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Preconception Healthcare: Clinical Insights & Emerging Evidence with Rhiannon Hardingham

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Preconception Healthcare Clinical Insights & Emerging Evidence with Rhiannon Hardingham

What is the evidence for preconception care, and why is this so important for naturopathic practitioners to understand?

Infertility rates are rising in almost all developed nations, including Australia, where approximately 1 in 6 couples struggle to conceive within 1 year. Furthermore, the number of couples seeking help from complementary medicine practitioners is increasing as well.

Today’s guest, Naturopath and Nutritionist Rhiannon Hardingham discusses the details of evidence-based preconception care, including why it is so important both during and before IVF, how toxins influence fertility and the benefits and contraindications of various supplemental and herbal treatments and when to use them. She also talks about how to work with doctors and other medical and complementary practitioners as part of a team approach to infertility.

Covered in this episode

[00:55] Welcoming Rhiannon Hardingham
[02:08] Preconception care timelines
[04:50] The male’s role in infertility 
[08:07] Why preconception care is important during and before IVF
[09:48] Toxins and how they influence fertility
[14:14] Awakening medicos to the issue
[16:13] Supplements for preconception care
[18:36] Herbal medicine & IVF
[23:50] Using Vitex for infertility
[26:36] Additional herbal considerations
[27:28] Phytoestrogens: helpful or harmful?
[30:53] Clarifying CoQ10 dose and research
[32:41] Additional supplements to consider
[36:40] Discussing Fertile Ground’s new book
[39:56] Rhiannon’s message to those who believe complementary care has no place in IVF
[41:18] Managing infertility is a team approach
[43:59] Thanking Rhiannon and final remarks


Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us on the line today is Rhiannon Hardingham. Rhiannon is a lead member of the naturopathic team at Melbourne's Fertile Ground Health Group. Committed to the successful integration of natural and conventional medicine, Rhiannon works closely with her patients' medical specialists to help them to achieve optimal fertility and best results from assisted reproductive treatments. 

Her success with patient outcomes is a reflection of her diligence and keen sense of curiosity to find long-awaited answers in complex cases, earning her the respect of many IVF specialists in Melbourne. As a testament to this collaborative approach, Rhiannon was invited to speak at the 2019 Fertility Society of Australia Conference on the topic of naturopathic IVF support. 

Rhiannon is also regularly invited to present to medical professionals and naturopaths alike regarding the benefits of collaborative management for IVF and obstetric patients. Welcome to FX Medicine, Rhiannon. How are you?

Rhiannon: I'm very well, Andrew. Thank you. How are you?

Andrew: I'm really good. Thank you.

Rhiannon: Good.

Andrew: Now, today, we're going to be talking about preconception healthcare. So, what exactly is preconception care? How far back does it extend, and who does it involve?

Rhiannon: It's a really interesting question, actually, and I was just pondering that yesterday in clinic. Routinely, of course, we talk about the three months prior to conception being that real window of preconception healthcare because the sperm and the egg take three months to mature, develop. And so, obviously, health in that time can significantly impact the health of the egg and the sperm, in particular the chromosomal and mitochondrial normalcy and function within that gamut. 

But, of course, really importantly, the health of the individual at the start of that same month window is absolutely integral. So, if I have a couple come in to see me and they are young and healthy, and of good weight, and already eat well, and don't smoke and don't drink excessively, don't have environmental exposures, then we're pretty good to go within three months, as a rule. 

But for those patients...and this, of course, in my practice at least, is actually the majority. Those patients who come in who are of advanced age and who have metabolic issues or complex comorbidities, it really can take a lot longer to help them to reach optimal fertility. So, really, preconception care, you could say, is your entire life. But in particular, your health in the three months leading up to it.

But when you look at the literature and clinically we know this very clearly, there's a lot of evidence around your health in the 12 months prior to conception and even the three years prior to conception influencing both your chance of conception and your pregnancy health outcomes.

Andrew: Right. Three years.

Rhiannon: There's an interesting graph in one of the research articles that I often reference that has the optimal time at which changes would be made for fertility outcomes and weight management, starts at three years out, according to the research.

Andrew: Okay. So, you know, often we concentrate on the female here. What about the male? What about somatic spermatogenesis and the issues there, let's say, with a tradie partner who might be a painter or somebody who works in the car industry, you know, the mechanics industry with toxins and heavy metals and things like that?

Rhiannon: Yeah. And, of course, similarly, white-collar workers who drink or smoke, or a lot of them we see are significantly overweight. And it is absolutely the case that male factor is relevant in around 50% of cases. 

It's considered the male factor alone is responsible for about a third of infertility cases, and that combines male and female relevance in about another 20% or 30%. So, it's about half. And, of course, spermatogenesis is that roughly three-month window.

I think it's really important to highlight, and I say this all the time to my patients because a lot of men don't accept this or don't acknowledge this maybe until it's explained to them in some detail. But second to female age, male factor infertility is the most common cause of infertility in Australia. 

So, female age being the first, but secondly, if the female is younger, the most likely scenario if a couple is not conceiving, is actually that it's him.

Andrew: Okay. So, you've just sort of discussed one factor in the reluctant male patient and that is the threat of being part of it. What sort of strategies do you use and can you help us with, with overcoming the issues? When presenting the evidence to males and getting them onboard with this, saying “Hey, you’re part of this union,” you know?

Rhiannon: Yeah, yeah. It’s an amazingly stubbornly challenging area of practice. I do a lot of mentoring for practitioners around fertility and it is something that I find is consistently a challenge for a lot of practitioners that I see.

And I think that is a unique aspect to working in fertility medicine when it comes to men and that is that they are often there under duress. Whereas if you’re working with them in other areas, whilst they may have been encouraged  or even pushed by their partners to turn up, they wouldn’t come unless partially they wanted to or felt they had to. 

But a lot of the guys that we see are there with their arms crossed, really stubbornly annoyed that they were even asked to come along in the first place. And it is sadly just not rare for us to see men who have refused their semen analysis testing or take any responsibility at all. And very often of course, when we do finally get them to do those tests, they turn out to be part of the problem.

Andrew: Got you. Now, is preconception care also important for those considering IVF at all?

Rhiannon: Yeah, it is. And probably even reasonable to argue that it's more important for those attempting IVF. 

When you really look into IVF medicine, you see that it is far from a perfect science. This number is debatable and debated, but there are some estimates in Australia that only one-third of individuals or couples seeking IVF walk away with the baby. So, the success rate is not overly impressive, unfortunately. 

And largely, the biggest challenge that most couples find or women doing it on their own find with the IVF, is the capacity to produce viable embryos in the first place. And there's very, very little, despite years and years of research, very little that conventional medicine can offer for improving gamut quality. 

Because, of course, we understand it's just a reflection of health and the cellular health. And, really, it's only those factors that are often largely within the individual's control that can influence that outcome. So, it's really actually particularly beneficial for those couples who have not had success with IVF.

Andrew: Are these people the canaries of a toxic world?

Rhiannon: Definitely. Definitely easy to see it that way. And I certainly do, especially in particular, the guys. When you look at the literature around the... And it's very, very confirmed now scientifically in the days that our foremother, I think you can call her, Francesca Naish, of this field, wrote her book. It was still, scientifically, these concepts were almost theories. But now, it's so utterly confirmed in the literature. She was well ahead of her time. 

So, utterly confirmed in the literature that it is discussed in mainstream scientific journals. And they actually say that male fertility in particular is the canary in the coal mine for human health in relation to environmental exposures.

Andrew: Yeah. It's really interesting. I mean, you can go back, right back to the book Silent Spring when it was first sort of hallmarked. But that was an overt toxicity.

Rhiannon: Yeah.

Andrew: Now that it's just this chronic smouldering, "Oh, there's antidepressants in the drinking water. But don't worry about that." It's really interesting how there's not a lot of attention being paid, even though things are measurable now, you know?

Rhiannon: Yeah. And I always say this to patients and practitioners that I'm speaking to alike. When you go to the conferences and you see the scientists speak about this, the toxicologists talk about the research that they've done in relation to exposures and fertility and cancer, they are screaming about the importance of this.They are really sounding a significant alarm. 

But, of course, politically, it's just not getting through. And until it's a political priority... And I don't know about you, but I can't imagine Scott Morrison talking about this anytime soon. Until it's a political priority, it just doesn't seem like we're going to get very far from an environmental human health perspective. 

So, unfortunately, it just falls back on the individual. And, of course, that's our role, is educating the individual about what it is that they can do to help to prevent their own exposures as much as possible.

Andrew: So, with regards to these scientists, though, there at the medical conference, are the medicos listening?

Rhiannon: Yes. Yes. And you often see some interesting interaction after their conversations. I remember a couple of years ago I went to the Andrology Conference around the time...I don't know if you remember, but a couple of years ago, there was a really significant paper released that got a lot of media attention about the halving of sperm count in human males over 40 years

Andrew: Yes.

Rhiannon: And the andrologists and the toxicologists that work in this field are there presenting what really looks like indisputable science. And many doctors are nodding in agreement. And then there is the odd one who will get up and go, "Oh, but you're talking about China. This isn't relevant to our population." 

Andrew: Oh, god.

Rhiannon. Yeah, the scientists are just like, "I just don't know what to do with you.”

Andrew: So, we have Australian data?

Rhiannon: We do have some Australian data. Certainly, in that research paper in particular, the populations considered for the halving of sperm count were developed nations. In developing nations, it was far less significant. And in that was included research from Australia and New Zealand, as well as Europe and Northern America.

Andrew: I've got to say, though, of course, if you don't call something by its proper name, it doesn't exist. 

Rhiannon: Yes.

Andrew:  Like, I'm reminded by things that the EPA did, let's say, for asbestos testing. If you're going to test, you know, the mouth of a river because there's an asbestos leak and it's being washed into the river. But if you conveniently test three months later, there's nothing there. There's no problem.

Rhiannon: Yeah.

Andrew: So you can get into conspiracy theories, but the fact of the matter is, there are games that are played.

Rhiannon: Yeah.

Andrew: And you talk about politics. How loud do we have to shout? What movement is being made to awaken medicos to this issue?

Rhiannon: Yeah. Well, I mean, that's a good question, isn’t it? And I’ve read a lot, obviously, and worked with and discussed this a lot with Nicole Bijlsma around a policy perspective. And I don't see us getting anywhere there, as I just said. 

But from a medico perspective, it really is down to the individual, isn't it? And I think what I can say from my experience with the specialists that we work with, there is a really significant cohort of relatively younger and, dare I say, predominantly female doctors in this field who are absolutely open-minded. And it's almost a ridiculous thing to call it open-minded, isn't it? Because it is just very fact-based. But open to the science and also aware of their own health, personally. 

Now, I think that really has an influence on how everybody practices as a clinician no matter what field you're in. If you are not particularly conscientious of your health, you're not really likely to bring that into your experience with patients in an everyday way.

So, there certainly are many doctors who are not turning a blind eye to it. And, of course, clinically, they have very little time to discuss these factors with patients. And I guess I'm probably biased in saying this, but I think it's fair to say that you can judge an excellent doctor by their willingness to refer to somebody who can help patients who need that support through that time. And we're lucky enough to work with some of them.

Andrew: Let's go a little bit into preconception care, what it includes. Now, you mentioned a few obvious things before: weight, alcohol, there's stress. How accepting are your medico colleagues with regards to supplements? And how judicial, how respectful do you have to be with regards to what pharmacological medicines they're on?

Rhiannon: Yeah. It's a really good question. And, of course, it comes up a lot in the work that I do with practitioners around supporting patients through IVF. And I think the first thing to say is that there is reasonably good evidence around the benefit of supplemental intervention for egg and sperm quality, in particular, sperm very, very clear. 

And that is even the case considering the fact that it's fair to say that we're missing some investment in high quality research as, of course, is often the…

Andrew: The case.

Rhiannon: ...circumstance of our medicines. But there is good evidence, in particular, around, of course, our folates and B vitamins and all of those things that affect methylation. It's really clear that zinc, for example, is an essential nutrient for egg maturation. If you starve poor, little rats of zinc and then put them through a stim cycle, they won't achieve any mature eggs for collection. 

And there's reasonably good evidence around antioxidants such as Coenzyme Q10 and melatonin and resveratrol for egg quality. And for men in particular, we know that vitamin C is a primary antioxidant in seminal fluids and that DHA in particular, Omega 3s with DHA in particular is a really key component of healthy sperm. 

So, there is absolutely enough evidence to convince us and our patients and the doctors that it is effective, and definitely worthwhile.

Andrew: You know, there's a lot of controversy in this area, though, because I remember a couple of articles talking about herbal medicines may hinder IVF treatment. So, how aware do we have to be with what's useful and safe versus what has only a tiny bit of evidence or even shaky evidence with regards to what's safe?

Rhiannon: Absolutely. And that is herbal medicine in particular is far more potentially complicating for IVF cycles than nutritional medicine can be. So, it is really important and we certainly suggest that practitioners who are not familiar with safe approaches to using herbal medicine with IVF patients refrain from doing so. 

However, I absolutely believe that for some patient groups and in particular those patient groups who have a really poor prognosis, so women with what we call premature ovarian insufficiency, which maybe in the bad old days this would have been called premature menopause, or genuinely menopausal women who have really poor ovarian response on IVF stimulation, and overall have a really poor prognosis with IVF. There is good research to show us that herbal medicine can improve their outcomes and clinically we have a lot of experience with working with those patients.

I have one doctor I work with in Melbourne with countless premature ovarian patients because she knows very clearly that it is really difficult to manage these patients from a medical perspective. 

But I really that I have quite a few patients that wouldn't have their babies if it wasn't for the benefit of herbal medicine preparing them for IVF. And so, I think it's really sad to dismiss that entirely. But you absolutely have to know what you're doing, when it's indicated, and then most importantly, when it is and isn't safe.

Andrew: Yeah. I was going to ask also, when do you use herbal medicines? Do you tend to have a period where they're not undergoing active treatment where you might address issues like smouldering stress? Do I say that word? You know, ongoing stressful issues that might be hindering their IVF purely on its own.

Rhiannon: Yes. Absolutely. And that is, prior to any IVF cycles, most patients won't be taking any medications. Occasionally, they might be taking a DHEA or using a testosterone cream. And occasionally, they'll be on the pill. But overwhelmingly, they won't be on any hormonal medication between cycles. 

And, of course, you're free then to do everything that you want to do from a nervous system and adrenal perspective. And often you are safe to continue non-hormonal herbs during the stim cycle. But we, of course, always only ever do that with full acknowledgement and support of the specialist and only with clear consent from the patient. But most importantly, only when we are 100% sure that it's safe.

Some of the doctors that I work with literally refer for herbal medicine. So, they will ring her and say, "Can you please use herbs with this patient?" And they want them on herbs during the stim cycle, but it is very specific when that is required and indicated.

Andrew: So, obviously, they've got the knowledge. These doctors that refer, they're actually quite comfortable with these specific herbal medicines. So, they've got to have some knowledge about them.

Rhiannon: Well, they don't... It's not so much that they know about the herbs in general, but they know a little bit about the research and they know from experience of working with Fertile Ground, we’ve been in Melbourne for 19 years now. And under the significant enthusiasm of our director Charmaine Dennis, we have a really, really strong collaborative bent. 

So, we do a lot of letter writing. We do a lot of presentations to doctors. We have a lot of meetings with specialists. We really...we... I guess, it's fair to say we're well-regarded and we've shared thousands of patients with the clinics in Melbourne. 

Andrew: Right.

Rhiannon: So, it's familiarity. You know, they know that if we're recommending it, it is safe, and they're comfortable with our expertise in the field that we wouldn't be putting their patients at risk.

Andrew: Okay. Now, I know this has got to be done under a situation of expertise. I get it. But are there any hallmark herbs that you might commonly use? And are there any caveats that you might put in there as well?

Rhiannon: For sure. There is... Going back to that premature ovarian insufficiency scenario, there is some research that shows us that Vitex is really beneficial for these patients. 

So, premature ovarian insufficiency from a pathology perspective is marked by low anti-Müllerian hormone, the old egg timer test as it's sometimes called. But low anti-Müllerian hormone and often high FSH is associated with low oestradiol. And we know from the literature that Vitex can help to improve that anti-Müllerian hormone, reduce the FSH, which helps to prepare a woman for IVF and improve her ovarian oestrogen synthesis.

So, Vitex is probably in a lot of ways the most useful herb for some patients, and then on the flip side, also the one that would be most likely to cause ovarian hyperstimulation syndrome in a patient if it was used incorrectly. So, yeah, both the most useful and the most controversial. And the one that a lot of doctors directly refer for and request, and also the one that a lot of doctors will say, "I don't care what you use, but don't use Vitex.”

Andrew: Right. Wow.

Rhiannon: Yeah. It's the best known and really it just comes back to, like everything that we do, just clinical insights and who it's indicated for, who it's safe for and who it is definitely contraindicated for.

Andrew: Yeah. Okay. So, I'm going to ask the next question. And we are non-branded here, but sometimes you have to stick to a researched extract. 

Rhiannon: Yes.

Andrew: So, can I ask, do you prefer fluid extracts? Is there a dosage consideration here? Because I understand Vitex can have a flipping effect if you use low versus high dose.

Rhiannon: Yes, absolutely. That's correct. And so, the research was done on a liquid form, but the important thing to understand about it is that it used a dose equivalent to 180 milligrams of dried fruit extract. You can either get that in a liquid form, which I'm sorry I've forgotten off the top of my head, it’s either 20 or 40 drops. And it's the same as the Ze 440 extract.

Andrew: Any other herbs of use that are safe, maybe in different conditions?

Rhiannon: Yeah. I definitely use a lot of the steroidal saponin containing herbs. In particular, there are indications of poor fertility prognosis and particularly poor IVF outcomes for women with low DHEAS and low androgens in general. 

And so, we have good research and clinically a lot of experience to know that Tribulus in particular is really beneficial in influencing endogenous levels of these hormones in a positive way, and other steroidal saponin containing herbs as well will do that job.

Andrew: Can I ask about the phytoestrogenic herbs that we use?

Rhiannon: Yes.

Andrew: What a bone of contention. Now, my understanding is that phytoestrogens are not oestrogen, and that in the normal amounts that is intaken even in herbal medicines they actually have a reducing effect, not an additive effect. Am I correct or am I wrong?

Rhiannon: Well, I think that really looking at it as a modulating effect is more accurate in that for those with low endogenous oestradiol, they may benefit. And a good example of this clinically, and you can see it quite easily with the use of herbs like black cohosh and hops, is that for women who experience a dramatic oestrogen drop just before they get their period, they'll often experience quite crippling migraines. And black cohosh and hops can really help because of their phytoestrogen content alongside phytoestrogens in soy, good whole soy foods can really help to improve their management of symptoms for this patient group.

We also know, there’s good research to show that black cohosh can absolutely improve pregnancy rates for women using Clomid for ovulation induction. So, women with PCOS and irregular or anovulatory cycles are given Clomid which helps to increase their oestrogen levels, but black cohosh alongside that increases pregnancy rates. 

So, it's a good oestrogen modulator. And I think probably also worth saying is that excessive oestrogen conditions such as endometriosis used in the right way, patients can also see benefit from that as well.

Andrew: Right. But, of course, I guess one of the caveats might be there's no little easy way to use a phytoestrogen to "block" high oestrogen if you've got polycystic ovarian syndrome. You really have to be looking at the weight and all of the other issues.

Rhiannon: Absolutely. Yes. And, of course, even for women with high oestrogen with PCOS, it's really prone to major fluctuations. 

Andrew: Got you.

Rhiannon: And, of course, the underlying mechanism underneath these hormone fluctuations is predominantly metabolic.

Andrew: Can I circle back to a few of the supplements that you mentioned?

Rhiannon: Yes.

Andrew: Any dosage considerations there? Like, CoQ10, I have a dose of 100 milligrams. Do you go higher, or is that around the dose that you use?

Rhiannon: No, I definitely go higher than that. 

Andrew: Right.

Rhiannon: We have some... We were using it for years before this because, of course, if we waited for research to come then the benefits that the patients got could be well delayed.

Andrew: Yes.

Rhiannon: But a couple of years ago, I think it was 2018, a research paper finally came out. We'd all been using CoQ10 for ages. But a research paper finally came out showing that the dose of 600 milligrams helped to improve egg quality, ovarian response. So, it does help to improve egg numbers for women with poor numbers in the past, as well as pregnancy rates. So, that 600 milligram dose of CoQ10 is actually what we're using in the three-month preceding and during the stim cycle.

Andrew: Got you. And sorry to harp on about this, but is this the CoQ10 ubiquinone or the newer ubiquinol which has less research?

Rhiannon: Yes. So, interestingly, the research was conducted on a very poor quality commercial brand Coenzyme Q10 that absolutely was not ubiquinol. So, we know that even in that less bioavailable form, it has a clinically significant benefit. What we, of course, assume from other research around plasma concentration with uniquinol is that the benefits would be greater. 

However, it's extraordinarily expensive. So, I will tend to use a combination in an individual, ensuring that they're on the 600 milligram dose, but using the best version of ubiquinone that we have found available to practitioners, which importantly from our perspective is oil-based rather than powder, for bioavailability. And then alongside that, a little bit of ubiquinol. But that is unfortunately often heavily indicated by the depth of the patient's pocket.

Andrew: Yes.

Rhiannon: It's a really expensive supplement to take 600 milligrams of every day. And I'm not sure it's necessary.

Andrew: Well, the lion's share of research is on the ubiquinone. You know?

Rhiannon: Exactly.

Andrew: So, any other supplements that we can consider to be safe? I'm very mindful of putting caveats in there. I guess I'm also very respectful that you guys have got extensive experience with this. And it's not something to be trodden lightly to go, "Ah, I'll just use a little bit of this." I don't think that's appropriate. But I guess there's also patients out there that may not be able to make it to Melbourne.

Rhiannon: Yes, indeed. Well, I can say, there's many good practitioners around the country that also have experience in this. But in general, I think it's fair to say that some of the basics are really integral, ensuring that the patient is on a quality multivitamin that you use in your clinic for skills to ensure that their methylation is working properly. 

If cellular methylation is not effective, then of course, that really rapid and integral DNA replication, especially for sperm, but also the egg maturation isn't contributing to optimal gamete quality in the individual. So, just really getting the basics of that with your B vitamins. 

Both for sperm, as I mentioned before, but also for eggs, essential fatty acids are integral. So, both the quality supplement form and also ensuring that from a dietary perspective, their ratio of fat is as optimal as it possibly can be. 

Vitamin C, as I said, in relation to sperm, primary antioxidant in seminal fluid, but also a key antioxidant in follicular fluid around maturing eggs. Beneficial for everybody except for those, especially guys, with iron overload or hemochromatosis. 

And, of course, zinc both for men and women, really essential aspect of both sperm and egg quality, and also hormonal expression.

Andrew: You know, you said something really interesting there. Good old zinc. And we've mentioned methylation before. I notice that a lot of the enzymes which convert our sex hormones have common pathways, zinc, B6 and magnesium, common substrates. Can it be often as simple as just adding in these very simple, cheap supplements?

Rhiannon: Yes.

Andrew: Or is it that you guys just deal with the really complex cases?

Rhiannon: In some cases, it really is just that simple, especially if you're getting a young patient and in relation to zinc, a young patient with an inherited tendency to very poor zinc management, as in they excrete their zinc excessively or a patient with a low-zinc diet. 

So, I'll see a lot of young women who are predominantly vegan with poor egg quality. And it is as basic as her nutrition is not supporting egg maturation. And some zinc and essential fatty acids and some B12 will make a remarkable difference. And in three months, she is successfully pregnant after having been unsuccessful in trying for a year or so. 

So, sometimes, it really is absolutely that simple. And our basic clinical skills can't be overlooked from that perspective. And also, of course, often these are the things that haven't been assessed for the individual medically.

Andrew: Of course. Now, I've got to ask. You and your colleagues at Fertile Ground have recently published a book. Right?

Rhiannon: Yes. Indeed, we have.

Andrew: Can you take us through this please? Because I think this is going to be really interesting for so many practitioners out there.

Rhiannon: It was a real passion project for Charmaine and also my colleague Jennifer. We worked on this book for a good six or seven years. And to be honest, if it was up to me, it probably would have got dropped by the wayside after two years. But if it wasn't for their drive and passion, we wouldn't have gotten here.

But it is a preconception care book. So, of course, Francesca Naish's excellent resource has served us all so well, and is still very relevant. But we thought that it was time for a bit of a clinical and scientific update on that because, as I said, there's so much research that's come out. We have 200 literature references in the book itself. So, it's very, very evidence-based as well as clinically relevant and informative and practical. 

But because of that evidence base, we've had a really positive response and uptake from the specialists that we work with. So, we have a few of them selling them in their own clinics. We have been hosting book launches for us, which is really, really great. We've run a couple of book launches ourselves, and different specialists from Melbourne have attended just in the audience and also have come to present on invitation.

But, yeah, it's been really well-received. And I guess, more importantly than all of that, we released it in September, October last year. And most importantly, it's been really well-received by patients, the number of patients that read that book. And for me, clinically, it takes that arduous aspect of working in this field out of clinic. I don't want to have to go through plastics in everyone's kitchens, plastic lining of cans, washing your hands after you touch receipts, your personal care products. I don't want to go through that all day every day. And my job, it's exhausting and repetitive. But now, I just get to give them this book. I say, "Read this." And then…

Andrew: Page 16, 23...

Rhiannon: Exactly. Exactly. "And then come back and we'll talk about what is relevant for you." And patients have been amazing. They come back with sticky notes all through the book. They come back with questions. They're like, "Oh, it said this or that. This might be an indication of thyroid issues. What do you think about that with me? I'm really interested to hear what you guys said about sun exposure," etc. They're really enthusiastic and embracing it. And it's, I think, fair to say it's kind of changing people's behaviour and, hopefully, lives, if it's not an exaggeration to say that.

Andrew: Well, it isn't. In fact, you guys have done exceptional work in bringing not just, helping not just the patients' lives, but obviously creating families.

Rhiannon: Yes.

Andrew: I have to ask the devil's advocate question here, Rhiannon. And that is, what do you say to those people who say that complementary care has no place in IVF?

Rhiannon: I would just say, just read the journal Fertility and Sterility. It's not a crazy left-wing idea, a left-field idea. It's actually conventional from a science perspective. And the evidence is absolutely in now, without question. So, it's become much, much, much easier to field those questions and dispute that these days. 

In defence of doctors, if I may, I think that a lot of them are… I think that they're generally aware of this. And whether or not they embrace it in their clinic or they just are aware that the science is in, is different. And then on the flip side, if I go back and say, back to male patients, there's often a real resistance amongst them to believe that this isn't a crazy idea that their partners come up with. 

But now, because of the evidence, it is just so easy to go, "I'm sorry buddy, but you're just not right about that. You're just going to have to listen to me and the world scientists on this.”

Andrew: Rhiannon, you often present on the subject of collaborative management for fertility patients. Why is this so important in this patient group?

Rhiannon: Yeah, it's particularly key, it's fair to say, I think, for this patient group because of those things that we discussed, the potential contraindications and interactions, and also because of the high potential benefit that these patients experience from complementary care for their IVF outcomes. 

But also, because we know from some research that was conducted about eight years ago now in Melbourne that about two-thirds to three-quarters of individuals accessing IVF in Australia also access complementary care. So, patients are choosing to see us.

I think even in general practice these days, particularly naturopaths and traditional Chinese medicine practitioners are very likely to see patients accessing some sort of assisted reproductive treatments. And it's really important for our recognition as a profession, and our professional recognition as a profession, that we are communicating this with our patients as well so that they understand that we are competent and coherent, I guess, in this field and that we are of genuine value.

A good opportunity to emphasise your usefulness to a doctor is when you're working with a patient with metabolic issues or weight issues. They are often the bane of the doctor's life because they really don't have any answers for improving this patient's outcomes, even though it's clear that the weight is an issue. 

And so, when you have success with those patients, doctors are really, really grateful. And then you'll find, if you're not careful, that you'll start receiving a lot of referrals for patients who need to lose 20 kilos. For better or for worse, you get what you're good at.

Andrew: Yeah.

Rhiannon: But yeah, just to help to improve our profiles and really importantly for patient confidence. Because they're a really, really, really anxious group.

Andrew: Absolutely. Well, Rhiannon Hardingham, I've got to say, the testimony of your genuine value and your group at Fertile Ground is because you have indeed helped thousands of couples to have families. 

Rhiannon: Yeah.

Andrew: And so, working, as you say, in a collaborative environment — thankfully, in a collaborative environment — you know, these patients are getting the pinnacle of both medical and complementary care. And you're doing brilliant work in helping people not just with creating families, but actually helping their general health along the way. So, thank you for joining us on FX Medicine. You've done exceptional work.

Rhiannon: Great. Thank you so much, Andrew. It's been a real pleasure.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.


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