was about the effect of live birth rate, right? Um, and that's you know, obviously everybody wants a babe in arms, but what other variables might you say in your experience and and you know, um, and and wisdom should be considered either in addition to or apart from uh the live birth rate outcomes?

SPEAKER_01 21:17

Well, as I mentioned before, definitely the mental health and emotional burden that patients consistently tell us in their experience survey and surveys of patients on their experience of going through IBF, the emotional burden of this of this process is it is robust. It is very large. Um and it is a very significant um and consistent thing that is reported by patients. So anyway, we can help reduce that. I I do I do think that we should. And acupuncture appears to be one of those things that can do that. Um, and so it's not that it appears it does. Um I think acupuncture's mental health support in this particular area is is one of the first things I would say. The second thing I would say is we should be looking at other outcomes like pregnancy loss and um biochemical pregnancies. So like the implantation essentially. Uh are there is there more implantation with acupuncture? Are there fewer miscarriages with acupuncture? These are other outcomes that I would definitely want to know about. Um, I can't remember off the top of my head right now if they have, I feel like I feel like they do have miscarriage in this paper, but I can't remember. Um, I probably could look really quickly, but let's not waste time on that. Um you'll have a link to the paper and you can look at the paper.

SPEAKER_02 22:32

Yeah, exactly. The paper's in there. But I think the point was the the focus, the sort of the primary question was live birth rates. So what as they added other considerations, they were almost, you know, not an afterthought, but but really not, they were weren't really the consideration that was being presented. Right.

SPEAKER_01 22:49

And and that's fair to them, actually. They they were very clear what their research question was. They wanted to know what IVF add-ons did improve live births, you know, and to do that, you I mean, you they had they did 10 separate meta-analyses. That's no small feat. Uh, and and my hat's off to them. They did a they actually did a very good job, but they can't possibly know all the nuances about acupuncture research. That's right why we're talking today. Um, I mean, they could, I guess, if they really wanted to, but it's it's fine that they don't.

SPEAKER_02 23:18

Well, I mean, the uh it I think it's safe to say that research that they would have otherwise been reviewing as part. the meta-analysis was not there. So they were, you know, they were working from from a you know a sort of a trove that had limited and uh limited data, old data that is not relevant to current clinical conditions, such as frozen embryo transfer and you know, um uh so so therefore my next question is are you aware of any studies underway that that do address some of these nuances with with acupuncture and Chinese medicine and IVF outcomes?

SPEAKER_01 23:57

I know well I'm working on something right now with a team from the Midwest on frozen embryo transfers so yes it's observational research we do not have a randomized controlled trial yet hopefully we will be able to do that in the future um again funding uh but you know I'm not familiar with anyone else doing any trials right now especially here's the other thing that's really been important for us to know about the limitations of the research is that a bulk of the research that's come out of all other countries around the world there's only been one or two that's been in the US and um so there was the one in Boston there was one in Chicago there have been no other studies and and sorry so three the one we had in Washington um Seattle Washington so we are woefully behind uh on again assessing acupuncture as an as a um adjuvant to IVF in a in an appropriate dose while we don't know what the appropriate dose is exactly we have some suggestions from observational research but you know I think if if we want to kind of shift our attention to what what should what should you do now if you're going through IVF and you're thinking about acupuncture you've heard about this study and you're like oh well should I do acupuncture here's what I would say to you one you could do day of embryo transfer acupuncture if you want to but I wouldn't do it in isolation I would add it as part of a larger dose of acupuncture I would start sooner with your acupuncturist so that you can be supported through the whole process of if you're going through egg retrieval you get support there if you're going from your for your embryo transfer that you start at the time that you are doing if you're taking the birth control pill before they start with the um estrogen or if you're doing a natural cycle you can do it alongside all of your medications very safely and an acupuncturist who is um well versed in in reproductive medicine and fertility they might be aborted certified they might be just very well known in your community they will be able to navigate that process with you give you education support you through the process help you with your nutrition help you with your sleep help you with your pooping all of the things that can sometimes get disrupted while you go through an IVF. This is not to be I don't think IV I'm sorry acupuncture on the day of IVF should be done in isolation specifically to improve your your chances of live birth I think it should be part of a larger intervention.

SPEAKER_02 26:29

Exactly and to your point if I just want I want to highlight you you mentioned ABORM it's the acupuncture and TCM board of reproductive medicine that will also be in the show notes you can find a practitioner near you and to your point one does not need to be a fellow of of ABORM in order to be successful in helping you yet that credential we have we have self-tested through that credential to to prove that we have the body of knowledge that can help translate uh conventional IVF medicine to Chinese medicine and help support and treat you before and the other thing I want to highlight is you years ago coined the phrase that we all use now whole systems traditional Chinese medicine and and to your point it's not just acupuncture a really well trained fertility specialist acupuncturist is going to be giving you a lot more support than the acupuncture treatment plan.

SPEAKER_01 27:32

I agree but I want to just correct you on one thing um uh politely is that I did not coin that phrase it is from Cheryl Rittenbaugh um and but we brought it to IVF and it had been investigated as part of people with MS um people with TMDD uh so uh I think the correction though yeah no I attribute it to you well I I think it's fair to say I brought it to IVF but I didn't I did not create it.

SPEAKER_02 28:00

Okay. All right well thank you for that correction. I appreciate that no problem. But yes to your point so you know if if if you know viewers listeners you you or your loved one is beginning their work with a credentialed acupuncturist 12 weeks before for or 15 weeks before for that dosage and frequency think about the added benefit you'll be getting when you're discussing your nutrition your supplementation your lifestyle your sleep wake cycles your your digestive complaints or concerns all of these are going to end up being part of your success and if they are ignored possibly the lack thereof. Yeah yeah thanks so much I I've been I'm I'm I'm the worst interviewer when I when it when it's people who I love love and and and are friends with because I'm because I'm always wanting to just like jump in but I also want to make sure that we don't that I don't uh deviate it so far that you're missing key points that you want to deliver.

SPEAKER_01 29:03

So are there any other uh points that I and I'll zip it for a minute and you can you know uh you can delve as deeply as you want into you know research for acupuncture and IVF Chinese medicine in general whatever it is that you want to make sure you're you're conveying I just would say start it start your acupuncture sooner don't wait but if you do it's okay you will still get some benefit from doing acupuncture the moment that you start your medications it it it could be in of various domains will it be enough for us to say definitively that it improved your outcomes I don't know but what we do know is that if you can start a little bit sooner if you can do it like starting at least six to eight weeks before your transfer or six to eight weeks before your retrieval you might get more benefit from that.

SPEAKER_02 29:52

And clinically you know we we are we are seeing that you know we are are we we see patients having you know improved outcomes than than was otherwise expected or predicted by their IVF doc. So um you know we we you don't we don't do the research but we have the our own individual clinic clinical observations.

SPEAKER_01 30:11

Yes and Chinese medicine has been one of the most highly documented um practices of medicine since you know before the common era two two centuries before the common era it's that's when the Huangdi Neijing was written right like so we have a very well documented practice have we always practiced IVF no we haven't but we do have neither has conventional medicine frankly exactly we have years and centuries of clearly documented um evidence of how how we have treated people they've been very well described what were the interventions that were given what were their outcomes and that helps to inform what we do today and I so if you are wondering about whether there is a dearth of evidence there is not there is evidence it's just not in the randomized control trial exactly it's not the double blind placebo control trials but there are hundreds if not thousands of years of evidence and and specific for the OBGYN set of of conditions.

SPEAKER_02 31:17

So it's not just this sort of high level you know get the qi flowing conversation it is very very specific in terms of you know what what you know how we view how we treat how we support. Yeah like what are the mechanisms that are supporting reproduction how are they going awry um or how are they going very well and and what do we need to support that if we even need to I think that a very skilled clinician will be able to tell you that oh I don't think you have to come as much actually you should only you only need to come once a week or maybe even once every two weeks but other people who are going to need a little more support are going to need to come a little more frequently and personally thanks to you because you are my you are my uh faculty if you will over at Health University's online course teaching the transcutaneous electrical acupoint stimulation I I find myself oftentimes uh if if if there's a short timeline and I don't want to add stress to the patient running for appointments, I will have them do a hybrid of the T's, that's the acronym, and and appointments so that we can sort of touch these regularly but they can have their continued care. They can have their acupuncture without needles three times a week or four times a week because it's every other day. So so you know here again that there there's a lot that we can do that isn't about uh tying up more of your time and resources by running to acupuncture appointments.

SPEAKER_01 32:44

Exactly and I totally agree with you I do a same hybrid approach.

SPEAKER_02 32:48

Excellent excellent well Lee again I I I could talk to you all day I always get smarter for anytime I'm I'm in in your presence and so grateful for it. And viewers listeners we thank you for your time as well because we know it could be spent anywhere. We hope that this has has kind of assuaged some concern because you know I was telling Lee off camera that I'm seeing you know the social media posts kind of using this research as reasons why oh don't go do acupuncture come do my nutrition course instead and you know that's that is a that is a marketing strategy but I wanted to make sure that we had Lee's wisdom and and ability to just really you know kind of delve into like the the the the nuances as you say so that you can really feel confident that acupuncture is in fact a a value added component to your IVF journey or your or your family planning journey even if it's not IVF but but of course this research was specific to IVF. So if if you've got any value please like share please share anyway because as we've said one in six people are struggling with fertility so this conversation could be helpful for someone who's thinking well maybe I'll do IVF but you know given this information maybe I won't do acupuncture let them have their their informed decision available to them before they proceed. So once again thank you thank you thank you for your time I hope to bring you back for other conversations there's so much we could talk about we could go down into you know the the the weeds of endo diminished ovarian reserve PMOS all of these things that finally are are getting some of their due in the in the uh realm of awareness uh and patient advocacy so the maybe I can rope you in for another Saturday morning. I'd be delighted thanks so much my pleasure and and viewers listeners we typically end our health university classes with class dismissed