Shweta Mishra: Hello everyone, it’s PCOS awareness month and today we are talking about Managing PCOS Symptoms with Acupuncture. I am Shweta Mishra and I welcome you all to this PCOS session on CureTalks in association with PCOS Tracker app. Today, I am honored and excited to welcome our guests Sandro Graca, a lecturer and published researcher in the field of Menstrual and Reproductive Health, fellow of the American Board of Oriental Reproductive Medicine and one of the Directors at Evidence-Based Acupuncture. On the patient panel, we have PCOS advocate, Tatiana Alafaouzo PCOS Warrior who is also a PCOS researcher studying Mindfulness Based Interventions in PCOS Management. Sandro and Tatiana, thank you for joining us today. Welcome to CureTalks once again.

Tatiana Alafaouzo: Thank you for having me.

Sandro Graca: Thank you so much for having me.

Shweta Mishra: My pleasure. Sandro to begin with we know acupuncture has been around ancient times about more than 3,000 years and although, there are controversies surrounding this among several groups it is growing in popularity in the western world. And there is evidence that in women with PCOS, it helps improve ovulation. So, before we delve into the PCOS management, or by using acupuncture, could you please give us a little bit of a background about the procedure itself and what is the scientific basis for acupuncture and how is it performed?

Sandro Graca: Yeah. Well so thank you very much for having me here. This is the first question and probably the one that we get most as well as clinicians because as you can imagine because it’s something different and that people are not used to, people want to know how does it work and what can it do for me? So luckily for me and hopefully for you as well, is the fact that in the last few years, I have been involved with evidence-based acupuncture. And one of the things that we do is try to simplify the language that we use to explain how it works, okay? And for example, one of the things that we always is prefer people to make it clear so that it’s easier for us to explain is does it work compared to what, or when you explaining to someone how it works we kind of want to know what your background because if your background is medical and it’s going to be really easy to explain it but if not. But for example, if your background is from biochemistry, that’s also going to be really easy to explain but in a different way. So, basically, we start by saying that people will know that acupuncture involves the insertion of needles in specific points in the body. And the reason why those are specific points in the body is that we know now from research, what happens at those particular points and this is where the biochemistry comes into play and we know now that these points because we’ve seen this through MRI, we’ve seen this even acting on brain function as well. We know that those are places where you can really activate the homeostatic functions of the body. And what you have in those points is the release of biochemicals so things that will be involved in people would have heard this thing in the last while, for example with cytokines, it’s been a big thing over the last couple of years because of what happened. And at the moment we are at animal studies with that. And knowing that in some of those specific points, you actually get a big release of cytokines which would be really good if you’re trying to fight inflammation. Other things that we know from the points, for example, is the analgesic part of it, and that is just the communication through those nerve fibers up and down all the way to the brain, and that will get that release of chemicals, for example, to give you an idea of how you can insert a needle some are do something in a particular part of the body and something else happening without you knowing or without you interfering in the clinic, I always explain what the orthopedic surgeon does with a little hammer and comes near your knee. And when they hit that particular point, your legs going to move, there’s nothing you can do to stop it from moving, it happens, right? So, these functions that happen in the body. If you want to tie this in then with menstrual And issues and I would get too near to the Pcos, there’s a lot of blood flow as well it involve not only just on the location of the needle where we would be doing the acupuncture points but also through that parasympathetic and the sympathetic nervous system. So, release of hormones, regulating the hormones that should be there or if there’s not enough of or too much of, so we can explain it at that biochemical level. And the reason why those are those specific points in the body, that would be connected through the nerve fibres, is that we know that at those, it’s going to be stronger. So that’s why we pick those.

Shweta Mishra: Right. Interesting. So, it’s the procedure itself painful. And how long does the pain persist and I just wonder you mentioned that electric acupuncture as well, how much current to use in those?

Sandro Graca: Oh, yeah, that’s interesting. And I’m glad you asked that because we love what we do so much we never even think about that because for us is just normal.

Shweta Mishra: Yeah. But I’m just asking from the perspective of a patient, right?

Sandro Graca: So yeah. That’s a very good point. So, here’s the thing for someone coming into the clinic for the very first time, the experience of getting the fine needle going through the skin, is the equivalent of like, if you pluck, like three or four hairs at the same time that pinch from it, that’s pretty much what it feels like. I can tell you one thing; you can make it more painful if you want to. And I always give the example in the clinic, if someone is choking and I pretend that I’m going to punch your arm, if you leave it, nice and relaxed, it’s going to be nice and relaxed, but if you tense up then there’s going to be more going on. So, this is part of the treatment, you go in, you’re lying down, we talk to you for a while and you are as relaxed as you can be, sometimes that might not even be possible, right? Because you are tense so we tried to get you as relaxed as possible. So, the needle itself going through the skin again, we help with that too. So, you will feel something like plucking a couple of hairs at the same time, that’s the pinch that you get. With the current, it feels like a muscle twitching. So, we talk about the current that goes past the needles and again tying it in with PCOS a lot of that is going to happen around the belly button area because of the local points and where the ovaries of uterus would be, there’s a lot of tissue there, so you feel the equivalent of a contraction of a muscle, if you ever noticed that you relax the muscle is still twitching and you can’t really stop it. That’s pretty much what you feel.

Shweta Mishra: Exactly. So, that gives a better idea about it because whenever you talk about needles, most people are afraid, right? So that was an important question to ask. You mentioned about talking about PCOS now. So, how does it actually work for PCOS and what are the specific points in the body that are of special interest to you when it comes to PCOS management and do these points change on the basis of what symptom of PCOS you’re treating?

Sandro Graca: Yeah, that’s a great point. So, again, great question for those that haven’t been to the clinic ever before and it’s one of those things that we answer either by email or at that first time coming into the clinic. So yeah, thanks for asking that because those are the really, really clarifying issues. So, I’ll start with the do the points change. Yes, they do. And that’s very, very easy to explain why because so do your hormones and so, does your menstrual cycle. So, the points will change depending on what’s happening with you, right? So more likely, you will come to the first treatment, I’ll try to explain this way will probably make a little bit more sense in the way that things work out. You come in for the first treatment, it doesn’t really matter what stage of the cycle you are at because at that first treatment, we really want to get as much information from you as possible and we want to have a good idea what the diagnosis is and how we’re going to follow through with the prognosis. Because remember and Tatiana is here. And she knows that I always like to joke about things and people often ask me, do you treat PCOS? And I’m like, no and they are like, oh but I heard that you are the PCOS guy or you treat PCOS and I’m like, no, I treat symptoms of PCOS but as for treating PCOS well I have no idea what you mean by that. And it is really like getting a sense from the person in front of you to find out what is the main issue right now, right and what is your goal because as you can imagine a lot of the times the goal could be because they’re trying to get pregnant and we have to accommodate the treatments around that. So, to start the treatment we would always try and get as much done within the first half of the cycle as possible because we’re trying to get through to ovulation, that’s not to say that there won’t be any treatments after there might be, but definitely less. So, the focus will always be more at the pre ovulation stage because we want to go towards that and points in the body you will have like just really random and just taking kind of like a sample from what we do even with research and then comparing with the clinic, definitely local points belly button area, below the belly button, what you can think of, where if you were to look inside with x-ray eyes, where the uterus would be, where the ovaries would be mainly because we want to get as much blood circulation there as possible, okay? Points in the legs, points in the legs are really, really important and that’s because of, as you know, that’s where you’ll find the metabolism points. So, points that are more related to metabolic system will be down the leg. So, we really want to go at those as well. And yeah, when you’re starting to come to the upper part of the body, I will use the points in the arms as well and those will be more psychologically related as we know that is also a big aspect of PCOS for some people. Yeah, so I will, also use some of those more calming, more relaxing, but that would be more upper part of the body.

Shweta Mishra: Sure. Thank you. Thank you for that. Just one more question before I invite Tatiana to the discussion, is there a way to predict to some extent if not only that the acupuncture procedure will work for one particular patient and will not work for another one. Is there any criteria that you look for in a patient to measure the success rate?

Sandro Graca: So not specifically, but I do, okay. And so, here’s the thing, just because there will be, I’m sure there will be people because I will share this with everyone there will be people that I’ve seen me in clinic and then I’m seeing me talking about this as well, I do, because I always say to everyone that it’s going to depend on the patient a lot. And I know it’s not fair to say that but I’m not going to ask too much. But remember you’re going to be with me in the clinic a few times a week. Everything else that you do around that matters too, right? So, I always say predictors for how long this is going to take are obviously past history, how long has this been going on for, and if someone is coming to me, obviously our do any clinic and they’ve been on the pill for a long, long time that’s going to be a little bit more tricky because the hormones have been suppressed for a long time. Could have been for a reason, which a lot of the times because of skin conditions, or there was something going on with the cycle. So, I would always try and give the expectation of at least you’re going to have to do the treatments, at least for the length of folliculogenesis. So, what that means is the length of time that it would take for a follicle to develop, grow and be ready to ovulate and that we always know that will be around three menstrual cycles. So, if someone is coming to me and say, well, my cycles are very long, are normally more than 40 days, I’m not going to say to them three months because their cycles might not be three months, might not be 27 to 29 to 30 days. So I’ll say, I want to get at least two good proper cycles that  you know what’s going on from bleeding is pretty normal and okay and manageable for you, you know when you’re ovulating, we know that the cycle is good. Once we get to the third one, then we get to talk serious. And then I’m on, okay, this is on cycle is regulated now, now what’s going to happen next? And remember I’m saying this because a lot of the times I get these people in the clinic is they’re trying to get pregnant. So, my predictors are always how much you can do and treatment dosage. So, if someone can only come in once a week, that’s going to be a little bit more tricky if they can come in two or three times a week, then that’s going to be a better prognosis within those three menstrual cycles.

Shweta Mishra: Thank you, thanks for sharing that Sandro. With that now I will invite Tatiana to the discussion. Tatiana, you were diagnosed in 2004 and you’re now a researcher focusing on complementary and alternative therapies for management of PCOS. And I know at some point in your journey, you have used acupuncture, would you like to share your experiences a bit before going on with your questions?

Tatiana Alafaouzo: Sure. First of all, Sandro, I’m really excited for you to be here so thank you. Yeah, I have used acupuncture haven’t used actually specifically for PCOS sometimes I might not be the best person to ask for that but I found it to be really great and really awesome. I actually it’s funny when Sandro was talking about the actual procedure for acupuncture even I haven’t done an electric acupuncture, I found that you could definitely feel when the needles were being inserted that something was happening. So, it’s almost like you definitely felt, I don’t know if I personally if I could describe it, I felt it almost as some kind of like electricity flowing through you, even though it wasn’t electroacupuncture, like you could almost feel like something is happening. I don’t know Sandro, how would you describe that for a more professional point of view?

Sandro Graca: Well, that’s a very good point that you’re making there and again, I’m sorry that it’s almost like I’m not the best person to describe it because for me, it’s just like, oh, I love it. And for me it just feels like puffy clouds and butterflies but be spot-on about talking about electricity because think about it, there is electricity enough, right? Like we have that that impulse inside us. And when you hit the funny bone, what does it feel like, right? So, hitting some of these sensory nerves does feel like electricity. So, when you’re using the acupuncture needle, just by the way, sometimes you can stimulate some of the points with pressure that’s what you hear about acupressure. So, it’s pressure on that acupuncture point. The thing with a needle is that you’re going deeper and you really going to get to that sensory fibre. So, sometimes yes, there is no way that some people might describe it as it feels like a little bit of electric shock, but it’s that temporary. And if you want to call it or making it like a visual for other people to understand when you hit the funny bone and you get that tingling sensation, that’s sometimes, what you can get from the needles.

Tatiana Alafaouzo: Yeah, I definitely did feel like that, and I will say that I think I went first more kind of a stress management type thing, and it definitely did help for that. And also, I did not hurt Shweta for at least.

Shweta Mishra: Good to know that.

Tatiana Alafaouzo: Definitely did not hurt for just Sandro’s description of pulling a few hairs was definitely fairly accurate. It was not, the needle insertion was not painful, but I did find what I found was for me, what was the most interesting was, despite the fact that there was like, no actual electricity, it was like you did feel like some kind of almost like vibrations moving throughout you almost what they were doing. And so quite interesting.

Shweta Mishra: Good to know that it worked for you, right, and you felt better after that.

Tatiana Alafaouzo: Yeah, definitely. I definitely recommend it to anyone. I think, yeah. And it definitely has been proven within the research. But my questions, Sandro are bit more specific to how you do things within your clinic, I hope that’s okay. So, my first question is just what are the most common PCOS symptoms that your patients can come to with?

Sandro Graca: Okay. So, full disclosure as I said to you and my introduction to the PCOS world was because of working with IVF clinics and that would be as far as I can go back and think about it that was my first contact with someone coming into the clinic and saying that I was diagnosed with PCOS and then from that point onwards just developed into as you know I’m a bit of a geek and that nerdy stuff going around, all the hormones and everything that is happening, really got me excited. So, the most common symptom if you want to call it that way, or at least the reasons, why people come to the clinic is because either they were told by their fertility clinic or they have been trying to get pregnant and they realize that their socks are too long or too short, normally more likely to be too long and there’s something going on that they’re not quite sure if they’re coming before actually visiting their endocrinologist or visiting their gynaecologist but they don’t know exactly what it is just yet. And it always goes back to that menstrual aspect of it. So, there’s something going on with the menstrual cycle and/or they’re trying to get pregnant and it’s not happening. And lately and things have changed in the last while you do see more of that psychological impact that it has as well and again we know this from research and people saying that it’s taking too long to get a diagnosis, no one is saying for sure, it’s this or it’s that and you go from one clinician to another clinician and you still have the symptoms and it’s impacting you, right? But for example, from the array of symptoms that could come with PCOS, I don’t really tend to see for example, skin conditions because that tends to be more skin specialist, that person would look after. So, basically, I would say yeah gynaecology, menstrual and the ones trying to get pregnant.

Tatiana Alafaouzo: Great. Thank you so much and do you work with these other clinicians and other disciplines in order to best help your patients? Like do you have like direct contact and communication with them?

Sandro Graca: Yeah. So, first and foremost if it was just me and if it was just me trying to fix everything with acupuncture and that’s never going to work out because there’s so much going on that it’s not possible and even if it was possible, it would just take too long and these people don’t have that amount of time. Another example would be if you have, for example, low back pain, which is one of the things that acupuncture has been the most studied for and it’s within guidelines and its use in hospitals and everything. Yeah, you can do acupuncture only but, if you do some physiotherapy and you look after your body, you’re going to get there way quicker, right? So, working with other clinicians is super important. So, there’s two things here. First of all, is I have to work with some of these clinicians if this patient is being referred by the IVF Clinic, because technically and this is the way that I like to see it they’re not really my patients, you know what I mean, like I love being in clinic, I love seeing people, I love chatting, I love helping them, but I always say that well I’m just here, like I’m just a piece of the puzzle. So, that is super important because the other aspect of it is I and  Tatiana you know that I am superb and a great clinician but I still don’t have x-ray eyes so I can’t see what’s going on inside them. That would be the next level, I guess, of supreme clinician, or research or whatever. But yeah, I need to know what’s going on. And again, it’s just for a matter of how much time is it going to take? So, I can go around and try different things or change my dosage or change my points, and try, or I can just go hey, this is taking a little bit longer than I was expecting, can you just check with your consultant? Can you do bloods again and just see what’s going on. Or if someone is coming in and they say, well, I did a scan a few years ago but they weren’t sure if it was PCOS or not. I always go, well, can you do one now? Because that would be really useful. So having that multidisciplinary approach, which is even now part of the guidelines for PCOS, and diagnosis and management is super crucial because the technology that is available to see what’s going on with these women is phenomenal. And it’s so so important to get to that diagnosis and then the treatment quicker and more efficiently so that we get them through this as quickly as possible and more efficiently.

Tatiana Alafaouzo: Absolutely. And how would your, I mean, you kind of hinted to this earlier with the different points, but how would your acupuncture practices differ with each symptom, with each of the PCOS symptoms?

Sandro Graca: So yeah, that’s interesting because I kind of answer that question almost every time with every patient, every time they come in, especially when they go through their initial menstrual cycles in the clinic because very, very quickly, there is a difference and I know if you experience this or not but there will be a difference between you getting acupuncture before ovulation versus you getting acupuncture after ovulation. And the reason being is that after ovulation there’s more progesterone and I know that I don’t have natural cycles, but I have to experience that after ovulation progesterone makes you a little bit more cranky. And so does your skin, right? So, when I get someone in for their first cycle they will always and this is interesting because this dialogue actually happens in the clinic and I promote this dialogue as well because they will go, if the points are the same they will say that feels different today. Like for example, blood movement, related point or even points on the belly tend to feel heavier and heavier as you get closer to ovulation and you can imagine why it’s that build up, right? You kind of start to visualize, I’m very visual anyway, so you start to visualize what’s happening inside. There’s more the ovaries are bigger, there’s more fluid retention, there’s the follicles are there everything is moist at the build-up before the ovulation. So, everything feels heavier when they’re getting that, those treatments before ovulation. After I always joke that after ovulation that’s the easy part because that’s going to be nice and easy going and, we’ve got to ovulation, we’ve got half way there, right? But do the points change? Yes, they will. So, for example, one quick change would be after ovulation, I don’t have the need to go at so many points around the belly, and ovary area, because that’s done now, right? So, at that stage, I can focus more on metabolism, right? If they are trying to get pregnant and if they’re actively trying, but I might actually be trying to promote, or look more at uterine function because that will be important if they are trying. So, the points will very little bit. So, you might have, for example, just quickly thinking, first treatment of the cycle after bleeding stops, you might get or even during bleeding, you will definitely get more points around the belly area. That’s for sure. The belly button down to the synthesis pubis and over to the side and hip kind of area, you’ll get more points there because that’s really trying to move there. As you get close and you will still have points on your legs. As they get closer to ovulation, you’re probably going to get more points on your legs and then some still of those on your belly, after ovulation, you’re probably going to get only a few in your belly, going to get more arms and legs because that’s definitely looking more at calming things down, uterine function and metabolic system.

Tatiana Alafaouzo: Very, very interesting. Thank you so much and I know that you said that you do believe in multidisciplinary approach in your practice. So, do you, how do you go best go about that? Do you ask about background information and such as diet and quality of life and exercise? And how do you if you feel that your patients are maybe not touching all of those aspects and do you refer them to people who perhaps could help them in those different aspects?

Sandro Graca: Yes. Answer to all of those is absolutely yes. Because so remember the question about what’s the prognosis and how long could it take, if you are not doing any of those things, it’s going to take a long time, right? So, I always get to patients informed a little bit like this is you, we’re only here to help you and to guide you. I’m not a nutritionist, I’m not sitting in the clinic as a nutritionist but I can imagine that as a nutritionist, as a physiotherapist even if you go to the gym and you have someone helping you, there’s going to be a much different result if you follow the advice versus if you try to do it by yourself, right? It’s just going to take more, you might get there, but it’s going to take you more time, right? So, I always make it very, very clear that I’m not pushing anyone away from the clinic, obviously, but I always say, look this good if you are able to do this because remember those where I practice, also come with the financial implication because you might have if you have health insurance or how many of these treatments can you afford, but for sure it’s going to make it so much easier if you have that team around you. We know the issues with, it is a metabolic condition, right? So you need that help and same to someone that you need to exercise, what is that, you need to eat better, what’s that mean? Everyone is different right? So, we have this almost like going to use the cliche of individualized approach, but specially in the beginning, it is individualized, there is no other word to use it. We need to find out who you are, what you’re doing and by the way, what works for you because if you want to take it away from PCOS and say, oh, I want to go in one year’s time, I want to go and run the marathon, but I have a really, really busy job and I only have like one or two hours a week to train. I’ll be like, well that’s going to take longer than you being prepared in one year, right? So, you have to be really realistic with what they are doing, if they’re coming from the IVF clinic, what’s your treatment schedule? What are we looking here? What does your clinician want to do? Are you going for IVF? Are you going for pixie? What tests have you done so far? What medication you were on before? What medication do you need to be on right now? So, this is way easier, even though like during the introduction you heard about being a fellow of the ABORM, even though we know these things and we study, and we have to do the exams on these things and we keep updating with CPDs on these. I’m not going to be as quick to think exactly what those mean compared to the clinician the IVF clinic. So, it’s way easier for me to just send an email and go, hey, I have patient X here with me and what exactly is your plan? What can we do? Sometimes, we might ask for, can we get an extra cycle with this person, right? Can we get this person to go, by the way I don’t know about where you practice or the people that are hearing this but the clinic that I’m involved, the most actually has counselling support for the patient as well. I might say, hey this patient could really do with some counselling support if they’re not getting it right now, can you arrange that through the clinic? So having all those tools it’s so much easier and being able to communicate with these different consultants and these different the endocrinologist, the nutritionist, the gyneacologist, it’s worth gold. I would not be able to do what I do right now if it wasn’t for having all these tools around me.

Tatiana Alafaouzo: Absolutely. And my last question is kind of akin to so much what I’ve asked earlier but it’s do you use particular measurements or forms or questionnaires to track the improvements of particular symptoms? This kind of goes into, the geeky research side.

Sandro Graca: It does. But you know what is super interesting about that question is, I’m not surprised that it comes from you who is also into research. And because none of this is really, really serious because before I got really into research, I probably wouldn’t really pay much attention to that type of question and more so to what, actually answer that question. So, you know a little bit about my ideas for research and what I’m involved with at the moment and obviously can’t say too much about it because it’s nothing official just yet, but hopefully in the near future, one of the main things that I’m super interested and I do this in the clinic now is patient centered outcomes. I’ve done enough and I actually have one of my slide presentations that I do inspired by a colleague of mine who at the time of that of preparing that slide, he was the President of the ABORM and he always has this thing that he says to us, you treat the person in front of you, you do not treat the lab results. If the lab results say the person is fine and the person is telling that they’re not fine, you don’t go well but the lab say you’re okay. So, what can what else can I do? So that was kind of like it’s one of those names that I have as part of my presentation and it’s something that I’m really, really passionate about and it’s what my research is focused on. I want to know from the patient, what is making a difference because I might have the best treatment in the world, that acupuncture points might be amazing. And it might have a procedure that would really work for them. But if they’re not comfortable, if it makes it harder for them to come into the clinic, two or three times a week, if it’s not facilitating their life and what they actually want as an outcome, I honestly don’t want to be doing it. I want to make sure that they are enjoying the process, , and sometimes as you said you might feel a bit more from the needles or if you’re trying you might have had another failed or not pregnant and you get today one again those are tough to deal within the clinic but I want to make sure that my outcomes are guided by the patient, was your cycle better? Is your skin better? Are you sleeping more? Are you sleeping better? Is your energy better during the day. Right? We know that energy levels are one of the issues with these people, right? So I don’t want to just to be about my lab results or scans or the cysts are now gone or my cycle is now better but I still don’t sleep or I still have the slums with energy during the day. I want my outcomes to be patient driven so that’s my passion and I think that I better stop talking about my passion because I get too loud, too excited without considering what to do…

Shweta Mishra: Absolutely. Thank you. No, that was very Illuminating to listen to you both. Thank you, Tatiana.

Tatiana Alafaouzo: Love that passion is amazing. We love it.

Shweta Mishra: Yeah, I know we are a little short of time. I have a couple more questions before we wrap up. What I want to understand is can acupuncture have any side effects and what are the common side effects that people who are dealing with PCOS should expect?

Sandro Graca: The one side effect that you can say straight away will be, you can bruise. For example, if you move with the needle, when you’re resting but again kids get acupuncture points needle and they move all over the place, and it’s okay. So, yeah, bruising can be one of the bruising is one of those that you hear about all the time. The points we need to be careful obviously to stay away from, any larger veins and arteries. So, side effects from it, I’ll tell you what my side effect is. So, my side effects from acupuncture is on the days that I get acupuncture, I can stay up late geeking out about research because I get really sleepy and my body tells me to go to bed at a normal time. So, all the other days of the week I could cheat on my body and go one more hour and just read one more sentence, write one more paragraph but on the other days I can’t do it. My body goes like no, sorry, side effect is go to sleep and rest now.

Shweta Mishra: Yeah, that’s not really a side effect. Okay, go ahead.

Sandro Graca: So, no, the only thing that you would hear would be like, really obviously, you’re talking about professionals doing the procedure. And yeah, sometimes that could be a little bit of a drop or two of blood, from where the needle was during the treatment, that can happen and bruising would be the thing that you would hear to the most.

Shweta Mishra: Okay, thank you for that. And that brings me to the question. How do you choose a qualified practitioner and a good acupuncture clinic? What is the first question that, what questions should you ask before your first session to a therapist?

Sandro Graca: Oh yeah, what question should I ask? You see, I’m sneaky. So, I would probably say something like, do you treat PCOS? And if they say yes, yes, I do. I’ll be like, okay, so what do you mean by that? But that’s me because I’m sneaking. And okay, so how do you pick a clinician? Let’s go with that first. So, first and foremost, make sure you talk to your clinician, apart from the referrals that I get in the clinic, the other majority of patients come to me because of word of mouth. So I then end up seeing, someone’s sister, someone’s friend, someone that’s been to the clinic but and works with someone who’s going through the same situation. So, word of mouth is a big, big deal. So, always ask questions and by the way, that links to something else, which is Tatiana does a lot of this work and you do too by doing these interviews, you do this work, talk to people, make sure that you share your experiences, you’re not alone. There’s going to be someone out there going through the same situation. So, ask and find a clinician that the first you want to know are they registered? Are they insured? Because a lot of the times that also means that you will be able to claim some money back from that treatment too depending on where you are. So, you want to make sure that they’re registered, they’re qualified, they have to be registered and if they are insured, or if that insurance means something to you, great. And then look for specialization in sense of you could go to a generalist acupuncturist, the thing is no disrespect to any of them. I’m at a conference now, and I spoke about this a GP, a General Practitioner might find the same problem that any other specialists will, but the specialist will find it quicker. So, if you drive a BMW and you take it to the garage, that does all types of cars, they probably will find the issue. But if you take that BMW to the BMW guy, he will still find it straight away because they’re used to it. That’s what they do all the time. So, find one like for example, what you said about me being a fellow of the ABORM, that’s kind of like internationally really really well known as like the pop because of the training and the exam to do it and my advice would be get to talk to the clinician before you actually booked at first appointment.

Shweta Mishra: Thank you. That’s awesome information and very useful. It was a great session. Both of you thank you so much and I know there is so much more to learn about this, how acupuncture can help folks with PCOS but I’m glad we were able to touch upon most of the important aspects of it. So, thank you. And we will make this talk available on curetalks.com and until we meet next time, we have more stuff to discuss. Thank you, everyone and have a great day.

Tatiana Alafaouzo: Thank you so much for that.

Sandro Graca: Thank you. Thank you for the opportunity.