No one can be blamed for infertility.About one-third of infertility cases can be attributed to male factors, about one-third to female factors and the remaining one-third of infertile couples, infertility is caused by a combination of problems in both partners.
The most common causes of infertility are:
- Ovulation problems
- Tubal factors
- Sperm problems
- Unexplained infertility
- Female age related
- Egg quantity
Less common causes:
- Uterine problems
- Previous tubal surgery
- Previous vasectomy in males
PCOS, short for polycystic ovarian syndrome is a common cause of anovulation. It is also sometimes referred to as PCO (polycystic ovaries) or PCOD (polycystic ovarian disease).
Woman with PCOS:
- Do not release an egg (ovulate) regularly
- Have ovaries that contain many small cystic structures, about 2-9 mm in diameter
- Have excess hair growth
- May have pimples
- May have infertility
The good news is that the chance of getting pregnant with polycystic ovarian syndrome is very good. Treatment for PCOD depends on the patient, her age and marital status.The specialist and the patient will decide upon medical or surgical management (PCO Drilling) depending on these factors.
Blood tests like day 3 follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), AMH, prolactin, progesterone (P4), thyroxin (T4), thyroid stimulating hormone (TSH) will be required for a complete fertility workup.
History of recurrent miscarriages (2 or more miscarriages) - lupus anticoagulant (LAC) and anti-cardiolipin antibody (ACL) are often done, as well.
FSH: Follicle-stimulating hormone (FSH) helps control a woman’s menstrual cycle and the production of eggs.For women, a FSH test is done on the third day of the menstrual cycle and is used to evaluate egg supply. For men, the test is used to determine sperm production. Estradiol: Estradiol is an important form of estrogen. An estradiol test is used to measure a woman’s ovarian function and to evaluate the quality of the eggs. Like FSH, it is done on the third day of a woman’s menstrual cycle. Luteinizing Hormone: In women, luteinizing hormone (LH) is linked to ovarian hormone production and egg maturation. Serum Progesterone: Progesterone is a female hormone produced by the ovaries during ovulation. It causes the endometrial lining of the uterus to get thicker, making it receptive for a fertilized egg. AMH (Anti-Mullerian hormone levels): Blood levels of the hormone AMH are often used by fertility specialists and gynaecologists as part of the evaluation of ovarian reserve and the response of the ovaries to stimulation with injectable gonadotropins (FSH).
The table below has AMH interpretation guidelines from the fertility literature and from our experience. Do not get carried away with the cutoff values shown here. For example, the difference between a 0.9 and a 1.1 ng/ml test result puts a woman in a “different box” in this table – but there is very little real difference in fertility potential. In reality, it is a continuum – and not something that categorises well.AMH Blood Level: 1. High (often PCOS) 2. Over: 4.0 ng/ml 3. Normal: 1.5 – 4.0 ng/ml 4. Low Normal: 1.0 – 1.5 ng/ml 5. Low: 0.5 – 1.0 ng/ml 6. Very Low: Less than 0.5 ng/ml
High AMH levels correlate with low cancellation rates, retrieval of more eggs, higher live birth rates and a high chance for freezing of leftover embryos. Low AMH levels (alone) do not predict low IVF success rates in women under 35. Couples should not be excluded from attempting.
For general assessment, doctors often choose transabdominal ultrasound. It is routinely used to evaluate the condition of the uterus and ovaries, and it’s helpful in the detection of cysts.Transvaginal ultrasound:
A directed physical exam that may include a pelvic ultrasound should be performed.Ultrasound can help us discover abnormalities with the uterus, fallopian tubes and/or ovaries. We can sometimes see evidence of pelvic scarring, such as when an ovary appears to be stuck to the uterus. We get information regarding the woman’s potential for adequate ovarian stimulation with medications by counting antral follicles.
More often, doctors request higher-resolution images, the kind that can be obtained with a transvaginal ultrasound. It may sound daunting, but it’s not so bad. The transvaginal ultrasound is performed with a small, very thin, sometimes chilly transducer that is covered and lubricated. If you’re allergic to latex, be sure to mention it to the technician before the exam so that a latex-free cover is used.
It’s used for monitoring endometrial development, follicle development, and ovulation, particularly for women who are taking fertility drugs. For these monitoring exams, your reproductive endocrinologist will be present to check your progress, and the good news is that these ultrasound check-ups only last about five minutes.
Doctors also employ ultrasound to guide medical instruments during surgical procedures, such as egg retrieval for IVF. If early pregnancy is detected, ultrasound is commonly used to confirm the location of the pregnancy and assess the gestational sac. And when fertility treatments have succeeded, an ultrasound is frequently used to detect the heartbeat of a fetus, or two!
Ultrasound tests for fertility don’t produce exciting, 3-D, look-at-our-baby sonograms, but they are useful and virtually risk- and pain-free. Most importantly, they provide information that can help and your partner achieve your dreams.
Ultrasound became an important help for the diagnosis of infertility by demonstration of the pelvic organs, of growing ovarian follicles, of intrafollicular structures and of cyclic uterine endometrial changes. Ultrasonic particularities of ovaries and their landmarks such as the ovarian artery, are described. Average ovarian blood flow can be measured. In hormone stimulated cycles, the ultrasonic examination is repeated through ovulation, induction and even afterward. The average diameter of the growing follicle is measured. The results of more than 8000 scans allowed the deduction that ovulation induction would be successful if the preovulatory follicular diameter was between 18 and 24 mm. Where two or more follicles of that diameter are present, multiple pregnancy occurs. The risk of overstimulation can be assessed. The importance of ultrasound is even higher than estradiol because it is impossible to differentiate between one big, some medium or many small follicles with hormone assays. It is possible to see the cumulus oöphorus, but not earlier than 1-2 days before ovulation. Following successful ovulation the mature follicle appears to have a more solid than cystic make-up.
Signs of a failure of ovulation are given. Cyclic changes in the histology of the endometrium are described and make it possible to predict ovulation within 12 hr. Ultrasound is an important aid in predicting the time of ovulation more accurately than the basal body temperature and faster and cheaper than hormone profiles.
Ultrasound plays a role in egg collection and replacement of the embryo. The detection of ovulation is very important in the treatment of infertility. This was only possible for a longtime by hormone profile. Nowadays ultrasound is an accepted method in the diagnostic procedures of this field. It permits the visualization of the position and size of the uterus, Fallopian tubes and ovaries, the exclusion of genital anomalies and the demonstration of physiological changes of these organs during the menstrual cycle. The main points of ultrasound in the diagnosis of infertility are as follows: Demonstration of the pelvic organs (uterus, Fallopian tube, ovary) and vascular structures. Demonstration of growing ovarian follicles (Measurement of their numbers and sizes). Demonstration of intrafollicular structures (Cumulus oöphorus, Corpus luteum). Demonstration of cyclic uterine endometrial changes. Most of the results were first obtained with high-resolution compound scanners, but the new generation of real-time scanners are equally capable Ovarian reserve testing can tell us quite a lot about the remaining quantity of eggs a woman has, but it tells us little about the quality of those eggs.
Semen analysis is probably the first test you will be asked to perform. Semen is the fluid that is released when a man has an orgasm. Semen carries the sperm in fluids that should nourish and protect it. You will typically be asked to provide a semen sample by masturbating into a sterile glass jar. If masturbation is not culturally acceptable, your doctor can provide you with a special condom in which to collect semen during intercourse.
The semen analysis provides a lot of information about the quantity and quality of both semen and the sperm it contains. Some of the things that are measured are:
- How much semen a man produces (volume)
- The total number of sperm in the semen sample (total count)
- The number of sperm in each milliliter of semen (concentration)
- The percentage of sperm that are moving (motility)
- If the sperm are the right shape or not (morphology)
The analysis can also suggest if you have an infection in your reproductive system.
The semen sample has to be tested within an hour of collection, which usually takes place in the doctor's office. You'll probably need to make two visits to provide samples on two different days more than two weeks apart, because samples from the same man can be different at different times. Collecting two samples makes it easier to tell if something really is wrong. You may be asked not to release sperm (ejaculate) for 2 to 5 days before you provide a sample.
This procedure uses transvaginal ultrasound after filling the uterus with saline (a salt solution). This improves detection of intrauterine problems such as endometrial polyps and fibroids compared with using transvaginal ultrasonography alone. If an abnormality is seen, a hysteroscopy is typically done. This test is often done in place of HSG.
This is an X-ray procedure to see if the fallopian tubes are open and to if the shape of the uterine cavity is normal. A catheter is inserted into the opening of the cervix through the vagina. A liquid containing iodine(contrast) is injected through the catheter. The contrast fills the uterus and enters the tubes, outlining the length of the tubes, and spills out their ends if they are open.
Diagnostic hystero-laparoscopy is a minimal access procedure aimed to visualise the pelvis and relating structures.This gives the specialist a visual impression of the uterus, fallopian tubes, and ovaries.A hysteroscopic procedure will give an idea of the uterine lining and the ostia (internal openings of the fallopian tubes)
A telescope is passed into the abdomen and dye is injected into the uterine cavity to check if the fallopian tubes are patent. In cases of the tubal block, the particular tube is canalized separately.
Post operative period is usually uneventful. You might have a slight discomfort for one to two days. You can start eating normally from the very next day and can exercise normally after a week.
Most patients with unexplained infertility spontaneously conceive after a diagnostic laparoscopic procedure.
The type of protocol used for a patient depends on her age, number of follicles prior to stimulation, E2 levels and her chances of developing OHSS. For either protocols the egg grows at a rate of 1-2 mm/day.
The most popular of all the protocols and was used for the longest of time for stimulating multiple follicles.
The protocol starts in the mid-luteal phase of the preceding cycle.
On day 21(of the preceding menstrual cycle)GnRH agonist of .5mg is started, this stimulates the pituitary to secrete initial very high levels of FSH and LH. After the initial rise of FSH and LH, there will be a period of down-regulation where the pituitary is desensitized thus lowering the levels of LH in the body.
Starting on day three (up to day7) of the current menstrual cycle, Recombinant FSH will be added to stimulate the follicles. At this point the GnRH agonist dose will be halved.
The dose of FSH will be adjusted depending on how well the follicles are developing. Ideally, we would like the 10 follicles around 17-20 mm diameter.Short protocol:
In this protocol, the recombinant FSH will be started on day 3 of stimulation.Flare Protocol :
OC Pills are given for a course of one month before starting the stimulation.
3 days after stopping OC pills, GnRH agonist is given daily at 100 micrograms divided into two doses. FSH is started 1 day after GnRH agonist. GnRH agonist is continued at the same dosage until HCG trigger. Ideally we would like 8 follicles around 16 – 19 mm diameter.Antagonist Protocol:
GnRH antagonist acts by competing with the body’s GnRH binding sites at the pituitary level thus inhibits the feedback mechanism to release FSH and LH. GnRH antagonist is usually started on the 6th day (fixed protocol) or when the most dominant follicle becomes 14 mm diameter. The dose of GnRH anatagonist is 0.25 mg and is given uptil hCG injection.Cycle Cancellation:
When the response to ovarian stimulation is insufficient, the ICSI cycle is cancelled and the cycle will be converted to an IUIAn hCG injection is given on the final day of the stimulation to induce final egg maturation
Some women are prone to premature ovarian failure. Such women have an elevated FSH level on the third day of menstrual period. Their AMH value will also be quite lower than normal. What this means is that the ovary is producing less feedback signals to the pituitary , hence body responds by elevating the FSH levels in an effort to stimulate follicular growth in the ovaries.
So a good way to evaluate women with POI would be with a day 3 ultrasound to check the antral follicular count (AFC)
So a good way to evaluate women with POI would be with a day 3 ultrasound to check the antral follicular count (AFC)
An AMH level of less than .6 has a high chance of cancellation rate than a patient with normal AMH levels.
There are several embryo grading systems available currently. We assess the quality by carefully evaluating and scoring some aspects of the appearance(morphology) of the embryos.As of 2016, time-lapse technology for embryo quality assessment is being widely used.Cell number:
Embryos should be in the two to four cell stage 2 days after ICSI and 7 cell stage by 3 days.These tiny cells inside the embryo are called blastomeres.Cell regularity:
If all the individual blastomeres within the embryos are of similar size, the quality is considered good.Fragmentation:
Fragmentation (or blebbing) is a phenomenon where a portion of the cells of the embryo have broken off and separated from the nucleated portion of the cells.The quality is considered good if there are little or no fragmentations.
However, fragmentation in human embryos is quite common and embryos with over 25 % fragments have low implantation potential.Multinucleation:
On day two or three after fertilization, if more than one nucleus is seen in the cells, chances are that the embryos are chromosomally abnormal. Generally, we do not transfer multinucleated embryos unless no other embryos are available for transfer.
Quality of the embryos are are determined 2 days after ICSI procedure.The embryos must be in a 2 cell stage (at least) otherwise they are termed as “arrested”. On day 3 a 6 cell stage is desirable.
Although these are the expected morphological parameters, we have seen beautiful babies being born with severely fragmented, slow growing, multinucleated embryos. This is because there are many more contributing factors to the “quality” and not just the morphological appearance. The true genetic potential of the embryo to continue normal development is important, which can be measured by PGD.
Women below 35 years of age Women who have more than 6 eggs during retrieval Lower success rates with less than 3 retrieved follicles. Our IVF Success rates as of 2017.
- 35 years and younger: 68 % live birth rate
- 35 – 38 years : 48.2 % live birth rate
- 38 – 40 years : 30.8 % live birth rate
- 40 years : 20 % live birth rate
As of 2014, time-lapse technology is available in the commercial market for assessment of embryo morphology.Using specialized incubators with microscopes, the rate of cleavage of the embryos can be assessed along with the process of compaction and blastulation.
DNA fragmentation is the breakage of DNA strands into tiny pieces. About 25% of infertile men have high levels of Sperm DNA Fragmentation. Usually, men with poorer semen analysis report have high DNA fragmentation. The sperm acts as a carrier of this DNA to deliver to the egg and combine with the maternal DNA to form an embryo. Semen analysis usually only tests how normal the sperm looks from the outside (morphology). A DNA fragmentation tests the integrity of the sperm on the inside. Some men who have a very normal semen analysis can have a severely fragmented DNA. Patients with repeated miscarriages or several IUI / ICSI failures are candidates for DNA fragmentation tests.Consequences of high DNA fragmentation:
- Unsuccessful IUI
- Unsuccessful ICSI
- Poor fertilization rates
The factors may be several and most are categorized as intrinsic or extrinsic factors. Some of them are: Infections, Excessive reactive oxygen species, Protamine deficiency, leucocytospermia, Varicocoele, Advanced age, Drug abuse, Under nourishment, Smoking, Testicular hyperthermia, etc.How do we test for DNA fragmentation?
The widely used test is called Sperm Chromatin Structure Assay (SCSA). The patient semen sample is frozen and shipped in liquid nitrogen. The sperm is thawed and mixed with a special orange dye that attaches itself to the damaged DNA inside the sperm.
Another test usually employed is the Terminal deoxynucleotidyl transferase (TUNEL) test where 3’- hydroxyl termini are labeled within the DNA when it breaks down (apoptotic DNA). Using flow cytometry several sperms are analyzed and counted using a computer. Depending on the number of abnormal sperm found, a DFI is assigned.DFI :
- <15% = Excellent fertility potential
- >15- 30% = Good fertility potential
- >30% = Poor fertility potential.
Studies have shown that patients with high DNA fragmentation fared much better after they had a few lifestyle modifications like quit smoking, a better diet with antioxidant and vitamin supplementation, lower bath temperatures, avoid being seated for long periods, etc.Treatments that reduce the impact of DNA damaged sperms:
- Varicocele repair
- ICSI with surgically retrieved sperm (MESA, TESA, PESA)
- ICSI after 3 months of antioxidant therapy
- IMSI – Selected sperm under high magnification optical system.
Endometrial Receptivity Assay is a new diagnostic method to evaluate the endometrial receptivity at a molecular level for a woman who is about to have an embryo transfer. The lack of synchronization between the embryo ready to be implanted and endometrial receptivity is one of the causes of recurring implantation failure. This is why it is imperative to assess the endometrium in order to determine the optimal day for embryo transfer.
This technique helps evaluate the woman’s expression of genes to evaluate whether the endometrial lining is properly developed to accept an embryo.
An endometrium is deemed receptive when it is ready for implantation of the embryo. This is called the window of implantation. This falls most likely on the 16th to 21st day of each menstrual cycle. It is highly sensitive in detecting expression of gene profiles associated with endometrial receptivity. The ERA is a personalized genetic test to get a specified implantation window forWho is ERA for?
An ERA is done for patients who have recurrent implantation failures after ICSI. Thus, an ERA assay will give us the optimal day to do the embryo transfer.
Patients with the normal uterus and normal endometrial thickness (≥6 mm), in which no problems are detected. Patients with an atrophic endometrium, whose thickness never reaches 6 mm consistently.How is it done?
The biopsy is taken in the Outpatient department using a pipelle and the sample is sent for analysis of 236 genes which are involved in endometrial receptivity. Using next-generation sequencing, we are able to retrieve the data required for the receptivity testing.ERA biopsy can be performed either during a natural or a stimulated cycle.Usually, about 70 mg of endometrial tissue is sufficient for the biopsy sample.
During a natural cycle – the biopsy is taken the 7th day (or 168 hours) after ovulation (LH surge). In a stimulated cycle (with estrogen+progesterone) – the biopsy is taken on the 5th day of progesterone supplementation. About 70 mg of tissue is sufficient to analyze levels of 236 genes related to the status of receptivity of the endometrium using RNA sequencing.Stimulated cycle:
From day 3 of menstrual cycle Estrogen 2mg twice daily from D3 to D7. Thrice daily from Day 8 – Day 9 , Day 11 to day 13 Four times . Day 14 and Day 15 4times a day + Crinone gel 8% Vaginally. Day 15 – Day 16 – 4 times a day + Crinone gel 8% Vaginally twice. ERA day 17What is the reporting?
The endometrial sample will be classified as receptive or non – receptive. ERA assesses the endometrial status whether or not the endometrium has a receptive gene profile at the time of biopsy. This analysis reveals a personalized window of implantation of each woman such that a personalized Embryo Transfer (pET) can be done. A non-receptive endometrium implies an incorrect window of implantation and the ERA biopsy would have to be repeated to estimate the window of implantation.Eligibility criteria for taking the sample:
- Woman <38 years of age
- Normal ovarian reserve
- FSH < 8mIU.mL
- >3 implantation failures with at least 2 good quality embryo transfers.
- Endometrium thickness >6
- Triple line pattern in ultrasound after progesterone priming
NIPT is a DNA test on maternal blood to screen pregnancies for the most common fetal chromosome anomalies:trisomy 21,trisomy 18 and trisomy 13. Also the gender of the fetus is determined.
An indication is when the triple test or FTS indicates an increased risk for Down syndrome, TRISOMY 18 OR TRISOMY 13 and in advanced maternal age. In the past, NIPTs were only recommended for women at high risk for carrying a baby with a chromosomal abnormality — like moms-to-be who are 35 or older, previously had a child with a genetic disorder or have a family history of these conditions — or if there was a concern about the result of another prenatal test.
ACOG now recommends that doctors discuss all screening options with all pregnant women — regardless of age or risk — to figure out which one, if any, is most appropriate.
The results of an NIPT screening can help you whether to have a diagnostic test like chorionic villus sampling (CVS) or amniocentesis (“amnio”). These genetic tests analyze a baby's own genetic material, collected from the amniotic fluid or placenta, to tell with 100 percent certainty whether a baby has a chromosome abnormality. However they are invasive, which means they slightly increase the chance of miscarriage.HOW NIPT IS DONE
Because an NIPT involves only a quick blood draw with a needle and syringe, it's safe for you and your baby. Your sample is then sent to a lab, where a technician will look at the cfDNA in your blood for signs of abnormalities.If it’s positive, your doctor may recommend following up with amniocentesis or CVS to confirm the result and check for other problems NIPTs can’t detect.WHAT ARE THE DIFFERENT KINDS OF NIPTS?
Some screen for abnormalities including triploidy and microdeletion. It’s worth noting that while some brands differentiate between maternal and fetal cfDNA, others do not (which means they’re less accurate), so you might want to ask your practitioner which type of test she uses.TRISOMIES
- Trisomy 21 Down Syndrome
- Trisomy 18 Edward syndrome
- Trisomy 13 Patau Syndrome
- 44Fetal sex chromosome
- 45X Turner syndrome
- 47XXY Klinefelter syndrome
- 47XXX Triple X syndrome
- 47XYY XYY syndrome
- 22q Digeorge syndrome
- 5p Cri-du-chat syndrome
- 1p36 1p36 deletion syndrome
- 15q Angelman/Prader-Willi syndromes
- 11Q Jacobson syndrome
- 8q Langer-Giedion syndrome
- 4p Wolf-Hirschhorn syndrome
NIPT can be performed any time after 9 weeks into your pregnancy — earlier than any other prenatal screening or diagnostic test. In comparison, nuchal translucency screening is done between weeks 11 and 13; CVS is done at 10 to 13 weeks; the quad screen is completed between weeks 14 and 22; and amniocentesis is usually performed between weeks 16 and 18, though it's sometimes done as early as week 13 or 14 and as late as week 23 or 24.THE ACCURACY OF NIPT
Research suggests that NIPTs create fewer false alarms than standard first-trimester blood screenings (like first-trimester bloodwork or quad screening) that measure hormones and special proteins in Mom's blood. Other research has shown that NIPTs are more accurate than those same standard screenings in predicting the risk of Down syndrome (NIPTs are 99 percent accurate) and Edwards syndrome. The American Congress of Obstetricians and Gynecologists (ACOG) says NIPT needs to be further evaluated before it will recommend the screening for all pregnant women. A screening like NIPT cannot, however, determine for sure whether your baby actually has a chromosomal disorder, only the likelihood of having that condition. But even though it can’t tell for sure whether your baby has a genetic abnormality, it is highly accurate — 97 to 99 percent accuracy for three of the most common conditions, according to a recent study.Contraindication
Fetal anomalies on ultrasound and known case of genetic anomalies that cannot be diagnosed by NIPTSperm Washing Techniques:
Sperms collected through masturbation can be washed by density gradient centrifugation or by swim-up” technique.Sperms are concentrated in F10 media, warmed to 37 degrees centigrade and a cryoprotectant is added to the sperm to aid freezing and thawing process. Further more chemicals may be added to separate the most active sperms in the sample.
Swim-up technique is the most common technique used in the andrology labs and is preferred if the semen sample has a normal number of sperms. Using this technique, sperms are selected on their capability to swim up with better motility.In the centrifuge technique, liquefied semen is divided into fractions of 1 ml in each tube, the medium is added (1:1) and after the centrifugation the supernatant is gently removed. After the migration of the sperms, the volume of the semen for the AI is removed and the sperm count and motility are assessed. In cases of oligozoospermia , teratozoospermia or asthenozoospermia , density gradient is the technique employed to separate good quality sperm from the dead sperm and debris.
Acupuncture is an alternative medical treatment that involves placing very thin needles at different points on the body. It was first recorded in China about 2,000 years ago, but most believe the practice began between 3,000–4,000 years ago. Insertion techniques and the type, style, and size of needle used can vary widely, as different styles were developed as acupuncture spread through Asia and the rest of the world. Traditional Chinese acupuncture is the more commonly used type of acupuncture in the IndiaHow might acupuncture help me? Acupuncture proponents have recommended it for a variety of medical conditions that affect fertility. These include polycystic ovary syndrome (PCOS), fibroids, endometriosis, and issues with ovarian reserve and sperm quality. It may also help relieve some of the side effects associated with fertility drugs (such as bloating and nausea). Acupuncture has been shown to promote relaxation. While some medical studies have shown acupuncture to be helpful in treating these fertility problems, other studies have not.
When should I start acupuncture treatment? Women are often advised to start acupuncture 3 months before they start treatments such as in vitro fertilization (IVF) or intrauterine insemination (IUI). However, starting acupuncture along with your doctor’s recommended fertility therapy may still be beneficial.What can I expect at my first visit with the acupuncturist?
Your acupuncturist may also perform an exam, including feeling your pulse and looking at your tongue. The use of acupuncture needles is next and can last from about 30 minutes to an hour.
How frequently should I do acupuncture? Your acupuncturist will tailor treatments to your condition but will generally recommend a treatment 1–3 times a week. Each session after the first one may last up to an hour—first a discussion period to update your acupuncturist followed by a 20–40-minute session with needles.Will the needles hurt?
Most patients experience little to no pain. Some might experience a mild, dull ache, pinch, or even shock sensation. Occasionally, bruising can occur at the places where the needles are inserted. Let your acupuncturist know if you are taking aspirin or other anticoagulants (blood thinners). Because qualified acupuncturists use disposable needles, the risk for infection is very, very low.
Are there activities I should avoid before/after an acupuncture session? Though your acupuncturist might advise following a healthy diet/lifestyle, nothing is strictly forbidden. Acupuncture helps with relaxation as well, so avoiding highly physical activities (running, gym class) immediately after a session might be helpful.