Korean Medicine Hospital Research Articles

추나 요법을 포함한 복합 한방치료를 이용한 오스굿-슐라터 병의 치료 증례보고

Objectives This case study aimed to investigate the effect of complex Korean medicine therapy and fascia Chuna therapy on Osgood-Schlatter disease. Methods Hospitalization treatment was performed on a 13-year-old Osgood-Schlatter patient who visited Woosuk University Korean Medicine Hospital. The patient complained of pain in both the tibial tuberosity and restriction on the range of knee joint movement. The results were evaluated using the visual analogue scale, knee injury and osteoarthritis outcome score, and range of motion. Results After treatment, knee pain decreased and range of movement angle improved. Conclusions This study suggests that complex Korean medicine therapy, including myofascial Chuna therapy, are effective in improving the range of motion and improving pain in early Osgood-Schlatter disease. The limitation of this study is that the subject of the study was limited to one case. Further clinical studies are required.

Three Cases of Post-Covid-19 Dry Cough Treated with <italic>Maekmundong-tang</italic>

Objective: The purpose of this study was to report three cases of post-COVID-19 dry cough that persisted even after taking Western medicine but was successfully treated with Maekmundong-tang.Methods: Three patients who were treated with Maekmundong-tang from March to June 2022 were selected from patients who visited Dong-Eui University Korean Medicine Hospital with post-Covid-19 dry cough. Jeil Maekmundong-tang Ext. granules were used to improve the cough. The effect of the treatment was evaluated using a visual analog scale, cough symptom score, and cough assessment test.Results: After the treatment, Cases 1, 2, and 3 showed decreases from 90 to 30, 65 to 0, and 70 to 20, respectively, for the visual analog scale score, decreases from 9 to 3, 5 to 0, and 5 to 3, respectively, for the cough symptom score, and decreases from 20 to 4, 9 to 1, and 8 to 3, respectively, for the cough assessment test score.Conclusion: Maekmundong-tang provided an effective improvement in the post-COVID-19 dry cough that persisted even after taking Western medicine.

An Exploratory Study of the Effect of <italic>Ongyeong-tang</italic> Administration on Insomnia Disorder in Patients with Neurological Diseases: A Retrospective Chart Review Study

Objectives: The aim of this study was to retrospectively evaluate the efficacy and safety of Ongyeong-tang (OGT) in the treatment of insomnia in patients afflicted with neurological diseases, according to the medical records of one medical institution. OGT is a herbal prescription that originates from the “Synopsis of Prescriptions of the Golden Chamber” and has been used for menopausal symptoms, uterine diseases, skin diseases, insomnia, and other neuropsychiatric symptoms.Methods: Medical records of patients who visited Kyung Hee University Korean Medicine Hospital from January 1, 2021 to June 30, 2022, received outpatient or inpatient treatment, and met the inclusion criteria were used in this study.Results: Twenty-four patients satisfied the inclusion criteria and were included. The Pittsburgh Sleep Quality Index-Korean version (PSQI-K) score was used to evaluate the outcomes before and after treatment. After an average of 14.42±9.2 days of OGT extract intake, 20 patients (83.3%) experienced improvement. The remaining four (16.7%) had no change in their symptoms, but none demonstrated worsening of symptoms. The total PSQI-K score showed a statistically significant decrease from 13.08±4.54 to 10.42±4.58 (p<0.001). Sleep quality, sleep duration, sleep disturbance, use of sleeping medications, and daytime dysfunction also showed statistically significant improvements.Conclusions: Administration of OGT extract may be a relatively safe and effective therapeutic option for insomnia in patients with neurological diseases.

A multicenter registry of neuropsychiatric outpatients in Korean medicine hospitals (KMental): Protocol of a prospective, multicenter, registry study.

Mental health is an important global health concern. In Korea, many people visit Korean medicine clinics due to Stagnation syndrome and Hwabyung (cultural idioms of distress). We established a research collaboration comprising of professionals from 8 Korean medicine hospitals and planned a prospective, multicenter registry study. Demographic, socioeconomic, and clinical data will be collected from patients with mental disorders visiting the Korean medicine neuropsychiatric department of Korean medicine hospitals. We will include major psychiatric diagnoses related to neurosis and Korean traditional mental disorders such as Stagnation syndrome and Hwabyung.We expect to identify comprehensive characteristics of participants, measure the severity of their symptoms or distress, and investigate patterns of Korean medicine interventions and treatment responses for both the short-term and long-term (at least 4 years). Additionally, this study will include Health Insurance Review & Assessment Service data to analyze the medical use of registered patients before and after registration, in case the participant submits the consent form for personal information collection and use.To analyze the effectiveness of Korean medicine treatment for the participants, stratified or corrected analyses of age, sex, and diagnosis will be performed. The difference in the change in the psychometric measurements, quality of life measured by short form 36, and quality-adjusted life years will be calculated to evaluate the effectiveness of Korean medicine treatment.

Correlation Between Accompanying Symptoms of Facial Nerve Palsy, Clinical Assessment Scales and Surface Electromyography

Background: This retrospective study aimed to determine whether there were correlations between the number and type of accompanying symptoms of peripheral facial nerve palsy, and surface electromyography (SEMG) and clinical assessment scales to help diagnosis.Methods: There were 30, cases of peripheral facial nerve palsy at Visit 1 to the Korean Medicine Hospital, Dong-eui University, 22 cases at Visit 2 and 10 cases at Visit 3. The study period was from July 19, 2021 to November 31, 2021. Symptoms were evaluated three times (with two-week intervals which began 7 days from onset) using SEMG, clinical assessment scales and accompanying symptoms. In this study, the House-Brackmann grading system (HBGS), and the Yanagihara’s unweighted grading system (Y-score) clinical assessment scales were used. The Pearson or Spearman correlation was used for statistical analysis.Results: On Visit 1, the number of accompanying symptoms of peripheral facial nerve palsy had no significant correlation with other measures. On Visits 1-3, the HBGS score had a significant negative correlation with the Y-score. On Visit 2, most of the mean values measured had significant correlations with each other although not between SEMG-Z and SEMG-O that Z means a zygomaticus muscle and O means a orbicularis oris muscle. On Visit 3, the number of accompanying symptoms significantly correlated with the clinical assessment scales. The HBGS score, Y-score, and SEMG measurements (except SEMG-Z) had significant correlations with each other. A significant positive correlation between SEMG-Z and SEMG-T was noted.Conclusion: We predict accompanying symptoms can be used to diagnose the peripheral facial nerve palsy including both clinical assessment scales and SEMG measurements at 2-5 weeks after onset.

A Case Report of Korean Medicine Treatment for a Wrist Drop Patient with Thoracic Outlet Syndrome Admitted to Korean Medicine Hospital

Taewoon Min, K.M.D., Dohyeon Kang, K.M.D., Jaeseo Ahn, K.M.D., Hyunjun Lee, K.M.D., Hansol Lee, K.M.D., Hankyul Kim, K.M.D., Seongmin Lee, K.M.D., Sohyun Cho, K.M.D., Hyungwook Ji, K.M.D., Ilhwan Ko, K.M.D., Jiwon Kim, K.M.D., Jungmin Yun, K.M.D., Hyukjin Jeong, K.M.D.. J Korean Med Rehabi 2022;32:89-96. https://doi.org/10.18325/jkmr.2022.32.4.89

A Case Report of Suspected Allergic Rhinitis in a Patient with LBP Hospitalized at a Korean Medicine Hospital and Treated with Korean Medicine

Objective: The purpose of this study is to report the efficacy of using Korean medical treatment for suspected allergic rhinitis.Methods: We used Korean medical treatments (herbal medicines and acupuncture) to treat a hospitalized patient with suspected allergic rhinitis. To evaluate the treatment, we used Total Nasal Symptom Scores to measure sneezing, rhinorrhea, itching, and obstruction. The degree of rhinitis was also evaluated using the Visual Analogue Scale, and the patient’s generic health status was measured using the European Quality of Life 5 Dimensions Scale.Results: Visual Analogue Scale and European Quality of Life 5 Dimensions Scale scores improved after treatment. The change in Total Nasal Symptom Scores showed that the patient’s suspected allergic rhinitis symptoms were relieved.Conclusions: The results of this study suggest that Korean medicine therapies may be effective for treating suspected allergic rhinitis.

A Case Report of Chronic Gastritis in a Patient with Spinal Stenosis Hospitalized at a Korean Medicine Hospital and Treated with Korean Medicine

Objectives: The purpose of this study is to report the efficacy of applying Korean medical treatment to chronic gastritis.Methods: We treated a chronic gastritis patient with Korean medical treatments (herbal medicines, acupuncture, and herbal acupuncture therapy). To evaluate the results of this treatment, we took measurements using the Gastrointestinal Symptom Rating Scale and Visual Analogue Scale for abdominal pain, heartburn, nausea, and abdominal distension. The patient’s generic health status was evaluated using the European Quality of Life 5 Dimensions Scale.Results: Improvements in gastrointestinal symptom ratings and the European Quality of Life 5 Dimensions Scale were observed after the treatments. Relief of symptoms was observed in abdominal pain, heartburn, nausea, vomiting, and abdominal distension using the Visual Analogue Scale.Conclusions: This study suggests that Korean medicine may be effective in the treatment of chronic gastritis.

A Case Report of Peripheral Facial Nerve Palsy in a Patient with Spinal Stenosis Hospitalized at a Korean Medicine Hospital and Treated with Korean Medicine

Objectives: The purpose of this study is to investigate the effectiveness of using Korean medical treatment for peripheral facial nerve palsy.Methods: We primarily treated the patient’s peripheral facial nerve palsy during hospitalization (06/28/21~07/13/21) without any other steroids or antiviral drug treatments and additionally treated their spinal stenosis, using Korean medical treatments in both cases (herbal medicine, acupuncture, and herbal acupuncture therapy). The House-Brackmann grading system and Yanagihara’s unweighted grading system were used to assess facial symptom changes, and the Numerical Rating Scale was used to evaluate the back pain caused by the spinal stenosis.Results: Following treatment, the patient’s House-Brackmann and Numerical Rating Scale scores decreased, while their Yanagihara unweighted score improved.Conclusions: This study suggests that Korean medicine may be effective in the treatment of facial nerve palsy.

A Case Report of a Patient with Parkinson’s Disease Treated with Acupuncture and Exercise Therapy

Objectives: Parkinson’s disease is characterized by progressive, irreversible damage to dopamine neurons in the substantia nigra pars compacta, as well as motor and non-motor symptoms. This disease currently has no dependable disease-modifying treatment. In this paper, we describe the treatment of a 67-year-old female with Parkinson’s disease using acupuncture and exercise therapy.Case Presentation: Clinical symptoms and the United Kingdom Parkinson’s Disease Society Brain Bank Diagnostic Criteria were used to diagnose the patient with Parkinson’s disease. Over a 12-week period, the patient visited a Korean medicine hospital 18 times and was treated with acupuncture and exercise therapy in addition to anti-Parkinson’s drugs. Before and after treatment, clinical examinations were performed using tools such as the Unified Parkinson’s Disease Rating Scale, Fall Efficacy Scale, Parkinson’s Disease Questionnaire, Berg Balance Scale, and Non-Motor Symptoms Scale. Furthermore, functional near-infrared spectroscopy was used to assess cortical hemodynamics. All clinical examination results improved after 12 weeks of intervention. In particular, improvements on the Total Unified Parkinson’s Disease Rating Scale and Part III of this scale demonstrated large, clinically important differences.Conclusion: This case suggests that combining acupuncture and exercise therapy could produce an effective treatment for Parkinson’s disease patients.

An Overview of Clinical Features, and Medical Access Among Patients with Post-Acute COVID-19 Syndromes: Analysis of a Nationwide Survey in Korea

Background: The objective of this study was to identify the clinical features of patients who recovered from COVID-19, and to determine their unmet medical needs and quality of life.Methods: A cross-sectional national survey was conducted in Korea in June 2022, targeting patients with at least four weeks of symptoms of COVID-19. The questionnaire survey had 37 items across: basic characteristics, acute COVID-19 and post-acute COVID-19 syndrome (long COVID) symptoms, access to medical facilities for long COVID, unmet medical needs, long COVID support system, and quality of life.Results: Among 1,430 responses, 745 (52.1%) respondents had experienced long COVID. The most common symptoms were ear, nose, and throat complications (n = 461, 61.9%), followed by weakness and fatigue (n = 393, 52.8%). Amongst the 745 respondents who experienced long COVID, 337 (45.2%) had visited a medical institution, of which, 84.9% had visited a clinic or hospital for treatment. Korean medicine clinics and hospitals had the highest satisfaction rates (43.4%). There were 242 respondents (32.5%) who reported unmet medical needs for their long COVID. Symptom severity and duration of COVID-19 were risk factors for unmet medical needs. Quality of life was low in those patients with long COVID and unmet medical needs, and decreased further with increased severity and longer duration of symptoms.Conclusion: Studies on the effects of Korean medicine treatment of long COVID, and establishing a system providing sufficient treatment for patients with long COVID are needed. These findings could be used by clinicians, researchers, and COVID-19-related policymakers.

Investigation of the Adverse Events Associated with Bee Venom Pharmacopuncture in Patients Hospitalized in a Korean Hospital: A Retrospective Chart Review Study.

In bee venom pharmacopuncture (BVP), bee venom isolated from the venom sac of bees is injected into the acupoint or muscle associated with a disease. However, the histamine component in bee venom can cause adverse events; therefore, attention is required for BVP use. This study investigated the frequency, severity and characteristics of patients developing BVP-associated adverse events. The medical records of patients treated with BVP at Kyung Hee University Korean Medicine Hospital between 1 January 2013 and 1 May 2021 were reviewed. The demographic characteristics, disease-related characteristics, treatment-related characteristics and impressions of each patient were analyzed. In this study, >50% of 4821 inpatients were hospitalized for neurological disorders. The mean age of the overall study population was 54.62 ± 16.38 years and 61% were women. The frequency of adverse events was 2.32%. The mean age in the adverse events group was 58.20 ± 16.10 years and 76% were women. Two patients experienced moderate adverse events, with no commonality between these events. Every patient recovered naturally with no sequelae. The results showed that BVP is a relatively safe therapeutic method. However, further studies are needed to determine the frequency of adverse events and identify the causality between baseline characteristics and adverse events.

Clinical Effectiveness of Ikgibohyeol-tang(Yìqìbǔxuè-tāng) and Deer Antler on Fatigue Symptoms and HRV Results in Outpatients at Korean Medical Hospital: A Retrospective Chart Review Study

Objectives: This study was designed to investigate the clinical effectiveness of Ikgibohyeol-tang(Yìqìbǔxuè-tāng) granules and Deer antler granules on fatigue symptoms.Methods: This is a 39-patient case series from a retrospective chart review of outpatients who were treated with Ikgibohyeol-tang granules and Deer antler granules at a Kyung Hee University Korean Medicine Hospital (Seoul) between 1st, January 2015 to 1st, August 2021. We reviewed the patients who complained of fatigue and analyzed changes in the degree of discomfort with fatigue and accompanying symptoms and HRV (Heart Rate Variability) score before and after treatment.Results: After taking Ikgibohyeol-tang granules and Deer antler granules, the degree of discomfort with fatigue and accompanying symptoms decreased significantly compared to before taking them. After treatment, Autonomic nervous system activity, Stress resistance, Heart Stability increased, and Stress index, Degree of fatigue decreased significantly.Conclusions: This study showed subjective symptoms and objective indicator (HRV score) were improved by taking Ikgibohyeol-tang granules and Deer antler granules.

Korean Medicine Treatment for Managing Complex Regional Pain Syndrome: Case Report

A 53-year-old male who had received surgery on his right ankle joint 10 years previously was diagnosed with Complex Regional Pain Syndrome the following year. Despite various treatments (sympathetic nerve-block medication, pain relievers, corticosteroids, nerve blocks, and transcutaneous electrical nerve stimulation) over the years there was no improvement in his symptoms. Recently the patient was admitted to a Korean medicine hospital where he received treatment (acupuncture, pharmacopuncture, and herbal treatment) and his symptoms gradually showed improvement. The patient was concurrently on psychiatric medicine, antihistamine medication, and opioids for pain (when necessary). A decrease in numeric rating scale, Oswestry disability index scores, and an increase in the Korean version of the 5-level EuroQol-5 dimension score showed symptom improvement within 36 days. This study suggests complex Korean medicine treatment for Complex Regional Pain Syndrome may result in a reduction in pain and improved quality of life.

Effectiveness and safety of Korean medicine treatment based on the clinical practice guidelines in patients with acute peripheral facial palsy: A protocol for a multicenter, prospective, observational study.

Introduction:Peripheral facial palsy (PFP) results in weakness or paralysis of the affected side of the face. In Korea, there is a high demand for Korean medicine treatment for PFP. The clinical practice guidelines (CPGs) of Korean medicine for facial palsy were developed; however, there remains insufficient evidence to support the effectiveness and safety of Korean medicine treatment. Thus, this study aimed to evaluate the effectiveness and safety of Korean medicine treatment based on the CPGs in patients with acute PFP.Methods:This is a multicenter, prospective, observational study. The participants will be recruited from one Korean medicine hospital and eight Korean medicine clinics. The participants will receive Korean medicine treatments based on the CPGs, fill in survey questionnaires, and undergo electrophysiologic testing. The changes in House-Brackmann (H-B) grade, movement of the lip and eye, symptoms related to or accompanied by facial palsy, Facial Disability Index, EuroQol 5-dimension 5-level (EQ-5D-5L), and EuroQol Visual Analogue Scale (EQ-VAS), and the results of electromyography (EMG), electroneurography (ENoG), and Blink Reflex test will be analyzed. For the safety analysis, adverse events will be recorded, and for the feasibility analysis, the results of the Was It Worth It questionnaire will be assessed.Conclusion:We expect to draw real-world clinical data on the effectiveness and safety of Korean medicine treatment based on the CPGs in patients with acute PFP from this study. It would be the basis for complementing and improving the CPGs and provide the basis of clinical and policy decision-making.Trial registration:This study was approved by the Institutional Review Board of Kyung Hee University Korean Medicine Hospital (2021-06-005-001), and registered with the Korean Clinical Trial Registry (CRIS), Republic of Korea (KCT0006562).

Comparison of Clinical Characteristics of Patients between Genuine and Pseudo Halitosis

Objectives: This study was designed to investigate the difference between genuine and pseudo-halitosis in terms of clinical characteristics.Methods: We recruited 51 halitosis patients who visited the halitosis clinic at Kyung Hee University Korean Medicine Hospital from March 2020 to March 2022. We classified the halitosis patients into two groups, genuine and pseudo halitosis, based on oral chroma and evaluated the status of hyposalivation using the drainage method, stress levels using heart rate variability (HRV) parameters, and Ryodoraku.Results: Comparing the genuine halitosis group and the pseudo halitosis group, there was no significant difference in the status of hyposalivation and HRV parameters. However, Ryodoraku was significantly different between genuine and pseudo halitosis. Compared to the genuine halitosis group, the pseudo halitosis group showed a significantly higher value of total average (TA) of Ryodoraku.Conclusion: The results of this study suggest that there is a significant difference in Ryodoraku between genuine halitosis and pseudo halitosis, so when approaching pseudo halitosis patients, we should consider their excitability of the sympathetic nervous system and metabolic function status.

A Case Report of Symptom Improvement with Recurrent Gallbladder Cancer Patients Treated with Korean Medicine-based Integrative Cancer Treatment

Objective: The purpose of this study was to report the improvement effect of symptoms of integrative cancer treatment (ICT) on recurrent gallbladder cancer patients.Methods: A 73-year-old patient with recurrent gallbladder cancer visited the Daejeon Korean Medicine Hospital of Daejeon University East West Cancer Center (EWCC) on February 2022. After the diagnosis of gallbladder cancer, the patient underwent cholecystectomy and relapsed during follow-up. After the operation, the cancer recurred during follow-up, and after radiation treatment, she had been receiving ICT since February 2022. The clinical outcomes were measured by X-ray, computed tomography (CT), laboratory findings, including tumor markers (CEA, CA19-9), and numeric rating scales (NRS).Results: After treatment, abdominal pain was relieved from NRS 5 to 2, and abdominal circumference decreased from 74.5 to 67. During and after treatment, we found neither hepatotoxicity nor nephrotoxicity in the laboratory findings.Conclusion: This case study suggests that ICT may improve symptoms in patients with gallbladder cancer.

Effects of Korean Medicine Treatment in Post-acute COVID-19 Syndrome: A Retrospective Case Series of 15 Patients

Objective: The aim of this study was to identify the clinical features of post-acute COVID-19 syndrome and the efficacy and safety of Korean medicine treatment.Methods: This study was conducted on 15 patients with post-acute COVID-19 syndrome who visited the outpatient Allergy, Immune, and Respiratory System Department at Kyung Hee University Korean Medicine Hospital from January 10, 2021 to April 10, 2022. We retrospectively analyzed the charts of 15 patients and collected clinical characteristics, Korean medicine treatments, outcome variables (Numeral Rating Scale (NRS), modified Medical Research Council scale (mMRC), Leicester Cough Questionnaire (LCQ), Quality of Life Visual Analog Scale (QOL-VAS), The Post-COVID-19 Functional Status (PCFS)), adverse events, etc.Results: Of the 15 patients, seven (46.7%) were men, and the average age of all patients was 49.7±13 years. The most common symptom was cough (n=9, 60%), and it was followed by dyspnea or increased respiratory effort, fatigue, insomnia, anosmia, etc. The herbal medicine was prescribed for all 15 patients, and <i>Saengmaek-san</i> (n=8, 53.5%) was the most prescribed. Additionally, acupuncture and cupping were performed in four patients (26.7%) each, and electroacupuncture was applied to one patient (6.7%). As a result of Korean medicine treatment, NRS, mMRC, LCQ, QOL-VAS, and PCFS showed improvement, and adverse events were mild.Conclusions: This study presented the clinical features of post-acute COVID-19 syndrome and suggested that Korean medicine treatment may be effective in alleviating related symptoms and enhancing quality of life.

Efficacy and Safety of Bojungikgi-Tang for Persistent Allergic Rhinitis: A Study Protocol for a Randomized, Double-Blind, Placebo-Controlled, Phase II Trial.

Background Allergic rhinitis (AR) is a common disease, and conventional medications are often insufficient for treatment. Bojungikgi-tang (BJIGT) is an herbal medicine widely used in traditional medicine and has anti-inflammatory and immunoregulatory effects. We hypothesize that BJIGT would improve nasal symptoms in patients with persistent AR (PAR). Methods This is a randomized, double-blind, placebo-controlled, phase II trial. A total of 105 patients, identified with perennial allergens, with a history of PAR and a mean total nasal symptom score (TNSS) ≥ 5 during the run-in period will be recruited from Daejeon Korean Medicine Hospital. Participants will be randomly assigned to a high-dose BJIGT group, standard-dose BJIGT group, or control group (placebo) in a 1 : 1 : 1 allocation ratio after a week run-in period. The treatment medication will be taken three times per day for 4 weeks. The primary outcome measure is the mean change in the TNSS before and after medication. The secondary outcome measures include the Korean Allergic Rhinitis-Specific Quality of Life Questionnaire, total IgE and eosinophil count, overall assessment of AR, pattern identification questionnaire for AR, and Sasang constitution. Discussion. The aim of this study is to investigate the efficacy and safety of BJIGT in the treatment of PAR and to determine the suitable dosage of BJIGT. Therefore, we planned a randomized, controlled, phase II trial of two different doses of BJIGT compared with placebo, and the results of this study are expected to provide evidence for the use of BJIGT as a treatment of PAR. Trial Registration. The National Clinical Trial Registry Clinical Research Information Service, CRIS, KCT0006616, https://cris.nih.go.kr/cris/search/detailSearch.do/20706.

A study on the current state of Korean medicine treatment in infertile women: an observational multi-center study protocol

Objectives: The purpose of this study is to investigate the characteristics of female infertility patients who come to Korean medicine clinics and analyze the trends of Korean medicine treatment methods and the effects of female infertility by registry data.Methods: We are recruiting study participants from Korean medicine hospitals and clinics. If female infertility patients come, we will ask them to register for this study. After enrollment, we will collect demographic information, treatment methods, pregnancy results, adverse events, and treatment costs.Result: First, we will analyze the characteristics of patients, the status of the use of Korean medicine treatment interventions, the cost status of Korean medicine infertility treatment, and the delivery characteristics of pregnant women after Korean medicine treatment. Second, we will analyze the effectiveness of Korean medicine treatment. The primary outcome is clinical pregnancy rate, and secondary outcomes are 12-week pregnancy maintenance rate, degree of dysmenorrhea and premenstrual syndrome, stress level, and health-related quality of life score.Discussion: This study is the first observational multi-center study in Korea for female infertility. By establishing the registry, we are creating a resource that contains patient-reported outcome measures for female infertility. The registry is expected to provide valuable data for developing Korean medicine Clinical practice guidelines for female infertility.